Quality

Editor’s note: Second in a three-part series.

This month continues my list of important issues that help position your hospitalist group for greatest success. SHM’s “Key Principles and Characteristics of an Effective Hospital Medicine Group” is the definitive list, and this is my much smaller list. Last month, I discussed a culture (or mindset) of practice ownership, a formal system of group decision-making, and the importance of hospitalists themselves playing an active role in recruitment.

Policy and Procedure Manual

New protocols and decisions are being implemented every day. It is impossible to keep track of them, especially the ones that come into play infrequently. For example, many adult hospitalist groups have reached decisions about whether to admit teenagers (e.g., admit only 16 and older or 18 and older, etc.) and whether a hospitalist or obstetrician serves as attending for pregnant women admitted for a medical problem like asthma or pneumonia. But ask everyone in your group to recite the policies, and I bet the answers will differ.

My experience is that only about 20% to 25% of hospitalist groups have written these things down in one place, but all should. It doesn’t need to be fancy and could just start as a Word document in which the lead hospitalist or other designated person writes down a handful of policies and then updates them on an ongoing basis. For example, if a group meeting results in adopting a new policy, it could be added to the document as soon as the meeting adjourns. In some cases, a policy is communicated by email; it would be fine to just copy the body of that email into the manual.

This “living” document could be maintained on a shared computer drive accessible from anywhere in or out of the hospital. That way, when the solo night doctor thinks, “Do we admit 17-year-olds or not?,” she has a place to find the answer right away. And the manual will be a real asset to orient new providers to your practice.

You could start the policy and procedure manual by listing categories, including human resource issues like sick-day policy, how to request days off or scheduling changes, clinical policies like which hip fractures are admitted by hospitalists versus orthopedics, billing and coding practices such as always turn in charges at end of each day, and so on.

I’ve seen useful manuals that are about 10 pages and others that run more than 50 pages.

An Effective Performance Dashboard

Every hospitalist group should have some sort of routine performance report (dashboard) provided in the same format at regular intervals, yet in my experience many, or even most, don’t. It is worth the sometimes considerable effort to develop a meaningful dashboard, and in 2006, SHM published a helpful guide. Even though it is getting old, most of the advice is still very relevant even if the metrics we care most about have changed.

I’m a big believer in providing unblinded performance data to all in the hospitalist group. For example, a report of individual work relative value unit (wRVU) productivity would show productivity for each doctor by name. I think it is healthy to be transparent and ensure all in the group know how others are performing. There is nothing like finding out you are a performance outlier to spark an interest in understanding why and what should be done about it.

Roles for NPs and PAs

Nurse practitioners (NPs) and physician assistants (PAs) can be valuable contributors to a successful hospitalist program, and according to the 2014 State of Hospital Medicine Report, 65% of hospitalist groups nationally had at least one such clinician—an increase over prior years.

 

While the idea of NP/PAs contributing to the practice is a sound one, my experience is that many groups execute the idea poorly and end up creating a role that can be both professionally unsatisfying and not serve as a platform to contribute effectively to the group. A common scenario is a hospitalist group has trouble with recruiting physicians, so it turns to NP/PAs because they are more readily available. But so often the group has thought little about the precise role NP/PAs will serve (nothing more than “they will help out the docs”). Too often the result is NP/PAs who will say many physician hospitalists simply repeat all the work on each patient, which certainly isn’t a rewarding or cost-effective role.

All should be convinced that the practice is better off in terms of increased overall productivity and/or other benefits by investing in NP/PAs than if those same dollars were instead invested in physician staffing. So one economic model to consider is to calculate the total cost (salary, benefits, malpractice, etc.) for an NP/PA and divide that by those costs for a physician. Let’s say that shows an NP/PA costs half as much as a physician (ranges 40% to 60% in my experience). That staffing cost could be considered in “physician FTE equivalents” so that, for example, a practice with four NP/PAs each costing 50% as much as a physician, or two physician equivalents, could be said to have a total of two physician-equivalent FTEs of staffing. Is the practice better off configured that way, or would it be better to have two physicians instead of the four NP/PAs? The answer will vary, but I think every practice should look at NP/PA staffing through this lens, as well as other considerations, to determine whether they’ve made the best choice.

Having NP/PAs and physicians share rounding duties can be tricky to do efficiently. In my experience, NP/PAs can be better positioned to contribute optimally and find greater professional satisfaction if responsible for a specific portion of the group’s work. For example, at a large hospital, NP/PAs might see all orthopedic consults or psych unit admissions reasonably independently, though with physician backup available. Or NP/PAs could serve as evening (“swing”) shift staffing and manage cross-cover and some admissions. In these roles, the division of labor between NP/PAs and physicians is clearer and allows NP/PAs to contribute most effectively. TH

---

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

Editor’s note: Second in a three-part series.

This month continues my list of important issues that help position your hospitalist group for greatest success. SHM’s “Key Principles and Characteristics of an Effective Hospital Medicine Group” is the definitive list, and this is my much smaller list. Last month, I discussed a culture (or mindset) of practice ownership, a formal system of group decision-making, and the importance of hospitalists themselves playing an active role in recruitment.

Policy and Procedure Manual

New protocols and decisions are being implemented every day. It is impossible to keep track of them, especially the ones that come into play infrequently. For example, many adult hospitalist groups have reached decisions about whether to admit teenagers (e.g., admit only 16 and older or 18 and older, etc.) and whether a hospitalist or obstetrician serves as attending for pregnant women admitted for a medical problem like asthma or pneumonia. But ask everyone in your group to recite the policies, and I bet the answers will differ.

My experience is that only about 20% to 25% of hospitalist groups have written these things down in one place, but all should. It doesn’t need to be fancy and could just start as a Word document in which the lead hospitalist or other designated person writes down a handful of policies and then updates them on an ongoing basis. For example, if a group meeting results in adopting a new policy, it could be added to the document as soon as the meeting adjourns. In some cases, a policy is communicated by email; it would be fine to just copy the body of that email into the manual.

This “living” document could be maintained on a shared computer drive accessible from anywhere in or out of the hospital. That way, when the solo night doctor thinks, “Do we admit 17-year-olds or not?,” she has a place to find the answer right away. And the manual will be a real asset to orient new providers to your practice.

You could start the policy and procedure manual by listing categories, including human resource issues like sick-day policy, how to request days off or scheduling changes, clinical policies like which hip fractures are admitted by hospitalists versus orthopedics, billing and coding practices such as always turn in charges at end of each day, and so on.

I’ve seen useful manuals that are about 10 pages and others that run more than 50 pages.

An Effective Performance Dashboard

Every hospitalist group should have some sort of routine performance report (dashboard) provided in the same format at regular intervals, yet in my experience many, or even most, don’t. It is worth the sometimes considerable effort to develop a meaningful dashboard, and in 2006, SHM published a helpful guide. Even though it is getting old, most of the advice is still very relevant even if the metrics we care most about have changed.

I’m a big believer in providing unblinded performance data to all in the hospitalist group. For example, a report of individual work relative value unit (wRVU) productivity would show productivity for each doctor by name. I think it is healthy to be transparent and ensure all in the group know how others are performing. There is nothing like finding out you are a performance outlier to spark an interest in understanding why and what should be done about it.

Roles for NPs and PAs

Nurse practitioners (NPs) and physician assistants (PAs) can be valuable contributors to a successful hospitalist program, and according to the 2014 State of Hospital Medicine Report, 65% of hospitalist groups nationally had at least one such clinician—an increase over prior years.

 

While the idea of NP/PAs contributing to the practice is a sound one, my experience is that many groups execute the idea poorly and end up creating a role that can be both professionally unsatisfying and not serve as a platform to contribute effectively to the group. A common scenario is a hospitalist group has trouble with recruiting physicians, so it turns to NP/PAs because they are more readily available. But so often the group has thought little about the precise role NP/PAs will serve (nothing more than “they will help out the docs”). Too often the result is NP/PAs who will say many physician hospitalists simply repeat all the work on each patient, which certainly isn’t a rewarding or cost-effective role.

All should be convinced that the practice is better off in terms of increased overall productivity and/or other benefits by investing in NP/PAs than if those same dollars were instead invested in physician staffing. So one economic model to consider is to calculate the total cost (salary, benefits, malpractice, etc.) for an NP/PA and divide that by those costs for a physician. Let’s say that shows an NP/PA costs half as much as a physician (ranges 40% to 60% in my experience). That staffing cost could be considered in “physician FTE equivalents” so that, for example, a practice with four NP/PAs each costing 50% as much as a physician, or two physician equivalents, could be said to have a total of two physician-equivalent FTEs of staffing. Is the practice better off configured that way, or would it be better to have two physicians instead of the four NP/PAs? The answer will vary, but I think every practice should look at NP/PA staffing through this lens, as well as other considerations, to determine whether they’ve made the best choice.

Having NP/PAs and physicians share rounding duties can be tricky to do efficiently. In my experience, NP/PAs can be better positioned to contribute optimally and find greater professional satisfaction if responsible for a specific portion of the group’s work. For example, at a large hospital, NP/PAs might see all orthopedic consults or psych unit admissions reasonably independently, though with physician backup available. Or NP/PAs could serve as evening (“swing”) shift staffing and manage cross-cover and some admissions. In these roles, the division of labor between NP/PAs and physicians is clearer and allows NP/PAs to contribute most effectively. TH

---

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

Editor’s note: Second in a three-part series.

This month continues my list of important issues that help position your hospitalist group for greatest success. SHM’s “Key Principles and Characteristics of an Effective Hospital Medicine Group” is the definitive list, and this is my much smaller list. Last month, I discussed a culture (or mindset) of practice ownership, a formal system of group decision-making, and the importance of hospitalists themselves playing an active role in recruitment.

Policy and Procedure Manual

New protocols and decisions are being implemented every day. It is impossible to keep track of them, especially the ones that come into play infrequently. For example, many adult hospitalist groups have reached decisions about whether to admit teenagers (e.g., admit only 16 and older or 18 and older, etc.) and whether a hospitalist or obstetrician serves as attending for pregnant women admitted for a medical problem like asthma or pneumonia. But ask everyone in your group to recite the policies, and I bet the answers will differ.

My experience is that only about 20% to 25% of hospitalist groups have written these things down in one place, but all should. It doesn’t need to be fancy and could just start as a Word document in which the lead hospitalist or other designated person writes down a handful of policies and then updates them on an ongoing basis. For example, if a group meeting results in adopting a new policy, it could be added to the document as soon as the meeting adjourns. In some cases, a policy is communicated by email; it would be fine to just copy the body of that email into the manual.

This “living” document could be maintained on a shared computer drive accessible from anywhere in or out of the hospital. That way, when the solo night doctor thinks, “Do we admit 17-year-olds or not?,” she has a place to find the answer right away. And the manual will be a real asset to orient new providers to your practice.

You could start the policy and procedure manual by listing categories, including human resource issues like sick-day policy, how to request days off or scheduling changes, clinical policies like which hip fractures are admitted by hospitalists versus orthopedics, billing and coding practices such as always turn in charges at end of each day, and so on.

I’ve seen useful manuals that are about 10 pages and others that run more than 50 pages.

An Effective Performance Dashboard

Every hospitalist group should have some sort of routine performance report (dashboard) provided in the same format at regular intervals, yet in my experience many, or even most, don’t. It is worth the sometimes considerable effort to develop a meaningful dashboard, and in 2006, SHM published a helpful guide. Even though it is getting old, most of the advice is still very relevant even if the metrics we care most about have changed.

I’m a big believer in providing unblinded performance data to all in the hospitalist group. For example, a report of individual work relative value unit (wRVU) productivity would show productivity for each doctor by name. I think it is healthy to be transparent and ensure all in the group know how others are performing. There is nothing like finding out you are a performance outlier to spark an interest in understanding why and what should be done about it.

Roles for NPs and PAs

Nurse practitioners (NPs) and physician assistants (PAs) can be valuable contributors to a successful hospitalist program, and according to the 2014 State of Hospital Medicine Report, 65% of hospitalist groups nationally had at least one such clinician—an increase over prior years.

 

While the idea of NP/PAs contributing to the practice is a sound one, my experience is that many groups execute the idea poorly and end up creating a role that can be both professionally unsatisfying and not serve as a platform to contribute effectively to the group. A common scenario is a hospitalist group has trouble with recruiting physicians, so it turns to NP/PAs because they are more readily available. But so often the group has thought little about the precise role NP/PAs will serve (nothing more than “they will help out the docs”). Too often the result is NP/PAs who will say many physician hospitalists simply repeat all the work on each patient, which certainly isn’t a rewarding or cost-effective role.

All should be convinced that the practice is better off in terms of increased overall productivity and/or other benefits by investing in NP/PAs than if those same dollars were instead invested in physician staffing. So one economic model to consider is to calculate the total cost (salary, benefits, malpractice, etc.) for an NP/PA and divide that by those costs for a physician. Let’s say that shows an NP/PA costs half as much as a physician (ranges 40% to 60% in my experience). That staffing cost could be considered in “physician FTE equivalents” so that, for example, a practice with four NP/PAs each costing 50% as much as a physician, or two physician equivalents, could be said to have a total of two physician-equivalent FTEs of staffing. Is the practice better off configured that way, or would it be better to have two physicians instead of the four NP/PAs? The answer will vary, but I think every practice should look at NP/PA staffing through this lens, as well as other considerations, to determine whether they’ve made the best choice.

Having NP/PAs and physicians share rounding duties can be tricky to do efficiently. In my experience, NP/PAs can be better positioned to contribute optimally and find greater professional satisfaction if responsible for a specific portion of the group’s work. For example, at a large hospital, NP/PAs might see all orthopedic consults or psych unit admissions reasonably independently, though with physician backup available. Or NP/PAs could serve as evening (“swing”) shift staffing and manage cross-cover and some admissions. In these roles, the division of labor between NP/PAs and physicians is clearer and allows NP/PAs to contribute most effectively. TH

---

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

I stumbled upon an absolutely brilliant TED talk about how we need to forget about the “pecking order” within workplaces and how we need to focus on team social connectedness as a strategy to enhance teamwork and productivity.1 I found the analogy in the presenter’s talk so incredibly poignant for the work we do every day in hospital medicine. As we work to solve incredibly challenging problems daily, we do so among continuously changing and highly charged teams. How can we create our teams to be the most effective and productive to serve the greater good?

The speaker, Margaret Heffernan, is an entrepreneur and former CEO of five companies. She tells a story about a study performed by an evolutionary biologist by the name of William Muir of Purdue University in West Lafayette, Ind.2 Muir undertook a series of studies evaluating the social order and productivity of chickens (as measured by egg production) and the team characteristics that make chickens more or less productive. After watching flocks of chickens for several generations, he picked out the most productive chickens and put them all together in a “super flock.” He then watched their productivity over the next several generations and compared their productivity to those in the regular flock.

What he found was that the regular flock became more productive and most of the members of the super flock were dead!

The most productive members of the super flock had essentially pecked the other members to death. He surmised that the only reason the super chickens were initially productive was by suppressing the productivity of the original flock members. The chickens in the regular flock that were initially less aggressive (and less productive) over time sustained fewer injuries and were able to be more productive in the absence of super chickens. The energy that the animals had previously invested in negative behaviors (pecking, injuries, and healing) was redirected into positive behaviors (making eggs).

Muir and his team have gone on to research a tool to predict social aggressiveness and social agreeableness in individual animals. Those high on the socially agreeable scales (and low on the socially aggressive scales) are more valuable for producing highly effective teams of agricultural animals by enhancing group dynamics, social interactions, and actual productivity.

Backward Thinking

Heffernan argues that we have run most businesses (hospitals included) and many societies (at least capitalistic ones) in the super chicken model. In this model, we view leadership as a trait to be individually owned and perfected, and we think that leaders are supposed to have all the answers. In order to determine our leaders, we charge highly competent people to compete against one another as if in a talent contest. It has long been thought that to be successful as teams, we should recruit the best and brightest, pit them against on another, and see who wins, then promote the winner, put them in charge of everything, and give them all the resources they could want or need to be a super chicken.

But this model inevitably suppresses the remainder of the flock and leads to aggression and waste.

In many scenarios in our hospitals, physicians view themselves as and act like super chickens; we try to be the hardest working, the brightest, and the most powerful. How many times have we heard of or witnessed circumstances where a physician suppresses the candor or opinion from other disciplines on the care team? I think we all know physicians (ourselves included) who demand the role of decision maker and ignore the opinions or needs of the remainder of the team, including patients or their family.

 

Alternatives

So if we should not be subscribing to the super chicken theory, then what type of leadership structures should we be subscribing to within medical teams to produce the best outcomes for ourselves and for our patients and their families?

A study performed by MIT scientists gives us some insight. Researchers found that when random groups of people are given very difficult problems to solve (e.g., think about diagnostic dilemmas or very difficult patients), certain group attributes made it more likely that the group would be successful in solving these difficult problems. The groups that were most effective were not those with a few people with extremely high IQs or with the highest collective IQ. The teams that were most effective and able to solve difficult problems were those that showed high degrees of social sensitivity among members (i.e., empathy). The highest-performing teams gave roughly equal time to each member (e.g., think about physicians, pharmacists, social workers, case managers, consultants on a typical medical team). They also found the highest-performing teams had more women in them. (I feel so redeemed!)

In summary, what they learned from these experiments was that the most successful teams were more socially connected and more highly attuned and sensitive to one another. This is not to say that highly successful teams were leaderless. There is absolutely a vital role that leaders play in such teams. In Jim Collins’ famous book Good to Great, in studying leadership and teams, he did not find the best leaders were super chickens who autocratically made unilateral decisions. Instead, he found the best leaders function more like facilitators, having the humility and skill to draw out shared solutions from large participatory teams.3 Doesn’t this sound like how a hospitalist should run multidisciplinary rounds?

The other major attribute that the MIT researchers noticed about highly functional teams is that each and every member of the team was extremely willing and able to give and receive help. They found that teams with high mutual understanding and trust were more likely to seamlessly—and almost effortlessly—give and receive help from one another. They ended up acting as one another’s social support network. If any team member was confronted by a difficult problem or situation, each felt confident that it could be easily solved with the collective skill and wisdom of the team.

As a result of such research, some companies have developed and implemented strategies to enhance such social capital, such as synchronizing coffee breaks and disallowing coffee mugs at individual desks. These companies consider it a vital strategic mission to ensure that team members get to know and understand one another and that they serve as a social support network at work. They believe that it is reliance and interdependency that ensures trust and enhances productivity.

So what really matters is the mortar, not just the bricks.

HM Takeaway

For hospital medicine teams, what we need to do is accept that teams work best when every member has a voice and is valued. When others look to us (usually seen as team leaders) to make all the decisions (as if we are super chickens), we need to empower our team members to make decisions with us.

We need to actively work toward this model of being a team leader, break any cycles of dependency that we have set up, and produce better outcomes.

We need to avoid acting like super chickens and appreciate and empower a true team effort.

We need to stop accepting that management and promotions occur by talent contests that pit employees against one another and insist that rivalry at every level has to be replaced by social capital and social connectedness.

 

Only then will our leadership result in creating effective and productive bricks and mortar. TH

References

1. Heffernan M. Margaret Heffernan: why it’s time to forget the pecking order at work. TED Talks. June 16, 2015. Available at: https://www.youtube.com/watch?v=Vyn_xLrtZaY&feature=youtu.be.
2. Steeves SA. Scientists find method to pick non-competitive animals, improve production. Available at: https://news.uns.purdue.edu/x/2007a/070212MuirSelection.html.
3. Collins J. Good to Great. New York, N.Y.: HarperBusiness; 2011.

---

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

I stumbled upon an absolutely brilliant TED talk about how we need to forget about the “pecking order” within workplaces and how we need to focus on team social connectedness as a strategy to enhance teamwork and productivity.1 I found the analogy in the presenter’s talk so incredibly poignant for the work we do every day in hospital medicine. As we work to solve incredibly challenging problems daily, we do so among continuously changing and highly charged teams. How can we create our teams to be the most effective and productive to serve the greater good?

The speaker, Margaret Heffernan, is an entrepreneur and former CEO of five companies. She tells a story about a study performed by an evolutionary biologist by the name of William Muir of Purdue University in West Lafayette, Ind.2 Muir undertook a series of studies evaluating the social order and productivity of chickens (as measured by egg production) and the team characteristics that make chickens more or less productive. After watching flocks of chickens for several generations, he picked out the most productive chickens and put them all together in a “super flock.” He then watched their productivity over the next several generations and compared their productivity to those in the regular flock.

What he found was that the regular flock became more productive and most of the members of the super flock were dead!

The most productive members of the super flock had essentially pecked the other members to death. He surmised that the only reason the super chickens were initially productive was by suppressing the productivity of the original flock members. The chickens in the regular flock that were initially less aggressive (and less productive) over time sustained fewer injuries and were able to be more productive in the absence of super chickens. The energy that the animals had previously invested in negative behaviors (pecking, injuries, and healing) was redirected into positive behaviors (making eggs).

Muir and his team have gone on to research a tool to predict social aggressiveness and social agreeableness in individual animals. Those high on the socially agreeable scales (and low on the socially aggressive scales) are more valuable for producing highly effective teams of agricultural animals by enhancing group dynamics, social interactions, and actual productivity.

Backward Thinking

Heffernan argues that we have run most businesses (hospitals included) and many societies (at least capitalistic ones) in the super chicken model. In this model, we view leadership as a trait to be individually owned and perfected, and we think that leaders are supposed to have all the answers. In order to determine our leaders, we charge highly competent people to compete against one another as if in a talent contest. It has long been thought that to be successful as teams, we should recruit the best and brightest, pit them against on another, and see who wins, then promote the winner, put them in charge of everything, and give them all the resources they could want or need to be a super chicken.

But this model inevitably suppresses the remainder of the flock and leads to aggression and waste.

In many scenarios in our hospitals, physicians view themselves as and act like super chickens; we try to be the hardest working, the brightest, and the most powerful. How many times have we heard of or witnessed circumstances where a physician suppresses the candor or opinion from other disciplines on the care team? I think we all know physicians (ourselves included) who demand the role of decision maker and ignore the opinions or needs of the remainder of the team, including patients or their family.

 

Alternatives

So if we should not be subscribing to the super chicken theory, then what type of leadership structures should we be subscribing to within medical teams to produce the best outcomes for ourselves and for our patients and their families?

A study performed by MIT scientists gives us some insight. Researchers found that when random groups of people are given very difficult problems to solve (e.g., think about diagnostic dilemmas or very difficult patients), certain group attributes made it more likely that the group would be successful in solving these difficult problems. The groups that were most effective were not those with a few people with extremely high IQs or with the highest collective IQ. The teams that were most effective and able to solve difficult problems were those that showed high degrees of social sensitivity among members (i.e., empathy). The highest-performing teams gave roughly equal time to each member (e.g., think about physicians, pharmacists, social workers, case managers, consultants on a typical medical team). They also found the highest-performing teams had more women in them. (I feel so redeemed!)

In summary, what they learned from these experiments was that the most successful teams were more socially connected and more highly attuned and sensitive to one another. This is not to say that highly successful teams were leaderless. There is absolutely a vital role that leaders play in such teams. In Jim Collins’ famous book Good to Great, in studying leadership and teams, he did not find the best leaders were super chickens who autocratically made unilateral decisions. Instead, he found the best leaders function more like facilitators, having the humility and skill to draw out shared solutions from large participatory teams.3 Doesn’t this sound like how a hospitalist should run multidisciplinary rounds?

The other major attribute that the MIT researchers noticed about highly functional teams is that each and every member of the team was extremely willing and able to give and receive help. They found that teams with high mutual understanding and trust were more likely to seamlessly—and almost effortlessly—give and receive help from one another. They ended up acting as one another’s social support network. If any team member was confronted by a difficult problem or situation, each felt confident that it could be easily solved with the collective skill and wisdom of the team.

As a result of such research, some companies have developed and implemented strategies to enhance such social capital, such as synchronizing coffee breaks and disallowing coffee mugs at individual desks. These companies consider it a vital strategic mission to ensure that team members get to know and understand one another and that they serve as a social support network at work. They believe that it is reliance and interdependency that ensures trust and enhances productivity.

So what really matters is the mortar, not just the bricks.

HM Takeaway

For hospital medicine teams, what we need to do is accept that teams work best when every member has a voice and is valued. When others look to us (usually seen as team leaders) to make all the decisions (as if we are super chickens), we need to empower our team members to make decisions with us.

We need to actively work toward this model of being a team leader, break any cycles of dependency that we have set up, and produce better outcomes.

We need to avoid acting like super chickens and appreciate and empower a true team effort.

We need to stop accepting that management and promotions occur by talent contests that pit employees against one another and insist that rivalry at every level has to be replaced by social capital and social connectedness.

 

Only then will our leadership result in creating effective and productive bricks and mortar. TH

References

1. Heffernan M. Margaret Heffernan: why it’s time to forget the pecking order at work. TED Talks. June 16, 2015. Available at: https://www.youtube.com/watch?v=Vyn_xLrtZaY&feature=youtu.be.
2. Steeves SA. Scientists find method to pick non-competitive animals, improve production. Available at: https://news.uns.purdue.edu/x/2007a/070212MuirSelection.html.
3. Collins J. Good to Great. New York, N.Y.: HarperBusiness; 2011.

---

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

I stumbled upon an absolutely brilliant TED talk about how we need to forget about the “pecking order” within workplaces and how we need to focus on team social connectedness as a strategy to enhance teamwork and productivity.1 I found the analogy in the presenter’s talk so incredibly poignant for the work we do every day in hospital medicine. As we work to solve incredibly challenging problems daily, we do so among continuously changing and highly charged teams. How can we create our teams to be the most effective and productive to serve the greater good?

The speaker, Margaret Heffernan, is an entrepreneur and former CEO of five companies. She tells a story about a study performed by an evolutionary biologist by the name of William Muir of Purdue University in West Lafayette, Ind.2 Muir undertook a series of studies evaluating the social order and productivity of chickens (as measured by egg production) and the team characteristics that make chickens more or less productive. After watching flocks of chickens for several generations, he picked out the most productive chickens and put them all together in a “super flock.” He then watched their productivity over the next several generations and compared their productivity to those in the regular flock.

What he found was that the regular flock became more productive and most of the members of the super flock were dead!

The most productive members of the super flock had essentially pecked the other members to death. He surmised that the only reason the super chickens were initially productive was by suppressing the productivity of the original flock members. The chickens in the regular flock that were initially less aggressive (and less productive) over time sustained fewer injuries and were able to be more productive in the absence of super chickens. The energy that the animals had previously invested in negative behaviors (pecking, injuries, and healing) was redirected into positive behaviors (making eggs).

Muir and his team have gone on to research a tool to predict social aggressiveness and social agreeableness in individual animals. Those high on the socially agreeable scales (and low on the socially aggressive scales) are more valuable for producing highly effective teams of agricultural animals by enhancing group dynamics, social interactions, and actual productivity.

Backward Thinking

Heffernan argues that we have run most businesses (hospitals included) and many societies (at least capitalistic ones) in the super chicken model. In this model, we view leadership as a trait to be individually owned and perfected, and we think that leaders are supposed to have all the answers. In order to determine our leaders, we charge highly competent people to compete against one another as if in a talent contest. It has long been thought that to be successful as teams, we should recruit the best and brightest, pit them against on another, and see who wins, then promote the winner, put them in charge of everything, and give them all the resources they could want or need to be a super chicken.

But this model inevitably suppresses the remainder of the flock and leads to aggression and waste.

In many scenarios in our hospitals, physicians view themselves as and act like super chickens; we try to be the hardest working, the brightest, and the most powerful. How many times have we heard of or witnessed circumstances where a physician suppresses the candor or opinion from other disciplines on the care team? I think we all know physicians (ourselves included) who demand the role of decision maker and ignore the opinions or needs of the remainder of the team, including patients or their family.

 

Alternatives

So if we should not be subscribing to the super chicken theory, then what type of leadership structures should we be subscribing to within medical teams to produce the best outcomes for ourselves and for our patients and their families?

A study performed by MIT scientists gives us some insight. Researchers found that when random groups of people are given very difficult problems to solve (e.g., think about diagnostic dilemmas or very difficult patients), certain group attributes made it more likely that the group would be successful in solving these difficult problems. The groups that were most effective were not those with a few people with extremely high IQs or with the highest collective IQ. The teams that were most effective and able to solve difficult problems were those that showed high degrees of social sensitivity among members (i.e., empathy). The highest-performing teams gave roughly equal time to each member (e.g., think about physicians, pharmacists, social workers, case managers, consultants on a typical medical team). They also found the highest-performing teams had more women in them. (I feel so redeemed!)

In summary, what they learned from these experiments was that the most successful teams were more socially connected and more highly attuned and sensitive to one another. This is not to say that highly successful teams were leaderless. There is absolutely a vital role that leaders play in such teams. In Jim Collins’ famous book Good to Great, in studying leadership and teams, he did not find the best leaders were super chickens who autocratically made unilateral decisions. Instead, he found the best leaders function more like facilitators, having the humility and skill to draw out shared solutions from large participatory teams.3 Doesn’t this sound like how a hospitalist should run multidisciplinary rounds?

The other major attribute that the MIT researchers noticed about highly functional teams is that each and every member of the team was extremely willing and able to give and receive help. They found that teams with high mutual understanding and trust were more likely to seamlessly—and almost effortlessly—give and receive help from one another. They ended up acting as one another’s social support network. If any team member was confronted by a difficult problem or situation, each felt confident that it could be easily solved with the collective skill and wisdom of the team.

As a result of such research, some companies have developed and implemented strategies to enhance such social capital, such as synchronizing coffee breaks and disallowing coffee mugs at individual desks. These companies consider it a vital strategic mission to ensure that team members get to know and understand one another and that they serve as a social support network at work. They believe that it is reliance and interdependency that ensures trust and enhances productivity.

So what really matters is the mortar, not just the bricks.

HM Takeaway

For hospital medicine teams, what we need to do is accept that teams work best when every member has a voice and is valued. When others look to us (usually seen as team leaders) to make all the decisions (as if we are super chickens), we need to empower our team members to make decisions with us.

We need to actively work toward this model of being a team leader, break any cycles of dependency that we have set up, and produce better outcomes.

We need to avoid acting like super chickens and appreciate and empower a true team effort.

We need to stop accepting that management and promotions occur by talent contests that pit employees against one another and insist that rivalry at every level has to be replaced by social capital and social connectedness.

 

Only then will our leadership result in creating effective and productive bricks and mortar. TH

References

1. Heffernan M. Margaret Heffernan: why it’s time to forget the pecking order at work. TED Talks. June 16, 2015. Available at: https://www.youtube.com/watch?v=Vyn_xLrtZaY&feature=youtu.be.
2. Steeves SA. Scientists find method to pick non-competitive animals, improve production. Available at: https://news.uns.purdue.edu/x/2007a/070212MuirSelection.html.
3. Collins J. Good to Great. New York, N.Y.: HarperBusiness; 2011.

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

Patient falls are a national issue, creating costs for every player in the healthcare system.

“Patient falls negatively impact patient outcomes, hospital costs, and costs for insurance and health systems,” says Jennifer Hefner, PhD, MPH, lead author of “A Falls Wheel in a Large Academic Medical Center: An Intervention to Reduce Patient Falls with Harm,” published in the Journal of Healthcare Quality.

“Patients are negatively impacted by falls in terms of outcomes like loss of confidence and readmission risks,” Dr. Hefner says. “Centers for Medicare & Medicaid Services in 2008 declared they wouldn’t reimburse hospitals for treatment of fall injuries if they occurred during a patient’s stay and they could be prevented by hospitals. In terms of the cost to society, the length of stay is longer if there’s been a fall with harm, and the total charges are 60% higher between those who fell and sustained an injury and those who didn’t.”

In the researchers’ yearlong study, a falls wheel—a tool that categorized each patient on two dimensions: risk of fall and risk of injury from fall—was placed on every patient’s door. During the year, the rate of falls with harm dropped by almost 50%.

The falls wheel was just one element—the main innovative element—of the hospital’s multifaceted approach to falls prevention. The hospital also enhanced staff education and focus on the issue, launched a resource website, and sent a daily email reporting the number of falls.

“The most important thing we learned is that falls are not a nurse-sensitive indicator,” says co-author Susan Moffatt-Bruce, MD, PhD. “Falls are a team-sensitive indicator. It’s only when you realize falls are not just a nurse’s responsibility but everybody’s responsibility can you actually impact them and reduce them.”

Focusing on the problem and developing specific, multifaceted interventions was the key, the authors say.

“I don’t think everybody needs to use a falls wheel, but you need some kind of system or program,” Dr. Moffatt-Bruce says. “Just putting a wristband on someone to say they’re at high risk is great, but so what? What are you going to do about it? What are the actual items you’re asking the team to do to prevent falls?”

Reference

1. Hefner JL, McAlearney AS, Mansfield J, Knupp AM, Moffatt-Bruce SD. A falls wheel in a large academic medical center: an intervention to reduce patient falls with harm. J Healthc Qual. 2015;37(6):374-380.

Patient falls are a national issue, creating costs for every player in the healthcare system.

“Patient falls negatively impact patient outcomes, hospital costs, and costs for insurance and health systems,” says Jennifer Hefner, PhD, MPH, lead author of “A Falls Wheel in a Large Academic Medical Center: An Intervention to Reduce Patient Falls with Harm,” published in the Journal of Healthcare Quality.

“Patients are negatively impacted by falls in terms of outcomes like loss of confidence and readmission risks,” Dr. Hefner says. “Centers for Medicare & Medicaid Services in 2008 declared they wouldn’t reimburse hospitals for treatment of fall injuries if they occurred during a patient’s stay and they could be prevented by hospitals. In terms of the cost to society, the length of stay is longer if there’s been a fall with harm, and the total charges are 60% higher between those who fell and sustained an injury and those who didn’t.”

In the researchers’ yearlong study, a falls wheel—a tool that categorized each patient on two dimensions: risk of fall and risk of injury from fall—was placed on every patient’s door. During the year, the rate of falls with harm dropped by almost 50%.

The falls wheel was just one element—the main innovative element—of the hospital’s multifaceted approach to falls prevention. The hospital also enhanced staff education and focus on the issue, launched a resource website, and sent a daily email reporting the number of falls.

“The most important thing we learned is that falls are not a nurse-sensitive indicator,” says co-author Susan Moffatt-Bruce, MD, PhD. “Falls are a team-sensitive indicator. It’s only when you realize falls are not just a nurse’s responsibility but everybody’s responsibility can you actually impact them and reduce them.”

Focusing on the problem and developing specific, multifaceted interventions was the key, the authors say.

“I don’t think everybody needs to use a falls wheel, but you need some kind of system or program,” Dr. Moffatt-Bruce says. “Just putting a wristband on someone to say they’re at high risk is great, but so what? What are you going to do about it? What are the actual items you’re asking the team to do to prevent falls?”

Reference

1. Hefner JL, McAlearney AS, Mansfield J, Knupp AM, Moffatt-Bruce SD. A falls wheel in a large academic medical center: an intervention to reduce patient falls with harm. J Healthc Qual. 2015;37(6):374-380.

Patient falls are a national issue, creating costs for every player in the healthcare system.

“Patient falls negatively impact patient outcomes, hospital costs, and costs for insurance and health systems,” says Jennifer Hefner, PhD, MPH, lead author of “A Falls Wheel in a Large Academic Medical Center: An Intervention to Reduce Patient Falls with Harm,” published in the Journal of Healthcare Quality.

“Patients are negatively impacted by falls in terms of outcomes like loss of confidence and readmission risks,” Dr. Hefner says. “Centers for Medicare & Medicaid Services in 2008 declared they wouldn’t reimburse hospitals for treatment of fall injuries if they occurred during a patient’s stay and they could be prevented by hospitals. In terms of the cost to society, the length of stay is longer if there’s been a fall with harm, and the total charges are 60% higher between those who fell and sustained an injury and those who didn’t.”

In the researchers’ yearlong study, a falls wheel—a tool that categorized each patient on two dimensions: risk of fall and risk of injury from fall—was placed on every patient’s door. During the year, the rate of falls with harm dropped by almost 50%.

The falls wheel was just one element—the main innovative element—of the hospital’s multifaceted approach to falls prevention. The hospital also enhanced staff education and focus on the issue, launched a resource website, and sent a daily email reporting the number of falls.

“The most important thing we learned is that falls are not a nurse-sensitive indicator,” says co-author Susan Moffatt-Bruce, MD, PhD. “Falls are a team-sensitive indicator. It’s only when you realize falls are not just a nurse’s responsibility but everybody’s responsibility can you actually impact them and reduce them.”

Focusing on the problem and developing specific, multifaceted interventions was the key, the authors say.

“I don’t think everybody needs to use a falls wheel, but you need some kind of system or program,” Dr. Moffatt-Bruce says. “Just putting a wristband on someone to say they’re at high risk is great, but so what? What are you going to do about it? What are the actual items you’re asking the team to do to prevent falls?”

Reference

1. Hefner JL, McAlearney AS, Mansfield J, Knupp AM, Moffatt-Bruce SD. A falls wheel in a large academic medical center: an intervention to reduce patient falls with harm. J Healthc Qual. 2015;37(6):374-380.

It has been two years since the “Key Characteristics” was published in the Journal of Hospital Medicine.1 The SHM board of directors envisions the Key Characteristics as a tool to improve the performance of hospital medicine groups (HMGs) and “raise the bar” for the specialty.

At SHM’s annual meeting (www.hospitalmedicine2016.org) next month in San Diego, the Key Characteristics will provide the framework for the Practice Management Pre-Course (Sunday, March 6). The pre-course faculty, of which I am a member, will address all 10 principles of the Key Characteristics (see Table 1), including case studies and practical ideas for performance improvement. As a preview, I will cover Principle 6 and provide a few practical tips that you can implement in your practice.

For a more comprehensive discussion of all the Key Characteristics and how to use them, visit the SHM website (visit www.hospitalmedicine.org, then click on the “Practice Management” icon at the top of the landing page).

Characteristic 6.1

The HMG has systems in place to ensure effective and reliable communication with the patient’s primary care physician and/or other provider(s) involved in the patient’s care in the non-acute-care setting.

Practical tip: Your practice probably has administrative procedures in place to notify PCPs that their patient has been admitted to the hospital, using the electronic health record or secure email, if available, or messaging by fax/phone. But are you receiving vital information from the PCP’s office or from the nursing facility? Establish a protocol for obtaining key history, medication, and diagnostic testing information from these sources. One approach is to request this information when notifying the PCP of the patient’s admission.

Practical tip: Use the “grocery store test” to determine when to contact the PCP during the hospital stay. For example, if the PCP were to run into a family member of the patient in the grocery store, would the PCP want to have learned of a change in the patient’s condition in advance of the family member encounter?

Practical tip: Because reaching skilling nursing facility (SNF) physicians/providers (SNFists) can be challenging, hold an annual social event so that they can meet the hospitalists in your practice face-to-face. At the event, exchange cellphone or beeper numbers with the SNFists, and establish an explicit understanding of how handoffs will occur, especially for high-risk patients.

Characteristic 6.2

The HMG contributes in meaningful ways to the hospital’s efforts to improve care transitions.

Because of readmissions penalties, every hospital in the country is concerned with care transitions and avoiding readmissions. But HMGs want to know which interventions reliably decrease readmissions. The Commonwealth Fund recently released the results of a study of 428 hospitals that participated in national efforts to reduce readmissions, including the State Action on Avoidable Rehospitalizations (STAAR) and Hospital to Home (H2H) initiatives. The study’s primary conclusions were as follows:

• The only strategy consistently associated with reduced risk-standardized readmissions was discharging patients with their appointments already made.2 No other single strategy was reliably associated with a reduction.
• Hospitals that implemented three or more readmission reduction strategies showed a significant decrease in risk-standardized readmissions versus those implementing fewer than three.

Practical tip: Ensure patients leave the hospital with a PCP follow-up appointment made and in hand.

Practical tip: Work with your hospital on at least three definitive strategies to reduce readmissions.

Implement to Improve Your HMG

The basic and updated 2015 versions of the “Key Principles and Characteristics of an Effective Hospital Medicine Group” can be downloaded from the SHM website (visit www.hospitalmedicine.org, then click on the “Practice Management” icon at the top of the landing page). The updated 2015 version provides definitions and requirements and suggested approaches to demonstrating the characteristic that enables the HMG to conduct a comprehensive self-assessment.

 

In addition, there is a new tool intended for use by hospitalist practice administrators that cross-references the Key Characteristics with another tool, The Core Competencies for a Hospitalist Practice Administrator. TH

---

Dr. Whitcomb is Chief Medical Officer of Remedy Partners. He is co-founder and past president of SHM. Email him at [email protected].

References

1. Cawley P, Deitelzweig S, Flores L, et al. The key principles and characteristics of an effective hospital medicine group: an assessment guide for hospitals and hospitalists. J Hosp Med. 2014;9(2):123-128.
2. Bradley EH, Brewster A, Curry L. National campaigns to reduce readmissions: what have we learned? The Commonwealth Fund website. Available at: commonwealthfund.org/publications/blog/2015/oct/national-campaigns-to-reduce-readmissions. Accessed December 28, 2015.

It has been two years since the “Key Characteristics” was published in the Journal of Hospital Medicine.1 The SHM board of directors envisions the Key Characteristics as a tool to improve the performance of hospital medicine groups (HMGs) and “raise the bar” for the specialty.

At SHM’s annual meeting (www.hospitalmedicine2016.org) next month in San Diego, the Key Characteristics will provide the framework for the Practice Management Pre-Course (Sunday, March 6). The pre-course faculty, of which I am a member, will address all 10 principles of the Key Characteristics (see Table 1), including case studies and practical ideas for performance improvement. As a preview, I will cover Principle 6 and provide a few practical tips that you can implement in your practice.

For a more comprehensive discussion of all the Key Characteristics and how to use them, visit the SHM website (visit www.hospitalmedicine.org, then click on the “Practice Management” icon at the top of the landing page).

Characteristic 6.1

The HMG has systems in place to ensure effective and reliable communication with the patient’s primary care physician and/or other provider(s) involved in the patient’s care in the non-acute-care setting.

Practical tip: Your practice probably has administrative procedures in place to notify PCPs that their patient has been admitted to the hospital, using the electronic health record or secure email, if available, or messaging by fax/phone. But are you receiving vital information from the PCP’s office or from the nursing facility? Establish a protocol for obtaining key history, medication, and diagnostic testing information from these sources. One approach is to request this information when notifying the PCP of the patient’s admission.

Practical tip: Use the “grocery store test” to determine when to contact the PCP during the hospital stay. For example, if the PCP were to run into a family member of the patient in the grocery store, would the PCP want to have learned of a change in the patient’s condition in advance of the family member encounter?

Practical tip: Because reaching skilling nursing facility (SNF) physicians/providers (SNFists) can be challenging, hold an annual social event so that they can meet the hospitalists in your practice face-to-face. At the event, exchange cellphone or beeper numbers with the SNFists, and establish an explicit understanding of how handoffs will occur, especially for high-risk patients.

Characteristic 6.2

The HMG contributes in meaningful ways to the hospital’s efforts to improve care transitions.

Because of readmissions penalties, every hospital in the country is concerned with care transitions and avoiding readmissions. But HMGs want to know which interventions reliably decrease readmissions. The Commonwealth Fund recently released the results of a study of 428 hospitals that participated in national efforts to reduce readmissions, including the State Action on Avoidable Rehospitalizations (STAAR) and Hospital to Home (H2H) initiatives. The study’s primary conclusions were as follows:

• The only strategy consistently associated with reduced risk-standardized readmissions was discharging patients with their appointments already made.2 No other single strategy was reliably associated with a reduction.
• Hospitals that implemented three or more readmission reduction strategies showed a significant decrease in risk-standardized readmissions versus those implementing fewer than three.

Practical tip: Ensure patients leave the hospital with a PCP follow-up appointment made and in hand.

Practical tip: Work with your hospital on at least three definitive strategies to reduce readmissions.

Implement to Improve Your HMG

The basic and updated 2015 versions of the “Key Principles and Characteristics of an Effective Hospital Medicine Group” can be downloaded from the SHM website (visit www.hospitalmedicine.org, then click on the “Practice Management” icon at the top of the landing page). The updated 2015 version provides definitions and requirements and suggested approaches to demonstrating the characteristic that enables the HMG to conduct a comprehensive self-assessment.

 

In addition, there is a new tool intended for use by hospitalist practice administrators that cross-references the Key Characteristics with another tool, The Core Competencies for a Hospitalist Practice Administrator. TH

---

Dr. Whitcomb is Chief Medical Officer of Remedy Partners. He is co-founder and past president of SHM. Email him at [email protected].

References

1. Cawley P, Deitelzweig S, Flores L, et al. The key principles and characteristics of an effective hospital medicine group: an assessment guide for hospitals and hospitalists. J Hosp Med. 2014;9(2):123-128.
2. Bradley EH, Brewster A, Curry L. National campaigns to reduce readmissions: what have we learned? The Commonwealth Fund website. Available at: commonwealthfund.org/publications/blog/2015/oct/national-campaigns-to-reduce-readmissions. Accessed December 28, 2015.

It has been two years since the “Key Characteristics” was published in the Journal of Hospital Medicine.1 The SHM board of directors envisions the Key Characteristics as a tool to improve the performance of hospital medicine groups (HMGs) and “raise the bar” for the specialty.

At SHM’s annual meeting (www.hospitalmedicine2016.org) next month in San Diego, the Key Characteristics will provide the framework for the Practice Management Pre-Course (Sunday, March 6). The pre-course faculty, of which I am a member, will address all 10 principles of the Key Characteristics (see Table 1), including case studies and practical ideas for performance improvement. As a preview, I will cover Principle 6 and provide a few practical tips that you can implement in your practice.

For a more comprehensive discussion of all the Key Characteristics and how to use them, visit the SHM website (visit www.hospitalmedicine.org, then click on the “Practice Management” icon at the top of the landing page).

Characteristic 6.1

The HMG has systems in place to ensure effective and reliable communication with the patient’s primary care physician and/or other provider(s) involved in the patient’s care in the non-acute-care setting.

Practical tip: Your practice probably has administrative procedures in place to notify PCPs that their patient has been admitted to the hospital, using the electronic health record or secure email, if available, or messaging by fax/phone. But are you receiving vital information from the PCP’s office or from the nursing facility? Establish a protocol for obtaining key history, medication, and diagnostic testing information from these sources. One approach is to request this information when notifying the PCP of the patient’s admission.

Practical tip: Use the “grocery store test” to determine when to contact the PCP during the hospital stay. For example, if the PCP were to run into a family member of the patient in the grocery store, would the PCP want to have learned of a change in the patient’s condition in advance of the family member encounter?

Practical tip: Because reaching skilling nursing facility (SNF) physicians/providers (SNFists) can be challenging, hold an annual social event so that they can meet the hospitalists in your practice face-to-face. At the event, exchange cellphone or beeper numbers with the SNFists, and establish an explicit understanding of how handoffs will occur, especially for high-risk patients.

Characteristic 6.2

The HMG contributes in meaningful ways to the hospital’s efforts to improve care transitions.

Because of readmissions penalties, every hospital in the country is concerned with care transitions and avoiding readmissions. But HMGs want to know which interventions reliably decrease readmissions. The Commonwealth Fund recently released the results of a study of 428 hospitals that participated in national efforts to reduce readmissions, including the State Action on Avoidable Rehospitalizations (STAAR) and Hospital to Home (H2H) initiatives. The study’s primary conclusions were as follows:

• The only strategy consistently associated with reduced risk-standardized readmissions was discharging patients with their appointments already made.2 No other single strategy was reliably associated with a reduction.
• Hospitals that implemented three or more readmission reduction strategies showed a significant decrease in risk-standardized readmissions versus those implementing fewer than three.

Practical tip: Ensure patients leave the hospital with a PCP follow-up appointment made and in hand.

Practical tip: Work with your hospital on at least three definitive strategies to reduce readmissions.

Implement to Improve Your HMG

The basic and updated 2015 versions of the “Key Principles and Characteristics of an Effective Hospital Medicine Group” can be downloaded from the SHM website (visit www.hospitalmedicine.org, then click on the “Practice Management” icon at the top of the landing page). The updated 2015 version provides definitions and requirements and suggested approaches to demonstrating the characteristic that enables the HMG to conduct a comprehensive self-assessment.

 

In addition, there is a new tool intended for use by hospitalist practice administrators that cross-references the Key Characteristics with another tool, The Core Competencies for a Hospitalist Practice Administrator. TH

---

Dr. Whitcomb is Chief Medical Officer of Remedy Partners. He is co-founder and past president of SHM. Email him at [email protected].

References

1. Cawley P, Deitelzweig S, Flores L, et al. The key principles and characteristics of an effective hospital medicine group: an assessment guide for hospitals and hospitalists. J Hosp Med. 2014;9(2):123-128.
2. Bradley EH, Brewster A, Curry L. National campaigns to reduce readmissions: what have we learned? The Commonwealth Fund website. Available at: commonwealthfund.org/publications/blog/2015/oct/national-campaigns-to-reduce-readmissions. Accessed December 28, 2015.

Presenter: Jordan Messler, MD, SHFM

Summary: The main objective of this lecture was to understand the culture that often limits physician engagement. It also offered insights on how to best understand motivators for engagement, and tried to focus on strategies to improve and create an environment for physician engagement.

Despite strong evidence, there remains a refusal to confront healthcare provider’s severe quality problems. There is a high rate of failure, considering that 80% of major initiatives don’t meet their objectives. Dr. Messler pointed out that the second principle of the "Key Characteristics of an Effective Hospital Medicine Group" is an engaged hospitalist. To make this more complicated, 40% of hospitalists report inpatient census that exceed safe levels at least once a month; and 52% of hospitalists have signs of burnout.

Dr. Messler explained are intrinsic and extrinsic motivators: the culture of the group will impact the extrinsic motivation factors when it tries to encourage physician to do their work because they expected of themselves, not because some else is looking over their shoulders. Among intrinsic motivators: a sense of autonomy, mastery and purpose drives a culture of not only do the work but also improve it. Some hospitalist groups are trying to explore new approaches, including protective time for physicians to allow them to get involved in committee and QI projects.

Applying behavioral economics concepts (science of human motivation) can help HMGs design incentives among such domains as inertia (by simplifying processes), immediacy (giving bonus right after achieving goals), mental accounting (using paper checks for rewards).

HM Takeaways:

• There is lack of awareness of physician disengagement.
• Burn out is the opposite of engagement and affects patient quality.
• There are intrinsic and extrinsic factors that drives engagement.
• By creating a culture of ownership, mastery, autonomy, and rediscovery of purpose and right mix of incentives physicians can engage more.
• SHM has an Engagement Survey that can help get to know baseline motivators driving among specific groups.

Dr. Villagra is a hospitalist in Batesville, Ark., and a member of Team Hospitalist.

 

 

Presenter: Jordan Messler, MD, SHFM

Summary: The main objective of this lecture was to understand the culture that often limits physician engagement. It also offered insights on how to best understand motivators for engagement, and tried to focus on strategies to improve and create an environment for physician engagement.

Despite strong evidence, there remains a refusal to confront healthcare provider’s severe quality problems. There is a high rate of failure, considering that 80% of major initiatives don’t meet their objectives. Dr. Messler pointed out that the second principle of the "Key Characteristics of an Effective Hospital Medicine Group" is an engaged hospitalist. To make this more complicated, 40% of hospitalists report inpatient census that exceed safe levels at least once a month; and 52% of hospitalists have signs of burnout.

Dr. Messler explained are intrinsic and extrinsic motivators: the culture of the group will impact the extrinsic motivation factors when it tries to encourage physician to do their work because they expected of themselves, not because some else is looking over their shoulders. Among intrinsic motivators: a sense of autonomy, mastery and purpose drives a culture of not only do the work but also improve it. Some hospitalist groups are trying to explore new approaches, including protective time for physicians to allow them to get involved in committee and QI projects.

Applying behavioral economics concepts (science of human motivation) can help HMGs design incentives among such domains as inertia (by simplifying processes), immediacy (giving bonus right after achieving goals), mental accounting (using paper checks for rewards).

HM Takeaways:

• There is lack of awareness of physician disengagement.
• Burn out is the opposite of engagement and affects patient quality.
• There are intrinsic and extrinsic factors that drives engagement.
• By creating a culture of ownership, mastery, autonomy, and rediscovery of purpose and right mix of incentives physicians can engage more.
• SHM has an Engagement Survey that can help get to know baseline motivators driving among specific groups.

Dr. Villagra is a hospitalist in Batesville, Ark., and a member of Team Hospitalist.

 

 

Presenter: Jordan Messler, MD, SHFM

Summary: The main objective of this lecture was to understand the culture that often limits physician engagement. It also offered insights on how to best understand motivators for engagement, and tried to focus on strategies to improve and create an environment for physician engagement.

Despite strong evidence, there remains a refusal to confront healthcare provider’s severe quality problems. There is a high rate of failure, considering that 80% of major initiatives don’t meet their objectives. Dr. Messler pointed out that the second principle of the "Key Characteristics of an Effective Hospital Medicine Group" is an engaged hospitalist. To make this more complicated, 40% of hospitalists report inpatient census that exceed safe levels at least once a month; and 52% of hospitalists have signs of burnout.

Dr. Messler explained are intrinsic and extrinsic motivators: the culture of the group will impact the extrinsic motivation factors when it tries to encourage physician to do their work because they expected of themselves, not because some else is looking over their shoulders. Among intrinsic motivators: a sense of autonomy, mastery and purpose drives a culture of not only do the work but also improve it. Some hospitalist groups are trying to explore new approaches, including protective time for physicians to allow them to get involved in committee and QI projects.

Applying behavioral economics concepts (science of human motivation) can help HMGs design incentives among such domains as inertia (by simplifying processes), immediacy (giving bonus right after achieving goals), mental accounting (using paper checks for rewards).

HM Takeaways:

• There is lack of awareness of physician disengagement.
• Burn out is the opposite of engagement and affects patient quality.
• There are intrinsic and extrinsic factors that drives engagement.
• By creating a culture of ownership, mastery, autonomy, and rediscovery of purpose and right mix of incentives physicians can engage more.
• SHM has an Engagement Survey that can help get to know baseline motivators driving among specific groups.

Dr. Villagra is a hospitalist in Batesville, Ark., and a member of Team Hospitalist.

 

 

At #HospMed16 Plenary, the U.S. Surgeon General, Vice Admiral Vivek H. Murthy, MD, MBA, spoke to a standing-room-only crowd about how hospitalists can lead in “Bringing Health to America.”

Dr. Murthy, who previously worked as a hospitalist in Boston, spoke about how the urgency to build a foundation for health in America, where chronic illness and healthcare costs have skyrocketed, could not be any greater. Health is the key to opportunity, he said. He explored the following strategies to make America healthier:

1. Make the pursuit of healthy appealing;
2. Improve the safety of our communities;
3. Focus on the mind and spirit; and,
4. Cultivate our ability to give and receive kindness.

Specifically, hospitalists should contemplate the following questions:

• How can hospitalists leverage their leadership in the hospital to improve systems and create a culture that supports healing and health?
• How can hospitalists be a powerful of force of change both inside and outside the hospital?
• How can hospitalists inspire the next generation of physicians to safeguard the health of their community by treating and preventing illness?

Dr. Murthy challenged hospitalists to commit to strengthening the foundation of health in our country and shift our culture towards the well-being of our communities through prevention.

He left the group by saying, “In the end, the world gets better when people choose to come together to make it better.” TH

At #HospMed16 Plenary, the U.S. Surgeon General, Vice Admiral Vivek H. Murthy, MD, MBA, spoke to a standing-room-only crowd about how hospitalists can lead in “Bringing Health to America.”

Dr. Murthy, who previously worked as a hospitalist in Boston, spoke about how the urgency to build a foundation for health in America, where chronic illness and healthcare costs have skyrocketed, could not be any greater. Health is the key to opportunity, he said. He explored the following strategies to make America healthier:

1. Make the pursuit of healthy appealing;
2. Improve the safety of our communities;
3. Focus on the mind and spirit; and,
4. Cultivate our ability to give and receive kindness.

Specifically, hospitalists should contemplate the following questions:

• How can hospitalists leverage their leadership in the hospital to improve systems and create a culture that supports healing and health?
• How can hospitalists be a powerful of force of change both inside and outside the hospital?
• How can hospitalists inspire the next generation of physicians to safeguard the health of their community by treating and preventing illness?

Dr. Murthy challenged hospitalists to commit to strengthening the foundation of health in our country and shift our culture towards the well-being of our communities through prevention.

He left the group by saying, “In the end, the world gets better when people choose to come together to make it better.” TH

At #HospMed16 Plenary, the U.S. Surgeon General, Vice Admiral Vivek H. Murthy, MD, MBA, spoke to a standing-room-only crowd about how hospitalists can lead in “Bringing Health to America.”

Dr. Murthy, who previously worked as a hospitalist in Boston, spoke about how the urgency to build a foundation for health in America, where chronic illness and healthcare costs have skyrocketed, could not be any greater. Health is the key to opportunity, he said. He explored the following strategies to make America healthier:

1. Make the pursuit of healthy appealing;
2. Improve the safety of our communities;
3. Focus on the mind and spirit; and,
4. Cultivate our ability to give and receive kindness.

Specifically, hospitalists should contemplate the following questions:

• How can hospitalists leverage their leadership in the hospital to improve systems and create a culture that supports healing and health?
• How can hospitalists be a powerful of force of change both inside and outside the hospital?
• How can hospitalists inspire the next generation of physicians to safeguard the health of their community by treating and preventing illness?

Dr. Murthy challenged hospitalists to commit to strengthening the foundation of health in our country and shift our culture towards the well-being of our communities through prevention.

He left the group by saying, “In the end, the world gets better when people choose to come together to make it better.” TH

Sound clinical reasoning is the foundation of patient safety, yet discussions of a physician’s raw thinking ability have become a “third rail” in hospitals, according to “Incorporating Metacognition into Morbidity and Mortality Rounds: The Next Frontier in Quality Improvement,” published in the Journal of Hospital Medicine. Authors David Katz, MD, MSc, and Allan S. Detsky, MD, PhD, suggest introducing concepts from cognitive psychology could help address this issue.

The underlying problem is that the search for causes of medical error focuses on systems-based issues—medication administration and dosing, communication, physician handover, etc. There’s a reluctance to talk about human decision making. In fact, in the authors’ own hospitals, improving diagnostic accuracy is almost never discussed; they suspect the same is true at other institutions.

But cognitive errors occur predictably and often, especially at times of high cognitive load (i.e., when many complex decisions are being made in a short period of time), according to research from cognitive psychology. The authors therefore suggest that introducing metacognition (or “thinking about thinking”) discussions during morbidity and mortality rounds (MMRs) might help expand the discussions so that human error can be recognized and addressed.

They suggest that cognitive heuristics be introduced to MMRs by experienced and respected clinicians who can tell stories of their own errors and the shortcuts in thinking that may have caused them.

“Thereafter, the traditional MMR format can be used: presenting a case, describing how an experienced clinician might manage the case, and then asking the audience members for comment,” they write. “Incorporating discussions of cognitive missteps, in medical and nonmedical contexts, would help normalize the understanding that even the most experienced and smartest people fall prey to them. The tone must be positive.”

Reference

1. Katz D, Detsky AS. Incorporating metacognition into morbidity and mortality rounds: the next frontier in quality improvement. J Hosp Med. 2016;11(2):120-122. doi:10.1002/jhm.2505.

Sound clinical reasoning is the foundation of patient safety, yet discussions of a physician’s raw thinking ability have become a “third rail” in hospitals, according to “Incorporating Metacognition into Morbidity and Mortality Rounds: The Next Frontier in Quality Improvement,” published in the Journal of Hospital Medicine. Authors David Katz, MD, MSc, and Allan S. Detsky, MD, PhD, suggest introducing concepts from cognitive psychology could help address this issue.

The underlying problem is that the search for causes of medical error focuses on systems-based issues—medication administration and dosing, communication, physician handover, etc. There’s a reluctance to talk about human decision making. In fact, in the authors’ own hospitals, improving diagnostic accuracy is almost never discussed; they suspect the same is true at other institutions.

But cognitive errors occur predictably and often, especially at times of high cognitive load (i.e., when many complex decisions are being made in a short period of time), according to research from cognitive psychology. The authors therefore suggest that introducing metacognition (or “thinking about thinking”) discussions during morbidity and mortality rounds (MMRs) might help expand the discussions so that human error can be recognized and addressed.

They suggest that cognitive heuristics be introduced to MMRs by experienced and respected clinicians who can tell stories of their own errors and the shortcuts in thinking that may have caused them.

“Thereafter, the traditional MMR format can be used: presenting a case, describing how an experienced clinician might manage the case, and then asking the audience members for comment,” they write. “Incorporating discussions of cognitive missteps, in medical and nonmedical contexts, would help normalize the understanding that even the most experienced and smartest people fall prey to them. The tone must be positive.”

Reference

1. Katz D, Detsky AS. Incorporating metacognition into morbidity and mortality rounds: the next frontier in quality improvement. J Hosp Med. 2016;11(2):120-122. doi:10.1002/jhm.2505.

Sound clinical reasoning is the foundation of patient safety, yet discussions of a physician’s raw thinking ability have become a “third rail” in hospitals, according to “Incorporating Metacognition into Morbidity and Mortality Rounds: The Next Frontier in Quality Improvement,” published in the Journal of Hospital Medicine. Authors David Katz, MD, MSc, and Allan S. Detsky, MD, PhD, suggest introducing concepts from cognitive psychology could help address this issue.

The underlying problem is that the search for causes of medical error focuses on systems-based issues—medication administration and dosing, communication, physician handover, etc. There’s a reluctance to talk about human decision making. In fact, in the authors’ own hospitals, improving diagnostic accuracy is almost never discussed; they suspect the same is true at other institutions.

But cognitive errors occur predictably and often, especially at times of high cognitive load (i.e., when many complex decisions are being made in a short period of time), according to research from cognitive psychology. The authors therefore suggest that introducing metacognition (or “thinking about thinking”) discussions during morbidity and mortality rounds (MMRs) might help expand the discussions so that human error can be recognized and addressed.

They suggest that cognitive heuristics be introduced to MMRs by experienced and respected clinicians who can tell stories of their own errors and the shortcuts in thinking that may have caused them.

“Thereafter, the traditional MMR format can be used: presenting a case, describing how an experienced clinician might manage the case, and then asking the audience members for comment,” they write. “Incorporating discussions of cognitive missteps, in medical and nonmedical contexts, would help normalize the understanding that even the most experienced and smartest people fall prey to them. The tone must be positive.”

Reference

1. Katz D, Detsky AS. Incorporating metacognition into morbidity and mortality rounds: the next frontier in quality improvement. J Hosp Med. 2016;11(2):120-122. doi:10.1002/jhm.2505.

The demand for training in healthcare quality and patient safety, for both medical students and residents, has never been higher. The Quality and Safety Educators Academy (QSEA, sites.hospitalmedicine.org/qsea) responds to that demand by providing medical educators with the knowledge and tools to integrate quality improvement and safety concepts into their curricula.

Sponsored by the Society of Hospital Medicine (SHM) and the Alliance for Academic Internal Medicine (AAIM), QSEA 2016 is a two-and-a-half-day course designed as a faculty development program. This year, QSEA will be held at Tempe Mission Palms Hotel and Conference Center in Tempe, Ariz., from May 23 to 25.

Attendees will enjoy a hands-on, interactive learning environment with a 10-to-1 student-to-faculty ratio. Participants will develop a professional network and leave with a tool kit of educational resources and curricular tools for quality and safety education.

Think QSEA is for you? Make plans to attend now if you are:

• A program director or assistant program director interested in acquiring new curricular ideas to help meet the ACGME requirements, which require residency programs to integrate quality and safety in their curriculum
• A medical school leader or clerkship director developing quality and safety curricula for students
• A faculty member beginning a new role or expanding an existing role in quality and safety education
• A quality and safety leader who wishes to extend influence and effectiveness by learning strategies to teach and engage trainees

QSEA has sold out each of the past four years, so don’t delay. Register online at sites.hospitalmedicine.org/qsea/register.html or via phone at 800-843-3360. Questions? Email [email protected]. TH

---

Brett Radler is SHM’s communications coordinator.

The demand for training in healthcare quality and patient safety, for both medical students and residents, has never been higher. The Quality and Safety Educators Academy (QSEA, sites.hospitalmedicine.org/qsea) responds to that demand by providing medical educators with the knowledge and tools to integrate quality improvement and safety concepts into their curricula.

Sponsored by the Society of Hospital Medicine (SHM) and the Alliance for Academic Internal Medicine (AAIM), QSEA 2016 is a two-and-a-half-day course designed as a faculty development program. This year, QSEA will be held at Tempe Mission Palms Hotel and Conference Center in Tempe, Ariz., from May 23 to 25.

Attendees will enjoy a hands-on, interactive learning environment with a 10-to-1 student-to-faculty ratio. Participants will develop a professional network and leave with a tool kit of educational resources and curricular tools for quality and safety education.

Think QSEA is for you? Make plans to attend now if you are:

• A program director or assistant program director interested in acquiring new curricular ideas to help meet the ACGME requirements, which require residency programs to integrate quality and safety in their curriculum
• A medical school leader or clerkship director developing quality and safety curricula for students
• A faculty member beginning a new role or expanding an existing role in quality and safety education
• A quality and safety leader who wishes to extend influence and effectiveness by learning strategies to teach and engage trainees

QSEA has sold out each of the past four years, so don’t delay. Register online at sites.hospitalmedicine.org/qsea/register.html or via phone at 800-843-3360. Questions? Email [email protected]. TH

---

Brett Radler is SHM’s communications coordinator.

The demand for training in healthcare quality and patient safety, for both medical students and residents, has never been higher. The Quality and Safety Educators Academy (QSEA, sites.hospitalmedicine.org/qsea) responds to that demand by providing medical educators with the knowledge and tools to integrate quality improvement and safety concepts into their curricula.

Sponsored by the Society of Hospital Medicine (SHM) and the Alliance for Academic Internal Medicine (AAIM), QSEA 2016 is a two-and-a-half-day course designed as a faculty development program. This year, QSEA will be held at Tempe Mission Palms Hotel and Conference Center in Tempe, Ariz., from May 23 to 25.

Attendees will enjoy a hands-on, interactive learning environment with a 10-to-1 student-to-faculty ratio. Participants will develop a professional network and leave with a tool kit of educational resources and curricular tools for quality and safety education.

Think QSEA is for you? Make plans to attend now if you are:

• A program director or assistant program director interested in acquiring new curricular ideas to help meet the ACGME requirements, which require residency programs to integrate quality and safety in their curriculum
• A medical school leader or clerkship director developing quality and safety curricula for students
• A faculty member beginning a new role or expanding an existing role in quality and safety education
• A quality and safety leader who wishes to extend influence and effectiveness by learning strategies to teach and engage trainees

QSEA has sold out each of the past four years, so don’t delay. Register online at sites.hospitalmedicine.org/qsea/register.html or via phone at 800-843-3360. Questions? Email [email protected]. TH

---

Brett Radler is SHM’s communications coordinator.

Excellent communication between physicians and patients is a crucial element of hospital quality, but it’s also an ongoing challenge for many institutions. One physician wondered whether letting patients read their physicians’ notes could help.

“I wanted to find new methods to improve patient understanding of their medical care plan,” says Craig Weinert, MD, MPH, medical director for adult inpatient services at the University of Minnesota Medical Center and author of “Giving Doctors’ Daily Progress Notes to Hospitalized Patients and Families to Improve Patient Experience” in the American Journal of Medical Quality. “It seemed logical to me that giving patients access to the same information that all the other members of the healthcare team were reading would improve communication. This is the overall hypothesis of the Open Notes movement.”

Another reason Dr. Weinert pursued the study: In his clinical job as an intensivist, he encounters frequent disagreements with patients’ families regarding prognosis and goals of care.

“No one has figured out how to increase the alignment of prognosis between the family and the medical team,” Dr. Weinert says. “I think having the families read the doctors’ notes, where the issues with poor-prognosis multi-organ failure are repeatedly spelled out, might help families more quickly grasp the futility of continuing care.”

During the study, hospitalized patients or family members on six wards of a university hospital received a printed copy of their medical team’s daily progress notes. Surveys afterward showed 74% to 86% of patients and family members responded favorably. Physicians were mostly satisfied, too.

“Most doctors, at the end of the study, thought that Open Notes went better than they had predicted,” Dr. Weinert says.

Complete transparency of medical records is the future of medicine, he says. It’s what patients want, “especially the younger generation.”

“Over the next 10 years,” he says, “I predict ... all [electronic medical record] vendors will have electronic portals that allow clinic and hospitalized patients access to almost everything in the EMR.”

Reference

1. Weinert C. Giving doctors’ daily progress notes to hospitalized patients and families to improve patient experience. Am J Med Qual. 2015. doi:10.1177/1062860615610424.

Excellent communication between physicians and patients is a crucial element of hospital quality, but it’s also an ongoing challenge for many institutions. One physician wondered whether letting patients read their physicians’ notes could help.

“I wanted to find new methods to improve patient understanding of their medical care plan,” says Craig Weinert, MD, MPH, medical director for adult inpatient services at the University of Minnesota Medical Center and author of “Giving Doctors’ Daily Progress Notes to Hospitalized Patients and Families to Improve Patient Experience” in the American Journal of Medical Quality. “It seemed logical to me that giving patients access to the same information that all the other members of the healthcare team were reading would improve communication. This is the overall hypothesis of the Open Notes movement.”

Another reason Dr. Weinert pursued the study: In his clinical job as an intensivist, he encounters frequent disagreements with patients’ families regarding prognosis and goals of care.

“No one has figured out how to increase the alignment of prognosis between the family and the medical team,” Dr. Weinert says. “I think having the families read the doctors’ notes, where the issues with poor-prognosis multi-organ failure are repeatedly spelled out, might help families more quickly grasp the futility of continuing care.”

During the study, hospitalized patients or family members on six wards of a university hospital received a printed copy of their medical team’s daily progress notes. Surveys afterward showed 74% to 86% of patients and family members responded favorably. Physicians were mostly satisfied, too.

“Most doctors, at the end of the study, thought that Open Notes went better than they had predicted,” Dr. Weinert says.

Complete transparency of medical records is the future of medicine, he says. It’s what patients want, “especially the younger generation.”

“Over the next 10 years,” he says, “I predict ... all [electronic medical record] vendors will have electronic portals that allow clinic and hospitalized patients access to almost everything in the EMR.”

Reference

1. Weinert C. Giving doctors’ daily progress notes to hospitalized patients and families to improve patient experience. Am J Med Qual. 2015. doi:10.1177/1062860615610424.

Excellent communication between physicians and patients is a crucial element of hospital quality, but it’s also an ongoing challenge for many institutions. One physician wondered whether letting patients read their physicians’ notes could help.

“I wanted to find new methods to improve patient understanding of their medical care plan,” says Craig Weinert, MD, MPH, medical director for adult inpatient services at the University of Minnesota Medical Center and author of “Giving Doctors’ Daily Progress Notes to Hospitalized Patients and Families to Improve Patient Experience” in the American Journal of Medical Quality. “It seemed logical to me that giving patients access to the same information that all the other members of the healthcare team were reading would improve communication. This is the overall hypothesis of the Open Notes movement.”

Another reason Dr. Weinert pursued the study: In his clinical job as an intensivist, he encounters frequent disagreements with patients’ families regarding prognosis and goals of care.

“No one has figured out how to increase the alignment of prognosis between the family and the medical team,” Dr. Weinert says. “I think having the families read the doctors’ notes, where the issues with poor-prognosis multi-organ failure are repeatedly spelled out, might help families more quickly grasp the futility of continuing care.”

During the study, hospitalized patients or family members on six wards of a university hospital received a printed copy of their medical team’s daily progress notes. Surveys afterward showed 74% to 86% of patients and family members responded favorably. Physicians were mostly satisfied, too.

“Most doctors, at the end of the study, thought that Open Notes went better than they had predicted,” Dr. Weinert says.

Complete transparency of medical records is the future of medicine, he says. It’s what patients want, “especially the younger generation.”

“Over the next 10 years,” he says, “I predict ... all [electronic medical record] vendors will have electronic portals that allow clinic and hospitalized patients access to almost everything in the EMR.”

Reference

1. Weinert C. Giving doctors’ daily progress notes to hospitalized patients and families to improve patient experience. Am J Med Qual. 2015. doi:10.1177/1062860615610424.

NEW YORK (Reuters Health) - Type 2 diabetes risk appears to be increased in youth who are treated with antipsychotics, according to new research.

"We believe that clinicians should take away from our study that type 2 diabetes is a risk when treating youth with antipsychotics, especially long-term," said senior author Dr. Christoff U. Correll of Zucker Hillside Hospital, North Shore-Long Island Jewish Health System, Glen Oaks, New York.

"Therefore, antipsychotics should be used judiciously and for as short a period as necessary and possible," he told Reuters Health by email. "Importantly, clinicians should routinely and proactively monitor the efficacy and need for ongoing antipsychotic treatment as well as the potential emergence of adverse effects. Specifically, clinicians and patients, as well as parents, should monitor weight change monthly, and fasting blood work for blood sugar and blood lipids

should be obtained before starting an antipsychotic, three months later, and every six months thereafter."

Dr. Correll and colleagues conducted a systematic review of studies reporting on type 2 diabetes incidence in youth up to 24 years old who were exposed to antipsychotics for at least three months. They did a meta-analysis of thirteen studies involving more than 185,000 youth exposed to antipsychotics, representing some 310,000 patient-years.

Seven studies included psychiatric controls and eight studies included healthy controls.

During a mean follow-up of 1.7 years, the cumulative type 2 diabetes risk was 5.72 per 1,000 patient-years (p<0.001). The overall incidence rate was 3.09 cases per 1,000 patient-years (p<0.001), according to an article online January 20 in JAMA Psychiatry.

Compared with healthy controls, antipsychotic-exposed youth had significantly higher cumulative type 2 diabetes risk (odds ratio, 2.58; p<0.0001) and incidence rate ratio (IRR, 3.02; p<0.0001). Compared with psychiatric controls, they had significantly higher risks (OR 2.09, p<0.0001, IRR 1.79,p<0.0001).

In multivariate regression analysis of 10 studies, diabetes was associated with longer follow-up, use of olanzapine, and male sex. Greater diabetes incidence was tied to use of second-generation antipsychotics, while it was inversely related to diagnosis of autism spectrum disorder.

"Although our findings cannot comment on the individual risk with any specific antipsychotic other than the significantly higher risk associated with olanzapine, other studies equally suggest the much increased cardiovascular risk associates with olanzapine than with other antipsychotics in youth. Based on all of these data, I personally believe that olanzapine should not be used first- or second-line in youth, but likely be reserved or treatment-resistant patients who cannot benefit sufficiently from antipsychotics with lower cardiometabolic risk," Dr. Correll told Reuters Health.

"Clearly, additional research is needed to identify the specific mechanisms of antipsychotic-related weight gain and development of diabetes in order to either counter these effects or develop medications that do not adversely affect cardiometabolic health," he added. "Moreover, research is needed seeking to identify patients who are at particularly high risk for weight gain and diabetes and those who seem to be protected against these antipsychotic-related side effects to help individualize treatment selection."

"Finally," he concluded, "research is required that tests lower-risk pharmacologic and nonpharmacologic interventions that may be used effectively before or instead of an antipsychotic when treating nonpsychotic conditions. This need pertains especially to youth presenting with severe mood or behavioral dysregulation, irritability, and aggression for whom antipsychotics are used a lot, often without even providing psychosocial treatments."

 

 

 

 

 

 

 

NEW YORK (Reuters Health) - Type 2 diabetes risk appears to be increased in youth who are treated with antipsychotics, according to new research.

"We believe that clinicians should take away from our study that type 2 diabetes is a risk when treating youth with antipsychotics, especially long-term," said senior author Dr. Christoff U. Correll of Zucker Hillside Hospital, North Shore-Long Island Jewish Health System, Glen Oaks, New York.

"Therefore, antipsychotics should be used judiciously and for as short a period as necessary and possible," he told Reuters Health by email. "Importantly, clinicians should routinely and proactively monitor the efficacy and need for ongoing antipsychotic treatment as well as the potential emergence of adverse effects. Specifically, clinicians and patients, as well as parents, should monitor weight change monthly, and fasting blood work for blood sugar and blood lipids

should be obtained before starting an antipsychotic, three months later, and every six months thereafter."

Dr. Correll and colleagues conducted a systematic review of studies reporting on type 2 diabetes incidence in youth up to 24 years old who were exposed to antipsychotics for at least three months. They did a meta-analysis of thirteen studies involving more than 185,000 youth exposed to antipsychotics, representing some 310,000 patient-years.

Seven studies included psychiatric controls and eight studies included healthy controls.

During a mean follow-up of 1.7 years, the cumulative type 2 diabetes risk was 5.72 per 1,000 patient-years (p<0.001). The overall incidence rate was 3.09 cases per 1,000 patient-years (p<0.001), according to an article online January 20 in JAMA Psychiatry.

Compared with healthy controls, antipsychotic-exposed youth had significantly higher cumulative type 2 diabetes risk (odds ratio, 2.58; p<0.0001) and incidence rate ratio (IRR, 3.02; p<0.0001). Compared with psychiatric controls, they had significantly higher risks (OR 2.09, p<0.0001, IRR 1.79,p<0.0001).

In multivariate regression analysis of 10 studies, diabetes was associated with longer follow-up, use of olanzapine, and male sex. Greater diabetes incidence was tied to use of second-generation antipsychotics, while it was inversely related to diagnosis of autism spectrum disorder.

"Although our findings cannot comment on the individual risk with any specific antipsychotic other than the significantly higher risk associated with olanzapine, other studies equally suggest the much increased cardiovascular risk associates with olanzapine than with other antipsychotics in youth. Based on all of these data, I personally believe that olanzapine should not be used first- or second-line in youth, but likely be reserved or treatment-resistant patients who cannot benefit sufficiently from antipsychotics with lower cardiometabolic risk," Dr. Correll told Reuters Health.

"Clearly, additional research is needed to identify the specific mechanisms of antipsychotic-related weight gain and development of diabetes in order to either counter these effects or develop medications that do not adversely affect cardiometabolic health," he added. "Moreover, research is needed seeking to identify patients who are at particularly high risk for weight gain and diabetes and those who seem to be protected against these antipsychotic-related side effects to help individualize treatment selection."

"Finally," he concluded, "research is required that tests lower-risk pharmacologic and nonpharmacologic interventions that may be used effectively before or instead of an antipsychotic when treating nonpsychotic conditions. This need pertains especially to youth presenting with severe mood or behavioral dysregulation, irritability, and aggression for whom antipsychotics are used a lot, often without even providing psychosocial treatments."

 

 

 

 

 

 

 

NEW YORK (Reuters Health) - Type 2 diabetes risk appears to be increased in youth who are treated with antipsychotics, according to new research.

"We believe that clinicians should take away from our study that type 2 diabetes is a risk when treating youth with antipsychotics, especially long-term," said senior author Dr. Christoff U. Correll of Zucker Hillside Hospital, North Shore-Long Island Jewish Health System, Glen Oaks, New York.

"Therefore, antipsychotics should be used judiciously and for as short a period as necessary and possible," he told Reuters Health by email. "Importantly, clinicians should routinely and proactively monitor the efficacy and need for ongoing antipsychotic treatment as well as the potential emergence of adverse effects. Specifically, clinicians and patients, as well as parents, should monitor weight change monthly, and fasting blood work for blood sugar and blood lipids

should be obtained before starting an antipsychotic, three months later, and every six months thereafter."

Dr. Correll and colleagues conducted a systematic review of studies reporting on type 2 diabetes incidence in youth up to 24 years old who were exposed to antipsychotics for at least three months. They did a meta-analysis of thirteen studies involving more than 185,000 youth exposed to antipsychotics, representing some 310,000 patient-years.

Seven studies included psychiatric controls and eight studies included healthy controls.

During a mean follow-up of 1.7 years, the cumulative type 2 diabetes risk was 5.72 per 1,000 patient-years (p<0.001). The overall incidence rate was 3.09 cases per 1,000 patient-years (p<0.001), according to an article online January 20 in JAMA Psychiatry.

Compared with healthy controls, antipsychotic-exposed youth had significantly higher cumulative type 2 diabetes risk (odds ratio, 2.58; p<0.0001) and incidence rate ratio (IRR, 3.02; p<0.0001). Compared with psychiatric controls, they had significantly higher risks (OR 2.09, p<0.0001, IRR 1.79,p<0.0001).

In multivariate regression analysis of 10 studies, diabetes was associated with longer follow-up, use of olanzapine, and male sex. Greater diabetes incidence was tied to use of second-generation antipsychotics, while it was inversely related to diagnosis of autism spectrum disorder.

"Although our findings cannot comment on the individual risk with any specific antipsychotic other than the significantly higher risk associated with olanzapine, other studies equally suggest the much increased cardiovascular risk associates with olanzapine than with other antipsychotics in youth. Based on all of these data, I personally believe that olanzapine should not be used first- or second-line in youth, but likely be reserved or treatment-resistant patients who cannot benefit sufficiently from antipsychotics with lower cardiometabolic risk," Dr. Correll told Reuters Health.

"Clearly, additional research is needed to identify the specific mechanisms of antipsychotic-related weight gain and development of diabetes in order to either counter these effects or develop medications that do not adversely affect cardiometabolic health," he added. "Moreover, research is needed seeking to identify patients who are at particularly high risk for weight gain and diabetes and those who seem to be protected against these antipsychotic-related side effects to help individualize treatment selection."

"Finally," he concluded, "research is required that tests lower-risk pharmacologic and nonpharmacologic interventions that may be used effectively before or instead of an antipsychotic when treating nonpsychotic conditions. This need pertains especially to youth presenting with severe mood or behavioral dysregulation, irritability, and aggression for whom antipsychotics are used a lot, often without even providing psychosocial treatments."