Managing Your Practice

This legislation would authorize Medicare to provide coverage for voluntary advance care consultations every five years or at changes in the patient’s health, health-related condition, or care setting.

Although inevitable, death is often difficult to conceptualize and even more sensitive to discuss. For hospitalists and other care providers, conversations about the end of life with families and caregivers can be fraught with emotion. The fact that something is uncomfortable does not mean it is not useful or valuable, however. Patients must be able to vocalize their end-of-life wishes and should feel confident that the healthcare system is able to respond.

To help with this effort, the Society of Hospital Medicine is supporting legislation that would encourage voluntary end-of-life conversations between patients and their healthcare providers. Sponsored by U.S. Rep. Earl Blumenauer (D-Ore.), the Personalize Your Care Act of 2013 (H.R. 1173) would make Medicare reimbursement available for advance-care planning consultations, establish grants for state-level physician orders for life-sustaining treatment (POLST) programs, and require that advance directives be honored across state lines.

Hospitalists are integral team leaders for coordinating care and, as such, are often highly involved in end-of-life care for patients. They are at the front lines of these conversations, often tasked to plan end-of-life care and then carry out those plans. Many of their patients are acutely ill and need to face these critical decisions, often in real time.

End-of-life planning, like many other cognitive medical services, is not adequately reimbursed under current Medicare payment policy. This legislation would authorize Medicare to provide coverage for voluntary advance care consultations every five years or following changes in health, health-related condition, or care setting of the patient.

SHM is strongly supportive of adequate reimbursement for the counseling these patients require in planning their end-of-life care. The bill would make these conversations a practicable addition to the care and counseling workflow for healthcare providers and would ensure that they could occur at reasonable intervals and at significant changes in health or life events. These conversations would help ensure that patient wishes are respected at the end of life and prevent the use of unwanted treatments or interventions.

As the healthcare system works toward being more coordinated and more patient-centered, voluntary advance care planning is essential. Patients often see multiple providers at the end of their lives and—particularly as questions arise—it is imperative that providers have access to the most up-to-date advance care plans. H.R. 1173 works to address this gap by moving toward electronic health record display of advance directives and POLST.

Hospitalists may be eligible for reimbursement for these consultations, particularly in cases where these discussions did not occur in the outpatient setting. SHM is actively working with Rep. Blumenauer to ensure that all providers in a position to have these important conversations would be appropriately reimbursed. Patients need to have an active mechanism to ensure that their wishes are appropriately followed; this legislation would give them better access to these important and difficult conversations.

Joshua Lapps is SHM’s government relations specialist.

This legislation would authorize Medicare to provide coverage for voluntary advance care consultations every five years or at changes in the patient’s health, health-related condition, or care setting.

Although inevitable, death is often difficult to conceptualize and even more sensitive to discuss. For hospitalists and other care providers, conversations about the end of life with families and caregivers can be fraught with emotion. The fact that something is uncomfortable does not mean it is not useful or valuable, however. Patients must be able to vocalize their end-of-life wishes and should feel confident that the healthcare system is able to respond.

To help with this effort, the Society of Hospital Medicine is supporting legislation that would encourage voluntary end-of-life conversations between patients and their healthcare providers. Sponsored by U.S. Rep. Earl Blumenauer (D-Ore.), the Personalize Your Care Act of 2013 (H.R. 1173) would make Medicare reimbursement available for advance-care planning consultations, establish grants for state-level physician orders for life-sustaining treatment (POLST) programs, and require that advance directives be honored across state lines.

Hospitalists are integral team leaders for coordinating care and, as such, are often highly involved in end-of-life care for patients. They are at the front lines of these conversations, often tasked to plan end-of-life care and then carry out those plans. Many of their patients are acutely ill and need to face these critical decisions, often in real time.

End-of-life planning, like many other cognitive medical services, is not adequately reimbursed under current Medicare payment policy. This legislation would authorize Medicare to provide coverage for voluntary advance care consultations every five years or following changes in health, health-related condition, or care setting of the patient.

SHM is strongly supportive of adequate reimbursement for the counseling these patients require in planning their end-of-life care. The bill would make these conversations a practicable addition to the care and counseling workflow for healthcare providers and would ensure that they could occur at reasonable intervals and at significant changes in health or life events. These conversations would help ensure that patient wishes are respected at the end of life and prevent the use of unwanted treatments or interventions.

As the healthcare system works toward being more coordinated and more patient-centered, voluntary advance care planning is essential. Patients often see multiple providers at the end of their lives and—particularly as questions arise—it is imperative that providers have access to the most up-to-date advance care plans. H.R. 1173 works to address this gap by moving toward electronic health record display of advance directives and POLST.

Hospitalists may be eligible for reimbursement for these consultations, particularly in cases where these discussions did not occur in the outpatient setting. SHM is actively working with Rep. Blumenauer to ensure that all providers in a position to have these important conversations would be appropriately reimbursed. Patients need to have an active mechanism to ensure that their wishes are appropriately followed; this legislation would give them better access to these important and difficult conversations.

Joshua Lapps is SHM’s government relations specialist.

This legislation would authorize Medicare to provide coverage for voluntary advance care consultations every five years or at changes in the patient’s health, health-related condition, or care setting.

Although inevitable, death is often difficult to conceptualize and even more sensitive to discuss. For hospitalists and other care providers, conversations about the end of life with families and caregivers can be fraught with emotion. The fact that something is uncomfortable does not mean it is not useful or valuable, however. Patients must be able to vocalize their end-of-life wishes and should feel confident that the healthcare system is able to respond.

To help with this effort, the Society of Hospital Medicine is supporting legislation that would encourage voluntary end-of-life conversations between patients and their healthcare providers. Sponsored by U.S. Rep. Earl Blumenauer (D-Ore.), the Personalize Your Care Act of 2013 (H.R. 1173) would make Medicare reimbursement available for advance-care planning consultations, establish grants for state-level physician orders for life-sustaining treatment (POLST) programs, and require that advance directives be honored across state lines.

Hospitalists are integral team leaders for coordinating care and, as such, are often highly involved in end-of-life care for patients. They are at the front lines of these conversations, often tasked to plan end-of-life care and then carry out those plans. Many of their patients are acutely ill and need to face these critical decisions, often in real time.

End-of-life planning, like many other cognitive medical services, is not adequately reimbursed under current Medicare payment policy. This legislation would authorize Medicare to provide coverage for voluntary advance care consultations every five years or following changes in health, health-related condition, or care setting of the patient.

SHM is strongly supportive of adequate reimbursement for the counseling these patients require in planning their end-of-life care. The bill would make these conversations a practicable addition to the care and counseling workflow for healthcare providers and would ensure that they could occur at reasonable intervals and at significant changes in health or life events. These conversations would help ensure that patient wishes are respected at the end of life and prevent the use of unwanted treatments or interventions.

As the healthcare system works toward being more coordinated and more patient-centered, voluntary advance care planning is essential. Patients often see multiple providers at the end of their lives and—particularly as questions arise—it is imperative that providers have access to the most up-to-date advance care plans. H.R. 1173 works to address this gap by moving toward electronic health record display of advance directives and POLST.

Hospitalists may be eligible for reimbursement for these consultations, particularly in cases where these discussions did not occur in the outpatient setting. SHM is actively working with Rep. Blumenauer to ensure that all providers in a position to have these important conversations would be appropriately reimbursed. Patients need to have an active mechanism to ensure that their wishes are appropriately followed; this legislation would give them better access to these important and difficult conversations.

Joshua Lapps is SHM’s government relations specialist.

Beth Papetti

Having nocturnist coverage in your practice is a coveted position to be in for many hospital medicine providers. Rick Washington, MD, medical director for WellStar Kennestone Hospital in Marietta, Ga., says that “not only does it make it easier to recruit and retain daytime physicians when you have nocturnists as a part of your program, but they also serve a very valuable role in the continuity of the program throughout the nighttime hours, providing a stable admitting presence in the emergency department at all times.”

According to the 2012 State of Hospital Medicine Report, nearly half of all hospital medicine groups (HMGs) serving adults only incorporate nocturnists into their programs. Nocturnists are most common in HMGs employed by universities or medical schools (67%) and hospitals/integrated delivery systems (50%). The prevalence among management company-employed groups is much lower (25%), and no data was available for multispecialty groups or private hospitalist-only groups (see Figure 1).

As could be expected, the prevalence of nocturnists increases dramatically as the number of total FTEs of the practice increases. As the number of patients on a service, and thus the number of FTEs, grows, so does the expectation to provide on-site night coverage.

The percentage of compensation paid as base salary also has an impact; in general, the higher the percentage of compensation in base salary, the more likely that practice is to have nocturnists. Typically, night shifts tend to be less productive from a billable encounter perspective, so having a base rate of pay tends to be an essential factor in successfully maintaining nocturnists.

click for large version

However, surprisingly, in the 63% of groups that reported paying a nocturnist differential, the clinicians earned only a median of 15% more in total compensation than their non-nocturnist counterparts. Perhaps this has to do with other factors that programs are utilizing in order to entice and retain nocturnists, which includes the possibility of doing fewer shifts or shorter shifts than their colleagues. In fact, 49% of respondent groups reported implementing a nocturnist schedule differential, most commonly in the range of one to 20% fewer shifts than non-nocturnist hospitalists in the same practice.

Other practices implement a schedule differential by shortening the length of nocturnist shifts, instead of reducing the number of shifts worked.

“For me, the key to doing this long term has been the ability to have an eight-hour shift rather than 12 hours,” says Dr. Nancy Maignan, who soon will celebrate five years as a nocturnist at WellStar Kennestone Hospital. “Another factor is flexibility with our schedule. We do not work 7-on/7-off. My schedule is dependent on my family’s schedule…this allows me to attend field trips and be off for most of their [her kids] school break.”

Although she points out that a supportive family is crucial, a supportive HMG is key. I would encourage groups thinking of implementing a nocturnist role to think carefully about how to make the job one that hospitalists can successfully do for a long time, rather than just trying to attract people to the role by making it financially lucrative.

Beth Papetti is assistant vice president of WellStar Medical Group in Marrietta, Ga. She is a member of SHM’s Practice Analysis Committee.

Beth Papetti

Having nocturnist coverage in your practice is a coveted position to be in for many hospital medicine providers. Rick Washington, MD, medical director for WellStar Kennestone Hospital in Marietta, Ga., says that “not only does it make it easier to recruit and retain daytime physicians when you have nocturnists as a part of your program, but they also serve a very valuable role in the continuity of the program throughout the nighttime hours, providing a stable admitting presence in the emergency department at all times.”

According to the 2012 State of Hospital Medicine Report, nearly half of all hospital medicine groups (HMGs) serving adults only incorporate nocturnists into their programs. Nocturnists are most common in HMGs employed by universities or medical schools (67%) and hospitals/integrated delivery systems (50%). The prevalence among management company-employed groups is much lower (25%), and no data was available for multispecialty groups or private hospitalist-only groups (see Figure 1).

As could be expected, the prevalence of nocturnists increases dramatically as the number of total FTEs of the practice increases. As the number of patients on a service, and thus the number of FTEs, grows, so does the expectation to provide on-site night coverage.

The percentage of compensation paid as base salary also has an impact; in general, the higher the percentage of compensation in base salary, the more likely that practice is to have nocturnists. Typically, night shifts tend to be less productive from a billable encounter perspective, so having a base rate of pay tends to be an essential factor in successfully maintaining nocturnists.

click for large version

However, surprisingly, in the 63% of groups that reported paying a nocturnist differential, the clinicians earned only a median of 15% more in total compensation than their non-nocturnist counterparts. Perhaps this has to do with other factors that programs are utilizing in order to entice and retain nocturnists, which includes the possibility of doing fewer shifts or shorter shifts than their colleagues. In fact, 49% of respondent groups reported implementing a nocturnist schedule differential, most commonly in the range of one to 20% fewer shifts than non-nocturnist hospitalists in the same practice.

Other practices implement a schedule differential by shortening the length of nocturnist shifts, instead of reducing the number of shifts worked.

“For me, the key to doing this long term has been the ability to have an eight-hour shift rather than 12 hours,” says Dr. Nancy Maignan, who soon will celebrate five years as a nocturnist at WellStar Kennestone Hospital. “Another factor is flexibility with our schedule. We do not work 7-on/7-off. My schedule is dependent on my family’s schedule…this allows me to attend field trips and be off for most of their [her kids] school break.”

Although she points out that a supportive family is crucial, a supportive HMG is key. I would encourage groups thinking of implementing a nocturnist role to think carefully about how to make the job one that hospitalists can successfully do for a long time, rather than just trying to attract people to the role by making it financially lucrative.

Beth Papetti is assistant vice president of WellStar Medical Group in Marrietta, Ga. She is a member of SHM’s Practice Analysis Committee.

Beth Papetti

Having nocturnist coverage in your practice is a coveted position to be in for many hospital medicine providers. Rick Washington, MD, medical director for WellStar Kennestone Hospital in Marietta, Ga., says that “not only does it make it easier to recruit and retain daytime physicians when you have nocturnists as a part of your program, but they also serve a very valuable role in the continuity of the program throughout the nighttime hours, providing a stable admitting presence in the emergency department at all times.”

According to the 2012 State of Hospital Medicine Report, nearly half of all hospital medicine groups (HMGs) serving adults only incorporate nocturnists into their programs. Nocturnists are most common in HMGs employed by universities or medical schools (67%) and hospitals/integrated delivery systems (50%). The prevalence among management company-employed groups is much lower (25%), and no data was available for multispecialty groups or private hospitalist-only groups (see Figure 1).

As could be expected, the prevalence of nocturnists increases dramatically as the number of total FTEs of the practice increases. As the number of patients on a service, and thus the number of FTEs, grows, so does the expectation to provide on-site night coverage.

The percentage of compensation paid as base salary also has an impact; in general, the higher the percentage of compensation in base salary, the more likely that practice is to have nocturnists. Typically, night shifts tend to be less productive from a billable encounter perspective, so having a base rate of pay tends to be an essential factor in successfully maintaining nocturnists.

click for large version

However, surprisingly, in the 63% of groups that reported paying a nocturnist differential, the clinicians earned only a median of 15% more in total compensation than their non-nocturnist counterparts. Perhaps this has to do with other factors that programs are utilizing in order to entice and retain nocturnists, which includes the possibility of doing fewer shifts or shorter shifts than their colleagues. In fact, 49% of respondent groups reported implementing a nocturnist schedule differential, most commonly in the range of one to 20% fewer shifts than non-nocturnist hospitalists in the same practice.

Other practices implement a schedule differential by shortening the length of nocturnist shifts, instead of reducing the number of shifts worked.

“For me, the key to doing this long term has been the ability to have an eight-hour shift rather than 12 hours,” says Dr. Nancy Maignan, who soon will celebrate five years as a nocturnist at WellStar Kennestone Hospital. “Another factor is flexibility with our schedule. We do not work 7-on/7-off. My schedule is dependent on my family’s schedule…this allows me to attend field trips and be off for most of their [her kids] school break.”

Although she points out that a supportive family is crucial, a supportive HMG is key. I would encourage groups thinking of implementing a nocturnist role to think carefully about how to make the job one that hospitalists can successfully do for a long time, rather than just trying to attract people to the role by making it financially lucrative.

Beth Papetti is assistant vice president of WellStar Medical Group in Marrietta, Ga. She is a member of SHM’s Practice Analysis Committee.

During a routine mammogram, an enlarged lymph node was found in the patient’s armpit. The patient’s primary care physician (PCP) ordered follow-up imaging and referred the patient to a surgeon for possible excisional biopsy. The surgeon suggested that the biopsy could be delayed until additional imaging studies were completed.

The patient transferred her care to another surgeon, who immediately performed the biopsy and found stage IV inoperable breast cancer. The patient underwent aggressive chemotherapy for 3 years, but died 39 months after diagnosis.

ESTATE’S CLAIM The first surgeon was negligent for not immediately performing the biopsy.

DEFENDANTS’ DEFENSE There was no negligence. An earlier biopsy would not have changed the outcome.

VERDICT A $1.5 million Massachusetts verdict was returned.

Treating bowel injury after uterine ablation
Following uterine ablation performed by a gynecologist, a 35-year-old woman suffered severe abdominal pain. Six days later, the gynecologist and a surgeon performed a hysterectomy.

Three days after discharge, the patient returned to the hospital with an abdominal infection and sepsis. During a third operation, a burn hole was found; the injured portion of bowel was resected. The patient has chronic abdominal pain.

PATIENT’S CLAIM Sepsis and infection could have been avoided if either physician had identified the injury during the second hospitalization and surgery. The patient developed psychological issues as a result of chronic pain.

DEFENDANTS’ DEFENSE A settlement was reached with the gynecologist during the trial. The surgeon denied negligence. During the second surgery, he examined her bowel for a possible injury but found none.

VERDICT A $3.5 million Illinois verdict was returned. It included
$1.5 million for past pain and suffering that was reduced by $100,000 due to the patient’s failure to report for psychological counseling. The jury found the gynecologist 65% at fault and the surgeon 35% at fault.

Mother in permanent vegetative state
When a 30-year-old woman went to a hospital in labor, she had gestational hypertension. The next morning, she suffered cardiopulmonary arrest. A healthy baby was born by emergency cesarean delivery, but the mother was left in a permanent vegetative state.

PATIENT’S CLAIM The nurses failed to ensure that the ObGyn came to the hospital and did not report blood pressure data to the ObGyn. Gestational hypertension progressed to preeclampsia. Early delivery should have been induced or magnesium sulfate should have been administered.

DEFENDANTS’ DEFENSE A confidential settlement was reached with the ObGyn before trial.

The nurses were right to rely on the ObGyn to make decisions regarding the patient’s care. They provided appropriate treatment.

VERDICT A New Jersey defense verdict was returned for the hospital.

What caused the child’s brain injuries?
After vaginal delivery, the baby was not breathing and required intubation. He had a seizure and displayed signs of oxygen deprivation, hypoxic ischemic injury, and brain damage. The child uses a special walker and can only communicate using a computer that speaks for him.

PARENTS’ CLAIM The nurses and ObGyn failed to properly assess the baby. The fetal heart-rate monitor electrode should have been placed on the fetal scalp. A cesarean delivery should have been performed.

DEFENDANTS’ DEFENSE The fetal monitor was properly placed. The child’s injury occurred 24 to 72 hours prior to birth due to an umbilical cord accident. A cesarean delivery would have not changed the outcome.  

VERDICT A Georgia defense verdict was returned.

Did a woman’s vaginal infection cause her baby’s death?
At 22 weeks’ gestation, a 26-year-old woman began to leak amniotic fluid and went to the hospital. She was in premature labor. The newborn died 19 minutes after birth.

PARENTS’ CLAIM The ObGyn and nurse midwife who provided prenatal care failed to diagnose and treat a vaginal infection. The infection resulted in premature rupture of membranes, leading to premature birth and the baby’s death.

DEFENDANTS’ DEFENSE A confidential settlement was reached with the ObGyn before trial. The nurse midwife claimed the patient did not have a vaginal infection; she never reported symptoms of a foul-smelling vaginal odor or discharge. Premature rupture of membranes was not caused by a vaginal infection. The newborn’s death was related to an umbilical cord defect, the patient’s delay in coming to the hospital, and the multiple obstetric procedures the mother had undergone before this pregnancy.   

VERDICT A $456,024 New Jersey verdict was returned.

Inadvertent ligation, ureteral obstruction
A 41-year-old woman suffered pelvic pain and had a history of endometriosis. In January 2007, a CT scan revealed a ruptured ovarian cyst; her ObGyn performed laparotomy for a hysterectomy and oophorectomy.

During surgery, a resident working under the supervision of the ObGyn inadvertently ligated the left ureter. The injury was close to the bladder near the ureteral vesicle junction. A few days later, cystoscopy showed ureteral obstruction. The patient underwent operative repair with nephrostomy tube placement. In May 2007, the patient had a third operation to reimplant the ureter. She has chronic flank pain.

PATIENT’S CLAIM The resident and, therefore, the ObGyn, were negligent in the performance of the procedure. Proper bladder dissection would have moved the ureter to a position where it could not have been ligated.

DEFENDANTS’ DEFENSE Ureter injury is a known risk of the procedure.

VERDICT An Illinois defense verdict was returned.

Foot drop after tubal ligatioN?
During tubal ligation, a woman in her 30s was restrained by a belt. Venodyne boots were applied to promote blood circulation.

PATIENT’S CLAIM The belt and/or boot damaged the perineal and tibial nerves in her left leg, causing foot drop. When asked to definitely identify what caused the nerve damage, the patient invoked the doctrine of res ipsa loquitur (presumed negligence during surgery).

DEFENDANTS’ DEFENSE A $400,000 settlement was reached with the hospital before the trial.

The gynecologist and anesthesiologist denied negligence. The Venodyne boots could not have caused the injury, nor could the belt, which was applied in an area that did not involve the perineal or tibial nerves. The patient did not complain of pain after surgery.  

VERDICT A New York defense verdict was returned for the physicians.

Avoid surgical menopause?
After a 10-year history of endometriosis and chronic pelvic pain, a 38-year-old woman underwent bilateral salpingo-oophorectomy. Postoperatively, she suffered surgical menopause that exacerbated pre-existing anxiety and depression.

PATIENT’S CLAIM It was unnecessary to remove the healthy right ovary; having it remain would have avoided early menopause. She would not have consented to the removal of both ovaries had she been properly advised. Alternative treatment was not offered. Her marriage dissolved, her children went to live with their grandparents, and she was unable to work because of complications.

PHYSICIAN’S DEFENSE Proper consent was obtained, including alternatives to surgery. Evidence of ovarian cancer or other medical necessity was not required because full consent was obtained. Removal of the ovaries was proper due to dense pelvic and bowel adhesions, cystic adnexal masses with questionable pathology, and her chronic pelvic pain. The patient’s appendix was adhesed, causing an unreasonable risk of ovarian torsion.

VERDICT A Michigan defense verdict was returned.

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Persistent voiding problems
A 52-year-old woman was given a diagnosis of stage II anterior pelvic organ prolapse, a high transverse fascial defect, stress urinary incontinence, and distal rectocele.

A gynecologist performed robotic supracervical hysterectomy and colposacropexy, with tension-free vaginal tape and perineal repair.

While in the hospital, she required a catheter to void, and was still unable to void 5 days after discharge. The gynecologist identified persistent urinary retention, released the tension-free vaginal tape, and performed a midurethral sling procedure, but the patient continued to have voiding problems.

The gynecologist suspected a neurogenic problem and referred the patient to a neuro-urologist. Continued intermittent catheterization was recommended by the neuro-urologist, but the patient had continued voiding problems and developed a urinary tract infection.

She went to her ObGyn, who performed a sling revision and cysto­scopy and removed all the mesh that could be found. The patient underwent additional treatment, with some improvement.

PATIENT’S CLAIM The gynecologist was negligent for failing to offer further surgery to improve the patient’s condition. 

PHYSICIAN’S DEFENSE There was no negligence. Further dissection in the presence of a neurogenic bladder carried a high risk of incontinence. The patient was told of the risk of urinary retention prior to the first procedure and signed an informed consent.   

VERDICT A Virginia defense verdict was returned.

Did pathologists fail to diagnose early breast cancer?
After A 45-year-old woman underwent mammography in May 2008 at a local hospital, an oncologist noted a suspicious finding in the right breast. The patient had an incisional biopsy interpreted by Dr. A, a pathologist, and a core biopsy interpreted by Dr. B, another pathologist from the same diagnostic medical group. Both pathologists interpreted the mass as atypia, a benign abnormality.

In 2010, the patient went to a university medical center, where the mass was biopsied and the patient was found to have cancer. She underwent a right mastectomy.

PATIENT’S CLAIM The pathologists failed to diagnose her breast cancer at an early stage. Dr. A should have interpreted the 2008 incisional biopsy as malignant. A diagnosis in 2008 would have avoided the need for a mastectomy, allowing her to have a lumpectomy with chemotherapy.

DEFENDANTS’ DEFENSE The 2010 review of the 2008 data was an over-interpretation with hindsight bias; the diagnosis in 2008 was correct.  

VERDICT The case against the local hospital and Dr. B were dismissed. The matter continued against Dr. A and the diagnostic medical group. A California defense verdict was returned.

Brachial plexus injury occurs after admitting physician leaves
A woman sought prenatal care from her family practitioner (FP). The FP admitted the mother to a hospital for induction of labor at 38 weeks’ gestation with concerns of increased uric acid, possible gestational hypertension, and leaking amniotic fluid. Labor progressed and the mother began pushing about 4 pm. After 30 minutes, the FP attempted vacu­um extraction three times; the device popped off during one of the attempts.

The FP then left for a planned trip, and an ObGyn assumed her care. The ObGyn chose to allow the mother to rest. At 6 pm, the mother began to feel the urge to push. The ObGyn attempted vacu­um extraction. Shoulder dystocia was encountered, and McRoberts and corkscrew maneuvers were used to deliver the fetus.

The child has C5–C6 brachial plexus injury with scapular winging and internal shoulder rotation.

PARENTS’ CLAIM A cesarean delivery should have been performed. The ObGyn applied excessive lateral traction, leading to the injury.

DEFENDANTS’ DEFENSE The FP and ObGyn argued that a cesarean ­delivery was not indicated because the fetus was not in distress. Fetal heart-rate monitoring strips were reassuring. The ObGyn denied using excessive lateral traction when freeing the shoulder dystocia. 

VERDICT The hospital settled before trial for $300,000. An Illinois defense verdict was returned for the FP. The jury deadlocked as to the ObGyn’s negligence.

These cases were selected by the editors of OBG Management from Medical Malpractice Verdicts, Settlements & Experts, with permission of the editor, Lewis Laska (www.verdictslaska.com). The information available to the editors about the cases presented here is sometimes incomplete. Moreover, the cases may or may not have merit. Nevertheless, these cases represent the types of clinical situations that typically result in litigation and are meant to illustrate nationwide variation in jury verdicts and awards.

During a routine mammogram, an enlarged lymph node was found in the patient’s armpit. The patient’s primary care physician (PCP) ordered follow-up imaging and referred the patient to a surgeon for possible excisional biopsy. The surgeon suggested that the biopsy could be delayed until additional imaging studies were completed.

The patient transferred her care to another surgeon, who immediately performed the biopsy and found stage IV inoperable breast cancer. The patient underwent aggressive chemotherapy for 3 years, but died 39 months after diagnosis.

ESTATE’S CLAIM The first surgeon was negligent for not immediately performing the biopsy.

DEFENDANTS’ DEFENSE There was no negligence. An earlier biopsy would not have changed the outcome.

VERDICT A $1.5 million Massachusetts verdict was returned.

Treating bowel injury after uterine ablation
Following uterine ablation performed by a gynecologist, a 35-year-old woman suffered severe abdominal pain. Six days later, the gynecologist and a surgeon performed a hysterectomy.

Three days after discharge, the patient returned to the hospital with an abdominal infection and sepsis. During a third operation, a burn hole was found; the injured portion of bowel was resected. The patient has chronic abdominal pain.

PATIENT’S CLAIM Sepsis and infection could have been avoided if either physician had identified the injury during the second hospitalization and surgery. The patient developed psychological issues as a result of chronic pain.

DEFENDANTS’ DEFENSE A settlement was reached with the gynecologist during the trial. The surgeon denied negligence. During the second surgery, he examined her bowel for a possible injury but found none.

VERDICT A $3.5 million Illinois verdict was returned. It included
$1.5 million for past pain and suffering that was reduced by $100,000 due to the patient’s failure to report for psychological counseling. The jury found the gynecologist 65% at fault and the surgeon 35% at fault.

Mother in permanent vegetative state
When a 30-year-old woman went to a hospital in labor, she had gestational hypertension. The next morning, she suffered cardiopulmonary arrest. A healthy baby was born by emergency cesarean delivery, but the mother was left in a permanent vegetative state.

PATIENT’S CLAIM The nurses failed to ensure that the ObGyn came to the hospital and did not report blood pressure data to the ObGyn. Gestational hypertension progressed to preeclampsia. Early delivery should have been induced or magnesium sulfate should have been administered.

DEFENDANTS’ DEFENSE A confidential settlement was reached with the ObGyn before trial.

The nurses were right to rely on the ObGyn to make decisions regarding the patient’s care. They provided appropriate treatment.

VERDICT A New Jersey defense verdict was returned for the hospital.

What caused the child’s brain injuries?
After vaginal delivery, the baby was not breathing and required intubation. He had a seizure and displayed signs of oxygen deprivation, hypoxic ischemic injury, and brain damage. The child uses a special walker and can only communicate using a computer that speaks for him.

PARENTS’ CLAIM The nurses and ObGyn failed to properly assess the baby. The fetal heart-rate monitor electrode should have been placed on the fetal scalp. A cesarean delivery should have been performed.

DEFENDANTS’ DEFENSE The fetal monitor was properly placed. The child’s injury occurred 24 to 72 hours prior to birth due to an umbilical cord accident. A cesarean delivery would have not changed the outcome.  

VERDICT A Georgia defense verdict was returned.

Did a woman’s vaginal infection cause her baby’s death?
At 22 weeks’ gestation, a 26-year-old woman began to leak amniotic fluid and went to the hospital. She was in premature labor. The newborn died 19 minutes after birth.

PARENTS’ CLAIM The ObGyn and nurse midwife who provided prenatal care failed to diagnose and treat a vaginal infection. The infection resulted in premature rupture of membranes, leading to premature birth and the baby’s death.

DEFENDANTS’ DEFENSE A confidential settlement was reached with the ObGyn before trial. The nurse midwife claimed the patient did not have a vaginal infection; she never reported symptoms of a foul-smelling vaginal odor or discharge. Premature rupture of membranes was not caused by a vaginal infection. The newborn’s death was related to an umbilical cord defect, the patient’s delay in coming to the hospital, and the multiple obstetric procedures the mother had undergone before this pregnancy.   

VERDICT A $456,024 New Jersey verdict was returned.

Inadvertent ligation, ureteral obstruction
A 41-year-old woman suffered pelvic pain and had a history of endometriosis. In January 2007, a CT scan revealed a ruptured ovarian cyst; her ObGyn performed laparotomy for a hysterectomy and oophorectomy.

During surgery, a resident working under the supervision of the ObGyn inadvertently ligated the left ureter. The injury was close to the bladder near the ureteral vesicle junction. A few days later, cystoscopy showed ureteral obstruction. The patient underwent operative repair with nephrostomy tube placement. In May 2007, the patient had a third operation to reimplant the ureter. She has chronic flank pain.

PATIENT’S CLAIM The resident and, therefore, the ObGyn, were negligent in the performance of the procedure. Proper bladder dissection would have moved the ureter to a position where it could not have been ligated.

DEFENDANTS’ DEFENSE Ureter injury is a known risk of the procedure.

VERDICT An Illinois defense verdict was returned.

Foot drop after tubal ligatioN?
During tubal ligation, a woman in her 30s was restrained by a belt. Venodyne boots were applied to promote blood circulation.

PATIENT’S CLAIM The belt and/or boot damaged the perineal and tibial nerves in her left leg, causing foot drop. When asked to definitely identify what caused the nerve damage, the patient invoked the doctrine of res ipsa loquitur (presumed negligence during surgery).

DEFENDANTS’ DEFENSE A $400,000 settlement was reached with the hospital before the trial.

The gynecologist and anesthesiologist denied negligence. The Venodyne boots could not have caused the injury, nor could the belt, which was applied in an area that did not involve the perineal or tibial nerves. The patient did not complain of pain after surgery.  

VERDICT A New York defense verdict was returned for the physicians.

Avoid surgical menopause?
After a 10-year history of endometriosis and chronic pelvic pain, a 38-year-old woman underwent bilateral salpingo-oophorectomy. Postoperatively, she suffered surgical menopause that exacerbated pre-existing anxiety and depression.

PATIENT’S CLAIM It was unnecessary to remove the healthy right ovary; having it remain would have avoided early menopause. She would not have consented to the removal of both ovaries had she been properly advised. Alternative treatment was not offered. Her marriage dissolved, her children went to live with their grandparents, and she was unable to work because of complications.

PHYSICIAN’S DEFENSE Proper consent was obtained, including alternatives to surgery. Evidence of ovarian cancer or other medical necessity was not required because full consent was obtained. Removal of the ovaries was proper due to dense pelvic and bowel adhesions, cystic adnexal masses with questionable pathology, and her chronic pelvic pain. The patient’s appendix was adhesed, causing an unreasonable risk of ovarian torsion.

VERDICT A Michigan defense verdict was returned.

Do you enjoy reading Medical Verdicts?
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Persistent voiding problems
A 52-year-old woman was given a diagnosis of stage II anterior pelvic organ prolapse, a high transverse fascial defect, stress urinary incontinence, and distal rectocele.

A gynecologist performed robotic supracervical hysterectomy and colposacropexy, with tension-free vaginal tape and perineal repair.

While in the hospital, she required a catheter to void, and was still unable to void 5 days after discharge. The gynecologist identified persistent urinary retention, released the tension-free vaginal tape, and performed a midurethral sling procedure, but the patient continued to have voiding problems.

The gynecologist suspected a neurogenic problem and referred the patient to a neuro-urologist. Continued intermittent catheterization was recommended by the neuro-urologist, but the patient had continued voiding problems and developed a urinary tract infection.

She went to her ObGyn, who performed a sling revision and cysto­scopy and removed all the mesh that could be found. The patient underwent additional treatment, with some improvement.

PATIENT’S CLAIM The gynecologist was negligent for failing to offer further surgery to improve the patient’s condition. 

PHYSICIAN’S DEFENSE There was no negligence. Further dissection in the presence of a neurogenic bladder carried a high risk of incontinence. The patient was told of the risk of urinary retention prior to the first procedure and signed an informed consent.   

VERDICT A Virginia defense verdict was returned.

Did pathologists fail to diagnose early breast cancer?
After A 45-year-old woman underwent mammography in May 2008 at a local hospital, an oncologist noted a suspicious finding in the right breast. The patient had an incisional biopsy interpreted by Dr. A, a pathologist, and a core biopsy interpreted by Dr. B, another pathologist from the same diagnostic medical group. Both pathologists interpreted the mass as atypia, a benign abnormality.

In 2010, the patient went to a university medical center, where the mass was biopsied and the patient was found to have cancer. She underwent a right mastectomy.

PATIENT’S CLAIM The pathologists failed to diagnose her breast cancer at an early stage. Dr. A should have interpreted the 2008 incisional biopsy as malignant. A diagnosis in 2008 would have avoided the need for a mastectomy, allowing her to have a lumpectomy with chemotherapy.

DEFENDANTS’ DEFENSE The 2010 review of the 2008 data was an over-interpretation with hindsight bias; the diagnosis in 2008 was correct.  

VERDICT The case against the local hospital and Dr. B were dismissed. The matter continued against Dr. A and the diagnostic medical group. A California defense verdict was returned.

Brachial plexus injury occurs after admitting physician leaves
A woman sought prenatal care from her family practitioner (FP). The FP admitted the mother to a hospital for induction of labor at 38 weeks’ gestation with concerns of increased uric acid, possible gestational hypertension, and leaking amniotic fluid. Labor progressed and the mother began pushing about 4 pm. After 30 minutes, the FP attempted vacu­um extraction three times; the device popped off during one of the attempts.

The FP then left for a planned trip, and an ObGyn assumed her care. The ObGyn chose to allow the mother to rest. At 6 pm, the mother began to feel the urge to push. The ObGyn attempted vacu­um extraction. Shoulder dystocia was encountered, and McRoberts and corkscrew maneuvers were used to deliver the fetus.

The child has C5–C6 brachial plexus injury with scapular winging and internal shoulder rotation.

PARENTS’ CLAIM A cesarean delivery should have been performed. The ObGyn applied excessive lateral traction, leading to the injury.

DEFENDANTS’ DEFENSE The FP and ObGyn argued that a cesarean ­delivery was not indicated because the fetus was not in distress. Fetal heart-rate monitoring strips were reassuring. The ObGyn denied using excessive lateral traction when freeing the shoulder dystocia. 

VERDICT The hospital settled before trial for $300,000. An Illinois defense verdict was returned for the FP. The jury deadlocked as to the ObGyn’s negligence.

These cases were selected by the editors of OBG Management from Medical Malpractice Verdicts, Settlements & Experts, with permission of the editor, Lewis Laska (www.verdictslaska.com). The information available to the editors about the cases presented here is sometimes incomplete. Moreover, the cases may or may not have merit. Nevertheless, these cases represent the types of clinical situations that typically result in litigation and are meant to illustrate nationwide variation in jury verdicts and awards.

During a routine mammogram, an enlarged lymph node was found in the patient’s armpit. The patient’s primary care physician (PCP) ordered follow-up imaging and referred the patient to a surgeon for possible excisional biopsy. The surgeon suggested that the biopsy could be delayed until additional imaging studies were completed.

The patient transferred her care to another surgeon, who immediately performed the biopsy and found stage IV inoperable breast cancer. The patient underwent aggressive chemotherapy for 3 years, but died 39 months after diagnosis.

ESTATE’S CLAIM The first surgeon was negligent for not immediately performing the biopsy.

DEFENDANTS’ DEFENSE There was no negligence. An earlier biopsy would not have changed the outcome.

VERDICT A $1.5 million Massachusetts verdict was returned.

Treating bowel injury after uterine ablation
Following uterine ablation performed by a gynecologist, a 35-year-old woman suffered severe abdominal pain. Six days later, the gynecologist and a surgeon performed a hysterectomy.

Three days after discharge, the patient returned to the hospital with an abdominal infection and sepsis. During a third operation, a burn hole was found; the injured portion of bowel was resected. The patient has chronic abdominal pain.

PATIENT’S CLAIM Sepsis and infection could have been avoided if either physician had identified the injury during the second hospitalization and surgery. The patient developed psychological issues as a result of chronic pain.

DEFENDANTS’ DEFENSE A settlement was reached with the gynecologist during the trial. The surgeon denied negligence. During the second surgery, he examined her bowel for a possible injury but found none.

VERDICT A $3.5 million Illinois verdict was returned. It included
$1.5 million for past pain and suffering that was reduced by $100,000 due to the patient’s failure to report for psychological counseling. The jury found the gynecologist 65% at fault and the surgeon 35% at fault.

Mother in permanent vegetative state
When a 30-year-old woman went to a hospital in labor, she had gestational hypertension. The next morning, she suffered cardiopulmonary arrest. A healthy baby was born by emergency cesarean delivery, but the mother was left in a permanent vegetative state.

PATIENT’S CLAIM The nurses failed to ensure that the ObGyn came to the hospital and did not report blood pressure data to the ObGyn. Gestational hypertension progressed to preeclampsia. Early delivery should have been induced or magnesium sulfate should have been administered.

DEFENDANTS’ DEFENSE A confidential settlement was reached with the ObGyn before trial.

The nurses were right to rely on the ObGyn to make decisions regarding the patient’s care. They provided appropriate treatment.

VERDICT A New Jersey defense verdict was returned for the hospital.

What caused the child’s brain injuries?
After vaginal delivery, the baby was not breathing and required intubation. He had a seizure and displayed signs of oxygen deprivation, hypoxic ischemic injury, and brain damage. The child uses a special walker and can only communicate using a computer that speaks for him.

PARENTS’ CLAIM The nurses and ObGyn failed to properly assess the baby. The fetal heart-rate monitor electrode should have been placed on the fetal scalp. A cesarean delivery should have been performed.

DEFENDANTS’ DEFENSE The fetal monitor was properly placed. The child’s injury occurred 24 to 72 hours prior to birth due to an umbilical cord accident. A cesarean delivery would have not changed the outcome.  

VERDICT A Georgia defense verdict was returned.

Did a woman’s vaginal infection cause her baby’s death?
At 22 weeks’ gestation, a 26-year-old woman began to leak amniotic fluid and went to the hospital. She was in premature labor. The newborn died 19 minutes after birth.

PARENTS’ CLAIM The ObGyn and nurse midwife who provided prenatal care failed to diagnose and treat a vaginal infection. The infection resulted in premature rupture of membranes, leading to premature birth and the baby’s death.

DEFENDANTS’ DEFENSE A confidential settlement was reached with the ObGyn before trial. The nurse midwife claimed the patient did not have a vaginal infection; she never reported symptoms of a foul-smelling vaginal odor or discharge. Premature rupture of membranes was not caused by a vaginal infection. The newborn’s death was related to an umbilical cord defect, the patient’s delay in coming to the hospital, and the multiple obstetric procedures the mother had undergone before this pregnancy.   

VERDICT A $456,024 New Jersey verdict was returned.

Inadvertent ligation, ureteral obstruction
A 41-year-old woman suffered pelvic pain and had a history of endometriosis. In January 2007, a CT scan revealed a ruptured ovarian cyst; her ObGyn performed laparotomy for a hysterectomy and oophorectomy.

During surgery, a resident working under the supervision of the ObGyn inadvertently ligated the left ureter. The injury was close to the bladder near the ureteral vesicle junction. A few days later, cystoscopy showed ureteral obstruction. The patient underwent operative repair with nephrostomy tube placement. In May 2007, the patient had a third operation to reimplant the ureter. She has chronic flank pain.

PATIENT’S CLAIM The resident and, therefore, the ObGyn, were negligent in the performance of the procedure. Proper bladder dissection would have moved the ureter to a position where it could not have been ligated.

DEFENDANTS’ DEFENSE Ureter injury is a known risk of the procedure.

VERDICT An Illinois defense verdict was returned.

Foot drop after tubal ligatioN?
During tubal ligation, a woman in her 30s was restrained by a belt. Venodyne boots were applied to promote blood circulation.

PATIENT’S CLAIM The belt and/or boot damaged the perineal and tibial nerves in her left leg, causing foot drop. When asked to definitely identify what caused the nerve damage, the patient invoked the doctrine of res ipsa loquitur (presumed negligence during surgery).

DEFENDANTS’ DEFENSE A $400,000 settlement was reached with the hospital before the trial.

The gynecologist and anesthesiologist denied negligence. The Venodyne boots could not have caused the injury, nor could the belt, which was applied in an area that did not involve the perineal or tibial nerves. The patient did not complain of pain after surgery.  

VERDICT A New York defense verdict was returned for the physicians.

Avoid surgical menopause?
After a 10-year history of endometriosis and chronic pelvic pain, a 38-year-old woman underwent bilateral salpingo-oophorectomy. Postoperatively, she suffered surgical menopause that exacerbated pre-existing anxiety and depression.

PATIENT’S CLAIM It was unnecessary to remove the healthy right ovary; having it remain would have avoided early menopause. She would not have consented to the removal of both ovaries had she been properly advised. Alternative treatment was not offered. Her marriage dissolved, her children went to live with their grandparents, and she was unable to work because of complications.

PHYSICIAN’S DEFENSE Proper consent was obtained, including alternatives to surgery. Evidence of ovarian cancer or other medical necessity was not required because full consent was obtained. Removal of the ovaries was proper due to dense pelvic and bowel adhesions, cystic adnexal masses with questionable pathology, and her chronic pelvic pain. The patient’s appendix was adhesed, causing an unreasonable risk of ovarian torsion.

VERDICT A Michigan defense verdict was returned.

Do you enjoy reading Medical Verdicts?
Find more in the PROFESSIONAL LIABILITY Topic Collection.

Persistent voiding problems
A 52-year-old woman was given a diagnosis of stage II anterior pelvic organ prolapse, a high transverse fascial defect, stress urinary incontinence, and distal rectocele.

A gynecologist performed robotic supracervical hysterectomy and colposacropexy, with tension-free vaginal tape and perineal repair.

While in the hospital, she required a catheter to void, and was still unable to void 5 days after discharge. The gynecologist identified persistent urinary retention, released the tension-free vaginal tape, and performed a midurethral sling procedure, but the patient continued to have voiding problems.

The gynecologist suspected a neurogenic problem and referred the patient to a neuro-urologist. Continued intermittent catheterization was recommended by the neuro-urologist, but the patient had continued voiding problems and developed a urinary tract infection.

She went to her ObGyn, who performed a sling revision and cysto­scopy and removed all the mesh that could be found. The patient underwent additional treatment, with some improvement.

PATIENT’S CLAIM The gynecologist was negligent for failing to offer further surgery to improve the patient’s condition. 

PHYSICIAN’S DEFENSE There was no negligence. Further dissection in the presence of a neurogenic bladder carried a high risk of incontinence. The patient was told of the risk of urinary retention prior to the first procedure and signed an informed consent.   

VERDICT A Virginia defense verdict was returned.

Did pathologists fail to diagnose early breast cancer?
After A 45-year-old woman underwent mammography in May 2008 at a local hospital, an oncologist noted a suspicious finding in the right breast. The patient had an incisional biopsy interpreted by Dr. A, a pathologist, and a core biopsy interpreted by Dr. B, another pathologist from the same diagnostic medical group. Both pathologists interpreted the mass as atypia, a benign abnormality.

In 2010, the patient went to a university medical center, where the mass was biopsied and the patient was found to have cancer. She underwent a right mastectomy.

PATIENT’S CLAIM The pathologists failed to diagnose her breast cancer at an early stage. Dr. A should have interpreted the 2008 incisional biopsy as malignant. A diagnosis in 2008 would have avoided the need for a mastectomy, allowing her to have a lumpectomy with chemotherapy.

DEFENDANTS’ DEFENSE The 2010 review of the 2008 data was an over-interpretation with hindsight bias; the diagnosis in 2008 was correct.  

VERDICT The case against the local hospital and Dr. B were dismissed. The matter continued against Dr. A and the diagnostic medical group. A California defense verdict was returned.

Brachial plexus injury occurs after admitting physician leaves
A woman sought prenatal care from her family practitioner (FP). The FP admitted the mother to a hospital for induction of labor at 38 weeks’ gestation with concerns of increased uric acid, possible gestational hypertension, and leaking amniotic fluid. Labor progressed and the mother began pushing about 4 pm. After 30 minutes, the FP attempted vacu­um extraction three times; the device popped off during one of the attempts.

The FP then left for a planned trip, and an ObGyn assumed her care. The ObGyn chose to allow the mother to rest. At 6 pm, the mother began to feel the urge to push. The ObGyn attempted vacu­um extraction. Shoulder dystocia was encountered, and McRoberts and corkscrew maneuvers were used to deliver the fetus.

The child has C5–C6 brachial plexus injury with scapular winging and internal shoulder rotation.

PARENTS’ CLAIM A cesarean delivery should have been performed. The ObGyn applied excessive lateral traction, leading to the injury.

DEFENDANTS’ DEFENSE The FP and ObGyn argued that a cesarean ­delivery was not indicated because the fetus was not in distress. Fetal heart-rate monitoring strips were reassuring. The ObGyn denied using excessive lateral traction when freeing the shoulder dystocia. 

VERDICT The hospital settled before trial for $300,000. An Illinois defense verdict was returned for the FP. The jury deadlocked as to the ObGyn’s negligence.

These cases were selected by the editors of OBG Management from Medical Malpractice Verdicts, Settlements & Experts, with permission of the editor, Lewis Laska (www.verdictslaska.com). The information available to the editors about the cases presented here is sometimes incomplete. Moreover, the cases may or may not have merit. Nevertheless, these cases represent the types of clinical situations that typically result in litigation and are meant to illustrate nationwide variation in jury verdicts and awards.

Clinical question: What are the characteristics of a large cohort of patients under observation status?

Background: The use of observation hospital services has increased significantly. The Centers for Medicare and Medicaid Services (CMS) defines observation status as a “well-defined set of specific, clinically appropriate services,” usually lasting <24 hours and exceeding 48 hours in “only rare and exceptional cases.”

Study design: Retrospective descriptive study.

Setting: University of Wisconsin Hospital and Clinics, a 566-bed tertiary academic medical center.

Synopsis: A total of 43,853 hospitalizations were reviewed during the study period. Of those, 4578 (10.4%) were observation. The mean observation LOS was 33.3 hours, which included 16.5% of patients with LOS >48 hours. Although chest pain was the top observation diagnosis, 1141 distinct observation diagnosis codes were found.

These findings illustrate a significant disparity between the CMS definition for observation stay and the description of observation patients in this cohort, despite using CMS-endorsed InterQual criteria to determine status. While the cost per encounter for observation care was less than inpatient care, reimbursement was insufficient to cover those reduced costs. Ultimately, the net loss of revenue per observation encounter was $331, compared to a net gain in revenue per inpatient encounter of $2,163. This operating loss for hospitals is coupled with the fact that some of this cost is being transferred to patients.

Bottom line: Definitions and reimbursement models for observation status warrant continued research and discussion in the context of our evolving healthcare climate.

Citation: Sheehy AM, Graf B, Gangireddy S, et al. Hospitalized but not admitted: characteristics of patients with “observation status” at an academic medical center [published online ahead of print July 8, 2013]. JAMA Intern Med.

Clinical question: What are the characteristics of a large cohort of patients under observation status?

Background: The use of observation hospital services has increased significantly. The Centers for Medicare and Medicaid Services (CMS) defines observation status as a “well-defined set of specific, clinically appropriate services,” usually lasting <24 hours and exceeding 48 hours in “only rare and exceptional cases.”

Study design: Retrospective descriptive study.

Setting: University of Wisconsin Hospital and Clinics, a 566-bed tertiary academic medical center.

Synopsis: A total of 43,853 hospitalizations were reviewed during the study period. Of those, 4578 (10.4%) were observation. The mean observation LOS was 33.3 hours, which included 16.5% of patients with LOS >48 hours. Although chest pain was the top observation diagnosis, 1141 distinct observation diagnosis codes were found.

These findings illustrate a significant disparity between the CMS definition for observation stay and the description of observation patients in this cohort, despite using CMS-endorsed InterQual criteria to determine status. While the cost per encounter for observation care was less than inpatient care, reimbursement was insufficient to cover those reduced costs. Ultimately, the net loss of revenue per observation encounter was $331, compared to a net gain in revenue per inpatient encounter of $2,163. This operating loss for hospitals is coupled with the fact that some of this cost is being transferred to patients.

Bottom line: Definitions and reimbursement models for observation status warrant continued research and discussion in the context of our evolving healthcare climate.

Citation: Sheehy AM, Graf B, Gangireddy S, et al. Hospitalized but not admitted: characteristics of patients with “observation status” at an academic medical center [published online ahead of print July 8, 2013]. JAMA Intern Med.

Clinical question: What are the characteristics of a large cohort of patients under observation status?

Background: The use of observation hospital services has increased significantly. The Centers for Medicare and Medicaid Services (CMS) defines observation status as a “well-defined set of specific, clinically appropriate services,” usually lasting <24 hours and exceeding 48 hours in “only rare and exceptional cases.”

Study design: Retrospective descriptive study.

Setting: University of Wisconsin Hospital and Clinics, a 566-bed tertiary academic medical center.

Synopsis: A total of 43,853 hospitalizations were reviewed during the study period. Of those, 4578 (10.4%) were observation. The mean observation LOS was 33.3 hours, which included 16.5% of patients with LOS >48 hours. Although chest pain was the top observation diagnosis, 1141 distinct observation diagnosis codes were found.

These findings illustrate a significant disparity between the CMS definition for observation stay and the description of observation patients in this cohort, despite using CMS-endorsed InterQual criteria to determine status. While the cost per encounter for observation care was less than inpatient care, reimbursement was insufficient to cover those reduced costs. Ultimately, the net loss of revenue per observation encounter was $331, compared to a net gain in revenue per inpatient encounter of $2,163. This operating loss for hospitals is coupled with the fact that some of this cost is being transferred to patients.

Bottom line: Definitions and reimbursement models for observation status warrant continued research and discussion in the context of our evolving healthcare climate.

Citation: Sheehy AM, Graf B, Gangireddy S, et al. Hospitalized but not admitted: characteristics of patients with “observation status” at an academic medical center [published online ahead of print July 8, 2013]. JAMA Intern Med.

Clinical question: Do programs that systematically provide smoking cessation support to admitted patients improve smoking cessation rates?

Background: Hospitalization is a good setting for initiation of smoking cessation. It is well known that conventional behavioral and pharmacotherapy interventions are effective. Intensive behavioral intervention provided to willing hospitalized patients is known to be useful; however, there is no established systematic delivery of these interventions.

Study design: Open, cluster-randomized, controlled trial.

Setting: Acute medical wards in a large teaching hospital in the United Kingdom.

Synopsis: More than 1,000 patients admitted between October 2010 and August 2011 were eligible for the study, of which 264 were included in the intervention and 229 in the usual care group (determination of smoking status and non-obligatory offer of cessation support). All of those in intervention received advice to quit smoking, compared to only 46% in the usual care group. Four-week smoking cessation was achieved by 38% of patients from the intervention group, compared to 17% from the usual care group. Secondary outcomes (use of behavioral cessation support, pharmacotherapy, and referral to and use of the local stop smoking service) were all significantly higher in the intervention group compared to the usual care group (P<0.001 in all cases).

This study shows that simple measures, when systematically delivered, are effective in initiating smoking cessation.

Bottom line: In-hospital systematic delivery of smoking cessation strategies is effective.

Citation: Murray RL, Leonardi-Bee J, Marsh J, et al. Systematic identification and treatment of smokers by hospital based cessation practitioners in a secondary care setting: cluster randomised controlled trial. BMJ. 2013;347:f4004.

Clinical question: Do programs that systematically provide smoking cessation support to admitted patients improve smoking cessation rates?

Background: Hospitalization is a good setting for initiation of smoking cessation. It is well known that conventional behavioral and pharmacotherapy interventions are effective. Intensive behavioral intervention provided to willing hospitalized patients is known to be useful; however, there is no established systematic delivery of these interventions.

Study design: Open, cluster-randomized, controlled trial.

Setting: Acute medical wards in a large teaching hospital in the United Kingdom.

Synopsis: More than 1,000 patients admitted between October 2010 and August 2011 were eligible for the study, of which 264 were included in the intervention and 229 in the usual care group (determination of smoking status and non-obligatory offer of cessation support). All of those in intervention received advice to quit smoking, compared to only 46% in the usual care group. Four-week smoking cessation was achieved by 38% of patients from the intervention group, compared to 17% from the usual care group. Secondary outcomes (use of behavioral cessation support, pharmacotherapy, and referral to and use of the local stop smoking service) were all significantly higher in the intervention group compared to the usual care group (P<0.001 in all cases).

This study shows that simple measures, when systematically delivered, are effective in initiating smoking cessation.

Bottom line: In-hospital systematic delivery of smoking cessation strategies is effective.

Citation: Murray RL, Leonardi-Bee J, Marsh J, et al. Systematic identification and treatment of smokers by hospital based cessation practitioners in a secondary care setting: cluster randomised controlled trial. BMJ. 2013;347:f4004.

Clinical question: Do programs that systematically provide smoking cessation support to admitted patients improve smoking cessation rates?

Background: Hospitalization is a good setting for initiation of smoking cessation. It is well known that conventional behavioral and pharmacotherapy interventions are effective. Intensive behavioral intervention provided to willing hospitalized patients is known to be useful; however, there is no established systematic delivery of these interventions.

Study design: Open, cluster-randomized, controlled trial.

Setting: Acute medical wards in a large teaching hospital in the United Kingdom.

Synopsis: More than 1,000 patients admitted between October 2010 and August 2011 were eligible for the study, of which 264 were included in the intervention and 229 in the usual care group (determination of smoking status and non-obligatory offer of cessation support). All of those in intervention received advice to quit smoking, compared to only 46% in the usual care group. Four-week smoking cessation was achieved by 38% of patients from the intervention group, compared to 17% from the usual care group. Secondary outcomes (use of behavioral cessation support, pharmacotherapy, and referral to and use of the local stop smoking service) were all significantly higher in the intervention group compared to the usual care group (P<0.001 in all cases).

This study shows that simple measures, when systematically delivered, are effective in initiating smoking cessation.

Bottom line: In-hospital systematic delivery of smoking cessation strategies is effective.

Citation: Murray RL, Leonardi-Bee J, Marsh J, et al. Systematic identification and treatment of smokers by hospital based cessation practitioners in a secondary care setting: cluster randomised controlled trial. BMJ. 2013;347:f4004.

Clinical question: What are physicians’ attitudes toward addressing healthcare costs and which strategies do they most enthusiastically support?

Background: Physicians are expected to take a lead role in containing healthcare costs, especially in the face of healthcare reform; however, their attitudes regarding this role are unknown.

Study design: Cross-sectional survey.

Setting: U.S. physicians randomly selected from the AMA master file.

Synopsis: Among 2,556 physicians who responded to the survey (response rate: 65%), most believed stakeholders other than physicians (e.g., lawyers, hospitals, insurers, pharmaceutical manufacturers, and patients) have a “major responsibility” for reducing healthcare costs. Most physicians were likely to support such quality initiatives as enhancing continuity of care and promoting chronic disease care coordination. Physicians were also enthusiastic with regard to expanding the use of electronic health records.

The majority of physicians expressed agreement about their responsibility to address healthcare costs by adhering to clinical guidelines, limiting unnecessary testing, and focusing on the individual patient’s best interest. However, a majority expressed limited enthusiasm for strategies that involved cost cutting to physicians, such as eliminating fee-for-service payment models, reducing compensation for the highest paid specialties, and allowing Medicare payment cuts to doctors.

Of note, in the multivariate model, physicians receiving salary-based compensation were more likely to be enthusiastic about eliminating fee-for-service.

Bottom line: Physicians expressed considerable enthusiasm for addressing healthcare costs and are in general agreement but are not enthusiastic about changes that involve physician payment cuts.

Citation: Tilburt JC, Wynia MK, Sheeler RD, et al. Views of US physicians about controlling health care costs. JAMA. 2013;310:380-388.

Clinical question: What are physicians’ attitudes toward addressing healthcare costs and which strategies do they most enthusiastically support?

Background: Physicians are expected to take a lead role in containing healthcare costs, especially in the face of healthcare reform; however, their attitudes regarding this role are unknown.

Study design: Cross-sectional survey.

Setting: U.S. physicians randomly selected from the AMA master file.

Synopsis: Among 2,556 physicians who responded to the survey (response rate: 65%), most believed stakeholders other than physicians (e.g., lawyers, hospitals, insurers, pharmaceutical manufacturers, and patients) have a “major responsibility” for reducing healthcare costs. Most physicians were likely to support such quality initiatives as enhancing continuity of care and promoting chronic disease care coordination. Physicians were also enthusiastic with regard to expanding the use of electronic health records.

The majority of physicians expressed agreement about their responsibility to address healthcare costs by adhering to clinical guidelines, limiting unnecessary testing, and focusing on the individual patient’s best interest. However, a majority expressed limited enthusiasm for strategies that involved cost cutting to physicians, such as eliminating fee-for-service payment models, reducing compensation for the highest paid specialties, and allowing Medicare payment cuts to doctors.

Of note, in the multivariate model, physicians receiving salary-based compensation were more likely to be enthusiastic about eliminating fee-for-service.

Bottom line: Physicians expressed considerable enthusiasm for addressing healthcare costs and are in general agreement but are not enthusiastic about changes that involve physician payment cuts.

Citation: Tilburt JC, Wynia MK, Sheeler RD, et al. Views of US physicians about controlling health care costs. JAMA. 2013;310:380-388.

Clinical question: What are physicians’ attitudes toward addressing healthcare costs and which strategies do they most enthusiastically support?

Background: Physicians are expected to take a lead role in containing healthcare costs, especially in the face of healthcare reform; however, their attitudes regarding this role are unknown.

Study design: Cross-sectional survey.

Setting: U.S. physicians randomly selected from the AMA master file.

Synopsis: Among 2,556 physicians who responded to the survey (response rate: 65%), most believed stakeholders other than physicians (e.g., lawyers, hospitals, insurers, pharmaceutical manufacturers, and patients) have a “major responsibility” for reducing healthcare costs. Most physicians were likely to support such quality initiatives as enhancing continuity of care and promoting chronic disease care coordination. Physicians were also enthusiastic with regard to expanding the use of electronic health records.

The majority of physicians expressed agreement about their responsibility to address healthcare costs by adhering to clinical guidelines, limiting unnecessary testing, and focusing on the individual patient’s best interest. However, a majority expressed limited enthusiasm for strategies that involved cost cutting to physicians, such as eliminating fee-for-service payment models, reducing compensation for the highest paid specialties, and allowing Medicare payment cuts to doctors.

Of note, in the multivariate model, physicians receiving salary-based compensation were more likely to be enthusiastic about eliminating fee-for-service.

Bottom line: Physicians expressed considerable enthusiasm for addressing healthcare costs and are in general agreement but are not enthusiastic about changes that involve physician payment cuts.

Citation: Tilburt JC, Wynia MK, Sheeler RD, et al. Views of US physicians about controlling health care costs. JAMA. 2013;310:380-388.

Let’s call them multi-site, hospital medicine group leaders, or just multi-site HMG leaders. Once rare, they’re now becoming common, and among the many people now holding this job are:

• Dr. Doug Apple at Spectrum Health Medical Group in Grand Rapids, Mich;
• Dr. Tierza Stephan at Allina Health in Minneapolis, Minn.;
• Dr. Darren Thomas at St. John Health System in Tulsa, Okla.;
• Dr. Thomas McIlraith at Dignity Health in Sacremento, Calif.; and
• Dr. Rohit Uppal at Ohio Health in Columbus, Ohio.

The career path that led to their current position usually follows a standard pattern. They are a successful leader of a single-site hospitalist program when, through merger or acquisition, their hospital becomes part of a larger system. The executives responsible for this larger system—typically four to eight hospitals—realize that the HMGs serving each hospital in the system vary significantly in their cost, productivity, and performance on things like patient satisfaction and quality metrics. So they tap the leader of the largest (or best performing) HMG in the system to be system-wide hospitalist medical director. They nearly always choose an internal candidate rather than recruiting from outside, which brings some level of cohesion in operations and performance improvement.

Multi-Site Challenges

This is not an easy job. After all, it isn’t easy to serve as lead hospitalist for a single-site group, so it makes sense that the difficulties and challenges only increase when trying to manage groups at different locations.

The new multi-site HMG leader is busy from the first day on the job. The HMG at one site is short on staffing and needs help right away, patient satisfaction scores are poor at the next site, and so on. Although putting out these fires is important, the new leader also needs to think about how to accomplish a broader mission: ensuring greater cohesion across all groups.

I don’t think there is a secret recipe to ensure success in such a job. Prerequisites include the usual leadership skills, such as patience, good listening, and diplomacy (collectively, one’s EQ, or emotional quotient), along with lots of energy and decisive action. But there are a number of practical matters to address that can influence the level of success.

Cohesion vs. Independence

In most situations, a health system will benefit from some common operating principles across all the HMGs who serve its hospitals. For example, it usually makes sense for any portion of compensation tied to performance (e.g., a bonus) to be based on the same performance domains at all sites. For example, if metrics such as the observed-to-expected mortality ratio (O:E ratio) and patient satisfaction are important to the hospital system, then they should probably influence hospitalist compensation at every site. However, it might be reasonable to target a level of performance for any given domain higher at one site than at another.

Among the many things that should be the same across all sites are operational practices: charge capture, coding audits, performance reviews, dashboard elements and format, and credentialing for new hires. Other things, like individual hospitalist productivity, work schedule, and method and amount of compensation, should vary by site because of the unique attributes of the work at each place.

Fixed Locale vs. Rotations

The travel time between hospitals and the value of extensive experience in the details of how each particular hospital operates usually make it most practical for each individual hospitalist to work nearly all of the time at one hospital. But every doctor should be credentialed at every other hospital in the system so that he can cover a staffing shortage elsewhere.

And, hospitalists hired to work primarily at one of the small hospitals would probably benefit from working at the large referral hospital for the first few weeks of employment. This seems like a great way for them to become familiar with the people and operations at the big hospital, especially since they will be transferring patients there periodically.

Governance

Some mix of central control vs. local autonomy in decision making at each site is important for success. There aren’t any clear guidelines here, but providing the local doctors at each location with the ability to make their own decisions on things like work schedule will contribute to their sense of ownership of the practice. That feeling is valuable and supports good performance.

My bias is that each site in a practice could adopt the same “internal governance” guidelines, or rules by which they make decisions when unable to reach consensus (see “Play by the Rules,” December 2007, for sample guidelines.)

There should also be some form of “umbrella” governance structure in which the local site leaders meet regularly with the multi-site HMG leader.

Patient Transfers

One reason hospitals merge into a single system is the hope that they can more effectively meet the needs of all patients in the system’s hospitals. A typical configuration is several small hospitals, along with a single, large, referral center, to which patients are sent if the small hospital can’t meet their needs. The hope is that if all the hospitals are in the same system, the process of transfer can be smoother and more efficient.

A large portion—maybe even the majority—of all transfers in the system will be between a hospitalist at the small hospital and a partner hospitalist at the large hospital. Things will work best when the transferring and receiving hospitalists know something about the strengths and weaknesses of each other’s hospitals. And, you only know one another reasonably well from working together on committees or being on clinical service together at the same hospital, as well as social functions that include hospitalists from all sites.

Therefore, the multi-site HMG leader should think deliberately about how to ensure that the hospitalists interact with one another often, and not just when a transfer needs to take place.

A written agreement outlining the criteria for an appropriate transfer can be helpful. But such agreements cannot address all the situations that will arise, so good relationships between doctors at the different sites are invaluable and worth taking the time to cultivate.

Communication

Like the five people I mentioned above, anyone holding the position of multi-site HMG leader would benefit from talking with others in the same position. I’m working to arrange some forum for such communication, potentially including an in-person meeting at HM14 in Las Vegas in March (www.hospitalmedicine2014.org). If you are a health system-employed, multi-site HMG leader and want to be part of this conversation, I would love to hear from you.

Dr. Nelson has been a practicing hospitalist since 1988. He is co-founder and past president of SHM, and principal in Nelson Flores Hospital Medicine Consultants. He is co-director for SHM’s “Best Practices in Managing a Hospital Medicine Program” course. Write to him at [email protected].

Let’s call them multi-site, hospital medicine group leaders, or just multi-site HMG leaders. Once rare, they’re now becoming common, and among the many people now holding this job are:

• Dr. Doug Apple at Spectrum Health Medical Group in Grand Rapids, Mich;
• Dr. Tierza Stephan at Allina Health in Minneapolis, Minn.;
• Dr. Darren Thomas at St. John Health System in Tulsa, Okla.;
• Dr. Thomas McIlraith at Dignity Health in Sacremento, Calif.; and
• Dr. Rohit Uppal at Ohio Health in Columbus, Ohio.

The career path that led to their current position usually follows a standard pattern. They are a successful leader of a single-site hospitalist program when, through merger or acquisition, their hospital becomes part of a larger system. The executives responsible for this larger system—typically four to eight hospitals—realize that the HMGs serving each hospital in the system vary significantly in their cost, productivity, and performance on things like patient satisfaction and quality metrics. So they tap the leader of the largest (or best performing) HMG in the system to be system-wide hospitalist medical director. They nearly always choose an internal candidate rather than recruiting from outside, which brings some level of cohesion in operations and performance improvement.

Multi-Site Challenges

This is not an easy job. After all, it isn’t easy to serve as lead hospitalist for a single-site group, so it makes sense that the difficulties and challenges only increase when trying to manage groups at different locations.

The new multi-site HMG leader is busy from the first day on the job. The HMG at one site is short on staffing and needs help right away, patient satisfaction scores are poor at the next site, and so on. Although putting out these fires is important, the new leader also needs to think about how to accomplish a broader mission: ensuring greater cohesion across all groups.

I don’t think there is a secret recipe to ensure success in such a job. Prerequisites include the usual leadership skills, such as patience, good listening, and diplomacy (collectively, one’s EQ, or emotional quotient), along with lots of energy and decisive action. But there are a number of practical matters to address that can influence the level of success.

Cohesion vs. Independence

In most situations, a health system will benefit from some common operating principles across all the HMGs who serve its hospitals. For example, it usually makes sense for any portion of compensation tied to performance (e.g., a bonus) to be based on the same performance domains at all sites. For example, if metrics such as the observed-to-expected mortality ratio (O:E ratio) and patient satisfaction are important to the hospital system, then they should probably influence hospitalist compensation at every site. However, it might be reasonable to target a level of performance for any given domain higher at one site than at another.

Among the many things that should be the same across all sites are operational practices: charge capture, coding audits, performance reviews, dashboard elements and format, and credentialing for new hires. Other things, like individual hospitalist productivity, work schedule, and method and amount of compensation, should vary by site because of the unique attributes of the work at each place.

Fixed Locale vs. Rotations

The travel time between hospitals and the value of extensive experience in the details of how each particular hospital operates usually make it most practical for each individual hospitalist to work nearly all of the time at one hospital. But every doctor should be credentialed at every other hospital in the system so that he can cover a staffing shortage elsewhere.

And, hospitalists hired to work primarily at one of the small hospitals would probably benefit from working at the large referral hospital for the first few weeks of employment. This seems like a great way for them to become familiar with the people and operations at the big hospital, especially since they will be transferring patients there periodically.

Governance

Some mix of central control vs. local autonomy in decision making at each site is important for success. There aren’t any clear guidelines here, but providing the local doctors at each location with the ability to make their own decisions on things like work schedule will contribute to their sense of ownership of the practice. That feeling is valuable and supports good performance.

My bias is that each site in a practice could adopt the same “internal governance” guidelines, or rules by which they make decisions when unable to reach consensus (see “Play by the Rules,” December 2007, for sample guidelines.)

There should also be some form of “umbrella” governance structure in which the local site leaders meet regularly with the multi-site HMG leader.

Patient Transfers

One reason hospitals merge into a single system is the hope that they can more effectively meet the needs of all patients in the system’s hospitals. A typical configuration is several small hospitals, along with a single, large, referral center, to which patients are sent if the small hospital can’t meet their needs. The hope is that if all the hospitals are in the same system, the process of transfer can be smoother and more efficient.

A large portion—maybe even the majority—of all transfers in the system will be between a hospitalist at the small hospital and a partner hospitalist at the large hospital. Things will work best when the transferring and receiving hospitalists know something about the strengths and weaknesses of each other’s hospitals. And, you only know one another reasonably well from working together on committees or being on clinical service together at the same hospital, as well as social functions that include hospitalists from all sites.

Therefore, the multi-site HMG leader should think deliberately about how to ensure that the hospitalists interact with one another often, and not just when a transfer needs to take place.

A written agreement outlining the criteria for an appropriate transfer can be helpful. But such agreements cannot address all the situations that will arise, so good relationships between doctors at the different sites are invaluable and worth taking the time to cultivate.

Communication

Like the five people I mentioned above, anyone holding the position of multi-site HMG leader would benefit from talking with others in the same position. I’m working to arrange some forum for such communication, potentially including an in-person meeting at HM14 in Las Vegas in March (www.hospitalmedicine2014.org). If you are a health system-employed, multi-site HMG leader and want to be part of this conversation, I would love to hear from you.

Dr. Nelson has been a practicing hospitalist since 1988. He is co-founder and past president of SHM, and principal in Nelson Flores Hospital Medicine Consultants. He is co-director for SHM’s “Best Practices in Managing a Hospital Medicine Program” course. Write to him at [email protected].

Let’s call them multi-site, hospital medicine group leaders, or just multi-site HMG leaders. Once rare, they’re now becoming common, and among the many people now holding this job are:

• Dr. Doug Apple at Spectrum Health Medical Group in Grand Rapids, Mich;
• Dr. Tierza Stephan at Allina Health in Minneapolis, Minn.;
• Dr. Darren Thomas at St. John Health System in Tulsa, Okla.;
• Dr. Thomas McIlraith at Dignity Health in Sacremento, Calif.; and
• Dr. Rohit Uppal at Ohio Health in Columbus, Ohio.

The career path that led to their current position usually follows a standard pattern. They are a successful leader of a single-site hospitalist program when, through merger or acquisition, their hospital becomes part of a larger system. The executives responsible for this larger system—typically four to eight hospitals—realize that the HMGs serving each hospital in the system vary significantly in their cost, productivity, and performance on things like patient satisfaction and quality metrics. So they tap the leader of the largest (or best performing) HMG in the system to be system-wide hospitalist medical director. They nearly always choose an internal candidate rather than recruiting from outside, which brings some level of cohesion in operations and performance improvement.

Multi-Site Challenges

This is not an easy job. After all, it isn’t easy to serve as lead hospitalist for a single-site group, so it makes sense that the difficulties and challenges only increase when trying to manage groups at different locations.

The new multi-site HMG leader is busy from the first day on the job. The HMG at one site is short on staffing and needs help right away, patient satisfaction scores are poor at the next site, and so on. Although putting out these fires is important, the new leader also needs to think about how to accomplish a broader mission: ensuring greater cohesion across all groups.

I don’t think there is a secret recipe to ensure success in such a job. Prerequisites include the usual leadership skills, such as patience, good listening, and diplomacy (collectively, one’s EQ, or emotional quotient), along with lots of energy and decisive action. But there are a number of practical matters to address that can influence the level of success.

Cohesion vs. Independence

In most situations, a health system will benefit from some common operating principles across all the HMGs who serve its hospitals. For example, it usually makes sense for any portion of compensation tied to performance (e.g., a bonus) to be based on the same performance domains at all sites. For example, if metrics such as the observed-to-expected mortality ratio (O:E ratio) and patient satisfaction are important to the hospital system, then they should probably influence hospitalist compensation at every site. However, it might be reasonable to target a level of performance for any given domain higher at one site than at another.

Among the many things that should be the same across all sites are operational practices: charge capture, coding audits, performance reviews, dashboard elements and format, and credentialing for new hires. Other things, like individual hospitalist productivity, work schedule, and method and amount of compensation, should vary by site because of the unique attributes of the work at each place.

Fixed Locale vs. Rotations

The travel time between hospitals and the value of extensive experience in the details of how each particular hospital operates usually make it most practical for each individual hospitalist to work nearly all of the time at one hospital. But every doctor should be credentialed at every other hospital in the system so that he can cover a staffing shortage elsewhere.

And, hospitalists hired to work primarily at one of the small hospitals would probably benefit from working at the large referral hospital for the first few weeks of employment. This seems like a great way for them to become familiar with the people and operations at the big hospital, especially since they will be transferring patients there periodically.

Governance

Some mix of central control vs. local autonomy in decision making at each site is important for success. There aren’t any clear guidelines here, but providing the local doctors at each location with the ability to make their own decisions on things like work schedule will contribute to their sense of ownership of the practice. That feeling is valuable and supports good performance.

My bias is that each site in a practice could adopt the same “internal governance” guidelines, or rules by which they make decisions when unable to reach consensus (see “Play by the Rules,” December 2007, for sample guidelines.)

There should also be some form of “umbrella” governance structure in which the local site leaders meet regularly with the multi-site HMG leader.

Patient Transfers

One reason hospitals merge into a single system is the hope that they can more effectively meet the needs of all patients in the system’s hospitals. A typical configuration is several small hospitals, along with a single, large, referral center, to which patients are sent if the small hospital can’t meet their needs. The hope is that if all the hospitals are in the same system, the process of transfer can be smoother and more efficient.

A large portion—maybe even the majority—of all transfers in the system will be between a hospitalist at the small hospital and a partner hospitalist at the large hospital. Things will work best when the transferring and receiving hospitalists know something about the strengths and weaknesses of each other’s hospitals. And, you only know one another reasonably well from working together on committees or being on clinical service together at the same hospital, as well as social functions that include hospitalists from all sites.

Therefore, the multi-site HMG leader should think deliberately about how to ensure that the hospitalists interact with one another often, and not just when a transfer needs to take place.

A written agreement outlining the criteria for an appropriate transfer can be helpful. But such agreements cannot address all the situations that will arise, so good relationships between doctors at the different sites are invaluable and worth taking the time to cultivate.

Communication

Like the five people I mentioned above, anyone holding the position of multi-site HMG leader would benefit from talking with others in the same position. I’m working to arrange some forum for such communication, potentially including an in-person meeting at HM14 in Las Vegas in March (www.hospitalmedicine2014.org). If you are a health system-employed, multi-site HMG leader and want to be part of this conversation, I would love to hear from you.

Dr. Nelson has been a practicing hospitalist since 1988. He is co-founder and past president of SHM, and principal in Nelson Flores Hospital Medicine Consultants. He is co-director for SHM’s “Best Practices in Managing a Hospital Medicine Program” course. Write to him at [email protected].

Don Berwick, MD, former president and CEO of the Institute for Healthcare Improvement (IHI) and former administrator for the Centers for Medicare and Medicaid Services (CMS), recently consulted with the National Health Service (NHS) on how to devise and implement a safer and better healthcare system for England. His services were solicited due to a number of high-profile scandals involving neglect in hospitals. His team’s work resulted in a report entitled “A Promise to Learn – A Commitment to Act: Improving the Safety of Patients in England.”¹ The purpose of the consultative visit and resulting series of recommendations was to identify and recommend solutions to ailments and limitations in the current NHS.

Many of the “current state” ailments outlined in Dr. Berwick’s report would not sound terribly novel or unfamiliar to most U.S. healthcare systems. The report listed problems with:

• Systems-procedures-conditions-environments-constraints that lead people to make bad or incorrect decisions;
• Incorrect priorities;
• Not heeding warning signals about patient safety;
• Diffusion of responsibility;
• Lack of support for continuous improvement; and
• Fear, which is “toxic to both safety and improvement.”

Dr. Berwick and his team made a number of recommendations to reshape priorities and resources, enhance the safety of the system, and rebuild the confidence of its customers (e.g., patients and caregivers).

The consultant group’s core message was simple and inspiring:

“The NHS in England can become the safest healthcare system in the world. It will require unified will, optimism, investment, and change. Everyone can and should help. And, it will require a culture firmly rooted in continual improvement. Rules, standards, regulations, and enforcement have a place in the pursuit of quality, but they pale in potential compared to the power of pervasive and constant learning.”

To achieve improvement, Dr. Berwick’s team recommended 10 guiding principles. Similar to The 10 Commandments, they offer a way of thinking, acting, and living—to make the healthcare industry a better place. These healthcare 10 commandments include the following:

1. “The NHS should continually and forever reduce patient harm by embracing wholeheartedly an ethic of learning.” While we should all aspire to zero harm, the reality is that getting there will be a long and difficult goal, more than likely a goal of continual reduction. Defining harm is also more difficult than looking just at what meets the eye; because the qualitative “you know it when you see it” will likely never be embraced widely, we are left with quantitative and imperfect measures, such as hospital-acquired conditions (HACs) and patient safety indicators (PSIs). Despite the imperfection of current measures, the goal for continual reduction is laudable and necessary.
2. “All leaders concerned with NHS healthcare—political, regulatory, governance, executive, clinical, and advocacy—should place quality of care in general, and patient safety in particular, at the top of their priorities for investment, inquiry, improvement, regular reporting, encouragement, and support.” As with anything, leadership sets the vision, mission, and values of an organization or system. Leadership will have to commit to placing patient safety at the top of the priority list, without sacrificing other priorities.

1. “Patients and their caregivers should be present, powerful, and involved at all levels of healthcare organizations, from the wards to the boards of trusts.” This directive is certainly ideal, but, realistically, it will take a while to develop a level of comfort from both the patients and the providers, because both are much more used to operating in parallel, with intermittent intersections. Involving patients in all organizational decision-making, and including the boards of trustees, will be prerequisite to true patient-caregiver-centered care.
2. “Government, Health Education England, and NHS England should assure that sufficient staff are available to meet the NHS’ needs now and in the future. Healthcare organizations should ensure staff are present in appropriate numbers to provide safe care at all times and are well-supported." All healthcare organizations should be on a relentless pursuit to match workload and intensity to staffing, pursue work standardization and efficiency, and match work to human intellect. These are the founding tenets of Lean and Six Sigma and should be pursued for all disciplines, both clinical and non-clinical.
3. “Mastery of quality and patient-safety sciences and practices should be part of initial preparation and lifelong education of all healthcare professionals, including managers and executives.” The U.S. has made great strides in incorporating at least a basic curriculum of quality and safety for most healthcare professionals, but we need to move the current level of understanding to the next level. We need to ensure that all healthcare professionals have at least a basic understanding of the fundamental principles.
4. “The NHS should become a learning organization. Its leaders should create and support the capability for learning, and therefore change, at scale within the NHS.” Healthcare organizations should not just be willing to learn from individual and system opportunities; they should be eager to learn. Quality and safety missions should uniformly extend into educational and research missions in all organizations, to enhance learning opportunities and create best practice.
5. “Transparency should be complete, timely, and unequivocal. All data on quality and safety, whether assembled by government, organizations, or professional societies, should be shared in a timely fashion with all parties who want it, including, in accessible form, with the public.” Many healthcare organizations equate transparency with marketing, where they tout their fanciest technology or latest innovation. And many also subscribe to the theory “if you’re gonna go bare, you better be buff” and only widely disseminate those metrics that make them appear superior. We all need to be more transparent across the board, because going “bare” can actually stimulate improvements more quickly and reliably than they would otherwise occur. Organizational metrics really should not belong to the organization; they should belong to the patients who created the metrics. As such, full transparency of organizational performance (on all the domains of quality) should be an organizational and patient expectation.
6. “All organizations should seek out the patient and caregiver voice as an essential asset in monitoring the safety and quality of care.” Organizations should seek out patient-caregiver feedback and should be eager to learn from their words. Most other industries regularly and routinely seek out customer feedback to improve upon their products and services; some even pay customers for a chance to hear what they have to say. Too often, the theme from disgruntled patients is that no one is listening to them.
7. “Supervisory and regulatory systems should be simple and clear. They should avoid diffusion of responsibility. They should be respectful of the goodwill and sound intention of the vast majority of staff. All incentives should point in the same direction.”
8. U.S. regulatory agencies have an incredible amount of simplification to accomplish, along with a need to align incentives for the betterment of the patient. “We support responsive regulation of organizations, with a hierarchy of responses. Recourse to criminal sanctions should be extremely rare, and should function primarily as a deterrent to willful or reckless neglect or mistreatment.”

This commandment acknowledges the rarity of willful misconduct, by organizations and providers, and calls for a simplification of the governance needed for such rare events and situations.

In Sum As with The 10 Commandments, these guiding principles can help transform the way we in the healthcare industry think, act, and live—and put us on the road to making it a better place.

Reference

1. National Advisory Group on the Safety of Patients in England. A promise to learn a commitment to act: improving the safety of patients in England. Available at: https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/226703/Berwick_Report.pdf. Accessed September 21, 2013.

Dr. Scheurer is a hospitalist and chief quality officer at the Medical University of South Carolina in Charleston. She is physician editor of The Hospitalist. Email her at [email protected].

Don Berwick, MD, former president and CEO of the Institute for Healthcare Improvement (IHI) and former administrator for the Centers for Medicare and Medicaid Services (CMS), recently consulted with the National Health Service (NHS) on how to devise and implement a safer and better healthcare system for England. His services were solicited due to a number of high-profile scandals involving neglect in hospitals. His team’s work resulted in a report entitled “A Promise to Learn – A Commitment to Act: Improving the Safety of Patients in England.”¹ The purpose of the consultative visit and resulting series of recommendations was to identify and recommend solutions to ailments and limitations in the current NHS.

Many of the “current state” ailments outlined in Dr. Berwick’s report would not sound terribly novel or unfamiliar to most U.S. healthcare systems. The report listed problems with:

• Systems-procedures-conditions-environments-constraints that lead people to make bad or incorrect decisions;
• Incorrect priorities;
• Not heeding warning signals about patient safety;
• Diffusion of responsibility;
• Lack of support for continuous improvement; and
• Fear, which is “toxic to both safety and improvement.”

Dr. Berwick and his team made a number of recommendations to reshape priorities and resources, enhance the safety of the system, and rebuild the confidence of its customers (e.g., patients and caregivers).

The consultant group’s core message was simple and inspiring:

“The NHS in England can become the safest healthcare system in the world. It will require unified will, optimism, investment, and change. Everyone can and should help. And, it will require a culture firmly rooted in continual improvement. Rules, standards, regulations, and enforcement have a place in the pursuit of quality, but they pale in potential compared to the power of pervasive and constant learning.”

To achieve improvement, Dr. Berwick’s team recommended 10 guiding principles. Similar to The 10 Commandments, they offer a way of thinking, acting, and living—to make the healthcare industry a better place. These healthcare 10 commandments include the following:

1. “The NHS should continually and forever reduce patient harm by embracing wholeheartedly an ethic of learning.” While we should all aspire to zero harm, the reality is that getting there will be a long and difficult goal, more than likely a goal of continual reduction. Defining harm is also more difficult than looking just at what meets the eye; because the qualitative “you know it when you see it” will likely never be embraced widely, we are left with quantitative and imperfect measures, such as hospital-acquired conditions (HACs) and patient safety indicators (PSIs). Despite the imperfection of current measures, the goal for continual reduction is laudable and necessary.
2. “All leaders concerned with NHS healthcare—political, regulatory, governance, executive, clinical, and advocacy—should place quality of care in general, and patient safety in particular, at the top of their priorities for investment, inquiry, improvement, regular reporting, encouragement, and support.” As with anything, leadership sets the vision, mission, and values of an organization or system. Leadership will have to commit to placing patient safety at the top of the priority list, without sacrificing other priorities.

1. “Patients and their caregivers should be present, powerful, and involved at all levels of healthcare organizations, from the wards to the boards of trusts.” This directive is certainly ideal, but, realistically, it will take a while to develop a level of comfort from both the patients and the providers, because both are much more used to operating in parallel, with intermittent intersections. Involving patients in all organizational decision-making, and including the boards of trustees, will be prerequisite to true patient-caregiver-centered care.
2. “Government, Health Education England, and NHS England should assure that sufficient staff are available to meet the NHS’ needs now and in the future. Healthcare organizations should ensure staff are present in appropriate numbers to provide safe care at all times and are well-supported." All healthcare organizations should be on a relentless pursuit to match workload and intensity to staffing, pursue work standardization and efficiency, and match work to human intellect. These are the founding tenets of Lean and Six Sigma and should be pursued for all disciplines, both clinical and non-clinical.
3. “Mastery of quality and patient-safety sciences and practices should be part of initial preparation and lifelong education of all healthcare professionals, including managers and executives.” The U.S. has made great strides in incorporating at least a basic curriculum of quality and safety for most healthcare professionals, but we need to move the current level of understanding to the next level. We need to ensure that all healthcare professionals have at least a basic understanding of the fundamental principles.
4. “The NHS should become a learning organization. Its leaders should create and support the capability for learning, and therefore change, at scale within the NHS.” Healthcare organizations should not just be willing to learn from individual and system opportunities; they should be eager to learn. Quality and safety missions should uniformly extend into educational and research missions in all organizations, to enhance learning opportunities and create best practice.
5. “Transparency should be complete, timely, and unequivocal. All data on quality and safety, whether assembled by government, organizations, or professional societies, should be shared in a timely fashion with all parties who want it, including, in accessible form, with the public.” Many healthcare organizations equate transparency with marketing, where they tout their fanciest technology or latest innovation. And many also subscribe to the theory “if you’re gonna go bare, you better be buff” and only widely disseminate those metrics that make them appear superior. We all need to be more transparent across the board, because going “bare” can actually stimulate improvements more quickly and reliably than they would otherwise occur. Organizational metrics really should not belong to the organization; they should belong to the patients who created the metrics. As such, full transparency of organizational performance (on all the domains of quality) should be an organizational and patient expectation.
6. “All organizations should seek out the patient and caregiver voice as an essential asset in monitoring the safety and quality of care.” Organizations should seek out patient-caregiver feedback and should be eager to learn from their words. Most other industries regularly and routinely seek out customer feedback to improve upon their products and services; some even pay customers for a chance to hear what they have to say. Too often, the theme from disgruntled patients is that no one is listening to them.
7. “Supervisory and regulatory systems should be simple and clear. They should avoid diffusion of responsibility. They should be respectful of the goodwill and sound intention of the vast majority of staff. All incentives should point in the same direction.”
8. U.S. regulatory agencies have an incredible amount of simplification to accomplish, along with a need to align incentives for the betterment of the patient. “We support responsive regulation of organizations, with a hierarchy of responses. Recourse to criminal sanctions should be extremely rare, and should function primarily as a deterrent to willful or reckless neglect or mistreatment.”

This commandment acknowledges the rarity of willful misconduct, by organizations and providers, and calls for a simplification of the governance needed for such rare events and situations.

In Sum As with The 10 Commandments, these guiding principles can help transform the way we in the healthcare industry think, act, and live—and put us on the road to making it a better place.

Reference

1. National Advisory Group on the Safety of Patients in England. A promise to learn a commitment to act: improving the safety of patients in England. Available at: https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/226703/Berwick_Report.pdf. Accessed September 21, 2013.

Dr. Scheurer is a hospitalist and chief quality officer at the Medical University of South Carolina in Charleston. She is physician editor of The Hospitalist. Email her at [email protected].

Don Berwick, MD, former president and CEO of the Institute for Healthcare Improvement (IHI) and former administrator for the Centers for Medicare and Medicaid Services (CMS), recently consulted with the National Health Service (NHS) on how to devise and implement a safer and better healthcare system for England. His services were solicited due to a number of high-profile scandals involving neglect in hospitals. His team’s work resulted in a report entitled “A Promise to Learn – A Commitment to Act: Improving the Safety of Patients in England.”¹ The purpose of the consultative visit and resulting series of recommendations was to identify and recommend solutions to ailments and limitations in the current NHS.

Many of the “current state” ailments outlined in Dr. Berwick’s report would not sound terribly novel or unfamiliar to most U.S. healthcare systems. The report listed problems with:

• Systems-procedures-conditions-environments-constraints that lead people to make bad or incorrect decisions;
• Incorrect priorities;
• Not heeding warning signals about patient safety;
• Diffusion of responsibility;
• Lack of support for continuous improvement; and
• Fear, which is “toxic to both safety and improvement.”

Dr. Berwick and his team made a number of recommendations to reshape priorities and resources, enhance the safety of the system, and rebuild the confidence of its customers (e.g., patients and caregivers).

The consultant group’s core message was simple and inspiring:

“The NHS in England can become the safest healthcare system in the world. It will require unified will, optimism, investment, and change. Everyone can and should help. And, it will require a culture firmly rooted in continual improvement. Rules, standards, regulations, and enforcement have a place in the pursuit of quality, but they pale in potential compared to the power of pervasive and constant learning.”

To achieve improvement, Dr. Berwick’s team recommended 10 guiding principles. Similar to The 10 Commandments, they offer a way of thinking, acting, and living—to make the healthcare industry a better place. These healthcare 10 commandments include the following:

1. “The NHS should continually and forever reduce patient harm by embracing wholeheartedly an ethic of learning.” While we should all aspire to zero harm, the reality is that getting there will be a long and difficult goal, more than likely a goal of continual reduction. Defining harm is also more difficult than looking just at what meets the eye; because the qualitative “you know it when you see it” will likely never be embraced widely, we are left with quantitative and imperfect measures, such as hospital-acquired conditions (HACs) and patient safety indicators (PSIs). Despite the imperfection of current measures, the goal for continual reduction is laudable and necessary.
2. “All leaders concerned with NHS healthcare—political, regulatory, governance, executive, clinical, and advocacy—should place quality of care in general, and patient safety in particular, at the top of their priorities for investment, inquiry, improvement, regular reporting, encouragement, and support.” As with anything, leadership sets the vision, mission, and values of an organization or system. Leadership will have to commit to placing patient safety at the top of the priority list, without sacrificing other priorities.

1. “Patients and their caregivers should be present, powerful, and involved at all levels of healthcare organizations, from the wards to the boards of trusts.” This directive is certainly ideal, but, realistically, it will take a while to develop a level of comfort from both the patients and the providers, because both are much more used to operating in parallel, with intermittent intersections. Involving patients in all organizational decision-making, and including the boards of trustees, will be prerequisite to true patient-caregiver-centered care.
2. “Government, Health Education England, and NHS England should assure that sufficient staff are available to meet the NHS’ needs now and in the future. Healthcare organizations should ensure staff are present in appropriate numbers to provide safe care at all times and are well-supported." All healthcare organizations should be on a relentless pursuit to match workload and intensity to staffing, pursue work standardization and efficiency, and match work to human intellect. These are the founding tenets of Lean and Six Sigma and should be pursued for all disciplines, both clinical and non-clinical.
3. “Mastery of quality and patient-safety sciences and practices should be part of initial preparation and lifelong education of all healthcare professionals, including managers and executives.” The U.S. has made great strides in incorporating at least a basic curriculum of quality and safety for most healthcare professionals, but we need to move the current level of understanding to the next level. We need to ensure that all healthcare professionals have at least a basic understanding of the fundamental principles.
4. “The NHS should become a learning organization. Its leaders should create and support the capability for learning, and therefore change, at scale within the NHS.” Healthcare organizations should not just be willing to learn from individual and system opportunities; they should be eager to learn. Quality and safety missions should uniformly extend into educational and research missions in all organizations, to enhance learning opportunities and create best practice.
5. “Transparency should be complete, timely, and unequivocal. All data on quality and safety, whether assembled by government, organizations, or professional societies, should be shared in a timely fashion with all parties who want it, including, in accessible form, with the public.” Many healthcare organizations equate transparency with marketing, where they tout their fanciest technology or latest innovation. And many also subscribe to the theory “if you’re gonna go bare, you better be buff” and only widely disseminate those metrics that make them appear superior. We all need to be more transparent across the board, because going “bare” can actually stimulate improvements more quickly and reliably than they would otherwise occur. Organizational metrics really should not belong to the organization; they should belong to the patients who created the metrics. As such, full transparency of organizational performance (on all the domains of quality) should be an organizational and patient expectation.
6. “All organizations should seek out the patient and caregiver voice as an essential asset in monitoring the safety and quality of care.” Organizations should seek out patient-caregiver feedback and should be eager to learn from their words. Most other industries regularly and routinely seek out customer feedback to improve upon their products and services; some even pay customers for a chance to hear what they have to say. Too often, the theme from disgruntled patients is that no one is listening to them.
7. “Supervisory and regulatory systems should be simple and clear. They should avoid diffusion of responsibility. They should be respectful of the goodwill and sound intention of the vast majority of staff. All incentives should point in the same direction.”
8. U.S. regulatory agencies have an incredible amount of simplification to accomplish, along with a need to align incentives for the betterment of the patient. “We support responsive regulation of organizations, with a hierarchy of responses. Recourse to criminal sanctions should be extremely rare, and should function primarily as a deterrent to willful or reckless neglect or mistreatment.”

This commandment acknowledges the rarity of willful misconduct, by organizations and providers, and calls for a simplification of the governance needed for such rare events and situations.

In Sum As with The 10 Commandments, these guiding principles can help transform the way we in the healthcare industry think, act, and live—and put us on the road to making it a better place.

Reference

1. National Advisory Group on the Safety of Patients in England. A promise to learn a commitment to act: improving the safety of patients in England. Available at: https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/226703/Berwick_Report.pdf. Accessed September 21, 2013.

Dr. Scheurer is a hospitalist and chief quality officer at the Medical University of South Carolina in Charleston. She is physician editor of The Hospitalist. Email her at [email protected].