Practice Economics

Dr. Morse

Global health hospitalists are passionate about their work. The Hospitalist asked them to expand on the reasons they choose this work.

“Working in Haiti has been the most compelling work in my life,” says Michelle Morse, MD, MPH, an instructor in medicine at Harvard Medical School and deputy chief medical officer for Partners in Health (PIH) in Boston. She has worked with the Navajo Nation in conjunction with PIH’s Community Outreach and Patient Empowerment (COPE) program. The sharing of information is “bi-directional,” Dr. Morse says.

Dr. Morse

Her Haitian colleagues, she says, have developed “transformative” systems improvements, and she’s found that her own diagnostic and physical exam skills have strengthened because of her work abroad.

“You really have to think bigger than your group of patients and bigger than your community, and think about the whole system to make things better around the world,” she says. “I think that is a fundamental part of becoming a physician.”

UCSF clinical fellow Varun Verma, MD, says he was tired of working in “fragmented volunteer assignments” with relief organizations. Three-month clinical rotations, in which he essentially functions as a teaching attending, have solved the “filling in” feeling he’d grown weary of.

“Here at St. Thérèse Hospital [in Hinche, Haiti], they do not need us to take care of patients on a moment-to-moment basis. There are Haitian clinicians for that,” he says. “Part of our job is to do medical teaching of residents and try to involve everyone in quality improvement projects. It’s sometimes challenging discussing best practices of managing conditions, given the resources at hand, but I find that the Haitian doctors are always interested in learning how we do things in the U.S.”

Evan Lyon, MD, assistant professor of medicine in the section of hospital medicine, supervises clinical fellows in the department of medicine at the University of Chicago. He believes hospitalists who take on global health assignments gain a deeper appreciation for assessing patients’ social histories.

“There’s no better way to deepen your learning of physical exam and history-taking skills than to be out here on the edge and have to rely on those skills,” he says. “Back in the states, you might order an echocardiogram before you listen to the patient’s heart. I think all of us have a different relationship to labs, testing, and X-rays when we return. But the deepest influence for me has been around understanding patients’ social histories and their social context, which is a neglected piece of American medicine.”

Dr. Shoeb

Sharing resources and knowledge is what drives Marwa Shoeb MD, MS, assistant professor in the division of hospital medicine at UCSF. “I see this as an extension of our daily work,” she says. “We are just taking it to a different context.”

Gretchen Henkel is a freelance writer in southern California.

Dr. Morse

Global health hospitalists are passionate about their work. The Hospitalist asked them to expand on the reasons they choose this work.

“Working in Haiti has been the most compelling work in my life,” says Michelle Morse, MD, MPH, an instructor in medicine at Harvard Medical School and deputy chief medical officer for Partners in Health (PIH) in Boston. She has worked with the Navajo Nation in conjunction with PIH’s Community Outreach and Patient Empowerment (COPE) program. The sharing of information is “bi-directional,” Dr. Morse says.

Dr. Morse

Her Haitian colleagues, she says, have developed “transformative” systems improvements, and she’s found that her own diagnostic and physical exam skills have strengthened because of her work abroad.

“You really have to think bigger than your group of patients and bigger than your community, and think about the whole system to make things better around the world,” she says. “I think that is a fundamental part of becoming a physician.”

UCSF clinical fellow Varun Verma, MD, says he was tired of working in “fragmented volunteer assignments” with relief organizations. Three-month clinical rotations, in which he essentially functions as a teaching attending, have solved the “filling in” feeling he’d grown weary of.

“Here at St. Thérèse Hospital [in Hinche, Haiti], they do not need us to take care of patients on a moment-to-moment basis. There are Haitian clinicians for that,” he says. “Part of our job is to do medical teaching of residents and try to involve everyone in quality improvement projects. It’s sometimes challenging discussing best practices of managing conditions, given the resources at hand, but I find that the Haitian doctors are always interested in learning how we do things in the U.S.”

Evan Lyon, MD, assistant professor of medicine in the section of hospital medicine, supervises clinical fellows in the department of medicine at the University of Chicago. He believes hospitalists who take on global health assignments gain a deeper appreciation for assessing patients’ social histories.

“There’s no better way to deepen your learning of physical exam and history-taking skills than to be out here on the edge and have to rely on those skills,” he says. “Back in the states, you might order an echocardiogram before you listen to the patient’s heart. I think all of us have a different relationship to labs, testing, and X-rays when we return. But the deepest influence for me has been around understanding patients’ social histories and their social context, which is a neglected piece of American medicine.”

Dr. Shoeb

Sharing resources and knowledge is what drives Marwa Shoeb MD, MS, assistant professor in the division of hospital medicine at UCSF. “I see this as an extension of our daily work,” she says. “We are just taking it to a different context.”

Gretchen Henkel is a freelance writer in southern California.

Dr. Morse

Global health hospitalists are passionate about their work. The Hospitalist asked them to expand on the reasons they choose this work.

“Working in Haiti has been the most compelling work in my life,” says Michelle Morse, MD, MPH, an instructor in medicine at Harvard Medical School and deputy chief medical officer for Partners in Health (PIH) in Boston. She has worked with the Navajo Nation in conjunction with PIH’s Community Outreach and Patient Empowerment (COPE) program. The sharing of information is “bi-directional,” Dr. Morse says.

Dr. Morse

Her Haitian colleagues, she says, have developed “transformative” systems improvements, and she’s found that her own diagnostic and physical exam skills have strengthened because of her work abroad.

“You really have to think bigger than your group of patients and bigger than your community, and think about the whole system to make things better around the world,” she says. “I think that is a fundamental part of becoming a physician.”

UCSF clinical fellow Varun Verma, MD, says he was tired of working in “fragmented volunteer assignments” with relief organizations. Three-month clinical rotations, in which he essentially functions as a teaching attending, have solved the “filling in” feeling he’d grown weary of.

“Here at St. Thérèse Hospital [in Hinche, Haiti], they do not need us to take care of patients on a moment-to-moment basis. There are Haitian clinicians for that,” he says. “Part of our job is to do medical teaching of residents and try to involve everyone in quality improvement projects. It’s sometimes challenging discussing best practices of managing conditions, given the resources at hand, but I find that the Haitian doctors are always interested in learning how we do things in the U.S.”

Evan Lyon, MD, assistant professor of medicine in the section of hospital medicine, supervises clinical fellows in the department of medicine at the University of Chicago. He believes hospitalists who take on global health assignments gain a deeper appreciation for assessing patients’ social histories.

“There’s no better way to deepen your learning of physical exam and history-taking skills than to be out here on the edge and have to rely on those skills,” he says. “Back in the states, you might order an echocardiogram before you listen to the patient’s heart. I think all of us have a different relationship to labs, testing, and X-rays when we return. But the deepest influence for me has been around understanding patients’ social histories and their social context, which is a neglected piece of American medicine.”

Dr. Shoeb

Sharing resources and knowledge is what drives Marwa Shoeb MD, MS, assistant professor in the division of hospital medicine at UCSF. “I see this as an extension of our daily work,” she says. “We are just taking it to a different context.”

Gretchen Henkel is a freelance writer in southern California.

Listen to more of our interview with Dr. Hendel-Paterson, as he discusses the advantages of a good needs assessment.

Listen to more of our interview with Dr. Hendel-Paterson, as he discusses the advantages of a good needs assessment.

Listen to more of our interview with Dr. Hendel-Paterson, as he discusses the advantages of a good needs assessment.

Dr. Nelson

Dr. Nelson

Serving as the lead physician for a hospital medicine group (HMG) makes for challenging work. And the challenges and complexity only increase for anyone who serves as the physician leader for multiple practice sites in the same hospital system. In my November 2013 column on multi-site HMG leaders, I listed a few of the tricky issues they face and will mention a few more here.

Large-Small Friction

Unfortunately, tension between hospitalists at the big hospital and doctors at the small, “feeder” hospitals seems pretty common, and I think it’s due largely to high stress and a wide variation in workload, neither of which are in our direct control. At facilities where there is significant tension, I’m impressed by how vigorously the hospitalists at both the small and large hospitals argue that their own site faces the most stress and challenges. (This is a little like the endless debate about who works harder, those who work with residents and those who don’t.)

The hospitalists at the small site point out that they work with little or no subspecialty help and might even have to take night call from home while working during the day. Those at the big hospital say they are the ones with the very large scope of clinical practice and that, rather than making their life easier, the presence of lots of subspecialists makes for additional work coordinating care and communicating with all parties.

Where it exists, this tension is most evident during a transfer from one of the small hospitals to the large one. After all, one of the reasons to form a system of hospitals is so that nearly all patient needs can be met at one of the facilities in the system. Yet, for many reasons, the hospitalists at the large hospital are—sometimes—not as receptive to transfers as might be ideal. They might be short staffed or facing a high census or an unusually high number of admissions from their own ED. Or, perhaps, they’re concerned that the subspecialty services for which the patient is being transferred (e.g. to be scoped by a GI doctor) won’t be as helpful or prompt as needed. Or maybe they’ve felt “burned” by their colleagues at the small hospital for past transfers that didn’t seem necessary.

The result can be that the doctors at the smaller hospital complain that the “mother ship” hospitalists often are unfriendly and unreceptive to transfer requests. Although there may not be a definitive “cure” for this issue, there are several ways to help address the problem.

• In my last column, I mentioned the value of one or more in-person meetings between those who tend to be on the sending and receiving end of transfers, to establish some criteria regarding transfers that are appropriate and review the process of requesting a transfer and making the associated arrangements. In most cases there will be value in the parties meeting routinely—perhaps two to four times annually—to review how the system is working and address any difficulties.
• Periodic social meetings among the hospitalists at each site will help to form relationships that can make it less likely that any conversation about transfers will go in an unhelpful direction. Things can be very different when the people on each end of the phone call know each other personally.
• Record the phone calls between those seeking and accepting/declining each transfer. Scott Rissmiller, MD, the lead hospitalist for the 17 practice sites in Carolinas Healthcare, has said that having underperforming doctors listen to recordings of their phone calls about transfers has, in most cases he’s been involved with, proven to be a very effective way to encourage improvement.

Shared Staffing

The small hospitals in many systems sometimes struggle to find a way to provide economical night coverage. Hospitals below a certain size find it very difficult to justify a separate, in-house night provider. Some hospital systems have had success sharing night staffing, with the large hospital’s night hospitalist, nurse practitioner, or physician assistant providing telephone coverage for “cross cover” issues that arise after hours.

For example, when a nurse at the small hospital needs to contact a night hospitalist, staff will page the provider at the big hospital, and, in many cases, the issue can be managed effectively by phone. This works best when both hospitals are on the same electronic medical record, so that the responding provider can look through the record as needed.

The hospitalist at the small hospital typically stays on back-up call and is contacted if bedside attention is required.

Or, if the large and small hospitals are a short drive apart, the night hospitalist at the large facility might make the short drive to the small hospital when needed. In the case of emergencies (i.e., a code blue), the in-house night ED physician is relied on as the first responder.

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

Dr. Nelson

Dr. Nelson

Serving as the lead physician for a hospital medicine group (HMG) makes for challenging work. And the challenges and complexity only increase for anyone who serves as the physician leader for multiple practice sites in the same hospital system. In my November 2013 column on multi-site HMG leaders, I listed a few of the tricky issues they face and will mention a few more here.

Large-Small Friction

Unfortunately, tension between hospitalists at the big hospital and doctors at the small, “feeder” hospitals seems pretty common, and I think it’s due largely to high stress and a wide variation in workload, neither of which are in our direct control. At facilities where there is significant tension, I’m impressed by how vigorously the hospitalists at both the small and large hospitals argue that their own site faces the most stress and challenges. (This is a little like the endless debate about who works harder, those who work with residents and those who don’t.)

The hospitalists at the small site point out that they work with little or no subspecialty help and might even have to take night call from home while working during the day. Those at the big hospital say they are the ones with the very large scope of clinical practice and that, rather than making their life easier, the presence of lots of subspecialists makes for additional work coordinating care and communicating with all parties.

Where it exists, this tension is most evident during a transfer from one of the small hospitals to the large one. After all, one of the reasons to form a system of hospitals is so that nearly all patient needs can be met at one of the facilities in the system. Yet, for many reasons, the hospitalists at the large hospital are—sometimes—not as receptive to transfers as might be ideal. They might be short staffed or facing a high census or an unusually high number of admissions from their own ED. Or, perhaps, they’re concerned that the subspecialty services for which the patient is being transferred (e.g. to be scoped by a GI doctor) won’t be as helpful or prompt as needed. Or maybe they’ve felt “burned” by their colleagues at the small hospital for past transfers that didn’t seem necessary.

The result can be that the doctors at the smaller hospital complain that the “mother ship” hospitalists often are unfriendly and unreceptive to transfer requests. Although there may not be a definitive “cure” for this issue, there are several ways to help address the problem.

• In my last column, I mentioned the value of one or more in-person meetings between those who tend to be on the sending and receiving end of transfers, to establish some criteria regarding transfers that are appropriate and review the process of requesting a transfer and making the associated arrangements. In most cases there will be value in the parties meeting routinely—perhaps two to four times annually—to review how the system is working and address any difficulties.
• Periodic social meetings among the hospitalists at each site will help to form relationships that can make it less likely that any conversation about transfers will go in an unhelpful direction. Things can be very different when the people on each end of the phone call know each other personally.
• Record the phone calls between those seeking and accepting/declining each transfer. Scott Rissmiller, MD, the lead hospitalist for the 17 practice sites in Carolinas Healthcare, has said that having underperforming doctors listen to recordings of their phone calls about transfers has, in most cases he’s been involved with, proven to be a very effective way to encourage improvement.

Shared Staffing

The small hospitals in many systems sometimes struggle to find a way to provide economical night coverage. Hospitals below a certain size find it very difficult to justify a separate, in-house night provider. Some hospital systems have had success sharing night staffing, with the large hospital’s night hospitalist, nurse practitioner, or physician assistant providing telephone coverage for “cross cover” issues that arise after hours.

For example, when a nurse at the small hospital needs to contact a night hospitalist, staff will page the provider at the big hospital, and, in many cases, the issue can be managed effectively by phone. This works best when both hospitals are on the same electronic medical record, so that the responding provider can look through the record as needed.

The hospitalist at the small hospital typically stays on back-up call and is contacted if bedside attention is required.

Or, if the large and small hospitals are a short drive apart, the night hospitalist at the large facility might make the short drive to the small hospital when needed. In the case of emergencies (i.e., a code blue), the in-house night ED physician is relied on as the first responder.

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

Dr. Nelson

Dr. Nelson

Serving as the lead physician for a hospital medicine group (HMG) makes for challenging work. And the challenges and complexity only increase for anyone who serves as the physician leader for multiple practice sites in the same hospital system. In my November 2013 column on multi-site HMG leaders, I listed a few of the tricky issues they face and will mention a few more here.

Large-Small Friction

Unfortunately, tension between hospitalists at the big hospital and doctors at the small, “feeder” hospitals seems pretty common, and I think it’s due largely to high stress and a wide variation in workload, neither of which are in our direct control. At facilities where there is significant tension, I’m impressed by how vigorously the hospitalists at both the small and large hospitals argue that their own site faces the most stress and challenges. (This is a little like the endless debate about who works harder, those who work with residents and those who don’t.)

The hospitalists at the small site point out that they work with little or no subspecialty help and might even have to take night call from home while working during the day. Those at the big hospital say they are the ones with the very large scope of clinical practice and that, rather than making their life easier, the presence of lots of subspecialists makes for additional work coordinating care and communicating with all parties.

Where it exists, this tension is most evident during a transfer from one of the small hospitals to the large one. After all, one of the reasons to form a system of hospitals is so that nearly all patient needs can be met at one of the facilities in the system. Yet, for many reasons, the hospitalists at the large hospital are—sometimes—not as receptive to transfers as might be ideal. They might be short staffed or facing a high census or an unusually high number of admissions from their own ED. Or, perhaps, they’re concerned that the subspecialty services for which the patient is being transferred (e.g. to be scoped by a GI doctor) won’t be as helpful or prompt as needed. Or maybe they’ve felt “burned” by their colleagues at the small hospital for past transfers that didn’t seem necessary.

The result can be that the doctors at the smaller hospital complain that the “mother ship” hospitalists often are unfriendly and unreceptive to transfer requests. Although there may not be a definitive “cure” for this issue, there are several ways to help address the problem.

• In my last column, I mentioned the value of one or more in-person meetings between those who tend to be on the sending and receiving end of transfers, to establish some criteria regarding transfers that are appropriate and review the process of requesting a transfer and making the associated arrangements. In most cases there will be value in the parties meeting routinely—perhaps two to four times annually—to review how the system is working and address any difficulties.
• Periodic social meetings among the hospitalists at each site will help to form relationships that can make it less likely that any conversation about transfers will go in an unhelpful direction. Things can be very different when the people on each end of the phone call know each other personally.
• Record the phone calls between those seeking and accepting/declining each transfer. Scott Rissmiller, MD, the lead hospitalist for the 17 practice sites in Carolinas Healthcare, has said that having underperforming doctors listen to recordings of their phone calls about transfers has, in most cases he’s been involved with, proven to be a very effective way to encourage improvement.

Shared Staffing

The small hospitals in many systems sometimes struggle to find a way to provide economical night coverage. Hospitals below a certain size find it very difficult to justify a separate, in-house night provider. Some hospital systems have had success sharing night staffing, with the large hospital’s night hospitalist, nurse practitioner, or physician assistant providing telephone coverage for “cross cover” issues that arise after hours.

For example, when a nurse at the small hospital needs to contact a night hospitalist, staff will page the provider at the big hospital, and, in many cases, the issue can be managed effectively by phone. This works best when both hospitals are on the same electronic medical record, so that the responding provider can look through the record as needed.

The hospitalist at the small hospital typically stays on back-up call and is contacted if bedside attention is required.

Or, if the large and small hospitals are a short drive apart, the night hospitalist at the large facility might make the short drive to the small hospital when needed. In the case of emergencies (i.e., a code blue), the in-house night ED physician is relied on as the first responder.

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

The American Hospital Association’s Health Research and Educational Trust (HRET) recently obtained a grant from the federal Agency for Healthcare Research and Quality to expand CUSP, the Comprehensive Unit-based Safety Program for reducing catheter-associated urinary tract infections (CAUTI) and other healthcare-associated infections, to nursing homes and skilled nursing facilities nationwide.

CUSP has posted a 40% reduction in central line-associated bloodstream infections (CLABSI) in 1,000 participating hospitals by providing education and support and an evidence-based protocol. The grant will be administered by HRET in partnership with others, including the University of Michigan Health System, the Association for Professionals in Infection Control and Epidemiology, and SHM.

Meanwhile, a study published in the American Journal of Infection Control found that rates of catheter-associated urinary tract infections in adult patients given urinary catheter placements dropped nationwide to 5.3% in 2010 from 9.4% in 2001.³ The retrospective analysis of data from the National Hospital Discharge Survey found that CAUTI-related mortality and associated length of hospital stay also declined during the same period.

Larry Beresford is a freelance writer in Alameda, Calif.

The American Hospital Association’s Health Research and Educational Trust (HRET) recently obtained a grant from the federal Agency for Healthcare Research and Quality to expand CUSP, the Comprehensive Unit-based Safety Program for reducing catheter-associated urinary tract infections (CAUTI) and other healthcare-associated infections, to nursing homes and skilled nursing facilities nationwide.

CUSP has posted a 40% reduction in central line-associated bloodstream infections (CLABSI) in 1,000 participating hospitals by providing education and support and an evidence-based protocol. The grant will be administered by HRET in partnership with others, including the University of Michigan Health System, the Association for Professionals in Infection Control and Epidemiology, and SHM.

Meanwhile, a study published in the American Journal of Infection Control found that rates of catheter-associated urinary tract infections in adult patients given urinary catheter placements dropped nationwide to 5.3% in 2010 from 9.4% in 2001.³ The retrospective analysis of data from the National Hospital Discharge Survey found that CAUTI-related mortality and associated length of hospital stay also declined during the same period.

Larry Beresford is a freelance writer in Alameda, Calif.

The American Hospital Association’s Health Research and Educational Trust (HRET) recently obtained a grant from the federal Agency for Healthcare Research and Quality to expand CUSP, the Comprehensive Unit-based Safety Program for reducing catheter-associated urinary tract infections (CAUTI) and other healthcare-associated infections, to nursing homes and skilled nursing facilities nationwide.

CUSP has posted a 40% reduction in central line-associated bloodstream infections (CLABSI) in 1,000 participating hospitals by providing education and support and an evidence-based protocol. The grant will be administered by HRET in partnership with others, including the University of Michigan Health System, the Association for Professionals in Infection Control and Epidemiology, and SHM.

Meanwhile, a study published in the American Journal of Infection Control found that rates of catheter-associated urinary tract infections in adult patients given urinary catheter placements dropped nationwide to 5.3% in 2010 from 9.4% in 2001.³ The retrospective analysis of data from the National Hospital Discharge Survey found that CAUTI-related mortality and associated length of hospital stay also declined during the same period.

Larry Beresford is a freelance writer in Alameda, Calif.

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

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

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

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

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

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

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

Larry Beresford is a freelance writer in Alameda, Calif.

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

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

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

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

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

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

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

Larry Beresford is a freelance writer in Alameda, Calif.

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

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

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

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

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

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

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

Larry Beresford is a freelance writer in Alameda, Calif.

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

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

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

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

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

Larry Beresford is a freelance writer in Alameda, Calif.

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

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

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

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

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

Larry Beresford is a freelance writer in Alameda, Calif.

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

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

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

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

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

Larry Beresford is a freelance writer in Alameda, Calif.

Dr. Hospitalist

“Infusion Privileges” a Simple Answer to Complex Issue

I have a couple of questions based on the following scenario: hospital infusion center treating patients referred by physicians who are not members of hospital staff and don’t have hospital privileges. Since they are not credentialed at the hospital, they cannot give orders for infusion treatment for their patients. And they are not interested in applying for membership and hospital privileges. First, is it OK for the referring physicians to talk to our hospitalist of the day and give an infusion treatment order? Second, what CPT code would the hospitalist use for just writing an infusion treatment order—and can they bill the service?

—Glena Loyola

Dr. Hospitalist responds:

The alternate site infusion therapy market has exploded in the U.S. in the past 25 years. Most of this surge has been driven by increased emphasis on cost containment and the desires of patients to resume their usual lifestyles while recovering from illness. Most recent estimates show that these services represent approximately $9-$11 billion a year. Although the cost is substantial, it is far lower than the cost of inpatient treatment.

Many hospitals have infusion centers, both as revenue-generating ventures and to provide a service for their patients without admitting them to the hospital. Initially, most centers focused on oncologic medications; most now provide a variety of infusion services and therapies. Having clinical staff, prescribing physicians, and pharmacists under the same roof, or in the same healthcare system, should lead to better communication, which is key when administering these specialty drugs. The center at my hospital is of average size, and it seems there are at least one or two medical emergencies there every month. I can imagine the wasted time and lives lost in situations where a full cadre of emergency staff was not immediately available.

The processes and procedures developed by hospital administrators to allow physicians to administer these medications are highly variable. When the centers first came on the scene, most of the prescribing physicians were practicing oncologists and active members of the medical staff. While oncologists still make up the largest group utilizing these centers, rheumatologists, cardiologists, and endocrinologists also are active participants. As these clinicians have aged, and as the services, as well as the variety of infusions, have expanded, hospitals have needed alternate staffing models to keep up.

My CMO created specific “infusion privileges” for health system physicians working on alternate campuses. This privilege allows them to write for the medications but does not give them core privileges like most courtesy staff designations. There is no associated hospital call or ED coverage requirement, and no quality monitoring is needed with this “special” designation. We did consider having our hospitalist write the orders for these docs, but there were many reasons not to go that route—most importantly the logistics and our current HM program’s bandwidth.

The situation you describe, in which physicians call in and give infusion orders to another physician/hospitalist, is the one I believe is most fraught with problems. The potential for prescribing error is very high. Plus, the multiple downstream opportunities for the patient’s care to be compromised are myriad. Because the consequences of a medication error with many of these infusions can be catastrophic, most institutions (including ours) limit who can prescribe them to those specializing in that field. Many also require physicians to use computerized physician order entry, which has been shown to reduce medication errors, for these agents.

The billing requirements for infusion centers and prescribers are very complex and were last globally consolidated in May 2004. CMS annually updates using National Correct Coding Initiative Edits, with which most coders are familiar. The CPT code is tied to the infusion or type of infusion that is given and even incorporates the amount of time it takes to administer. Prior to 2004, the codes incorporated practice expense as well as malpractice relative value units (RVUs), but zero physician RVUs. Since then, a lot has changed. Although a physician can usually bill for services using E&M codes, most require face-to-face time to be allowable. If you would like to bill independently as a prescriber for your services, I recommend you sit down with your coders and decide if it’s feasible.

Dr. Hospitalist

“Infusion Privileges” a Simple Answer to Complex Issue

I have a couple of questions based on the following scenario: hospital infusion center treating patients referred by physicians who are not members of hospital staff and don’t have hospital privileges. Since they are not credentialed at the hospital, they cannot give orders for infusion treatment for their patients. And they are not interested in applying for membership and hospital privileges. First, is it OK for the referring physicians to talk to our hospitalist of the day and give an infusion treatment order? Second, what CPT code would the hospitalist use for just writing an infusion treatment order—and can they bill the service?

—Glena Loyola

Dr. Hospitalist responds:

The alternate site infusion therapy market has exploded in the U.S. in the past 25 years. Most of this surge has been driven by increased emphasis on cost containment and the desires of patients to resume their usual lifestyles while recovering from illness. Most recent estimates show that these services represent approximately $9-$11 billion a year. Although the cost is substantial, it is far lower than the cost of inpatient treatment.

Many hospitals have infusion centers, both as revenue-generating ventures and to provide a service for their patients without admitting them to the hospital. Initially, most centers focused on oncologic medications; most now provide a variety of infusion services and therapies. Having clinical staff, prescribing physicians, and pharmacists under the same roof, or in the same healthcare system, should lead to better communication, which is key when administering these specialty drugs. The center at my hospital is of average size, and it seems there are at least one or two medical emergencies there every month. I can imagine the wasted time and lives lost in situations where a full cadre of emergency staff was not immediately available.

The processes and procedures developed by hospital administrators to allow physicians to administer these medications are highly variable. When the centers first came on the scene, most of the prescribing physicians were practicing oncologists and active members of the medical staff. While oncologists still make up the largest group utilizing these centers, rheumatologists, cardiologists, and endocrinologists also are active participants. As these clinicians have aged, and as the services, as well as the variety of infusions, have expanded, hospitals have needed alternate staffing models to keep up.

My CMO created specific “infusion privileges” for health system physicians working on alternate campuses. This privilege allows them to write for the medications but does not give them core privileges like most courtesy staff designations. There is no associated hospital call or ED coverage requirement, and no quality monitoring is needed with this “special” designation. We did consider having our hospitalist write the orders for these docs, but there were many reasons not to go that route—most importantly the logistics and our current HM program’s bandwidth.

The situation you describe, in which physicians call in and give infusion orders to another physician/hospitalist, is the one I believe is most fraught with problems. The potential for prescribing error is very high. Plus, the multiple downstream opportunities for the patient’s care to be compromised are myriad. Because the consequences of a medication error with many of these infusions can be catastrophic, most institutions (including ours) limit who can prescribe them to those specializing in that field. Many also require physicians to use computerized physician order entry, which has been shown to reduce medication errors, for these agents.

The billing requirements for infusion centers and prescribers are very complex and were last globally consolidated in May 2004. CMS annually updates using National Correct Coding Initiative Edits, with which most coders are familiar. The CPT code is tied to the infusion or type of infusion that is given and even incorporates the amount of time it takes to administer. Prior to 2004, the codes incorporated practice expense as well as malpractice relative value units (RVUs), but zero physician RVUs. Since then, a lot has changed. Although a physician can usually bill for services using E&M codes, most require face-to-face time to be allowable. If you would like to bill independently as a prescriber for your services, I recommend you sit down with your coders and decide if it’s feasible.

Dr. Hospitalist

“Infusion Privileges” a Simple Answer to Complex Issue

I have a couple of questions based on the following scenario: hospital infusion center treating patients referred by physicians who are not members of hospital staff and don’t have hospital privileges. Since they are not credentialed at the hospital, they cannot give orders for infusion treatment for their patients. And they are not interested in applying for membership and hospital privileges. First, is it OK for the referring physicians to talk to our hospitalist of the day and give an infusion treatment order? Second, what CPT code would the hospitalist use for just writing an infusion treatment order—and can they bill the service?

—Glena Loyola

Dr. Hospitalist responds:

The alternate site infusion therapy market has exploded in the U.S. in the past 25 years. Most of this surge has been driven by increased emphasis on cost containment and the desires of patients to resume their usual lifestyles while recovering from illness. Most recent estimates show that these services represent approximately $9-$11 billion a year. Although the cost is substantial, it is far lower than the cost of inpatient treatment.

Many hospitals have infusion centers, both as revenue-generating ventures and to provide a service for their patients without admitting them to the hospital. Initially, most centers focused on oncologic medications; most now provide a variety of infusion services and therapies. Having clinical staff, prescribing physicians, and pharmacists under the same roof, or in the same healthcare system, should lead to better communication, which is key when administering these specialty drugs. The center at my hospital is of average size, and it seems there are at least one or two medical emergencies there every month. I can imagine the wasted time and lives lost in situations where a full cadre of emergency staff was not immediately available.

The processes and procedures developed by hospital administrators to allow physicians to administer these medications are highly variable. When the centers first came on the scene, most of the prescribing physicians were practicing oncologists and active members of the medical staff. While oncologists still make up the largest group utilizing these centers, rheumatologists, cardiologists, and endocrinologists also are active participants. As these clinicians have aged, and as the services, as well as the variety of infusions, have expanded, hospitals have needed alternate staffing models to keep up.

My CMO created specific “infusion privileges” for health system physicians working on alternate campuses. This privilege allows them to write for the medications but does not give them core privileges like most courtesy staff designations. There is no associated hospital call or ED coverage requirement, and no quality monitoring is needed with this “special” designation. We did consider having our hospitalist write the orders for these docs, but there were many reasons not to go that route—most importantly the logistics and our current HM program’s bandwidth.

The situation you describe, in which physicians call in and give infusion orders to another physician/hospitalist, is the one I believe is most fraught with problems. The potential for prescribing error is very high. Plus, the multiple downstream opportunities for the patient’s care to be compromised are myriad. Because the consequences of a medication error with many of these infusions can be catastrophic, most institutions (including ours) limit who can prescribe them to those specializing in that field. Many also require physicians to use computerized physician order entry, which has been shown to reduce medication errors, for these agents.

The billing requirements for infusion centers and prescribers are very complex and were last globally consolidated in May 2004. CMS annually updates using National Correct Coding Initiative Edits, with which most coders are familiar. The CPT code is tied to the infusion or type of infusion that is given and even incorporates the amount of time it takes to administer. Prior to 2004, the codes incorporated practice expense as well as malpractice relative value units (RVUs), but zero physician RVUs. Since then, a lot has changed. Although a physician can usually bill for services using E&M codes, most require face-to-face time to be allowable. If you would like to bill independently as a prescriber for your services, I recommend you sit down with your coders and decide if it’s feasible.

Are you looking to improve your hospital medicine group (HMG)? Would you like to measure your group against other groups?

The February 2013 issue of the Journal of Hospital Medicine included a seminal article for our specialty, “The Key Principles and Characteristics of an Effective Hospital Medicine Group: an assessment guide for hospitals and hospitalists.” This paper has received a vast amount of attention around the country from hospitalists, hospitalist leaders, HMGs, and hospital executives. The report (www.hospitalmedicine.org/keychar) is a first step for physicians and executives looking to benchmark their practices, and it has stimulated discussions among many HMGs, beginning a process of self-review and considering action.

I am coming up on my 20th year as a hospitalist, and the debate over what makes a high-performing HMG has continued that entire time. In the beginning, there were questions about the mere existence of hospital medicine and HMGs. The discussion about what makes a high-performing HMG started among the physicians, medical groups, and hospitals that signed on early to the HM movement. At conferences, HMG leaders debated how to set up a program. A series of pioneer hospitalists, many with only a few years of experience, roamed the country as consultants giving advice on best practices. A professional society, the National Association of Inpatient Physicians, was born and, later, recast as the Society of Hospital Medicine (SHM)—and the discussion continued.

SHM furthered the debate with such important milestones as The Core Competencies in Hospital Medicine: A Framework for Curriculum Development, white papers on career satisfaction and hospitalist involvement in quality/safety and transitions of care. Different types of practice arrangements developed. Some were hospital-based, some physician practice-centered. Some were local, and others were regional and national. Each of these spawned innovations in HMG processes and contributed to the growing body of best practices.

Over the past five years, a consensus regarding those best practices has seemingly developed, and the discussions are centered on fine details rather than significant differences. To that end, approximately three years ago, a small group of SHM members met and discussed how to capture this information and disseminate it better among hospitalists, HMGs, and hospitals. We had all come to a similar conclusion—high-performing HMGs share common characteristics. Furthermore, every hospital and HMG seeks excellence, striving to be the best that they can be. We settled on a plan to write this up.

After a year of debate, we sought SHM’s help in the development phase and, in early 2012, SHM’s board of directors appointed a workgroup to identify the key principles and characteristics of an effective HMG. The initial group was widened to make sure we included different backgrounds and experiences in hospital medicine. The group had a wide array of involvement in HMG models, including HMG members, HMG leaders, hospital executives, and some involved in consulting. Many of the individuals had multiple experiences. The conversation among these individuals was lively!

The workgroup developed an initial draft of characteristics, which then went through a multi-step process of review and redrafting. More than 200 individuals, representing a broad group of stakeholders in hospital medicine and in the healthcare industry in general, provided comments and feedback. In addition, the workgroup went through a two-step Delphi process to consolidate and/or eliminate characteristics that were redundant or unnecessary.

In the final framework, 47 key characteristics were defined and organized under 10 principles (see Figure 1).

The authors and SHM’s board of directors view this document as an aspirational approach to improvement. We feel it helps to “raise the bar” for the specialty of hospital medicine by laying out a roadmap of potential improvement. These principles and characteristics provide a framework for HMGs seeking to conduct self-assessments, outlining a pathway for improvement, and better defining the central role of hospitalists in coordinating team-based, patient-centered care in the acute care setting.

In enhancing quality, the approach of a gap analysis is a very effective tool. These principles provide an excellent approach to begin that review.

So how do you get started? Hopefully, your HMG has a regular meeting. Take a principle and have a conversation. For example, what do we have? What don’t we have?

Other groups may want to tackle the entire document in a daylong strategy review. Some may want an outside facilitator. Bottom line: It doesn’t matter how you do it; just start with a conversation.

Dr. Cawley is CEO of Medical University of South Carolina Medical Center in Charleston. He is past president of SHM.

Reference

1. Cawley P, Deitelzweig S, Flores L, et al. The key principles and characteristics of an effective hospital medicine group: An assessment guide for hospitals and hospitalists. J Hosp Med. 2014;9(2):123-128.

Are you looking to improve your hospital medicine group (HMG)? Would you like to measure your group against other groups?

The February 2013 issue of the Journal of Hospital Medicine included a seminal article for our specialty, “The Key Principles and Characteristics of an Effective Hospital Medicine Group: an assessment guide for hospitals and hospitalists.” This paper has received a vast amount of attention around the country from hospitalists, hospitalist leaders, HMGs, and hospital executives. The report (www.hospitalmedicine.org/keychar) is a first step for physicians and executives looking to benchmark their practices, and it has stimulated discussions among many HMGs, beginning a process of self-review and considering action.

I am coming up on my 20th year as a hospitalist, and the debate over what makes a high-performing HMG has continued that entire time. In the beginning, there were questions about the mere existence of hospital medicine and HMGs. The discussion about what makes a high-performing HMG started among the physicians, medical groups, and hospitals that signed on early to the HM movement. At conferences, HMG leaders debated how to set up a program. A series of pioneer hospitalists, many with only a few years of experience, roamed the country as consultants giving advice on best practices. A professional society, the National Association of Inpatient Physicians, was born and, later, recast as the Society of Hospital Medicine (SHM)—and the discussion continued.

SHM furthered the debate with such important milestones as The Core Competencies in Hospital Medicine: A Framework for Curriculum Development, white papers on career satisfaction and hospitalist involvement in quality/safety and transitions of care. Different types of practice arrangements developed. Some were hospital-based, some physician practice-centered. Some were local, and others were regional and national. Each of these spawned innovations in HMG processes and contributed to the growing body of best practices.

Over the past five years, a consensus regarding those best practices has seemingly developed, and the discussions are centered on fine details rather than significant differences. To that end, approximately three years ago, a small group of SHM members met and discussed how to capture this information and disseminate it better among hospitalists, HMGs, and hospitals. We had all come to a similar conclusion—high-performing HMGs share common characteristics. Furthermore, every hospital and HMG seeks excellence, striving to be the best that they can be. We settled on a plan to write this up.

After a year of debate, we sought SHM’s help in the development phase and, in early 2012, SHM’s board of directors appointed a workgroup to identify the key principles and characteristics of an effective HMG. The initial group was widened to make sure we included different backgrounds and experiences in hospital medicine. The group had a wide array of involvement in HMG models, including HMG members, HMG leaders, hospital executives, and some involved in consulting. Many of the individuals had multiple experiences. The conversation among these individuals was lively!

The workgroup developed an initial draft of characteristics, which then went through a multi-step process of review and redrafting. More than 200 individuals, representing a broad group of stakeholders in hospital medicine and in the healthcare industry in general, provided comments and feedback. In addition, the workgroup went through a two-step Delphi process to consolidate and/or eliminate characteristics that were redundant or unnecessary.

In the final framework, 47 key characteristics were defined and organized under 10 principles (see Figure 1).

The authors and SHM’s board of directors view this document as an aspirational approach to improvement. We feel it helps to “raise the bar” for the specialty of hospital medicine by laying out a roadmap of potential improvement. These principles and characteristics provide a framework for HMGs seeking to conduct self-assessments, outlining a pathway for improvement, and better defining the central role of hospitalists in coordinating team-based, patient-centered care in the acute care setting.

In enhancing quality, the approach of a gap analysis is a very effective tool. These principles provide an excellent approach to begin that review.

So how do you get started? Hopefully, your HMG has a regular meeting. Take a principle and have a conversation. For example, what do we have? What don’t we have?

Other groups may want to tackle the entire document in a daylong strategy review. Some may want an outside facilitator. Bottom line: It doesn’t matter how you do it; just start with a conversation.

Dr. Cawley is CEO of Medical University of South Carolina Medical Center in Charleston. He is past president of SHM.

Reference

1. Cawley P, Deitelzweig S, Flores L, et al. The key principles and characteristics of an effective hospital medicine group: An assessment guide for hospitals and hospitalists. J Hosp Med. 2014;9(2):123-128.

Are you looking to improve your hospital medicine group (HMG)? Would you like to measure your group against other groups?

The February 2013 issue of the Journal of Hospital Medicine included a seminal article for our specialty, “The Key Principles and Characteristics of an Effective Hospital Medicine Group: an assessment guide for hospitals and hospitalists.” This paper has received a vast amount of attention around the country from hospitalists, hospitalist leaders, HMGs, and hospital executives. The report (www.hospitalmedicine.org/keychar) is a first step for physicians and executives looking to benchmark their practices, and it has stimulated discussions among many HMGs, beginning a process of self-review and considering action.

I am coming up on my 20th year as a hospitalist, and the debate over what makes a high-performing HMG has continued that entire time. In the beginning, there were questions about the mere existence of hospital medicine and HMGs. The discussion about what makes a high-performing HMG started among the physicians, medical groups, and hospitals that signed on early to the HM movement. At conferences, HMG leaders debated how to set up a program. A series of pioneer hospitalists, many with only a few years of experience, roamed the country as consultants giving advice on best practices. A professional society, the National Association of Inpatient Physicians, was born and, later, recast as the Society of Hospital Medicine (SHM)—and the discussion continued.

SHM furthered the debate with such important milestones as The Core Competencies in Hospital Medicine: A Framework for Curriculum Development, white papers on career satisfaction and hospitalist involvement in quality/safety and transitions of care. Different types of practice arrangements developed. Some were hospital-based, some physician practice-centered. Some were local, and others were regional and national. Each of these spawned innovations in HMG processes and contributed to the growing body of best practices.

Over the past five years, a consensus regarding those best practices has seemingly developed, and the discussions are centered on fine details rather than significant differences. To that end, approximately three years ago, a small group of SHM members met and discussed how to capture this information and disseminate it better among hospitalists, HMGs, and hospitals. We had all come to a similar conclusion—high-performing HMGs share common characteristics. Furthermore, every hospital and HMG seeks excellence, striving to be the best that they can be. We settled on a plan to write this up.

After a year of debate, we sought SHM’s help in the development phase and, in early 2012, SHM’s board of directors appointed a workgroup to identify the key principles and characteristics of an effective HMG. The initial group was widened to make sure we included different backgrounds and experiences in hospital medicine. The group had a wide array of involvement in HMG models, including HMG members, HMG leaders, hospital executives, and some involved in consulting. Many of the individuals had multiple experiences. The conversation among these individuals was lively!

The workgroup developed an initial draft of characteristics, which then went through a multi-step process of review and redrafting. More than 200 individuals, representing a broad group of stakeholders in hospital medicine and in the healthcare industry in general, provided comments and feedback. In addition, the workgroup went through a two-step Delphi process to consolidate and/or eliminate characteristics that were redundant or unnecessary.

In the final framework, 47 key characteristics were defined and organized under 10 principles (see Figure 1).

The authors and SHM’s board of directors view this document as an aspirational approach to improvement. We feel it helps to “raise the bar” for the specialty of hospital medicine by laying out a roadmap of potential improvement. These principles and characteristics provide a framework for HMGs seeking to conduct self-assessments, outlining a pathway for improvement, and better defining the central role of hospitalists in coordinating team-based, patient-centered care in the acute care setting.

In enhancing quality, the approach of a gap analysis is a very effective tool. These principles provide an excellent approach to begin that review.

So how do you get started? Hopefully, your HMG has a regular meeting. Take a principle and have a conversation. For example, what do we have? What don’t we have?

Other groups may want to tackle the entire document in a daylong strategy review. Some may want an outside facilitator. Bottom line: It doesn’t matter how you do it; just start with a conversation.

Dr. Cawley is CEO of Medical University of South Carolina Medical Center in Charleston. He is past president of SHM.

Reference

1. Cawley P, Deitelzweig S, Flores L, et al. The key principles and characteristics of an effective hospital medicine group: An assessment guide for hospitals and hospitalists. J Hosp Med. 2014;9(2):123-128.