QI Initiatives

Dr. Frost

In my previous column, we considered a comprehensive and practical definition of accountability advanced by Connors, Smith, and Hickman in their well-written book “The Oz Principle.”¹ In order to apply these concepts successfully to HM practice, it is useful to conceive of accountability as a process that should be approached in a step-wise manner. In this month’s column, we will explore the “process of accountability” by considering how “The Oz Principle” can further assist hospitalists in accomplishing what is expected of them as agents of high-quality, cost-effective healthcare delivery.

The Process

Recall that Connors and colleagues define accountability as “a personal choice to rise above one’s circumstances, and demonstrate ownership necessary for achieving results.” Such a definition empowers us to anticipate the future by proactively avoiding problems versus retrospectively explaining why problems occurred. To apply this definition in our daily lives, we must contemplate how to proactively avoid problems. This can be accomplished by following a process described as the four-step approach: “see it, own it, solve it, and do it.”

Step No. 1 on the road to accountability requires that hospitalists be aware of issues in their external environments that affect their practice, and is referred to by Connors et al as “seeing it.” As it concerns healthcare reform, Step 1 requires that hospitalists educate themselves about such keystone reform initiatives as value-based purchasing and the public reporting of performance. Initiatives such as these are centerpieces of care delivery reform, and will occur irrespective of the fate of such legislation as the Affordable Care Act. Clinicians thus must understand the features of these initiatives, and appreciate how policies and programs emanating from them will necessitate changes in medical practice.

There are innumerable resources available to assist with understanding these concepts. If you have yet to do so, I encourage you to explore the hospital value-based purchasing (HVBP) toolkit on SHM’s website (www.hospitalmedicine.org/hvbp). Additionally, in order to appreciate the power of public performance reporting, please review the Hospital Compare and Physician Compare pages on the Centers for Medicare & Medicaid Services (CMS) website. Knowledge is power, and in this situation it is essential to ensure your continued professional success. “The Oz Principle” admonishes that “if changes are inevitable, then those who resist them will inevitably fail.” Please ensure that failure is not an option by seeking first to understand how healthcare reform will impact your practice.

Step No. 2 on the road to accountability requires that hospitalists sincerely accept healthcare challenges as theirs to personally embrace. Connors et al define this step as “owning it.” In order to truly own our country’s problem of substandard healthcare delivery, “The Oz Principle” suggests that the profession of medicine must “accept ownership of past and present behaviors that keep it mired in current circumstances, (as this is the only way it can) hope to improve its future situation.”

This is challenging for hospitalists, as most HM practitioners are only a few years removed from completion of clinical training. It is thus tempting for young hospitalists to refuse ownership of healthcare system problems as ones that they personally created. Although this position is understandable, we should not accept it. It might be true that a single physician’s practice contributed little to our current overall healthcare challenges; however, we are all members of the same profession, and a collective identity when it comes to ownership of healthcare system problems is essential to our ability to eventually solve these problems. Complaining that our predecessors are responsible for our present maladies will stifle improvement efforts by creating a culture of victimization. According to “The Oz Principle,” “owning our circumstances gives us the strength to overcome the powerlessness that comes from being a victim, and allows us to move forward and achieve more satisfying results.”

Step No. 3 mandates that hospitalists capitalize on reform opportunities by designing process-improvement strategies through critical analysis and innovative thinking. Connors and colleagues define this step as “solving it.” Contributing to “solving it” is a fundamental job responsibility of every hospitalist, and not the exclusive province of hospitalist leaders. HM clinicians focusing primarily on bedside care must actively participate in the process of solving the problems that currently plague our healthcare system.

To do so should not necessitate an overly burdensome time commitment. It is often sufficient to simply attend and actively participate in your team and hospital staff meetings. At other times, it might be necessary for you to volunteer an hour or so once a month in service to a hospital committee or a team activity. Contributing your observations and thoughts in these forums is essential to creating effective solutions. Although you might not be the ultimate decision-maker, you have an obligation to build a broad collective understanding of the issues through the voicing of your opinions.

According to “The Oz Principle,” “solving it is not an extra activity, but part of the job.” Each of us has a professional obligation to identify better methods to deliver high-value healthcare. Doing so necessitates that we each identify improvement opportunities by critically evaluating the success of our current situations. We must then, at a minimum, share our thoughts with the decision-makers responsible for enacting improvement strategies.

The fourth and final step on the road to accountability requires that hospitalists successfully implement solutions and ensure that the desired results are achieved. Connors and colleagues define this step as “doing it.” Successfully “doing it” to enhance healthcare quality and efficiency necessitates hard work, because rarely is it sufficient to simply implement a healthcare improvement project. In order to achieve true results, projects must be actively managed after initial deployment, tweaked to become better, then redeployed and reanalyzed to ensure effectiveness.

In healthcare, it is tempting to become satisfied with simply deploying processes, as much of the healthcare reform work done to date has focused on payment for process improvements. This, however, will change in the near future. For example, Medicare’s hospital value-based purchasing program (see “Value-Based Purchasing Raises the Stakes,” January 2012, p. 1) will incorporate outcome measures as soon as 2014. We must, therefore, get into the habit of aggressively managing the processes that we operate through diligent data collection and subsequent decision-making that is informed by actionable information.

Conclusion

Holding ourselves accountable for enacting healthcare reform initiatives to improve the care of our patients will be difficult. The task is made easier by employing a process to guide our efforts. “The Oz Principle” teaches us a succinct, four-step approach. Applying this approach to changes mandated by healthcare reform will make it easier for hospitalists to transcend their current dysfunctional situations and achieve demonstrable healthcare system improvements for the betterment of patient care.

Dr. Frost is president of SHM.

Reference

1. Connors R, Smith T, Hickman C. The Oz Principle: Getting Results Through Individual and Organizational Accountability. New York: Portfolio; 2004.

Dr. Frost

In my previous column, we considered a comprehensive and practical definition of accountability advanced by Connors, Smith, and Hickman in their well-written book “The Oz Principle.”¹ In order to apply these concepts successfully to HM practice, it is useful to conceive of accountability as a process that should be approached in a step-wise manner. In this month’s column, we will explore the “process of accountability” by considering how “The Oz Principle” can further assist hospitalists in accomplishing what is expected of them as agents of high-quality, cost-effective healthcare delivery.

The Process

Recall that Connors and colleagues define accountability as “a personal choice to rise above one’s circumstances, and demonstrate ownership necessary for achieving results.” Such a definition empowers us to anticipate the future by proactively avoiding problems versus retrospectively explaining why problems occurred. To apply this definition in our daily lives, we must contemplate how to proactively avoid problems. This can be accomplished by following a process described as the four-step approach: “see it, own it, solve it, and do it.”

Step No. 1 on the road to accountability requires that hospitalists be aware of issues in their external environments that affect their practice, and is referred to by Connors et al as “seeing it.” As it concerns healthcare reform, Step 1 requires that hospitalists educate themselves about such keystone reform initiatives as value-based purchasing and the public reporting of performance. Initiatives such as these are centerpieces of care delivery reform, and will occur irrespective of the fate of such legislation as the Affordable Care Act. Clinicians thus must understand the features of these initiatives, and appreciate how policies and programs emanating from them will necessitate changes in medical practice.

There are innumerable resources available to assist with understanding these concepts. If you have yet to do so, I encourage you to explore the hospital value-based purchasing (HVBP) toolkit on SHM’s website (www.hospitalmedicine.org/hvbp). Additionally, in order to appreciate the power of public performance reporting, please review the Hospital Compare and Physician Compare pages on the Centers for Medicare & Medicaid Services (CMS) website. Knowledge is power, and in this situation it is essential to ensure your continued professional success. “The Oz Principle” admonishes that “if changes are inevitable, then those who resist them will inevitably fail.” Please ensure that failure is not an option by seeking first to understand how healthcare reform will impact your practice.

Step No. 2 on the road to accountability requires that hospitalists sincerely accept healthcare challenges as theirs to personally embrace. Connors et al define this step as “owning it.” In order to truly own our country’s problem of substandard healthcare delivery, “The Oz Principle” suggests that the profession of medicine must “accept ownership of past and present behaviors that keep it mired in current circumstances, (as this is the only way it can) hope to improve its future situation.”

This is challenging for hospitalists, as most HM practitioners are only a few years removed from completion of clinical training. It is thus tempting for young hospitalists to refuse ownership of healthcare system problems as ones that they personally created. Although this position is understandable, we should not accept it. It might be true that a single physician’s practice contributed little to our current overall healthcare challenges; however, we are all members of the same profession, and a collective identity when it comes to ownership of healthcare system problems is essential to our ability to eventually solve these problems. Complaining that our predecessors are responsible for our present maladies will stifle improvement efforts by creating a culture of victimization. According to “The Oz Principle,” “owning our circumstances gives us the strength to overcome the powerlessness that comes from being a victim, and allows us to move forward and achieve more satisfying results.”

Step No. 3 mandates that hospitalists capitalize on reform opportunities by designing process-improvement strategies through critical analysis and innovative thinking. Connors and colleagues define this step as “solving it.” Contributing to “solving it” is a fundamental job responsibility of every hospitalist, and not the exclusive province of hospitalist leaders. HM clinicians focusing primarily on bedside care must actively participate in the process of solving the problems that currently plague our healthcare system.

To do so should not necessitate an overly burdensome time commitment. It is often sufficient to simply attend and actively participate in your team and hospital staff meetings. At other times, it might be necessary for you to volunteer an hour or so once a month in service to a hospital committee or a team activity. Contributing your observations and thoughts in these forums is essential to creating effective solutions. Although you might not be the ultimate decision-maker, you have an obligation to build a broad collective understanding of the issues through the voicing of your opinions.

According to “The Oz Principle,” “solving it is not an extra activity, but part of the job.” Each of us has a professional obligation to identify better methods to deliver high-value healthcare. Doing so necessitates that we each identify improvement opportunities by critically evaluating the success of our current situations. We must then, at a minimum, share our thoughts with the decision-makers responsible for enacting improvement strategies.

The fourth and final step on the road to accountability requires that hospitalists successfully implement solutions and ensure that the desired results are achieved. Connors and colleagues define this step as “doing it.” Successfully “doing it” to enhance healthcare quality and efficiency necessitates hard work, because rarely is it sufficient to simply implement a healthcare improvement project. In order to achieve true results, projects must be actively managed after initial deployment, tweaked to become better, then redeployed and reanalyzed to ensure effectiveness.

In healthcare, it is tempting to become satisfied with simply deploying processes, as much of the healthcare reform work done to date has focused on payment for process improvements. This, however, will change in the near future. For example, Medicare’s hospital value-based purchasing program (see “Value-Based Purchasing Raises the Stakes,” January 2012, p. 1) will incorporate outcome measures as soon as 2014. We must, therefore, get into the habit of aggressively managing the processes that we operate through diligent data collection and subsequent decision-making that is informed by actionable information.

Conclusion

Holding ourselves accountable for enacting healthcare reform initiatives to improve the care of our patients will be difficult. The task is made easier by employing a process to guide our efforts. “The Oz Principle” teaches us a succinct, four-step approach. Applying this approach to changes mandated by healthcare reform will make it easier for hospitalists to transcend their current dysfunctional situations and achieve demonstrable healthcare system improvements for the betterment of patient care.

Dr. Frost is president of SHM.

Reference

1. Connors R, Smith T, Hickman C. The Oz Principle: Getting Results Through Individual and Organizational Accountability. New York: Portfolio; 2004.

Dr. Frost

In my previous column, we considered a comprehensive and practical definition of accountability advanced by Connors, Smith, and Hickman in their well-written book “The Oz Principle.”¹ In order to apply these concepts successfully to HM practice, it is useful to conceive of accountability as a process that should be approached in a step-wise manner. In this month’s column, we will explore the “process of accountability” by considering how “The Oz Principle” can further assist hospitalists in accomplishing what is expected of them as agents of high-quality, cost-effective healthcare delivery.

The Process

Recall that Connors and colleagues define accountability as “a personal choice to rise above one’s circumstances, and demonstrate ownership necessary for achieving results.” Such a definition empowers us to anticipate the future by proactively avoiding problems versus retrospectively explaining why problems occurred. To apply this definition in our daily lives, we must contemplate how to proactively avoid problems. This can be accomplished by following a process described as the four-step approach: “see it, own it, solve it, and do it.”

Step No. 1 on the road to accountability requires that hospitalists be aware of issues in their external environments that affect their practice, and is referred to by Connors et al as “seeing it.” As it concerns healthcare reform, Step 1 requires that hospitalists educate themselves about such keystone reform initiatives as value-based purchasing and the public reporting of performance. Initiatives such as these are centerpieces of care delivery reform, and will occur irrespective of the fate of such legislation as the Affordable Care Act. Clinicians thus must understand the features of these initiatives, and appreciate how policies and programs emanating from them will necessitate changes in medical practice.

There are innumerable resources available to assist with understanding these concepts. If you have yet to do so, I encourage you to explore the hospital value-based purchasing (HVBP) toolkit on SHM’s website (www.hospitalmedicine.org/hvbp). Additionally, in order to appreciate the power of public performance reporting, please review the Hospital Compare and Physician Compare pages on the Centers for Medicare & Medicaid Services (CMS) website. Knowledge is power, and in this situation it is essential to ensure your continued professional success. “The Oz Principle” admonishes that “if changes are inevitable, then those who resist them will inevitably fail.” Please ensure that failure is not an option by seeking first to understand how healthcare reform will impact your practice.

Step No. 2 on the road to accountability requires that hospitalists sincerely accept healthcare challenges as theirs to personally embrace. Connors et al define this step as “owning it.” In order to truly own our country’s problem of substandard healthcare delivery, “The Oz Principle” suggests that the profession of medicine must “accept ownership of past and present behaviors that keep it mired in current circumstances, (as this is the only way it can) hope to improve its future situation.”

This is challenging for hospitalists, as most HM practitioners are only a few years removed from completion of clinical training. It is thus tempting for young hospitalists to refuse ownership of healthcare system problems as ones that they personally created. Although this position is understandable, we should not accept it. It might be true that a single physician’s practice contributed little to our current overall healthcare challenges; however, we are all members of the same profession, and a collective identity when it comes to ownership of healthcare system problems is essential to our ability to eventually solve these problems. Complaining that our predecessors are responsible for our present maladies will stifle improvement efforts by creating a culture of victimization. According to “The Oz Principle,” “owning our circumstances gives us the strength to overcome the powerlessness that comes from being a victim, and allows us to move forward and achieve more satisfying results.”

Step No. 3 mandates that hospitalists capitalize on reform opportunities by designing process-improvement strategies through critical analysis and innovative thinking. Connors and colleagues define this step as “solving it.” Contributing to “solving it” is a fundamental job responsibility of every hospitalist, and not the exclusive province of hospitalist leaders. HM clinicians focusing primarily on bedside care must actively participate in the process of solving the problems that currently plague our healthcare system.

To do so should not necessitate an overly burdensome time commitment. It is often sufficient to simply attend and actively participate in your team and hospital staff meetings. At other times, it might be necessary for you to volunteer an hour or so once a month in service to a hospital committee or a team activity. Contributing your observations and thoughts in these forums is essential to creating effective solutions. Although you might not be the ultimate decision-maker, you have an obligation to build a broad collective understanding of the issues through the voicing of your opinions.

According to “The Oz Principle,” “solving it is not an extra activity, but part of the job.” Each of us has a professional obligation to identify better methods to deliver high-value healthcare. Doing so necessitates that we each identify improvement opportunities by critically evaluating the success of our current situations. We must then, at a minimum, share our thoughts with the decision-makers responsible for enacting improvement strategies.

The fourth and final step on the road to accountability requires that hospitalists successfully implement solutions and ensure that the desired results are achieved. Connors and colleagues define this step as “doing it.” Successfully “doing it” to enhance healthcare quality and efficiency necessitates hard work, because rarely is it sufficient to simply implement a healthcare improvement project. In order to achieve true results, projects must be actively managed after initial deployment, tweaked to become better, then redeployed and reanalyzed to ensure effectiveness.

In healthcare, it is tempting to become satisfied with simply deploying processes, as much of the healthcare reform work done to date has focused on payment for process improvements. This, however, will change in the near future. For example, Medicare’s hospital value-based purchasing program (see “Value-Based Purchasing Raises the Stakes,” January 2012, p. 1) will incorporate outcome measures as soon as 2014. We must, therefore, get into the habit of aggressively managing the processes that we operate through diligent data collection and subsequent decision-making that is informed by actionable information.

Conclusion

Holding ourselves accountable for enacting healthcare reform initiatives to improve the care of our patients will be difficult. The task is made easier by employing a process to guide our efforts. “The Oz Principle” teaches us a succinct, four-step approach. Applying this approach to changes mandated by healthcare reform will make it easier for hospitalists to transcend their current dysfunctional situations and achieve demonstrable healthcare system improvements for the betterment of patient care.

Dr. Frost is president of SHM.

Reference

1. Connors R, Smith T, Hickman C. The Oz Principle: Getting Results Through Individual and Organizational Accountability. New York: Portfolio; 2004.

Dr. Hospitalist

One of our providers wants to use adult hospitalists for coverage of inpatient orthopedic surgery patients. Is this acceptable practice? Are there qualifiers?

—Libby Gardner

Dr. Hospitalist responds:

Let’s see how far we can tackle this open-ended question. There has been lots of discussion on the topic of comanagement in the past by people eminently more qualified than I am. Still, it never hurts to take a fresh look at things.

For one, on the subject of admissions, I am a firm believer that hospitalists should admit all adult hip fractures. The overwhelming majority of the time, these patients are elderly with comorbid conditions. Sure, they are going to get their hip fixed, because the alternative usually is unacceptable, but some thought needs to go into the process.

The orthopedic surgeon sees a hip that needs fixing and not much else. When such issues as renal failure, afib, congestive heart failure, prior DVT, dementia, and all the other common conditions are present, we as adult hospitalists should take charge of the case. That is the best way to ensure that the patient receives optimal medical care and the documentation that goes along with it. I love our orthopedic surgeons, but I don’t want them primarily admitting, managing, and discharging my elderly patients. Let the surgeon do what they do best—operate—and leave the rest to us as hospitalists.

On the subject of orthopedic trauma, I take the exact opposite approach—this is not something where we have daily expertise. A young, healthy patient with trauma should be admitted by the orthopedic service; that patient population’s complications are much more likely to be directly related to their trauma.

When it comes to elective surgery when the admitting surgeon (orthopedic or otherwise) wants the help of a hospitalist, then I think it is of paramount importance to establish clear “rules of engagement” (see “The Comanagement Conundrum,” April 2011, p. 1). I think with good expectations, you can have a fantastic relationship with your surgeons. Without them, it becomes a nightmare. As a real-life example, here are my HM group’s rules for elective orthopedic surgery:

• Orthopedics handles all pain medications and VTE prophylaxis, including discharge prescriptions;
• Medicine does the admission and medication reconciliation (“med rec”) at discharge;
• There is shared discussion on the need for transfusion; and
• There is shared discussion on the need for VTE prophylaxis when a patient already is on chronic anticoagulation.

We do not vary from this protocol. I never adjust a patient’s pain medications—even the floor nurses know this. Because I’m doing the admit and med rec, it also means that the patient doesn’t have their HCTZ continued after 600cc of EBL and spinal anesthesia. It works because the rules are clear and the communication is consistent.

This does not mean that we cover the orthopedic service at night; they are equally responsible for their patients under the items outlined above. In my view—and this might sound simplistic—the surgeon caused the post-op pain, so they should be responsible for managing it. With regard to VTE prophylaxis, I might take a more nuanced view, but for our surgeons, they own the wound and the post-op follow-up, so they get the choice on what agent to use.

Would I accept an arrangement in which I covered all the orthopedic issues out of regular hours? Nope—not when they have primary responsibility for the case; they should always be directly available to the nurse. I think that anything else would be a system ripe for abuse.

Our exact rules will not work for every situation, but I would strongly encourage the two basic tenets from above: No. 1, the hospitalist should primarily admit and manage elderly hip fractures, and No. 2, there should be clear rules of engagement with your orthopedic or surgery group. It’s a discussion worth having during daylight hours, because trying to figure out the rules at 3 in the morning rarely ends well.

Dr. Hospitalist

One of our providers wants to use adult hospitalists for coverage of inpatient orthopedic surgery patients. Is this acceptable practice? Are there qualifiers?

—Libby Gardner

Dr. Hospitalist responds:

Let’s see how far we can tackle this open-ended question. There has been lots of discussion on the topic of comanagement in the past by people eminently more qualified than I am. Still, it never hurts to take a fresh look at things.

For one, on the subject of admissions, I am a firm believer that hospitalists should admit all adult hip fractures. The overwhelming majority of the time, these patients are elderly with comorbid conditions. Sure, they are going to get their hip fixed, because the alternative usually is unacceptable, but some thought needs to go into the process.

The orthopedic surgeon sees a hip that needs fixing and not much else. When such issues as renal failure, afib, congestive heart failure, prior DVT, dementia, and all the other common conditions are present, we as adult hospitalists should take charge of the case. That is the best way to ensure that the patient receives optimal medical care and the documentation that goes along with it. I love our orthopedic surgeons, but I don’t want them primarily admitting, managing, and discharging my elderly patients. Let the surgeon do what they do best—operate—and leave the rest to us as hospitalists.

On the subject of orthopedic trauma, I take the exact opposite approach—this is not something where we have daily expertise. A young, healthy patient with trauma should be admitted by the orthopedic service; that patient population’s complications are much more likely to be directly related to their trauma.

When it comes to elective surgery when the admitting surgeon (orthopedic or otherwise) wants the help of a hospitalist, then I think it is of paramount importance to establish clear “rules of engagement” (see “The Comanagement Conundrum,” April 2011, p. 1). I think with good expectations, you can have a fantastic relationship with your surgeons. Without them, it becomes a nightmare. As a real-life example, here are my HM group’s rules for elective orthopedic surgery:

• Orthopedics handles all pain medications and VTE prophylaxis, including discharge prescriptions;
• Medicine does the admission and medication reconciliation (“med rec”) at discharge;
• There is shared discussion on the need for transfusion; and
• There is shared discussion on the need for VTE prophylaxis when a patient already is on chronic anticoagulation.

We do not vary from this protocol. I never adjust a patient’s pain medications—even the floor nurses know this. Because I’m doing the admit and med rec, it also means that the patient doesn’t have their HCTZ continued after 600cc of EBL and spinal anesthesia. It works because the rules are clear and the communication is consistent.

This does not mean that we cover the orthopedic service at night; they are equally responsible for their patients under the items outlined above. In my view—and this might sound simplistic—the surgeon caused the post-op pain, so they should be responsible for managing it. With regard to VTE prophylaxis, I might take a more nuanced view, but for our surgeons, they own the wound and the post-op follow-up, so they get the choice on what agent to use.

Would I accept an arrangement in which I covered all the orthopedic issues out of regular hours? Nope—not when they have primary responsibility for the case; they should always be directly available to the nurse. I think that anything else would be a system ripe for abuse.

Our exact rules will not work for every situation, but I would strongly encourage the two basic tenets from above: No. 1, the hospitalist should primarily admit and manage elderly hip fractures, and No. 2, there should be clear rules of engagement with your orthopedic or surgery group. It’s a discussion worth having during daylight hours, because trying to figure out the rules at 3 in the morning rarely ends well.

Dr. Hospitalist

One of our providers wants to use adult hospitalists for coverage of inpatient orthopedic surgery patients. Is this acceptable practice? Are there qualifiers?

—Libby Gardner

Dr. Hospitalist responds:

Let’s see how far we can tackle this open-ended question. There has been lots of discussion on the topic of comanagement in the past by people eminently more qualified than I am. Still, it never hurts to take a fresh look at things.

For one, on the subject of admissions, I am a firm believer that hospitalists should admit all adult hip fractures. The overwhelming majority of the time, these patients are elderly with comorbid conditions. Sure, they are going to get their hip fixed, because the alternative usually is unacceptable, but some thought needs to go into the process.

The orthopedic surgeon sees a hip that needs fixing and not much else. When such issues as renal failure, afib, congestive heart failure, prior DVT, dementia, and all the other common conditions are present, we as adult hospitalists should take charge of the case. That is the best way to ensure that the patient receives optimal medical care and the documentation that goes along with it. I love our orthopedic surgeons, but I don’t want them primarily admitting, managing, and discharging my elderly patients. Let the surgeon do what they do best—operate—and leave the rest to us as hospitalists.

On the subject of orthopedic trauma, I take the exact opposite approach—this is not something where we have daily expertise. A young, healthy patient with trauma should be admitted by the orthopedic service; that patient population’s complications are much more likely to be directly related to their trauma.

When it comes to elective surgery when the admitting surgeon (orthopedic or otherwise) wants the help of a hospitalist, then I think it is of paramount importance to establish clear “rules of engagement” (see “The Comanagement Conundrum,” April 2011, p. 1). I think with good expectations, you can have a fantastic relationship with your surgeons. Without them, it becomes a nightmare. As a real-life example, here are my HM group’s rules for elective orthopedic surgery:

• Orthopedics handles all pain medications and VTE prophylaxis, including discharge prescriptions;
• Medicine does the admission and medication reconciliation (“med rec”) at discharge;
• There is shared discussion on the need for transfusion; and
• There is shared discussion on the need for VTE prophylaxis when a patient already is on chronic anticoagulation.

We do not vary from this protocol. I never adjust a patient’s pain medications—even the floor nurses know this. Because I’m doing the admit and med rec, it also means that the patient doesn’t have their HCTZ continued after 600cc of EBL and spinal anesthesia. It works because the rules are clear and the communication is consistent.

This does not mean that we cover the orthopedic service at night; they are equally responsible for their patients under the items outlined above. In my view—and this might sound simplistic—the surgeon caused the post-op pain, so they should be responsible for managing it. With regard to VTE prophylaxis, I might take a more nuanced view, but for our surgeons, they own the wound and the post-op follow-up, so they get the choice on what agent to use.

Would I accept an arrangement in which I covered all the orthopedic issues out of regular hours? Nope—not when they have primary responsibility for the case; they should always be directly available to the nurse. I think that anything else would be a system ripe for abuse.

Our exact rules will not work for every situation, but I would strongly encourage the two basic tenets from above: No. 1, the hospitalist should primarily admit and manage elderly hip fractures, and No. 2, there should be clear rules of engagement with your orthopedic or surgery group. It’s a discussion worth having during daylight hours, because trying to figure out the rules at 3 in the morning rarely ends well.

Laura Vento, MSN, RN, first took an interest in the teach-back process when her father had a liver transplant. Following a prolonged hospitalization, Vento’s dad was sent home with little understanding of how to take care of himself; most notably, he had no wound-care education. And when she reviewed his medications, Vento found serious discrepancies with his anti-rejection drug prescriptions.

Her mind was filled with questions: “What kind of transition of care was this? How well am I as a nurse preparing my patients for discharge?” says Vento, a clinical nurse leader on an acute-care medical unit at the University of California at San Diego (UCSD) Medical Center. “I have since learned that shocking numbers of [hospitalized] patients receive little or no education about how to care for themselves.”

About the same time as her dad’s recovery, Vento’s nurse manager heard about SHM’s Project BOOST. They applied for a grant to support training hospital staff in the teach-back system, an integral Project BOOST strategy for educating patients about their post-discharge care needs.

At UCSD, teach-back was incorporated into a larger process of improving care transitions and preventing avoidable readmissions. In addition to the new communication techniques, the process also includes risk assessment, post-discharge follow-up phone calls, and other strategies, supported by a hospitalwide, multidisciplinary education council.

Following a four-hour teach-back curriculum presented to nursing staff, “we did role modeling and role plays,” Vento says. “We followed up with a teach-back coach, me, going to patients’ bedsides with the nurses, because the workshop content alone was not enough without the patient interaction. We needed to verify the nurses’ competency.”

From its initial piloting on two units, teach-back is being hard-wired into UCSD’s electronic health record, with guides to ask for five basic teach-back checks: reason for admission, self-care needs, when to call a physician or 9ll, scheduled follow-up appointments, and changes to the medication list. The education council is now rolling out teach-back to nurses across the system. For her efforts in disseminating the strategy the past two years, Vento was named the UCSD health system’s Nurse of the Year for 2011.

And yet, despite this systemwide recognition, “the focus up to this point has mostly been on the nurses, who are responsible for the bulk of patient education,” says UCSD hospitalist and Project BOOST mentor Jennifer Quartarolo, MD, SFHM. “It’s probably been underutilized by other members of the care team.”

Despite competing demands on physicians’ time, Dr. Quartarolo says hospitalists need to improve their patient education skills. “Teach-back can help us effectively communicate the key teaching points that we’d like our hospitalized patients and their caregivers to take home with them,” she says.

Laura Vento, MSN, RN, first took an interest in the teach-back process when her father had a liver transplant. Following a prolonged hospitalization, Vento’s dad was sent home with little understanding of how to take care of himself; most notably, he had no wound-care education. And when she reviewed his medications, Vento found serious discrepancies with his anti-rejection drug prescriptions.

Her mind was filled with questions: “What kind of transition of care was this? How well am I as a nurse preparing my patients for discharge?” says Vento, a clinical nurse leader on an acute-care medical unit at the University of California at San Diego (UCSD) Medical Center. “I have since learned that shocking numbers of [hospitalized] patients receive little or no education about how to care for themselves.”

About the same time as her dad’s recovery, Vento’s nurse manager heard about SHM’s Project BOOST. They applied for a grant to support training hospital staff in the teach-back system, an integral Project BOOST strategy for educating patients about their post-discharge care needs.

At UCSD, teach-back was incorporated into a larger process of improving care transitions and preventing avoidable readmissions. In addition to the new communication techniques, the process also includes risk assessment, post-discharge follow-up phone calls, and other strategies, supported by a hospitalwide, multidisciplinary education council.

Following a four-hour teach-back curriculum presented to nursing staff, “we did role modeling and role plays,” Vento says. “We followed up with a teach-back coach, me, going to patients’ bedsides with the nurses, because the workshop content alone was not enough without the patient interaction. We needed to verify the nurses’ competency.”

From its initial piloting on two units, teach-back is being hard-wired into UCSD’s electronic health record, with guides to ask for five basic teach-back checks: reason for admission, self-care needs, when to call a physician or 9ll, scheduled follow-up appointments, and changes to the medication list. The education council is now rolling out teach-back to nurses across the system. For her efforts in disseminating the strategy the past two years, Vento was named the UCSD health system’s Nurse of the Year for 2011.

And yet, despite this systemwide recognition, “the focus up to this point has mostly been on the nurses, who are responsible for the bulk of patient education,” says UCSD hospitalist and Project BOOST mentor Jennifer Quartarolo, MD, SFHM. “It’s probably been underutilized by other members of the care team.”

Despite competing demands on physicians’ time, Dr. Quartarolo says hospitalists need to improve their patient education skills. “Teach-back can help us effectively communicate the key teaching points that we’d like our hospitalized patients and their caregivers to take home with them,” she says.

Laura Vento, MSN, RN, first took an interest in the teach-back process when her father had a liver transplant. Following a prolonged hospitalization, Vento’s dad was sent home with little understanding of how to take care of himself; most notably, he had no wound-care education. And when she reviewed his medications, Vento found serious discrepancies with his anti-rejection drug prescriptions.

Her mind was filled with questions: “What kind of transition of care was this? How well am I as a nurse preparing my patients for discharge?” says Vento, a clinical nurse leader on an acute-care medical unit at the University of California at San Diego (UCSD) Medical Center. “I have since learned that shocking numbers of [hospitalized] patients receive little or no education about how to care for themselves.”

About the same time as her dad’s recovery, Vento’s nurse manager heard about SHM’s Project BOOST. They applied for a grant to support training hospital staff in the teach-back system, an integral Project BOOST strategy for educating patients about their post-discharge care needs.

At UCSD, teach-back was incorporated into a larger process of improving care transitions and preventing avoidable readmissions. In addition to the new communication techniques, the process also includes risk assessment, post-discharge follow-up phone calls, and other strategies, supported by a hospitalwide, multidisciplinary education council.

Following a four-hour teach-back curriculum presented to nursing staff, “we did role modeling and role plays,” Vento says. “We followed up with a teach-back coach, me, going to patients’ bedsides with the nurses, because the workshop content alone was not enough without the patient interaction. We needed to verify the nurses’ competency.”

From its initial piloting on two units, teach-back is being hard-wired into UCSD’s electronic health record, with guides to ask for five basic teach-back checks: reason for admission, self-care needs, when to call a physician or 9ll, scheduled follow-up appointments, and changes to the medication list. The education council is now rolling out teach-back to nurses across the system. For her efforts in disseminating the strategy the past two years, Vento was named the UCSD health system’s Nurse of the Year for 2011.

And yet, despite this systemwide recognition, “the focus up to this point has mostly been on the nurses, who are responsible for the bulk of patient education,” says UCSD hospitalist and Project BOOST mentor Jennifer Quartarolo, MD, SFHM. “It’s probably been underutilized by other members of the care team.”

Despite competing demands on physicians’ time, Dr. Quartarolo says hospitalists need to improve their patient education skills. “Teach-back can help us effectively communicate the key teaching points that we’d like our hospitalized patients and their caregivers to take home with them,” she says.

Although a recently released study of Medicare data uncovers little progress in reducing hospital readmissions, and the Oct. 1 deadline to implement CMS’ Hospital Readmissions Reduction Program looms, Carolyn Clancy, MD, director of the Agency for Healthcare Research and Quality (AHRQ), says she's not worried about the ability of America’s hospitalists to rise to the occasion and get a handle on the problem.

Dr. Clancy recently wrote a commentary outlining the government's approach to controlling readmissions, stating that taking aim at readmissions is 1) an integral component of its value-based purchasing program and 2) is an opportunity for improving hospital quality and patient safety.

"Hospitalists are often on the receiving end of hospitalizations resulting from poor coordination of care. I think it would be very exciting to be part of the solution," Dr. Clancy says. She says she observed firsthand during a recent hospital stay how hospitalists helped her to think about how she should care for herself after returning home. But her father suffered a needless rehospitalization when important information (how much Coumadin to take) was miscommunicated in a post-discharge follow-up phone call, causing him to start bleeding.

"Hospitalists who want to embrace the challenge will find a phenomenal amount of information on Innovations Exchange, where people from all over America are sharing their clinical innovations."

Dr. Clancy says she hopes AHRQ-supported tools and studies "will make it easier for hospitals to do the right thing."

Although a recently released study of Medicare data uncovers little progress in reducing hospital readmissions, and the Oct. 1 deadline to implement CMS’ Hospital Readmissions Reduction Program looms, Carolyn Clancy, MD, director of the Agency for Healthcare Research and Quality (AHRQ), says she's not worried about the ability of America’s hospitalists to rise to the occasion and get a handle on the problem.

Dr. Clancy recently wrote a commentary outlining the government's approach to controlling readmissions, stating that taking aim at readmissions is 1) an integral component of its value-based purchasing program and 2) is an opportunity for improving hospital quality and patient safety.

"Hospitalists are often on the receiving end of hospitalizations resulting from poor coordination of care. I think it would be very exciting to be part of the solution," Dr. Clancy says. She says she observed firsthand during a recent hospital stay how hospitalists helped her to think about how she should care for herself after returning home. But her father suffered a needless rehospitalization when important information (how much Coumadin to take) was miscommunicated in a post-discharge follow-up phone call, causing him to start bleeding.

"Hospitalists who want to embrace the challenge will find a phenomenal amount of information on Innovations Exchange, where people from all over America are sharing their clinical innovations."

Dr. Clancy says she hopes AHRQ-supported tools and studies "will make it easier for hospitals to do the right thing."

Although a recently released study of Medicare data uncovers little progress in reducing hospital readmissions, and the Oct. 1 deadline to implement CMS’ Hospital Readmissions Reduction Program looms, Carolyn Clancy, MD, director of the Agency for Healthcare Research and Quality (AHRQ), says she's not worried about the ability of America’s hospitalists to rise to the occasion and get a handle on the problem.

Dr. Clancy recently wrote a commentary outlining the government's approach to controlling readmissions, stating that taking aim at readmissions is 1) an integral component of its value-based purchasing program and 2) is an opportunity for improving hospital quality and patient safety.

"Hospitalists are often on the receiving end of hospitalizations resulting from poor coordination of care. I think it would be very exciting to be part of the solution," Dr. Clancy says. She says she observed firsthand during a recent hospital stay how hospitalists helped her to think about how she should care for herself after returning home. But her father suffered a needless rehospitalization when important information (how much Coumadin to take) was miscommunicated in a post-discharge follow-up phone call, causing him to start bleeding.

"Hospitalists who want to embrace the challenge will find a phenomenal amount of information on Innovations Exchange, where people from all over America are sharing their clinical innovations."

Dr. Clancy says she hopes AHRQ-supported tools and studies "will make it easier for hospitals to do the right thing."

Just as the federal government is introducing several new programs to promote the recruitment, training, and placement of more primary-care providers, other efforts are being threatened with funding decreases or elimination.

One, the Children’s Hospitals Graduate Medical Education program, distributed $268 million in pediatric training funds to 55 freestanding children’s teaching hospitals in fiscal-year 2012. The program, however, was zeroed out in President Obama’s initial budget proposal last year, and the president’s fiscal-year 2013 budget proposal recommends slashing the program’s annual funding by two-thirds to $88 million.

Kathleen Klink, MD, director of the Division of Medicine and Dentistry in the federal Health Resources and Services Administration, also points to the Title VII Area Health Education Center program as an example of government-funded assistance. The competitive grant process supports innovation and access to care for vulnerable populations, in part by improving the primary-care workforce’s geographic and ethnic distribution. Some of the grantees introduce high school students to medical careers, while others recruit and train minorities or place providers in underserved communities, effectively targeting both ends of the pipeline.

Robert Phillips, MD, MSPH, director of the Washington, D.C.-based Robert Graham Center, a primary-care research center, has high regard for the Title VII program. But making an impact requires a long-term investment, he cautions. “In the states that do this well, like Arkansas and North Carolina, it pays off,” he says. “But they can’t prove it sufficiently to save their budget.” The federal program received $233 million in fiscal-year 2012. Under the president’s fiscal-year 2013 budget proposal, however, the funding is likewise eliminated.

Other programs have debuted in recent legislation. One program, introduced under the Affordable Care Act, provides $230 million over five years to expand residency training slots within ambulatory primary-care settings. Dr. Klink says the Teaching Health Center Graduate Medical Education program, as it is known, has so far supported 22 health centers and 150 enrolled residents. “It’s just the beginning,” she adds.

Another program, the Primary Care Residency Expansion, likewise initiated under the Affordable Care Act, will distribute $167 million to train an estimated 700 primary-care physicians (PCPs), 900 physician assistants, and 600 nurse practitioners and nurse midwives over five years. Glen Stream, president of the American Academy of Family Physicians, recently told The Washington Post, “It’s good, but it’s also a drop in the bucket.”

Bryn Nelson is a freelance medical writer in Seattle.

Just as the federal government is introducing several new programs to promote the recruitment, training, and placement of more primary-care providers, other efforts are being threatened with funding decreases or elimination.

One, the Children’s Hospitals Graduate Medical Education program, distributed $268 million in pediatric training funds to 55 freestanding children’s teaching hospitals in fiscal-year 2012. The program, however, was zeroed out in President Obama’s initial budget proposal last year, and the president’s fiscal-year 2013 budget proposal recommends slashing the program’s annual funding by two-thirds to $88 million.

Kathleen Klink, MD, director of the Division of Medicine and Dentistry in the federal Health Resources and Services Administration, also points to the Title VII Area Health Education Center program as an example of government-funded assistance. The competitive grant process supports innovation and access to care for vulnerable populations, in part by improving the primary-care workforce’s geographic and ethnic distribution. Some of the grantees introduce high school students to medical careers, while others recruit and train minorities or place providers in underserved communities, effectively targeting both ends of the pipeline.

Robert Phillips, MD, MSPH, director of the Washington, D.C.-based Robert Graham Center, a primary-care research center, has high regard for the Title VII program. But making an impact requires a long-term investment, he cautions. “In the states that do this well, like Arkansas and North Carolina, it pays off,” he says. “But they can’t prove it sufficiently to save their budget.” The federal program received $233 million in fiscal-year 2012. Under the president’s fiscal-year 2013 budget proposal, however, the funding is likewise eliminated.

Other programs have debuted in recent legislation. One program, introduced under the Affordable Care Act, provides $230 million over five years to expand residency training slots within ambulatory primary-care settings. Dr. Klink says the Teaching Health Center Graduate Medical Education program, as it is known, has so far supported 22 health centers and 150 enrolled residents. “It’s just the beginning,” she adds.

Another program, the Primary Care Residency Expansion, likewise initiated under the Affordable Care Act, will distribute $167 million to train an estimated 700 primary-care physicians (PCPs), 900 physician assistants, and 600 nurse practitioners and nurse midwives over five years. Glen Stream, president of the American Academy of Family Physicians, recently told The Washington Post, “It’s good, but it’s also a drop in the bucket.”

Bryn Nelson is a freelance medical writer in Seattle.

Just as the federal government is introducing several new programs to promote the recruitment, training, and placement of more primary-care providers, other efforts are being threatened with funding decreases or elimination.

One, the Children’s Hospitals Graduate Medical Education program, distributed $268 million in pediatric training funds to 55 freestanding children’s teaching hospitals in fiscal-year 2012. The program, however, was zeroed out in President Obama’s initial budget proposal last year, and the president’s fiscal-year 2013 budget proposal recommends slashing the program’s annual funding by two-thirds to $88 million.

Kathleen Klink, MD, director of the Division of Medicine and Dentistry in the federal Health Resources and Services Administration, also points to the Title VII Area Health Education Center program as an example of government-funded assistance. The competitive grant process supports innovation and access to care for vulnerable populations, in part by improving the primary-care workforce’s geographic and ethnic distribution. Some of the grantees introduce high school students to medical careers, while others recruit and train minorities or place providers in underserved communities, effectively targeting both ends of the pipeline.

Robert Phillips, MD, MSPH, director of the Washington, D.C.-based Robert Graham Center, a primary-care research center, has high regard for the Title VII program. But making an impact requires a long-term investment, he cautions. “In the states that do this well, like Arkansas and North Carolina, it pays off,” he says. “But they can’t prove it sufficiently to save their budget.” The federal program received $233 million in fiscal-year 2012. Under the president’s fiscal-year 2013 budget proposal, however, the funding is likewise eliminated.

Other programs have debuted in recent legislation. One program, introduced under the Affordable Care Act, provides $230 million over five years to expand residency training slots within ambulatory primary-care settings. Dr. Klink says the Teaching Health Center Graduate Medical Education program, as it is known, has so far supported 22 health centers and 150 enrolled residents. “It’s just the beginning,” she adds.

Another program, the Primary Care Residency Expansion, likewise initiated under the Affordable Care Act, will distribute $167 million to train an estimated 700 primary-care physicians (PCPs), 900 physician assistants, and 600 nurse practitioners and nurse midwives over five years. Glen Stream, president of the American Academy of Family Physicians, recently told The Washington Post, “It’s good, but it’s also a drop in the bucket.”

Bryn Nelson is a freelance medical writer in Seattle.

A paper published in the May/June issue of the Journal of Hospital Medicine shows that a collaborative approach to medication reconciliation ("med rec") appears to both prevent adverse drug events and pay for itself.

The paper, "Nurse-Pharmacist Collaboration on Medication Reconciliation Prevents Potential Harm," found that 225 of 500 surveyed patients had at least one unintended discrepancy in their house medication list (HML) on admission or discharge. And 162 of those patients had a discrepancy ranked on the upper end of the study's risk scale.

However, having nurses and pharmacists work together "allowed many discrepancies to be reconciled before causing harm," the study concluded.

"It absolutely supports the idea that we need to approach medicine as a team game," says hospitalist and lead author Lenny Feldman, MD, FACP, FAAP, SFHM, of John Hopkins School of Medicine in Baltimore. "We can't do this alone, and patients don't do better when we do this alone."

The study noted that it cost $113.64 to find one potentially harmful medication discrepancy. To offset those costs, an institution would have to prevent one discrepancy for every 290 patient encounters. The Johns Hopkins team averted 81 such events, but Dr. Feldman notes that without a control group, it’s difficult to say how many of those potential issues would have been caught at some other point in a patient's stay.

Still, he says, part of the value of a multidisciplinary approach to med rec is that it can help hospitalists improve patient care. By having nurses, physicians, and pharmacists working together, more potential adverse drug events could be prevented, Dr. Feldman says.

"That data-gathering is difficult and time-consuming, and it is not something hospitalists need do on their own," he adds.

A paper published in the May/June issue of the Journal of Hospital Medicine shows that a collaborative approach to medication reconciliation ("med rec") appears to both prevent adverse drug events and pay for itself.

The paper, "Nurse-Pharmacist Collaboration on Medication Reconciliation Prevents Potential Harm," found that 225 of 500 surveyed patients had at least one unintended discrepancy in their house medication list (HML) on admission or discharge. And 162 of those patients had a discrepancy ranked on the upper end of the study's risk scale.

However, having nurses and pharmacists work together "allowed many discrepancies to be reconciled before causing harm," the study concluded.

"It absolutely supports the idea that we need to approach medicine as a team game," says hospitalist and lead author Lenny Feldman, MD, FACP, FAAP, SFHM, of John Hopkins School of Medicine in Baltimore. "We can't do this alone, and patients don't do better when we do this alone."

The study noted that it cost $113.64 to find one potentially harmful medication discrepancy. To offset those costs, an institution would have to prevent one discrepancy for every 290 patient encounters. The Johns Hopkins team averted 81 such events, but Dr. Feldman notes that without a control group, it’s difficult to say how many of those potential issues would have been caught at some other point in a patient's stay.

Still, he says, part of the value of a multidisciplinary approach to med rec is that it can help hospitalists improve patient care. By having nurses, physicians, and pharmacists working together, more potential adverse drug events could be prevented, Dr. Feldman says.

"That data-gathering is difficult and time-consuming, and it is not something hospitalists need do on their own," he adds.

A paper published in the May/June issue of the Journal of Hospital Medicine shows that a collaborative approach to medication reconciliation ("med rec") appears to both prevent adverse drug events and pay for itself.

The paper, "Nurse-Pharmacist Collaboration on Medication Reconciliation Prevents Potential Harm," found that 225 of 500 surveyed patients had at least one unintended discrepancy in their house medication list (HML) on admission or discharge. And 162 of those patients had a discrepancy ranked on the upper end of the study's risk scale.

However, having nurses and pharmacists work together "allowed many discrepancies to be reconciled before causing harm," the study concluded.

"It absolutely supports the idea that we need to approach medicine as a team game," says hospitalist and lead author Lenny Feldman, MD, FACP, FAAP, SFHM, of John Hopkins School of Medicine in Baltimore. "We can't do this alone, and patients don't do better when we do this alone."

The study noted that it cost $113.64 to find one potentially harmful medication discrepancy. To offset those costs, an institution would have to prevent one discrepancy for every 290 patient encounters. The Johns Hopkins team averted 81 such events, but Dr. Feldman notes that without a control group, it’s difficult to say how many of those potential issues would have been caught at some other point in a patient's stay.

Still, he says, part of the value of a multidisciplinary approach to med rec is that it can help hospitalists improve patient care. By having nurses, physicians, and pharmacists working together, more potential adverse drug events could be prevented, Dr. Feldman says.

"That data-gathering is difficult and time-consuming, and it is not something hospitalists need do on their own," he adds.

At first blush, some hospitalists might see it as bad news that a recent report found a pharmacist-assisted medication reconciliation ("med rec") intervention did not significantly reduce clinically important medication errors after discharge. But a deeper reading of the study tells a different story, says a hospitalist who worked on the report.

"This is the latest in our growing understanding of the roles of certain interventions on transitions of care," says Jeffrey Schnipper, MD, MPH, FHM, director of clinical research and an associate physician in the general medicine division at Brigham and Women's Hospitalist Service in Boston, and co-author of the study "Effect of a Pharmacist Intervention on Clinically Important Medication Errors after Hospital Discharge." "What I don't want to have happen is for people to read this article ... and say, 'Oh, pharmacists don't make a difference.' They absolutely make a difference. This is a more nuanced issue of who do they have the biggest impact with, and 'On top of what other interventions are you doing this?'"

The researchers set out to determine whether a pharmacist-delivered intervention on patients with low health literacy (including a post-discharge telephone call) would lower adverse drug events and other clinically important medication errors. They concluded that it did not (unadjusted incidence rate ratio, 0.92 [95% CI, 0.77 to 1.10]).

Dr. Schnipper says the impact was likely muted because the patients studied had higher health-literacy levels than researchers expected. Also, because most follow-up phone calls occurred within a few days of discharge, the intervention failed to capture any events that happened in the 30 days after discharge.

He also notes that the institutions that participated in the study have already implemented multiple med-rec interventions over the past few years. Hospitals that have not focused intently on the issue could find much larger gains from implementing pharmacist-led programs.

"If you're a hospital that has not been fixated on improving medication safety and transitions of care, I think pharmacists are huge," Dr. Schnipper says. "The key, then, is to focus them on the highest-risk patients."

At first blush, some hospitalists might see it as bad news that a recent report found a pharmacist-assisted medication reconciliation ("med rec") intervention did not significantly reduce clinically important medication errors after discharge. But a deeper reading of the study tells a different story, says a hospitalist who worked on the report.

"This is the latest in our growing understanding of the roles of certain interventions on transitions of care," says Jeffrey Schnipper, MD, MPH, FHM, director of clinical research and an associate physician in the general medicine division at Brigham and Women's Hospitalist Service in Boston, and co-author of the study "Effect of a Pharmacist Intervention on Clinically Important Medication Errors after Hospital Discharge." "What I don't want to have happen is for people to read this article ... and say, 'Oh, pharmacists don't make a difference.' They absolutely make a difference. This is a more nuanced issue of who do they have the biggest impact with, and 'On top of what other interventions are you doing this?'"

The researchers set out to determine whether a pharmacist-delivered intervention on patients with low health literacy (including a post-discharge telephone call) would lower adverse drug events and other clinically important medication errors. They concluded that it did not (unadjusted incidence rate ratio, 0.92 [95% CI, 0.77 to 1.10]).

Dr. Schnipper says the impact was likely muted because the patients studied had higher health-literacy levels than researchers expected. Also, because most follow-up phone calls occurred within a few days of discharge, the intervention failed to capture any events that happened in the 30 days after discharge.

He also notes that the institutions that participated in the study have already implemented multiple med-rec interventions over the past few years. Hospitals that have not focused intently on the issue could find much larger gains from implementing pharmacist-led programs.

"If you're a hospital that has not been fixated on improving medication safety and transitions of care, I think pharmacists are huge," Dr. Schnipper says. "The key, then, is to focus them on the highest-risk patients."

At first blush, some hospitalists might see it as bad news that a recent report found a pharmacist-assisted medication reconciliation ("med rec") intervention did not significantly reduce clinically important medication errors after discharge. But a deeper reading of the study tells a different story, says a hospitalist who worked on the report.

"This is the latest in our growing understanding of the roles of certain interventions on transitions of care," says Jeffrey Schnipper, MD, MPH, FHM, director of clinical research and an associate physician in the general medicine division at Brigham and Women's Hospitalist Service in Boston, and co-author of the study "Effect of a Pharmacist Intervention on Clinically Important Medication Errors after Hospital Discharge." "What I don't want to have happen is for people to read this article ... and say, 'Oh, pharmacists don't make a difference.' They absolutely make a difference. This is a more nuanced issue of who do they have the biggest impact with, and 'On top of what other interventions are you doing this?'"

The researchers set out to determine whether a pharmacist-delivered intervention on patients with low health literacy (including a post-discharge telephone call) would lower adverse drug events and other clinically important medication errors. They concluded that it did not (unadjusted incidence rate ratio, 0.92 [95% CI, 0.77 to 1.10]).

Dr. Schnipper says the impact was likely muted because the patients studied had higher health-literacy levels than researchers expected. Also, because most follow-up phone calls occurred within a few days of discharge, the intervention failed to capture any events that happened in the 30 days after discharge.

He also notes that the institutions that participated in the study have already implemented multiple med-rec interventions over the past few years. Hospitals that have not focused intently on the issue could find much larger gains from implementing pharmacist-led programs.

"If you're a hospital that has not been fixated on improving medication safety and transitions of care, I think pharmacists are huge," Dr. Schnipper says. "The key, then, is to focus them on the highest-risk patients."

Although Medicare's looming financial penalties for hospitals with excessive readmissions might seem like a blunt weapon, private health plans often have the flexibility to negotiate with partnering hospitals around incentives for readmissions prevention.

"We have arrangements with private insurance companies where we put at risk future compensation, based on achieving negotiated readmissions results," says Mark Carley, vice president of managed care and network development for Centura Health, a 13-hospital system in Colorado.

Payors, including United Healthcare, have developed their own readmissions programs and reporting mechanisms, although each program’s incentives are a little different, Carley says. Target rates are negotiated based on each hospital's readmissions in the previous 12-month period and national averages. The plan can also provide helpful data on its beneficiaries and other forms of assistance, because it wants to see the hospital hit the target, he adds. "If the target has been set too high, they may be willing to renegotiate."

But the plan doesn't tell the hospital how to reach that target.

"Where the complexity comes in is how we as a system implement internal policies and procedures to improve our care coordination, discharge processes, follow-up, and communication with downstream providers," says Carley. Centura Health's approach to readmissions has included close study of past performance data in search of opportunities for improvement, fine-tuning of the discharge planning process, and follow-up phone calls to patients and providers.

"In addition, we are working with post-acute providers to provide smoother transitions in the discharge process," he says.

Although Medicare's looming financial penalties for hospitals with excessive readmissions might seem like a blunt weapon, private health plans often have the flexibility to negotiate with partnering hospitals around incentives for readmissions prevention.

"We have arrangements with private insurance companies where we put at risk future compensation, based on achieving negotiated readmissions results," says Mark Carley, vice president of managed care and network development for Centura Health, a 13-hospital system in Colorado.

Payors, including United Healthcare, have developed their own readmissions programs and reporting mechanisms, although each program’s incentives are a little different, Carley says. Target rates are negotiated based on each hospital's readmissions in the previous 12-month period and national averages. The plan can also provide helpful data on its beneficiaries and other forms of assistance, because it wants to see the hospital hit the target, he adds. "If the target has been set too high, they may be willing to renegotiate."

But the plan doesn't tell the hospital how to reach that target.

"Where the complexity comes in is how we as a system implement internal policies and procedures to improve our care coordination, discharge processes, follow-up, and communication with downstream providers," says Carley. Centura Health's approach to readmissions has included close study of past performance data in search of opportunities for improvement, fine-tuning of the discharge planning process, and follow-up phone calls to patients and providers.

"In addition, we are working with post-acute providers to provide smoother transitions in the discharge process," he says.

Although Medicare's looming financial penalties for hospitals with excessive readmissions might seem like a blunt weapon, private health plans often have the flexibility to negotiate with partnering hospitals around incentives for readmissions prevention.

"We have arrangements with private insurance companies where we put at risk future compensation, based on achieving negotiated readmissions results," says Mark Carley, vice president of managed care and network development for Centura Health, a 13-hospital system in Colorado.

Payors, including United Healthcare, have developed their own readmissions programs and reporting mechanisms, although each program’s incentives are a little different, Carley says. Target rates are negotiated based on each hospital's readmissions in the previous 12-month period and national averages. The plan can also provide helpful data on its beneficiaries and other forms of assistance, because it wants to see the hospital hit the target, he adds. "If the target has been set too high, they may be willing to renegotiate."

But the plan doesn't tell the hospital how to reach that target.

"Where the complexity comes in is how we as a system implement internal policies and procedures to improve our care coordination, discharge processes, follow-up, and communication with downstream providers," says Carley. Centura Health's approach to readmissions has included close study of past performance data in search of opportunities for improvement, fine-tuning of the discharge planning process, and follow-up phone calls to patients and providers.

"In addition, we are working with post-acute providers to provide smoother transitions in the discharge process," he says.

Clinical question: Can a quality-improvement (QI) collaborative decrease patient identification (ID) band errors?

Background: ID band errors often result in medication errors and unsafe care. Consequently, correct patient identification, through the use of at least two identifiers, has been an ongoing Joint Commission National Patient Safety Goal. Although individual sites have demonstrated improvement in accuracy of patient identification, there have not been reports of dissemination of successful practices.

Study design: Collaborative quality-improvement initiative.

Setting: Six hospitals.

Synopsis: ID band audits in 11,377 patients were performed in the learning collaborative’s six participating hospitals.

The audits were organized primarily around monthly conference calls. The hospital settings were diverse: community hospitals, hospitals within an academic medical center, and freestanding children’s hospitals. The aim of the collaborative was to reduce ID band errors by 50% within a one-year time frame across the collective sites.

Key interventions included transparent data collection and reporting; engagement of staff, families and leadership; voluntary event reporting; and auditing of failures. The mean combined ID band failure rate decreased to 4% from 22% within 13 months, representing a 77% relative reduction (P<0.001).

QI collaboratives are not designed to specifically result in generalizable knowledge, yet they might produce widespread improvement, as this effort demonstrates. The careful documentation of iterative factors implemented across sites in this initiative provides a blueprint for hospitals looking to replicate this success. Additionally, the interventions represent feasible and logical concepts within the basic constructs of improvement science methodology.

Bottom line: A QI collaborative might result in rapid and significant reductions in ID band errors.

Citation: Phillips SC, Saysana M, Worley S, Hain PD. Reduction in pediatric identification band errors: a quality collaborative. Pediatrics. 2012;129(6):e1587-e1593.

Reviewed by Pediatric Editor Mark Shen, MD, SFHM, medical director of hospital medicine at Dell Children's Medical Center, Austin, Texas.

Clinical question: Can a quality-improvement (QI) collaborative decrease patient identification (ID) band errors?

Background: ID band errors often result in medication errors and unsafe care. Consequently, correct patient identification, through the use of at least two identifiers, has been an ongoing Joint Commission National Patient Safety Goal. Although individual sites have demonstrated improvement in accuracy of patient identification, there have not been reports of dissemination of successful practices.

Study design: Collaborative quality-improvement initiative.

Setting: Six hospitals.

Synopsis: ID band audits in 11,377 patients were performed in the learning collaborative’s six participating hospitals.

The audits were organized primarily around monthly conference calls. The hospital settings were diverse: community hospitals, hospitals within an academic medical center, and freestanding children’s hospitals. The aim of the collaborative was to reduce ID band errors by 50% within a one-year time frame across the collective sites.

Key interventions included transparent data collection and reporting; engagement of staff, families and leadership; voluntary event reporting; and auditing of failures. The mean combined ID band failure rate decreased to 4% from 22% within 13 months, representing a 77% relative reduction (P<0.001).

QI collaboratives are not designed to specifically result in generalizable knowledge, yet they might produce widespread improvement, as this effort demonstrates. The careful documentation of iterative factors implemented across sites in this initiative provides a blueprint for hospitals looking to replicate this success. Additionally, the interventions represent feasible and logical concepts within the basic constructs of improvement science methodology.

Bottom line: A QI collaborative might result in rapid and significant reductions in ID band errors.

Citation: Phillips SC, Saysana M, Worley S, Hain PD. Reduction in pediatric identification band errors: a quality collaborative. Pediatrics. 2012;129(6):e1587-e1593.

Reviewed by Pediatric Editor Mark Shen, MD, SFHM, medical director of hospital medicine at Dell Children's Medical Center, Austin, Texas.

Clinical question: Can a quality-improvement (QI) collaborative decrease patient identification (ID) band errors?

Background: ID band errors often result in medication errors and unsafe care. Consequently, correct patient identification, through the use of at least two identifiers, has been an ongoing Joint Commission National Patient Safety Goal. Although individual sites have demonstrated improvement in accuracy of patient identification, there have not been reports of dissemination of successful practices.

Study design: Collaborative quality-improvement initiative.

Setting: Six hospitals.

Synopsis: ID band audits in 11,377 patients were performed in the learning collaborative’s six participating hospitals.

The audits were organized primarily around monthly conference calls. The hospital settings were diverse: community hospitals, hospitals within an academic medical center, and freestanding children’s hospitals. The aim of the collaborative was to reduce ID band errors by 50% within a one-year time frame across the collective sites.

Key interventions included transparent data collection and reporting; engagement of staff, families and leadership; voluntary event reporting; and auditing of failures. The mean combined ID band failure rate decreased to 4% from 22% within 13 months, representing a 77% relative reduction (P<0.001).

QI collaboratives are not designed to specifically result in generalizable knowledge, yet they might produce widespread improvement, as this effort demonstrates. The careful documentation of iterative factors implemented across sites in this initiative provides a blueprint for hospitals looking to replicate this success. Additionally, the interventions represent feasible and logical concepts within the basic constructs of improvement science methodology.

Bottom line: A QI collaborative might result in rapid and significant reductions in ID band errors.

Citation: Phillips SC, Saysana M, Worley S, Hain PD. Reduction in pediatric identification band errors: a quality collaborative. Pediatrics. 2012;129(6):e1587-e1593.

Reviewed by Pediatric Editor Mark Shen, MD, SFHM, medical director of hospital medicine at Dell Children's Medical Center, Austin, Texas.

More than 100 hospitals across the country have used Project BOOST to reduce readmissions and improve their discharge processes. You and your hospital can be next by applying for Project BOOST. The deadline for the next national cohort of Project BOOST is Sept. 1.

To improve your chances of acceptance, start soon. In addition to an online form, the application requires a letter of support from an executive sponsor from each institution.

In October, accepted Project BOOST sites will receive:

• A comprehensive intervention developed by a panel of nationally recognized experts based on the best available evidence;
• A comprehensive implementation guide that provides step-by-step instructions and project management tools, such as the “teachback” training curriculum, to help interdisciplinary teams redesign work flow and plan, implement, and evaluate the intervention;
• Longitudinal technical assistance that provides face-to-face training and a year of expert mentoring and coaching to implement BOOST interventions that build a culture that supports safe and complete transitions. The mentoring program provides a “train-the-trainer” DVD and curriculum for nurses and case managers on using the teachback process, and webinars targeting the educational needs of other team members, including administrators, data analysts, physicians, nurses; and others;
• A collaboration that allows sites to communicate with and learn from each other via the BOOST listserv, BOOST community site, and quarterly all-site teleconferences and webinars; and
• Access to the BOOST data center, an online resource center that allows sites to store and benchmark data against control units and other sites and generate reports.

To start the application process, visit www.hospitalmedicine.org/boost.

Brendon Shank is SHM’s associate vice president for communications.

More than 100 hospitals across the country have used Project BOOST to reduce readmissions and improve their discharge processes. You and your hospital can be next by applying for Project BOOST. The deadline for the next national cohort of Project BOOST is Sept. 1.

To improve your chances of acceptance, start soon. In addition to an online form, the application requires a letter of support from an executive sponsor from each institution.

In October, accepted Project BOOST sites will receive:

• A comprehensive intervention developed by a panel of nationally recognized experts based on the best available evidence;
• A comprehensive implementation guide that provides step-by-step instructions and project management tools, such as the “teachback” training curriculum, to help interdisciplinary teams redesign work flow and plan, implement, and evaluate the intervention;
• Longitudinal technical assistance that provides face-to-face training and a year of expert mentoring and coaching to implement BOOST interventions that build a culture that supports safe and complete transitions. The mentoring program provides a “train-the-trainer” DVD and curriculum for nurses and case managers on using the teachback process, and webinars targeting the educational needs of other team members, including administrators, data analysts, physicians, nurses; and others;
• A collaboration that allows sites to communicate with and learn from each other via the BOOST listserv, BOOST community site, and quarterly all-site teleconferences and webinars; and
• Access to the BOOST data center, an online resource center that allows sites to store and benchmark data against control units and other sites and generate reports.

To start the application process, visit www.hospitalmedicine.org/boost.

Brendon Shank is SHM’s associate vice president for communications.

More than 100 hospitals across the country have used Project BOOST to reduce readmissions and improve their discharge processes. You and your hospital can be next by applying for Project BOOST. The deadline for the next national cohort of Project BOOST is Sept. 1.

To improve your chances of acceptance, start soon. In addition to an online form, the application requires a letter of support from an executive sponsor from each institution.

In October, accepted Project BOOST sites will receive:

• A comprehensive intervention developed by a panel of nationally recognized experts based on the best available evidence;
• A comprehensive implementation guide that provides step-by-step instructions and project management tools, such as the “teachback” training curriculum, to help interdisciplinary teams redesign work flow and plan, implement, and evaluate the intervention;
• Longitudinal technical assistance that provides face-to-face training and a year of expert mentoring and coaching to implement BOOST interventions that build a culture that supports safe and complete transitions. The mentoring program provides a “train-the-trainer” DVD and curriculum for nurses and case managers on using the teachback process, and webinars targeting the educational needs of other team members, including administrators, data analysts, physicians, nurses; and others;
• A collaboration that allows sites to communicate with and learn from each other via the BOOST listserv, BOOST community site, and quarterly all-site teleconferences and webinars; and
• Access to the BOOST data center, an online resource center that allows sites to store and benchmark data against control units and other sites and generate reports.

To start the application process, visit www.hospitalmedicine.org/boost.

Brendon Shank is SHM’s associate vice president for communications.