QI Initiatives

A recent study published in the Journal of Hospital Medicine reports on an early warning and response system (EWRS) for sepsis used in all three hospitals within the Philadelphia-based University of Pennsylvania Health System (UPHS) for three-month spans in 2012 and 2013. The system integrates laboratory values and vital signs into patients EHRs and establishes a threshold for triggering the alert.

After implementing the EWRS, at-risk patients received faster care for sepsis and/or were transferred to the ICU more quickly, says lead author Craig A. Umscheid, MD, MSCE, director of the Center for Evidence-Based Practice at the University of Pennsylvania in Philadelphia. Study authors also note that quicker care suggested reduced mortality from sepsis as well.

"Whenever a patient triggered the alert, their probability of mortality was much higher than patients who didn't trigger the alert," Dr. Umscheid says. "I think what makes our study unique compared to other studies that have tried to predict sepsis is that beyond just creating a prediction rule for sepsis, we actually implemented it into a clinical care setting, alerted providers in real time, and then those providers changed their care based on the prediction."

More than 90% of care teams arrived at the bedside when they received an alert. "Meaning that they saw some value in the alert, and the infrastructure that we put in place was able to mobilize the team and get them to the bedside within 30 minutes," Dr. Umscheid adds. "We saw an increase in sepsis antibiotics used, and we saw an increase in fluid boluses within six hours.”

As many as 3 million cases of severe sepsis occur in the U.S. annually, and 750,000 result in deaths, according to the study. The high number of cases has led to several efforts to create better clinical practices for sepsis patients.

"Sepsis is arguably one of the most, if not the most important, causes of preventable mortality in the inpatient setting," Dr. Umscheid says. "One thing that we thought we could do better was identify sepsis cases earlier so that we could provide early antibiotics and fluids."

Visit our website for more information on identifying and treating sepsis.

A recent study published in the Journal of Hospital Medicine reports on an early warning and response system (EWRS) for sepsis used in all three hospitals within the Philadelphia-based University of Pennsylvania Health System (UPHS) for three-month spans in 2012 and 2013. The system integrates laboratory values and vital signs into patients EHRs and establishes a threshold for triggering the alert.

After implementing the EWRS, at-risk patients received faster care for sepsis and/or were transferred to the ICU more quickly, says lead author Craig A. Umscheid, MD, MSCE, director of the Center for Evidence-Based Practice at the University of Pennsylvania in Philadelphia. Study authors also note that quicker care suggested reduced mortality from sepsis as well.

"Whenever a patient triggered the alert, their probability of mortality was much higher than patients who didn't trigger the alert," Dr. Umscheid says. "I think what makes our study unique compared to other studies that have tried to predict sepsis is that beyond just creating a prediction rule for sepsis, we actually implemented it into a clinical care setting, alerted providers in real time, and then those providers changed their care based on the prediction."

More than 90% of care teams arrived at the bedside when they received an alert. "Meaning that they saw some value in the alert, and the infrastructure that we put in place was able to mobilize the team and get them to the bedside within 30 minutes," Dr. Umscheid adds. "We saw an increase in sepsis antibiotics used, and we saw an increase in fluid boluses within six hours.”

As many as 3 million cases of severe sepsis occur in the U.S. annually, and 750,000 result in deaths, according to the study. The high number of cases has led to several efforts to create better clinical practices for sepsis patients.

"Sepsis is arguably one of the most, if not the most important, causes of preventable mortality in the inpatient setting," Dr. Umscheid says. "One thing that we thought we could do better was identify sepsis cases earlier so that we could provide early antibiotics and fluids."

Visit our website for more information on identifying and treating sepsis.

A recent study published in the Journal of Hospital Medicine reports on an early warning and response system (EWRS) for sepsis used in all three hospitals within the Philadelphia-based University of Pennsylvania Health System (UPHS) for three-month spans in 2012 and 2013. The system integrates laboratory values and vital signs into patients EHRs and establishes a threshold for triggering the alert.

After implementing the EWRS, at-risk patients received faster care for sepsis and/or were transferred to the ICU more quickly, says lead author Craig A. Umscheid, MD, MSCE, director of the Center for Evidence-Based Practice at the University of Pennsylvania in Philadelphia. Study authors also note that quicker care suggested reduced mortality from sepsis as well.

"Whenever a patient triggered the alert, their probability of mortality was much higher than patients who didn't trigger the alert," Dr. Umscheid says. "I think what makes our study unique compared to other studies that have tried to predict sepsis is that beyond just creating a prediction rule for sepsis, we actually implemented it into a clinical care setting, alerted providers in real time, and then those providers changed their care based on the prediction."

More than 90% of care teams arrived at the bedside when they received an alert. "Meaning that they saw some value in the alert, and the infrastructure that we put in place was able to mobilize the team and get them to the bedside within 30 minutes," Dr. Umscheid adds. "We saw an increase in sepsis antibiotics used, and we saw an increase in fluid boluses within six hours.”

As many as 3 million cases of severe sepsis occur in the U.S. annually, and 750,000 result in deaths, according to the study. The high number of cases has led to several efforts to create better clinical practices for sepsis patients.

"Sepsis is arguably one of the most, if not the most important, causes of preventable mortality in the inpatient setting," Dr. Umscheid says. "One thing that we thought we could do better was identify sepsis cases earlier so that we could provide early antibiotics and fluids."

Visit our website for more information on identifying and treating sepsis.

Kristen Kulasa, MD, assistant clinical professor of medicine and director of Inpatient Glycemic Control, Division of Endocrinology, Diabetes, and Metabolism at the University of California in San Diego, provides tips on how hospitalists can work with nutritionists and dieticians for the betterment of diabetic patients. As a mentor for SHM's care coordination program on inpatient diabetes, Dr. Kulasa offers hospitalists advice in treating diabetic patients. She points to SHM’s website, which has a lot of resources to help hospitalists feel comfortable with insulin dosing.

Kristen Kulasa, MD, assistant clinical professor of medicine and director of Inpatient Glycemic Control, Division of Endocrinology, Diabetes, and Metabolism at the University of California in San Diego, provides tips on how hospitalists can work with nutritionists and dieticians for the betterment of diabetic patients. As a mentor for SHM's care coordination program on inpatient diabetes, Dr. Kulasa offers hospitalists advice in treating diabetic patients. She points to SHM’s website, which has a lot of resources to help hospitalists feel comfortable with insulin dosing.

Kristen Kulasa, MD, assistant clinical professor of medicine and director of Inpatient Glycemic Control, Division of Endocrinology, Diabetes, and Metabolism at the University of California in San Diego, provides tips on how hospitalists can work with nutritionists and dieticians for the betterment of diabetic patients. As a mentor for SHM's care coordination program on inpatient diabetes, Dr. Kulasa offers hospitalists advice in treating diabetic patients. She points to SHM’s website, which has a lot of resources to help hospitalists feel comfortable with insulin dosing.

A new study on transitions of care gives hospitalists a view from the other side.

Published recently online in the Journal of Hospital Medicine, the authors surveyed 22 primary-care physician leaders in California-based post-discharge clinics and asked them about ways to improve care transitions.

Physicians' responses focused on several areas that need work, most notably aligned financial incentives, regulations to standardize interoperability among electronic health records (EHR) and data sharing, and more opportunities for professional networking, the authors note.

Although the qualitative study takes a broad view of the healthcare system, its lead author says hospitalists should view "systems change" as a long-term goal achievable via incremental improvements that can start now.

"National policy change is needed to move the needle for the whole health system," says hospitalist Oanh Kieu Nguyen, MD, MAS, of the University of Texas Southwestern Medical Center in Dallas. "But locally, you can innovate within these domains and start to make changes to improve practice settings more immediately. National policy to align financial incentives and improve EHR interoperability will be key to helping local changes take hold and spread across systems. Otherwise, there will continue to be a lot of variability and fragmentation around care transitions on a national level."

Dr. Nguyen, who has practiced as both a hospitalist and PCP, says that because policies and studies on post-discharge care transitions primarily have focused on the hospital perspective, it is important to gain an understanding of the primary-care point of view.

"As a hospitalist, it's really easy to get caught up in just wanting to get patients teed up and sent home. Once they're out, we think they're no longer really our problem," Dr. Nguyen adds. "It's easy to forget that primary care is an important part of the other side of the equation. The way our healthcare system is designed doesn't really give physicians an incentive to look at the whole picture of a patient across all the environments they're in."

Many hospitalists are sharing their challenges and successes in care transitions through HMX. Join the conversation now.

Visit our website for more information on transitions of care.

A new study on transitions of care gives hospitalists a view from the other side.

Published recently online in the Journal of Hospital Medicine, the authors surveyed 22 primary-care physician leaders in California-based post-discharge clinics and asked them about ways to improve care transitions.

Physicians' responses focused on several areas that need work, most notably aligned financial incentives, regulations to standardize interoperability among electronic health records (EHR) and data sharing, and more opportunities for professional networking, the authors note.

Although the qualitative study takes a broad view of the healthcare system, its lead author says hospitalists should view "systems change" as a long-term goal achievable via incremental improvements that can start now.

"National policy change is needed to move the needle for the whole health system," says hospitalist Oanh Kieu Nguyen, MD, MAS, of the University of Texas Southwestern Medical Center in Dallas. "But locally, you can innovate within these domains and start to make changes to improve practice settings more immediately. National policy to align financial incentives and improve EHR interoperability will be key to helping local changes take hold and spread across systems. Otherwise, there will continue to be a lot of variability and fragmentation around care transitions on a national level."

Dr. Nguyen, who has practiced as both a hospitalist and PCP, says that because policies and studies on post-discharge care transitions primarily have focused on the hospital perspective, it is important to gain an understanding of the primary-care point of view.

"As a hospitalist, it's really easy to get caught up in just wanting to get patients teed up and sent home. Once they're out, we think they're no longer really our problem," Dr. Nguyen adds. "It's easy to forget that primary care is an important part of the other side of the equation. The way our healthcare system is designed doesn't really give physicians an incentive to look at the whole picture of a patient across all the environments they're in."

Many hospitalists are sharing their challenges and successes in care transitions through HMX. Join the conversation now.

Visit our website for more information on transitions of care.

A new study on transitions of care gives hospitalists a view from the other side.

Published recently online in the Journal of Hospital Medicine, the authors surveyed 22 primary-care physician leaders in California-based post-discharge clinics and asked them about ways to improve care transitions.

Physicians' responses focused on several areas that need work, most notably aligned financial incentives, regulations to standardize interoperability among electronic health records (EHR) and data sharing, and more opportunities for professional networking, the authors note.

Although the qualitative study takes a broad view of the healthcare system, its lead author says hospitalists should view "systems change" as a long-term goal achievable via incremental improvements that can start now.

"National policy change is needed to move the needle for the whole health system," says hospitalist Oanh Kieu Nguyen, MD, MAS, of the University of Texas Southwestern Medical Center in Dallas. "But locally, you can innovate within these domains and start to make changes to improve practice settings more immediately. National policy to align financial incentives and improve EHR interoperability will be key to helping local changes take hold and spread across systems. Otherwise, there will continue to be a lot of variability and fragmentation around care transitions on a national level."

Dr. Nguyen, who has practiced as both a hospitalist and PCP, says that because policies and studies on post-discharge care transitions primarily have focused on the hospital perspective, it is important to gain an understanding of the primary-care point of view.

"As a hospitalist, it's really easy to get caught up in just wanting to get patients teed up and sent home. Once they're out, we think they're no longer really our problem," Dr. Nguyen adds. "It's easy to forget that primary care is an important part of the other side of the equation. The way our healthcare system is designed doesn't really give physicians an incentive to look at the whole picture of a patient across all the environments they're in."

Many hospitalists are sharing their challenges and successes in care transitions through HMX. Join the conversation now.

Visit our website for more information on transitions of care.

Clinical question: Do signouts vary in the quality and quantity of information, and what are the various factors affecting signout quality?

Background: Miscommunication during transfers of responsibility for hospitalized patients is common and can result in harm. Recommendations for safe and effective handoffs emphasize key content, clear communication, senior staff supervision, and adequate time for questions. Still, little is known about adherence to these recommendations in clinical practice.

Study design: Prospective, observational cohort.

Setting: Medical unit of an acute-care teaching hospital.

Synopsis: Oral signouts were audiotaped among IM house staff teams and the accompanying written signouts were collected for review of content. Signout sessions (n=88) included eight IM teams at one hospital and contained 503 patient signouts.

The median signout duration was 35 seconds (IQR 19-62) per patient. Key clinical information was present in just 62% of combined written or oral signouts. Most signouts included no questions from the recipient. Factors associated with higher rate of content inclusion included: familiarity with the patient, sense of responsibility (primary team vs. covering team), only one signout per day (as compared to sequential signout), presence of a senior resident, and comprehensive, written signouts.

Study limitations include the Hawthorne effect, as several participants mentioned that the presence of audiotape led to more comprehensive signouts than are typical. Also, the signout quality assessment in this study has not been validated with patient-safety outcomes.

Bottom line: Signouts among internal-medicine residents at this one hospital showed variability in terms of quantitative and qualitative information and often missed crucial information about patient care.

Citation: Horwitz LI, Moin T, Krumholz HM, Wang L, Bradley EH. What are covering doctors told about their patients? Analysis of sign-out among internal medicine house staff. Qual Saf Health Care. 2009;18(4):248-255.

Clinical question: Do signouts vary in the quality and quantity of information, and what are the various factors affecting signout quality?

Background: Miscommunication during transfers of responsibility for hospitalized patients is common and can result in harm. Recommendations for safe and effective handoffs emphasize key content, clear communication, senior staff supervision, and adequate time for questions. Still, little is known about adherence to these recommendations in clinical practice.

Study design: Prospective, observational cohort.

Setting: Medical unit of an acute-care teaching hospital.

Synopsis: Oral signouts were audiotaped among IM house staff teams and the accompanying written signouts were collected for review of content. Signout sessions (n=88) included eight IM teams at one hospital and contained 503 patient signouts.

The median signout duration was 35 seconds (IQR 19-62) per patient. Key clinical information was present in just 62% of combined written or oral signouts. Most signouts included no questions from the recipient. Factors associated with higher rate of content inclusion included: familiarity with the patient, sense of responsibility (primary team vs. covering team), only one signout per day (as compared to sequential signout), presence of a senior resident, and comprehensive, written signouts.

Study limitations include the Hawthorne effect, as several participants mentioned that the presence of audiotape led to more comprehensive signouts than are typical. Also, the signout quality assessment in this study has not been validated with patient-safety outcomes.

Bottom line: Signouts among internal-medicine residents at this one hospital showed variability in terms of quantitative and qualitative information and often missed crucial information about patient care.

Citation: Horwitz LI, Moin T, Krumholz HM, Wang L, Bradley EH. What are covering doctors told about their patients? Analysis of sign-out among internal medicine house staff. Qual Saf Health Care. 2009;18(4):248-255.

Clinical question: Do signouts vary in the quality and quantity of information, and what are the various factors affecting signout quality?

Background: Miscommunication during transfers of responsibility for hospitalized patients is common and can result in harm. Recommendations for safe and effective handoffs emphasize key content, clear communication, senior staff supervision, and adequate time for questions. Still, little is known about adherence to these recommendations in clinical practice.

Study design: Prospective, observational cohort.

Setting: Medical unit of an acute-care teaching hospital.

Synopsis: Oral signouts were audiotaped among IM house staff teams and the accompanying written signouts were collected for review of content. Signout sessions (n=88) included eight IM teams at one hospital and contained 503 patient signouts.

The median signout duration was 35 seconds (IQR 19-62) per patient. Key clinical information was present in just 62% of combined written or oral signouts. Most signouts included no questions from the recipient. Factors associated with higher rate of content inclusion included: familiarity with the patient, sense of responsibility (primary team vs. covering team), only one signout per day (as compared to sequential signout), presence of a senior resident, and comprehensive, written signouts.

Study limitations include the Hawthorne effect, as several participants mentioned that the presence of audiotape led to more comprehensive signouts than are typical. Also, the signout quality assessment in this study has not been validated with patient-safety outcomes.

Bottom line: Signouts among internal-medicine residents at this one hospital showed variability in terms of quantitative and qualitative information and often missed crucial information about patient care.

Citation: Horwitz LI, Moin T, Krumholz HM, Wang L, Bradley EH. What are covering doctors told about their patients? Analysis of sign-out among internal medicine house staff. Qual Saf Health Care. 2009;18(4):248-255.

Costs of Care (www.costsofcare.org), a nonprofit dedicated to empowering patients and their caregivers to deflate medical bills, and the American Board of Internal Medicine (ABIM) Foundation plan to launch their second annual Teaching Value and Choosing Wisely Competition this fall to highlight healthcare innovations promoting value. The submission deadline is Feb. 1, 2015.

The Teaching Value Project, the main educational arm of Costs of Care, has developed web-based video training modules based on actual cases, along with other educational materials to help residents and medical students learn to make clinical decisions optimizing quality and cost, says Christopher Moriates, MD, hospitalist and co-chair of the University of California-San Francisco’s High-Value Care Committee.

Details of the contest will be posted at www.teachingvalue.org. For more information, send an e-mail to [email protected].

Larry Beresford is a freelance writer in Alameda, Calif.

Costs of Care (www.costsofcare.org), a nonprofit dedicated to empowering patients and their caregivers to deflate medical bills, and the American Board of Internal Medicine (ABIM) Foundation plan to launch their second annual Teaching Value and Choosing Wisely Competition this fall to highlight healthcare innovations promoting value. The submission deadline is Feb. 1, 2015.

The Teaching Value Project, the main educational arm of Costs of Care, has developed web-based video training modules based on actual cases, along with other educational materials to help residents and medical students learn to make clinical decisions optimizing quality and cost, says Christopher Moriates, MD, hospitalist and co-chair of the University of California-San Francisco’s High-Value Care Committee.

Details of the contest will be posted at www.teachingvalue.org. For more information, send an e-mail to [email protected].

Larry Beresford is a freelance writer in Alameda, Calif.

Costs of Care (www.costsofcare.org), a nonprofit dedicated to empowering patients and their caregivers to deflate medical bills, and the American Board of Internal Medicine (ABIM) Foundation plan to launch their second annual Teaching Value and Choosing Wisely Competition this fall to highlight healthcare innovations promoting value. The submission deadline is Feb. 1, 2015.

The Teaching Value Project, the main educational arm of Costs of Care, has developed web-based video training modules based on actual cases, along with other educational materials to help residents and medical students learn to make clinical decisions optimizing quality and cost, says Christopher Moriates, MD, hospitalist and co-chair of the University of California-San Francisco’s High-Value Care Committee.

Details of the contest will be posted at www.teachingvalue.org. For more information, send an e-mail to [email protected].

Larry Beresford is a freelance writer in Alameda, Calif.

Overuse of antibiotics is fueling antimicrobial resistance, posing a threat to people around the world and prompting increased attention to antibiotic stewardship practices. Good stewardship requires hospitals and clinicians to adopt coordinated interventions that focus on reducing inappropriate antibiotic prescribing while remaining focused on the health of patients.

Although it can seem overwhelming to physicians with busy workloads and sick patients to engage in these practices, not addressing the issue of responsible antibiotic prescribing is putting patients at risk.

“We know development of resistance is complicated,” says Arjun Srinivasan, MD, FSHEA, associate director for the CDC’s Healthcare Associated Infection Prevention Program and medical director of Get Smart for Healthcare in the CDC’s division of Healthcare Quality Promotion. Dr. Srinivasan is one of the authors of a recent CDC report on antibiotic prescribing practices across the U.S. “Nonetheless, we know that overuse of antibiotics leads to increases in resistance. We also know that if we can improve the way we prescribe them, we can reduce antibiotic resistance.”

The CDC recommends that hospitals adopt, at a minimum, the following antibiotic stewardship checklist:

• Commit leadership: Dedicate necessary human, financial, and information technology resources.
• Create accountability: Appoint a single leader responsible for program outcomes. Physicians have proven successful in this role.
• Provide drug expertise: Appoint a single pharmacist leader to support improved prescribing.
• Act: Take at least one prescribing improvement action, such as requiring reassessment within 48 hours to check drug choice, dose, and duration.
• Track: Monitor prescribing and antibiotic resistance patterns.
• Report: Regularly report to staff on prescribing and resistance patterns, as well as steps to improve.
• Educate: Offer education about antibiotic resistance and improving prescribing practices.
• Work with other healthcare facilities to prevent infections, transmission, and resistance.

These practices are not just the domain of infectious disease clinicians, either, says Neil Fishman, MD, chief patient safety officer and associate chief medical officer at the University of Pennsylvania Health System and past president of the Society for Healthcare Epidemiology of America. In 1992, Dr. Fishman helped establish an antibiotic stewardship program at Penn, working with infectious disease staff to identify and adopt best practices tailored to their needs.

Their efforts have shown promise in improving the health of their patients, he says, and many institutions that adopt stewardship programs typically see cost savings, too.

“These programs do usually end up decreasing drug costs but also increasing the quality of care,”

Dr. Fishman says. “If you can cut out 30% of unnecessary drugs, you cut drug costs. To me, that meets the true definition of value in healthcare.”

In one study that looked at stewardship-related cost reduction, primarily among larger healthcare settings, the average annual savings from reduced inappropriate antibiotic prescribing ranged from $200,000 to $900,000.

The recent CDC report, to which Dr. Srinivasan contributed, was published March 4 in Vital Signs. The study found that as many as a third of antibiotics prescribed are done so inappropriately. According to experts, hospitals and other healthcare institutions need to develop processes and standards to assist physicians in efforts to be responsible antibiotic prescribers.

“Sometimes, when you’re focusing on other issues, antibiotics are a bit of an afterthought,” says Scott Flanders, MD, FACP, MHM, professor of internal medicine and director of hospital medicine at University of Michigan Medical School in Ann Arbor.

“If there is not a checklist of processes [and] things are not accounted for in a systematic way, it doesn’t happen.”

Dr. Flanders and colleague Sanjay Saint, MD, MPH, the University of Michigan George Dock Collegiate professor of internal medicine and associate chief of medicine at the VA Ann Arbor Healthcare System, recently published an article in the Journal of the American Medical Association Internal Medicine in which they recommend the following:

• Antimicrobial stewardship programs, which aim to develop guidelines and implement programs that help optimize antibiotic use among hospitalized patients, should partner with front-line clinicians to tackle the problem.
• Clinicians should better document aspects of antibiotic use that can be shared with other providers caring for the same patient throughout his or her hospital stay and after discharge.
• Clinicians should take an “antibiotic time-out” after 48-72 hours of a patient’s use of antibiotics to reassess the use of these drugs.
• Treatment and its duration should be in line with evidence-based guidelines, and institutions should work to clearly identify appropriate treatment duration.
• Improved diagnostic tests should be available to physicians.
• Target diagnostic error by working to improve how physicians think when considering whether to provide antibiotics.
• Develop performance measures that highlight common conditions in which antibiotics are overprescribed, to shine a brighter light on the problem.

“I think we can make a lot of progress,” Dr. Flanders says. “The problem is complex; it developed over decades, and any solutions are unlikely to solve the problem immediately. But there are several examples of institutions and hospitals making significant inroads in a short period of time.” —KAT

Overuse of antibiotics is fueling antimicrobial resistance, posing a threat to people around the world and prompting increased attention to antibiotic stewardship practices. Good stewardship requires hospitals and clinicians to adopt coordinated interventions that focus on reducing inappropriate antibiotic prescribing while remaining focused on the health of patients.

Although it can seem overwhelming to physicians with busy workloads and sick patients to engage in these practices, not addressing the issue of responsible antibiotic prescribing is putting patients at risk.

“We know development of resistance is complicated,” says Arjun Srinivasan, MD, FSHEA, associate director for the CDC’s Healthcare Associated Infection Prevention Program and medical director of Get Smart for Healthcare in the CDC’s division of Healthcare Quality Promotion. Dr. Srinivasan is one of the authors of a recent CDC report on antibiotic prescribing practices across the U.S. “Nonetheless, we know that overuse of antibiotics leads to increases in resistance. We also know that if we can improve the way we prescribe them, we can reduce antibiotic resistance.”

The CDC recommends that hospitals adopt, at a minimum, the following antibiotic stewardship checklist:

• Commit leadership: Dedicate necessary human, financial, and information technology resources.
• Create accountability: Appoint a single leader responsible for program outcomes. Physicians have proven successful in this role.
• Provide drug expertise: Appoint a single pharmacist leader to support improved prescribing.
• Act: Take at least one prescribing improvement action, such as requiring reassessment within 48 hours to check drug choice, dose, and duration.
• Track: Monitor prescribing and antibiotic resistance patterns.
• Report: Regularly report to staff on prescribing and resistance patterns, as well as steps to improve.
• Educate: Offer education about antibiotic resistance and improving prescribing practices.
• Work with other healthcare facilities to prevent infections, transmission, and resistance.

These practices are not just the domain of infectious disease clinicians, either, says Neil Fishman, MD, chief patient safety officer and associate chief medical officer at the University of Pennsylvania Health System and past president of the Society for Healthcare Epidemiology of America. In 1992, Dr. Fishman helped establish an antibiotic stewardship program at Penn, working with infectious disease staff to identify and adopt best practices tailored to their needs.

Their efforts have shown promise in improving the health of their patients, he says, and many institutions that adopt stewardship programs typically see cost savings, too.

“These programs do usually end up decreasing drug costs but also increasing the quality of care,”

Dr. Fishman says. “If you can cut out 30% of unnecessary drugs, you cut drug costs. To me, that meets the true definition of value in healthcare.”

In one study that looked at stewardship-related cost reduction, primarily among larger healthcare settings, the average annual savings from reduced inappropriate antibiotic prescribing ranged from $200,000 to $900,000.

The recent CDC report, to which Dr. Srinivasan contributed, was published March 4 in Vital Signs. The study found that as many as a third of antibiotics prescribed are done so inappropriately. According to experts, hospitals and other healthcare institutions need to develop processes and standards to assist physicians in efforts to be responsible antibiotic prescribers.

“Sometimes, when you’re focusing on other issues, antibiotics are a bit of an afterthought,” says Scott Flanders, MD, FACP, MHM, professor of internal medicine and director of hospital medicine at University of Michigan Medical School in Ann Arbor.

“If there is not a checklist of processes [and] things are not accounted for in a systematic way, it doesn’t happen.”

Dr. Flanders and colleague Sanjay Saint, MD, MPH, the University of Michigan George Dock Collegiate professor of internal medicine and associate chief of medicine at the VA Ann Arbor Healthcare System, recently published an article in the Journal of the American Medical Association Internal Medicine in which they recommend the following:

• Antimicrobial stewardship programs, which aim to develop guidelines and implement programs that help optimize antibiotic use among hospitalized patients, should partner with front-line clinicians to tackle the problem.
• Clinicians should better document aspects of antibiotic use that can be shared with other providers caring for the same patient throughout his or her hospital stay and after discharge.
• Clinicians should take an “antibiotic time-out” after 48-72 hours of a patient’s use of antibiotics to reassess the use of these drugs.
• Treatment and its duration should be in line with evidence-based guidelines, and institutions should work to clearly identify appropriate treatment duration.
• Improved diagnostic tests should be available to physicians.
• Target diagnostic error by working to improve how physicians think when considering whether to provide antibiotics.
• Develop performance measures that highlight common conditions in which antibiotics are overprescribed, to shine a brighter light on the problem.

“I think we can make a lot of progress,” Dr. Flanders says. “The problem is complex; it developed over decades, and any solutions are unlikely to solve the problem immediately. But there are several examples of institutions and hospitals making significant inroads in a short period of time.” —KAT

Overuse of antibiotics is fueling antimicrobial resistance, posing a threat to people around the world and prompting increased attention to antibiotic stewardship practices. Good stewardship requires hospitals and clinicians to adopt coordinated interventions that focus on reducing inappropriate antibiotic prescribing while remaining focused on the health of patients.

Although it can seem overwhelming to physicians with busy workloads and sick patients to engage in these practices, not addressing the issue of responsible antibiotic prescribing is putting patients at risk.

“We know development of resistance is complicated,” says Arjun Srinivasan, MD, FSHEA, associate director for the CDC’s Healthcare Associated Infection Prevention Program and medical director of Get Smart for Healthcare in the CDC’s division of Healthcare Quality Promotion. Dr. Srinivasan is one of the authors of a recent CDC report on antibiotic prescribing practices across the U.S. “Nonetheless, we know that overuse of antibiotics leads to increases in resistance. We also know that if we can improve the way we prescribe them, we can reduce antibiotic resistance.”

The CDC recommends that hospitals adopt, at a minimum, the following antibiotic stewardship checklist:

• Commit leadership: Dedicate necessary human, financial, and information technology resources.
• Create accountability: Appoint a single leader responsible for program outcomes. Physicians have proven successful in this role.
• Provide drug expertise: Appoint a single pharmacist leader to support improved prescribing.
• Act: Take at least one prescribing improvement action, such as requiring reassessment within 48 hours to check drug choice, dose, and duration.
• Track: Monitor prescribing and antibiotic resistance patterns.
• Report: Regularly report to staff on prescribing and resistance patterns, as well as steps to improve.
• Educate: Offer education about antibiotic resistance and improving prescribing practices.
• Work with other healthcare facilities to prevent infections, transmission, and resistance.

These practices are not just the domain of infectious disease clinicians, either, says Neil Fishman, MD, chief patient safety officer and associate chief medical officer at the University of Pennsylvania Health System and past president of the Society for Healthcare Epidemiology of America. In 1992, Dr. Fishman helped establish an antibiotic stewardship program at Penn, working with infectious disease staff to identify and adopt best practices tailored to their needs.

Their efforts have shown promise in improving the health of their patients, he says, and many institutions that adopt stewardship programs typically see cost savings, too.

“These programs do usually end up decreasing drug costs but also increasing the quality of care,”

Dr. Fishman says. “If you can cut out 30% of unnecessary drugs, you cut drug costs. To me, that meets the true definition of value in healthcare.”

In one study that looked at stewardship-related cost reduction, primarily among larger healthcare settings, the average annual savings from reduced inappropriate antibiotic prescribing ranged from $200,000 to $900,000.

The recent CDC report, to which Dr. Srinivasan contributed, was published March 4 in Vital Signs. The study found that as many as a third of antibiotics prescribed are done so inappropriately. According to experts, hospitals and other healthcare institutions need to develop processes and standards to assist physicians in efforts to be responsible antibiotic prescribers.

“Sometimes, when you’re focusing on other issues, antibiotics are a bit of an afterthought,” says Scott Flanders, MD, FACP, MHM, professor of internal medicine and director of hospital medicine at University of Michigan Medical School in Ann Arbor.

“If there is not a checklist of processes [and] things are not accounted for in a systematic way, it doesn’t happen.”

Dr. Flanders and colleague Sanjay Saint, MD, MPH, the University of Michigan George Dock Collegiate professor of internal medicine and associate chief of medicine at the VA Ann Arbor Healthcare System, recently published an article in the Journal of the American Medical Association Internal Medicine in which they recommend the following:

• Antimicrobial stewardship programs, which aim to develop guidelines and implement programs that help optimize antibiotic use among hospitalized patients, should partner with front-line clinicians to tackle the problem.
• Clinicians should better document aspects of antibiotic use that can be shared with other providers caring for the same patient throughout his or her hospital stay and after discharge.
• Clinicians should take an “antibiotic time-out” after 48-72 hours of a patient’s use of antibiotics to reassess the use of these drugs.
• Treatment and its duration should be in line with evidence-based guidelines, and institutions should work to clearly identify appropriate treatment duration.
• Improved diagnostic tests should be available to physicians.
• Target diagnostic error by working to improve how physicians think when considering whether to provide antibiotics.
• Develop performance measures that highlight common conditions in which antibiotics are overprescribed, to shine a brighter light on the problem.

“I think we can make a lot of progress,” Dr. Flanders says. “The problem is complex; it developed over decades, and any solutions are unlikely to solve the problem immediately. But there are several examples of institutions and hospitals making significant inroads in a short period of time.” —KAT

A recent CDC study found that nearly a third of antibiotics might be inappropriately prescribed.¹ The report also found wide variation in antibiotic prescribing practices for patients in similar treatment areas in hospitals across the country.

Across the globe, antibiotic resistance has become a daunting threat. Some public health officials have labeled it a crisis, and improper prescribing and use of antibiotics is at least partly to blame, experts say.

“We’re dangerously close to a pre-antibiotic era where we don’t have antibiotics to treat common infections,” says Neil Fishman, MD, chief patient safety officer and associate chief medical officer at the University of Pennsylvania Health System and past president of the Society for Healthcare Epidemiology of America. “We are seeing more and more infections, usually hospital-based, caused by bacterial resistance to most, if not all, of the antibiotics that we have.”

It’s an issue hospitalists around the country are championing.

“I think for a long time there’s been a misperception that antibiotic stewardship is at odds with hospitalists, who are managing very busy patient loads and managing inpatient prescribing,” says Arjun Srinivasan, MD, FSHEA, associate director for the CDC’s Healthcare Associated Infection Prevention Program and medical director of Get Smart for Healthcare in the division of Healthcare Quality Promotion at the CDC. Dr. Srinivasan is one of the authors of the new CDC study.

But “they have taken that ball and run with it,” says Dr. Srinivasan, who has worked with the Society of Hospital Medicine to address antibiotic resistance issues.

The goals of the study, published in the CDC’s Vital Signs on March 4, 2014, were to evaluate the extent and rationale for the prescribing of antibiotics in U.S. hospitals, while demonstrating opportunities for improvement in prescribing practices.

Study authors analyzed data from the Truven Health MarketScan Hospital Drug Database and the CDC’s Emerging Infection Program and, using a model based on the data, demonstrated that a 30% reduction in broad-spectrum antibiotics use would decrease Clostridium difficile infection (CDI) by 26%. Overall antibiotic use would drop by 5%.

According to the CDC, antibiotics are among the most frequent causes of adverse drug events among hospitalized patients in the U.S., and complications like CDI can be deadly. In fact, 250,000 hospitalized patients are infected with CDI each year, resulting in 14,000 deaths.

“We’re really at a critical juncture in healthcare now,” Dr. Fishman says. “The field of stewardship has evolved mainly in academic tertiary care settings. The CDC report is timely because it highlights the necessity of making sure antibiotics are used appropriately in all healthcare settings.”

Take a Break

One of the ways in which hospitalists have addressed the need for more appropriate antibiotic prescribing in their institutions is the practice of an “antibiotic time-out.”

“After some point, when the dust settles at about 48-72 hours, you can evaluate the patient’s progress, evaluate their studies, [and] you may have culture results,” says Scott Flanders, MD, FACP, MHM, professor of internal medicine and director of hospital medicine at the University of Michigan Medical School in Ann Arbor. At that point, physicians can decide whether to maintain a patient on the original antibiotic, alter the duration of treatment, or take them off the treatment altogether.

Dr. Flanders and a colleague published an editorial in the Journal of the American Medical Association Internal Medicine that coincided with the CDC report.² A 2007 study published in Clinical Infectious Diseases found that the choice of antibiotic agent or duration of treatment can be incorrect in as many as half of all cases in which antibiotics are prescribed.³

Dr. Flanders, a past president of SHM who has worked extensively with the CDC and the Institute for Healthcare Improvement, was behind the development of the time-out strategy. Dr. Srinivasan says the clinical utility of the method was “eye-opening.”

The strategy, which has taken hold among hospital groups the CDC has worked with, has demonstrated that stewardship and patient management are not at odds, Dr. Srinivasan says. Despite patient sign-outs and hand-offs, the time-out strategy allows any clinician to track a patient’s antibiotic status and reevaluate the treatment plan.

Having a process is critical to more responsible prescribing practices, Dr. Flanders says. He attributes much of the variability in antibiotics prescribing among similar departments at hospitals across the country to a lack of standards, though he noted that variability in patient populations undoubtedly plays a role.

Lack of Stats

The CDC report showed up to a threefold difference in the number of antibiotics prescribed to patients in similar hospital settings at hospitals across the country. The reasons for this are not known, Dr. Fishman says.

“The main reason we don’t know is we don’t have a good mechanism in the U.S. right now to monitor antibiotics use,” he explains. “We don’t have a way for healthcare facilities to benchmark their use.”

Without good strategies to monitor and develop more responsible antibiotics prescription practices, Dr. Flanders believes many physicians find themselves trapped by the “chagrin” of not prescribing.

“Patients often enter the hospital without a clear diagnosis,” he says. “They are quite ill. They may have a serious bacterial infection, and, in diagnosing them, we can’t guess wrong and make the decision to withhold antibiotics, only to find out later the patient is infected.

“We know delays increase mortality, and that’s not an acceptable option.”

Patients often enter the hospital without a clear diagnosis. They are quite ill. They may have a serious bacterial infection, and, in diagnosing them, we can’t guess wrong and make the decision to withhold antibiotics, only to find out later the patient is infected.

 

—Scott Flanders, MD, FACP, MHM, professor of internal medicine, director of hospital medicine, University of Michigan Medical School, Ann Arbor, past president, SHM

Beyond the Bedside

Many physicians fail to consider the bigger societal implications when prescribing antibiotics for sick patients in their charge, because their responsibility is, first and foremost, to that individual. But, Dr. Srinivasan says, “good antibiotic stewardship is beneficial to the patient lying in the bed in front of you, because every day we are confronted with C. diff. infections, adverse drug events, all of these issues.”

Strategies and processes help hospitalists make the best decision for their patients at the time they require care, while providing room for adaptation and the improvements that serve all patients.

Some institutions use interventions like prospective audit and feedback monitoring to help physicians become more responsible antibiotic prescribers, says Dr. Fishman, who worked with infectious disease specialists at the University of Pennsylvania in the early 1990s to develop a stewardship program there.

“In our institution, we see better outcomes—lower complications—usually associated with a decreased length of stay, at least in the ICU for critically ill patients—and increased cure rates,” he says.

Stewardship efforts take investment on the part of the hospital. Dr. Fishman cited a recent study at the Children’s Hospital of Pennsylvania that looked at whether a particular education strategy the hospital implemented actually led to improvements.⁴

“It was successful in intervening in this problem [of inappropriate prescribing] in pediatricians, but it did take ongoing education of both healthcare providers and patients,” he says, noting that large financial and time investments are necessary for the ongoing training and follow-up that is necessary.

And patients need to be educated, too.

“It takes a minute to write that prescription and probably 15 or 20 minutes not to write it,” Dr. Fishman says. “We need to educate patients about potential complications of antibiotics use, as well as the signs and symptoms of infection.”

The CDC report is a call to action for all healthcare providers to consider how they can become better antibiotic stewards. There are very few new antibiotics on the market and little in the pipeline. All providers must do what they can to preserve the antibiotics we currently have, Dr. Fishman says.

“There is opportunity, and I think hospitalists are up to the challenge,” Dr. Flanders says. “They are doing lots of work to improve quality across lots of domains in their hospitals. I think this is an area where attention is deserved.”

Kelly April Tyrrell is a freelance writer in Madison, Wis.

References

1. Centers for Disease Control and Prevention. Morbidity and Mortality Weekly Report. Vital signs: improving antibiotic use among hospitalized patients. Available at: www.cdc.gov/mmwr/preview/mmwrhtml/mm6309a4.htm?s_cid=mm6309a4_w. Accessed August 31, 2014.
2. Flanders SA, Saint S. Why does antrimicrobial overuse in hospitalized patients persist? JAMA Internal Medicine online. Available at: http://archinte.jamanetwork.com/article.aspx?articleid=1838720. Accessed August 31, 2014.
3. Dellit TH, Owens RC, McGowan JE, et al. Clinical Infectious Diseases online. Available at: http://cid.oxfordjournals.org/content/44/2/159.full. Accessed August 31, 2014.
4. Gerber JS, Prasad PA, Fiks A, et al. Effect of an outpatient antimicrobial stewardship intervention on broad-spectrum antibiotic prescribing by primary care pediatricians. JAMA. 2013;309(22):2345-2352.

A recent CDC study found that nearly a third of antibiotics might be inappropriately prescribed.¹ The report also found wide variation in antibiotic prescribing practices for patients in similar treatment areas in hospitals across the country.

Across the globe, antibiotic resistance has become a daunting threat. Some public health officials have labeled it a crisis, and improper prescribing and use of antibiotics is at least partly to blame, experts say.

“We’re dangerously close to a pre-antibiotic era where we don’t have antibiotics to treat common infections,” says Neil Fishman, MD, chief patient safety officer and associate chief medical officer at the University of Pennsylvania Health System and past president of the Society for Healthcare Epidemiology of America. “We are seeing more and more infections, usually hospital-based, caused by bacterial resistance to most, if not all, of the antibiotics that we have.”

It’s an issue hospitalists around the country are championing.

“I think for a long time there’s been a misperception that antibiotic stewardship is at odds with hospitalists, who are managing very busy patient loads and managing inpatient prescribing,” says Arjun Srinivasan, MD, FSHEA, associate director for the CDC’s Healthcare Associated Infection Prevention Program and medical director of Get Smart for Healthcare in the division of Healthcare Quality Promotion at the CDC. Dr. Srinivasan is one of the authors of the new CDC study.

But “they have taken that ball and run with it,” says Dr. Srinivasan, who has worked with the Society of Hospital Medicine to address antibiotic resistance issues.

The goals of the study, published in the CDC’s Vital Signs on March 4, 2014, were to evaluate the extent and rationale for the prescribing of antibiotics in U.S. hospitals, while demonstrating opportunities for improvement in prescribing practices.

Study authors analyzed data from the Truven Health MarketScan Hospital Drug Database and the CDC’s Emerging Infection Program and, using a model based on the data, demonstrated that a 30% reduction in broad-spectrum antibiotics use would decrease Clostridium difficile infection (CDI) by 26%. Overall antibiotic use would drop by 5%.

According to the CDC, antibiotics are among the most frequent causes of adverse drug events among hospitalized patients in the U.S., and complications like CDI can be deadly. In fact, 250,000 hospitalized patients are infected with CDI each year, resulting in 14,000 deaths.

“We’re really at a critical juncture in healthcare now,” Dr. Fishman says. “The field of stewardship has evolved mainly in academic tertiary care settings. The CDC report is timely because it highlights the necessity of making sure antibiotics are used appropriately in all healthcare settings.”

Take a Break

One of the ways in which hospitalists have addressed the need for more appropriate antibiotic prescribing in their institutions is the practice of an “antibiotic time-out.”

“After some point, when the dust settles at about 48-72 hours, you can evaluate the patient’s progress, evaluate their studies, [and] you may have culture results,” says Scott Flanders, MD, FACP, MHM, professor of internal medicine and director of hospital medicine at the University of Michigan Medical School in Ann Arbor. At that point, physicians can decide whether to maintain a patient on the original antibiotic, alter the duration of treatment, or take them off the treatment altogether.

Dr. Flanders and a colleague published an editorial in the Journal of the American Medical Association Internal Medicine that coincided with the CDC report.² A 2007 study published in Clinical Infectious Diseases found that the choice of antibiotic agent or duration of treatment can be incorrect in as many as half of all cases in which antibiotics are prescribed.³

Dr. Flanders, a past president of SHM who has worked extensively with the CDC and the Institute for Healthcare Improvement, was behind the development of the time-out strategy. Dr. Srinivasan says the clinical utility of the method was “eye-opening.”

The strategy, which has taken hold among hospital groups the CDC has worked with, has demonstrated that stewardship and patient management are not at odds, Dr. Srinivasan says. Despite patient sign-outs and hand-offs, the time-out strategy allows any clinician to track a patient’s antibiotic status and reevaluate the treatment plan.

Having a process is critical to more responsible prescribing practices, Dr. Flanders says. He attributes much of the variability in antibiotics prescribing among similar departments at hospitals across the country to a lack of standards, though he noted that variability in patient populations undoubtedly plays a role.

Lack of Stats

The CDC report showed up to a threefold difference in the number of antibiotics prescribed to patients in similar hospital settings at hospitals across the country. The reasons for this are not known, Dr. Fishman says.

“The main reason we don’t know is we don’t have a good mechanism in the U.S. right now to monitor antibiotics use,” he explains. “We don’t have a way for healthcare facilities to benchmark their use.”

Without good strategies to monitor and develop more responsible antibiotics prescription practices, Dr. Flanders believes many physicians find themselves trapped by the “chagrin” of not prescribing.

“Patients often enter the hospital without a clear diagnosis,” he says. “They are quite ill. They may have a serious bacterial infection, and, in diagnosing them, we can’t guess wrong and make the decision to withhold antibiotics, only to find out later the patient is infected.

“We know delays increase mortality, and that’s not an acceptable option.”

Patients often enter the hospital without a clear diagnosis. They are quite ill. They may have a serious bacterial infection, and, in diagnosing them, we can’t guess wrong and make the decision to withhold antibiotics, only to find out later the patient is infected.

 

—Scott Flanders, MD, FACP, MHM, professor of internal medicine, director of hospital medicine, University of Michigan Medical School, Ann Arbor, past president, SHM

Beyond the Bedside

Many physicians fail to consider the bigger societal implications when prescribing antibiotics for sick patients in their charge, because their responsibility is, first and foremost, to that individual. But, Dr. Srinivasan says, “good antibiotic stewardship is beneficial to the patient lying in the bed in front of you, because every day we are confronted with C. diff. infections, adverse drug events, all of these issues.”

Strategies and processes help hospitalists make the best decision for their patients at the time they require care, while providing room for adaptation and the improvements that serve all patients.

Some institutions use interventions like prospective audit and feedback monitoring to help physicians become more responsible antibiotic prescribers, says Dr. Fishman, who worked with infectious disease specialists at the University of Pennsylvania in the early 1990s to develop a stewardship program there.

“In our institution, we see better outcomes—lower complications—usually associated with a decreased length of stay, at least in the ICU for critically ill patients—and increased cure rates,” he says.

Stewardship efforts take investment on the part of the hospital. Dr. Fishman cited a recent study at the Children’s Hospital of Pennsylvania that looked at whether a particular education strategy the hospital implemented actually led to improvements.⁴

“It was successful in intervening in this problem [of inappropriate prescribing] in pediatricians, but it did take ongoing education of both healthcare providers and patients,” he says, noting that large financial and time investments are necessary for the ongoing training and follow-up that is necessary.

And patients need to be educated, too.

“It takes a minute to write that prescription and probably 15 or 20 minutes not to write it,” Dr. Fishman says. “We need to educate patients about potential complications of antibiotics use, as well as the signs and symptoms of infection.”

The CDC report is a call to action for all healthcare providers to consider how they can become better antibiotic stewards. There are very few new antibiotics on the market and little in the pipeline. All providers must do what they can to preserve the antibiotics we currently have, Dr. Fishman says.

“There is opportunity, and I think hospitalists are up to the challenge,” Dr. Flanders says. “They are doing lots of work to improve quality across lots of domains in their hospitals. I think this is an area where attention is deserved.”

Kelly April Tyrrell is a freelance writer in Madison, Wis.

References

1. Centers for Disease Control and Prevention. Morbidity and Mortality Weekly Report. Vital signs: improving antibiotic use among hospitalized patients. Available at: www.cdc.gov/mmwr/preview/mmwrhtml/mm6309a4.htm?s_cid=mm6309a4_w. Accessed August 31, 2014.
2. Flanders SA, Saint S. Why does antrimicrobial overuse in hospitalized patients persist? JAMA Internal Medicine online. Available at: http://archinte.jamanetwork.com/article.aspx?articleid=1838720. Accessed August 31, 2014.
3. Dellit TH, Owens RC, McGowan JE, et al. Clinical Infectious Diseases online. Available at: http://cid.oxfordjournals.org/content/44/2/159.full. Accessed August 31, 2014.
4. Gerber JS, Prasad PA, Fiks A, et al. Effect of an outpatient antimicrobial stewardship intervention on broad-spectrum antibiotic prescribing by primary care pediatricians. JAMA. 2013;309(22):2345-2352.

A recent CDC study found that nearly a third of antibiotics might be inappropriately prescribed.¹ The report also found wide variation in antibiotic prescribing practices for patients in similar treatment areas in hospitals across the country.

Across the globe, antibiotic resistance has become a daunting threat. Some public health officials have labeled it a crisis, and improper prescribing and use of antibiotics is at least partly to blame, experts say.

“We’re dangerously close to a pre-antibiotic era where we don’t have antibiotics to treat common infections,” says Neil Fishman, MD, chief patient safety officer and associate chief medical officer at the University of Pennsylvania Health System and past president of the Society for Healthcare Epidemiology of America. “We are seeing more and more infections, usually hospital-based, caused by bacterial resistance to most, if not all, of the antibiotics that we have.”

It’s an issue hospitalists around the country are championing.

“I think for a long time there’s been a misperception that antibiotic stewardship is at odds with hospitalists, who are managing very busy patient loads and managing inpatient prescribing,” says Arjun Srinivasan, MD, FSHEA, associate director for the CDC’s Healthcare Associated Infection Prevention Program and medical director of Get Smart for Healthcare in the division of Healthcare Quality Promotion at the CDC. Dr. Srinivasan is one of the authors of the new CDC study.

But “they have taken that ball and run with it,” says Dr. Srinivasan, who has worked with the Society of Hospital Medicine to address antibiotic resistance issues.

The goals of the study, published in the CDC’s Vital Signs on March 4, 2014, were to evaluate the extent and rationale for the prescribing of antibiotics in U.S. hospitals, while demonstrating opportunities for improvement in prescribing practices.

Study authors analyzed data from the Truven Health MarketScan Hospital Drug Database and the CDC’s Emerging Infection Program and, using a model based on the data, demonstrated that a 30% reduction in broad-spectrum antibiotics use would decrease Clostridium difficile infection (CDI) by 26%. Overall antibiotic use would drop by 5%.

According to the CDC, antibiotics are among the most frequent causes of adverse drug events among hospitalized patients in the U.S., and complications like CDI can be deadly. In fact, 250,000 hospitalized patients are infected with CDI each year, resulting in 14,000 deaths.

“We’re really at a critical juncture in healthcare now,” Dr. Fishman says. “The field of stewardship has evolved mainly in academic tertiary care settings. The CDC report is timely because it highlights the necessity of making sure antibiotics are used appropriately in all healthcare settings.”

Take a Break

One of the ways in which hospitalists have addressed the need for more appropriate antibiotic prescribing in their institutions is the practice of an “antibiotic time-out.”

“After some point, when the dust settles at about 48-72 hours, you can evaluate the patient’s progress, evaluate their studies, [and] you may have culture results,” says Scott Flanders, MD, FACP, MHM, professor of internal medicine and director of hospital medicine at the University of Michigan Medical School in Ann Arbor. At that point, physicians can decide whether to maintain a patient on the original antibiotic, alter the duration of treatment, or take them off the treatment altogether.

Dr. Flanders and a colleague published an editorial in the Journal of the American Medical Association Internal Medicine that coincided with the CDC report.² A 2007 study published in Clinical Infectious Diseases found that the choice of antibiotic agent or duration of treatment can be incorrect in as many as half of all cases in which antibiotics are prescribed.³

Dr. Flanders, a past president of SHM who has worked extensively with the CDC and the Institute for Healthcare Improvement, was behind the development of the time-out strategy. Dr. Srinivasan says the clinical utility of the method was “eye-opening.”

The strategy, which has taken hold among hospital groups the CDC has worked with, has demonstrated that stewardship and patient management are not at odds, Dr. Srinivasan says. Despite patient sign-outs and hand-offs, the time-out strategy allows any clinician to track a patient’s antibiotic status and reevaluate the treatment plan.

Having a process is critical to more responsible prescribing practices, Dr. Flanders says. He attributes much of the variability in antibiotics prescribing among similar departments at hospitals across the country to a lack of standards, though he noted that variability in patient populations undoubtedly plays a role.

Lack of Stats

The CDC report showed up to a threefold difference in the number of antibiotics prescribed to patients in similar hospital settings at hospitals across the country. The reasons for this are not known, Dr. Fishman says.

“The main reason we don’t know is we don’t have a good mechanism in the U.S. right now to monitor antibiotics use,” he explains. “We don’t have a way for healthcare facilities to benchmark their use.”

Without good strategies to monitor and develop more responsible antibiotics prescription practices, Dr. Flanders believes many physicians find themselves trapped by the “chagrin” of not prescribing.

“Patients often enter the hospital without a clear diagnosis,” he says. “They are quite ill. They may have a serious bacterial infection, and, in diagnosing them, we can’t guess wrong and make the decision to withhold antibiotics, only to find out later the patient is infected.

“We know delays increase mortality, and that’s not an acceptable option.”

Patients often enter the hospital without a clear diagnosis. They are quite ill. They may have a serious bacterial infection, and, in diagnosing them, we can’t guess wrong and make the decision to withhold antibiotics, only to find out later the patient is infected.

 

—Scott Flanders, MD, FACP, MHM, professor of internal medicine, director of hospital medicine, University of Michigan Medical School, Ann Arbor, past president, SHM

Beyond the Bedside

Many physicians fail to consider the bigger societal implications when prescribing antibiotics for sick patients in their charge, because their responsibility is, first and foremost, to that individual. But, Dr. Srinivasan says, “good antibiotic stewardship is beneficial to the patient lying in the bed in front of you, because every day we are confronted with C. diff. infections, adverse drug events, all of these issues.”

Strategies and processes help hospitalists make the best decision for their patients at the time they require care, while providing room for adaptation and the improvements that serve all patients.

Some institutions use interventions like prospective audit and feedback monitoring to help physicians become more responsible antibiotic prescribers, says Dr. Fishman, who worked with infectious disease specialists at the University of Pennsylvania in the early 1990s to develop a stewardship program there.

“In our institution, we see better outcomes—lower complications—usually associated with a decreased length of stay, at least in the ICU for critically ill patients—and increased cure rates,” he says.

Stewardship efforts take investment on the part of the hospital. Dr. Fishman cited a recent study at the Children’s Hospital of Pennsylvania that looked at whether a particular education strategy the hospital implemented actually led to improvements.⁴

“It was successful in intervening in this problem [of inappropriate prescribing] in pediatricians, but it did take ongoing education of both healthcare providers and patients,” he says, noting that large financial and time investments are necessary for the ongoing training and follow-up that is necessary.

And patients need to be educated, too.

“It takes a minute to write that prescription and probably 15 or 20 minutes not to write it,” Dr. Fishman says. “We need to educate patients about potential complications of antibiotics use, as well as the signs and symptoms of infection.”

The CDC report is a call to action for all healthcare providers to consider how they can become better antibiotic stewards. There are very few new antibiotics on the market and little in the pipeline. All providers must do what they can to preserve the antibiotics we currently have, Dr. Fishman says.

“There is opportunity, and I think hospitalists are up to the challenge,” Dr. Flanders says. “They are doing lots of work to improve quality across lots of domains in their hospitals. I think this is an area where attention is deserved.”

Kelly April Tyrrell is a freelance writer in Madison, Wis.

References

1. Centers for Disease Control and Prevention. Morbidity and Mortality Weekly Report. Vital signs: improving antibiotic use among hospitalized patients. Available at: www.cdc.gov/mmwr/preview/mmwrhtml/mm6309a4.htm?s_cid=mm6309a4_w. Accessed August 31, 2014.
2. Flanders SA, Saint S. Why does antrimicrobial overuse in hospitalized patients persist? JAMA Internal Medicine online. Available at: http://archinte.jamanetwork.com/article.aspx?articleid=1838720. Accessed August 31, 2014.
3. Dellit TH, Owens RC, McGowan JE, et al. Clinical Infectious Diseases online. Available at: http://cid.oxfordjournals.org/content/44/2/159.full. Accessed August 31, 2014.
4. Gerber JS, Prasad PA, Fiks A, et al. Effect of an outpatient antimicrobial stewardship intervention on broad-spectrum antibiotic prescribing by primary care pediatricians. JAMA. 2013;309(22):2345-2352.

Summary

Behavioral emergencies occur when a patient is physically aggressive or potentially harmful to himself/herself or others. Although they may be rare, behavioral emergencies are high-risk situations, and untrained staff might be uncomfortable dealing with these events.

Patients with underlying psychiatric or developmental disorders, those who have ingested substances, or those who have a medication side effect are at the highest risk for becoming violent. Triggers for these events could be pain, hunger, isolation, change in routine, or even the hospital’s physical environment. Early warning signs for a behavioral emergency can include verbal threats, yelling, or silence. Physical signs may include pacing, crossed arms, furrowed brow, or throwing objects.

The first response to a potential behavioral emergency is to try to de-escalate the situation. Speak in a quiet, calm voice; back off and give personal space. Try to reduce a source of discomfort, and use distractions or rewards. If de-escalation is not successful and a patient becomes violent, the provider’s first role is to be safe: Get away and get help. Hospitals should have—or should develop—a violent patient response team, which may then physically restrain the patient. Medications can be used to treat medical issues but should not be used solely for chemical restraint.

Once a patient is safely restrained, a number of Joint Commission on Accreditation of Healthcare Organizations-mandated actions must occur. The legal guardian and attending of record must be notified. A debrief must occur regarding the events; this must be documented in the medical record. Finally, a strategy must be formulated to enable the patient to be safely removed from restraints as soon as it is safe.

The presenters demonstrated various personal safety techniques to escape from a violent patient, as well as the use of physical restraints. Participants engaged in a mock behavioral emergency to experience the chaos of these events.

Summary

Behavioral emergencies occur when a patient is physically aggressive or potentially harmful to himself/herself or others. Although they may be rare, behavioral emergencies are high-risk situations, and untrained staff might be uncomfortable dealing with these events.

Patients with underlying psychiatric or developmental disorders, those who have ingested substances, or those who have a medication side effect are at the highest risk for becoming violent. Triggers for these events could be pain, hunger, isolation, change in routine, or even the hospital’s physical environment. Early warning signs for a behavioral emergency can include verbal threats, yelling, or silence. Physical signs may include pacing, crossed arms, furrowed brow, or throwing objects.

The first response to a potential behavioral emergency is to try to de-escalate the situation. Speak in a quiet, calm voice; back off and give personal space. Try to reduce a source of discomfort, and use distractions or rewards. If de-escalation is not successful and a patient becomes violent, the provider’s first role is to be safe: Get away and get help. Hospitals should have—or should develop—a violent patient response team, which may then physically restrain the patient. Medications can be used to treat medical issues but should not be used solely for chemical restraint.

Once a patient is safely restrained, a number of Joint Commission on Accreditation of Healthcare Organizations-mandated actions must occur. The legal guardian and attending of record must be notified. A debrief must occur regarding the events; this must be documented in the medical record. Finally, a strategy must be formulated to enable the patient to be safely removed from restraints as soon as it is safe.

The presenters demonstrated various personal safety techniques to escape from a violent patient, as well as the use of physical restraints. Participants engaged in a mock behavioral emergency to experience the chaos of these events.

Summary

Behavioral emergencies occur when a patient is physically aggressive or potentially harmful to himself/herself or others. Although they may be rare, behavioral emergencies are high-risk situations, and untrained staff might be uncomfortable dealing with these events.

Patients with underlying psychiatric or developmental disorders, those who have ingested substances, or those who have a medication side effect are at the highest risk for becoming violent. Triggers for these events could be pain, hunger, isolation, change in routine, or even the hospital’s physical environment. Early warning signs for a behavioral emergency can include verbal threats, yelling, or silence. Physical signs may include pacing, crossed arms, furrowed brow, or throwing objects.

The first response to a potential behavioral emergency is to try to de-escalate the situation. Speak in a quiet, calm voice; back off and give personal space. Try to reduce a source of discomfort, and use distractions or rewards. If de-escalation is not successful and a patient becomes violent, the provider’s first role is to be safe: Get away and get help. Hospitals should have—or should develop—a violent patient response team, which may then physically restrain the patient. Medications can be used to treat medical issues but should not be used solely for chemical restraint.

Once a patient is safely restrained, a number of Joint Commission on Accreditation of Healthcare Organizations-mandated actions must occur. The legal guardian and attending of record must be notified. A debrief must occur regarding the events; this must be documented in the medical record. Finally, a strategy must be formulated to enable the patient to be safely removed from restraints as soon as it is safe.

The presenters demonstrated various personal safety techniques to escape from a violent patient, as well as the use of physical restraints. Participants engaged in a mock behavioral emergency to experience the chaos of these events.

Christine Lum Lung, MD, SFHM

When SHM received the Joint Commission’s John M. Eisenberg Patient Safety and Quality Award for 2011 for innovation in patient safety and quality at the national level, the award represented national recognition for the society’s three major hospital quality improvement initiatives. Moreover, it highlighted the integral role mentors play in each of the programs, helping physicians and hospitals make accelerated progress on important patient safety and quality issues.

Mentored implementation assigns a physician expert to train, guide, and work with the participating facilities’ hospitalist-led, multidisciplinary team through the life cycle of a QI initiative. The three programs focus on VTE prevention, glycemic control, and transitions of care. The first hospital cohort for VTE prevention—the VTE Prevention Collaborative—was in 2007. The care transitions program, known as Project BOOST, started in 2008. The Glycemic Control Mentored Implementation (GCMI) Program began in 2009. A fourth SHM mentored implementation program is MARQUIS, the Multi-Center Medication Reconciliation Quality Improvement Study.

In basic terms, mentoring is “coaching from a physician who has expertise both in the clinical subject matter and in implementing the processes and tools of quality improvement—usually because they’ve done it themselves,” says Gregory Maynard, MD, MSc, SFHM, senior vice president of SHM’s Center for Hospital Innovation and Improvement and a co-founder of two of its mentored implementation programs.

Mentors typically are paired with one or two participating hospitals for 12 to 18 months, conducting monthly conference calls with the team, sharing tools and resources from SHM’s online library, and offering advice on how to navigate the treacherous currents of culture change within a hospital. BOOST mentors also make in-person site visits. They are well versed in protocol and order set design and quality measurement strategies, and they know how to engage frontline professionals and institutional leadership, Dr. Maynard says.

Some mentors have received formal QI training, and many have attended Mentor University, a 1-1/2 day intensive training course offered by SHM that reinforces the nuances of coaching, the contents of SHM’s quality toolkits, and ideas for overcoming common barriers to improvement. SHM’s mentor support provides continuous professional development for the mentors, pairing new mentors with senior mentors to coach them in the process and hosting an online community with other mentors.

“What’s telling to me is that many of the people who have been mentored by SHM’s programs in one topic go on to become mentors in another topic, taking those portable skills and principles and applying them in other quality areas,” Dr. Maynard says. “We’re fostering leadership and quality improvement skills among hospitalists; that’s really one of our main goals. People learn the skill and then spread it within their system.”

Mark Williams, MD, FACP, MHM, Project BOOST principal investigator and a veteran SHM mentor, says that just providing educational materials to health professionals often isn’t enough for them to overcome the barriers to change.

“I’ve seen many large-scale quality projects that didn’t work, as they were simply disseminating information, content, or knowledge,” he says. Mentored implementation as practiced by SHM is “a model for disseminating quality improvement nationally,” he adds. “Pretty much any quality improvement project can be done this way.”

Key to the mentored implementation program’s success is the personalized approach and customized solutions.

“You directly meet with the team in their own setting and begin to see what’s going on,” Dr. Williams says. “You also meet with the hospital’s senior leadership. That’s when you start to see change.”

The Hospitalist connected with eight SHM mentors. The following are snapshots of their work in the mentorship program and some of the lessons they taught—and learned—from the program.

Christine Lum Lung, MD, SFHM

Christine Lum Lung, MD, SFHM

Title: Medical director, Northern Colorado Hospitalists, Fort Collins

Program: VTE Prevention Collaborative

Background: As a practicing hospitalist and medical director of the HM group for a two-hospital system, Dr. Lum Lung chaired its quality committee for VTE protocol development. “It was obvious at our hospitals that we needed to do better at VTE prevention,” she explains.

Dr. Lum Lung’s team received VTE mentorship from Dr. Maynard, who later asked her to become a VTE mentor. She also attended all three levels of SHM’s Leadership Academy and has since become a mentor for the new HP3 (Hospitalist Program Peak Performance) mentored implementation program, a one-year collaboration among SHM, Northwestern University, Blue Cross/Blue Shield of Illinois, and the Illinois Hospital Association that is designed to help hospitalist groups optimize their programs and build healthy group culture.

Teachable moment: The essential qualities of a good mentee, Dr. Lum Lung says, are drive and dedication. “You believe strongly about it, so you can sell it to others. You also need a thick skin to face the adversities that come up. When my mentor gave me tasks and deadlines, I met those deadlines.”

Success story: “I’ve been impressed with how hard groups and individuals can work.” Most of the teams she has worked with were facing significant external stressors—starting a new program, moving into a new hospital, rolling out a new EHR, becoming part of a growing medical group. “Yet each of them has been incredibly engaged in the process and dedicated to completing their projects.”

Lessons learned: “That we all have something to learn from each other. While I am officially the mentor, I have learned a lot about processes, teamwork, and flow issues from the sites that could potentially be incorporated in our program.”

Advice: Working on a project as a team can be very powerful, she says. Even seemingly ‘small’ projects have allowed teams to learn how to work better together on day-to-day issues. With the victory of a small project behind them, they make lists of the next thing that they want to tackle.

“Our profession is constantly changing. We need to be thinking ahead for how we will face those challenges,” Dr. Lum Lung says. “A team that works well together will have an advantage in this new environment. Even if you have people who are new to quality improvement, their participation can still be important.”

Jordan Messler, MD, SFHM

Jordan Messler, MD, SFHM

Title: Medical director, Morton Plant Hospitalists, Clearwater, Fla.

Program: GCMI; Project BOOST

Background: Dr. Messler’s interest in QI led him to work with colleagues in SHM who are national leaders in quality. “A couple of years ago, I enrolled in Emory’s Quality Academy, a sister course to Intermountain Health’s course on quality. Then I enrolled our hospital in both the GCMI Program and Project BOOST. My mentors for those programs were terrific guides, which led to my interest in seeing their side of the program as a mentor myself.”

Teachable moment: One program had difficulty implementing a VTE prevention tool and couldn’t get nursing support as it had expected, largely due to lack of nursing engagement on the project team, he says. “We started talking about the history of the projects, and prior interventions. In addition, we talked to the different disciplines separately. It seems there used to be an excellent system where nursing helped out on the project team for risk assessment.”

As VTE prevention became more of a priority, some physicians separately created a new tool to replace the nursing tool without involving the whole team. “And they couldn’t understand why nursing wasn’t buying into the new process.”

Success story: There are similar themes to success and failure. Sites that have strong administrative support (i.e., C-suite representation on the QI team), that have “accountability structure and stick to the basics of QI, with clear goals, ability to gather and report data, and use of a QI model [such as PDSA or Six Sigma] are the ones that succeed,” Dr. Messler says. “And the reverse is consistently true. Sustainable QI needs to be multidisciplinary, involving every voice, considering prior interventions and understanding of the culture.”

Lessons learned: “As mentors, we all continue to say we learn as much or more from these sites as they, hopefully, are learning from us. This collaboration and sharing of ideas has been instrumental to the success of the program.”

Advice: Get started today, and don’t give up. Follow the road map of QI projects, gather support, and get started. You will learn as much from your failures as your successes.

Dr. Messler says hospitals are looking for physician leaders to improve quality, and hospitalists are perfectly positioned to be those QI leaders. These big projects can last for years, so quality teams and hospitals need to be prepared to take the long view.

Stephanie Rennke, MD

Stephanie Rennke, MD

Title: Associate clinical professor of medicine, co-director of faculty development, division of hospital medicine, University of California San Francisco Medical Center.

Program: Project BOOST

Background: “When I started as a hospitalist right out of residency, QI had not been part of my training. But I noticed that quality was at the forefront of the academic interests of all the hospitalists at UCSF. I was personally interested in transitions of care. I still do home visits after hours for at-risk patients when they leave the hospital.”

Dr. Rennke started in QI as a member of UCSF’s BOOST team in 2008. “I worked with other faculty in the division who had previous experience in quality improvement and transitions in care. One of the co-principal investigators for BOOST, Dr. Arpana Vidyarthi, suggested that it would be a really rewarding experience to mentor—and it was.”

Teachable moment: “I’ve been so impressed by the diversity of what’s out there. No hospitalist program or hospital is the same. There is no one-size-fits-all for quality improvement or transitions of care, so it is incredibly important that the mentor takes the time to get to know both the team and the hospital.”

Success story: “During a site visit, I had an opportunity to watch one of the nurses, who had received training from a competency-based Teach Back program, practice Teach Back with a patient at the bedside,” Dr. Rennke says. “I was doing a tour of the floor and went into the room of a patient about to be discharged. A young float nurse, not long out of school, sat down with the patient and went through the medications and discharge plan using Teach Back. It didn’t take more time, but the time was spent more constructively, with interaction back and forth. I remember that ‘aha’ moment for the patient and the look in her eyes. For me, as a mentor, it was exciting to think that something I had tried to bring to them had been incorporated by the site and was really working.”

Lessons learned: “I have learned that, while at a large institution like UCSF we tend to work in silos, smaller sites are often more integrated with the various disciplines. You can walk down the hall to the clinical pharmacist or have lunch with the charge nurse. So I’ve tried to bring back home a commitment to really get to know professional colleagues and have them feel that I’m interested in their perspectives.”

Advice: “Work in teams. You cannot do this alone. Include frontline staff. And don’t forget to advertise to others that the program exists. Get the word out—let people know.”

Jennifer Quartarolo, MD, SFHM

Jennifer Quartarolo, MD, SFHM

Title: Medical director, clinical resource management; associate clinical professor, division of hospital medicine, University of California San Diego Health System

Program: Project BOOST

Background: Dr. Quartarolo has 11 years of clinical experience as an academic hospitalist at two different medical centers, and she completed a training program in healthcare delivery and improvement through the Institute for Health Care Delivery Research in Salt Lake City, Utah. “At my own institution, I had been involved in multiple QI projects,” she says. “Since joining the faculty, I worked with our care transitions team for five years before becoming a mentor. We incorporated many elements from Project BOOST as we worked to improve our care transitions process,” which led to an invitation to be a mentor.

Teachable moment: “I had one site that I worked with that had a great new form they had developed to incorporate into their transition process; however, when they decided to implement the form, they got a lot of pushback from nursing,” she says. “Then they realized that they had not involved any frontline nurses in their planning. This example points out how important it is to have all the key players involved on your team, as improving transitions of care is a complex process requiring multidisciplinary collaboration.”

Success story: Dr. Quartarolo says she has worked with several hospitals that have seen significant improvement in their readmission rates after participating in Project BOOST and implementing its tools.

Lessons learned: “I am constantly impressed by the innovative ideas that teams come up with to deal with the challenges that their hospitals face,” she says. Every hospital is unique and needs to do self-evaluation before deciding what to focus on. “I have also worked with many sites that have challenges getting physicians engaged in their efforts, particularly if they do not have a hospitalist program.”

Advice: “We are in a unique role as hospitalists to identify systems issues and improve quality of care in the inpatient setting, and this is particularly useful in improving care transitions and decreasing readmissions rates.”

Rich Balaban, MD

Rich Balaban, MD

Title: Medical director, Hospital-to-Home Community Collaboration Program, Cambridge Health Alliance; assistant professor of medicine, Harvard Medical School, Boston

Program: Project BOOST

Background: Dr. Balaban has worked clinically in both the inpatient setting as a hospitalist and the outpatient setting as a primary care doctor. “I have seen hospital discharges as both a receiver and a sender, so [I] have been able to appreciate the challenges facing doctors, nurses, case managers, and patients involved in the care transition process,” he says.

Dr. Balaban also conducted a randomized controlled trial that demonstrated the benefits of engaging nurses at a patient’s primary care site to make outreach phone calls immediately after hospital discharge. Dr. Williams asked him to present on the study.

“It was a great opportunity for me to share the results of our work and for Mark to see my presentation skills,” he says. “When I asked if there were opportunities to get more involved in care transitions work, he invited me to consider becoming a BOOST mentor.”

Teachable moment: “Wearing my primary care hat, I believe that while it is very important to structure an effective discharge for the patient while in the hospital, success or failure ultimately is determined by what happens in the outpatient setting,” Dr. Balaban says. Even if a ‘perfect discharge’ occurs in the hospital, it can all quickly unravel once the patient arrives at home.

Success story: “At several sites, I have encouraged the inpatient care team to invite the outpatient care team to become part of the care transitions team. This has frequently brought an important viewpoint and voice to the care transitions table. While hospitalists have initiated the discussion about care transitions, they need an effective outpatient partner to create a truly effective process.”

Lessons learned: “I have learned to hold judgment until seeing with my own eyes,” Dr. Balaban says. “One of the first sites I visited had developed a post-discharge clinic, which they were excited to show me. From my point of view, I thought that after discharge, patient care should be assumed by the primary care office as soon as possible, and a post-discharge clinic would only delay that process.

“To my great surprise, their post-discharge clinic provided an ideal bridge between the hospital and primary care. The post-discharge clinic really worked and provided patients with a wonderful resource. … I’ve learned that there are many ways to solve problems, often based on the available resources at a specific site.”

Advice: In order to best understand the challenges of hospital discharge, it is critical that you understand what happens to patients after they leave the hospital. Make a home visit to a recently discharged patient to really understand the challenges that patients face when they return home.

Amitkumar R. Patel, MD, MBA, FACP, SFHM

Amitkumar R. Patel, MD, MBA, FACP, SFHM

Title: Clinical instructor in hospital medicine, Feinberg School of Medicine, Northwestern University, Chicago

Program: Project BOOST; also working with critical access hospitals in Illinois through PREP (Preventing Readmissions through Effective Partnerships)

Background: Although he now works in an urban teaching hospital, Dr. Patel also did private practice as a community hospitalist and has pursued formal healthcare management-focused training.

“I became a mentor because my experience and interest in quality improvement fit well with Project BOOST,” he says. “I enjoy coaching teams as they face challenges in quality improvement, especially in relation to readmissions reduction. My work with critical access hospitals is the result of my first year as a mentor with the PREP collaborative in Illinois.”

PREP, a collaborative initiative of SHM and the Illinois Hospital Association that is funded by Blue Cross/Blue Shield of Illinois, aims to help hospitals focus on quality initiatives, including BOOST.

Teachable moment/success story: One of Dr. Patel’s BOOST sites believed the team included all appropriate personnel to obtain discharge appointments prior to patients’ discharges. But as they began to work through the process of making sure each appointment was appropriately documented, the various team members assigned to this process could not consistently complete the task within their workflow.

The pilot unit secretaries were not part of the BOOST team initially but saw that they could fulfill this role quickly and easily. They knew who to call at the physicians’ offices to avoid getting stuck in the phone menu trees, and they used this knowledge to reach the schedulers directly. The BOOST team quickly realized the unit secretaries were the most appropriate personnel to capture this information and work with the patients or their families/caregivers to obtain the most convenient appointments. This role was added to the team, and the unit secretaries took ownership of this process. Other teams may also want to look beyond the customary team members to roles that may not be thought of as quality team members.

Lessons learned: “The biggest take-away for me involves the unique culture that exists in many of our urban and rural communities,” he says. Every BOOST site implements the project’s elements in its own unique way, and what works well in one location may not fit the needs of another. The role of the mentor is to balance the need for community-specific advice with unique attributes of the facility and the elements of Project BOOST. “Often, we use our mentor calls to brainstorm solutions, and the teams are teaching me what will work best in their environment.”

Advice: “Responsibility for hospital change management should not be abdicated to administrators or quality improvement staff members,” he says. “QI is not a sometime thing for some staff; it’s an all-the-time process for every staff member, including physicians, to participate in and actively manage.”

Cheryl O’Malley, MD, FHM

Cheryl O’Malley, MD, FHM

Title: Internal medicine residency program director, Banner Good Samaritan Medical Center, Phoenix

Program: GCMI

Background: Banner Good Samaritan has participated in the BOOST, VTE, and GCMI programs. Dr. O’Malley brought her experience from developing, implementing, and leading local glycemic control efforts to mentoring others.

“When I first started working on our hospital’s process, I had so many questions and asked one of my mentors from residency, Dr. Greg Maynard,” she says. “He helped me to see that people around the country were asking the same questions and invited me to join SHM’s glycemic control work group. When the GCMI program started, I was asked to be a mentor.”

Teachable moment: “When I was a new attending on the wards after residency, my patients would ask me why their blood sugars were so much better controlled at home than in the hospital. Usually, the answer was that they were put on a sliding scale when they came into the hospital,” she says, noting that what was done at home wasn’t going to work in the hospital. Patients needed a different regimen—a more proactive approach than just the customary sliding scale.

“I started to learn more about basal rates, nutrition, and correction insulin regimens in the hospital, but I realized that to really have adequate safety and direction for the nursing staff, it would require a formal order set and systematic approach,” she says.

Success story: “One of my sites invited me to come and present grand rounds at the hospital, and the local physician team leader invited the whole quality team to her home. It was a very exciting team and had achieved a lot. Fifteen or 20 of us spent the evening talking about the project but also just enjoying the collegiality,” Dr. O’Malley says. “Even though we had never seen one another, I instantly knew everyone by voice from spending so much time on the phone. And we knew a lot about one another’s personal lives and careers.”

Lessons learned: “Hearing a program describe what they are doing and knowing that they were far ahead of my own hospital in many ways but still being able to provide an insight or a perspective to help them achieve their own next steps. Everyone has something to learn from another hospital or another discipline. We can all leverage our experiences to improve patient care.”

Advice: “Be patient. This is a really long process of constant improvements. I have been working on glycemic control for 10 years now and still feel like we have many opportunities to further improve.”

Cheryl O’Malley, MD, FHM

Christopher Kim, MD, MBA, SFHM

Title: Clinical associate professor of internal medicine and assistant professor of pediatrics, University of Michigan Health System, Ann Arbor

Program: Project BOOST; Michigan Transitions of Care Collaborative (M-TC2)

Background: Dr. Kim brings clinical, quality improvement, leadership, collaborative learning, and discussion facilitation skills to his work as program director of M-TC2 and as mentor to the sites he works with.

The collaborative is part of a set of state collaborative quality initiatives funded by Blue Cross Blue Shield of Michigan. One of those initiatives is focused on improving care transitions between the hospital setting and ambulatory care providers, using Project BOOST tools—expanded to integrate more closely with primary care providers, physician organizations, and ambulatory care. The eight Michigan-based mentors for M-TC2 have all attended SHM’s Mentor University.

Teachable moment: There are local challenges and there are general challenges—those that are commonly shared by most hospitals, Dr. Kim explains. Both need to be overcome when working on an improvement project such as transitions of care. The local hospitalist brings expertise about the former—which are often more difficult to understand and overcome. The mentor brings knowledge and experience of the universal challenges, as well as the benefit of having seen or heard about what other programs have done. Together, they can work to help the organization become better equipped to improve the initiative at hand.

Success story: “One hospital in the collaborative realized that it could roll out the Teach Back concept to both nurses and physicians,” he says. They started to teach residents how to interact with patients and began using this approach in physician-nurse teams. Subsequently, the team shared with the collaborative how physicians have embraced the concept.

Lessons learned: Every site has its successes and challenges, he says. Sharing both sides of the story can only advance the mission of the collaborative, as each organization learns from the successes and failures of the others.

Mentored implementation really does what it’s intended to do—helping to support the sites and keeping an organization on track and accountable for the work it does, because someone external to the organization is working with it and providing information about what other sites are doing.

Advice: Talk with different disciplines and find out how much they long to work with other care providers, and then have discussions about how to make interdisciplinary practice happen. “At our collaborative meetings over time, many of the 24 participating sites have shared their progress—the good things and the struggles,” Dr. Kim says.

Larry Beresford is a freelance writer in Alameda, Calif.

Christine Lum Lung, MD, SFHM

When SHM received the Joint Commission’s John M. Eisenberg Patient Safety and Quality Award for 2011 for innovation in patient safety and quality at the national level, the award represented national recognition for the society’s three major hospital quality improvement initiatives. Moreover, it highlighted the integral role mentors play in each of the programs, helping physicians and hospitals make accelerated progress on important patient safety and quality issues.

Mentored implementation assigns a physician expert to train, guide, and work with the participating facilities’ hospitalist-led, multidisciplinary team through the life cycle of a QI initiative. The three programs focus on VTE prevention, glycemic control, and transitions of care. The first hospital cohort for VTE prevention—the VTE Prevention Collaborative—was in 2007. The care transitions program, known as Project BOOST, started in 2008. The Glycemic Control Mentored Implementation (GCMI) Program began in 2009. A fourth SHM mentored implementation program is MARQUIS, the Multi-Center Medication Reconciliation Quality Improvement Study.

In basic terms, mentoring is “coaching from a physician who has expertise both in the clinical subject matter and in implementing the processes and tools of quality improvement—usually because they’ve done it themselves,” says Gregory Maynard, MD, MSc, SFHM, senior vice president of SHM’s Center for Hospital Innovation and Improvement and a co-founder of two of its mentored implementation programs.

Mentors typically are paired with one or two participating hospitals for 12 to 18 months, conducting monthly conference calls with the team, sharing tools and resources from SHM’s online library, and offering advice on how to navigate the treacherous currents of culture change within a hospital. BOOST mentors also make in-person site visits. They are well versed in protocol and order set design and quality measurement strategies, and they know how to engage frontline professionals and institutional leadership, Dr. Maynard says.

Some mentors have received formal QI training, and many have attended Mentor University, a 1-1/2 day intensive training course offered by SHM that reinforces the nuances of coaching, the contents of SHM’s quality toolkits, and ideas for overcoming common barriers to improvement. SHM’s mentor support provides continuous professional development for the mentors, pairing new mentors with senior mentors to coach them in the process and hosting an online community with other mentors.

“What’s telling to me is that many of the people who have been mentored by SHM’s programs in one topic go on to become mentors in another topic, taking those portable skills and principles and applying them in other quality areas,” Dr. Maynard says. “We’re fostering leadership and quality improvement skills among hospitalists; that’s really one of our main goals. People learn the skill and then spread it within their system.”

Mark Williams, MD, FACP, MHM, Project BOOST principal investigator and a veteran SHM mentor, says that just providing educational materials to health professionals often isn’t enough for them to overcome the barriers to change.

“I’ve seen many large-scale quality projects that didn’t work, as they were simply disseminating information, content, or knowledge,” he says. Mentored implementation as practiced by SHM is “a model for disseminating quality improvement nationally,” he adds. “Pretty much any quality improvement project can be done this way.”

Key to the mentored implementation program’s success is the personalized approach and customized solutions.

“You directly meet with the team in their own setting and begin to see what’s going on,” Dr. Williams says. “You also meet with the hospital’s senior leadership. That’s when you start to see change.”

The Hospitalist connected with eight SHM mentors. The following are snapshots of their work in the mentorship program and some of the lessons they taught—and learned—from the program.

Christine Lum Lung, MD, SFHM

Christine Lum Lung, MD, SFHM

Title: Medical director, Northern Colorado Hospitalists, Fort Collins

Program: VTE Prevention Collaborative

Background: As a practicing hospitalist and medical director of the HM group for a two-hospital system, Dr. Lum Lung chaired its quality committee for VTE protocol development. “It was obvious at our hospitals that we needed to do better at VTE prevention,” she explains.

Dr. Lum Lung’s team received VTE mentorship from Dr. Maynard, who later asked her to become a VTE mentor. She also attended all three levels of SHM’s Leadership Academy and has since become a mentor for the new HP3 (Hospitalist Program Peak Performance) mentored implementation program, a one-year collaboration among SHM, Northwestern University, Blue Cross/Blue Shield of Illinois, and the Illinois Hospital Association that is designed to help hospitalist groups optimize their programs and build healthy group culture.

Teachable moment: The essential qualities of a good mentee, Dr. Lum Lung says, are drive and dedication. “You believe strongly about it, so you can sell it to others. You also need a thick skin to face the adversities that come up. When my mentor gave me tasks and deadlines, I met those deadlines.”

Success story: “I’ve been impressed with how hard groups and individuals can work.” Most of the teams she has worked with were facing significant external stressors—starting a new program, moving into a new hospital, rolling out a new EHR, becoming part of a growing medical group. “Yet each of them has been incredibly engaged in the process and dedicated to completing their projects.”

Lessons learned: “That we all have something to learn from each other. While I am officially the mentor, I have learned a lot about processes, teamwork, and flow issues from the sites that could potentially be incorporated in our program.”

Advice: Working on a project as a team can be very powerful, she says. Even seemingly ‘small’ projects have allowed teams to learn how to work better together on day-to-day issues. With the victory of a small project behind them, they make lists of the next thing that they want to tackle.

“Our profession is constantly changing. We need to be thinking ahead for how we will face those challenges,” Dr. Lum Lung says. “A team that works well together will have an advantage in this new environment. Even if you have people who are new to quality improvement, their participation can still be important.”

Jordan Messler, MD, SFHM

Jordan Messler, MD, SFHM

Title: Medical director, Morton Plant Hospitalists, Clearwater, Fla.

Program: GCMI; Project BOOST

Background: Dr. Messler’s interest in QI led him to work with colleagues in SHM who are national leaders in quality. “A couple of years ago, I enrolled in Emory’s Quality Academy, a sister course to Intermountain Health’s course on quality. Then I enrolled our hospital in both the GCMI Program and Project BOOST. My mentors for those programs were terrific guides, which led to my interest in seeing their side of the program as a mentor myself.”

Teachable moment: One program had difficulty implementing a VTE prevention tool and couldn’t get nursing support as it had expected, largely due to lack of nursing engagement on the project team, he says. “We started talking about the history of the projects, and prior interventions. In addition, we talked to the different disciplines separately. It seems there used to be an excellent system where nursing helped out on the project team for risk assessment.”

As VTE prevention became more of a priority, some physicians separately created a new tool to replace the nursing tool without involving the whole team. “And they couldn’t understand why nursing wasn’t buying into the new process.”

Success story: There are similar themes to success and failure. Sites that have strong administrative support (i.e., C-suite representation on the QI team), that have “accountability structure and stick to the basics of QI, with clear goals, ability to gather and report data, and use of a QI model [such as PDSA or Six Sigma] are the ones that succeed,” Dr. Messler says. “And the reverse is consistently true. Sustainable QI needs to be multidisciplinary, involving every voice, considering prior interventions and understanding of the culture.”

Lessons learned: “As mentors, we all continue to say we learn as much or more from these sites as they, hopefully, are learning from us. This collaboration and sharing of ideas has been instrumental to the success of the program.”

Advice: Get started today, and don’t give up. Follow the road map of QI projects, gather support, and get started. You will learn as much from your failures as your successes.

Dr. Messler says hospitals are looking for physician leaders to improve quality, and hospitalists are perfectly positioned to be those QI leaders. These big projects can last for years, so quality teams and hospitals need to be prepared to take the long view.

Stephanie Rennke, MD

Stephanie Rennke, MD

Title: Associate clinical professor of medicine, co-director of faculty development, division of hospital medicine, University of California San Francisco Medical Center.

Program: Project BOOST

Background: “When I started as a hospitalist right out of residency, QI had not been part of my training. But I noticed that quality was at the forefront of the academic interests of all the hospitalists at UCSF. I was personally interested in transitions of care. I still do home visits after hours for at-risk patients when they leave the hospital.”

Dr. Rennke started in QI as a member of UCSF’s BOOST team in 2008. “I worked with other faculty in the division who had previous experience in quality improvement and transitions in care. One of the co-principal investigators for BOOST, Dr. Arpana Vidyarthi, suggested that it would be a really rewarding experience to mentor—and it was.”

Teachable moment: “I’ve been so impressed by the diversity of what’s out there. No hospitalist program or hospital is the same. There is no one-size-fits-all for quality improvement or transitions of care, so it is incredibly important that the mentor takes the time to get to know both the team and the hospital.”

Success story: “During a site visit, I had an opportunity to watch one of the nurses, who had received training from a competency-based Teach Back program, practice Teach Back with a patient at the bedside,” Dr. Rennke says. “I was doing a tour of the floor and went into the room of a patient about to be discharged. A young float nurse, not long out of school, sat down with the patient and went through the medications and discharge plan using Teach Back. It didn’t take more time, but the time was spent more constructively, with interaction back and forth. I remember that ‘aha’ moment for the patient and the look in her eyes. For me, as a mentor, it was exciting to think that something I had tried to bring to them had been incorporated by the site and was really working.”

Lessons learned: “I have learned that, while at a large institution like UCSF we tend to work in silos, smaller sites are often more integrated with the various disciplines. You can walk down the hall to the clinical pharmacist or have lunch with the charge nurse. So I’ve tried to bring back home a commitment to really get to know professional colleagues and have them feel that I’m interested in their perspectives.”

Advice: “Work in teams. You cannot do this alone. Include frontline staff. And don’t forget to advertise to others that the program exists. Get the word out—let people know.”

Jennifer Quartarolo, MD, SFHM

Jennifer Quartarolo, MD, SFHM

Title: Medical director, clinical resource management; associate clinical professor, division of hospital medicine, University of California San Diego Health System

Program: Project BOOST

Background: Dr. Quartarolo has 11 years of clinical experience as an academic hospitalist at two different medical centers, and she completed a training program in healthcare delivery and improvement through the Institute for Health Care Delivery Research in Salt Lake City, Utah. “At my own institution, I had been involved in multiple QI projects,” she says. “Since joining the faculty, I worked with our care transitions team for five years before becoming a mentor. We incorporated many elements from Project BOOST as we worked to improve our care transitions process,” which led to an invitation to be a mentor.

Teachable moment: “I had one site that I worked with that had a great new form they had developed to incorporate into their transition process; however, when they decided to implement the form, they got a lot of pushback from nursing,” she says. “Then they realized that they had not involved any frontline nurses in their planning. This example points out how important it is to have all the key players involved on your team, as improving transitions of care is a complex process requiring multidisciplinary collaboration.”

Success story: Dr. Quartarolo says she has worked with several hospitals that have seen significant improvement in their readmission rates after participating in Project BOOST and implementing its tools.

Lessons learned: “I am constantly impressed by the innovative ideas that teams come up with to deal with the challenges that their hospitals face,” she says. Every hospital is unique and needs to do self-evaluation before deciding what to focus on. “I have also worked with many sites that have challenges getting physicians engaged in their efforts, particularly if they do not have a hospitalist program.”

Advice: “We are in a unique role as hospitalists to identify systems issues and improve quality of care in the inpatient setting, and this is particularly useful in improving care transitions and decreasing readmissions rates.”

Rich Balaban, MD

Rich Balaban, MD

Title: Medical director, Hospital-to-Home Community Collaboration Program, Cambridge Health Alliance; assistant professor of medicine, Harvard Medical School, Boston

Program: Project BOOST

Background: Dr. Balaban has worked clinically in both the inpatient setting as a hospitalist and the outpatient setting as a primary care doctor. “I have seen hospital discharges as both a receiver and a sender, so [I] have been able to appreciate the challenges facing doctors, nurses, case managers, and patients involved in the care transition process,” he says.

Dr. Balaban also conducted a randomized controlled trial that demonstrated the benefits of engaging nurses at a patient’s primary care site to make outreach phone calls immediately after hospital discharge. Dr. Williams asked him to present on the study.

“It was a great opportunity for me to share the results of our work and for Mark to see my presentation skills,” he says. “When I asked if there were opportunities to get more involved in care transitions work, he invited me to consider becoming a BOOST mentor.”

Teachable moment: “Wearing my primary care hat, I believe that while it is very important to structure an effective discharge for the patient while in the hospital, success or failure ultimately is determined by what happens in the outpatient setting,” Dr. Balaban says. Even if a ‘perfect discharge’ occurs in the hospital, it can all quickly unravel once the patient arrives at home.

Success story: “At several sites, I have encouraged the inpatient care team to invite the outpatient care team to become part of the care transitions team. This has frequently brought an important viewpoint and voice to the care transitions table. While hospitalists have initiated the discussion about care transitions, they need an effective outpatient partner to create a truly effective process.”

Lessons learned: “I have learned to hold judgment until seeing with my own eyes,” Dr. Balaban says. “One of the first sites I visited had developed a post-discharge clinic, which they were excited to show me. From my point of view, I thought that after discharge, patient care should be assumed by the primary care office as soon as possible, and a post-discharge clinic would only delay that process.

“To my great surprise, their post-discharge clinic provided an ideal bridge between the hospital and primary care. The post-discharge clinic really worked and provided patients with a wonderful resource. … I’ve learned that there are many ways to solve problems, often based on the available resources at a specific site.”

Advice: In order to best understand the challenges of hospital discharge, it is critical that you understand what happens to patients after they leave the hospital. Make a home visit to a recently discharged patient to really understand the challenges that patients face when they return home.

Amitkumar R. Patel, MD, MBA, FACP, SFHM

Amitkumar R. Patel, MD, MBA, FACP, SFHM

Title: Clinical instructor in hospital medicine, Feinberg School of Medicine, Northwestern University, Chicago

Program: Project BOOST; also working with critical access hospitals in Illinois through PREP (Preventing Readmissions through Effective Partnerships)

Background: Although he now works in an urban teaching hospital, Dr. Patel also did private practice as a community hospitalist and has pursued formal healthcare management-focused training.

“I became a mentor because my experience and interest in quality improvement fit well with Project BOOST,” he says. “I enjoy coaching teams as they face challenges in quality improvement, especially in relation to readmissions reduction. My work with critical access hospitals is the result of my first year as a mentor with the PREP collaborative in Illinois.”

PREP, a collaborative initiative of SHM and the Illinois Hospital Association that is funded by Blue Cross/Blue Shield of Illinois, aims to help hospitals focus on quality initiatives, including BOOST.

Teachable moment/success story: One of Dr. Patel’s BOOST sites believed the team included all appropriate personnel to obtain discharge appointments prior to patients’ discharges. But as they began to work through the process of making sure each appointment was appropriately documented, the various team members assigned to this process could not consistently complete the task within their workflow.

The pilot unit secretaries were not part of the BOOST team initially but saw that they could fulfill this role quickly and easily. They knew who to call at the physicians’ offices to avoid getting stuck in the phone menu trees, and they used this knowledge to reach the schedulers directly. The BOOST team quickly realized the unit secretaries were the most appropriate personnel to capture this information and work with the patients or their families/caregivers to obtain the most convenient appointments. This role was added to the team, and the unit secretaries took ownership of this process. Other teams may also want to look beyond the customary team members to roles that may not be thought of as quality team members.

Lessons learned: “The biggest take-away for me involves the unique culture that exists in many of our urban and rural communities,” he says. Every BOOST site implements the project’s elements in its own unique way, and what works well in one location may not fit the needs of another. The role of the mentor is to balance the need for community-specific advice with unique attributes of the facility and the elements of Project BOOST. “Often, we use our mentor calls to brainstorm solutions, and the teams are teaching me what will work best in their environment.”

Advice: “Responsibility for hospital change management should not be abdicated to administrators or quality improvement staff members,” he says. “QI is not a sometime thing for some staff; it’s an all-the-time process for every staff member, including physicians, to participate in and actively manage.”

Cheryl O’Malley, MD, FHM

Cheryl O’Malley, MD, FHM

Title: Internal medicine residency program director, Banner Good Samaritan Medical Center, Phoenix

Program: GCMI

Background: Banner Good Samaritan has participated in the BOOST, VTE, and GCMI programs. Dr. O’Malley brought her experience from developing, implementing, and leading local glycemic control efforts to mentoring others.

“When I first started working on our hospital’s process, I had so many questions and asked one of my mentors from residency, Dr. Greg Maynard,” she says. “He helped me to see that people around the country were asking the same questions and invited me to join SHM’s glycemic control work group. When the GCMI program started, I was asked to be a mentor.”

Teachable moment: “When I was a new attending on the wards after residency, my patients would ask me why their blood sugars were so much better controlled at home than in the hospital. Usually, the answer was that they were put on a sliding scale when they came into the hospital,” she says, noting that what was done at home wasn’t going to work in the hospital. Patients needed a different regimen—a more proactive approach than just the customary sliding scale.

“I started to learn more about basal rates, nutrition, and correction insulin regimens in the hospital, but I realized that to really have adequate safety and direction for the nursing staff, it would require a formal order set and systematic approach,” she says.

Success story: “One of my sites invited me to come and present grand rounds at the hospital, and the local physician team leader invited the whole quality team to her home. It was a very exciting team and had achieved a lot. Fifteen or 20 of us spent the evening talking about the project but also just enjoying the collegiality,” Dr. O’Malley says. “Even though we had never seen one another, I instantly knew everyone by voice from spending so much time on the phone. And we knew a lot about one another’s personal lives and careers.”

Lessons learned: “Hearing a program describe what they are doing and knowing that they were far ahead of my own hospital in many ways but still being able to provide an insight or a perspective to help them achieve their own next steps. Everyone has something to learn from another hospital or another discipline. We can all leverage our experiences to improve patient care.”

Advice: “Be patient. This is a really long process of constant improvements. I have been working on glycemic control for 10 years now and still feel like we have many opportunities to further improve.”

Cheryl O’Malley, MD, FHM

Christopher Kim, MD, MBA, SFHM

Title: Clinical associate professor of internal medicine and assistant professor of pediatrics, University of Michigan Health System, Ann Arbor

Program: Project BOOST; Michigan Transitions of Care Collaborative (M-TC2)

Background: Dr. Kim brings clinical, quality improvement, leadership, collaborative learning, and discussion facilitation skills to his work as program director of M-TC2 and as mentor to the sites he works with.

The collaborative is part of a set of state collaborative quality initiatives funded by Blue Cross Blue Shield of Michigan. One of those initiatives is focused on improving care transitions between the hospital setting and ambulatory care providers, using Project BOOST tools—expanded to integrate more closely with primary care providers, physician organizations, and ambulatory care. The eight Michigan-based mentors for M-TC2 have all attended SHM’s Mentor University.

Teachable moment: There are local challenges and there are general challenges—those that are commonly shared by most hospitals, Dr. Kim explains. Both need to be overcome when working on an improvement project such as transitions of care. The local hospitalist brings expertise about the former—which are often more difficult to understand and overcome. The mentor brings knowledge and experience of the universal challenges, as well as the benefit of having seen or heard about what other programs have done. Together, they can work to help the organization become better equipped to improve the initiative at hand.

Success story: “One hospital in the collaborative realized that it could roll out the Teach Back concept to both nurses and physicians,” he says. They started to teach residents how to interact with patients and began using this approach in physician-nurse teams. Subsequently, the team shared with the collaborative how physicians have embraced the concept.

Lessons learned: Every site has its successes and challenges, he says. Sharing both sides of the story can only advance the mission of the collaborative, as each organization learns from the successes and failures of the others.

Mentored implementation really does what it’s intended to do—helping to support the sites and keeping an organization on track and accountable for the work it does, because someone external to the organization is working with it and providing information about what other sites are doing.

Advice: Talk with different disciplines and find out how much they long to work with other care providers, and then have discussions about how to make interdisciplinary practice happen. “At our collaborative meetings over time, many of the 24 participating sites have shared their progress—the good things and the struggles,” Dr. Kim says.

Larry Beresford is a freelance writer in Alameda, Calif.

Christine Lum Lung, MD, SFHM

When SHM received the Joint Commission’s John M. Eisenberg Patient Safety and Quality Award for 2011 for innovation in patient safety and quality at the national level, the award represented national recognition for the society’s three major hospital quality improvement initiatives. Moreover, it highlighted the integral role mentors play in each of the programs, helping physicians and hospitals make accelerated progress on important patient safety and quality issues.

Mentored implementation assigns a physician expert to train, guide, and work with the participating facilities’ hospitalist-led, multidisciplinary team through the life cycle of a QI initiative. The three programs focus on VTE prevention, glycemic control, and transitions of care. The first hospital cohort for VTE prevention—the VTE Prevention Collaborative—was in 2007. The care transitions program, known as Project BOOST, started in 2008. The Glycemic Control Mentored Implementation (GCMI) Program began in 2009. A fourth SHM mentored implementation program is MARQUIS, the Multi-Center Medication Reconciliation Quality Improvement Study.

In basic terms, mentoring is “coaching from a physician who has expertise both in the clinical subject matter and in implementing the processes and tools of quality improvement—usually because they’ve done it themselves,” says Gregory Maynard, MD, MSc, SFHM, senior vice president of SHM’s Center for Hospital Innovation and Improvement and a co-founder of two of its mentored implementation programs.

Mentors typically are paired with one or two participating hospitals for 12 to 18 months, conducting monthly conference calls with the team, sharing tools and resources from SHM’s online library, and offering advice on how to navigate the treacherous currents of culture change within a hospital. BOOST mentors also make in-person site visits. They are well versed in protocol and order set design and quality measurement strategies, and they know how to engage frontline professionals and institutional leadership, Dr. Maynard says.

Some mentors have received formal QI training, and many have attended Mentor University, a 1-1/2 day intensive training course offered by SHM that reinforces the nuances of coaching, the contents of SHM’s quality toolkits, and ideas for overcoming common barriers to improvement. SHM’s mentor support provides continuous professional development for the mentors, pairing new mentors with senior mentors to coach them in the process and hosting an online community with other mentors.

“What’s telling to me is that many of the people who have been mentored by SHM’s programs in one topic go on to become mentors in another topic, taking those portable skills and principles and applying them in other quality areas,” Dr. Maynard says. “We’re fostering leadership and quality improvement skills among hospitalists; that’s really one of our main goals. People learn the skill and then spread it within their system.”

Mark Williams, MD, FACP, MHM, Project BOOST principal investigator and a veteran SHM mentor, says that just providing educational materials to health professionals often isn’t enough for them to overcome the barriers to change.

“I’ve seen many large-scale quality projects that didn’t work, as they were simply disseminating information, content, or knowledge,” he says. Mentored implementation as practiced by SHM is “a model for disseminating quality improvement nationally,” he adds. “Pretty much any quality improvement project can be done this way.”

Key to the mentored implementation program’s success is the personalized approach and customized solutions.

“You directly meet with the team in their own setting and begin to see what’s going on,” Dr. Williams says. “You also meet with the hospital’s senior leadership. That’s when you start to see change.”

The Hospitalist connected with eight SHM mentors. The following are snapshots of their work in the mentorship program and some of the lessons they taught—and learned—from the program.

Christine Lum Lung, MD, SFHM

Christine Lum Lung, MD, SFHM

Title: Medical director, Northern Colorado Hospitalists, Fort Collins

Program: VTE Prevention Collaborative

Background: As a practicing hospitalist and medical director of the HM group for a two-hospital system, Dr. Lum Lung chaired its quality committee for VTE protocol development. “It was obvious at our hospitals that we needed to do better at VTE prevention,” she explains.

Dr. Lum Lung’s team received VTE mentorship from Dr. Maynard, who later asked her to become a VTE mentor. She also attended all three levels of SHM’s Leadership Academy and has since become a mentor for the new HP3 (Hospitalist Program Peak Performance) mentored implementation program, a one-year collaboration among SHM, Northwestern University, Blue Cross/Blue Shield of Illinois, and the Illinois Hospital Association that is designed to help hospitalist groups optimize their programs and build healthy group culture.

Teachable moment: The essential qualities of a good mentee, Dr. Lum Lung says, are drive and dedication. “You believe strongly about it, so you can sell it to others. You also need a thick skin to face the adversities that come up. When my mentor gave me tasks and deadlines, I met those deadlines.”

Success story: “I’ve been impressed with how hard groups and individuals can work.” Most of the teams she has worked with were facing significant external stressors—starting a new program, moving into a new hospital, rolling out a new EHR, becoming part of a growing medical group. “Yet each of them has been incredibly engaged in the process and dedicated to completing their projects.”

Lessons learned: “That we all have something to learn from each other. While I am officially the mentor, I have learned a lot about processes, teamwork, and flow issues from the sites that could potentially be incorporated in our program.”

Advice: Working on a project as a team can be very powerful, she says. Even seemingly ‘small’ projects have allowed teams to learn how to work better together on day-to-day issues. With the victory of a small project behind them, they make lists of the next thing that they want to tackle.

“Our profession is constantly changing. We need to be thinking ahead for how we will face those challenges,” Dr. Lum Lung says. “A team that works well together will have an advantage in this new environment. Even if you have people who are new to quality improvement, their participation can still be important.”

Jordan Messler, MD, SFHM

Jordan Messler, MD, SFHM

Title: Medical director, Morton Plant Hospitalists, Clearwater, Fla.

Program: GCMI; Project BOOST

Background: Dr. Messler’s interest in QI led him to work with colleagues in SHM who are national leaders in quality. “A couple of years ago, I enrolled in Emory’s Quality Academy, a sister course to Intermountain Health’s course on quality. Then I enrolled our hospital in both the GCMI Program and Project BOOST. My mentors for those programs were terrific guides, which led to my interest in seeing their side of the program as a mentor myself.”

Teachable moment: One program had difficulty implementing a VTE prevention tool and couldn’t get nursing support as it had expected, largely due to lack of nursing engagement on the project team, he says. “We started talking about the history of the projects, and prior interventions. In addition, we talked to the different disciplines separately. It seems there used to be an excellent system where nursing helped out on the project team for risk assessment.”

As VTE prevention became more of a priority, some physicians separately created a new tool to replace the nursing tool without involving the whole team. “And they couldn’t understand why nursing wasn’t buying into the new process.”

Success story: There are similar themes to success and failure. Sites that have strong administrative support (i.e., C-suite representation on the QI team), that have “accountability structure and stick to the basics of QI, with clear goals, ability to gather and report data, and use of a QI model [such as PDSA or Six Sigma] are the ones that succeed,” Dr. Messler says. “And the reverse is consistently true. Sustainable QI needs to be multidisciplinary, involving every voice, considering prior interventions and understanding of the culture.”

Lessons learned: “As mentors, we all continue to say we learn as much or more from these sites as they, hopefully, are learning from us. This collaboration and sharing of ideas has been instrumental to the success of the program.”

Advice: Get started today, and don’t give up. Follow the road map of QI projects, gather support, and get started. You will learn as much from your failures as your successes.

Dr. Messler says hospitals are looking for physician leaders to improve quality, and hospitalists are perfectly positioned to be those QI leaders. These big projects can last for years, so quality teams and hospitals need to be prepared to take the long view.

Stephanie Rennke, MD

Stephanie Rennke, MD

Title: Associate clinical professor of medicine, co-director of faculty development, division of hospital medicine, University of California San Francisco Medical Center.

Program: Project BOOST

Background: “When I started as a hospitalist right out of residency, QI had not been part of my training. But I noticed that quality was at the forefront of the academic interests of all the hospitalists at UCSF. I was personally interested in transitions of care. I still do home visits after hours for at-risk patients when they leave the hospital.”

Dr. Rennke started in QI as a member of UCSF’s BOOST team in 2008. “I worked with other faculty in the division who had previous experience in quality improvement and transitions in care. One of the co-principal investigators for BOOST, Dr. Arpana Vidyarthi, suggested that it would be a really rewarding experience to mentor—and it was.”

Teachable moment: “I’ve been so impressed by the diversity of what’s out there. No hospitalist program or hospital is the same. There is no one-size-fits-all for quality improvement or transitions of care, so it is incredibly important that the mentor takes the time to get to know both the team and the hospital.”

Success story: “During a site visit, I had an opportunity to watch one of the nurses, who had received training from a competency-based Teach Back program, practice Teach Back with a patient at the bedside,” Dr. Rennke says. “I was doing a tour of the floor and went into the room of a patient about to be discharged. A young float nurse, not long out of school, sat down with the patient and went through the medications and discharge plan using Teach Back. It didn’t take more time, but the time was spent more constructively, with interaction back and forth. I remember that ‘aha’ moment for the patient and the look in her eyes. For me, as a mentor, it was exciting to think that something I had tried to bring to them had been incorporated by the site and was really working.”

Lessons learned: “I have learned that, while at a large institution like UCSF we tend to work in silos, smaller sites are often more integrated with the various disciplines. You can walk down the hall to the clinical pharmacist or have lunch with the charge nurse. So I’ve tried to bring back home a commitment to really get to know professional colleagues and have them feel that I’m interested in their perspectives.”

Advice: “Work in teams. You cannot do this alone. Include frontline staff. And don’t forget to advertise to others that the program exists. Get the word out—let people know.”

Jennifer Quartarolo, MD, SFHM

Jennifer Quartarolo, MD, SFHM

Title: Medical director, clinical resource management; associate clinical professor, division of hospital medicine, University of California San Diego Health System

Program: Project BOOST

Background: Dr. Quartarolo has 11 years of clinical experience as an academic hospitalist at two different medical centers, and she completed a training program in healthcare delivery and improvement through the Institute for Health Care Delivery Research in Salt Lake City, Utah. “At my own institution, I had been involved in multiple QI projects,” she says. “Since joining the faculty, I worked with our care transitions team for five years before becoming a mentor. We incorporated many elements from Project BOOST as we worked to improve our care transitions process,” which led to an invitation to be a mentor.

Teachable moment: “I had one site that I worked with that had a great new form they had developed to incorporate into their transition process; however, when they decided to implement the form, they got a lot of pushback from nursing,” she says. “Then they realized that they had not involved any frontline nurses in their planning. This example points out how important it is to have all the key players involved on your team, as improving transitions of care is a complex process requiring multidisciplinary collaboration.”

Success story: Dr. Quartarolo says she has worked with several hospitals that have seen significant improvement in their readmission rates after participating in Project BOOST and implementing its tools.

Lessons learned: “I am constantly impressed by the innovative ideas that teams come up with to deal with the challenges that their hospitals face,” she says. Every hospital is unique and needs to do self-evaluation before deciding what to focus on. “I have also worked with many sites that have challenges getting physicians engaged in their efforts, particularly if they do not have a hospitalist program.”

Advice: “We are in a unique role as hospitalists to identify systems issues and improve quality of care in the inpatient setting, and this is particularly useful in improving care transitions and decreasing readmissions rates.”

Rich Balaban, MD

Rich Balaban, MD

Title: Medical director, Hospital-to-Home Community Collaboration Program, Cambridge Health Alliance; assistant professor of medicine, Harvard Medical School, Boston

Program: Project BOOST

Background: Dr. Balaban has worked clinically in both the inpatient setting as a hospitalist and the outpatient setting as a primary care doctor. “I have seen hospital discharges as both a receiver and a sender, so [I] have been able to appreciate the challenges facing doctors, nurses, case managers, and patients involved in the care transition process,” he says.

Dr. Balaban also conducted a randomized controlled trial that demonstrated the benefits of engaging nurses at a patient’s primary care site to make outreach phone calls immediately after hospital discharge. Dr. Williams asked him to present on the study.

“It was a great opportunity for me to share the results of our work and for Mark to see my presentation skills,” he says. “When I asked if there were opportunities to get more involved in care transitions work, he invited me to consider becoming a BOOST mentor.”

Teachable moment: “Wearing my primary care hat, I believe that while it is very important to structure an effective discharge for the patient while in the hospital, success or failure ultimately is determined by what happens in the outpatient setting,” Dr. Balaban says. Even if a ‘perfect discharge’ occurs in the hospital, it can all quickly unravel once the patient arrives at home.

Success story: “At several sites, I have encouraged the inpatient care team to invite the outpatient care team to become part of the care transitions team. This has frequently brought an important viewpoint and voice to the care transitions table. While hospitalists have initiated the discussion about care transitions, they need an effective outpatient partner to create a truly effective process.”

Lessons learned: “I have learned to hold judgment until seeing with my own eyes,” Dr. Balaban says. “One of the first sites I visited had developed a post-discharge clinic, which they were excited to show me. From my point of view, I thought that after discharge, patient care should be assumed by the primary care office as soon as possible, and a post-discharge clinic would only delay that process.

“To my great surprise, their post-discharge clinic provided an ideal bridge between the hospital and primary care. The post-discharge clinic really worked and provided patients with a wonderful resource. … I’ve learned that there are many ways to solve problems, often based on the available resources at a specific site.”

Advice: In order to best understand the challenges of hospital discharge, it is critical that you understand what happens to patients after they leave the hospital. Make a home visit to a recently discharged patient to really understand the challenges that patients face when they return home.

Amitkumar R. Patel, MD, MBA, FACP, SFHM

Amitkumar R. Patel, MD, MBA, FACP, SFHM

Title: Clinical instructor in hospital medicine, Feinberg School of Medicine, Northwestern University, Chicago

Program: Project BOOST; also working with critical access hospitals in Illinois through PREP (Preventing Readmissions through Effective Partnerships)

Background: Although he now works in an urban teaching hospital, Dr. Patel also did private practice as a community hospitalist and has pursued formal healthcare management-focused training.

“I became a mentor because my experience and interest in quality improvement fit well with Project BOOST,” he says. “I enjoy coaching teams as they face challenges in quality improvement, especially in relation to readmissions reduction. My work with critical access hospitals is the result of my first year as a mentor with the PREP collaborative in Illinois.”

PREP, a collaborative initiative of SHM and the Illinois Hospital Association that is funded by Blue Cross/Blue Shield of Illinois, aims to help hospitals focus on quality initiatives, including BOOST.

Teachable moment/success story: One of Dr. Patel’s BOOST sites believed the team included all appropriate personnel to obtain discharge appointments prior to patients’ discharges. But as they began to work through the process of making sure each appointment was appropriately documented, the various team members assigned to this process could not consistently complete the task within their workflow.

The pilot unit secretaries were not part of the BOOST team initially but saw that they could fulfill this role quickly and easily. They knew who to call at the physicians’ offices to avoid getting stuck in the phone menu trees, and they used this knowledge to reach the schedulers directly. The BOOST team quickly realized the unit secretaries were the most appropriate personnel to capture this information and work with the patients or their families/caregivers to obtain the most convenient appointments. This role was added to the team, and the unit secretaries took ownership of this process. Other teams may also want to look beyond the customary team members to roles that may not be thought of as quality team members.

Lessons learned: “The biggest take-away for me involves the unique culture that exists in many of our urban and rural communities,” he says. Every BOOST site implements the project’s elements in its own unique way, and what works well in one location may not fit the needs of another. The role of the mentor is to balance the need for community-specific advice with unique attributes of the facility and the elements of Project BOOST. “Often, we use our mentor calls to brainstorm solutions, and the teams are teaching me what will work best in their environment.”

Advice: “Responsibility for hospital change management should not be abdicated to administrators or quality improvement staff members,” he says. “QI is not a sometime thing for some staff; it’s an all-the-time process for every staff member, including physicians, to participate in and actively manage.”

Cheryl O’Malley, MD, FHM

Cheryl O’Malley, MD, FHM

Title: Internal medicine residency program director, Banner Good Samaritan Medical Center, Phoenix

Program: GCMI

Background: Banner Good Samaritan has participated in the BOOST, VTE, and GCMI programs. Dr. O’Malley brought her experience from developing, implementing, and leading local glycemic control efforts to mentoring others.

“When I first started working on our hospital’s process, I had so many questions and asked one of my mentors from residency, Dr. Greg Maynard,” she says. “He helped me to see that people around the country were asking the same questions and invited me to join SHM’s glycemic control work group. When the GCMI program started, I was asked to be a mentor.”

Teachable moment: “When I was a new attending on the wards after residency, my patients would ask me why their blood sugars were so much better controlled at home than in the hospital. Usually, the answer was that they were put on a sliding scale when they came into the hospital,” she says, noting that what was done at home wasn’t going to work in the hospital. Patients needed a different regimen—a more proactive approach than just the customary sliding scale.

“I started to learn more about basal rates, nutrition, and correction insulin regimens in the hospital, but I realized that to really have adequate safety and direction for the nursing staff, it would require a formal order set and systematic approach,” she says.

Success story: “One of my sites invited me to come and present grand rounds at the hospital, and the local physician team leader invited the whole quality team to her home. It was a very exciting team and had achieved a lot. Fifteen or 20 of us spent the evening talking about the project but also just enjoying the collegiality,” Dr. O’Malley says. “Even though we had never seen one another, I instantly knew everyone by voice from spending so much time on the phone. And we knew a lot about one another’s personal lives and careers.”

Lessons learned: “Hearing a program describe what they are doing and knowing that they were far ahead of my own hospital in many ways but still being able to provide an insight or a perspective to help them achieve their own next steps. Everyone has something to learn from another hospital or another discipline. We can all leverage our experiences to improve patient care.”

Advice: “Be patient. This is a really long process of constant improvements. I have been working on glycemic control for 10 years now and still feel like we have many opportunities to further improve.”

Cheryl O’Malley, MD, FHM

Christopher Kim, MD, MBA, SFHM

Title: Clinical associate professor of internal medicine and assistant professor of pediatrics, University of Michigan Health System, Ann Arbor

Program: Project BOOST; Michigan Transitions of Care Collaborative (M-TC2)

Background: Dr. Kim brings clinical, quality improvement, leadership, collaborative learning, and discussion facilitation skills to his work as program director of M-TC2 and as mentor to the sites he works with.

The collaborative is part of a set of state collaborative quality initiatives funded by Blue Cross Blue Shield of Michigan. One of those initiatives is focused on improving care transitions between the hospital setting and ambulatory care providers, using Project BOOST tools—expanded to integrate more closely with primary care providers, physician organizations, and ambulatory care. The eight Michigan-based mentors for M-TC2 have all attended SHM’s Mentor University.

Teachable moment: There are local challenges and there are general challenges—those that are commonly shared by most hospitals, Dr. Kim explains. Both need to be overcome when working on an improvement project such as transitions of care. The local hospitalist brings expertise about the former—which are often more difficult to understand and overcome. The mentor brings knowledge and experience of the universal challenges, as well as the benefit of having seen or heard about what other programs have done. Together, they can work to help the organization become better equipped to improve the initiative at hand.

Success story: “One hospital in the collaborative realized that it could roll out the Teach Back concept to both nurses and physicians,” he says. They started to teach residents how to interact with patients and began using this approach in physician-nurse teams. Subsequently, the team shared with the collaborative how physicians have embraced the concept.

Lessons learned: Every site has its successes and challenges, he says. Sharing both sides of the story can only advance the mission of the collaborative, as each organization learns from the successes and failures of the others.

Mentored implementation really does what it’s intended to do—helping to support the sites and keeping an organization on track and accountable for the work it does, because someone external to the organization is working with it and providing information about what other sites are doing.

Advice: Talk with different disciplines and find out how much they long to work with other care providers, and then have discussions about how to make interdisciplinary practice happen. “At our collaborative meetings over time, many of the 24 participating sites have shared their progress—the good things and the struggles,” Dr. Kim says.

Larry Beresford is a freelance writer in Alameda, Calif.

Click here to listen to excerpts of our interview with Dr. Williams

Click here to listen to excerpts of our interview with Dr. Williams

Click here to listen to excerpts of our interview with Dr. Williams