Quality

Drs. Pate and Engel presented a hot topic in pediatric hospital medicine, sparking fruitful conversation about current evidence, identified gaps, and controversies regarding the management of febrile infants with urinary tract infections. After the American Academy of Pediatrics published the updated clinical guideline in 2011, controversies about radioimaging, duration of treatment, and pursuit of laboratory evaluations arose. These controversies continue today, and value and gold standard tests are now being questioned. Should urine culture truly be the gold standard to define a UTI?

The current evidence (applying to 2 month-2 years) in a nutshell includes:

• Oral and parental antibiotics are equally efficacious,
• Duration of treatment is a wide range of 7-14 days,
• Positive UA indicating inflammation/infection and a culture >50,000 uropathogens/ml is needed to make the diagnosis, and
• Febrile infants with first UTI should get a renal ultrasound; only if the ultrasound is abnormal should patients get a Voiding Cystourethrogram (VCUG).

Since the guideline was published in 2011, there has been continued disagreement between pediatricians and pediatric urologists. When thinking about high-value care, what value is added by doing the renal ultrasound and/or VCUG? The research over the last couple of years shows that although there is concern that UTIs lead to renal scarring and chronic kidney disease, in the absence of structural kidney abnormalities, recurrent UTIs cause at most 0.3% of chronic kidney disease. The takehome point from the 2014 RIVUR study is:

• The treatment group had significantly higher rates of resistance organisms (63% ppx 19% placebo).
• The NNT with prophylaxis in children with VUR is 9 children for 2 years to prevent 1 UTI, or 6570 days of antibiotics to prevent one 7-14 day course.

The RIVUR study raised more questions:

• Is there a difference in outcome if a child had concurrent bacteremia?

  • There is no significant difference in clinical presentation between an isolated UTI and an infant with bacteremia. Those patients with bacteremia received longer duration of parenteral antibiotics, but the number of days were highly variable and outcomes were excellent overall regardless.

• How accurate is UA in the diagnosis of urinary tract infections in infants less than 3 months of age?

  • Urinalysis in those infants

• Could inflammatory markers accurately identify infants at high risk for more severe disease?

  • Not really.

Guidelines were reviewed, controversies were discussed, and questions were proposed. The session ended with tools to take home to help change hospital practice, and quality-UTI projects metrics were shared, as this is the next AAP VIP project about to launch.

Key Takeaways:

• The guidelines represent a living and dynamic tool that integrates the best evidence we have.
• There is new research evolving and lessons to be learned.

Dr. Hopkins is an academic pediatric hospitalist and instructor at All Children's Hospital Johns Hopkins Medicine, St. Petersburg, Fla.​

Drs. Pate and Engel presented a hot topic in pediatric hospital medicine, sparking fruitful conversation about current evidence, identified gaps, and controversies regarding the management of febrile infants with urinary tract infections. After the American Academy of Pediatrics published the updated clinical guideline in 2011, controversies about radioimaging, duration of treatment, and pursuit of laboratory evaluations arose. These controversies continue today, and value and gold standard tests are now being questioned. Should urine culture truly be the gold standard to define a UTI?

The current evidence (applying to 2 month-2 years) in a nutshell includes:

• Oral and parental antibiotics are equally efficacious,
• Duration of treatment is a wide range of 7-14 days,
• Positive UA indicating inflammation/infection and a culture >50,000 uropathogens/ml is needed to make the diagnosis, and
• Febrile infants with first UTI should get a renal ultrasound; only if the ultrasound is abnormal should patients get a Voiding Cystourethrogram (VCUG).

Since the guideline was published in 2011, there has been continued disagreement between pediatricians and pediatric urologists. When thinking about high-value care, what value is added by doing the renal ultrasound and/or VCUG? The research over the last couple of years shows that although there is concern that UTIs lead to renal scarring and chronic kidney disease, in the absence of structural kidney abnormalities, recurrent UTIs cause at most 0.3% of chronic kidney disease. The takehome point from the 2014 RIVUR study is:

• The treatment group had significantly higher rates of resistance organisms (63% ppx 19% placebo).
• The NNT with prophylaxis in children with VUR is 9 children for 2 years to prevent 1 UTI, or 6570 days of antibiotics to prevent one 7-14 day course.

The RIVUR study raised more questions:

• Is there a difference in outcome if a child had concurrent bacteremia?

  • There is no significant difference in clinical presentation between an isolated UTI and an infant with bacteremia. Those patients with bacteremia received longer duration of parenteral antibiotics, but the number of days were highly variable and outcomes were excellent overall regardless.

• How accurate is UA in the diagnosis of urinary tract infections in infants less than 3 months of age?

  • Urinalysis in those infants

• Could inflammatory markers accurately identify infants at high risk for more severe disease?

  • Not really.

Guidelines were reviewed, controversies were discussed, and questions were proposed. The session ended with tools to take home to help change hospital practice, and quality-UTI projects metrics were shared, as this is the next AAP VIP project about to launch.

Key Takeaways:

• The guidelines represent a living and dynamic tool that integrates the best evidence we have.
• There is new research evolving and lessons to be learned.

Dr. Hopkins is an academic pediatric hospitalist and instructor at All Children's Hospital Johns Hopkins Medicine, St. Petersburg, Fla.​

Drs. Pate and Engel presented a hot topic in pediatric hospital medicine, sparking fruitful conversation about current evidence, identified gaps, and controversies regarding the management of febrile infants with urinary tract infections. After the American Academy of Pediatrics published the updated clinical guideline in 2011, controversies about radioimaging, duration of treatment, and pursuit of laboratory evaluations arose. These controversies continue today, and value and gold standard tests are now being questioned. Should urine culture truly be the gold standard to define a UTI?

The current evidence (applying to 2 month-2 years) in a nutshell includes:

• Oral and parental antibiotics are equally efficacious,
• Duration of treatment is a wide range of 7-14 days,
• Positive UA indicating inflammation/infection and a culture >50,000 uropathogens/ml is needed to make the diagnosis, and
• Febrile infants with first UTI should get a renal ultrasound; only if the ultrasound is abnormal should patients get a Voiding Cystourethrogram (VCUG).

Since the guideline was published in 2011, there has been continued disagreement between pediatricians and pediatric urologists. When thinking about high-value care, what value is added by doing the renal ultrasound and/or VCUG? The research over the last couple of years shows that although there is concern that UTIs lead to renal scarring and chronic kidney disease, in the absence of structural kidney abnormalities, recurrent UTIs cause at most 0.3% of chronic kidney disease. The takehome point from the 2014 RIVUR study is:

• The treatment group had significantly higher rates of resistance organisms (63% ppx 19% placebo).
• The NNT with prophylaxis in children with VUR is 9 children for 2 years to prevent 1 UTI, or 6570 days of antibiotics to prevent one 7-14 day course.

The RIVUR study raised more questions:

• Is there a difference in outcome if a child had concurrent bacteremia?

  • There is no significant difference in clinical presentation between an isolated UTI and an infant with bacteremia. Those patients with bacteremia received longer duration of parenteral antibiotics, but the number of days were highly variable and outcomes were excellent overall regardless.

• How accurate is UA in the diagnosis of urinary tract infections in infants less than 3 months of age?

  • Urinalysis in those infants

• Could inflammatory markers accurately identify infants at high risk for more severe disease?

  • Not really.

Guidelines were reviewed, controversies were discussed, and questions were proposed. The session ended with tools to take home to help change hospital practice, and quality-UTI projects metrics were shared, as this is the next AAP VIP project about to launch.

Key Takeaways:

• The guidelines represent a living and dynamic tool that integrates the best evidence we have.
• There is new research evolving and lessons to be learned.

Dr. Hopkins is an academic pediatric hospitalist and instructor at All Children's Hospital Johns Hopkins Medicine, St. Petersburg, Fla.​

An Australian team conducted a literature review of expected deaths in the hospital—where the majority of deaths in the developed world occur—and identified elements of end-of-life care that are important to patients and families.¹ Published in the British journal Palliative Medicine, the review of nine electronic data bases and 1859 articles released between 1990 and 2014 identified eight quantitative studies that met inclusion criteria.

The authors, led by Claudia Virdun, RN, of the faculty of health at the University of Technology in Sydney, found four end-of-life domains that were most important to both patients and families:

• Effective communication and shared decision-making;
• Expert care;
• Respectful and compassionate care; and
• Trust and confidence in clinicians.

Not all patients dying in hospitals receive best evidence-based palliative care, the authors note, adding that the “challenge for healthcare services is to act on this evidence, reconfigure care systems accordingly and ensure universal access to optimal end-of-life care within hospitals.”

Reference

1. Virdun C, Luckett T, Davidson PM, Phillips J. Dying in the hospital setting: A systematic review of quantitative studies identifying the elements of end-of-life care that patients and their families rank as being most important [published online ahead of print April 28, 2015]. Palliat Med.

An Australian team conducted a literature review of expected deaths in the hospital—where the majority of deaths in the developed world occur—and identified elements of end-of-life care that are important to patients and families.¹ Published in the British journal Palliative Medicine, the review of nine electronic data bases and 1859 articles released between 1990 and 2014 identified eight quantitative studies that met inclusion criteria.

The authors, led by Claudia Virdun, RN, of the faculty of health at the University of Technology in Sydney, found four end-of-life domains that were most important to both patients and families:

• Effective communication and shared decision-making;
• Expert care;
• Respectful and compassionate care; and
• Trust and confidence in clinicians.

Not all patients dying in hospitals receive best evidence-based palliative care, the authors note, adding that the “challenge for healthcare services is to act on this evidence, reconfigure care systems accordingly and ensure universal access to optimal end-of-life care within hospitals.”

Reference

1. Virdun C, Luckett T, Davidson PM, Phillips J. Dying in the hospital setting: A systematic review of quantitative studies identifying the elements of end-of-life care that patients and their families rank as being most important [published online ahead of print April 28, 2015]. Palliat Med.

An Australian team conducted a literature review of expected deaths in the hospital—where the majority of deaths in the developed world occur—and identified elements of end-of-life care that are important to patients and families.¹ Published in the British journal Palliative Medicine, the review of nine electronic data bases and 1859 articles released between 1990 and 2014 identified eight quantitative studies that met inclusion criteria.

The authors, led by Claudia Virdun, RN, of the faculty of health at the University of Technology in Sydney, found four end-of-life domains that were most important to both patients and families:

• Effective communication and shared decision-making;
• Expert care;
• Respectful and compassionate care; and
• Trust and confidence in clinicians.

Not all patients dying in hospitals receive best evidence-based palliative care, the authors note, adding that the “challenge for healthcare services is to act on this evidence, reconfigure care systems accordingly and ensure universal access to optimal end-of-life care within hospitals.”

Reference

1. Virdun C, Luckett T, Davidson PM, Phillips J. Dying in the hospital setting: A systematic review of quantitative studies identifying the elements of end-of-life care that patients and their families rank as being most important [published online ahead of print April 28, 2015]. Palliat Med.

Although 2019 may seem like a long way away, it isn’t too soon to start thinking about and preparing for the Merit-based Incentive Payment System (MIPS) or its (seemingly preferable) alternative, participation in an alternative payment model (APM) such as an ACO, a medical home, or a bundled payment program.

In April, Congress permanently repealed Medicare’s sustainable growth rate (SGR) formula for controlling physician payment. In yet another sign that we are in the midst of the biggest healthcare transformation in a generation, the 18-year-old SGR formula will be replaced by a far-reaching package of payment reforms. Here we will focus on the MIPS and its alternative, an APM, which involves assuming risk for financial loss or gain and measuring and reporting on quality.

The MIPS replaces three existing quality measurement programs that, to greater and lesser degrees, physicians have struggled with:

• Physician Quality Reporting System (PQRS);
• Value-based payment modifier; and
• Meaningful use of electronic health records.

MIPS will not totally eliminate these programs but will instead incorporate yet-to-be-defined elements of them and, presumably, though it is yet unclear, add new elements. For 2015-2018, the current payment system will remain intact. For 2019, physicians will have a choice. Either they must participate in MIPS, which will likely be complex and involve some administrative burden, or derive at least 25% of their practice revenue from an APM.

For those participating in MIPS, physician payment rates will be subject to an up or down adjustment based on performance in four categories: quality, meaningful use of EHRs, resource use, and clinical practice improvement.

There is an opportunity to avoid MIPS altogether, however. One of the most notable elements of the SGR fix is its push for physicians to participate in APMs such as ACOs, medical homes, bundled payment arrangements, and other payment models now being evaluated by the CMS Innovation Center. Physicians who gain a substantial portion—this means 25% in 2019 and 2020, and likely more thereafter—of their revenue through APMs like these will have the dual benefit of being exempt from MIPS participation and receiving a 5% annual bonus through 2024. After that, physicians in APMs will receive annual fee increases of 0.75%, while all other physicians will receive only a 0.25% increase.¹

Strategic Thinking for Hospitalists: Enter an APM

If you’re asking yourself where you want your hospitalist practice to be in three years, I would suggest the answer is “in an alternative payment model of one kind or another.”

If you are an employed practice, strategic planning will involve assessing the APMs your hospital or health system is participating in and planning how your hospitalist practice can become a formal member of the arrangement.

If you are a freestanding practice, you should become a student of the APM policy coming from the CMS Innovation Center, and determine the best “insertion point” for your practice, such that you gain at least a quarter of your revenue through an APM within three years.

Reference

1. Steinbrook R. The repeal of Medicare’s sustainable growth rate for physician payment. JAMA. 2015;313(20):2025-2026.

Obituary

Remembering Frank Michota, 1967-2015

On June 6, 2015, we lost one of hospital medicine’s original and most creative figures. Frank Michota, MD, FACP, FHM, established the Cleveland Clinic hospital medicine “lineage’” in 1997 and paved the way for hospitalists to be leaders in peri-operative medicine and related disciplines.

Frank founded the “Update in Hospital Medicine” series at SHM annual meetings and in the Annals of Internal Medicine. He was a prolific speaker, writer, and teacher. More than that, Frank was an original kind of persona, one who collaborated often and led frequently, but rarely followed. Yet he had the humility to engage and contribute whenever he was asked.

I had the good fortune of working with him on a number of speaking and writing projects in the early days. I recall his charisma, irreverence, and larger-than-life presence whenever he addressed an audience.

Frank’s signature is etched forever on hospital medicine; our patients and hospitalists everywhere are the lucky beneficiaries of his work.

Although 2019 may seem like a long way away, it isn’t too soon to start thinking about and preparing for the Merit-based Incentive Payment System (MIPS) or its (seemingly preferable) alternative, participation in an alternative payment model (APM) such as an ACO, a medical home, or a bundled payment program.

In April, Congress permanently repealed Medicare’s sustainable growth rate (SGR) formula for controlling physician payment. In yet another sign that we are in the midst of the biggest healthcare transformation in a generation, the 18-year-old SGR formula will be replaced by a far-reaching package of payment reforms. Here we will focus on the MIPS and its alternative, an APM, which involves assuming risk for financial loss or gain and measuring and reporting on quality.

The MIPS replaces three existing quality measurement programs that, to greater and lesser degrees, physicians have struggled with:

• Physician Quality Reporting System (PQRS);
• Value-based payment modifier; and
• Meaningful use of electronic health records.

MIPS will not totally eliminate these programs but will instead incorporate yet-to-be-defined elements of them and, presumably, though it is yet unclear, add new elements. For 2015-2018, the current payment system will remain intact. For 2019, physicians will have a choice. Either they must participate in MIPS, which will likely be complex and involve some administrative burden, or derive at least 25% of their practice revenue from an APM.

For those participating in MIPS, physician payment rates will be subject to an up or down adjustment based on performance in four categories: quality, meaningful use of EHRs, resource use, and clinical practice improvement.

There is an opportunity to avoid MIPS altogether, however. One of the most notable elements of the SGR fix is its push for physicians to participate in APMs such as ACOs, medical homes, bundled payment arrangements, and other payment models now being evaluated by the CMS Innovation Center. Physicians who gain a substantial portion—this means 25% in 2019 and 2020, and likely more thereafter—of their revenue through APMs like these will have the dual benefit of being exempt from MIPS participation and receiving a 5% annual bonus through 2024. After that, physicians in APMs will receive annual fee increases of 0.75%, while all other physicians will receive only a 0.25% increase.¹

Strategic Thinking for Hospitalists: Enter an APM

If you’re asking yourself where you want your hospitalist practice to be in three years, I would suggest the answer is “in an alternative payment model of one kind or another.”

If you are an employed practice, strategic planning will involve assessing the APMs your hospital or health system is participating in and planning how your hospitalist practice can become a formal member of the arrangement.

If you are a freestanding practice, you should become a student of the APM policy coming from the CMS Innovation Center, and determine the best “insertion point” for your practice, such that you gain at least a quarter of your revenue through an APM within three years.

Reference

1. Steinbrook R. The repeal of Medicare’s sustainable growth rate for physician payment. JAMA. 2015;313(20):2025-2026.

Obituary

Remembering Frank Michota, 1967-2015

On June 6, 2015, we lost one of hospital medicine’s original and most creative figures. Frank Michota, MD, FACP, FHM, established the Cleveland Clinic hospital medicine “lineage’” in 1997 and paved the way for hospitalists to be leaders in peri-operative medicine and related disciplines.

Frank founded the “Update in Hospital Medicine” series at SHM annual meetings and in the Annals of Internal Medicine. He was a prolific speaker, writer, and teacher. More than that, Frank was an original kind of persona, one who collaborated often and led frequently, but rarely followed. Yet he had the humility to engage and contribute whenever he was asked.

I had the good fortune of working with him on a number of speaking and writing projects in the early days. I recall his charisma, irreverence, and larger-than-life presence whenever he addressed an audience.

Frank’s signature is etched forever on hospital medicine; our patients and hospitalists everywhere are the lucky beneficiaries of his work.

Although 2019 may seem like a long way away, it isn’t too soon to start thinking about and preparing for the Merit-based Incentive Payment System (MIPS) or its (seemingly preferable) alternative, participation in an alternative payment model (APM) such as an ACO, a medical home, or a bundled payment program.

In April, Congress permanently repealed Medicare’s sustainable growth rate (SGR) formula for controlling physician payment. In yet another sign that we are in the midst of the biggest healthcare transformation in a generation, the 18-year-old SGR formula will be replaced by a far-reaching package of payment reforms. Here we will focus on the MIPS and its alternative, an APM, which involves assuming risk for financial loss or gain and measuring and reporting on quality.

The MIPS replaces three existing quality measurement programs that, to greater and lesser degrees, physicians have struggled with:

• Physician Quality Reporting System (PQRS);
• Value-based payment modifier; and
• Meaningful use of electronic health records.

MIPS will not totally eliminate these programs but will instead incorporate yet-to-be-defined elements of them and, presumably, though it is yet unclear, add new elements. For 2015-2018, the current payment system will remain intact. For 2019, physicians will have a choice. Either they must participate in MIPS, which will likely be complex and involve some administrative burden, or derive at least 25% of their practice revenue from an APM.

For those participating in MIPS, physician payment rates will be subject to an up or down adjustment based on performance in four categories: quality, meaningful use of EHRs, resource use, and clinical practice improvement.

There is an opportunity to avoid MIPS altogether, however. One of the most notable elements of the SGR fix is its push for physicians to participate in APMs such as ACOs, medical homes, bundled payment arrangements, and other payment models now being evaluated by the CMS Innovation Center. Physicians who gain a substantial portion—this means 25% in 2019 and 2020, and likely more thereafter—of their revenue through APMs like these will have the dual benefit of being exempt from MIPS participation and receiving a 5% annual bonus through 2024. After that, physicians in APMs will receive annual fee increases of 0.75%, while all other physicians will receive only a 0.25% increase.¹

Strategic Thinking for Hospitalists: Enter an APM

If you’re asking yourself where you want your hospitalist practice to be in three years, I would suggest the answer is “in an alternative payment model of one kind or another.”

If you are an employed practice, strategic planning will involve assessing the APMs your hospital or health system is participating in and planning how your hospitalist practice can become a formal member of the arrangement.

If you are a freestanding practice, you should become a student of the APM policy coming from the CMS Innovation Center, and determine the best “insertion point” for your practice, such that you gain at least a quarter of your revenue through an APM within three years.

Reference

1. Steinbrook R. The repeal of Medicare’s sustainable growth rate for physician payment. JAMA. 2015;313(20):2025-2026.

Obituary

Remembering Frank Michota, 1967-2015

On June 6, 2015, we lost one of hospital medicine’s original and most creative figures. Frank Michota, MD, FACP, FHM, established the Cleveland Clinic hospital medicine “lineage’” in 1997 and paved the way for hospitalists to be leaders in peri-operative medicine and related disciplines.

Frank founded the “Update in Hospital Medicine” series at SHM annual meetings and in the Annals of Internal Medicine. He was a prolific speaker, writer, and teacher. More than that, Frank was an original kind of persona, one who collaborated often and led frequently, but rarely followed. Yet he had the humility to engage and contribute whenever he was asked.

I had the good fortune of working with him on a number of speaking and writing projects in the early days. I recall his charisma, irreverence, and larger-than-life presence whenever he addressed an audience.

Frank’s signature is etched forever on hospital medicine; our patients and hospitalists everywhere are the lucky beneficiaries of his work.

In a May 12 JAMA “Viewpoint” article, Mark Chassin, MD, FACP, MPP, MPH, The Joint Commission’s president and CEO, and David Baker, MD, FACP, MPH, The Joint Commission’s vice president for healthcare quality evaluation, called on American physicians to acquire the necessary skills to take on new responsibilities to become leaders for QI and patient safety in an increasingly complex healthcare environment.¹

The Joint Commission, they said, has embraced the tools, methods, and science of QI used in other industries, including Lean Six Sigma and change management, for all of its internal improvement functions and for its Center for Transforming Healthcare. They urge physicians to do the same or risk jeopardizing medicine’s long-standing self-governance status because of societal concerns about patient safety.

Drs. Chassin and Baker note that medicine has too often tolerated problematic behaviors and is viewed by some stakeholders as failing to address poor quality of care and safety, lack of access, and high costs of care.

“Physicians could make a much stronger case for continued self-government if they took a more visible and vigorous leadership role in efforts that led to major improvement in the quality and safety of patient care,” they said.

Reference

1. Chassin MR, Baker DW. Aiming higher to enhance professionalism: beyond accreditation and certification. JAMA. 2015;313(18):1795-1796.

In a May 12 JAMA “Viewpoint” article, Mark Chassin, MD, FACP, MPP, MPH, The Joint Commission’s president and CEO, and David Baker, MD, FACP, MPH, The Joint Commission’s vice president for healthcare quality evaluation, called on American physicians to acquire the necessary skills to take on new responsibilities to become leaders for QI and patient safety in an increasingly complex healthcare environment.¹

The Joint Commission, they said, has embraced the tools, methods, and science of QI used in other industries, including Lean Six Sigma and change management, for all of its internal improvement functions and for its Center for Transforming Healthcare. They urge physicians to do the same or risk jeopardizing medicine’s long-standing self-governance status because of societal concerns about patient safety.

Drs. Chassin and Baker note that medicine has too often tolerated problematic behaviors and is viewed by some stakeholders as failing to address poor quality of care and safety, lack of access, and high costs of care.

“Physicians could make a much stronger case for continued self-government if they took a more visible and vigorous leadership role in efforts that led to major improvement in the quality and safety of patient care,” they said.

Reference

1. Chassin MR, Baker DW. Aiming higher to enhance professionalism: beyond accreditation and certification. JAMA. 2015;313(18):1795-1796.

In a May 12 JAMA “Viewpoint” article, Mark Chassin, MD, FACP, MPP, MPH, The Joint Commission’s president and CEO, and David Baker, MD, FACP, MPH, The Joint Commission’s vice president for healthcare quality evaluation, called on American physicians to acquire the necessary skills to take on new responsibilities to become leaders for QI and patient safety in an increasingly complex healthcare environment.¹

The Joint Commission, they said, has embraced the tools, methods, and science of QI used in other industries, including Lean Six Sigma and change management, for all of its internal improvement functions and for its Center for Transforming Healthcare. They urge physicians to do the same or risk jeopardizing medicine’s long-standing self-governance status because of societal concerns about patient safety.

Drs. Chassin and Baker note that medicine has too often tolerated problematic behaviors and is viewed by some stakeholders as failing to address poor quality of care and safety, lack of access, and high costs of care.

“Physicians could make a much stronger case for continued self-government if they took a more visible and vigorous leadership role in efforts that led to major improvement in the quality and safety of patient care,” they said.

Reference

1. Chassin MR, Baker DW. Aiming higher to enhance professionalism: beyond accreditation and certification. JAMA. 2015;313(18):1795-1796.

Fantasy sports, hospital medicine, and quality metrics. Those were the unique elements of an RIV poster presented by Noppon Setji, MD, medical director of the Duke University Medical Center’s hospital medicine program in Durham, N.C., at HM15.

Dr. Setji, who participates in a fantasy football league for physicians, says he aimed to apply the approaches of fantasy sports leagues to hospitalist quality metrics.¹ Dr. Setji wanted to find a way to recognize high-performing hospitalists in his group on a regular basis, beyond the group metrics that had been reported to faculty members—and to create greater accountability and evaluate physicians’ performance over time.

A team developed a survey instrument compiling common clinical process and outcome measures for hospitalists, and faculty members were asked to rate how important the various metrics were to them individually as indicators of physician performance. Their responses were combined into a weighted, composite hospital medicine provider performance score, which reflects the relative value practicing hospitalists assign to available performance measures. Results are easily tabulated on an Excel spreadsheet, Dr. Setji says.

Every three months—or football quarter—the top overall performer is awarded two bottles of wine and possession of the traveling trophy.

“We’re always looking for ways to measure our performance,” Dr. Setji says, “and we all want to know how we’re doing relative to our peers.”

Reference

1. Setji NP, Bae JG, Griffith BC, Daley C. Fantasy physician leagues? Introducing the physician equivalent of the Qbr (Quarterly Metric-Based Rating) [abstract]. J Hosp Med. 2015;10(suppl 2).

Fantasy sports, hospital medicine, and quality metrics. Those were the unique elements of an RIV poster presented by Noppon Setji, MD, medical director of the Duke University Medical Center’s hospital medicine program in Durham, N.C., at HM15.

Dr. Setji, who participates in a fantasy football league for physicians, says he aimed to apply the approaches of fantasy sports leagues to hospitalist quality metrics.¹ Dr. Setji wanted to find a way to recognize high-performing hospitalists in his group on a regular basis, beyond the group metrics that had been reported to faculty members—and to create greater accountability and evaluate physicians’ performance over time.

A team developed a survey instrument compiling common clinical process and outcome measures for hospitalists, and faculty members were asked to rate how important the various metrics were to them individually as indicators of physician performance. Their responses were combined into a weighted, composite hospital medicine provider performance score, which reflects the relative value practicing hospitalists assign to available performance measures. Results are easily tabulated on an Excel spreadsheet, Dr. Setji says.

Every three months—or football quarter—the top overall performer is awarded two bottles of wine and possession of the traveling trophy.

“We’re always looking for ways to measure our performance,” Dr. Setji says, “and we all want to know how we’re doing relative to our peers.”

Reference

1. Setji NP, Bae JG, Griffith BC, Daley C. Fantasy physician leagues? Introducing the physician equivalent of the Qbr (Quarterly Metric-Based Rating) [abstract]. J Hosp Med. 2015;10(suppl 2).

Fantasy sports, hospital medicine, and quality metrics. Those were the unique elements of an RIV poster presented by Noppon Setji, MD, medical director of the Duke University Medical Center’s hospital medicine program in Durham, N.C., at HM15.

Dr. Setji, who participates in a fantasy football league for physicians, says he aimed to apply the approaches of fantasy sports leagues to hospitalist quality metrics.¹ Dr. Setji wanted to find a way to recognize high-performing hospitalists in his group on a regular basis, beyond the group metrics that had been reported to faculty members—and to create greater accountability and evaluate physicians’ performance over time.

A team developed a survey instrument compiling common clinical process and outcome measures for hospitalists, and faculty members were asked to rate how important the various metrics were to them individually as indicators of physician performance. Their responses were combined into a weighted, composite hospital medicine provider performance score, which reflects the relative value practicing hospitalists assign to available performance measures. Results are easily tabulated on an Excel spreadsheet, Dr. Setji says.

Every three months—or football quarter—the top overall performer is awarded two bottles of wine and possession of the traveling trophy.

“We’re always looking for ways to measure our performance,” Dr. Setji says, “and we all want to know how we’re doing relative to our peers.”

Reference

1. Setji NP, Bae JG, Griffith BC, Daley C. Fantasy physician leagues? Introducing the physician equivalent of the Qbr (Quarterly Metric-Based Rating) [abstract]. J Hosp Med. 2015;10(suppl 2).

The Society of Hospital Medicine has launched a new scholarship program to bring the "best and brightest" medical students into the specialty.

The Student Hospitalist Scholar Grant program awards eligible students a $5,000 summer stipend for scholarly work on a project related to patient safety, quality improvement (QI), or other areas relevant to the field of hospital medicine. The program also provides up to $1,500 in travel-related reimbursement for students to attend the SHM annual meeting.

This summer's inaugural class has three students, all going into their second year of medical school: Frank Zadravecz Jr. of the University of Illinois College of Medicine at Chicago, Miriam Zander of Touro College of Osteopathic Medicine in New York City, and Monica Shah of Wayne State University School of Medicine in Detroit.

"Getting medical students involved is important for us," says hospitalist Darlene Tad-y, MD, an assistant professor of medicine at the University of Colorado in Denver and chair of SHM's Physicians in Training Committee. It means "the future of medicine will have people who know how to do this work, people who will be more skilled and effective at this work."

Dr. Tad-y says it makes sense to merge efforts to recruit the "best and brightest" medical students to HM with QI research. This year's projects include examinations of post-hospital syndrome and physiologic alarm responses.

The program drew about a dozen applicants in its first year. Over the next few years, SHM hopes to award 10 scholarships each summer.

"QI work is really only getting off the ground broadly with people who've been in the field for a really long time," Dr. Tad-y says. "To have that many students early on in their medical school career already understand some of these concepts and be aware that this is going on, for us, it's really exciting." TH

Visit our website for more information on engaging young physicians in HM.

The Society of Hospital Medicine has launched a new scholarship program to bring the "best and brightest" medical students into the specialty.

The Student Hospitalist Scholar Grant program awards eligible students a $5,000 summer stipend for scholarly work on a project related to patient safety, quality improvement (QI), or other areas relevant to the field of hospital medicine. The program also provides up to $1,500 in travel-related reimbursement for students to attend the SHM annual meeting.

This summer's inaugural class has three students, all going into their second year of medical school: Frank Zadravecz Jr. of the University of Illinois College of Medicine at Chicago, Miriam Zander of Touro College of Osteopathic Medicine in New York City, and Monica Shah of Wayne State University School of Medicine in Detroit.

"Getting medical students involved is important for us," says hospitalist Darlene Tad-y, MD, an assistant professor of medicine at the University of Colorado in Denver and chair of SHM's Physicians in Training Committee. It means "the future of medicine will have people who know how to do this work, people who will be more skilled and effective at this work."

Dr. Tad-y says it makes sense to merge efforts to recruit the "best and brightest" medical students to HM with QI research. This year's projects include examinations of post-hospital syndrome and physiologic alarm responses.

The program drew about a dozen applicants in its first year. Over the next few years, SHM hopes to award 10 scholarships each summer.

"QI work is really only getting off the ground broadly with people who've been in the field for a really long time," Dr. Tad-y says. "To have that many students early on in their medical school career already understand some of these concepts and be aware that this is going on, for us, it's really exciting." TH

Visit our website for more information on engaging young physicians in HM.

The Society of Hospital Medicine has launched a new scholarship program to bring the "best and brightest" medical students into the specialty.

The Student Hospitalist Scholar Grant program awards eligible students a $5,000 summer stipend for scholarly work on a project related to patient safety, quality improvement (QI), or other areas relevant to the field of hospital medicine. The program also provides up to $1,500 in travel-related reimbursement for students to attend the SHM annual meeting.

This summer's inaugural class has three students, all going into their second year of medical school: Frank Zadravecz Jr. of the University of Illinois College of Medicine at Chicago, Miriam Zander of Touro College of Osteopathic Medicine in New York City, and Monica Shah of Wayne State University School of Medicine in Detroit.

"Getting medical students involved is important for us," says hospitalist Darlene Tad-y, MD, an assistant professor of medicine at the University of Colorado in Denver and chair of SHM's Physicians in Training Committee. It means "the future of medicine will have people who know how to do this work, people who will be more skilled and effective at this work."

Dr. Tad-y says it makes sense to merge efforts to recruit the "best and brightest" medical students to HM with QI research. This year's projects include examinations of post-hospital syndrome and physiologic alarm responses.

The program drew about a dozen applicants in its first year. Over the next few years, SHM hopes to award 10 scholarships each summer.

"QI work is really only getting off the ground broadly with people who've been in the field for a really long time," Dr. Tad-y says. "To have that many students early on in their medical school career already understand some of these concepts and be aware that this is going on, for us, it's really exciting." TH

Visit our website for more information on engaging young physicians in HM.

Summary:

In an era where a majority of the pediatric hospital workforce is just starting to recognize fish bone diagrams, five why questions, root cause analysis, IHI, Lean, six sigma and pareto charts, hospitalists can be daunted as they try to serve as the home for quality improvement and patient safety in hospitals. Hospitalists are expected to know, understand, and practice these models for improvement with limited training and expertise. Beyond being looked at as experts, they are expected to teach residents and other learners when they are unsure of it ourselves. Governing education bodies (i.e., ACGME and CLER) have made it a requirement that residents have these concepts integrated into their curriculums and tracked.

Presented by an inter-professional team from Floating Hospital for Children at Tufts Medical Center in Boston, this PHM15 workshop focused on how to work in multidisciplinary teams to identify, analyze, and create patient-safety solutions, and, therefore, set the stage for systems- or department-based QI projects.

“It is OK to make mistakes, but it is not OK to not learn from them,” stated the presenters.

Starting with a near-miss event that led to a department/resident-led root cause analysis, the importance of system improvement became apparent. Presenters discussed the 12-week curriculum they created for pediatric residents and nursing students, which includes:

• Didactics,
• Online, self-directed learning, and
• An inter-professional, small-group project.

Trainees present their analysis and action items to their departments and, at times, even administration. This helps align hospital goals with resident teaching, while simultaneously providing an environment where discussing errors safely in order to prevent further harms.

Attendees of the workshop walked away with a generalizable, step-by-step toolkit to take home to their home institution.

Key Takeaways:

1. Convene a leadership team of nurses and physicians to develop the inter-professional program
2. Consider scheduling demands of nurses, physicians and residents.
3. Implement administrative support to assist with scheduling of meetings, maintenance of documents and email distribution.
4. Program participation must bring value to the staff such as CME credits
5. Make the educational experience program flexible in a blended learning environment.
6. Recognize staff’s completion of the program with a certificate.
7. Provide the opportunity, mentorship and support for staff willing to continue the project as a quality improvement initiative. TH

Dr. Hopkins is a pediatric hospitalist at All Children's Hospital Johns Hopkins Medicine, and an instructor at Johns Hopkins Medicine in St. Petersburg, Fla.

Summary:

In an era where a majority of the pediatric hospital workforce is just starting to recognize fish bone diagrams, five why questions, root cause analysis, IHI, Lean, six sigma and pareto charts, hospitalists can be daunted as they try to serve as the home for quality improvement and patient safety in hospitals. Hospitalists are expected to know, understand, and practice these models for improvement with limited training and expertise. Beyond being looked at as experts, they are expected to teach residents and other learners when they are unsure of it ourselves. Governing education bodies (i.e., ACGME and CLER) have made it a requirement that residents have these concepts integrated into their curriculums and tracked.

Presented by an inter-professional team from Floating Hospital for Children at Tufts Medical Center in Boston, this PHM15 workshop focused on how to work in multidisciplinary teams to identify, analyze, and create patient-safety solutions, and, therefore, set the stage for systems- or department-based QI projects.

“It is OK to make mistakes, but it is not OK to not learn from them,” stated the presenters.

Starting with a near-miss event that led to a department/resident-led root cause analysis, the importance of system improvement became apparent. Presenters discussed the 12-week curriculum they created for pediatric residents and nursing students, which includes:

• Didactics,
• Online, self-directed learning, and
• An inter-professional, small-group project.

Trainees present their analysis and action items to their departments and, at times, even administration. This helps align hospital goals with resident teaching, while simultaneously providing an environment where discussing errors safely in order to prevent further harms.

Attendees of the workshop walked away with a generalizable, step-by-step toolkit to take home to their home institution.

Key Takeaways:

1. Convene a leadership team of nurses and physicians to develop the inter-professional program
2. Consider scheduling demands of nurses, physicians and residents.
3. Implement administrative support to assist with scheduling of meetings, maintenance of documents and email distribution.
4. Program participation must bring value to the staff such as CME credits
5. Make the educational experience program flexible in a blended learning environment.
6. Recognize staff’s completion of the program with a certificate.
7. Provide the opportunity, mentorship and support for staff willing to continue the project as a quality improvement initiative. TH

Dr. Hopkins is a pediatric hospitalist at All Children's Hospital Johns Hopkins Medicine, and an instructor at Johns Hopkins Medicine in St. Petersburg, Fla.

Summary:

In an era where a majority of the pediatric hospital workforce is just starting to recognize fish bone diagrams, five why questions, root cause analysis, IHI, Lean, six sigma and pareto charts, hospitalists can be daunted as they try to serve as the home for quality improvement and patient safety in hospitals. Hospitalists are expected to know, understand, and practice these models for improvement with limited training and expertise. Beyond being looked at as experts, they are expected to teach residents and other learners when they are unsure of it ourselves. Governing education bodies (i.e., ACGME and CLER) have made it a requirement that residents have these concepts integrated into their curriculums and tracked.

Presented by an inter-professional team from Floating Hospital for Children at Tufts Medical Center in Boston, this PHM15 workshop focused on how to work in multidisciplinary teams to identify, analyze, and create patient-safety solutions, and, therefore, set the stage for systems- or department-based QI projects.

“It is OK to make mistakes, but it is not OK to not learn from them,” stated the presenters.

Starting with a near-miss event that led to a department/resident-led root cause analysis, the importance of system improvement became apparent. Presenters discussed the 12-week curriculum they created for pediatric residents and nursing students, which includes:

• Didactics,
• Online, self-directed learning, and
• An inter-professional, small-group project.

Trainees present their analysis and action items to their departments and, at times, even administration. This helps align hospital goals with resident teaching, while simultaneously providing an environment where discussing errors safely in order to prevent further harms.

Attendees of the workshop walked away with a generalizable, step-by-step toolkit to take home to their home institution.

Key Takeaways:

1. Convene a leadership team of nurses and physicians to develop the inter-professional program
2. Consider scheduling demands of nurses, physicians and residents.
3. Implement administrative support to assist with scheduling of meetings, maintenance of documents and email distribution.
4. Program participation must bring value to the staff such as CME credits
5. Make the educational experience program flexible in a blended learning environment.
6. Recognize staff’s completion of the program with a certificate.
7. Provide the opportunity, mentorship and support for staff willing to continue the project as a quality improvement initiative. TH

Dr. Hopkins is a pediatric hospitalist at All Children's Hospital Johns Hopkins Medicine, and an instructor at Johns Hopkins Medicine in St. Petersburg, Fla.

Session: Let’s Measure Our Own Performance: Propose and Evaluate Pediatric Hospital Medicine Quality Indicators

Summary: During this workshop, a staff of multiple, nationally-recognized quality leaders led a group to review, help develop, and help validate quality measures. The workshop was facilitated via the use of interactive survey tools, didactic sessions, and small groups.

Presenters discussed why quality measures are important and relevant. These included:

1. Improved quality of care,
2. Demonstration of value,
3. Third-party pay for performance indicators,
4. Determining our own indicators (versus being chosen for us), and
5. Performance incentives.

As part of the introduction to the workshop, the various quality measure validation methods were reviewed. These consisted of methods such as UCLA/RAND and Delphi Panel, as a means to determine validation and feasibility.

Validation was discussed in terms of what is being measured is the true outcome that was hoped to be achieved. The feasibility component used to make sure that the data used for quality measures, or process to be implemented for improvement, can easily be acquired to determine adherence, and that data is free of error. Facilitators reviewed various examples of validity and feasibility of quality measures with direct examples and discussions with attendees.

During the first breakout session, the groups were separated into teams focused on 1. care transitions, 2. safety, and 3. clinical care. The groups were asked to determine three quality indicators per individual, discuss the top five indicators voted on by the group, and than to review and discuss as a group the validity and feasibility of the measures using a scoring tool of 1-3: Not Valid/Feasible, 4-6: Equivocal, 7-9: Valid/Feasible. At the end, a delegated group speaker was asked to discuss either the pros/cons of one of their measures in regards to validity and feasibility to the total audience. Facilitators assisted on clarifying the reasons of why validity and feasibility metrics were appropriate.

During the final parts of workshop, positive and negatives of quality metrics determination methodology were discussed. The attendees reflected on the process of how quality measures are determined along with how these may be used within their settings.

Key Takeaways

Clearly determining the validity and feasibility of quality metrics for pediatrics has become an important topic. It not only has significant ramifications to the value we provide to our patients, but also the financial sustainability of programs and institutions, especially with the current changes in payment models. The workshop gave a clear and concise way of how to come up with quality metrics and the facilitators greatly added to the understanding of how we can “raise the floor” and “raise the ceiling” of pediatric care. TH

Dr. Alvarez is a pediatric hospitalist and medical director of community hospital services at Children’s National Health System in Washington, D.C.

Session: Let’s Measure Our Own Performance: Propose and Evaluate Pediatric Hospital Medicine Quality Indicators

Summary: During this workshop, a staff of multiple, nationally-recognized quality leaders led a group to review, help develop, and help validate quality measures. The workshop was facilitated via the use of interactive survey tools, didactic sessions, and small groups.

Presenters discussed why quality measures are important and relevant. These included:

1. Improved quality of care,
2. Demonstration of value,
3. Third-party pay for performance indicators,
4. Determining our own indicators (versus being chosen for us), and
5. Performance incentives.

As part of the introduction to the workshop, the various quality measure validation methods were reviewed. These consisted of methods such as UCLA/RAND and Delphi Panel, as a means to determine validation and feasibility.

Validation was discussed in terms of what is being measured is the true outcome that was hoped to be achieved. The feasibility component used to make sure that the data used for quality measures, or process to be implemented for improvement, can easily be acquired to determine adherence, and that data is free of error. Facilitators reviewed various examples of validity and feasibility of quality measures with direct examples and discussions with attendees.

During the first breakout session, the groups were separated into teams focused on 1. care transitions, 2. safety, and 3. clinical care. The groups were asked to determine three quality indicators per individual, discuss the top five indicators voted on by the group, and than to review and discuss as a group the validity and feasibility of the measures using a scoring tool of 1-3: Not Valid/Feasible, 4-6: Equivocal, 7-9: Valid/Feasible. At the end, a delegated group speaker was asked to discuss either the pros/cons of one of their measures in regards to validity and feasibility to the total audience. Facilitators assisted on clarifying the reasons of why validity and feasibility metrics were appropriate.

During the final parts of workshop, positive and negatives of quality metrics determination methodology were discussed. The attendees reflected on the process of how quality measures are determined along with how these may be used within their settings.

Key Takeaways

Clearly determining the validity and feasibility of quality metrics for pediatrics has become an important topic. It not only has significant ramifications to the value we provide to our patients, but also the financial sustainability of programs and institutions, especially with the current changes in payment models. The workshop gave a clear and concise way of how to come up with quality metrics and the facilitators greatly added to the understanding of how we can “raise the floor” and “raise the ceiling” of pediatric care. TH

Dr. Alvarez is a pediatric hospitalist and medical director of community hospital services at Children’s National Health System in Washington, D.C.

Session: Let’s Measure Our Own Performance: Propose and Evaluate Pediatric Hospital Medicine Quality Indicators

Summary: During this workshop, a staff of multiple, nationally-recognized quality leaders led a group to review, help develop, and help validate quality measures. The workshop was facilitated via the use of interactive survey tools, didactic sessions, and small groups.

Presenters discussed why quality measures are important and relevant. These included:

1. Improved quality of care,
2. Demonstration of value,
3. Third-party pay for performance indicators,
4. Determining our own indicators (versus being chosen for us), and
5. Performance incentives.

As part of the introduction to the workshop, the various quality measure validation methods were reviewed. These consisted of methods such as UCLA/RAND and Delphi Panel, as a means to determine validation and feasibility.

Validation was discussed in terms of what is being measured is the true outcome that was hoped to be achieved. The feasibility component used to make sure that the data used for quality measures, or process to be implemented for improvement, can easily be acquired to determine adherence, and that data is free of error. Facilitators reviewed various examples of validity and feasibility of quality measures with direct examples and discussions with attendees.

During the first breakout session, the groups were separated into teams focused on 1. care transitions, 2. safety, and 3. clinical care. The groups were asked to determine three quality indicators per individual, discuss the top five indicators voted on by the group, and than to review and discuss as a group the validity and feasibility of the measures using a scoring tool of 1-3: Not Valid/Feasible, 4-6: Equivocal, 7-9: Valid/Feasible. At the end, a delegated group speaker was asked to discuss either the pros/cons of one of their measures in regards to validity and feasibility to the total audience. Facilitators assisted on clarifying the reasons of why validity and feasibility metrics were appropriate.

During the final parts of workshop, positive and negatives of quality metrics determination methodology were discussed. The attendees reflected on the process of how quality measures are determined along with how these may be used within their settings.

Key Takeaways

Clearly determining the validity and feasibility of quality metrics for pediatrics has become an important topic. It not only has significant ramifications to the value we provide to our patients, but also the financial sustainability of programs and institutions, especially with the current changes in payment models. The workshop gave a clear and concise way of how to come up with quality metrics and the facilitators greatly added to the understanding of how we can “raise the floor” and “raise the ceiling” of pediatric care. TH

Dr. Alvarez is a pediatric hospitalist and medical director of community hospital services at Children’s National Health System in Washington, D.C.

Pediatric Hospital Medicine 2015's keynote speaker, Rita Mangione-Smith, MD, MPH, reviewed quality measures being developed for medically complex patients by the Center of Excellence on Quality of Care Measures for Children with Complex Needs (COE4CCN). As one of the most challenging groups to not only provide care but to determine if the management provided brings value, the importance of quality measures was emphasized.

Dr. Mangione-Smith, of Seattle Children’s Hospital, reviewed the need for quality measures, as well as the process of developing these measures. Quality measures help to quantify outcomes from care practices, stated Dr. Mangione-Smith, to compare similar settings, and also to set possible benchmarks. The processes range from identifying and prioritizing measures to how they are validated as true value added outcomes. Data sources, sample size, and reliability/validity of the measures are considered important components to ensure that answers or results acquired are applicable and relevant to the population. Another important component is to clearly define a child with medical complexity.

Some reasons why medically complex patients require this focus:

• The low amount of information about their quality of care, investment, and need for coordination;
• Lack of understanding of which care practices make the biggest differences on their outcomes; and
• Their high rate of resource utilization.

The objective was to see which areas of care, such as care coordination, have the highest benefit/improvement on outcomes so as to prioritize resources more effectively. Dr. Mangione-Smith also touched on some obstacles and challenges, such as lack of insurance coverage leading to use of emergency resources as their primary care and its effect on increasing resource utilization.

Measures were determined via a multi-component methodology. Surveys using a binary and linear mean scoring tool were used. This provided multiple types of information such as assessing family’s perception of care, their understanding of medical information and care plans, and their accessibility to medical care services or information about their child.

Currently there is very little evidence on which management methods have the most significant, or any, effect on children with medical complexity. The use of quality measures to help guide which practices may have the highest positive impact on their outcomes greatly adds to the challenging care of this population and can be “used to assess quality of care coordination over time.” TH

Dr. Alvarez is a pediatric hospitalist and medical director of community hospital services at Children’s National Health System in Washington, D.C.

Pediatric Hospital Medicine 2015's keynote speaker, Rita Mangione-Smith, MD, MPH, reviewed quality measures being developed for medically complex patients by the Center of Excellence on Quality of Care Measures for Children with Complex Needs (COE4CCN). As one of the most challenging groups to not only provide care but to determine if the management provided brings value, the importance of quality measures was emphasized.

Dr. Mangione-Smith, of Seattle Children’s Hospital, reviewed the need for quality measures, as well as the process of developing these measures. Quality measures help to quantify outcomes from care practices, stated Dr. Mangione-Smith, to compare similar settings, and also to set possible benchmarks. The processes range from identifying and prioritizing measures to how they are validated as true value added outcomes. Data sources, sample size, and reliability/validity of the measures are considered important components to ensure that answers or results acquired are applicable and relevant to the population. Another important component is to clearly define a child with medical complexity.

Some reasons why medically complex patients require this focus:

• The low amount of information about their quality of care, investment, and need for coordination;
• Lack of understanding of which care practices make the biggest differences on their outcomes; and
• Their high rate of resource utilization.

The objective was to see which areas of care, such as care coordination, have the highest benefit/improvement on outcomes so as to prioritize resources more effectively. Dr. Mangione-Smith also touched on some obstacles and challenges, such as lack of insurance coverage leading to use of emergency resources as their primary care and its effect on increasing resource utilization.

Measures were determined via a multi-component methodology. Surveys using a binary and linear mean scoring tool were used. This provided multiple types of information such as assessing family’s perception of care, their understanding of medical information and care plans, and their accessibility to medical care services or information about their child.

Currently there is very little evidence on which management methods have the most significant, or any, effect on children with medical complexity. The use of quality measures to help guide which practices may have the highest positive impact on their outcomes greatly adds to the challenging care of this population and can be “used to assess quality of care coordination over time.” TH

Dr. Alvarez is a pediatric hospitalist and medical director of community hospital services at Children’s National Health System in Washington, D.C.

Pediatric Hospital Medicine 2015's keynote speaker, Rita Mangione-Smith, MD, MPH, reviewed quality measures being developed for medically complex patients by the Center of Excellence on Quality of Care Measures for Children with Complex Needs (COE4CCN). As one of the most challenging groups to not only provide care but to determine if the management provided brings value, the importance of quality measures was emphasized.

Dr. Mangione-Smith, of Seattle Children’s Hospital, reviewed the need for quality measures, as well as the process of developing these measures. Quality measures help to quantify outcomes from care practices, stated Dr. Mangione-Smith, to compare similar settings, and also to set possible benchmarks. The processes range from identifying and prioritizing measures to how they are validated as true value added outcomes. Data sources, sample size, and reliability/validity of the measures are considered important components to ensure that answers or results acquired are applicable and relevant to the population. Another important component is to clearly define a child with medical complexity.

Some reasons why medically complex patients require this focus:

• The low amount of information about their quality of care, investment, and need for coordination;
• Lack of understanding of which care practices make the biggest differences on their outcomes; and
• Their high rate of resource utilization.

The objective was to see which areas of care, such as care coordination, have the highest benefit/improvement on outcomes so as to prioritize resources more effectively. Dr. Mangione-Smith also touched on some obstacles and challenges, such as lack of insurance coverage leading to use of emergency resources as their primary care and its effect on increasing resource utilization.

Measures were determined via a multi-component methodology. Surveys using a binary and linear mean scoring tool were used. This provided multiple types of information such as assessing family’s perception of care, their understanding of medical information and care plans, and their accessibility to medical care services or information about their child.

Currently there is very little evidence on which management methods have the most significant, or any, effect on children with medical complexity. The use of quality measures to help guide which practices may have the highest positive impact on their outcomes greatly adds to the challenging care of this population and can be “used to assess quality of care coordination over time.” TH

Dr. Alvarez is a pediatric hospitalist and medical director of community hospital services at Children’s National Health System in Washington, D.C.

As a hospitalist myself, I have seen firsthand the need for a healthcare system that provides better care, spends dollars more wisely, and keeps people healthier. I practice on weekends taking care of children, many of whom have multiple chronic conditions and fragile social support, and their families. I love patient care; however, too many times, we hospitalists see patients whose fragmented care results in poor outcomes and repeated hospitalizations.

In my current role at the Centers for Medicare and Medicaid Services (CMS), I am pleased to see that Secretary Burwell is confronting these problems head on, with concrete goals for shifting the equation in how we pay for care. Specifically, we announced the goal of moving 30% of payments by 2016 into alternative payment models such as accountable care organizations (ACOs) or bundled payments, where the provider is accountable for total cost of care and quality. We set the goal of 50% of payments in these models by 2018. In 2011, Medicare had essentially zero payments in these models, but by 2014, we have reached 20% and growing in alternative payment models. Hospitalists can play a significant role in this healthcare transformation, and several initiatives in CMS’ Innovation Center, which I lead, are relevant to our work.

Recently, a Department of Health and Human Services (HHS) report showed that an estimated 50,000 fewer patients died in hospitals, 1.3 million fewer adverse events and infections occurred, and approximately $12 billion in healthcare costs were saved as a result of a reduction in hospital-acquired conditions from 2010 to 2013. This progress toward a safer healthcare system occurred during a period of concerted attention directed by hospitals and hospitalists throughout the country at reducing adverse events. These efforts were also due in part to provisions of the Affordable Care Act such as Medicare payment incentives to improve the quality of care and the HHS Partnership for Patients initiative. The Partnership for Patients is a nationwide public-private collaboration that began in April 2011 with two main goals: Reduce preventable hospital-acquired conditions by 40% and 30-day readmissions by 20%. Since the Partnership for Patients was launched, the vast majority of U.S. hospitals and many other stakeholders have joined the collaborative effort and delivered results.

CMS is committed to making even greater progress toward keeping people as safe and healthy as possible. That is why we have launched a second round of Hospital Engagement Network (HEN) contracts to continue reducing preventable hospital-acquired conditions and readmissions. HEN funding will be available to award contracts to national, regional, or state hospital associations, large healthcare organizations, or national affinity organizations that will support hospitals in their efforts to reduce preventable hospital-acquired conditions and readmissions. In February, CMS posted a request for proposals for HEN contracts to continue the success achieved in improving patient safety.

The Partnership for Patients and HENs are just one part of an overall effort by HHS to deliver better care, spend dollars more wisely, and improve health. Initiatives like the Partnership for Patients, accountable care organizations, quality improvement organizations, and others have helped reduce hospital readmissions in Medicare by nearly 8% between January 2012 and December 2013—translating into 150,000 fewer readmissions. Hospitalists have played a major role in these improvements.

On a broader front, CMS is taking action to improve healthcare so patients and their families can get the best care possible. To this end, CMS is focused on three key areas: (1) improving the way providers and hospitals are paid, (2) improving and innovating in care delivery, and (3) sharing information more broadly with providers and hospitals, consumers, and others to support better decisions.

When it comes to improving the way providers are paid, we want to reward value and care coordination—rather than volume and care duplication. We have over 25 payment and service delivery models at the CMS Innovation Center, but I will call out three that are particularly relevant to hospitalists. First, the ACO program is demonstrating positive results. Medicare has over 400 ACOs serving almost eight million beneficiaries. The Pioneer ACO program evaluation results demonstrated over $380 million in savings and improved quality—for example, improvement in 28 out of 33 quality measures, including patient experience of care. Based on these results, this model was the first from the CMS Innovation Center to be certified by the CMS actuary, and the Secretary of Health and Human Services announced her intent to expand the model components as a permanent part of the Medicare program through rulemaking. Second, in the Bundled Payments for Care Improvement model, we have thousands of providers (e.g. hospitals, physician groups) in phase 1 determining how they might improve care and considering taking on financial risk. The model includes acute and post-acute care, such as a 90-day episode for hip and knee replacement. We have 500 providers, and more that are willing to take on two-sided financial risk will likely be added in the next quarter. Hospitalists have a large role to play in improving quality and reducing costs in this model. Finally, the State Innovation Model is driving state and local change. In this model, we are funding and partnering with states on comprehensive delivery system reform. Seventeen states are implementing interventions, and 21 states and territories are designing their plans. The state is encouraged to partner with payers, providers, employers, public health entities, and others in the state to strive within the whole state population for better care, smarter spending, and healthier people. Many states are implementing payment models such as ACOs and bundled payments in Medicaid and with private payers. Increasingly, hospital medicine groups are going to value-based in the quality and efficiency of care delivery, both within the hospital walls and for episodes of care. This will entail stronger linkages and teamwork, both within the hospital and with clinicians in the community. It will also require a much stronger focus on predicting which patients are at risk of decompensation and delivering tailored interventions, including care management and technology to monitor patients in the home and other settings.

To improve care delivery, we are supporting providers to find new ways to coordinate and integrate care. For example, discharging a patient from the hospital without clear instructions on how to take care of themselves at home, when they should take their medicines, or when to check back in with the doctor can lead to an unnecessary readmission back into the hospital. This is especially true of individuals who have complex illnesses or diseases that may be more difficult to manage. We are supporting care improvement through a variety of channels, including facilitating hospitals and community groups teaming up to share best practices, and we applaud the Society of Hospital Medicine’s BOOST program, which is focused on peer mentoring and improvement.

Finally, as we look to improve the way information is distributed, we are working to create more transparency on the cost and quality of care, to bring electronic health information to inform care, and to bring the most recent scientific evidence to the point of care so we can bolster clinical decision making. Necessary information needs to be available to the treating physician and patients across settings. We must continue to improve the interoperability and usability of electronic health records so that they can enable improvement and care delivery.

I hope that as hospitalists you will take a closer look at the HHS initiatives I’ve described here—and others—and consider becoming a participant. Hospital medicine physicians are already leading many of these initiatives and are a positive force for health system transformation. As I look back on my last four-plus years at CMS (which sometimes feel like 30 years), I am amazed by how much progress we have made in improving the quality of care (e.g. over 95% of measures in CMS quality programs have improved over the last three years), spending dollars more wisely (e.g. lowest cost growth in the last four years in over 50 years), and improving the health of the nation (e.g. decreased smoking rates). Our nation is moving rapidly toward accountable, alternative payment models, including the recent legislation to “fix the SGR,” and I have seen hospitalists lead progress towards adopting these models nationally and locally. A challenge for all of us is to accelerate the pace of positive change and relentlessly pursue improved patient outcomes and a higher performing health system. But I know hospitalists are up to this challenge.

Thank you for all the work that you do every day on behalf of your patients and a better health system.

As a hospitalist myself, I have seen firsthand the need for a healthcare system that provides better care, spends dollars more wisely, and keeps people healthier. I practice on weekends taking care of children, many of whom have multiple chronic conditions and fragile social support, and their families. I love patient care; however, too many times, we hospitalists see patients whose fragmented care results in poor outcomes and repeated hospitalizations.

In my current role at the Centers for Medicare and Medicaid Services (CMS), I am pleased to see that Secretary Burwell is confronting these problems head on, with concrete goals for shifting the equation in how we pay for care. Specifically, we announced the goal of moving 30% of payments by 2016 into alternative payment models such as accountable care organizations (ACOs) or bundled payments, where the provider is accountable for total cost of care and quality. We set the goal of 50% of payments in these models by 2018. In 2011, Medicare had essentially zero payments in these models, but by 2014, we have reached 20% and growing in alternative payment models. Hospitalists can play a significant role in this healthcare transformation, and several initiatives in CMS’ Innovation Center, which I lead, are relevant to our work.

Recently, a Department of Health and Human Services (HHS) report showed that an estimated 50,000 fewer patients died in hospitals, 1.3 million fewer adverse events and infections occurred, and approximately $12 billion in healthcare costs were saved as a result of a reduction in hospital-acquired conditions from 2010 to 2013. This progress toward a safer healthcare system occurred during a period of concerted attention directed by hospitals and hospitalists throughout the country at reducing adverse events. These efforts were also due in part to provisions of the Affordable Care Act such as Medicare payment incentives to improve the quality of care and the HHS Partnership for Patients initiative. The Partnership for Patients is a nationwide public-private collaboration that began in April 2011 with two main goals: Reduce preventable hospital-acquired conditions by 40% and 30-day readmissions by 20%. Since the Partnership for Patients was launched, the vast majority of U.S. hospitals and many other stakeholders have joined the collaborative effort and delivered results.

CMS is committed to making even greater progress toward keeping people as safe and healthy as possible. That is why we have launched a second round of Hospital Engagement Network (HEN) contracts to continue reducing preventable hospital-acquired conditions and readmissions. HEN funding will be available to award contracts to national, regional, or state hospital associations, large healthcare organizations, or national affinity organizations that will support hospitals in their efforts to reduce preventable hospital-acquired conditions and readmissions. In February, CMS posted a request for proposals for HEN contracts to continue the success achieved in improving patient safety.

The Partnership for Patients and HENs are just one part of an overall effort by HHS to deliver better care, spend dollars more wisely, and improve health. Initiatives like the Partnership for Patients, accountable care organizations, quality improvement organizations, and others have helped reduce hospital readmissions in Medicare by nearly 8% between January 2012 and December 2013—translating into 150,000 fewer readmissions. Hospitalists have played a major role in these improvements.

On a broader front, CMS is taking action to improve healthcare so patients and their families can get the best care possible. To this end, CMS is focused on three key areas: (1) improving the way providers and hospitals are paid, (2) improving and innovating in care delivery, and (3) sharing information more broadly with providers and hospitals, consumers, and others to support better decisions.

When it comes to improving the way providers are paid, we want to reward value and care coordination—rather than volume and care duplication. We have over 25 payment and service delivery models at the CMS Innovation Center, but I will call out three that are particularly relevant to hospitalists. First, the ACO program is demonstrating positive results. Medicare has over 400 ACOs serving almost eight million beneficiaries. The Pioneer ACO program evaluation results demonstrated over $380 million in savings and improved quality—for example, improvement in 28 out of 33 quality measures, including patient experience of care. Based on these results, this model was the first from the CMS Innovation Center to be certified by the CMS actuary, and the Secretary of Health and Human Services announced her intent to expand the model components as a permanent part of the Medicare program through rulemaking. Second, in the Bundled Payments for Care Improvement model, we have thousands of providers (e.g. hospitals, physician groups) in phase 1 determining how they might improve care and considering taking on financial risk. The model includes acute and post-acute care, such as a 90-day episode for hip and knee replacement. We have 500 providers, and more that are willing to take on two-sided financial risk will likely be added in the next quarter. Hospitalists have a large role to play in improving quality and reducing costs in this model. Finally, the State Innovation Model is driving state and local change. In this model, we are funding and partnering with states on comprehensive delivery system reform. Seventeen states are implementing interventions, and 21 states and territories are designing their plans. The state is encouraged to partner with payers, providers, employers, public health entities, and others in the state to strive within the whole state population for better care, smarter spending, and healthier people. Many states are implementing payment models such as ACOs and bundled payments in Medicaid and with private payers. Increasingly, hospital medicine groups are going to value-based in the quality and efficiency of care delivery, both within the hospital walls and for episodes of care. This will entail stronger linkages and teamwork, both within the hospital and with clinicians in the community. It will also require a much stronger focus on predicting which patients are at risk of decompensation and delivering tailored interventions, including care management and technology to monitor patients in the home and other settings.

To improve care delivery, we are supporting providers to find new ways to coordinate and integrate care. For example, discharging a patient from the hospital without clear instructions on how to take care of themselves at home, when they should take their medicines, or when to check back in with the doctor can lead to an unnecessary readmission back into the hospital. This is especially true of individuals who have complex illnesses or diseases that may be more difficult to manage. We are supporting care improvement through a variety of channels, including facilitating hospitals and community groups teaming up to share best practices, and we applaud the Society of Hospital Medicine’s BOOST program, which is focused on peer mentoring and improvement.

Finally, as we look to improve the way information is distributed, we are working to create more transparency on the cost and quality of care, to bring electronic health information to inform care, and to bring the most recent scientific evidence to the point of care so we can bolster clinical decision making. Necessary information needs to be available to the treating physician and patients across settings. We must continue to improve the interoperability and usability of electronic health records so that they can enable improvement and care delivery.

I hope that as hospitalists you will take a closer look at the HHS initiatives I’ve described here—and others—and consider becoming a participant. Hospital medicine physicians are already leading many of these initiatives and are a positive force for health system transformation. As I look back on my last four-plus years at CMS (which sometimes feel like 30 years), I am amazed by how much progress we have made in improving the quality of care (e.g. over 95% of measures in CMS quality programs have improved over the last three years), spending dollars more wisely (e.g. lowest cost growth in the last four years in over 50 years), and improving the health of the nation (e.g. decreased smoking rates). Our nation is moving rapidly toward accountable, alternative payment models, including the recent legislation to “fix the SGR,” and I have seen hospitalists lead progress towards adopting these models nationally and locally. A challenge for all of us is to accelerate the pace of positive change and relentlessly pursue improved patient outcomes and a higher performing health system. But I know hospitalists are up to this challenge.

Thank you for all the work that you do every day on behalf of your patients and a better health system.

As a hospitalist myself, I have seen firsthand the need for a healthcare system that provides better care, spends dollars more wisely, and keeps people healthier. I practice on weekends taking care of children, many of whom have multiple chronic conditions and fragile social support, and their families. I love patient care; however, too many times, we hospitalists see patients whose fragmented care results in poor outcomes and repeated hospitalizations.

In my current role at the Centers for Medicare and Medicaid Services (CMS), I am pleased to see that Secretary Burwell is confronting these problems head on, with concrete goals for shifting the equation in how we pay for care. Specifically, we announced the goal of moving 30% of payments by 2016 into alternative payment models such as accountable care organizations (ACOs) or bundled payments, where the provider is accountable for total cost of care and quality. We set the goal of 50% of payments in these models by 2018. In 2011, Medicare had essentially zero payments in these models, but by 2014, we have reached 20% and growing in alternative payment models. Hospitalists can play a significant role in this healthcare transformation, and several initiatives in CMS’ Innovation Center, which I lead, are relevant to our work.

Recently, a Department of Health and Human Services (HHS) report showed that an estimated 50,000 fewer patients died in hospitals, 1.3 million fewer adverse events and infections occurred, and approximately $12 billion in healthcare costs were saved as a result of a reduction in hospital-acquired conditions from 2010 to 2013. This progress toward a safer healthcare system occurred during a period of concerted attention directed by hospitals and hospitalists throughout the country at reducing adverse events. These efforts were also due in part to provisions of the Affordable Care Act such as Medicare payment incentives to improve the quality of care and the HHS Partnership for Patients initiative. The Partnership for Patients is a nationwide public-private collaboration that began in April 2011 with two main goals: Reduce preventable hospital-acquired conditions by 40% and 30-day readmissions by 20%. Since the Partnership for Patients was launched, the vast majority of U.S. hospitals and many other stakeholders have joined the collaborative effort and delivered results.

CMS is committed to making even greater progress toward keeping people as safe and healthy as possible. That is why we have launched a second round of Hospital Engagement Network (HEN) contracts to continue reducing preventable hospital-acquired conditions and readmissions. HEN funding will be available to award contracts to national, regional, or state hospital associations, large healthcare organizations, or national affinity organizations that will support hospitals in their efforts to reduce preventable hospital-acquired conditions and readmissions. In February, CMS posted a request for proposals for HEN contracts to continue the success achieved in improving patient safety.

The Partnership for Patients and HENs are just one part of an overall effort by HHS to deliver better care, spend dollars more wisely, and improve health. Initiatives like the Partnership for Patients, accountable care organizations, quality improvement organizations, and others have helped reduce hospital readmissions in Medicare by nearly 8% between January 2012 and December 2013—translating into 150,000 fewer readmissions. Hospitalists have played a major role in these improvements.

On a broader front, CMS is taking action to improve healthcare so patients and their families can get the best care possible. To this end, CMS is focused on three key areas: (1) improving the way providers and hospitals are paid, (2) improving and innovating in care delivery, and (3) sharing information more broadly with providers and hospitals, consumers, and others to support better decisions.

When it comes to improving the way providers are paid, we want to reward value and care coordination—rather than volume and care duplication. We have over 25 payment and service delivery models at the CMS Innovation Center, but I will call out three that are particularly relevant to hospitalists. First, the ACO program is demonstrating positive results. Medicare has over 400 ACOs serving almost eight million beneficiaries. The Pioneer ACO program evaluation results demonstrated over $380 million in savings and improved quality—for example, improvement in 28 out of 33 quality measures, including patient experience of care. Based on these results, this model was the first from the CMS Innovation Center to be certified by the CMS actuary, and the Secretary of Health and Human Services announced her intent to expand the model components as a permanent part of the Medicare program through rulemaking. Second, in the Bundled Payments for Care Improvement model, we have thousands of providers (e.g. hospitals, physician groups) in phase 1 determining how they might improve care and considering taking on financial risk. The model includes acute and post-acute care, such as a 90-day episode for hip and knee replacement. We have 500 providers, and more that are willing to take on two-sided financial risk will likely be added in the next quarter. Hospitalists have a large role to play in improving quality and reducing costs in this model. Finally, the State Innovation Model is driving state and local change. In this model, we are funding and partnering with states on comprehensive delivery system reform. Seventeen states are implementing interventions, and 21 states and territories are designing their plans. The state is encouraged to partner with payers, providers, employers, public health entities, and others in the state to strive within the whole state population for better care, smarter spending, and healthier people. Many states are implementing payment models such as ACOs and bundled payments in Medicaid and with private payers. Increasingly, hospital medicine groups are going to value-based in the quality and efficiency of care delivery, both within the hospital walls and for episodes of care. This will entail stronger linkages and teamwork, both within the hospital and with clinicians in the community. It will also require a much stronger focus on predicting which patients are at risk of decompensation and delivering tailored interventions, including care management and technology to monitor patients in the home and other settings.

To improve care delivery, we are supporting providers to find new ways to coordinate and integrate care. For example, discharging a patient from the hospital without clear instructions on how to take care of themselves at home, when they should take their medicines, or when to check back in with the doctor can lead to an unnecessary readmission back into the hospital. This is especially true of individuals who have complex illnesses or diseases that may be more difficult to manage. We are supporting care improvement through a variety of channels, including facilitating hospitals and community groups teaming up to share best practices, and we applaud the Society of Hospital Medicine’s BOOST program, which is focused on peer mentoring and improvement.

Finally, as we look to improve the way information is distributed, we are working to create more transparency on the cost and quality of care, to bring electronic health information to inform care, and to bring the most recent scientific evidence to the point of care so we can bolster clinical decision making. Necessary information needs to be available to the treating physician and patients across settings. We must continue to improve the interoperability and usability of electronic health records so that they can enable improvement and care delivery.

I hope that as hospitalists you will take a closer look at the HHS initiatives I’ve described here—and others—and consider becoming a participant. Hospital medicine physicians are already leading many of these initiatives and are a positive force for health system transformation. As I look back on my last four-plus years at CMS (which sometimes feel like 30 years), I am amazed by how much progress we have made in improving the quality of care (e.g. over 95% of measures in CMS quality programs have improved over the last three years), spending dollars more wisely (e.g. lowest cost growth in the last four years in over 50 years), and improving the health of the nation (e.g. decreased smoking rates). Our nation is moving rapidly toward accountable, alternative payment models, including the recent legislation to “fix the SGR,” and I have seen hospitalists lead progress towards adopting these models nationally and locally. A challenge for all of us is to accelerate the pace of positive change and relentlessly pursue improved patient outcomes and a higher performing health system. But I know hospitalists are up to this challenge.

Thank you for all the work that you do every day on behalf of your patients and a better health system.