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Building a career in quality improvement
As quality continues to take on a more important role in the health care delivery system, new opportunities for employment are taking shape.
For the hospitalist, that can mean a number of different career paths. What those paths could look like is the subject of the session “Making a Career Out of Quality” at 11:00 a.m. Tuesday.
“Because [quality] is a growing field and because many of the roles that are being created are often new within health systems,” the options hospitalists might have – or the highest value–added roles they might create – are not obvious, said Paul W. Helgerson, MD, SFHM, of the University of Virginia, Charlottesville, a presenter at the session.
Shedding light on those opportunities is the overall objective of this session, he said.
“One objective is to display for attendees what the diversity of roles looks like in this space,” Dr. Helgerson said. “If I am interested in spending part of my time or part of my career in quality, ‘What do people do?’ The truth is there is a whole array of different things.”
The second objective addresses the training that is required for some of these career options.
“We want to be able to represent what the whole breadth of the training experience could look like, from individual mentorship at the local level to formal training for a few days or even a few months nationwide,” he said.
Finally, the session will provide some boots-on-the-ground insight from clinicians at various stages in this space. Dr. Helgerson wants to highlight effective strategies to develop one’s career efficiently and effectively, to align with institutional leadership to create high-impact projects, and to look outside institutions for mentors to help make the career path successful.
The panel features three different perspectives. Dr. Helgerson will talk about his role at the University of Virginia and the work he has done in faculty development and interdisciplinary team development. Read G. Pierce, MD, of the University of Colorado at Denver, Aurora, is heavily involved in leadership training, and Nazima Allaudeen, MD, of the VA Palo Alto (Calif.) Health Care System, will talk about quality outcomes improvement on an operational level.
“My specific section is about different training in QI and that takes a lot of different shapes,” Dr. Allaudeen said. “There is a lot out there that people may not know about, and we will help explain how to match people with the right type of training that will be of the most value.”
“A hospitalist will be able to walk out of this session with a plan,” Dr. Helgerson said.
Making a Career Out of Quality
Tuesday, 11 a.m.-Noon
Crystal Ballroom G1/A&B
As quality continues to take on a more important role in the health care delivery system, new opportunities for employment are taking shape.
For the hospitalist, that can mean a number of different career paths. What those paths could look like is the subject of the session “Making a Career Out of Quality” at 11:00 a.m. Tuesday.
“Because [quality] is a growing field and because many of the roles that are being created are often new within health systems,” the options hospitalists might have – or the highest value–added roles they might create – are not obvious, said Paul W. Helgerson, MD, SFHM, of the University of Virginia, Charlottesville, a presenter at the session.
Shedding light on those opportunities is the overall objective of this session, he said.
“One objective is to display for attendees what the diversity of roles looks like in this space,” Dr. Helgerson said. “If I am interested in spending part of my time or part of my career in quality, ‘What do people do?’ The truth is there is a whole array of different things.”
The second objective addresses the training that is required for some of these career options.
“We want to be able to represent what the whole breadth of the training experience could look like, from individual mentorship at the local level to formal training for a few days or even a few months nationwide,” he said.
Finally, the session will provide some boots-on-the-ground insight from clinicians at various stages in this space. Dr. Helgerson wants to highlight effective strategies to develop one’s career efficiently and effectively, to align with institutional leadership to create high-impact projects, and to look outside institutions for mentors to help make the career path successful.
The panel features three different perspectives. Dr. Helgerson will talk about his role at the University of Virginia and the work he has done in faculty development and interdisciplinary team development. Read G. Pierce, MD, of the University of Colorado at Denver, Aurora, is heavily involved in leadership training, and Nazima Allaudeen, MD, of the VA Palo Alto (Calif.) Health Care System, will talk about quality outcomes improvement on an operational level.
“My specific section is about different training in QI and that takes a lot of different shapes,” Dr. Allaudeen said. “There is a lot out there that people may not know about, and we will help explain how to match people with the right type of training that will be of the most value.”
“A hospitalist will be able to walk out of this session with a plan,” Dr. Helgerson said.
Making a Career Out of Quality
Tuesday, 11 a.m.-Noon
Crystal Ballroom G1/A&B
As quality continues to take on a more important role in the health care delivery system, new opportunities for employment are taking shape.
For the hospitalist, that can mean a number of different career paths. What those paths could look like is the subject of the session “Making a Career Out of Quality” at 11:00 a.m. Tuesday.
“Because [quality] is a growing field and because many of the roles that are being created are often new within health systems,” the options hospitalists might have – or the highest value–added roles they might create – are not obvious, said Paul W. Helgerson, MD, SFHM, of the University of Virginia, Charlottesville, a presenter at the session.
Shedding light on those opportunities is the overall objective of this session, he said.
“One objective is to display for attendees what the diversity of roles looks like in this space,” Dr. Helgerson said. “If I am interested in spending part of my time or part of my career in quality, ‘What do people do?’ The truth is there is a whole array of different things.”
The second objective addresses the training that is required for some of these career options.
“We want to be able to represent what the whole breadth of the training experience could look like, from individual mentorship at the local level to formal training for a few days or even a few months nationwide,” he said.
Finally, the session will provide some boots-on-the-ground insight from clinicians at various stages in this space. Dr. Helgerson wants to highlight effective strategies to develop one’s career efficiently and effectively, to align with institutional leadership to create high-impact projects, and to look outside institutions for mentors to help make the career path successful.
The panel features three different perspectives. Dr. Helgerson will talk about his role at the University of Virginia and the work he has done in faculty development and interdisciplinary team development. Read G. Pierce, MD, of the University of Colorado at Denver, Aurora, is heavily involved in leadership training, and Nazima Allaudeen, MD, of the VA Palo Alto (Calif.) Health Care System, will talk about quality outcomes improvement on an operational level.
“My specific section is about different training in QI and that takes a lot of different shapes,” Dr. Allaudeen said. “There is a lot out there that people may not know about, and we will help explain how to match people with the right type of training that will be of the most value.”
“A hospitalist will be able to walk out of this session with a plan,” Dr. Helgerson said.
Making a Career Out of Quality
Tuesday, 11 a.m.-Noon
Crystal Ballroom G1/A&B
Admitting medicine patients to off-service, nonmedicine units linked with increased in-hospital mortality
Background: Increased saturation of hospital capacity compromises patient outcomes. This creates additional challenges for the provision of appropriate specialized care. In some hospitals, patients are “bed-spaced,” or admitted to non–internal medicine service locations, such as a surgical ward, in order to free up space in the emergency department. Whether bed-spacing reduces quality of care or patient outcomes has not been previously studied.
Study design: Retrospective cohort study.
Setting: Large tertiary care academic hospital in Canada, during Jan. 1, 2015-Jan. 1, 2016.
Synopsis: There were 3,243 patients included in the analysis, of which 1,125 (35%) were bed-spaced to the off-service wards. The remaining 2,118 patients (65%) were admitted to the assigned internal medicine units. In the first week of hospitalization, in-hospital mortality among bed-spaced patients was approximately three times that of patients admitted to the assigned internal medicine wards. Upon admission, in-hospital mortality for the bed-spaced patients had a hazard ratio of 3.42 (95% confidence interval, 2.23-5.26; P less than .0001) with subsequent decrease by 0.97 (95% CI, 0.94-0.99; P = .0133) per day in the hospital. By the third week of hospitalization, the mortality risks had equalized. Sensitivity analyses revealed similar results.
Bottom line: This retrospective study is based on a single center; however, the observed increased mortality among the bed-spaced patients merits further investigation. Assessment of study generalizability and formulation of strategies for improving patient safety are needed.
Citation: Bai AD et al. Mortality of hospitalised internal medicine patients bed-spaced to non–internal medicine inpatient units: Retrospective cohort study. BMJ Qual Saf. 2018 Jan;27(1):11-20. doi: 10.1136/bmjqs-2017-006925.
Dr. Burklin is assistant professor of medicine in the division of hospital medicine, Emory University, Atlanta.
Background: Increased saturation of hospital capacity compromises patient outcomes. This creates additional challenges for the provision of appropriate specialized care. In some hospitals, patients are “bed-spaced,” or admitted to non–internal medicine service locations, such as a surgical ward, in order to free up space in the emergency department. Whether bed-spacing reduces quality of care or patient outcomes has not been previously studied.
Study design: Retrospective cohort study.
Setting: Large tertiary care academic hospital in Canada, during Jan. 1, 2015-Jan. 1, 2016.
Synopsis: There were 3,243 patients included in the analysis, of which 1,125 (35%) were bed-spaced to the off-service wards. The remaining 2,118 patients (65%) were admitted to the assigned internal medicine units. In the first week of hospitalization, in-hospital mortality among bed-spaced patients was approximately three times that of patients admitted to the assigned internal medicine wards. Upon admission, in-hospital mortality for the bed-spaced patients had a hazard ratio of 3.42 (95% confidence interval, 2.23-5.26; P less than .0001) with subsequent decrease by 0.97 (95% CI, 0.94-0.99; P = .0133) per day in the hospital. By the third week of hospitalization, the mortality risks had equalized. Sensitivity analyses revealed similar results.
Bottom line: This retrospective study is based on a single center; however, the observed increased mortality among the bed-spaced patients merits further investigation. Assessment of study generalizability and formulation of strategies for improving patient safety are needed.
Citation: Bai AD et al. Mortality of hospitalised internal medicine patients bed-spaced to non–internal medicine inpatient units: Retrospective cohort study. BMJ Qual Saf. 2018 Jan;27(1):11-20. doi: 10.1136/bmjqs-2017-006925.
Dr. Burklin is assistant professor of medicine in the division of hospital medicine, Emory University, Atlanta.
Background: Increased saturation of hospital capacity compromises patient outcomes. This creates additional challenges for the provision of appropriate specialized care. In some hospitals, patients are “bed-spaced,” or admitted to non–internal medicine service locations, such as a surgical ward, in order to free up space in the emergency department. Whether bed-spacing reduces quality of care or patient outcomes has not been previously studied.
Study design: Retrospective cohort study.
Setting: Large tertiary care academic hospital in Canada, during Jan. 1, 2015-Jan. 1, 2016.
Synopsis: There were 3,243 patients included in the analysis, of which 1,125 (35%) were bed-spaced to the off-service wards. The remaining 2,118 patients (65%) were admitted to the assigned internal medicine units. In the first week of hospitalization, in-hospital mortality among bed-spaced patients was approximately three times that of patients admitted to the assigned internal medicine wards. Upon admission, in-hospital mortality for the bed-spaced patients had a hazard ratio of 3.42 (95% confidence interval, 2.23-5.26; P less than .0001) with subsequent decrease by 0.97 (95% CI, 0.94-0.99; P = .0133) per day in the hospital. By the third week of hospitalization, the mortality risks had equalized. Sensitivity analyses revealed similar results.
Bottom line: This retrospective study is based on a single center; however, the observed increased mortality among the bed-spaced patients merits further investigation. Assessment of study generalizability and formulation of strategies for improving patient safety are needed.
Citation: Bai AD et al. Mortality of hospitalised internal medicine patients bed-spaced to non–internal medicine inpatient units: Retrospective cohort study. BMJ Qual Saf. 2018 Jan;27(1):11-20. doi: 10.1136/bmjqs-2017-006925.
Dr. Burklin is assistant professor of medicine in the division of hospital medicine, Emory University, Atlanta.
Engaging skeptical parents
While every day seems to bring extraordinary new advances in science – robotic surgery, individually targeted medications, and even gene therapy – there are many people who currently approach the science of medicine with skepticism.
While it is the right of legally competent adults in a free society to chose how best to care for their own health, to explore holistic or alternative therapies, or avoid medicine altogether, it is more complex when they are skeptical of accepted medical practice in managing the health of their children. For those parents who trust you enough to bring their children to you for care but remain skeptical of vaccines or other treatments, you have an opportunity to work with that trust and engage in a discussion so that they might reconsider their position on valuable and even life-saving treatments for their children.
In each of these cases, launching into an enthusiastic explanation of the advanced statistics that underpin your recommendation is unlikely to bridge the gap. Instead, you want to start with these parents by being curious. Resist the urge to tell, and listen instead. What is their understanding of the problem you are treating or preventing? What have they heard or read about the treatment or test in question? What do they most fear is going to happen to their child if they do or do not accept your recommendation? Are there specific events (with their child or with the health care system) that have informed this fear?
Respectfully listening to their experiences, thoughts, and feelings goes a long way toward building a trusting alliance. It can help overcome feelings of distrust or defensiveness around authority figures. And it models the thoughtful, respectful give and take that are essential to a healthy collaboration between pediatrician and parents.
Once you have information about what they think and some about how they think and make decisions, you then can offer your perspective. “You are the expert on your child, what I bring to this equation is experience with (this problem) and with assessing the scientific evidence that guides treatments in medicine. It is true that treatments often change as we learn more, but here is what the evidence currently supports.”
After learning something about how they think, you might offer more data or more warm acknowledgment of how difficult it can be to make medical decisions for your children with imperfect information. Be humble while also being accurate about your level of confidence in a recommendation. Humility is important because it is easy for parents to feel insecure and condescended to. You understand their greatest fear, now let them know what your greatest worry is for their child should they forgo a recommended treatment. Explaining all of this with humility and warmth makes it more likely that the parents will take in the facts you are trying to share with them and not be derailed by suspicion, defensiveness, or insecurity.
Make building an alliance with the parents your top priority. This does not mean that you do not offer your best recommendation for their child. Rather, it means that, if they still decline recommended treatment, you treat them with respect and invest your time in explaining what they should be watching or monitoring their child for without recommended treatment. Building trust is a long game. If you patiently stick with parents even when it’s not easy, they may be ready to trust you with a subsequent decision when the stakes are even higher.
Of course, all this thoughtful communication takes a lot of time! You may learn to block off more time for certain families. It also can be helpful to have these conversations as a team. If you and your nurse or social worker can meet with parents together, then some of the listening and learning can be done by the nurse or social worker alone, so that everyone’s time might be managed more efficiently. And managing skeptical parents as a team also can help to prevent frustration or burnout. It will not always succeed, but in some cases, your investment will pay off in a trusting alliance, mutual respect, and healthy patients.
Dr. Swick is an attending psychiatrist in the division of child psychiatry at Massachusetts General Hospital, Boston, and director of the Parenting at a Challenging Time (PACT) Program at the Vernon Cancer Center at Newton Wellesley Hospital, also in Boston. Dr. Jellinek is professor emeritus of psychiatry and pediatrics at Harvard Medical School, Boston. Email them at [email protected].
While every day seems to bring extraordinary new advances in science – robotic surgery, individually targeted medications, and even gene therapy – there are many people who currently approach the science of medicine with skepticism.
While it is the right of legally competent adults in a free society to chose how best to care for their own health, to explore holistic or alternative therapies, or avoid medicine altogether, it is more complex when they are skeptical of accepted medical practice in managing the health of their children. For those parents who trust you enough to bring their children to you for care but remain skeptical of vaccines or other treatments, you have an opportunity to work with that trust and engage in a discussion so that they might reconsider their position on valuable and even life-saving treatments for their children.
In each of these cases, launching into an enthusiastic explanation of the advanced statistics that underpin your recommendation is unlikely to bridge the gap. Instead, you want to start with these parents by being curious. Resist the urge to tell, and listen instead. What is their understanding of the problem you are treating or preventing? What have they heard or read about the treatment or test in question? What do they most fear is going to happen to their child if they do or do not accept your recommendation? Are there specific events (with their child or with the health care system) that have informed this fear?
Respectfully listening to their experiences, thoughts, and feelings goes a long way toward building a trusting alliance. It can help overcome feelings of distrust or defensiveness around authority figures. And it models the thoughtful, respectful give and take that are essential to a healthy collaboration between pediatrician and parents.
Once you have information about what they think and some about how they think and make decisions, you then can offer your perspective. “You are the expert on your child, what I bring to this equation is experience with (this problem) and with assessing the scientific evidence that guides treatments in medicine. It is true that treatments often change as we learn more, but here is what the evidence currently supports.”
After learning something about how they think, you might offer more data or more warm acknowledgment of how difficult it can be to make medical decisions for your children with imperfect information. Be humble while also being accurate about your level of confidence in a recommendation. Humility is important because it is easy for parents to feel insecure and condescended to. You understand their greatest fear, now let them know what your greatest worry is for their child should they forgo a recommended treatment. Explaining all of this with humility and warmth makes it more likely that the parents will take in the facts you are trying to share with them and not be derailed by suspicion, defensiveness, or insecurity.
Make building an alliance with the parents your top priority. This does not mean that you do not offer your best recommendation for their child. Rather, it means that, if they still decline recommended treatment, you treat them with respect and invest your time in explaining what they should be watching or monitoring their child for without recommended treatment. Building trust is a long game. If you patiently stick with parents even when it’s not easy, they may be ready to trust you with a subsequent decision when the stakes are even higher.
Of course, all this thoughtful communication takes a lot of time! You may learn to block off more time for certain families. It also can be helpful to have these conversations as a team. If you and your nurse or social worker can meet with parents together, then some of the listening and learning can be done by the nurse or social worker alone, so that everyone’s time might be managed more efficiently. And managing skeptical parents as a team also can help to prevent frustration or burnout. It will not always succeed, but in some cases, your investment will pay off in a trusting alliance, mutual respect, and healthy patients.
Dr. Swick is an attending psychiatrist in the division of child psychiatry at Massachusetts General Hospital, Boston, and director of the Parenting at a Challenging Time (PACT) Program at the Vernon Cancer Center at Newton Wellesley Hospital, also in Boston. Dr. Jellinek is professor emeritus of psychiatry and pediatrics at Harvard Medical School, Boston. Email them at [email protected].
While every day seems to bring extraordinary new advances in science – robotic surgery, individually targeted medications, and even gene therapy – there are many people who currently approach the science of medicine with skepticism.
While it is the right of legally competent adults in a free society to chose how best to care for their own health, to explore holistic or alternative therapies, or avoid medicine altogether, it is more complex when they are skeptical of accepted medical practice in managing the health of their children. For those parents who trust you enough to bring their children to you for care but remain skeptical of vaccines or other treatments, you have an opportunity to work with that trust and engage in a discussion so that they might reconsider their position on valuable and even life-saving treatments for their children.
In each of these cases, launching into an enthusiastic explanation of the advanced statistics that underpin your recommendation is unlikely to bridge the gap. Instead, you want to start with these parents by being curious. Resist the urge to tell, and listen instead. What is their understanding of the problem you are treating or preventing? What have they heard or read about the treatment or test in question? What do they most fear is going to happen to their child if they do or do not accept your recommendation? Are there specific events (with their child or with the health care system) that have informed this fear?
Respectfully listening to their experiences, thoughts, and feelings goes a long way toward building a trusting alliance. It can help overcome feelings of distrust or defensiveness around authority figures. And it models the thoughtful, respectful give and take that are essential to a healthy collaboration between pediatrician and parents.
Once you have information about what they think and some about how they think and make decisions, you then can offer your perspective. “You are the expert on your child, what I bring to this equation is experience with (this problem) and with assessing the scientific evidence that guides treatments in medicine. It is true that treatments often change as we learn more, but here is what the evidence currently supports.”
After learning something about how they think, you might offer more data or more warm acknowledgment of how difficult it can be to make medical decisions for your children with imperfect information. Be humble while also being accurate about your level of confidence in a recommendation. Humility is important because it is easy for parents to feel insecure and condescended to. You understand their greatest fear, now let them know what your greatest worry is for their child should they forgo a recommended treatment. Explaining all of this with humility and warmth makes it more likely that the parents will take in the facts you are trying to share with them and not be derailed by suspicion, defensiveness, or insecurity.
Make building an alliance with the parents your top priority. This does not mean that you do not offer your best recommendation for their child. Rather, it means that, if they still decline recommended treatment, you treat them with respect and invest your time in explaining what they should be watching or monitoring their child for without recommended treatment. Building trust is a long game. If you patiently stick with parents even when it’s not easy, they may be ready to trust you with a subsequent decision when the stakes are even higher.
Of course, all this thoughtful communication takes a lot of time! You may learn to block off more time for certain families. It also can be helpful to have these conversations as a team. If you and your nurse or social worker can meet with parents together, then some of the listening and learning can be done by the nurse or social worker alone, so that everyone’s time might be managed more efficiently. And managing skeptical parents as a team also can help to prevent frustration or burnout. It will not always succeed, but in some cases, your investment will pay off in a trusting alliance, mutual respect, and healthy patients.
Dr. Swick is an attending psychiatrist in the division of child psychiatry at Massachusetts General Hospital, Boston, and director of the Parenting at a Challenging Time (PACT) Program at the Vernon Cancer Center at Newton Wellesley Hospital, also in Boston. Dr. Jellinek is professor emeritus of psychiatry and pediatrics at Harvard Medical School, Boston. Email them at [email protected].
Hospital boards can promote quality improvement
Hospital boards play an important role in quality improvement (QI), and now researchers in England have developed a framework they can use to help develop their QI capability by comparing 15 health care organizations.
“We already know that certain board practices are associated with higher quality care,” said lead researcher Lorelei Jones, PhD. “For example, hospital boards that regularly review quality performance have better patient outcomes. But we don’t know a lot about what boards actually do, or what ‘good’ looks like in relation to quality governance. There is a lot of guidance for boards on what they should be doing, but very little research evidence.”
In their study, researchers developed an evidence-based measure of QI “maturity” – how developed boards were in how they led and oversaw quality improvement. They applied this measure to various organizations and then looked at the characteristics of organizations that showed a highly developed approach to QI.
“Organizations with higher levels of QI maturity prioritized QI; balanced attention to short-term (external) priorities with a long-term (internal) investment in QI; used data for quality improvement, not just quality assurance; engaged staff and patients in QI; and had a culture of continuous improvement,” Dr. Jones said. These characteristics often seemed to be facilitated by clinical leaders; the study also highlighted the importance of board-level clinical leaders in hospitals, she said.
Researchers found that organizations with a highly developed approach to QI did the following:
- Brought in-depth knowledge and understanding of quality issues and provided the board with meaningful analyses of data.
- Contributed knowledge of relevant developments in national policy and links to external networks.
- Played an important role as “boundary spanners,” providing a link between “the board and the ward,” making connections between sources of data and aligning external demands with internal priorities.
“Boards can use our framework to help develop their QI capability,” Dr. Jones said. “For example, boards can use it to do a gap analysis to explore areas that might need strengthening and for ideas on how they could do this.”
Reference
Jones L et al. How do hospital boards govern for quality improvement? A mixed methods study of 15 organisations in England. BMJ Qual Saf. 2017 Dec;26(12):978-86.
Hospital boards play an important role in quality improvement (QI), and now researchers in England have developed a framework they can use to help develop their QI capability by comparing 15 health care organizations.
“We already know that certain board practices are associated with higher quality care,” said lead researcher Lorelei Jones, PhD. “For example, hospital boards that regularly review quality performance have better patient outcomes. But we don’t know a lot about what boards actually do, or what ‘good’ looks like in relation to quality governance. There is a lot of guidance for boards on what they should be doing, but very little research evidence.”
In their study, researchers developed an evidence-based measure of QI “maturity” – how developed boards were in how they led and oversaw quality improvement. They applied this measure to various organizations and then looked at the characteristics of organizations that showed a highly developed approach to QI.
“Organizations with higher levels of QI maturity prioritized QI; balanced attention to short-term (external) priorities with a long-term (internal) investment in QI; used data for quality improvement, not just quality assurance; engaged staff and patients in QI; and had a culture of continuous improvement,” Dr. Jones said. These characteristics often seemed to be facilitated by clinical leaders; the study also highlighted the importance of board-level clinical leaders in hospitals, she said.
Researchers found that organizations with a highly developed approach to QI did the following:
- Brought in-depth knowledge and understanding of quality issues and provided the board with meaningful analyses of data.
- Contributed knowledge of relevant developments in national policy and links to external networks.
- Played an important role as “boundary spanners,” providing a link between “the board and the ward,” making connections between sources of data and aligning external demands with internal priorities.
“Boards can use our framework to help develop their QI capability,” Dr. Jones said. “For example, boards can use it to do a gap analysis to explore areas that might need strengthening and for ideas on how they could do this.”
Reference
Jones L et al. How do hospital boards govern for quality improvement? A mixed methods study of 15 organisations in England. BMJ Qual Saf. 2017 Dec;26(12):978-86.
Hospital boards play an important role in quality improvement (QI), and now researchers in England have developed a framework they can use to help develop their QI capability by comparing 15 health care organizations.
“We already know that certain board practices are associated with higher quality care,” said lead researcher Lorelei Jones, PhD. “For example, hospital boards that regularly review quality performance have better patient outcomes. But we don’t know a lot about what boards actually do, or what ‘good’ looks like in relation to quality governance. There is a lot of guidance for boards on what they should be doing, but very little research evidence.”
In their study, researchers developed an evidence-based measure of QI “maturity” – how developed boards were in how they led and oversaw quality improvement. They applied this measure to various organizations and then looked at the characteristics of organizations that showed a highly developed approach to QI.
“Organizations with higher levels of QI maturity prioritized QI; balanced attention to short-term (external) priorities with a long-term (internal) investment in QI; used data for quality improvement, not just quality assurance; engaged staff and patients in QI; and had a culture of continuous improvement,” Dr. Jones said. These characteristics often seemed to be facilitated by clinical leaders; the study also highlighted the importance of board-level clinical leaders in hospitals, she said.
Researchers found that organizations with a highly developed approach to QI did the following:
- Brought in-depth knowledge and understanding of quality issues and provided the board with meaningful analyses of data.
- Contributed knowledge of relevant developments in national policy and links to external networks.
- Played an important role as “boundary spanners,” providing a link between “the board and the ward,” making connections between sources of data and aligning external demands with internal priorities.
“Boards can use our framework to help develop their QI capability,” Dr. Jones said. “For example, boards can use it to do a gap analysis to explore areas that might need strengthening and for ideas on how they could do this.”
Reference
Jones L et al. How do hospital boards govern for quality improvement? A mixed methods study of 15 organisations in England. BMJ Qual Saf. 2017 Dec;26(12):978-86.
Making structural improvements in health care
Every day, hospitalists devote time and energy to the best practices that can limit the spread of infection and the development of antibiotic resistance. Infection Prevention (IP) and Antimicrobial Stewardship (ASP) are two hospital programs that address that same goal.
But there may be a more effective approach possible, according to Jerome A. Leis, MD, MSc, FRCPC, of the Centre for Quality Improvement and Patient Safety at the University of Toronto.
“Despite the high-quality evidence supporting these IP/ASP interventions, our approach to adding these to our current practice sometimes feels like adding scaffolding to a rickety building,” he said. “It supports the underlying structure, but remove the scaffolding without fixing the building, and it may just come tumbling down.” Sometimes the work seems like an uphill battle, he added, as the same problems continue to recur.
That’s because there’s a systemic element to the problems. “Hospitalists know first hand about how the system that we work in makes it difficult to ensure that all the best IP/ASP practices are adhered to all the time,” Dr. Leis said. “Simply reminding staff to remove a urinary catheter in a timely fashion or clean their hands every single time they touch a patient or the environment can only get us so far.” That’s where improvement science comes in.
The relatively new field of improvement science provides a framework for research focused on health care improvement; its goal is to determine which improvement strategies are most effective. Dr. Leis argued that, “when our approach to IP and ASP incorporate principles of improvement science, we are more likely to be successful in achieving sustainable changes in practice.”
Rather than constantly adding extra steps and reminders for hospitalists about patient safety, he said, we need to recognize that there are systemic factors that lead to specific practices. “Our focus should be to use improvement-science methodology to understand these barriers and redesign the processes of care in a way that makes it easier for hospitalists to adhere to the best IP/ASP practices for our patients.”
These structural changes should come from collaboration among content experts in IP/ASP and those with training in improvement science, he said – many IP and ASP programs are already putting this in practice, using improvement science to create safer systems of care.
Reference
Leis J. Advancing infection prevention and antimicrobial stewardship through improvement science. BMJ Qual Saf. 2017 Jun 14. doi: 10.1136/bmjqs-2017-006793.
Every day, hospitalists devote time and energy to the best practices that can limit the spread of infection and the development of antibiotic resistance. Infection Prevention (IP) and Antimicrobial Stewardship (ASP) are two hospital programs that address that same goal.
But there may be a more effective approach possible, according to Jerome A. Leis, MD, MSc, FRCPC, of the Centre for Quality Improvement and Patient Safety at the University of Toronto.
“Despite the high-quality evidence supporting these IP/ASP interventions, our approach to adding these to our current practice sometimes feels like adding scaffolding to a rickety building,” he said. “It supports the underlying structure, but remove the scaffolding without fixing the building, and it may just come tumbling down.” Sometimes the work seems like an uphill battle, he added, as the same problems continue to recur.
That’s because there’s a systemic element to the problems. “Hospitalists know first hand about how the system that we work in makes it difficult to ensure that all the best IP/ASP practices are adhered to all the time,” Dr. Leis said. “Simply reminding staff to remove a urinary catheter in a timely fashion or clean their hands every single time they touch a patient or the environment can only get us so far.” That’s where improvement science comes in.
The relatively new field of improvement science provides a framework for research focused on health care improvement; its goal is to determine which improvement strategies are most effective. Dr. Leis argued that, “when our approach to IP and ASP incorporate principles of improvement science, we are more likely to be successful in achieving sustainable changes in practice.”
Rather than constantly adding extra steps and reminders for hospitalists about patient safety, he said, we need to recognize that there are systemic factors that lead to specific practices. “Our focus should be to use improvement-science methodology to understand these barriers and redesign the processes of care in a way that makes it easier for hospitalists to adhere to the best IP/ASP practices for our patients.”
These structural changes should come from collaboration among content experts in IP/ASP and those with training in improvement science, he said – many IP and ASP programs are already putting this in practice, using improvement science to create safer systems of care.
Reference
Leis J. Advancing infection prevention and antimicrobial stewardship through improvement science. BMJ Qual Saf. 2017 Jun 14. doi: 10.1136/bmjqs-2017-006793.
Every day, hospitalists devote time and energy to the best practices that can limit the spread of infection and the development of antibiotic resistance. Infection Prevention (IP) and Antimicrobial Stewardship (ASP) are two hospital programs that address that same goal.
But there may be a more effective approach possible, according to Jerome A. Leis, MD, MSc, FRCPC, of the Centre for Quality Improvement and Patient Safety at the University of Toronto.
“Despite the high-quality evidence supporting these IP/ASP interventions, our approach to adding these to our current practice sometimes feels like adding scaffolding to a rickety building,” he said. “It supports the underlying structure, but remove the scaffolding without fixing the building, and it may just come tumbling down.” Sometimes the work seems like an uphill battle, he added, as the same problems continue to recur.
That’s because there’s a systemic element to the problems. “Hospitalists know first hand about how the system that we work in makes it difficult to ensure that all the best IP/ASP practices are adhered to all the time,” Dr. Leis said. “Simply reminding staff to remove a urinary catheter in a timely fashion or clean their hands every single time they touch a patient or the environment can only get us so far.” That’s where improvement science comes in.
The relatively new field of improvement science provides a framework for research focused on health care improvement; its goal is to determine which improvement strategies are most effective. Dr. Leis argued that, “when our approach to IP and ASP incorporate principles of improvement science, we are more likely to be successful in achieving sustainable changes in practice.”
Rather than constantly adding extra steps and reminders for hospitalists about patient safety, he said, we need to recognize that there are systemic factors that lead to specific practices. “Our focus should be to use improvement-science methodology to understand these barriers and redesign the processes of care in a way that makes it easier for hospitalists to adhere to the best IP/ASP practices for our patients.”
These structural changes should come from collaboration among content experts in IP/ASP and those with training in improvement science, he said – many IP and ASP programs are already putting this in practice, using improvement science to create safer systems of care.
Reference
Leis J. Advancing infection prevention and antimicrobial stewardship through improvement science. BMJ Qual Saf. 2017 Jun 14. doi: 10.1136/bmjqs-2017-006793.
New tool improves hand-off communications
Transitions of care can be rife with communications issues – and subsequent adverse events. They are also a place where hospitalists can take the lead in making improvements.
“They are the team leaders, typically,” said Ana Pujols McKee, MD, the executive vice president and chief medical officer for The Joint Commission. “The hospitalist really owns this process of the transfer of this accurate information.”
To help, The Joint Commission has issued a new Sentinel Event Alert, which provides seven recommendations to improve the communication failures that can occur when patients are transitioned from one caregiver to another, as well as a Targeted Solutions Tool to put the recommendations into action.
“Every organization is challenged in communicating accurate and timely information regarding patients,” Dr. McKee said. “One of the riskiest transitions that patients go through is when they change levels of care from ICU to med-surg, or from the ER to ICU, OR to ICU, med-surg to home, and home to home care. All of those transitions inherently carry a certain amount of risk and are deeply reliant on the transfer of the right information at the right time to the right person.”
These resources reflect what The Joint Commission has found: “The knowledge that we now have is that one of the defects that occurs in this transitioning is that – I’ll speak of sender and receiver – the information that is sent is always sent from the perspective of what the sender thinks is important, not the information the receiver needs to manage that patient safely.”
The tool uses the principles of Lean Six Sigma and change management, and organizations can use it to identify their opportunities for improvement and develop strategies to address their specific root causes in their organization.
“It’s a self-guided tool,” Dr. McKee said. “Organizations have reduced errors significantly in using this tool. I think if the hospitalist community takes this on, that would really help transform how we do transitions of care.”
Transitions of care can be rife with communications issues – and subsequent adverse events. They are also a place where hospitalists can take the lead in making improvements.
“They are the team leaders, typically,” said Ana Pujols McKee, MD, the executive vice president and chief medical officer for The Joint Commission. “The hospitalist really owns this process of the transfer of this accurate information.”
To help, The Joint Commission has issued a new Sentinel Event Alert, which provides seven recommendations to improve the communication failures that can occur when patients are transitioned from one caregiver to another, as well as a Targeted Solutions Tool to put the recommendations into action.
“Every organization is challenged in communicating accurate and timely information regarding patients,” Dr. McKee said. “One of the riskiest transitions that patients go through is when they change levels of care from ICU to med-surg, or from the ER to ICU, OR to ICU, med-surg to home, and home to home care. All of those transitions inherently carry a certain amount of risk and are deeply reliant on the transfer of the right information at the right time to the right person.”
These resources reflect what The Joint Commission has found: “The knowledge that we now have is that one of the defects that occurs in this transitioning is that – I’ll speak of sender and receiver – the information that is sent is always sent from the perspective of what the sender thinks is important, not the information the receiver needs to manage that patient safely.”
The tool uses the principles of Lean Six Sigma and change management, and organizations can use it to identify their opportunities for improvement and develop strategies to address their specific root causes in their organization.
“It’s a self-guided tool,” Dr. McKee said. “Organizations have reduced errors significantly in using this tool. I think if the hospitalist community takes this on, that would really help transform how we do transitions of care.”
Transitions of care can be rife with communications issues – and subsequent adverse events. They are also a place where hospitalists can take the lead in making improvements.
“They are the team leaders, typically,” said Ana Pujols McKee, MD, the executive vice president and chief medical officer for The Joint Commission. “The hospitalist really owns this process of the transfer of this accurate information.”
To help, The Joint Commission has issued a new Sentinel Event Alert, which provides seven recommendations to improve the communication failures that can occur when patients are transitioned from one caregiver to another, as well as a Targeted Solutions Tool to put the recommendations into action.
“Every organization is challenged in communicating accurate and timely information regarding patients,” Dr. McKee said. “One of the riskiest transitions that patients go through is when they change levels of care from ICU to med-surg, or from the ER to ICU, OR to ICU, med-surg to home, and home to home care. All of those transitions inherently carry a certain amount of risk and are deeply reliant on the transfer of the right information at the right time to the right person.”
These resources reflect what The Joint Commission has found: “The knowledge that we now have is that one of the defects that occurs in this transitioning is that – I’ll speak of sender and receiver – the information that is sent is always sent from the perspective of what the sender thinks is important, not the information the receiver needs to manage that patient safely.”
The tool uses the principles of Lean Six Sigma and change management, and organizations can use it to identify their opportunities for improvement and develop strategies to address their specific root causes in their organization.
“It’s a self-guided tool,” Dr. McKee said. “Organizations have reduced errors significantly in using this tool. I think if the hospitalist community takes this on, that would really help transform how we do transitions of care.”
Analytics, board support are quality improvement keys
Jeffrey Glasheen, MD, had not considered focusing on quality improvement (QI) while studying at the University of Wisconsin, Madison. It was not until a medical error led to the death of a family member that his eyes were opened to the potential consequences of a system not invested in care quality.
“I couldn’t square with it because I had spent the last two to three years of my life working with some of the most dedicated, passionate, hard working people who all were trying to improve lives, and the fact that what I was seeing could result in a family member dying just didn’t make sense,” said Dr. Glasheen. “At the time I thought ‘This must be one of those unfortunate things that happens once in a lifetime,’ and I put it on the back burner.”
As more research on medical errors emerged, however, Dr. Glasheen realized his family’s experience was not as unique as he had thought.
It was after reading the now famous Institute of Medicine report, “To err is human,” which found that medical errors were responsible for 44,000-98,000 deaths a year, that Dr. Glasheen resolved to pursue a career in quality improvement.
Because it was early in his medical career, he began on a small level, teaching his residents about the importance of patient safety and giving lessons on core competencies involved in quality care and higher liability. But he quickly expanded his efforts.
“I started with what I had control over,” Dr. Glasheen explained. “From there, I moved to teaching more medical students, which lead to teaching in front of classrooms, which opened the door to the idea of starting a hospitalist training program.”
In 2003, Dr. Glasheen pitched the program to the University of Colorado at Denver, Aurora, where he completed his residency; this pitch led to the development of a hospitalist training program that focused on improving safety outcomes.
He served as the director of the University of Colorado Hospital Medicine Group from 2003 to 2015, during which time he was approached by the dean to assist in creating and leading the hospitalist training program for internal medicine residents.
The first of its kind, the rigorous University of Colorado program was designed to give residents tools useful beyond the clinical setting to become successful health system leaders.
In 2013, Dr. Glasheen and his colleagues founded the Institute for Healthcare Quality, Safety & Efficiency, which is guided by the mission to improve the quality of care provided on the local level. He has since become the chief quality officer for UCHealth and the University of Colorado Hospital Authority and an associate dean for clinical affairs in quality and safety education, as well as continuing to be a professor of medicine.
For those hoping to pursue quality improvement, Dr. Glasheen stressed the importance of a strong basis in data analytics.
“One of the most common things I see with data is people start to chase what’s called common cause variation, which means they’ll look at a run chart over the course of 12 months and react to every up and down when those are essentially random,” Dr. Glasheen said. “Being able to understand when something is particularly significant and when your interventions are actually making an impact is a skill set I think people who are new to quality improvement don’t often have.”
Having support from board members is also critical to success, although starting without such support should not deter future QI leaders.
“There needs to be a vision from the leadership that this work is important, and not just through words but through deeds, because no board in the country will say that quality is not important,” Dr. Glasheen said. “I would say start with small projects you can control, that tie back not only to patient lives but financial performance as well. If you can tell a board you saved the lives of 40 patients who would have died during the year and saved $1-$2 million in the process, the question will shift from whether the board should invest in QI resources to how much should be invested.”
Looking ahead, Dr. Glasheen highlighted the growing importance of hospital-acquired infections, such as surgical-site infections, catheter-associated urinary tract infections, and ventilator-associated pneumonia, as areas that need to be focused on in the QI sphere.
Jeffrey Glasheen, MD, had not considered focusing on quality improvement (QI) while studying at the University of Wisconsin, Madison. It was not until a medical error led to the death of a family member that his eyes were opened to the potential consequences of a system not invested in care quality.
“I couldn’t square with it because I had spent the last two to three years of my life working with some of the most dedicated, passionate, hard working people who all were trying to improve lives, and the fact that what I was seeing could result in a family member dying just didn’t make sense,” said Dr. Glasheen. “At the time I thought ‘This must be one of those unfortunate things that happens once in a lifetime,’ and I put it on the back burner.”
As more research on medical errors emerged, however, Dr. Glasheen realized his family’s experience was not as unique as he had thought.
It was after reading the now famous Institute of Medicine report, “To err is human,” which found that medical errors were responsible for 44,000-98,000 deaths a year, that Dr. Glasheen resolved to pursue a career in quality improvement.
Because it was early in his medical career, he began on a small level, teaching his residents about the importance of patient safety and giving lessons on core competencies involved in quality care and higher liability. But he quickly expanded his efforts.
“I started with what I had control over,” Dr. Glasheen explained. “From there, I moved to teaching more medical students, which lead to teaching in front of classrooms, which opened the door to the idea of starting a hospitalist training program.”
In 2003, Dr. Glasheen pitched the program to the University of Colorado at Denver, Aurora, where he completed his residency; this pitch led to the development of a hospitalist training program that focused on improving safety outcomes.
He served as the director of the University of Colorado Hospital Medicine Group from 2003 to 2015, during which time he was approached by the dean to assist in creating and leading the hospitalist training program for internal medicine residents.
The first of its kind, the rigorous University of Colorado program was designed to give residents tools useful beyond the clinical setting to become successful health system leaders.
In 2013, Dr. Glasheen and his colleagues founded the Institute for Healthcare Quality, Safety & Efficiency, which is guided by the mission to improve the quality of care provided on the local level. He has since become the chief quality officer for UCHealth and the University of Colorado Hospital Authority and an associate dean for clinical affairs in quality and safety education, as well as continuing to be a professor of medicine.
For those hoping to pursue quality improvement, Dr. Glasheen stressed the importance of a strong basis in data analytics.
“One of the most common things I see with data is people start to chase what’s called common cause variation, which means they’ll look at a run chart over the course of 12 months and react to every up and down when those are essentially random,” Dr. Glasheen said. “Being able to understand when something is particularly significant and when your interventions are actually making an impact is a skill set I think people who are new to quality improvement don’t often have.”
Having support from board members is also critical to success, although starting without such support should not deter future QI leaders.
“There needs to be a vision from the leadership that this work is important, and not just through words but through deeds, because no board in the country will say that quality is not important,” Dr. Glasheen said. “I would say start with small projects you can control, that tie back not only to patient lives but financial performance as well. If you can tell a board you saved the lives of 40 patients who would have died during the year and saved $1-$2 million in the process, the question will shift from whether the board should invest in QI resources to how much should be invested.”
Looking ahead, Dr. Glasheen highlighted the growing importance of hospital-acquired infections, such as surgical-site infections, catheter-associated urinary tract infections, and ventilator-associated pneumonia, as areas that need to be focused on in the QI sphere.
Jeffrey Glasheen, MD, had not considered focusing on quality improvement (QI) while studying at the University of Wisconsin, Madison. It was not until a medical error led to the death of a family member that his eyes were opened to the potential consequences of a system not invested in care quality.
“I couldn’t square with it because I had spent the last two to three years of my life working with some of the most dedicated, passionate, hard working people who all were trying to improve lives, and the fact that what I was seeing could result in a family member dying just didn’t make sense,” said Dr. Glasheen. “At the time I thought ‘This must be one of those unfortunate things that happens once in a lifetime,’ and I put it on the back burner.”
As more research on medical errors emerged, however, Dr. Glasheen realized his family’s experience was not as unique as he had thought.
It was after reading the now famous Institute of Medicine report, “To err is human,” which found that medical errors were responsible for 44,000-98,000 deaths a year, that Dr. Glasheen resolved to pursue a career in quality improvement.
Because it was early in his medical career, he began on a small level, teaching his residents about the importance of patient safety and giving lessons on core competencies involved in quality care and higher liability. But he quickly expanded his efforts.
“I started with what I had control over,” Dr. Glasheen explained. “From there, I moved to teaching more medical students, which lead to teaching in front of classrooms, which opened the door to the idea of starting a hospitalist training program.”
In 2003, Dr. Glasheen pitched the program to the University of Colorado at Denver, Aurora, where he completed his residency; this pitch led to the development of a hospitalist training program that focused on improving safety outcomes.
He served as the director of the University of Colorado Hospital Medicine Group from 2003 to 2015, during which time he was approached by the dean to assist in creating and leading the hospitalist training program for internal medicine residents.
The first of its kind, the rigorous University of Colorado program was designed to give residents tools useful beyond the clinical setting to become successful health system leaders.
In 2013, Dr. Glasheen and his colleagues founded the Institute for Healthcare Quality, Safety & Efficiency, which is guided by the mission to improve the quality of care provided on the local level. He has since become the chief quality officer for UCHealth and the University of Colorado Hospital Authority and an associate dean for clinical affairs in quality and safety education, as well as continuing to be a professor of medicine.
For those hoping to pursue quality improvement, Dr. Glasheen stressed the importance of a strong basis in data analytics.
“One of the most common things I see with data is people start to chase what’s called common cause variation, which means they’ll look at a run chart over the course of 12 months and react to every up and down when those are essentially random,” Dr. Glasheen said. “Being able to understand when something is particularly significant and when your interventions are actually making an impact is a skill set I think people who are new to quality improvement don’t often have.”
Having support from board members is also critical to success, although starting without such support should not deter future QI leaders.
“There needs to be a vision from the leadership that this work is important, and not just through words but through deeds, because no board in the country will say that quality is not important,” Dr. Glasheen said. “I would say start with small projects you can control, that tie back not only to patient lives but financial performance as well. If you can tell a board you saved the lives of 40 patients who would have died during the year and saved $1-$2 million in the process, the question will shift from whether the board should invest in QI resources to how much should be invested.”
Looking ahead, Dr. Glasheen highlighted the growing importance of hospital-acquired infections, such as surgical-site infections, catheter-associated urinary tract infections, and ventilator-associated pneumonia, as areas that need to be focused on in the QI sphere.
Measuring high-value care practices
Because health care in the United States is extremely expensive, it’s driving an increased focus on high-value care (HVC), said Carolyn D. Sy, MD. And, she added, while hospitalists and other physicians are the ones responsible for translating HVC from formalized settings (lectures, modules, etc.) to the bedside, there are few instruments designed to measure the success of HVC practices.
So Dr. Sy, director of the University of Washington Medical Center Hospital Medicine Service in Seattle and her colleagues developed an HVC Rounding Tool, which allows users to empirically assess the discussion of HVC topics at the bedside. They divided 10 HVC topics into three domains (quality, cost, patient values) to create an observational tool and tested its validity.
“It addresses an important educational gap in translating HVC from theoretical knowledge to bedside practice,” she said.
The tool is designed to capture multidisciplinary participation: involvement from faculty, fellows or trainees, nurses, pharmacists, families, and other members of the health care team.
It has multidisciplinary benefits too. “The HVC Rounding Tool provides an opportunity for faculty development through peer observation and feedback on the integration and role modeling of HVC at the bedside,” Dr. Sy said. “It also is an instrument to help assess the educational efficacy of formal HVC curriculum and translation into bedside practice. Lastly, it is a tool that could be used to measure the relationship between HVC behaviors and actual patient outcomes, such as length of stay, readmissions, and cost of hospitalization – a feature with increasing importance given our move towards value-based health care.”
Reference
1. Sy CD et al. The development and validation of a high-value care rounding tool using the Delphi method. J Hosp Med. 2017;12(suppl 2). Accessed Oct 10, 2017.
Because health care in the United States is extremely expensive, it’s driving an increased focus on high-value care (HVC), said Carolyn D. Sy, MD. And, she added, while hospitalists and other physicians are the ones responsible for translating HVC from formalized settings (lectures, modules, etc.) to the bedside, there are few instruments designed to measure the success of HVC practices.
So Dr. Sy, director of the University of Washington Medical Center Hospital Medicine Service in Seattle and her colleagues developed an HVC Rounding Tool, which allows users to empirically assess the discussion of HVC topics at the bedside. They divided 10 HVC topics into three domains (quality, cost, patient values) to create an observational tool and tested its validity.
“It addresses an important educational gap in translating HVC from theoretical knowledge to bedside practice,” she said.
The tool is designed to capture multidisciplinary participation: involvement from faculty, fellows or trainees, nurses, pharmacists, families, and other members of the health care team.
It has multidisciplinary benefits too. “The HVC Rounding Tool provides an opportunity for faculty development through peer observation and feedback on the integration and role modeling of HVC at the bedside,” Dr. Sy said. “It also is an instrument to help assess the educational efficacy of formal HVC curriculum and translation into bedside practice. Lastly, it is a tool that could be used to measure the relationship between HVC behaviors and actual patient outcomes, such as length of stay, readmissions, and cost of hospitalization – a feature with increasing importance given our move towards value-based health care.”
Reference
1. Sy CD et al. The development and validation of a high-value care rounding tool using the Delphi method. J Hosp Med. 2017;12(suppl 2). Accessed Oct 10, 2017.
Because health care in the United States is extremely expensive, it’s driving an increased focus on high-value care (HVC), said Carolyn D. Sy, MD. And, she added, while hospitalists and other physicians are the ones responsible for translating HVC from formalized settings (lectures, modules, etc.) to the bedside, there are few instruments designed to measure the success of HVC practices.
So Dr. Sy, director of the University of Washington Medical Center Hospital Medicine Service in Seattle and her colleagues developed an HVC Rounding Tool, which allows users to empirically assess the discussion of HVC topics at the bedside. They divided 10 HVC topics into three domains (quality, cost, patient values) to create an observational tool and tested its validity.
“It addresses an important educational gap in translating HVC from theoretical knowledge to bedside practice,” she said.
The tool is designed to capture multidisciplinary participation: involvement from faculty, fellows or trainees, nurses, pharmacists, families, and other members of the health care team.
It has multidisciplinary benefits too. “The HVC Rounding Tool provides an opportunity for faculty development through peer observation and feedback on the integration and role modeling of HVC at the bedside,” Dr. Sy said. “It also is an instrument to help assess the educational efficacy of formal HVC curriculum and translation into bedside practice. Lastly, it is a tool that could be used to measure the relationship between HVC behaviors and actual patient outcomes, such as length of stay, readmissions, and cost of hospitalization – a feature with increasing importance given our move towards value-based health care.”
Reference
1. Sy CD et al. The development and validation of a high-value care rounding tool using the Delphi method. J Hosp Med. 2017;12(suppl 2). Accessed Oct 10, 2017.
Caring for transgender inpatients
Henry Ng, MD, MPH, an internal medicine physician and pediatrician in Cleveland who specializes in the treatment of lesbian, gay, bisexual, and transgender (LGBT) patients, walked into an exam room to meet a patient several years ago. The patient was 65 years old and presented as a man.
“Oh,” the man replied. “I’m here to transition.”
Dr. Ng immediately regretted how he had addressed the patient. In this case, his normally innocuous greeting could have been harmful. The man did not identify as a man – as “Mister” – and this could have derailed the health care encounter, Dr. Ng said. Luckily the patient corrected him.
“I made an assumption about this person based on the cues that I saw and I misperceived this person’s identity,” he said. “A patient less comfortable in their skin may have left. And a younger patient would likely have been offended if I had met and misgendered them.”
If Dr. Ng could make this kind of error, it’s clear how easy it is for clinicians with less training and experience to make clumsy assumptions about gender identity.
Even with wider societal awareness of gender identity issues, the cultural sensibilities and training among hospitalists and other clinicians required for quality care of transgender patients is still lacking, Dr. Ng said. Unfortunately, many physicians may have little interest in providing this care, or lack the skills for it, he said.
In the hospital, patients already feel vulnerable because of their medical conditions, and treating transgender inpatients may require additional layers of complexity, experts say. For instance, how should a physician address a patient? The initial encounter can have a huge impact on the clinician’s ability to earn the patient’s trust, and sets the tone for the entire hospital stay. Which bathroom should a transgender patient use? What unique family issues must clinicians be aware of? Transgender patients may be more likely to have simmering tensions with immediate and extended family, and may not want certain family members involved in medical decisions.
Physicians and nurses must be aware of these issues to create a welcoming and logistically sound environment, said Nicole Rosendale, MD, a neurohospitalist at the University of California San Francisco who has a special interest in LGBT care.
Dr. Ng noted that even the information technology clinicians rely upon may not be optimized for transgender patients. For instance, he said electronic health records may pose problems if they haven’t been adapted to include the necessary gender identity options or preferred names and pronouns.
“Most electronic health records are fairly binary-driven,” Dr. Ng said. “Our transgender patients turn that model on its head. We have had to create many additional workarounds.”
Need for more training
Hospitalists will increasingly find themselves caring for transgender patients, as more people openly claim a gender identity outside the traditional gender categories. A recent study in the United Kingdom found that 20%-25% of people under 25 did not identify as heterosexual, or considered themselves as having a personal gender identity that did not correspond with the sex assigned at birth, Dr. Ng said.
“I don’t think this is something that is a trend, I don’t think it’s a fad,” Dr. Ng said. “I don’t think it’s going to go away.”
The amount of resources available for training clinicians in caring for transgender patients is expanding, he said, and both trainees and veteran clinicians can find educational programs tailored to their needs, although they might have to seek them out. Nonetheless, Dr. Ng thinks hospitalists would be wise to pursue such training.
Unfortunately, most medical schools do not as yet offer targeted training in transgender care, or even LGBT care more broadly, said Vin Tangpricha, MD, PhD, president elect of the World Professional Association for Transgender Health (WPATH).
“The biggest gap is training in medical school and residency,” Dr. Tangpricha said. “Only one out of three medical schools have any transgender curriculum taught to students. Physicians lack knowledge on the diagnosis of gender dysphoria and the hormone regimens that are commonly used. Also, physicians don’t feel comfortable speaking to transgender patients because they lack experience working with this population.”
Training in caring for transgender patients and other segments of the LGBT patient population is available through WPATH, the Fenway Institute in Boston, and GLMA, formerly known as the Gay & Lesbian Medical Association, as well some other organizations, Dr. Tangpricha said.
Dr. Rosendale took training into her own hands. She saw gaps in the curriculum, and started LGBT training programs at New York University, where she went to medical school, and at UCSF, where she completed her neurology residency and neurohospitalist fellowship.
The curriculum, which was blended with diversity training at UCSF, involved basic concepts such as terminology, the difference between gender identity and sexual orientation, communication tips, and discussions of the health care experience from the LGBT patient perspective. Even a relatively small amount of training can go a long way, she said.
“When I work with trainees now who have heard some of the lectures and have gone through some of the training, their fluency and their comfort with the terminology, with the concepts that are used within the LGBT community, is much better than it was before,” Dr. Rosendale said.
Demonstrating the importance of training to those in charge of curriculum decisions is the most important step for anyone interested in adding instruction for transgender care at their centers, she said.
Katie Imborek, MD, cofounder of the University of Iowa LGBTQ Clinic, has worked with hospitalists on improving their care for transgender patients. She and internal medicine physician Nicole Nisly, MD, opened the clinic when a need became apparent.
Before the University of Iowa clinic opened, a transgender advocacy group hosted a forum on LGBT health care, at which patients shared stories of frustration. One patient related a story about calling a department at the university, only to be told, “We don’t take care of people like you.” In another frustrating case, a transgender man had been having vaginal bleeding and called the obstetrics department seeking help. He was repeatedly told he was calling the wrong place. During a white board exercise at the forum, one patient drew buildings representing the university health care system surrounded by barbed wire, symbolizing an off-putting atmosphere in the emergency department that was rife with misgendering of patients.
“Many providers feel like they haven’t had the appropriate training to provide medically competent care for transgender patients – including cross-sex hormones, referrals, and care coordination to ensure patients receive the mental health care, medications, and procedures needed to treat their gender dysphoria,” Dr. Imborek said.
Despite the knowledge gaps, a shift is definitely underway, she said. Dr. Tangpricha concurred, noting that the interest in WPATH’s training programs has increased dramatically.
“In the past, there was a CME program on transgender medicine every 2 years. Now we have courses every 3-4 months and we still can’t keep up with the demand. Employers and hospital systems are adopting transgender medicine as a covered benefit which has driven the need for physician education.”
Henry Ng, MD, MPH, an internal medicine physician and pediatrician in Cleveland who specializes in the treatment of lesbian, gay, bisexual, and transgender (LGBT) patients, walked into an exam room to meet a patient several years ago. The patient was 65 years old and presented as a man.
“Oh,” the man replied. “I’m here to transition.”
Dr. Ng immediately regretted how he had addressed the patient. In this case, his normally innocuous greeting could have been harmful. The man did not identify as a man – as “Mister” – and this could have derailed the health care encounter, Dr. Ng said. Luckily the patient corrected him.
“I made an assumption about this person based on the cues that I saw and I misperceived this person’s identity,” he said. “A patient less comfortable in their skin may have left. And a younger patient would likely have been offended if I had met and misgendered them.”
If Dr. Ng could make this kind of error, it’s clear how easy it is for clinicians with less training and experience to make clumsy assumptions about gender identity.
Even with wider societal awareness of gender identity issues, the cultural sensibilities and training among hospitalists and other clinicians required for quality care of transgender patients is still lacking, Dr. Ng said. Unfortunately, many physicians may have little interest in providing this care, or lack the skills for it, he said.
In the hospital, patients already feel vulnerable because of their medical conditions, and treating transgender inpatients may require additional layers of complexity, experts say. For instance, how should a physician address a patient? The initial encounter can have a huge impact on the clinician’s ability to earn the patient’s trust, and sets the tone for the entire hospital stay. Which bathroom should a transgender patient use? What unique family issues must clinicians be aware of? Transgender patients may be more likely to have simmering tensions with immediate and extended family, and may not want certain family members involved in medical decisions.
Physicians and nurses must be aware of these issues to create a welcoming and logistically sound environment, said Nicole Rosendale, MD, a neurohospitalist at the University of California San Francisco who has a special interest in LGBT care.
Dr. Ng noted that even the information technology clinicians rely upon may not be optimized for transgender patients. For instance, he said electronic health records may pose problems if they haven’t been adapted to include the necessary gender identity options or preferred names and pronouns.
“Most electronic health records are fairly binary-driven,” Dr. Ng said. “Our transgender patients turn that model on its head. We have had to create many additional workarounds.”
Need for more training
Hospitalists will increasingly find themselves caring for transgender patients, as more people openly claim a gender identity outside the traditional gender categories. A recent study in the United Kingdom found that 20%-25% of people under 25 did not identify as heterosexual, or considered themselves as having a personal gender identity that did not correspond with the sex assigned at birth, Dr. Ng said.
“I don’t think this is something that is a trend, I don’t think it’s a fad,” Dr. Ng said. “I don’t think it’s going to go away.”
The amount of resources available for training clinicians in caring for transgender patients is expanding, he said, and both trainees and veteran clinicians can find educational programs tailored to their needs, although they might have to seek them out. Nonetheless, Dr. Ng thinks hospitalists would be wise to pursue such training.
Unfortunately, most medical schools do not as yet offer targeted training in transgender care, or even LGBT care more broadly, said Vin Tangpricha, MD, PhD, president elect of the World Professional Association for Transgender Health (WPATH).
“The biggest gap is training in medical school and residency,” Dr. Tangpricha said. “Only one out of three medical schools have any transgender curriculum taught to students. Physicians lack knowledge on the diagnosis of gender dysphoria and the hormone regimens that are commonly used. Also, physicians don’t feel comfortable speaking to transgender patients because they lack experience working with this population.”
Training in caring for transgender patients and other segments of the LGBT patient population is available through WPATH, the Fenway Institute in Boston, and GLMA, formerly known as the Gay & Lesbian Medical Association, as well some other organizations, Dr. Tangpricha said.
Dr. Rosendale took training into her own hands. She saw gaps in the curriculum, and started LGBT training programs at New York University, where she went to medical school, and at UCSF, where she completed her neurology residency and neurohospitalist fellowship.
The curriculum, which was blended with diversity training at UCSF, involved basic concepts such as terminology, the difference between gender identity and sexual orientation, communication tips, and discussions of the health care experience from the LGBT patient perspective. Even a relatively small amount of training can go a long way, she said.
“When I work with trainees now who have heard some of the lectures and have gone through some of the training, their fluency and their comfort with the terminology, with the concepts that are used within the LGBT community, is much better than it was before,” Dr. Rosendale said.
Demonstrating the importance of training to those in charge of curriculum decisions is the most important step for anyone interested in adding instruction for transgender care at their centers, she said.
Katie Imborek, MD, cofounder of the University of Iowa LGBTQ Clinic, has worked with hospitalists on improving their care for transgender patients. She and internal medicine physician Nicole Nisly, MD, opened the clinic when a need became apparent.
Before the University of Iowa clinic opened, a transgender advocacy group hosted a forum on LGBT health care, at which patients shared stories of frustration. One patient related a story about calling a department at the university, only to be told, “We don’t take care of people like you.” In another frustrating case, a transgender man had been having vaginal bleeding and called the obstetrics department seeking help. He was repeatedly told he was calling the wrong place. During a white board exercise at the forum, one patient drew buildings representing the university health care system surrounded by barbed wire, symbolizing an off-putting atmosphere in the emergency department that was rife with misgendering of patients.
“Many providers feel like they haven’t had the appropriate training to provide medically competent care for transgender patients – including cross-sex hormones, referrals, and care coordination to ensure patients receive the mental health care, medications, and procedures needed to treat their gender dysphoria,” Dr. Imborek said.
Despite the knowledge gaps, a shift is definitely underway, she said. Dr. Tangpricha concurred, noting that the interest in WPATH’s training programs has increased dramatically.
“In the past, there was a CME program on transgender medicine every 2 years. Now we have courses every 3-4 months and we still can’t keep up with the demand. Employers and hospital systems are adopting transgender medicine as a covered benefit which has driven the need for physician education.”
Henry Ng, MD, MPH, an internal medicine physician and pediatrician in Cleveland who specializes in the treatment of lesbian, gay, bisexual, and transgender (LGBT) patients, walked into an exam room to meet a patient several years ago. The patient was 65 years old and presented as a man.
“Oh,” the man replied. “I’m here to transition.”
Dr. Ng immediately regretted how he had addressed the patient. In this case, his normally innocuous greeting could have been harmful. The man did not identify as a man – as “Mister” – and this could have derailed the health care encounter, Dr. Ng said. Luckily the patient corrected him.
“I made an assumption about this person based on the cues that I saw and I misperceived this person’s identity,” he said. “A patient less comfortable in their skin may have left. And a younger patient would likely have been offended if I had met and misgendered them.”
If Dr. Ng could make this kind of error, it’s clear how easy it is for clinicians with less training and experience to make clumsy assumptions about gender identity.
Even with wider societal awareness of gender identity issues, the cultural sensibilities and training among hospitalists and other clinicians required for quality care of transgender patients is still lacking, Dr. Ng said. Unfortunately, many physicians may have little interest in providing this care, or lack the skills for it, he said.
In the hospital, patients already feel vulnerable because of their medical conditions, and treating transgender inpatients may require additional layers of complexity, experts say. For instance, how should a physician address a patient? The initial encounter can have a huge impact on the clinician’s ability to earn the patient’s trust, and sets the tone for the entire hospital stay. Which bathroom should a transgender patient use? What unique family issues must clinicians be aware of? Transgender patients may be more likely to have simmering tensions with immediate and extended family, and may not want certain family members involved in medical decisions.
Physicians and nurses must be aware of these issues to create a welcoming and logistically sound environment, said Nicole Rosendale, MD, a neurohospitalist at the University of California San Francisco who has a special interest in LGBT care.
Dr. Ng noted that even the information technology clinicians rely upon may not be optimized for transgender patients. For instance, he said electronic health records may pose problems if they haven’t been adapted to include the necessary gender identity options or preferred names and pronouns.
“Most electronic health records are fairly binary-driven,” Dr. Ng said. “Our transgender patients turn that model on its head. We have had to create many additional workarounds.”
Need for more training
Hospitalists will increasingly find themselves caring for transgender patients, as more people openly claim a gender identity outside the traditional gender categories. A recent study in the United Kingdom found that 20%-25% of people under 25 did not identify as heterosexual, or considered themselves as having a personal gender identity that did not correspond with the sex assigned at birth, Dr. Ng said.
“I don’t think this is something that is a trend, I don’t think it’s a fad,” Dr. Ng said. “I don’t think it’s going to go away.”
The amount of resources available for training clinicians in caring for transgender patients is expanding, he said, and both trainees and veteran clinicians can find educational programs tailored to their needs, although they might have to seek them out. Nonetheless, Dr. Ng thinks hospitalists would be wise to pursue such training.
Unfortunately, most medical schools do not as yet offer targeted training in transgender care, or even LGBT care more broadly, said Vin Tangpricha, MD, PhD, president elect of the World Professional Association for Transgender Health (WPATH).
“The biggest gap is training in medical school and residency,” Dr. Tangpricha said. “Only one out of three medical schools have any transgender curriculum taught to students. Physicians lack knowledge on the diagnosis of gender dysphoria and the hormone regimens that are commonly used. Also, physicians don’t feel comfortable speaking to transgender patients because they lack experience working with this population.”
Training in caring for transgender patients and other segments of the LGBT patient population is available through WPATH, the Fenway Institute in Boston, and GLMA, formerly known as the Gay & Lesbian Medical Association, as well some other organizations, Dr. Tangpricha said.
Dr. Rosendale took training into her own hands. She saw gaps in the curriculum, and started LGBT training programs at New York University, where she went to medical school, and at UCSF, where she completed her neurology residency and neurohospitalist fellowship.
The curriculum, which was blended with diversity training at UCSF, involved basic concepts such as terminology, the difference between gender identity and sexual orientation, communication tips, and discussions of the health care experience from the LGBT patient perspective. Even a relatively small amount of training can go a long way, she said.
“When I work with trainees now who have heard some of the lectures and have gone through some of the training, their fluency and their comfort with the terminology, with the concepts that are used within the LGBT community, is much better than it was before,” Dr. Rosendale said.
Demonstrating the importance of training to those in charge of curriculum decisions is the most important step for anyone interested in adding instruction for transgender care at their centers, she said.
Katie Imborek, MD, cofounder of the University of Iowa LGBTQ Clinic, has worked with hospitalists on improving their care for transgender patients. She and internal medicine physician Nicole Nisly, MD, opened the clinic when a need became apparent.
Before the University of Iowa clinic opened, a transgender advocacy group hosted a forum on LGBT health care, at which patients shared stories of frustration. One patient related a story about calling a department at the university, only to be told, “We don’t take care of people like you.” In another frustrating case, a transgender man had been having vaginal bleeding and called the obstetrics department seeking help. He was repeatedly told he was calling the wrong place. During a white board exercise at the forum, one patient drew buildings representing the university health care system surrounded by barbed wire, symbolizing an off-putting atmosphere in the emergency department that was rife with misgendering of patients.
“Many providers feel like they haven’t had the appropriate training to provide medically competent care for transgender patients – including cross-sex hormones, referrals, and care coordination to ensure patients receive the mental health care, medications, and procedures needed to treat their gender dysphoria,” Dr. Imborek said.
Despite the knowledge gaps, a shift is definitely underway, she said. Dr. Tangpricha concurred, noting that the interest in WPATH’s training programs has increased dramatically.
“In the past, there was a CME program on transgender medicine every 2 years. Now we have courses every 3-4 months and we still can’t keep up with the demand. Employers and hospital systems are adopting transgender medicine as a covered benefit which has driven the need for physician education.”
Team engagement and motivation critical to QI success
Thomas McIlraith, MD, SFHM, CLHM, never imagined he would be leading hospitalists and launching quality improvement (QI) initiatives, but only one year out of residency, he was doing just that.
In 2000, Dr. McIlraith had spent a year working as a hospitalist at South Sacramento (Calif.) Kaiser Permanente when he was tapped for the QI program director role.
“Obviously I didn’t have a lot of preparation,” he said of that first job as director. “All of a sudden I found myself in charge of 15 hospitalists, … and I really didn’t know what I was getting myself into.”
But a passion for quality improvement – for striving to always find ways to do better – put Dr. McIlraith on that path and kept him on it through two terms as chair of the hospital medicine department of Mercy Medical Group in Sacramento, where he was hired in 2004. He completed his second term in June 2016 (the department quintupled in size during his tenure), and then chose to return to the ranks as a hospitalist focusing on patient care – and on spending time with his kids before they finished high school.
But quality improvement is in his blood, and he can see himself returning to it someday, Dr. McIlraith said.
“For me it was never about rising up in the ranks of leadership. It was really about making the world I exist in better,” he said.
In recounting some of the lessons he learned over the last 17 years, Dr. McIlraith recalled his first and all-time favorite quality initiative: Central Coordination. It was a concept he implemented around 2002 at Kaiser Permanante that fundamentally changed the way patients were admitted from the emergency department.
The previous system had separate admitting and rounding physicians, which lead to too many patient hand-offs, increased risk of mistakes, poor efficiency, and low patient satisfaction, he said.
“We actually took the job of distributing patients out of physicians’ hands altogether,” Dr. McIlraith explained.
Under Central Coordination, patient assignments were coordinated by a clerical staffer who distributed them evenly among a team of six doctors.
“The most amazing thing was that after this was implemented we went back and looked at ER responsiveness, and our ability to respond to the needs of the ER improved dramatically,” he said. “That wasn’t even an outcome I intended to impact, or look at, but the data were unequivocal. It ended up being really enduring and substantial on many fronts.”
Mercy Medical Group still uses Central Coordination systemwide, and the results of Dr. McIlraith’s initiative were eventually published.
“At the same time, due to my lack of experience in 2002, I definitely made some mistakes,” he said of the undertaking. Among them was failing to recognize just how resistant people can be to change. “I thought [the plan] was so brilliant that everyone would see that and get in line behind me,” he said. “Then I had a rude awakening that not everyone sees things the same way I do. I was completely taken aback by the resistance.”
Even though the existing system left a lot to be desired, the doctors were comfortable with it, Dr. McIlraith explained, stressing that implementing change requires the buy-in of team members.
If he could do it over again, he would follow the eight-step “Road Map for Change” as outlined by Jeffrey Glasheen, MD, SFHM, during the Society of Hospital Medicine’s Leadership Academy, Dr. McIlraith said.
Dr. Glasheen’s road map emphasizes team engagement and motivation, as well as the importance of creating a “burning platform” (the imperative for change).
“You need to be systematic about it to get people to change behaviors,” Dr. McIlraith said, noting that behavioral change is one of the greatest challenges and one of the leading causes of failure to attain the “holy grail” of quality improvement: sustained results.
In fact, the main reason for the enduring success of Central Coordination was that it took the focus off of behavioral change and put it on the process. “We took the behavior aspect out of the equation and put form over function,” Dr. McIlraith said.
One recent quality improvement initiative involved increasing the percentage of discharge orders delivered before 11 a.m. Dr. McIlraith put the lessons he learned to work by creating an “excellence team” that met regularly to identify key problems and to create “SMART (Specific, Measurable, Attainable, Relevant, and Timely) goals,” which are necessary for success.
Because the team not only bought into the plan to meet the target but also helped create the plan, it wasn’t necessary to force behavioral change, Dr. McIlraith said. Instead the team lead the initiative, set the targets and goals, and ended up surpassing the initial goal of reaching 30% of discharge orders in by 11 a.m. (in fact, they hit 40%).
Dr. McIlraith’s advice for QI success is to know the problem you are trying to solve so that you can tell if the solution you implement is having the desired impact and also to measure the impact of that solution using the SMART goals.
For those who hope to follow a quality improvement career path to leadership, he strongly recommends the Society of Hospital Medicine’s Leadership Academies, which are excellent resources for mentorship, networking, and leadership training through SHM.
Ultimately, Dr. McIlraith stressed the importance of mentoring team members for development as future QI leaders. If mentoring relationships are successful, then when the time comes for a QI veteran to “step back” to focus more on family or take a different career path, there will be others who can step in and keep the quality momentum going.
Thomas McIlraith, MD, SFHM, CLHM, never imagined he would be leading hospitalists and launching quality improvement (QI) initiatives, but only one year out of residency, he was doing just that.
In 2000, Dr. McIlraith had spent a year working as a hospitalist at South Sacramento (Calif.) Kaiser Permanente when he was tapped for the QI program director role.
“Obviously I didn’t have a lot of preparation,” he said of that first job as director. “All of a sudden I found myself in charge of 15 hospitalists, … and I really didn’t know what I was getting myself into.”
But a passion for quality improvement – for striving to always find ways to do better – put Dr. McIlraith on that path and kept him on it through two terms as chair of the hospital medicine department of Mercy Medical Group in Sacramento, where he was hired in 2004. He completed his second term in June 2016 (the department quintupled in size during his tenure), and then chose to return to the ranks as a hospitalist focusing on patient care – and on spending time with his kids before they finished high school.
But quality improvement is in his blood, and he can see himself returning to it someday, Dr. McIlraith said.
“For me it was never about rising up in the ranks of leadership. It was really about making the world I exist in better,” he said.
In recounting some of the lessons he learned over the last 17 years, Dr. McIlraith recalled his first and all-time favorite quality initiative: Central Coordination. It was a concept he implemented around 2002 at Kaiser Permanante that fundamentally changed the way patients were admitted from the emergency department.
The previous system had separate admitting and rounding physicians, which lead to too many patient hand-offs, increased risk of mistakes, poor efficiency, and low patient satisfaction, he said.
“We actually took the job of distributing patients out of physicians’ hands altogether,” Dr. McIlraith explained.
Under Central Coordination, patient assignments were coordinated by a clerical staffer who distributed them evenly among a team of six doctors.
“The most amazing thing was that after this was implemented we went back and looked at ER responsiveness, and our ability to respond to the needs of the ER improved dramatically,” he said. “That wasn’t even an outcome I intended to impact, or look at, but the data were unequivocal. It ended up being really enduring and substantial on many fronts.”
Mercy Medical Group still uses Central Coordination systemwide, and the results of Dr. McIlraith’s initiative were eventually published.
“At the same time, due to my lack of experience in 2002, I definitely made some mistakes,” he said of the undertaking. Among them was failing to recognize just how resistant people can be to change. “I thought [the plan] was so brilliant that everyone would see that and get in line behind me,” he said. “Then I had a rude awakening that not everyone sees things the same way I do. I was completely taken aback by the resistance.”
Even though the existing system left a lot to be desired, the doctors were comfortable with it, Dr. McIlraith explained, stressing that implementing change requires the buy-in of team members.
If he could do it over again, he would follow the eight-step “Road Map for Change” as outlined by Jeffrey Glasheen, MD, SFHM, during the Society of Hospital Medicine’s Leadership Academy, Dr. McIlraith said.
Dr. Glasheen’s road map emphasizes team engagement and motivation, as well as the importance of creating a “burning platform” (the imperative for change).
“You need to be systematic about it to get people to change behaviors,” Dr. McIlraith said, noting that behavioral change is one of the greatest challenges and one of the leading causes of failure to attain the “holy grail” of quality improvement: sustained results.
In fact, the main reason for the enduring success of Central Coordination was that it took the focus off of behavioral change and put it on the process. “We took the behavior aspect out of the equation and put form over function,” Dr. McIlraith said.
One recent quality improvement initiative involved increasing the percentage of discharge orders delivered before 11 a.m. Dr. McIlraith put the lessons he learned to work by creating an “excellence team” that met regularly to identify key problems and to create “SMART (Specific, Measurable, Attainable, Relevant, and Timely) goals,” which are necessary for success.
Because the team not only bought into the plan to meet the target but also helped create the plan, it wasn’t necessary to force behavioral change, Dr. McIlraith said. Instead the team lead the initiative, set the targets and goals, and ended up surpassing the initial goal of reaching 30% of discharge orders in by 11 a.m. (in fact, they hit 40%).
Dr. McIlraith’s advice for QI success is to know the problem you are trying to solve so that you can tell if the solution you implement is having the desired impact and also to measure the impact of that solution using the SMART goals.
For those who hope to follow a quality improvement career path to leadership, he strongly recommends the Society of Hospital Medicine’s Leadership Academies, which are excellent resources for mentorship, networking, and leadership training through SHM.
Ultimately, Dr. McIlraith stressed the importance of mentoring team members for development as future QI leaders. If mentoring relationships are successful, then when the time comes for a QI veteran to “step back” to focus more on family or take a different career path, there will be others who can step in and keep the quality momentum going.
Thomas McIlraith, MD, SFHM, CLHM, never imagined he would be leading hospitalists and launching quality improvement (QI) initiatives, but only one year out of residency, he was doing just that.
In 2000, Dr. McIlraith had spent a year working as a hospitalist at South Sacramento (Calif.) Kaiser Permanente when he was tapped for the QI program director role.
“Obviously I didn’t have a lot of preparation,” he said of that first job as director. “All of a sudden I found myself in charge of 15 hospitalists, … and I really didn’t know what I was getting myself into.”
But a passion for quality improvement – for striving to always find ways to do better – put Dr. McIlraith on that path and kept him on it through two terms as chair of the hospital medicine department of Mercy Medical Group in Sacramento, where he was hired in 2004. He completed his second term in June 2016 (the department quintupled in size during his tenure), and then chose to return to the ranks as a hospitalist focusing on patient care – and on spending time with his kids before they finished high school.
But quality improvement is in his blood, and he can see himself returning to it someday, Dr. McIlraith said.
“For me it was never about rising up in the ranks of leadership. It was really about making the world I exist in better,” he said.
In recounting some of the lessons he learned over the last 17 years, Dr. McIlraith recalled his first and all-time favorite quality initiative: Central Coordination. It was a concept he implemented around 2002 at Kaiser Permanante that fundamentally changed the way patients were admitted from the emergency department.
The previous system had separate admitting and rounding physicians, which lead to too many patient hand-offs, increased risk of mistakes, poor efficiency, and low patient satisfaction, he said.
“We actually took the job of distributing patients out of physicians’ hands altogether,” Dr. McIlraith explained.
Under Central Coordination, patient assignments were coordinated by a clerical staffer who distributed them evenly among a team of six doctors.
“The most amazing thing was that after this was implemented we went back and looked at ER responsiveness, and our ability to respond to the needs of the ER improved dramatically,” he said. “That wasn’t even an outcome I intended to impact, or look at, but the data were unequivocal. It ended up being really enduring and substantial on many fronts.”
Mercy Medical Group still uses Central Coordination systemwide, and the results of Dr. McIlraith’s initiative were eventually published.
“At the same time, due to my lack of experience in 2002, I definitely made some mistakes,” he said of the undertaking. Among them was failing to recognize just how resistant people can be to change. “I thought [the plan] was so brilliant that everyone would see that and get in line behind me,” he said. “Then I had a rude awakening that not everyone sees things the same way I do. I was completely taken aback by the resistance.”
Even though the existing system left a lot to be desired, the doctors were comfortable with it, Dr. McIlraith explained, stressing that implementing change requires the buy-in of team members.
If he could do it over again, he would follow the eight-step “Road Map for Change” as outlined by Jeffrey Glasheen, MD, SFHM, during the Society of Hospital Medicine’s Leadership Academy, Dr. McIlraith said.
Dr. Glasheen’s road map emphasizes team engagement and motivation, as well as the importance of creating a “burning platform” (the imperative for change).
“You need to be systematic about it to get people to change behaviors,” Dr. McIlraith said, noting that behavioral change is one of the greatest challenges and one of the leading causes of failure to attain the “holy grail” of quality improvement: sustained results.
In fact, the main reason for the enduring success of Central Coordination was that it took the focus off of behavioral change and put it on the process. “We took the behavior aspect out of the equation and put form over function,” Dr. McIlraith said.
One recent quality improvement initiative involved increasing the percentage of discharge orders delivered before 11 a.m. Dr. McIlraith put the lessons he learned to work by creating an “excellence team” that met regularly to identify key problems and to create “SMART (Specific, Measurable, Attainable, Relevant, and Timely) goals,” which are necessary for success.
Because the team not only bought into the plan to meet the target but also helped create the plan, it wasn’t necessary to force behavioral change, Dr. McIlraith said. Instead the team lead the initiative, set the targets and goals, and ended up surpassing the initial goal of reaching 30% of discharge orders in by 11 a.m. (in fact, they hit 40%).
Dr. McIlraith’s advice for QI success is to know the problem you are trying to solve so that you can tell if the solution you implement is having the desired impact and also to measure the impact of that solution using the SMART goals.
For those who hope to follow a quality improvement career path to leadership, he strongly recommends the Society of Hospital Medicine’s Leadership Academies, which are excellent resources for mentorship, networking, and leadership training through SHM.
Ultimately, Dr. McIlraith stressed the importance of mentoring team members for development as future QI leaders. If mentoring relationships are successful, then when the time comes for a QI veteran to “step back” to focus more on family or take a different career path, there will be others who can step in and keep the quality momentum going.