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Performance Disconnect: Measures Don’t Improve Hospitals’ Readmissions Experience
Two recent studies have reached the same surprising conclusion: Adherence to national quality and performance guidelines does not translate into reduced readmissions rates.
Sula Mazimba, MD, MPH, and colleagues at Kettering Medical Center in Kettering, Ohio, focused on congestive heart failure (CHF) patients, documenting compliance with four core CHF performance measures at discharge and subsequent 30-day readmissions. Only one measure-assessment of left ventricular function-had a significant association with readmissions.
A second study published the same month looked at a wider range of diagnoses in a Medicare population at more than 2,000 hospitals nationwide. That study reached similar conclusions about the disconnect between hospitals that followed Hospital Compare process quality measures and their readmission rates.
Dr. Mazimba says hospitalists and other physicians involved in quality improvement (QI) should be more involved in defining quality measures that reflect quality of care for their patients.
“We should be looking for parameters that have a higher yield for outcomes, such as preventing readmissions,” he says, encouraging better symptom management before the CHF patient is hospitalized and enhanced coordination of care after discharge.
Alpesh Amin, MD, MBA, SFHM, professor and chair of the department of medicine and executive director of the hospitalist program at the University of California at Irvine, says the findings are important, but he adds that the core quality measures studied were never designed to address readmissions.
“The challenge is to find a way to connect the dots between the core measures and readmissions,” he says.
Learn more about the four "core" heart failure quality measures for hospitals by visiting the Resource Rooms on the SHM website, or check out this 80-page implementation guide, “Improving Heart Failure Care for Hospitalized Patients [PDF],” also available on SHM’s website.
Read The Hospitalist columnist Win Whitcomb’s take on readmissions penalty programs.
Two recent studies have reached the same surprising conclusion: Adherence to national quality and performance guidelines does not translate into reduced readmissions rates.
Sula Mazimba, MD, MPH, and colleagues at Kettering Medical Center in Kettering, Ohio, focused on congestive heart failure (CHF) patients, documenting compliance with four core CHF performance measures at discharge and subsequent 30-day readmissions. Only one measure-assessment of left ventricular function-had a significant association with readmissions.
A second study published the same month looked at a wider range of diagnoses in a Medicare population at more than 2,000 hospitals nationwide. That study reached similar conclusions about the disconnect between hospitals that followed Hospital Compare process quality measures and their readmission rates.
Dr. Mazimba says hospitalists and other physicians involved in quality improvement (QI) should be more involved in defining quality measures that reflect quality of care for their patients.
“We should be looking for parameters that have a higher yield for outcomes, such as preventing readmissions,” he says, encouraging better symptom management before the CHF patient is hospitalized and enhanced coordination of care after discharge.
Alpesh Amin, MD, MBA, SFHM, professor and chair of the department of medicine and executive director of the hospitalist program at the University of California at Irvine, says the findings are important, but he adds that the core quality measures studied were never designed to address readmissions.
“The challenge is to find a way to connect the dots between the core measures and readmissions,” he says.
Learn more about the four "core" heart failure quality measures for hospitals by visiting the Resource Rooms on the SHM website, or check out this 80-page implementation guide, “Improving Heart Failure Care for Hospitalized Patients [PDF],” also available on SHM’s website.
Read The Hospitalist columnist Win Whitcomb’s take on readmissions penalty programs.
Two recent studies have reached the same surprising conclusion: Adherence to national quality and performance guidelines does not translate into reduced readmissions rates.
Sula Mazimba, MD, MPH, and colleagues at Kettering Medical Center in Kettering, Ohio, focused on congestive heart failure (CHF) patients, documenting compliance with four core CHF performance measures at discharge and subsequent 30-day readmissions. Only one measure-assessment of left ventricular function-had a significant association with readmissions.
A second study published the same month looked at a wider range of diagnoses in a Medicare population at more than 2,000 hospitals nationwide. That study reached similar conclusions about the disconnect between hospitals that followed Hospital Compare process quality measures and their readmission rates.
Dr. Mazimba says hospitalists and other physicians involved in quality improvement (QI) should be more involved in defining quality measures that reflect quality of care for their patients.
“We should be looking for parameters that have a higher yield for outcomes, such as preventing readmissions,” he says, encouraging better symptom management before the CHF patient is hospitalized and enhanced coordination of care after discharge.
Alpesh Amin, MD, MBA, SFHM, professor and chair of the department of medicine and executive director of the hospitalist program at the University of California at Irvine, says the findings are important, but he adds that the core quality measures studied were never designed to address readmissions.
“The challenge is to find a way to connect the dots between the core measures and readmissions,” he says.
Learn more about the four "core" heart failure quality measures for hospitals by visiting the Resource Rooms on the SHM website, or check out this 80-page implementation guide, “Improving Heart Failure Care for Hospitalized Patients [PDF],” also available on SHM’s website.
Read The Hospitalist columnist Win Whitcomb’s take on readmissions penalty programs.
ONLINE EXCLUSIVE: Experts discuss how HM group's rely on locum tenens
Listen to Robert Bessler, CEO of Sound Physicians, discuss the importance of locum agencies.
Listen to Brent Bormaster, of StaffCare, discuss expectations for filling an open hospitalist position and what to look for in a locum agency.
Listen to Robert Bessler, CEO of Sound Physicians, discuss the importance of locum agencies.
Listen to Brent Bormaster, of StaffCare, discuss expectations for filling an open hospitalist position and what to look for in a locum agency.
Listen to Robert Bessler, CEO of Sound Physicians, discuss the importance of locum agencies.
Listen to Brent Bormaster, of StaffCare, discuss expectations for filling an open hospitalist position and what to look for in a locum agency.
Soaring Healthcare Expenses Draw Attention to Price Transparency As Cost Control
As efforts intensify to rein in the soaring cost of healthcare, greater attention is being paid to the cost-control potential of price transparency. Initially envisioned as a consumer-driven dynamic, price transparency beckons physicians to consider much more seriously the cost impacts of their diagnostic and treatment decisions.
Consumer-Driven Approach
The U.S. Department of Health and Human Services (HHS) regards price transparency as an important weapon in its armamentarium of “value-driven” approaches to drive down the cost of healthcare. By unleashing the energy of the savvy shopper and empowering consumers with the ability to compare the price and quality of healthcare services, they can make informed choices of their doctors and hospitals. In turn, HHS hopes to motivate the entire system to provide better care for less money.
That “empowered consumerism” principle is the guiding impetus for the Affordable Care Act’s state-regulated health insurance exchange apparatus, which, beginning in 2014, will present a side-by-side comparison of health plan choices, premium costs, and out-of-pocket copays in a way that is designed to help consumers shop for better-value health plans.
Some health plans are using price transparency to nudge consumers to choose lower-cost healthcare service options. Anthem BlueCross BlueShield, for example, has launched the Compass SmartShopper program (www.compasssmartshopper.com), which gives members in New Hampshire, Connecticut, and Indiana $50 to $200 if they get a diagnostic test or surgical procedure at a less expensive facility. Anthem notes that the cost for the same service can vary greatly. For example, hernia repairs range in price from $4,026 to $7,498, and colonoscopies range from $1,450 to $2,973.
New price transparency tools also are available (HealthCareBlueBook.com and FairHealthConsumer.org, for example) to help consumers who face high deductibles or out-of-pocket costs to find “fair prices” for surgeries, hospital stays, doctor visits, and medical tests—and shop accordingly.
Despite these developments, however, there is limited evidence that the “empowered consumerism” approach to price transparency will spur consumers to choose lower-cost providers. Some experts note that many consumers equate higher-cost providers with higher quality, and caution that healthcare cost-profiling initiatives might even have the perverse effect of deterring them from seeking these providers.1 Cost measures, they argue, must be tied to quality information in order to neutralize the typical association of high costs with higher quality.1
Provider-Driven Approach
There are healthcare price transparency initiatives that address the supply side of the healthcare cost equation. These initiatives seek to educate physicians about the ways in which their clinical decisions drive cost and affect what patients pay for care. Some believe that this approach has the potential to make a much bigger dent in cost containment than the empowered-consumerism approach.
“Ninety percent of healthcare cost comes from a physician’s pen, but a lot of that spending doesn’t help patients get better,” says Neel Shah, MD, a Harvard-affiliated OBGYN and executive director of Costs of Care (www.costsofcare.org), a nonprofit aimed at empowering both patients and their caregivers to deflate medical bills. The challenge, he adds, is making physicians aware of how their decisions can inflate costs unnecessarily, and giving them the training and tools they need to take appropriate action.
“Just as the patient-safety movement helped caregivers think about how to prevent unintended harm, a new movement is needed to educate doctors, nurses, and other caregivers about the cost and value of their decisions, so they can avoid waste and protect patients from unintended financial harms as well,” Dr. Shah says.
Costs of Care recently launched its Teaching Value Project, which employs Web-based video education modules to help medical students and residents learn to optimize both quality and cost in clinical decision-making.
“We’re also developing an iPhone app to put cost and quality information at physicians’ fingertips at the critical moment when medical decisions are made,” Dr. Shah adds. “Just being able to see the price variation—an ultrasound versus a CT scan, a generic versus a brand-name medication, or the cost of a marginally valuable test—can help drive physician ordering behavior.”
Hospitalist Impacts
Robert A. Bessler, MD, CEO of Tacoma, Wash.-based hospitalist management firm Sound Physicians, says his hospitalists spend about $2 million a year “with their pen or computerized physician order entry.” A quarter of the cost is pharmacy-related, and the “majority of the rest is from bed-days.”
“The most expensive thing we do is make the decision to admit,” Dr. Bessler notes. “With hospitals switching from revenue centers to cost centers in a population health/ACO [accountable-care organization] environment, an increasingly important part of the hospitalist’s job will be asking
questions, such as, ‘Could this patient go to a nursing home tonight from the ER?’ and ‘Can my colleague in the post-acute environment take care of this patient, with the same effective outcome, if we provide more intense services in the nursing home, going forward?’”
Because most diagnostic testing is done on the front end of an inpatient’s stay, the hospitalist’s main contribution to cost control is to get that diagnosis right and use consults to answer specific questions, Dr. Bessler explains. “There is a direct correlation between the number of consults and the volume of procedures which lead to higher inpatient costs,” he adds.
As hospitals convert to value-based care models, and pressure increases on hospitalists to ramp up their analysis and sharing of cost data and resource utilization, not all physicians will find that conversion easy.
—Neel Shah, MD, executive director, Costs of Care
“We are trained to take good care of our patients, not to be financial stewards of the healthcare system,” says SHM Public Policy Committee member Bradley Flansbaum, DO, MPH, SFHM. “Now, physicians are being asked to do both—to watch our resource use without looking like we’re selling out to payors. You’re putting physicians in a difficult position. Will they say to patients, ‘You can’t have this service’? When does being pragmatic stewards of resources become rationing?” he cautions.
Dr. Shah concedes that there is a perceived tension between “what’s best” for my patient and “what’s best” for society. “We, as a profession, haven’t given serious attention to how to navigate those tensions,” he says.
Dr. Flansbaum, a hospitalist at Lenox Hill Hospital in New York City, says it’s time to start down the transparency road.
“Otherwise, we will have a centralized body making these decisions for us,” he says.
Christopher Guadagnino is a freelance medical writer in Philadelphia.
Reference
As efforts intensify to rein in the soaring cost of healthcare, greater attention is being paid to the cost-control potential of price transparency. Initially envisioned as a consumer-driven dynamic, price transparency beckons physicians to consider much more seriously the cost impacts of their diagnostic and treatment decisions.
Consumer-Driven Approach
The U.S. Department of Health and Human Services (HHS) regards price transparency as an important weapon in its armamentarium of “value-driven” approaches to drive down the cost of healthcare. By unleashing the energy of the savvy shopper and empowering consumers with the ability to compare the price and quality of healthcare services, they can make informed choices of their doctors and hospitals. In turn, HHS hopes to motivate the entire system to provide better care for less money.
That “empowered consumerism” principle is the guiding impetus for the Affordable Care Act’s state-regulated health insurance exchange apparatus, which, beginning in 2014, will present a side-by-side comparison of health plan choices, premium costs, and out-of-pocket copays in a way that is designed to help consumers shop for better-value health plans.
Some health plans are using price transparency to nudge consumers to choose lower-cost healthcare service options. Anthem BlueCross BlueShield, for example, has launched the Compass SmartShopper program (www.compasssmartshopper.com), which gives members in New Hampshire, Connecticut, and Indiana $50 to $200 if they get a diagnostic test or surgical procedure at a less expensive facility. Anthem notes that the cost for the same service can vary greatly. For example, hernia repairs range in price from $4,026 to $7,498, and colonoscopies range from $1,450 to $2,973.
New price transparency tools also are available (HealthCareBlueBook.com and FairHealthConsumer.org, for example) to help consumers who face high deductibles or out-of-pocket costs to find “fair prices” for surgeries, hospital stays, doctor visits, and medical tests—and shop accordingly.
Despite these developments, however, there is limited evidence that the “empowered consumerism” approach to price transparency will spur consumers to choose lower-cost providers. Some experts note that many consumers equate higher-cost providers with higher quality, and caution that healthcare cost-profiling initiatives might even have the perverse effect of deterring them from seeking these providers.1 Cost measures, they argue, must be tied to quality information in order to neutralize the typical association of high costs with higher quality.1
Provider-Driven Approach
There are healthcare price transparency initiatives that address the supply side of the healthcare cost equation. These initiatives seek to educate physicians about the ways in which their clinical decisions drive cost and affect what patients pay for care. Some believe that this approach has the potential to make a much bigger dent in cost containment than the empowered-consumerism approach.
“Ninety percent of healthcare cost comes from a physician’s pen, but a lot of that spending doesn’t help patients get better,” says Neel Shah, MD, a Harvard-affiliated OBGYN and executive director of Costs of Care (www.costsofcare.org), a nonprofit aimed at empowering both patients and their caregivers to deflate medical bills. The challenge, he adds, is making physicians aware of how their decisions can inflate costs unnecessarily, and giving them the training and tools they need to take appropriate action.
“Just as the patient-safety movement helped caregivers think about how to prevent unintended harm, a new movement is needed to educate doctors, nurses, and other caregivers about the cost and value of their decisions, so they can avoid waste and protect patients from unintended financial harms as well,” Dr. Shah says.
Costs of Care recently launched its Teaching Value Project, which employs Web-based video education modules to help medical students and residents learn to optimize both quality and cost in clinical decision-making.
“We’re also developing an iPhone app to put cost and quality information at physicians’ fingertips at the critical moment when medical decisions are made,” Dr. Shah adds. “Just being able to see the price variation—an ultrasound versus a CT scan, a generic versus a brand-name medication, or the cost of a marginally valuable test—can help drive physician ordering behavior.”
Hospitalist Impacts
Robert A. Bessler, MD, CEO of Tacoma, Wash.-based hospitalist management firm Sound Physicians, says his hospitalists spend about $2 million a year “with their pen or computerized physician order entry.” A quarter of the cost is pharmacy-related, and the “majority of the rest is from bed-days.”
“The most expensive thing we do is make the decision to admit,” Dr. Bessler notes. “With hospitals switching from revenue centers to cost centers in a population health/ACO [accountable-care organization] environment, an increasingly important part of the hospitalist’s job will be asking
questions, such as, ‘Could this patient go to a nursing home tonight from the ER?’ and ‘Can my colleague in the post-acute environment take care of this patient, with the same effective outcome, if we provide more intense services in the nursing home, going forward?’”
Because most diagnostic testing is done on the front end of an inpatient’s stay, the hospitalist’s main contribution to cost control is to get that diagnosis right and use consults to answer specific questions, Dr. Bessler explains. “There is a direct correlation between the number of consults and the volume of procedures which lead to higher inpatient costs,” he adds.
As hospitals convert to value-based care models, and pressure increases on hospitalists to ramp up their analysis and sharing of cost data and resource utilization, not all physicians will find that conversion easy.
—Neel Shah, MD, executive director, Costs of Care
“We are trained to take good care of our patients, not to be financial stewards of the healthcare system,” says SHM Public Policy Committee member Bradley Flansbaum, DO, MPH, SFHM. “Now, physicians are being asked to do both—to watch our resource use without looking like we’re selling out to payors. You’re putting physicians in a difficult position. Will they say to patients, ‘You can’t have this service’? When does being pragmatic stewards of resources become rationing?” he cautions.
Dr. Shah concedes that there is a perceived tension between “what’s best” for my patient and “what’s best” for society. “We, as a profession, haven’t given serious attention to how to navigate those tensions,” he says.
Dr. Flansbaum, a hospitalist at Lenox Hill Hospital in New York City, says it’s time to start down the transparency road.
“Otherwise, we will have a centralized body making these decisions for us,” he says.
Christopher Guadagnino is a freelance medical writer in Philadelphia.
Reference
As efforts intensify to rein in the soaring cost of healthcare, greater attention is being paid to the cost-control potential of price transparency. Initially envisioned as a consumer-driven dynamic, price transparency beckons physicians to consider much more seriously the cost impacts of their diagnostic and treatment decisions.
Consumer-Driven Approach
The U.S. Department of Health and Human Services (HHS) regards price transparency as an important weapon in its armamentarium of “value-driven” approaches to drive down the cost of healthcare. By unleashing the energy of the savvy shopper and empowering consumers with the ability to compare the price and quality of healthcare services, they can make informed choices of their doctors and hospitals. In turn, HHS hopes to motivate the entire system to provide better care for less money.
That “empowered consumerism” principle is the guiding impetus for the Affordable Care Act’s state-regulated health insurance exchange apparatus, which, beginning in 2014, will present a side-by-side comparison of health plan choices, premium costs, and out-of-pocket copays in a way that is designed to help consumers shop for better-value health plans.
Some health plans are using price transparency to nudge consumers to choose lower-cost healthcare service options. Anthem BlueCross BlueShield, for example, has launched the Compass SmartShopper program (www.compasssmartshopper.com), which gives members in New Hampshire, Connecticut, and Indiana $50 to $200 if they get a diagnostic test or surgical procedure at a less expensive facility. Anthem notes that the cost for the same service can vary greatly. For example, hernia repairs range in price from $4,026 to $7,498, and colonoscopies range from $1,450 to $2,973.
New price transparency tools also are available (HealthCareBlueBook.com and FairHealthConsumer.org, for example) to help consumers who face high deductibles or out-of-pocket costs to find “fair prices” for surgeries, hospital stays, doctor visits, and medical tests—and shop accordingly.
Despite these developments, however, there is limited evidence that the “empowered consumerism” approach to price transparency will spur consumers to choose lower-cost providers. Some experts note that many consumers equate higher-cost providers with higher quality, and caution that healthcare cost-profiling initiatives might even have the perverse effect of deterring them from seeking these providers.1 Cost measures, they argue, must be tied to quality information in order to neutralize the typical association of high costs with higher quality.1
Provider-Driven Approach
There are healthcare price transparency initiatives that address the supply side of the healthcare cost equation. These initiatives seek to educate physicians about the ways in which their clinical decisions drive cost and affect what patients pay for care. Some believe that this approach has the potential to make a much bigger dent in cost containment than the empowered-consumerism approach.
“Ninety percent of healthcare cost comes from a physician’s pen, but a lot of that spending doesn’t help patients get better,” says Neel Shah, MD, a Harvard-affiliated OBGYN and executive director of Costs of Care (www.costsofcare.org), a nonprofit aimed at empowering both patients and their caregivers to deflate medical bills. The challenge, he adds, is making physicians aware of how their decisions can inflate costs unnecessarily, and giving them the training and tools they need to take appropriate action.
“Just as the patient-safety movement helped caregivers think about how to prevent unintended harm, a new movement is needed to educate doctors, nurses, and other caregivers about the cost and value of their decisions, so they can avoid waste and protect patients from unintended financial harms as well,” Dr. Shah says.
Costs of Care recently launched its Teaching Value Project, which employs Web-based video education modules to help medical students and residents learn to optimize both quality and cost in clinical decision-making.
“We’re also developing an iPhone app to put cost and quality information at physicians’ fingertips at the critical moment when medical decisions are made,” Dr. Shah adds. “Just being able to see the price variation—an ultrasound versus a CT scan, a generic versus a brand-name medication, or the cost of a marginally valuable test—can help drive physician ordering behavior.”
Hospitalist Impacts
Robert A. Bessler, MD, CEO of Tacoma, Wash.-based hospitalist management firm Sound Physicians, says his hospitalists spend about $2 million a year “with their pen or computerized physician order entry.” A quarter of the cost is pharmacy-related, and the “majority of the rest is from bed-days.”
“The most expensive thing we do is make the decision to admit,” Dr. Bessler notes. “With hospitals switching from revenue centers to cost centers in a population health/ACO [accountable-care organization] environment, an increasingly important part of the hospitalist’s job will be asking
questions, such as, ‘Could this patient go to a nursing home tonight from the ER?’ and ‘Can my colleague in the post-acute environment take care of this patient, with the same effective outcome, if we provide more intense services in the nursing home, going forward?’”
Because most diagnostic testing is done on the front end of an inpatient’s stay, the hospitalist’s main contribution to cost control is to get that diagnosis right and use consults to answer specific questions, Dr. Bessler explains. “There is a direct correlation between the number of consults and the volume of procedures which lead to higher inpatient costs,” he adds.
As hospitals convert to value-based care models, and pressure increases on hospitalists to ramp up their analysis and sharing of cost data and resource utilization, not all physicians will find that conversion easy.
—Neel Shah, MD, executive director, Costs of Care
“We are trained to take good care of our patients, not to be financial stewards of the healthcare system,” says SHM Public Policy Committee member Bradley Flansbaum, DO, MPH, SFHM. “Now, physicians are being asked to do both—to watch our resource use without looking like we’re selling out to payors. You’re putting physicians in a difficult position. Will they say to patients, ‘You can’t have this service’? When does being pragmatic stewards of resources become rationing?” he cautions.
Dr. Shah concedes that there is a perceived tension between “what’s best” for my patient and “what’s best” for society. “We, as a profession, haven’t given serious attention to how to navigate those tensions,” he says.
Dr. Flansbaum, a hospitalist at Lenox Hill Hospital in New York City, says it’s time to start down the transparency road.
“Otherwise, we will have a centralized body making these decisions for us,” he says.
Christopher Guadagnino is a freelance medical writer in Philadelphia.
Reference
The Global Hospitalist
Born, raised, educated, and trained in the shadow of the Statue of Liberty, Nick Fitterman, MD, FACP, SFHM, is as New York as New Yorkers get. After 14 years in private practice, he “saw the handwriting on the wall” and founded a hospitalist program in the community hospital down the street. He served six years as HM group director at Huntington (N.Y.) Hospital, immersing himself in patient care and the inner workings of the health system.
Six months ago, he moved into a new, full-time administrative position as medical director of group health management for North Shore Long Island Jewish Health System, a 16-hospital system that includes 408-bed Huntington. The post is in a newly created department and focuses on “connecting parts of our healthcare system that will help serve us in the new landscape of healthcare reform as we move from individual health to population health, as we move from a model of illness to a model of wellness,” he says.
“Parts are already in our system, and my job is to link them together, help build up what needs to be built up, and to fill gaps where they exist,” he says.
Dr. Fitterman, who joined Team Hospitalist earlier this year, plans to continue working a few hospitalist shifts a month with his former group, but his new mission is clear: “Getting providers to recognize the need and the sense of urgency to redesign the way they practice medicine,” he says.
Question: What is the biggest difference between outpatient and inpatient care?
Answer: There are two significant differences. One would be the acuity of the patient. The outpatient is not as acutely ill as those in the hospital. That’s one of the things that drew me to hospital medicine. The other big difference is continuity; it is lost in the hospital. In outpatient medicine, I was able to take care of multiple generations of the same family over many years. In hospital medicine, I would only see an individual patient for three to five days.
Q: What do you like most about working as a hospitalist?
A: I enjoy the challenge of taking care of the acutely ill. An illness may be compressed into a few days, and you need to figure out quickly, and take action that has meaningful impact swiftly. I find that challenging. The other thing that I found quite challenging is the opportunity for hospitalists to help create and execute policy in the hospital that will impact the care of the whole community. As a hospitalist, you can be involved in drafting and executing policy that will impact literally tens of thousands of lives in your community. In your office, you will be more limited to the average 2,500-patient panel that an internist has.
Q: Why have you dedicated yourself to committee work?
A: I encourage any early-career physician to get involved in committees. I entered into a lot of committees … and then I broadened my committee involvement to have a better idea of all the on-goings in the hospital. It also served as a teaching vehicle, to help me understand that people are working on things just like you want to. Committee work allows you to collaborate with people who have mutual interests, instead of feeling like you’re at the end of a process and being prescribed some policy.
Q: It sounds like you’re seeing patients less and doing more what you consider “population health.” How has your experience as a hospitalist helped you in your new position?
A: All of the committee work that I did set the tone for these changes in my career. And that committee work included committee work in my practice, committee work at the hospital, committee work in national organizations, such as SHM and the American College of Physicians.
Q: When you speak about population health, what types of problems and solutions are you looking at?
A: It’s important to recognize that healthcare is only a small part of population health. Now, understanding the other side of social issues that impact our patients, you can bring to them the best healthcare possible, but if we don’t address those other needs or at least recognize them and steer them to a place where they help them with those needs, our care will not be as meaningful as we hope.
Q: Can you give an example?
A: The asthmatic who’s in your ED four times a year and gets excellent care but gets discharged home with an inability to get their medicine or to take their medicines appropriately or to reduce an environmental exposure that keeps triggering the asthmatic exacerbations. These are all the things that population health must now consider. We cannot confine ourselves simply to what we do behind closed doors of the office or within the four walls of a hospital.
Q: How much of your new job is the offspring of regulations coming down the pipe from healthcare reform?
A: Not so much because of the regulations. The changes we are seeing are driven by the market, driven by employers, and by states. Yes, the Affordable Care Act has an impact, but hopefully only to accelerate changes that we already saw taking shape. Our hope is to create a system that will provide that help to the individual and help the population to do that or reduce per-capita cost, but also by enriching the lives of providers and, of course, doing this before the regulations tell us how before someone tells us how to do it.
Q: As a former chief resident, what advice do you have for trainees entering into a new paradigm of medicine?
A: They should consider the population and not just the individual. They should consider the model wellness and not just illness to focus on in an acute-care setting. They should be trained and well-prepared. This is what hospitalist medicine does quite well: to continuously look at quality improvement and PDSA [Plan-Do-Study-Act] cycles. It should be common that they are reviewing quality metrics and planning on how they can get better as a group or even as an individual in a practice and the concept of team medicine.
Q: What is the biggest challenge hospitalists face today?
A: We need to be better versed in the change equation, how to manage change. That’s the biggest challenge.
Q: Tell me about your work with SHM. What does the society mean to you?
A: The society has really helped me understand the process in managing change, in quality-improvement cycles. Having participated in one of the mentored implementation programs [Project BOOST], I was afforded an opportunity to be coached by experts in the field. The toolkits on the SHM website I found very helpful. It was a mini-fellowship, if you will. If I didn’t take the interest that I have in SHM, I don’t think I would have either known the opportunities I have or availed myself of all the opportunities SHM can provide.
Q: What has the senior fellowship in HM meant to you?
A: It was a proud moment standing up with the first class of Senior Fellows in Hospital Medicine. We all recognize the importance of embracing the movement, recognizing the need to help lead this movement, and how we can impact the lives of hospitalist patients in our community by bringing to bear the quality initiatives, the call for focus on quality in hospital medicine that this specialty has.
Richard Quinn is a freelance writer in New Jersey.
Born, raised, educated, and trained in the shadow of the Statue of Liberty, Nick Fitterman, MD, FACP, SFHM, is as New York as New Yorkers get. After 14 years in private practice, he “saw the handwriting on the wall” and founded a hospitalist program in the community hospital down the street. He served six years as HM group director at Huntington (N.Y.) Hospital, immersing himself in patient care and the inner workings of the health system.
Six months ago, he moved into a new, full-time administrative position as medical director of group health management for North Shore Long Island Jewish Health System, a 16-hospital system that includes 408-bed Huntington. The post is in a newly created department and focuses on “connecting parts of our healthcare system that will help serve us in the new landscape of healthcare reform as we move from individual health to population health, as we move from a model of illness to a model of wellness,” he says.
“Parts are already in our system, and my job is to link them together, help build up what needs to be built up, and to fill gaps where they exist,” he says.
Dr. Fitterman, who joined Team Hospitalist earlier this year, plans to continue working a few hospitalist shifts a month with his former group, but his new mission is clear: “Getting providers to recognize the need and the sense of urgency to redesign the way they practice medicine,” he says.
Question: What is the biggest difference between outpatient and inpatient care?
Answer: There are two significant differences. One would be the acuity of the patient. The outpatient is not as acutely ill as those in the hospital. That’s one of the things that drew me to hospital medicine. The other big difference is continuity; it is lost in the hospital. In outpatient medicine, I was able to take care of multiple generations of the same family over many years. In hospital medicine, I would only see an individual patient for three to five days.
Q: What do you like most about working as a hospitalist?
A: I enjoy the challenge of taking care of the acutely ill. An illness may be compressed into a few days, and you need to figure out quickly, and take action that has meaningful impact swiftly. I find that challenging. The other thing that I found quite challenging is the opportunity for hospitalists to help create and execute policy in the hospital that will impact the care of the whole community. As a hospitalist, you can be involved in drafting and executing policy that will impact literally tens of thousands of lives in your community. In your office, you will be more limited to the average 2,500-patient panel that an internist has.
Q: Why have you dedicated yourself to committee work?
A: I encourage any early-career physician to get involved in committees. I entered into a lot of committees … and then I broadened my committee involvement to have a better idea of all the on-goings in the hospital. It also served as a teaching vehicle, to help me understand that people are working on things just like you want to. Committee work allows you to collaborate with people who have mutual interests, instead of feeling like you’re at the end of a process and being prescribed some policy.
Q: It sounds like you’re seeing patients less and doing more what you consider “population health.” How has your experience as a hospitalist helped you in your new position?
A: All of the committee work that I did set the tone for these changes in my career. And that committee work included committee work in my practice, committee work at the hospital, committee work in national organizations, such as SHM and the American College of Physicians.
Q: When you speak about population health, what types of problems and solutions are you looking at?
A: It’s important to recognize that healthcare is only a small part of population health. Now, understanding the other side of social issues that impact our patients, you can bring to them the best healthcare possible, but if we don’t address those other needs or at least recognize them and steer them to a place where they help them with those needs, our care will not be as meaningful as we hope.
Q: Can you give an example?
A: The asthmatic who’s in your ED four times a year and gets excellent care but gets discharged home with an inability to get their medicine or to take their medicines appropriately or to reduce an environmental exposure that keeps triggering the asthmatic exacerbations. These are all the things that population health must now consider. We cannot confine ourselves simply to what we do behind closed doors of the office or within the four walls of a hospital.
Q: How much of your new job is the offspring of regulations coming down the pipe from healthcare reform?
A: Not so much because of the regulations. The changes we are seeing are driven by the market, driven by employers, and by states. Yes, the Affordable Care Act has an impact, but hopefully only to accelerate changes that we already saw taking shape. Our hope is to create a system that will provide that help to the individual and help the population to do that or reduce per-capita cost, but also by enriching the lives of providers and, of course, doing this before the regulations tell us how before someone tells us how to do it.
Q: As a former chief resident, what advice do you have for trainees entering into a new paradigm of medicine?
A: They should consider the population and not just the individual. They should consider the model wellness and not just illness to focus on in an acute-care setting. They should be trained and well-prepared. This is what hospitalist medicine does quite well: to continuously look at quality improvement and PDSA [Plan-Do-Study-Act] cycles. It should be common that they are reviewing quality metrics and planning on how they can get better as a group or even as an individual in a practice and the concept of team medicine.
Q: What is the biggest challenge hospitalists face today?
A: We need to be better versed in the change equation, how to manage change. That’s the biggest challenge.
Q: Tell me about your work with SHM. What does the society mean to you?
A: The society has really helped me understand the process in managing change, in quality-improvement cycles. Having participated in one of the mentored implementation programs [Project BOOST], I was afforded an opportunity to be coached by experts in the field. The toolkits on the SHM website I found very helpful. It was a mini-fellowship, if you will. If I didn’t take the interest that I have in SHM, I don’t think I would have either known the opportunities I have or availed myself of all the opportunities SHM can provide.
Q: What has the senior fellowship in HM meant to you?
A: It was a proud moment standing up with the first class of Senior Fellows in Hospital Medicine. We all recognize the importance of embracing the movement, recognizing the need to help lead this movement, and how we can impact the lives of hospitalist patients in our community by bringing to bear the quality initiatives, the call for focus on quality in hospital medicine that this specialty has.
Richard Quinn is a freelance writer in New Jersey.
Born, raised, educated, and trained in the shadow of the Statue of Liberty, Nick Fitterman, MD, FACP, SFHM, is as New York as New Yorkers get. After 14 years in private practice, he “saw the handwriting on the wall” and founded a hospitalist program in the community hospital down the street. He served six years as HM group director at Huntington (N.Y.) Hospital, immersing himself in patient care and the inner workings of the health system.
Six months ago, he moved into a new, full-time administrative position as medical director of group health management for North Shore Long Island Jewish Health System, a 16-hospital system that includes 408-bed Huntington. The post is in a newly created department and focuses on “connecting parts of our healthcare system that will help serve us in the new landscape of healthcare reform as we move from individual health to population health, as we move from a model of illness to a model of wellness,” he says.
“Parts are already in our system, and my job is to link them together, help build up what needs to be built up, and to fill gaps where they exist,” he says.
Dr. Fitterman, who joined Team Hospitalist earlier this year, plans to continue working a few hospitalist shifts a month with his former group, but his new mission is clear: “Getting providers to recognize the need and the sense of urgency to redesign the way they practice medicine,” he says.
Question: What is the biggest difference between outpatient and inpatient care?
Answer: There are two significant differences. One would be the acuity of the patient. The outpatient is not as acutely ill as those in the hospital. That’s one of the things that drew me to hospital medicine. The other big difference is continuity; it is lost in the hospital. In outpatient medicine, I was able to take care of multiple generations of the same family over many years. In hospital medicine, I would only see an individual patient for three to five days.
Q: What do you like most about working as a hospitalist?
A: I enjoy the challenge of taking care of the acutely ill. An illness may be compressed into a few days, and you need to figure out quickly, and take action that has meaningful impact swiftly. I find that challenging. The other thing that I found quite challenging is the opportunity for hospitalists to help create and execute policy in the hospital that will impact the care of the whole community. As a hospitalist, you can be involved in drafting and executing policy that will impact literally tens of thousands of lives in your community. In your office, you will be more limited to the average 2,500-patient panel that an internist has.
Q: Why have you dedicated yourself to committee work?
A: I encourage any early-career physician to get involved in committees. I entered into a lot of committees … and then I broadened my committee involvement to have a better idea of all the on-goings in the hospital. It also served as a teaching vehicle, to help me understand that people are working on things just like you want to. Committee work allows you to collaborate with people who have mutual interests, instead of feeling like you’re at the end of a process and being prescribed some policy.
Q: It sounds like you’re seeing patients less and doing more what you consider “population health.” How has your experience as a hospitalist helped you in your new position?
A: All of the committee work that I did set the tone for these changes in my career. And that committee work included committee work in my practice, committee work at the hospital, committee work in national organizations, such as SHM and the American College of Physicians.
Q: When you speak about population health, what types of problems and solutions are you looking at?
A: It’s important to recognize that healthcare is only a small part of population health. Now, understanding the other side of social issues that impact our patients, you can bring to them the best healthcare possible, but if we don’t address those other needs or at least recognize them and steer them to a place where they help them with those needs, our care will not be as meaningful as we hope.
Q: Can you give an example?
A: The asthmatic who’s in your ED four times a year and gets excellent care but gets discharged home with an inability to get their medicine or to take their medicines appropriately or to reduce an environmental exposure that keeps triggering the asthmatic exacerbations. These are all the things that population health must now consider. We cannot confine ourselves simply to what we do behind closed doors of the office or within the four walls of a hospital.
Q: How much of your new job is the offspring of regulations coming down the pipe from healthcare reform?
A: Not so much because of the regulations. The changes we are seeing are driven by the market, driven by employers, and by states. Yes, the Affordable Care Act has an impact, but hopefully only to accelerate changes that we already saw taking shape. Our hope is to create a system that will provide that help to the individual and help the population to do that or reduce per-capita cost, but also by enriching the lives of providers and, of course, doing this before the regulations tell us how before someone tells us how to do it.
Q: As a former chief resident, what advice do you have for trainees entering into a new paradigm of medicine?
A: They should consider the population and not just the individual. They should consider the model wellness and not just illness to focus on in an acute-care setting. They should be trained and well-prepared. This is what hospitalist medicine does quite well: to continuously look at quality improvement and PDSA [Plan-Do-Study-Act] cycles. It should be common that they are reviewing quality metrics and planning on how they can get better as a group or even as an individual in a practice and the concept of team medicine.
Q: What is the biggest challenge hospitalists face today?
A: We need to be better versed in the change equation, how to manage change. That’s the biggest challenge.
Q: Tell me about your work with SHM. What does the society mean to you?
A: The society has really helped me understand the process in managing change, in quality-improvement cycles. Having participated in one of the mentored implementation programs [Project BOOST], I was afforded an opportunity to be coached by experts in the field. The toolkits on the SHM website I found very helpful. It was a mini-fellowship, if you will. If I didn’t take the interest that I have in SHM, I don’t think I would have either known the opportunities I have or availed myself of all the opportunities SHM can provide.
Q: What has the senior fellowship in HM meant to you?
A: It was a proud moment standing up with the first class of Senior Fellows in Hospital Medicine. We all recognize the importance of embracing the movement, recognizing the need to help lead this movement, and how we can impact the lives of hospitalist patients in our community by bringing to bear the quality initiatives, the call for focus on quality in hospital medicine that this specialty has.
Richard Quinn is a freelance writer in New Jersey.
iPad Rollout at UC-Irvine Medical Center Prompts Security Measures
The University of California’s Irvine Medical Center has been issuing iPads to its incoming class of 100 medical students and to all 18 resident physicians in its department of emergency medicine.1 The entire medical curriculum is on the iPad and employs document sharing via the SharePoint collaborative software platform, says Adam Gold, the medical center’s director of emerging technologies.
But the use of these new technologies and subsequent clamoring by students, professors, physicians, and other staff to connect their own mobile devices to the network have led to the establishment of security and management guidelines for monitoring technology use, now spelled out in the new “Bring Your Own Device” policy, Gold explains.
Reference
The University of California’s Irvine Medical Center has been issuing iPads to its incoming class of 100 medical students and to all 18 resident physicians in its department of emergency medicine.1 The entire medical curriculum is on the iPad and employs document sharing via the SharePoint collaborative software platform, says Adam Gold, the medical center’s director of emerging technologies.
But the use of these new technologies and subsequent clamoring by students, professors, physicians, and other staff to connect their own mobile devices to the network have led to the establishment of security and management guidelines for monitoring technology use, now spelled out in the new “Bring Your Own Device” policy, Gold explains.
Reference
The University of California’s Irvine Medical Center has been issuing iPads to its incoming class of 100 medical students and to all 18 resident physicians in its department of emergency medicine.1 The entire medical curriculum is on the iPad and employs document sharing via the SharePoint collaborative software platform, says Adam Gold, the medical center’s director of emerging technologies.
But the use of these new technologies and subsequent clamoring by students, professors, physicians, and other staff to connect their own mobile devices to the network have led to the establishment of security and management guidelines for monitoring technology use, now spelled out in the new “Bring Your Own Device” policy, Gold explains.
Reference
More Hospitals Report Zero Central-Line-Associated Bloodstream Infections (CLABSIs)
Percentage of hospitals participating in the Agency for Healthcare Research and Quality’s Comprehensive Unit-Based Safety Program (CUSP) that reported zero central-line-associated bloodstream infections (CLABSIs) during a quarter of 2011. That figure is up from 27.3% the year before. CUSP (www.OnTheCuspStopHAI.org) was launched in 2009 to promote the use of customizable, standardized checklists of evidence-based interventions to prevent hospital-acquired infections. It now includes 1,055 hospitals in 44 states, and the program collectively charted a decrease from 1.87 CLABSIs per 1,000 central-line days to 1.25, a 33% reduction.
Percentage of hospitals participating in the Agency for Healthcare Research and Quality’s Comprehensive Unit-Based Safety Program (CUSP) that reported zero central-line-associated bloodstream infections (CLABSIs) during a quarter of 2011. That figure is up from 27.3% the year before. CUSP (www.OnTheCuspStopHAI.org) was launched in 2009 to promote the use of customizable, standardized checklists of evidence-based interventions to prevent hospital-acquired infections. It now includes 1,055 hospitals in 44 states, and the program collectively charted a decrease from 1.87 CLABSIs per 1,000 central-line days to 1.25, a 33% reduction.
Percentage of hospitals participating in the Agency for Healthcare Research and Quality’s Comprehensive Unit-Based Safety Program (CUSP) that reported zero central-line-associated bloodstream infections (CLABSIs) during a quarter of 2011. That figure is up from 27.3% the year before. CUSP (www.OnTheCuspStopHAI.org) was launched in 2009 to promote the use of customizable, standardized checklists of evidence-based interventions to prevent hospital-acquired infections. It now includes 1,055 hospitals in 44 states, and the program collectively charted a decrease from 1.87 CLABSIs per 1,000 central-line days to 1.25, a 33% reduction.
Win Whitcomb: Introducing Neuroquality and Neurosafety
The prefix “neuro” has become quite popular the last couple of years. We have neuroeconomics, neuroplasticity, neuroergonomics, and, of course, neurohospitalist. The explosion of interest in the brain can be seen in the popular press, television, blogs, and the Journal of the American Medical Association.
I predict that recent breakthroughs in brain science and related fields (cognitive psychology, neurobiology, molecular biology, linguistics, and artificial intelligence, among others) will have a profound impact on the fields of quality improvement (QI) and patient safety, and, consequently on HM. To date, the patient safety movement has focused on systems issues in an effort to reduce harm induced by the healthcare system. I submit that for healthcare to be reliable and error-free in the future, we must leverage the innate strengths of the brain. Here I mention four areas where brain science breakthroughs can enable us to improve patient safety practices.
Diagnostic Error
Patrick Croskerry, an emergency physician and researcher, has described errors in diagnosis as stemming in part from cognitive bias. He offers “de-biasing strategies” as an approach to decreasing diagnostic error.
One of the most powerful de-biasing strategies is metacognition, or awareness of one’s own thinking processes. Closely related to metacognition is mindfulness, defined as the “nonjudgmental awareness of the present moment.” A growing body of literature makes the case that enhancing mindfulness might reduce the impact bias has on diagnostic error.1 Table 1 (right) mentions a subset of bias types and how mindfulness might mitigate them. I’m sure you can think of cases you’ve encountered where bias has affected the diagnostic outcome.
Empathy and Patient Experience
As the focus on patient experience grows, approaches to improving performance on patient satisfaction surveys are proliferating. Whatever technical components you choose to employ, a capacity for caregiver empathy is a crucial underlying factor to a better patient experience. Harvard psychiatrist Helen Riess, MD, points out that we are now beginning to understand the neurobiological basis of empathy. She and others present evidence that we may be able to “up-regulate” empathy through education or cognitive practices.2 Several studies suggest we might be able to realize improved therapeutic relationships between physicians and patients, and they have led to programs, such as the ones at Stanford and Emory universities, that train caregivers to enhance empathy and compassion.
Interruptions and Cognitive Error
It has been customary in high-risk industries to ensure that certain procedures are free of interruptions. There is recognition that disturbances during high-stakes tasks, such as airline takeoff, carry disastrous consequences. We now know that multitasking is a myth and that the brain instead switches between tasks sequentially. But task-switching comes at the high cost of a marked increase in the rate of cognitive error.3 As we learn more, decreasing interruptions or delineating “interruption-free” zones in healthcare could be a way to mitigate an inherent vulnerability in our cognitive abilities.
Fatigue and Medical Error
It is well documented that sleep deprivation correlates with a decline in cognitive
performance in a number of classes of healthcare workers. Fatigue has also increased diagnostic error among residents. A 2011 Sentinel Alert from The Joint Commission creates a standard that healthcare organizations implement a fatigue-management plan to mitigate the potential harm caused by tired professionals.
Most of the approaches to improving outcomes in the hospital have focused on process improvement and systems thinking. But errors also occur due to the thinking process of clinicians. In the book “Brain Rules,” author John Medina argues that schools and businesses create an environment that is less than friendly to the brain, citing current classroom design and cubicles for office workers. As a result, he states, we often have poor educational and business performance. I have little doubt that if Medina spent a few hours in a hospital, he would come to a similar conclusion: We don’t do the brain any favors when it comes to creating a healthy environment for providing safe and reliable care to our patients.
References
- Sibinga EM, Wu AW. Clinician mindfulness and patient safety. JAMA. 2010;304(22):2532-2533.
- Riess H. Empathy in medicine─a neurobiological perspective. JAMA. 2010;304(14):1604-1605.
- Rogers RD, Monsell S. The costs of a predictable switch between simple cognitive tasks. J Exper Psychol. 1995;124(2):207–231.
Dr. Whitcomb is medical director of healthcare quality at Baystate Medical Center in Springfield, Mass. He is a co-founder and past president of SHM. Email him at [email protected].
The prefix “neuro” has become quite popular the last couple of years. We have neuroeconomics, neuroplasticity, neuroergonomics, and, of course, neurohospitalist. The explosion of interest in the brain can be seen in the popular press, television, blogs, and the Journal of the American Medical Association.
I predict that recent breakthroughs in brain science and related fields (cognitive psychology, neurobiology, molecular biology, linguistics, and artificial intelligence, among others) will have a profound impact on the fields of quality improvement (QI) and patient safety, and, consequently on HM. To date, the patient safety movement has focused on systems issues in an effort to reduce harm induced by the healthcare system. I submit that for healthcare to be reliable and error-free in the future, we must leverage the innate strengths of the brain. Here I mention four areas where brain science breakthroughs can enable us to improve patient safety practices.
Diagnostic Error
Patrick Croskerry, an emergency physician and researcher, has described errors in diagnosis as stemming in part from cognitive bias. He offers “de-biasing strategies” as an approach to decreasing diagnostic error.
One of the most powerful de-biasing strategies is metacognition, or awareness of one’s own thinking processes. Closely related to metacognition is mindfulness, defined as the “nonjudgmental awareness of the present moment.” A growing body of literature makes the case that enhancing mindfulness might reduce the impact bias has on diagnostic error.1 Table 1 (right) mentions a subset of bias types and how mindfulness might mitigate them. I’m sure you can think of cases you’ve encountered where bias has affected the diagnostic outcome.
Empathy and Patient Experience
As the focus on patient experience grows, approaches to improving performance on patient satisfaction surveys are proliferating. Whatever technical components you choose to employ, a capacity for caregiver empathy is a crucial underlying factor to a better patient experience. Harvard psychiatrist Helen Riess, MD, points out that we are now beginning to understand the neurobiological basis of empathy. She and others present evidence that we may be able to “up-regulate” empathy through education or cognitive practices.2 Several studies suggest we might be able to realize improved therapeutic relationships between physicians and patients, and they have led to programs, such as the ones at Stanford and Emory universities, that train caregivers to enhance empathy and compassion.
Interruptions and Cognitive Error
It has been customary in high-risk industries to ensure that certain procedures are free of interruptions. There is recognition that disturbances during high-stakes tasks, such as airline takeoff, carry disastrous consequences. We now know that multitasking is a myth and that the brain instead switches between tasks sequentially. But task-switching comes at the high cost of a marked increase in the rate of cognitive error.3 As we learn more, decreasing interruptions or delineating “interruption-free” zones in healthcare could be a way to mitigate an inherent vulnerability in our cognitive abilities.
Fatigue and Medical Error
It is well documented that sleep deprivation correlates with a decline in cognitive
performance in a number of classes of healthcare workers. Fatigue has also increased diagnostic error among residents. A 2011 Sentinel Alert from The Joint Commission creates a standard that healthcare organizations implement a fatigue-management plan to mitigate the potential harm caused by tired professionals.
Most of the approaches to improving outcomes in the hospital have focused on process improvement and systems thinking. But errors also occur due to the thinking process of clinicians. In the book “Brain Rules,” author John Medina argues that schools and businesses create an environment that is less than friendly to the brain, citing current classroom design and cubicles for office workers. As a result, he states, we often have poor educational and business performance. I have little doubt that if Medina spent a few hours in a hospital, he would come to a similar conclusion: We don’t do the brain any favors when it comes to creating a healthy environment for providing safe and reliable care to our patients.
References
- Sibinga EM, Wu AW. Clinician mindfulness and patient safety. JAMA. 2010;304(22):2532-2533.
- Riess H. Empathy in medicine─a neurobiological perspective. JAMA. 2010;304(14):1604-1605.
- Rogers RD, Monsell S. The costs of a predictable switch between simple cognitive tasks. J Exper Psychol. 1995;124(2):207–231.
Dr. Whitcomb is medical director of healthcare quality at Baystate Medical Center in Springfield, Mass. He is a co-founder and past president of SHM. Email him at [email protected].
The prefix “neuro” has become quite popular the last couple of years. We have neuroeconomics, neuroplasticity, neuroergonomics, and, of course, neurohospitalist. The explosion of interest in the brain can be seen in the popular press, television, blogs, and the Journal of the American Medical Association.
I predict that recent breakthroughs in brain science and related fields (cognitive psychology, neurobiology, molecular biology, linguistics, and artificial intelligence, among others) will have a profound impact on the fields of quality improvement (QI) and patient safety, and, consequently on HM. To date, the patient safety movement has focused on systems issues in an effort to reduce harm induced by the healthcare system. I submit that for healthcare to be reliable and error-free in the future, we must leverage the innate strengths of the brain. Here I mention four areas where brain science breakthroughs can enable us to improve patient safety practices.
Diagnostic Error
Patrick Croskerry, an emergency physician and researcher, has described errors in diagnosis as stemming in part from cognitive bias. He offers “de-biasing strategies” as an approach to decreasing diagnostic error.
One of the most powerful de-biasing strategies is metacognition, or awareness of one’s own thinking processes. Closely related to metacognition is mindfulness, defined as the “nonjudgmental awareness of the present moment.” A growing body of literature makes the case that enhancing mindfulness might reduce the impact bias has on diagnostic error.1 Table 1 (right) mentions a subset of bias types and how mindfulness might mitigate them. I’m sure you can think of cases you’ve encountered where bias has affected the diagnostic outcome.
Empathy and Patient Experience
As the focus on patient experience grows, approaches to improving performance on patient satisfaction surveys are proliferating. Whatever technical components you choose to employ, a capacity for caregiver empathy is a crucial underlying factor to a better patient experience. Harvard psychiatrist Helen Riess, MD, points out that we are now beginning to understand the neurobiological basis of empathy. She and others present evidence that we may be able to “up-regulate” empathy through education or cognitive practices.2 Several studies suggest we might be able to realize improved therapeutic relationships between physicians and patients, and they have led to programs, such as the ones at Stanford and Emory universities, that train caregivers to enhance empathy and compassion.
Interruptions and Cognitive Error
It has been customary in high-risk industries to ensure that certain procedures are free of interruptions. There is recognition that disturbances during high-stakes tasks, such as airline takeoff, carry disastrous consequences. We now know that multitasking is a myth and that the brain instead switches between tasks sequentially. But task-switching comes at the high cost of a marked increase in the rate of cognitive error.3 As we learn more, decreasing interruptions or delineating “interruption-free” zones in healthcare could be a way to mitigate an inherent vulnerability in our cognitive abilities.
Fatigue and Medical Error
It is well documented that sleep deprivation correlates with a decline in cognitive
performance in a number of classes of healthcare workers. Fatigue has also increased diagnostic error among residents. A 2011 Sentinel Alert from The Joint Commission creates a standard that healthcare organizations implement a fatigue-management plan to mitigate the potential harm caused by tired professionals.
Most of the approaches to improving outcomes in the hospital have focused on process improvement and systems thinking. But errors also occur due to the thinking process of clinicians. In the book “Brain Rules,” author John Medina argues that schools and businesses create an environment that is less than friendly to the brain, citing current classroom design and cubicles for office workers. As a result, he states, we often have poor educational and business performance. I have little doubt that if Medina spent a few hours in a hospital, he would come to a similar conclusion: We don’t do the brain any favors when it comes to creating a healthy environment for providing safe and reliable care to our patients.
References
- Sibinga EM, Wu AW. Clinician mindfulness and patient safety. JAMA. 2010;304(22):2532-2533.
- Riess H. Empathy in medicine─a neurobiological perspective. JAMA. 2010;304(14):1604-1605.
- Rogers RD, Monsell S. The costs of a predictable switch between simple cognitive tasks. J Exper Psychol. 1995;124(2):207–231.
Dr. Whitcomb is medical director of healthcare quality at Baystate Medical Center in Springfield, Mass. He is a co-founder and past president of SHM. Email him at [email protected].
Hospitalists' Morale Is More Than Mere Job Satisfaction
An abstract poster presented at HM12 in San Diego called the “Hospitalist Morale Assessment” a validated tool for identifying HM groups’ strengths and weaknesses by quantifying their members’ morale. Morale involves more than just job satisfaction, says Shalini Chandra, MD, MS, a hospitalist at Johns Hopkins Bayview Medical Center in Baltimore and lead author of both the abstract and the assessment instrument.
“We’ve been measuring morale here since 2006. We’ve tried to drill down to what drives hospitalists’ morale. We’ve learned that it is not one-size-fits-all,” Dr. Chandra says.
The tool has gradually been refined to quantify both importance of and contentment with 36 domains of hospitalist morale.
Five hospitals and 93 physicians participated in the 2011 survey. Each hospital received a “morale report” that broke out its results. Overall, survey respondents ranked “family time” as the most important morale factor. “Supportive and effective leadership” was rated as next important.
At Johns Hopkins Bayview, results from the annual surveys have led to the opening of a lactation room to accommodate physicians who are new mothers and to the elimination of mandatory double shifts when staffing is short.
Morale is a critical issue in staff retention and in the prevention of costly and time-consuming recruitment searches to address turnover.
“You can’t expect to have happy patients if you don’t have happy providers who exude an air that suggests to patients, ‘I’m happy to be here and you’re my No. 1 priority,’” Dr. Chandra says. “From my perspective, it is important to address morale as an issue if we’re going to keep growing as hospitalist groups and as a specialty.”
For more information or to join future morale surveys, contact Dr. Chandra at [email protected].
Larry Beresford is a freelance writer in Oakland, Calif.
An abstract poster presented at HM12 in San Diego called the “Hospitalist Morale Assessment” a validated tool for identifying HM groups’ strengths and weaknesses by quantifying their members’ morale. Morale involves more than just job satisfaction, says Shalini Chandra, MD, MS, a hospitalist at Johns Hopkins Bayview Medical Center in Baltimore and lead author of both the abstract and the assessment instrument.
“We’ve been measuring morale here since 2006. We’ve tried to drill down to what drives hospitalists’ morale. We’ve learned that it is not one-size-fits-all,” Dr. Chandra says.
The tool has gradually been refined to quantify both importance of and contentment with 36 domains of hospitalist morale.
Five hospitals and 93 physicians participated in the 2011 survey. Each hospital received a “morale report” that broke out its results. Overall, survey respondents ranked “family time” as the most important morale factor. “Supportive and effective leadership” was rated as next important.
At Johns Hopkins Bayview, results from the annual surveys have led to the opening of a lactation room to accommodate physicians who are new mothers and to the elimination of mandatory double shifts when staffing is short.
Morale is a critical issue in staff retention and in the prevention of costly and time-consuming recruitment searches to address turnover.
“You can’t expect to have happy patients if you don’t have happy providers who exude an air that suggests to patients, ‘I’m happy to be here and you’re my No. 1 priority,’” Dr. Chandra says. “From my perspective, it is important to address morale as an issue if we’re going to keep growing as hospitalist groups and as a specialty.”
For more information or to join future morale surveys, contact Dr. Chandra at [email protected].
Larry Beresford is a freelance writer in Oakland, Calif.
An abstract poster presented at HM12 in San Diego called the “Hospitalist Morale Assessment” a validated tool for identifying HM groups’ strengths and weaknesses by quantifying their members’ morale. Morale involves more than just job satisfaction, says Shalini Chandra, MD, MS, a hospitalist at Johns Hopkins Bayview Medical Center in Baltimore and lead author of both the abstract and the assessment instrument.
“We’ve been measuring morale here since 2006. We’ve tried to drill down to what drives hospitalists’ morale. We’ve learned that it is not one-size-fits-all,” Dr. Chandra says.
The tool has gradually been refined to quantify both importance of and contentment with 36 domains of hospitalist morale.
Five hospitals and 93 physicians participated in the 2011 survey. Each hospital received a “morale report” that broke out its results. Overall, survey respondents ranked “family time” as the most important morale factor. “Supportive and effective leadership” was rated as next important.
At Johns Hopkins Bayview, results from the annual surveys have led to the opening of a lactation room to accommodate physicians who are new mothers and to the elimination of mandatory double shifts when staffing is short.
Morale is a critical issue in staff retention and in the prevention of costly and time-consuming recruitment searches to address turnover.
“You can’t expect to have happy patients if you don’t have happy providers who exude an air that suggests to patients, ‘I’m happy to be here and you’re my No. 1 priority,’” Dr. Chandra says. “From my perspective, it is important to address morale as an issue if we’re going to keep growing as hospitalist groups and as a specialty.”
For more information or to join future morale surveys, contact Dr. Chandra at [email protected].
Larry Beresford is a freelance writer in Oakland, Calif.
The Hospital Home Team: Physicians Increase Focus on Inpatient Care
For most of my medical career, the hospital functioned more as a swap meet, where every physician had his or her own booth, than as an integrated, community health resource with a focused mission. Although the innovation of HM might be counted as the beginning of a new, more aligned approach between physicians and the hospital as an institution, the rapidly evolving employment of physicians by hospitals and the focusing of physician practice primarily on inpatient care has taken this to another level.
The New Paradigm
A number of recent surveys by physician recruitment firms and physician management companies have found that less than 25% of physicians are self-employed. Planned changes to insurance and Medicare reimbursement for healthcare have driven cardiologists, orthopedists, surgeons, and many other physicians, who want to protect their flow of patients and dollars, to readily become hospital or large-group-practice employees. The entrance of accountable-care organizations (ACOs) to the landscape and the greater need for physician and hospital alignment have only accelerated this trend.
At the same time, the growth of all sorts of hospitalist specialties has further changed the medical staff of the hospital. Internal-medicine and family-practice hospitalists now number more than 35,000. There are probably more than 2,000 pediatric hospitalists. The newly formed Society of OB/GYN Hospitalists (SOGH) estimates there are more than 1,500 so-called laborists in the U.S., and there are several hundred neurohospitalists, orthopedic hospitalists, and acute-care surgeons.
It is clear to me that a “home team” for the hospital of the future is developing, and it includes hospitalists, ED physicians, critical-care physicians, and the growing panoply of hospital-employed cardiologists and surgeons. There is an opportunity for alignment and integration in what has been a fragmented delivery of healthcare.
On the commercial side of the equation, this new opportunity for physician-hospital alignment might allow for a new distribution of compensation. It already is common for hospitals to be transferring some of “their” Medicare Part A dollars to hospitalists. With penalties or additional payments in the ACO model (e.g. shared savings) or in value-based purchasing, there certainly are mechanisms to redistribute funding to new physician compensation models, based more on performance than on volume of services (i.e. the old productivity model).
On another level, where compensation and performance merge, the new medical staff has the ability to deliver a safer hospital experience to our patients and to improve performance. This could take the form of reduction in hospital-acquired infections (HAIs) or reducing unnecessary DVTs and PEs. It could take the form of a better discharge process that leads to fewer unnecessary readmissions or fewer preventable ED visits. On the OB side, 24-hour on-site availability of OB hospitalists has been shown to reduce adverse birth events and, therefore, reduce liability risk and malpractice premiums. On-site availability for patients with fractures and trauma cases by orthopedic hospitalists or hospital-employed orthopedists also can reduce expenses and adverse events for these acutely ill patients.
HM’s Role
With all these changes occurring so rapidly and with all these new players being thrown into the stew at the hospital, it may be worth a few minutes for the “traditional” hospitalist on the medical service to step back and see how our role may evolve. We already have an increasing role in comanagement of surgical and subspecialty patients, as well as a more integrated role at the ED-hospitalist interface. As hospitals look for hospital-focused physicians, there is a potential for scope creep that must be thoughtfully managed.
This may require “rules of engagement” with other key services. While it may be appropriate for a patient with an acute abdomen to be admitted to the hospitalist service, if the hospitalist determines that this patient needs surgery sooner rather than later, there needs to be a straightforward way to get the surgeon in house and on the case and the patient to the operating room. To this point, medical hospitalists can help manage the medical aspects of a neurosurgical case, but we don’t do burr holes. And if there is to be pushback from the surgeon, this can’t happen at 2 a.m. over the telephone; it must be handled by the service leaders at their weekly meeting.
On another level, hospitalists need to be careful that the hospital doesn’t just hand us the administrative functions of other physicians’ care. Hospitalists are not the default to do H&Ps on surgical cases or handle their discharges, even if this falls into the hospital strategy to be able to employ fewer high-priced surgeons and subspecialists by handing off some of their work to their hospitalists.
On the other hand, it is totally appropriate for many of the hospital-focused physicians to come together, possibly under the leadership of the hospital CMO, to look at the workflow and to set up a new way to deliver healthcare that not only redefines the workload, but also involves the rest of the team, including nursing, pharmacy, case management, and social services. Medical hospitalists will need to consider whether we should be the hub of the new physician enterprise and what that would mean for workload, FTEs, and scope of practice.
Such organizations as SHM and the American Hospital Association (AHA) are thinking how best to support and convene the hospital-based physician. AHA has developed a Physician Forum with more than 6,000 members who now have their practices aligned with their hospital. SHM has held meetings of the leaders of hospital-focused practice and is developing virtual forums on Hospital Medicine Exchange to keep the discussion going. Through the Hospital Care Collaborative (HCC), SHM is engaging the leadership of pharmacy, nursing, case management, social services, and respiratory therapy.
Although we are still early in creating the direction for the new medical staff, the water is rising and the current is moving rapidly. The strong forces that are driving new payment paradigms are leading to changes in compensation and an emphasis on definable, measureable outcomes of performance and safety. Hospitalists, who have been thinking in this way and who have some experience in the new ways, should be well positioned to lead and participate actively in the formation of the new hospital home team.
When opportunity knocks, you still have to get up and answer the door. It’s time to get ready to step up.
Dr. Wellikson is CEO of SHM.
For most of my medical career, the hospital functioned more as a swap meet, where every physician had his or her own booth, than as an integrated, community health resource with a focused mission. Although the innovation of HM might be counted as the beginning of a new, more aligned approach between physicians and the hospital as an institution, the rapidly evolving employment of physicians by hospitals and the focusing of physician practice primarily on inpatient care has taken this to another level.
The New Paradigm
A number of recent surveys by physician recruitment firms and physician management companies have found that less than 25% of physicians are self-employed. Planned changes to insurance and Medicare reimbursement for healthcare have driven cardiologists, orthopedists, surgeons, and many other physicians, who want to protect their flow of patients and dollars, to readily become hospital or large-group-practice employees. The entrance of accountable-care organizations (ACOs) to the landscape and the greater need for physician and hospital alignment have only accelerated this trend.
At the same time, the growth of all sorts of hospitalist specialties has further changed the medical staff of the hospital. Internal-medicine and family-practice hospitalists now number more than 35,000. There are probably more than 2,000 pediatric hospitalists. The newly formed Society of OB/GYN Hospitalists (SOGH) estimates there are more than 1,500 so-called laborists in the U.S., and there are several hundred neurohospitalists, orthopedic hospitalists, and acute-care surgeons.
It is clear to me that a “home team” for the hospital of the future is developing, and it includes hospitalists, ED physicians, critical-care physicians, and the growing panoply of hospital-employed cardiologists and surgeons. There is an opportunity for alignment and integration in what has been a fragmented delivery of healthcare.
On the commercial side of the equation, this new opportunity for physician-hospital alignment might allow for a new distribution of compensation. It already is common for hospitals to be transferring some of “their” Medicare Part A dollars to hospitalists. With penalties or additional payments in the ACO model (e.g. shared savings) or in value-based purchasing, there certainly are mechanisms to redistribute funding to new physician compensation models, based more on performance than on volume of services (i.e. the old productivity model).
On another level, where compensation and performance merge, the new medical staff has the ability to deliver a safer hospital experience to our patients and to improve performance. This could take the form of reduction in hospital-acquired infections (HAIs) or reducing unnecessary DVTs and PEs. It could take the form of a better discharge process that leads to fewer unnecessary readmissions or fewer preventable ED visits. On the OB side, 24-hour on-site availability of OB hospitalists has been shown to reduce adverse birth events and, therefore, reduce liability risk and malpractice premiums. On-site availability for patients with fractures and trauma cases by orthopedic hospitalists or hospital-employed orthopedists also can reduce expenses and adverse events for these acutely ill patients.
HM’s Role
With all these changes occurring so rapidly and with all these new players being thrown into the stew at the hospital, it may be worth a few minutes for the “traditional” hospitalist on the medical service to step back and see how our role may evolve. We already have an increasing role in comanagement of surgical and subspecialty patients, as well as a more integrated role at the ED-hospitalist interface. As hospitals look for hospital-focused physicians, there is a potential for scope creep that must be thoughtfully managed.
This may require “rules of engagement” with other key services. While it may be appropriate for a patient with an acute abdomen to be admitted to the hospitalist service, if the hospitalist determines that this patient needs surgery sooner rather than later, there needs to be a straightforward way to get the surgeon in house and on the case and the patient to the operating room. To this point, medical hospitalists can help manage the medical aspects of a neurosurgical case, but we don’t do burr holes. And if there is to be pushback from the surgeon, this can’t happen at 2 a.m. over the telephone; it must be handled by the service leaders at their weekly meeting.
On another level, hospitalists need to be careful that the hospital doesn’t just hand us the administrative functions of other physicians’ care. Hospitalists are not the default to do H&Ps on surgical cases or handle their discharges, even if this falls into the hospital strategy to be able to employ fewer high-priced surgeons and subspecialists by handing off some of their work to their hospitalists.
On the other hand, it is totally appropriate for many of the hospital-focused physicians to come together, possibly under the leadership of the hospital CMO, to look at the workflow and to set up a new way to deliver healthcare that not only redefines the workload, but also involves the rest of the team, including nursing, pharmacy, case management, and social services. Medical hospitalists will need to consider whether we should be the hub of the new physician enterprise and what that would mean for workload, FTEs, and scope of practice.
Such organizations as SHM and the American Hospital Association (AHA) are thinking how best to support and convene the hospital-based physician. AHA has developed a Physician Forum with more than 6,000 members who now have their practices aligned with their hospital. SHM has held meetings of the leaders of hospital-focused practice and is developing virtual forums on Hospital Medicine Exchange to keep the discussion going. Through the Hospital Care Collaborative (HCC), SHM is engaging the leadership of pharmacy, nursing, case management, social services, and respiratory therapy.
Although we are still early in creating the direction for the new medical staff, the water is rising and the current is moving rapidly. The strong forces that are driving new payment paradigms are leading to changes in compensation and an emphasis on definable, measureable outcomes of performance and safety. Hospitalists, who have been thinking in this way and who have some experience in the new ways, should be well positioned to lead and participate actively in the formation of the new hospital home team.
When opportunity knocks, you still have to get up and answer the door. It’s time to get ready to step up.
Dr. Wellikson is CEO of SHM.
For most of my medical career, the hospital functioned more as a swap meet, where every physician had his or her own booth, than as an integrated, community health resource with a focused mission. Although the innovation of HM might be counted as the beginning of a new, more aligned approach between physicians and the hospital as an institution, the rapidly evolving employment of physicians by hospitals and the focusing of physician practice primarily on inpatient care has taken this to another level.
The New Paradigm
A number of recent surveys by physician recruitment firms and physician management companies have found that less than 25% of physicians are self-employed. Planned changes to insurance and Medicare reimbursement for healthcare have driven cardiologists, orthopedists, surgeons, and many other physicians, who want to protect their flow of patients and dollars, to readily become hospital or large-group-practice employees. The entrance of accountable-care organizations (ACOs) to the landscape and the greater need for physician and hospital alignment have only accelerated this trend.
At the same time, the growth of all sorts of hospitalist specialties has further changed the medical staff of the hospital. Internal-medicine and family-practice hospitalists now number more than 35,000. There are probably more than 2,000 pediatric hospitalists. The newly formed Society of OB/GYN Hospitalists (SOGH) estimates there are more than 1,500 so-called laborists in the U.S., and there are several hundred neurohospitalists, orthopedic hospitalists, and acute-care surgeons.
It is clear to me that a “home team” for the hospital of the future is developing, and it includes hospitalists, ED physicians, critical-care physicians, and the growing panoply of hospital-employed cardiologists and surgeons. There is an opportunity for alignment and integration in what has been a fragmented delivery of healthcare.
On the commercial side of the equation, this new opportunity for physician-hospital alignment might allow for a new distribution of compensation. It already is common for hospitals to be transferring some of “their” Medicare Part A dollars to hospitalists. With penalties or additional payments in the ACO model (e.g. shared savings) or in value-based purchasing, there certainly are mechanisms to redistribute funding to new physician compensation models, based more on performance than on volume of services (i.e. the old productivity model).
On another level, where compensation and performance merge, the new medical staff has the ability to deliver a safer hospital experience to our patients and to improve performance. This could take the form of reduction in hospital-acquired infections (HAIs) or reducing unnecessary DVTs and PEs. It could take the form of a better discharge process that leads to fewer unnecessary readmissions or fewer preventable ED visits. On the OB side, 24-hour on-site availability of OB hospitalists has been shown to reduce adverse birth events and, therefore, reduce liability risk and malpractice premiums. On-site availability for patients with fractures and trauma cases by orthopedic hospitalists or hospital-employed orthopedists also can reduce expenses and adverse events for these acutely ill patients.
HM’s Role
With all these changes occurring so rapidly and with all these new players being thrown into the stew at the hospital, it may be worth a few minutes for the “traditional” hospitalist on the medical service to step back and see how our role may evolve. We already have an increasing role in comanagement of surgical and subspecialty patients, as well as a more integrated role at the ED-hospitalist interface. As hospitals look for hospital-focused physicians, there is a potential for scope creep that must be thoughtfully managed.
This may require “rules of engagement” with other key services. While it may be appropriate for a patient with an acute abdomen to be admitted to the hospitalist service, if the hospitalist determines that this patient needs surgery sooner rather than later, there needs to be a straightforward way to get the surgeon in house and on the case and the patient to the operating room. To this point, medical hospitalists can help manage the medical aspects of a neurosurgical case, but we don’t do burr holes. And if there is to be pushback from the surgeon, this can’t happen at 2 a.m. over the telephone; it must be handled by the service leaders at their weekly meeting.
On another level, hospitalists need to be careful that the hospital doesn’t just hand us the administrative functions of other physicians’ care. Hospitalists are not the default to do H&Ps on surgical cases or handle their discharges, even if this falls into the hospital strategy to be able to employ fewer high-priced surgeons and subspecialists by handing off some of their work to their hospitalists.
On the other hand, it is totally appropriate for many of the hospital-focused physicians to come together, possibly under the leadership of the hospital CMO, to look at the workflow and to set up a new way to deliver healthcare that not only redefines the workload, but also involves the rest of the team, including nursing, pharmacy, case management, and social services. Medical hospitalists will need to consider whether we should be the hub of the new physician enterprise and what that would mean for workload, FTEs, and scope of practice.
Such organizations as SHM and the American Hospital Association (AHA) are thinking how best to support and convene the hospital-based physician. AHA has developed a Physician Forum with more than 6,000 members who now have their practices aligned with their hospital. SHM has held meetings of the leaders of hospital-focused practice and is developing virtual forums on Hospital Medicine Exchange to keep the discussion going. Through the Hospital Care Collaborative (HCC), SHM is engaging the leadership of pharmacy, nursing, case management, social services, and respiratory therapy.
Although we are still early in creating the direction for the new medical staff, the water is rising and the current is moving rapidly. The strong forces that are driving new payment paradigms are leading to changes in compensation and an emphasis on definable, measureable outcomes of performance and safety. Hospitalists, who have been thinking in this way and who have some experience in the new ways, should be well positioned to lead and participate actively in the formation of the new hospital home team.
When opportunity knocks, you still have to get up and answer the door. It’s time to get ready to step up.
Dr. Wellikson is CEO of SHM.
Defining a Safe Workload for Pediatric Hospitalists
As I write this column, I am on the second leg of an overnight flight back home to Austin, Texas. I think it actually went pretty well, considering my 2-year-old daughter was wide awake after sleeping for the first three hours of this 14-hour odyssey. The remainder of the trip is a blur of awkward sleep positions interspersed with brief periods of semilucidity. Those of you with first-hand knowledge of what this experience is like might be feeling sorry for me, but you shouldn’t. I am returning from a “why don’t I live here” kind of vacation week in Hawaii. The rest of you are probably wondering how anyone could write a coherent column at this point, which is fair, but to which I would reply: Aren’t all hospitalists expected to function at high levels during periods of sleep deprivation?
While the issue of resident duty-hours has been discussed endlessly and studied increasingly, in terms of effects on outcomes, I am surprised there has not been more discussion surrounding the concept of attending duty-hours. The subject might not always be phrased to include the term “duty-hours,” but it seems that when it comes to scheduling, strong opinions come out in my group when the duration of, frequency of, or time off between night shifts are brought up. And when it comes to safety, I am certain sleep deprivation and sleep inertia (that period of haziness immediately after being awakened in the middle of the night) have led to questionable decisions on my part.
Why? Well...
So why do pediatric hospitalists avoid the issue of sleep hygiene, work schedules, and clinical impact? I think the reasons are multifactorial.
First, there are definitely individual variations in how all of us tolerate this work, and I suspect some of this is based on such traits as age and general ability to adapt to uncomfortable circadian flip-flops. I will admit that every time I wake up achy after a call night, I begin to wonder if I will be able to handle this in 10 to 15 years.
Second, I think pediatric HM as a field has not yet explored this topic fully because we are young both in terms of chronological age as well as nocturnal work-years. The work has not yet aged us to the point of making this a critical issue. We’re also somewhat behind our adult-hospitalist colleagues in terms of the volume of nocturnal work. Adult HM groups have long explored different shift schedules (seven-on/seven-off, day/evening/overnight distribution, etc.) because they routinely cover large services of more than 100 patients in large hospitals with more than 500 beds. In pediatrics, most of us operate in small community hospital settings or large academic centers where the nightly in-house quantity of work is relatively low, mitigated by the smaller size of most community programs and the presence of residents in most large children’s hospitals.
But I see this as an important issue for us to define: the imperative to define safe, round-the-clock clinical care and sustainable careers. Although we will need to learn from other fields, HM is somewhat different from other types of 24/7 medicine in that we require more continuity in our daytime work, which also carries over to night shifts both in terms of how the schedule is made as well as the benefit on the clinical side. The need for continuity adds an extra degree of difficulty in creating and studying different schedules that try to optimize nocturnal functioning.
Clarity, Please
Unfortunately, those looking for evidence-based, or even consensus-based, solutions might have to wait. A recent article in the Journal of Hospital Medicine does a nice job of synthesizing the literature and highlights the lack of clear answers for what kind of shift schedules work best.1
In the absence of scientific solutions, it might be too easy to say that we need “more research,” because what doesn’t need more research? (OK, we don’t need more research on interventions for bronchiolitis.) But in the same manner in which pediatric hospitalists have taken the lead in defining a night curriculum for residents (congratulations, Becky Blankenburg, on winning the Ray E. Helfer award in pediatric education), I believe there is an opportunity to improve circadian functioning for all hospital-based physicians, but more specifically attendings. This is even more important as residents work less and a 24/7 attending presence becomes the norm in teaching facilities. While the link between safety and fatigue may have been seen as a nonissue in past decades, I think that in our current era, this is something that we own and/or will be asked to define in the near future.
In the meantime, I think we’re left to our own schedules. And in defense of all schedulers like me out there, I will say that there are no proven solutions, so local culture will predominate. Different groups with different personalities and family makeups will have varying preferences. Smaller groups will tend to have longer shift times with less flexibility in “swing”-type midday or evening shifts, while larger groups might have increased flexibility in defining different shifts at the expense of added complexity in terms of creating a schedule with no gaps.
As we come up with more rules about night shifts, such as “clockwise” scheduling of day-evening-overnight shifts, single versus clustered nights based on frequency, and days off after night shifts, the more complex and awkward our Tetris-like schedule will become. I predict that this is something hospitalists will begin to think about more, with a necessary push for safe and sustainable schedules. In the short-term, allowing for financial and structural wiggle room in the scheduling process (i.e. adjusting shift patterns and differential pay for night work) might be the most balanced approach for the immediate future.
Dr. Shen is pediatric editor of The Hospitalist. Write to him at [email protected].
Reference
As I write this column, I am on the second leg of an overnight flight back home to Austin, Texas. I think it actually went pretty well, considering my 2-year-old daughter was wide awake after sleeping for the first three hours of this 14-hour odyssey. The remainder of the trip is a blur of awkward sleep positions interspersed with brief periods of semilucidity. Those of you with first-hand knowledge of what this experience is like might be feeling sorry for me, but you shouldn’t. I am returning from a “why don’t I live here” kind of vacation week in Hawaii. The rest of you are probably wondering how anyone could write a coherent column at this point, which is fair, but to which I would reply: Aren’t all hospitalists expected to function at high levels during periods of sleep deprivation?
While the issue of resident duty-hours has been discussed endlessly and studied increasingly, in terms of effects on outcomes, I am surprised there has not been more discussion surrounding the concept of attending duty-hours. The subject might not always be phrased to include the term “duty-hours,” but it seems that when it comes to scheduling, strong opinions come out in my group when the duration of, frequency of, or time off between night shifts are brought up. And when it comes to safety, I am certain sleep deprivation and sleep inertia (that period of haziness immediately after being awakened in the middle of the night) have led to questionable decisions on my part.
Why? Well...
So why do pediatric hospitalists avoid the issue of sleep hygiene, work schedules, and clinical impact? I think the reasons are multifactorial.
First, there are definitely individual variations in how all of us tolerate this work, and I suspect some of this is based on such traits as age and general ability to adapt to uncomfortable circadian flip-flops. I will admit that every time I wake up achy after a call night, I begin to wonder if I will be able to handle this in 10 to 15 years.
Second, I think pediatric HM as a field has not yet explored this topic fully because we are young both in terms of chronological age as well as nocturnal work-years. The work has not yet aged us to the point of making this a critical issue. We’re also somewhat behind our adult-hospitalist colleagues in terms of the volume of nocturnal work. Adult HM groups have long explored different shift schedules (seven-on/seven-off, day/evening/overnight distribution, etc.) because they routinely cover large services of more than 100 patients in large hospitals with more than 500 beds. In pediatrics, most of us operate in small community hospital settings or large academic centers where the nightly in-house quantity of work is relatively low, mitigated by the smaller size of most community programs and the presence of residents in most large children’s hospitals.
But I see this as an important issue for us to define: the imperative to define safe, round-the-clock clinical care and sustainable careers. Although we will need to learn from other fields, HM is somewhat different from other types of 24/7 medicine in that we require more continuity in our daytime work, which also carries over to night shifts both in terms of how the schedule is made as well as the benefit on the clinical side. The need for continuity adds an extra degree of difficulty in creating and studying different schedules that try to optimize nocturnal functioning.
Clarity, Please
Unfortunately, those looking for evidence-based, or even consensus-based, solutions might have to wait. A recent article in the Journal of Hospital Medicine does a nice job of synthesizing the literature and highlights the lack of clear answers for what kind of shift schedules work best.1
In the absence of scientific solutions, it might be too easy to say that we need “more research,” because what doesn’t need more research? (OK, we don’t need more research on interventions for bronchiolitis.) But in the same manner in which pediatric hospitalists have taken the lead in defining a night curriculum for residents (congratulations, Becky Blankenburg, on winning the Ray E. Helfer award in pediatric education), I believe there is an opportunity to improve circadian functioning for all hospital-based physicians, but more specifically attendings. This is even more important as residents work less and a 24/7 attending presence becomes the norm in teaching facilities. While the link between safety and fatigue may have been seen as a nonissue in past decades, I think that in our current era, this is something that we own and/or will be asked to define in the near future.
In the meantime, I think we’re left to our own schedules. And in defense of all schedulers like me out there, I will say that there are no proven solutions, so local culture will predominate. Different groups with different personalities and family makeups will have varying preferences. Smaller groups will tend to have longer shift times with less flexibility in “swing”-type midday or evening shifts, while larger groups might have increased flexibility in defining different shifts at the expense of added complexity in terms of creating a schedule with no gaps.
As we come up with more rules about night shifts, such as “clockwise” scheduling of day-evening-overnight shifts, single versus clustered nights based on frequency, and days off after night shifts, the more complex and awkward our Tetris-like schedule will become. I predict that this is something hospitalists will begin to think about more, with a necessary push for safe and sustainable schedules. In the short-term, allowing for financial and structural wiggle room in the scheduling process (i.e. adjusting shift patterns and differential pay for night work) might be the most balanced approach for the immediate future.
Dr. Shen is pediatric editor of The Hospitalist. Write to him at [email protected].
Reference
As I write this column, I am on the second leg of an overnight flight back home to Austin, Texas. I think it actually went pretty well, considering my 2-year-old daughter was wide awake after sleeping for the first three hours of this 14-hour odyssey. The remainder of the trip is a blur of awkward sleep positions interspersed with brief periods of semilucidity. Those of you with first-hand knowledge of what this experience is like might be feeling sorry for me, but you shouldn’t. I am returning from a “why don’t I live here” kind of vacation week in Hawaii. The rest of you are probably wondering how anyone could write a coherent column at this point, which is fair, but to which I would reply: Aren’t all hospitalists expected to function at high levels during periods of sleep deprivation?
While the issue of resident duty-hours has been discussed endlessly and studied increasingly, in terms of effects on outcomes, I am surprised there has not been more discussion surrounding the concept of attending duty-hours. The subject might not always be phrased to include the term “duty-hours,” but it seems that when it comes to scheduling, strong opinions come out in my group when the duration of, frequency of, or time off between night shifts are brought up. And when it comes to safety, I am certain sleep deprivation and sleep inertia (that period of haziness immediately after being awakened in the middle of the night) have led to questionable decisions on my part.
Why? Well...
So why do pediatric hospitalists avoid the issue of sleep hygiene, work schedules, and clinical impact? I think the reasons are multifactorial.
First, there are definitely individual variations in how all of us tolerate this work, and I suspect some of this is based on such traits as age and general ability to adapt to uncomfortable circadian flip-flops. I will admit that every time I wake up achy after a call night, I begin to wonder if I will be able to handle this in 10 to 15 years.
Second, I think pediatric HM as a field has not yet explored this topic fully because we are young both in terms of chronological age as well as nocturnal work-years. The work has not yet aged us to the point of making this a critical issue. We’re also somewhat behind our adult-hospitalist colleagues in terms of the volume of nocturnal work. Adult HM groups have long explored different shift schedules (seven-on/seven-off, day/evening/overnight distribution, etc.) because they routinely cover large services of more than 100 patients in large hospitals with more than 500 beds. In pediatrics, most of us operate in small community hospital settings or large academic centers where the nightly in-house quantity of work is relatively low, mitigated by the smaller size of most community programs and the presence of residents in most large children’s hospitals.
But I see this as an important issue for us to define: the imperative to define safe, round-the-clock clinical care and sustainable careers. Although we will need to learn from other fields, HM is somewhat different from other types of 24/7 medicine in that we require more continuity in our daytime work, which also carries over to night shifts both in terms of how the schedule is made as well as the benefit on the clinical side. The need for continuity adds an extra degree of difficulty in creating and studying different schedules that try to optimize nocturnal functioning.
Clarity, Please
Unfortunately, those looking for evidence-based, or even consensus-based, solutions might have to wait. A recent article in the Journal of Hospital Medicine does a nice job of synthesizing the literature and highlights the lack of clear answers for what kind of shift schedules work best.1
In the absence of scientific solutions, it might be too easy to say that we need “more research,” because what doesn’t need more research? (OK, we don’t need more research on interventions for bronchiolitis.) But in the same manner in which pediatric hospitalists have taken the lead in defining a night curriculum for residents (congratulations, Becky Blankenburg, on winning the Ray E. Helfer award in pediatric education), I believe there is an opportunity to improve circadian functioning for all hospital-based physicians, but more specifically attendings. This is even more important as residents work less and a 24/7 attending presence becomes the norm in teaching facilities. While the link between safety and fatigue may have been seen as a nonissue in past decades, I think that in our current era, this is something that we own and/or will be asked to define in the near future.
In the meantime, I think we’re left to our own schedules. And in defense of all schedulers like me out there, I will say that there are no proven solutions, so local culture will predominate. Different groups with different personalities and family makeups will have varying preferences. Smaller groups will tend to have longer shift times with less flexibility in “swing”-type midday or evening shifts, while larger groups might have increased flexibility in defining different shifts at the expense of added complexity in terms of creating a schedule with no gaps.
As we come up with more rules about night shifts, such as “clockwise” scheduling of day-evening-overnight shifts, single versus clustered nights based on frequency, and days off after night shifts, the more complex and awkward our Tetris-like schedule will become. I predict that this is something hospitalists will begin to think about more, with a necessary push for safe and sustainable schedules. In the short-term, allowing for financial and structural wiggle room in the scheduling process (i.e. adjusting shift patterns and differential pay for night work) might be the most balanced approach for the immediate future.
Dr. Shen is pediatric editor of The Hospitalist. Write to him at [email protected].