QI Initiatives

Dr. Kealey

Hippocrates, Epidemics.“The Physician must be able to do good or to do no harm.”

This is part three of my ongoing series on the journey of hospital medicine and how we are poised for greater things yet. In part one, “Tinder and Spark,” macro changes in the American healthcare landscape pressured primary care physicians to get creative with new ways to practice, the most prominent result being the creation of hospitalist practices. Wachter and Goldman provided the spark that gave the field its name and cohesiveness. In part two, “Fuel,” the Baby Boomers shaped the field, setting the stage for the Generation X physicians who fueled HM’s early growth.

But the field might have stagnated there, the fire attenuated, if not for the rise of something new, something that stoked our growth to new heights.

Orlando, Fla., December 2006.

SHM President-Elect Rusty Holman, MD, MHM, was on stage representing hospitalists at the annual Institute for Healthcare Improvement (IHI) National Forum in front of more than 5,000 enthusiastic attendees representing every discipline of clinical care from hundreds of healthcare organizations across the country and internationally. This was a special event. Two years earlier, IHI President Don Berwick, MD, MPP, had launched an audacious campaign, called the 100,000 Lives Campaign, that aimed to prevent the deaths of 100,000 patients in our nation’s hospitals in the following 18 months, not by utilizing some great new technological advance but by changing the culture around safety and quality in our nation’s hospitals and enacting proven safety methods and processes.1 Out of this plan came widespread use of terms and programs that weren’t widely adopted then but are familiar to all of us now: rapid response teams, medicine reconciliation, surgical site infection prevention, and ventilator-acquired pneumonia.

That program estimated that it saved 122,000 lives.¹

IHI was looking to build on the safety and quality infrastructure that had been built up to make the 100,000 Lives Campaign a success and to launch an even bigger program. The 5 Million Lives Campaign’s goal was to reduce incidents of harm in five million patients over the next two years. For this campaign, IHI understood that success could only be achieved with partners. SHM and the field of hospital medicine, which had grown in size and influence, was seen as a critical and influential partner in achieving the goal of reducing harm in our nation’s hospitals. Thus, Dr. Holman was standing on that stage for SHM at the launch of the biggest safety and quality initiative in our nation’s history. SHM was among seven partner organizations, including the American Nurses Association, the Centers for Medicare and Medicaid Services (CMS), the American Heart Association, and the CDC. SHM was the only medical society represented. Pretty heady stuff for a field barely 10 years old. How did we get there? For that story, we need to go back a few years.

In 1984, Libby Zion, an 18-year-old college student, died from serotonin syndrome. A contributing factor was felt to be overworked residents not getting enough sleep. In his landmark 1990 article, “Human Factors in Hazardous Situations,” James Reason, PhD, introduced the world to some key concepts: active versus latent errors and the Swiss cheese model of errors.² These concepts influence our thinking to this day. In 1994, Betsy Lehman, a health reporter for the Boston Globe, died from a massive chemotherapy overdose. That same year Lucian Leape, MD, a Harvard pediatric surgeon, published his influential article in JAMA, “Errors in Medicine,” which called for a systems approach to improving patient safety.³

These key moments in safety and quality, all of which occurred in the years leading up to hospitalists gaining their identity, were but a prelude to the widespread patient safety and quality movement. Like our own social movement, “Patient Safety and Quality” was born with an influential publication. This was the 1999 release of the Institute of Medicine’s “To Err is Human,” a report that reiterated claims that up to 98,000 U.S. patients per year were dying from medical errors.⁴ It also supported Dr. Leape’s earlier work calling for systems changes. In 2001, the Institute of Medicine published a second report, “Crossing the Quality Chasm: A New Health System for the 21st Century,” which introduced the six aims for healthcare improvement: safe, timely, effective, efficient, equitable, and patient-centered.⁵

Before 1999, hospitalists were just getting their feet on the ground. Groups were experimenting with practice models and recruiting young talent, mostly with a pitch for a new way to practice with freedom to design their day and often an interesting work schedule.

After the publication of “To Err is Human” in 1999, changes in patient safety and quality began to accelerate. Taking one of the recommendations from “To Err is Human,” which suggested that employers should use their market power to improve quality and safety, the Leapfrog Group, a consortium of large employers, organized in 2000. Leapfrog began rewarding and recognizing hospitals that put accepted safety measures in place.⁶ Suddenly, hospital CEOs began to see tangible rewards for improving quality in their hospitals.

Here is where the hospitalist movement and the patient safety and quality movement began to intersect.

Shift to Quality and Safety

In 2001, the same year “Crossing the Quality Chasm” was published, Congress created the Center for Quality Improvement and Patient Safety within the Agency for Healthcare Research and Quality. Significant funding was suddenly available for quality and safety research, and a more organized reporting mechanism for quality would soon be available.

In 2002, the Joint Commission released its first set of National Patient Safety Goals. There were seven, and key goals for hospitalists included improving the effectiveness of communication among caregivers, reducing the risk of healthcare-acquired infections, and reconciling medications.

And, lastly, as if that weren’t enough activity in the patient safety and quality world, the Joint Commission and CMS released in 2003 the first joint, aligned set of core measures, with which we are all now very familiar, around acute myocardial infarction, congestive heart failure, and pneumonia.

Hospital executives were trying to get a handle on the meaning of this flurry of activity for their hospitals. It certainly meant new regulatory requirements. It probably meant greater visibility to the public around what happened behind the walls of their facilities. No doubt dollars on the line wouldn’t be too far behind. They needed help, and they needed it fast.

No longer were hospitalists a small group of young docs roaming the halls; now, instead of just taking care of one patient at a time, they were reaching the threshold of size—and even status in some organizations—where they could leverage their working knowledge of the system and presence on site to affect the various facets of quality now being measured and incented. Additionally, as the information technology (IT) revolution rolled out, hospitalists, mostly tech-savvy Gen X’ers, looked to ease the transition into the new world of EHRs, which promised to serve as a new base for improving quality.

As the C-suite continued making value calculations in their heads, they saw that, in addition to helping them manage the many facets of the transition of primary care and specialty teaching attendings out of the hospital, hospitalists could now be a powerful weapon in helping them stay competitive in the looming patient safety and quality revolution. They pulled out their checkbooks.

When SHM first started gathering data to explore this gap, we discovered that in 2003 the reported median support per FTE of an adult hospitalist in this country was $60,000.⁷ With an estimated 11,000 hospitalists in the country at that time, C-suite funders paid out over $600 million to help overcome the deficit between hospitalist professional billings and salary and benefits. By the time SHM partnered with IHI on the 5 Million Lives Campaign in 2006, the figure stood at well over $2 billion. The 2011 SHM/Medical Group Management Association survey data showed $139,090 support per FTE. With 31,000 U.S. hospitalists estimated at the time, that figure had doubled to over $4 billion in just five years’ time.

The new generation of doctors had come along in the late 1990s looking for a practice that fit their wants and needs. HM gave them what they were looking for: autonomy, the promise of work-life balance, and the ability to help patients in their most vulnerable time. The traditional E&M [evaluation and management]-based funding mechanisms simply weren’t designed to account for physicians who spend all of their time doing the critical cognitive and coordinating clinical work. To account for this, hospitals and medical groups, seeing the value to their organizations in this new specialty, anteed up to cover the difference. That gave us a great beginning.

But it was the convergence of the early hospitalist movement and the emergent patient safety and quality movement that created a synergy that propelled both movements forward. Boosted by the influx of funding directly and indirectly related to patient safety and quality, hospitalists grew in number from an estimated 5,000 physicians at the 1999 publication of “To Err is Human” to north of 40,000 today.

The synergy was evident when SHM President-Elect Dr. Holman, representing our fledgling specialty and society, faced that cheering throng in Orlando alongside Dr. Don Berwick, the face of the patient safety and quality movement.

But that’s not quite the end of the story.

To get us up to the present and on to our bright future, there will be a few more additions to the quality story and an all-new generation arriving on the scene to shake things up.

Dr. Kealey is SHM president and medical director of hospital specialties at HealthPartners Medical Group in St. Paul, Minn.

References

1. Institute for Healthcare Improvement. Overview of the 100,000 Lives Campaign. Available at: http://www.ihi.org/Engage/Initiatives/Completed/5MillionLivesCampaign/Documents/Overview%20of%20the%20100K%20Campaign.pdf. Accessed July 6, 2014.
2. Broadbent DE, Reason J, Baddeley A, eds. Human Factors in Hazardous Situations: Proceedings of a Royal Society Discussion Meeting Held on 28 and 29 June 1989. Gloucestershire, England: Clarendon Press; 1990:475-484.
3. Leape LL. Error in medicine JAMA.1994;272(23):1851-1857.
4. Institute of Medicine. Kohn LT, Corrigan JM, Donaldson MS, eds. To Err Is Human: Building a Safer Health System. Washington, D.C.: The National Academy Press; 2000.
5. Institute of Medicine. Committee on Quality of Healthcare in America. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, D.C.: The National Academy Press; 2001.
6. The Leapfrog Group. About Leapfrog. Available at: http://www.leapfroggroup.org/about_leapfrog. Accessed July 6, 2014.
7. Society of Hospital Medicine. SHM’s State of Hospital Medicine Surveys 2003-2012. Available at: www.hospitalmedicine.org/survey. Accessed July 3, 2014.

Dr. Kealey

Hippocrates, Epidemics.“The Physician must be able to do good or to do no harm.”

This is part three of my ongoing series on the journey of hospital medicine and how we are poised for greater things yet. In part one, “Tinder and Spark,” macro changes in the American healthcare landscape pressured primary care physicians to get creative with new ways to practice, the most prominent result being the creation of hospitalist practices. Wachter and Goldman provided the spark that gave the field its name and cohesiveness. In part two, “Fuel,” the Baby Boomers shaped the field, setting the stage for the Generation X physicians who fueled HM’s early growth.

But the field might have stagnated there, the fire attenuated, if not for the rise of something new, something that stoked our growth to new heights.

Orlando, Fla., December 2006.

SHM President-Elect Rusty Holman, MD, MHM, was on stage representing hospitalists at the annual Institute for Healthcare Improvement (IHI) National Forum in front of more than 5,000 enthusiastic attendees representing every discipline of clinical care from hundreds of healthcare organizations across the country and internationally. This was a special event. Two years earlier, IHI President Don Berwick, MD, MPP, had launched an audacious campaign, called the 100,000 Lives Campaign, that aimed to prevent the deaths of 100,000 patients in our nation’s hospitals in the following 18 months, not by utilizing some great new technological advance but by changing the culture around safety and quality in our nation’s hospitals and enacting proven safety methods and processes.1 Out of this plan came widespread use of terms and programs that weren’t widely adopted then but are familiar to all of us now: rapid response teams, medicine reconciliation, surgical site infection prevention, and ventilator-acquired pneumonia.

That program estimated that it saved 122,000 lives.¹

IHI was looking to build on the safety and quality infrastructure that had been built up to make the 100,000 Lives Campaign a success and to launch an even bigger program. The 5 Million Lives Campaign’s goal was to reduce incidents of harm in five million patients over the next two years. For this campaign, IHI understood that success could only be achieved with partners. SHM and the field of hospital medicine, which had grown in size and influence, was seen as a critical and influential partner in achieving the goal of reducing harm in our nation’s hospitals. Thus, Dr. Holman was standing on that stage for SHM at the launch of the biggest safety and quality initiative in our nation’s history. SHM was among seven partner organizations, including the American Nurses Association, the Centers for Medicare and Medicaid Services (CMS), the American Heart Association, and the CDC. SHM was the only medical society represented. Pretty heady stuff for a field barely 10 years old. How did we get there? For that story, we need to go back a few years.

In 1984, Libby Zion, an 18-year-old college student, died from serotonin syndrome. A contributing factor was felt to be overworked residents not getting enough sleep. In his landmark 1990 article, “Human Factors in Hazardous Situations,” James Reason, PhD, introduced the world to some key concepts: active versus latent errors and the Swiss cheese model of errors.² These concepts influence our thinking to this day. In 1994, Betsy Lehman, a health reporter for the Boston Globe, died from a massive chemotherapy overdose. That same year Lucian Leape, MD, a Harvard pediatric surgeon, published his influential article in JAMA, “Errors in Medicine,” which called for a systems approach to improving patient safety.³

These key moments in safety and quality, all of which occurred in the years leading up to hospitalists gaining their identity, were but a prelude to the widespread patient safety and quality movement. Like our own social movement, “Patient Safety and Quality” was born with an influential publication. This was the 1999 release of the Institute of Medicine’s “To Err is Human,” a report that reiterated claims that up to 98,000 U.S. patients per year were dying from medical errors.⁴ It also supported Dr. Leape’s earlier work calling for systems changes. In 2001, the Institute of Medicine published a second report, “Crossing the Quality Chasm: A New Health System for the 21st Century,” which introduced the six aims for healthcare improvement: safe, timely, effective, efficient, equitable, and patient-centered.⁵

Before 1999, hospitalists were just getting their feet on the ground. Groups were experimenting with practice models and recruiting young talent, mostly with a pitch for a new way to practice with freedom to design their day and often an interesting work schedule.

After the publication of “To Err is Human” in 1999, changes in patient safety and quality began to accelerate. Taking one of the recommendations from “To Err is Human,” which suggested that employers should use their market power to improve quality and safety, the Leapfrog Group, a consortium of large employers, organized in 2000. Leapfrog began rewarding and recognizing hospitals that put accepted safety measures in place.⁶ Suddenly, hospital CEOs began to see tangible rewards for improving quality in their hospitals.

Here is where the hospitalist movement and the patient safety and quality movement began to intersect.

Shift to Quality and Safety

In 2001, the same year “Crossing the Quality Chasm” was published, Congress created the Center for Quality Improvement and Patient Safety within the Agency for Healthcare Research and Quality. Significant funding was suddenly available for quality and safety research, and a more organized reporting mechanism for quality would soon be available.

In 2002, the Joint Commission released its first set of National Patient Safety Goals. There were seven, and key goals for hospitalists included improving the effectiveness of communication among caregivers, reducing the risk of healthcare-acquired infections, and reconciling medications.

And, lastly, as if that weren’t enough activity in the patient safety and quality world, the Joint Commission and CMS released in 2003 the first joint, aligned set of core measures, with which we are all now very familiar, around acute myocardial infarction, congestive heart failure, and pneumonia.

Hospital executives were trying to get a handle on the meaning of this flurry of activity for their hospitals. It certainly meant new regulatory requirements. It probably meant greater visibility to the public around what happened behind the walls of their facilities. No doubt dollars on the line wouldn’t be too far behind. They needed help, and they needed it fast.

No longer were hospitalists a small group of young docs roaming the halls; now, instead of just taking care of one patient at a time, they were reaching the threshold of size—and even status in some organizations—where they could leverage their working knowledge of the system and presence on site to affect the various facets of quality now being measured and incented. Additionally, as the information technology (IT) revolution rolled out, hospitalists, mostly tech-savvy Gen X’ers, looked to ease the transition into the new world of EHRs, which promised to serve as a new base for improving quality.

As the C-suite continued making value calculations in their heads, they saw that, in addition to helping them manage the many facets of the transition of primary care and specialty teaching attendings out of the hospital, hospitalists could now be a powerful weapon in helping them stay competitive in the looming patient safety and quality revolution. They pulled out their checkbooks.

When SHM first started gathering data to explore this gap, we discovered that in 2003 the reported median support per FTE of an adult hospitalist in this country was $60,000.⁷ With an estimated 11,000 hospitalists in the country at that time, C-suite funders paid out over $600 million to help overcome the deficit between hospitalist professional billings and salary and benefits. By the time SHM partnered with IHI on the 5 Million Lives Campaign in 2006, the figure stood at well over $2 billion. The 2011 SHM/Medical Group Management Association survey data showed $139,090 support per FTE. With 31,000 U.S. hospitalists estimated at the time, that figure had doubled to over $4 billion in just five years’ time.

The new generation of doctors had come along in the late 1990s looking for a practice that fit their wants and needs. HM gave them what they were looking for: autonomy, the promise of work-life balance, and the ability to help patients in their most vulnerable time. The traditional E&M [evaluation and management]-based funding mechanisms simply weren’t designed to account for physicians who spend all of their time doing the critical cognitive and coordinating clinical work. To account for this, hospitals and medical groups, seeing the value to their organizations in this new specialty, anteed up to cover the difference. That gave us a great beginning.

But it was the convergence of the early hospitalist movement and the emergent patient safety and quality movement that created a synergy that propelled both movements forward. Boosted by the influx of funding directly and indirectly related to patient safety and quality, hospitalists grew in number from an estimated 5,000 physicians at the 1999 publication of “To Err is Human” to north of 40,000 today.

The synergy was evident when SHM President-Elect Dr. Holman, representing our fledgling specialty and society, faced that cheering throng in Orlando alongside Dr. Don Berwick, the face of the patient safety and quality movement.

But that’s not quite the end of the story.

To get us up to the present and on to our bright future, there will be a few more additions to the quality story and an all-new generation arriving on the scene to shake things up.

Dr. Kealey is SHM president and medical director of hospital specialties at HealthPartners Medical Group in St. Paul, Minn.

References

1. Institute for Healthcare Improvement. Overview of the 100,000 Lives Campaign. Available at: http://www.ihi.org/Engage/Initiatives/Completed/5MillionLivesCampaign/Documents/Overview%20of%20the%20100K%20Campaign.pdf. Accessed July 6, 2014.
2. Broadbent DE, Reason J, Baddeley A, eds. Human Factors in Hazardous Situations: Proceedings of a Royal Society Discussion Meeting Held on 28 and 29 June 1989. Gloucestershire, England: Clarendon Press; 1990:475-484.
3. Leape LL. Error in medicine JAMA.1994;272(23):1851-1857.
4. Institute of Medicine. Kohn LT, Corrigan JM, Donaldson MS, eds. To Err Is Human: Building a Safer Health System. Washington, D.C.: The National Academy Press; 2000.
5. Institute of Medicine. Committee on Quality of Healthcare in America. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, D.C.: The National Academy Press; 2001.
6. The Leapfrog Group. About Leapfrog. Available at: http://www.leapfroggroup.org/about_leapfrog. Accessed July 6, 2014.
7. Society of Hospital Medicine. SHM’s State of Hospital Medicine Surveys 2003-2012. Available at: www.hospitalmedicine.org/survey. Accessed July 3, 2014.

Dr. Kealey

Hippocrates, Epidemics.“The Physician must be able to do good or to do no harm.”

This is part three of my ongoing series on the journey of hospital medicine and how we are poised for greater things yet. In part one, “Tinder and Spark,” macro changes in the American healthcare landscape pressured primary care physicians to get creative with new ways to practice, the most prominent result being the creation of hospitalist practices. Wachter and Goldman provided the spark that gave the field its name and cohesiveness. In part two, “Fuel,” the Baby Boomers shaped the field, setting the stage for the Generation X physicians who fueled HM’s early growth.

But the field might have stagnated there, the fire attenuated, if not for the rise of something new, something that stoked our growth to new heights.

Orlando, Fla., December 2006.

SHM President-Elect Rusty Holman, MD, MHM, was on stage representing hospitalists at the annual Institute for Healthcare Improvement (IHI) National Forum in front of more than 5,000 enthusiastic attendees representing every discipline of clinical care from hundreds of healthcare organizations across the country and internationally. This was a special event. Two years earlier, IHI President Don Berwick, MD, MPP, had launched an audacious campaign, called the 100,000 Lives Campaign, that aimed to prevent the deaths of 100,000 patients in our nation’s hospitals in the following 18 months, not by utilizing some great new technological advance but by changing the culture around safety and quality in our nation’s hospitals and enacting proven safety methods and processes.1 Out of this plan came widespread use of terms and programs that weren’t widely adopted then but are familiar to all of us now: rapid response teams, medicine reconciliation, surgical site infection prevention, and ventilator-acquired pneumonia.

That program estimated that it saved 122,000 lives.¹

IHI was looking to build on the safety and quality infrastructure that had been built up to make the 100,000 Lives Campaign a success and to launch an even bigger program. The 5 Million Lives Campaign’s goal was to reduce incidents of harm in five million patients over the next two years. For this campaign, IHI understood that success could only be achieved with partners. SHM and the field of hospital medicine, which had grown in size and influence, was seen as a critical and influential partner in achieving the goal of reducing harm in our nation’s hospitals. Thus, Dr. Holman was standing on that stage for SHM at the launch of the biggest safety and quality initiative in our nation’s history. SHM was among seven partner organizations, including the American Nurses Association, the Centers for Medicare and Medicaid Services (CMS), the American Heart Association, and the CDC. SHM was the only medical society represented. Pretty heady stuff for a field barely 10 years old. How did we get there? For that story, we need to go back a few years.

In 1984, Libby Zion, an 18-year-old college student, died from serotonin syndrome. A contributing factor was felt to be overworked residents not getting enough sleep. In his landmark 1990 article, “Human Factors in Hazardous Situations,” James Reason, PhD, introduced the world to some key concepts: active versus latent errors and the Swiss cheese model of errors.² These concepts influence our thinking to this day. In 1994, Betsy Lehman, a health reporter for the Boston Globe, died from a massive chemotherapy overdose. That same year Lucian Leape, MD, a Harvard pediatric surgeon, published his influential article in JAMA, “Errors in Medicine,” which called for a systems approach to improving patient safety.³

These key moments in safety and quality, all of which occurred in the years leading up to hospitalists gaining their identity, were but a prelude to the widespread patient safety and quality movement. Like our own social movement, “Patient Safety and Quality” was born with an influential publication. This was the 1999 release of the Institute of Medicine’s “To Err is Human,” a report that reiterated claims that up to 98,000 U.S. patients per year were dying from medical errors.⁴ It also supported Dr. Leape’s earlier work calling for systems changes. In 2001, the Institute of Medicine published a second report, “Crossing the Quality Chasm: A New Health System for the 21st Century,” which introduced the six aims for healthcare improvement: safe, timely, effective, efficient, equitable, and patient-centered.⁵

Before 1999, hospitalists were just getting their feet on the ground. Groups were experimenting with practice models and recruiting young talent, mostly with a pitch for a new way to practice with freedom to design their day and often an interesting work schedule.

After the publication of “To Err is Human” in 1999, changes in patient safety and quality began to accelerate. Taking one of the recommendations from “To Err is Human,” which suggested that employers should use their market power to improve quality and safety, the Leapfrog Group, a consortium of large employers, organized in 2000. Leapfrog began rewarding and recognizing hospitals that put accepted safety measures in place.⁶ Suddenly, hospital CEOs began to see tangible rewards for improving quality in their hospitals.

Here is where the hospitalist movement and the patient safety and quality movement began to intersect.

Shift to Quality and Safety

In 2001, the same year “Crossing the Quality Chasm” was published, Congress created the Center for Quality Improvement and Patient Safety within the Agency for Healthcare Research and Quality. Significant funding was suddenly available for quality and safety research, and a more organized reporting mechanism for quality would soon be available.

In 2002, the Joint Commission released its first set of National Patient Safety Goals. There were seven, and key goals for hospitalists included improving the effectiveness of communication among caregivers, reducing the risk of healthcare-acquired infections, and reconciling medications.

And, lastly, as if that weren’t enough activity in the patient safety and quality world, the Joint Commission and CMS released in 2003 the first joint, aligned set of core measures, with which we are all now very familiar, around acute myocardial infarction, congestive heart failure, and pneumonia.

Hospital executives were trying to get a handle on the meaning of this flurry of activity for their hospitals. It certainly meant new regulatory requirements. It probably meant greater visibility to the public around what happened behind the walls of their facilities. No doubt dollars on the line wouldn’t be too far behind. They needed help, and they needed it fast.

No longer were hospitalists a small group of young docs roaming the halls; now, instead of just taking care of one patient at a time, they were reaching the threshold of size—and even status in some organizations—where they could leverage their working knowledge of the system and presence on site to affect the various facets of quality now being measured and incented. Additionally, as the information technology (IT) revolution rolled out, hospitalists, mostly tech-savvy Gen X’ers, looked to ease the transition into the new world of EHRs, which promised to serve as a new base for improving quality.

As the C-suite continued making value calculations in their heads, they saw that, in addition to helping them manage the many facets of the transition of primary care and specialty teaching attendings out of the hospital, hospitalists could now be a powerful weapon in helping them stay competitive in the looming patient safety and quality revolution. They pulled out their checkbooks.

When SHM first started gathering data to explore this gap, we discovered that in 2003 the reported median support per FTE of an adult hospitalist in this country was $60,000.⁷ With an estimated 11,000 hospitalists in the country at that time, C-suite funders paid out over $600 million to help overcome the deficit between hospitalist professional billings and salary and benefits. By the time SHM partnered with IHI on the 5 Million Lives Campaign in 2006, the figure stood at well over $2 billion. The 2011 SHM/Medical Group Management Association survey data showed $139,090 support per FTE. With 31,000 U.S. hospitalists estimated at the time, that figure had doubled to over $4 billion in just five years’ time.

The new generation of doctors had come along in the late 1990s looking for a practice that fit their wants and needs. HM gave them what they were looking for: autonomy, the promise of work-life balance, and the ability to help patients in their most vulnerable time. The traditional E&M [evaluation and management]-based funding mechanisms simply weren’t designed to account for physicians who spend all of their time doing the critical cognitive and coordinating clinical work. To account for this, hospitals and medical groups, seeing the value to their organizations in this new specialty, anteed up to cover the difference. That gave us a great beginning.

But it was the convergence of the early hospitalist movement and the emergent patient safety and quality movement that created a synergy that propelled both movements forward. Boosted by the influx of funding directly and indirectly related to patient safety and quality, hospitalists grew in number from an estimated 5,000 physicians at the 1999 publication of “To Err is Human” to north of 40,000 today.

The synergy was evident when SHM President-Elect Dr. Holman, representing our fledgling specialty and society, faced that cheering throng in Orlando alongside Dr. Don Berwick, the face of the patient safety and quality movement.

But that’s not quite the end of the story.

To get us up to the present and on to our bright future, there will be a few more additions to the quality story and an all-new generation arriving on the scene to shake things up.

Dr. Kealey is SHM president and medical director of hospital specialties at HealthPartners Medical Group in St. Paul, Minn.

References

1. Institute for Healthcare Improvement. Overview of the 100,000 Lives Campaign. Available at: http://www.ihi.org/Engage/Initiatives/Completed/5MillionLivesCampaign/Documents/Overview%20of%20the%20100K%20Campaign.pdf. Accessed July 6, 2014.
2. Broadbent DE, Reason J, Baddeley A, eds. Human Factors in Hazardous Situations: Proceedings of a Royal Society Discussion Meeting Held on 28 and 29 June 1989. Gloucestershire, England: Clarendon Press; 1990:475-484.
3. Leape LL. Error in medicine JAMA.1994;272(23):1851-1857.
4. Institute of Medicine. Kohn LT, Corrigan JM, Donaldson MS, eds. To Err Is Human: Building a Safer Health System. Washington, D.C.: The National Academy Press; 2000.
5. Institute of Medicine. Committee on Quality of Healthcare in America. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, D.C.: The National Academy Press; 2001.
6. The Leapfrog Group. About Leapfrog. Available at: http://www.leapfroggroup.org/about_leapfrog. Accessed July 6, 2014.
7. Society of Hospital Medicine. SHM’s State of Hospital Medicine Surveys 2003-2012. Available at: www.hospitalmedicine.org/survey. Accessed July 3, 2014.

Financial pressures to reduce 30-day hospital readmissions and improve discharge processes continue to grow. The Centers for Medicare and Medicaid Services started by penalizing hospitals for up to 1% of their Medicare reimbursement via the Hospital Readmissions Reduction Program. By 2015, the program will penalize hospitals up to 3%.

This is no longer news to the hospital C-suite. A 2013 survey reported that 85% of hospital leaders had addressed the readmissions penalty in their business plan (http://content.hcpro.com/pdf/content/296905.pdf); however, the same survey revealed that only 62% of hospital leaders reported changes to clinical protocols and practices during acute care, and even fewer were providing care navigators or coaches for high-risk patients.

That’s where hospitalists can help. Through SHM’s Project BOOST, hospitalists and hospital-based care teams improve transition from hospital to home. Project BOOST also helps hospitals identify high-risk patients and target risk-specific interventions, a critical part of reducing readmissions.

Beyond the immediate financial implications, implementing programs like Project BOOST to reduce readmissions can position hospitals as leaders for better healthcare in their communities.

“I recommend Project BOOST enthusiastically and unequivocally,” says Manasi Kekan, MD, MS, FACP, medical director for Houston Methodist Hospital. “If implemented efficiently, it could result in a ‘win-win’ situation for patients, the hospital, and the healthcare providers.”

SHM is accepting applications for the 2014 Project BOOST cohort through August 30. For details and application, visit www.hospitalmedicine.org/boost.

Financial pressures to reduce 30-day hospital readmissions and improve discharge processes continue to grow. The Centers for Medicare and Medicaid Services started by penalizing hospitals for up to 1% of their Medicare reimbursement via the Hospital Readmissions Reduction Program. By 2015, the program will penalize hospitals up to 3%.

This is no longer news to the hospital C-suite. A 2013 survey reported that 85% of hospital leaders had addressed the readmissions penalty in their business plan (http://content.hcpro.com/pdf/content/296905.pdf); however, the same survey revealed that only 62% of hospital leaders reported changes to clinical protocols and practices during acute care, and even fewer were providing care navigators or coaches for high-risk patients.

That’s where hospitalists can help. Through SHM’s Project BOOST, hospitalists and hospital-based care teams improve transition from hospital to home. Project BOOST also helps hospitals identify high-risk patients and target risk-specific interventions, a critical part of reducing readmissions.

Beyond the immediate financial implications, implementing programs like Project BOOST to reduce readmissions can position hospitals as leaders for better healthcare in their communities.

“I recommend Project BOOST enthusiastically and unequivocally,” says Manasi Kekan, MD, MS, FACP, medical director for Houston Methodist Hospital. “If implemented efficiently, it could result in a ‘win-win’ situation for patients, the hospital, and the healthcare providers.”

SHM is accepting applications for the 2014 Project BOOST cohort through August 30. For details and application, visit www.hospitalmedicine.org/boost.

Financial pressures to reduce 30-day hospital readmissions and improve discharge processes continue to grow. The Centers for Medicare and Medicaid Services started by penalizing hospitals for up to 1% of their Medicare reimbursement via the Hospital Readmissions Reduction Program. By 2015, the program will penalize hospitals up to 3%.

This is no longer news to the hospital C-suite. A 2013 survey reported that 85% of hospital leaders had addressed the readmissions penalty in their business plan (http://content.hcpro.com/pdf/content/296905.pdf); however, the same survey revealed that only 62% of hospital leaders reported changes to clinical protocols and practices during acute care, and even fewer were providing care navigators or coaches for high-risk patients.

That’s where hospitalists can help. Through SHM’s Project BOOST, hospitalists and hospital-based care teams improve transition from hospital to home. Project BOOST also helps hospitals identify high-risk patients and target risk-specific interventions, a critical part of reducing readmissions.

Beyond the immediate financial implications, implementing programs like Project BOOST to reduce readmissions can position hospitals as leaders for better healthcare in their communities.

“I recommend Project BOOST enthusiastically and unequivocally,” says Manasi Kekan, MD, MS, FACP, medical director for Houston Methodist Hospital. “If implemented efficiently, it could result in a ‘win-win’ situation for patients, the hospital, and the healthcare providers.”

SHM is accepting applications for the 2014 Project BOOST cohort through August 30. For details and application, visit www.hospitalmedicine.org/boost.

Are you helping your hospital choose wisely? You could receive thousands of dollars in return for your good work in providing high-value care to hospitalized patients through SHM’s Choosing Wisely case study competition.

SHM will be awarding a total of $20,000 to hospitalists who submit winning case studies illustrating their implementation of the Choosing Wisely principles published by SHM in 2013. Grand prize winners for both adult and pediatric HM will receive $4,000 each, and three honorable mention winners in both categories will each receive $2,000.

But don’t wait long. The deadline for submissions is September 9. For information and submission forms, visit www.hospitalmedicine.org/choosingwisely.

Are you helping your hospital choose wisely? You could receive thousands of dollars in return for your good work in providing high-value care to hospitalized patients through SHM’s Choosing Wisely case study competition.

SHM will be awarding a total of $20,000 to hospitalists who submit winning case studies illustrating their implementation of the Choosing Wisely principles published by SHM in 2013. Grand prize winners for both adult and pediatric HM will receive $4,000 each, and three honorable mention winners in both categories will each receive $2,000.

But don’t wait long. The deadline for submissions is September 9. For information and submission forms, visit www.hospitalmedicine.org/choosingwisely.

Are you helping your hospital choose wisely? You could receive thousands of dollars in return for your good work in providing high-value care to hospitalized patients through SHM’s Choosing Wisely case study competition.

SHM will be awarding a total of $20,000 to hospitalists who submit winning case studies illustrating their implementation of the Choosing Wisely principles published by SHM in 2013. Grand prize winners for both adult and pediatric HM will receive $4,000 each, and three honorable mention winners in both categories will each receive $2,000.

But don’t wait long. The deadline for submissions is September 9. For information and submission forms, visit www.hospitalmedicine.org/choosingwisely.

LAS VEGAS—Hospitalist Ijeoma “Carol” Nwelue, MD, has been more focused on patient readmissions over the past year at her practice in Lansing, Mich. So when the directors at Sparrow Hospitalists told her she had a meeting a few weeks after HM14 to discuss different risk assessment tools that might be used to pre-identify patients at high risk for readmission, she wasn’t nervous.

Instead, she prepped at SHM’s annual meeting at Mandalay Bay Resort and Casino—a veritable three-day crash course in the latest and greatest approaches to preventing readmissions.

“It’s very helpful,” she says. “It helps to see things that I haven’t thought about in our practice that other people are looking into.”

Quality improvement (QI) and patient safety are at the core of what hospitalists do, and the HM14 organizers understand that. From multiple pre-courses on the topics trending today to a dedicated educational track of breakout sessions and expert speakers to hundreds of posters identifying HM-specific QI projects, SHM’s annual meeting is a veritable QI opportunity of its own.

Take the annual pre-course, “ABIM Maintenance of Certification Facilitated Modules.” One attendee told presenter Read Pierce, MD, director of quality improvement and clinical innovation for the hospitalist group at the University of Colorado Denver, that before the session in Las Vegas he had always had “the sense that quality and safety is soft science or fuzzy stuff around the edges, and if you were a smart clinician, that was good enough.”

After some time in the session, Dr. Pierce recounts, the man “realized it’s not just enough to have great intellectual horsepower. You have to have some approach for dealing with these complex systems. And I think that’s the really fun thing....It’s not just about the discreet concepts; it’s about understanding the environment in which we practice, the importance of engaging systems and of using the tools of quality and safety to augment what physicians have always been good at doing.”

John Coppes, MD, FHM, a hospitalist at Mount Nittany Medical Center in State College, Pa., says quality and patient safety are the “most important things that we do.”

“It’s our responsibility to our patients to do the best job we can,” he notes. “It’s our responsibility to society to do it as efficiently as we can.”

Veteran meeting faculty John Bulger, DO, MBA, FACP, SFHM, hospitalist and chief quality officer at Geisinger Health System in Pennsylvania, agrees completely and is one of HM’s biggest proponents of the American Board of Internal Medicine (ABIM) Foundation’s Choosing Wisely (www.hospitalmedicine.org/choosingwisely) campaign. The national initiative, aimed at educating physicians—and patients—about wasteful medical tests, procedures, and treatments, launched in 2012, but SHM joined the chorus as a strategic partner last year.

“Choosing Wisely is about bending the cost curve,” Dr. Bulger says.

He added that although standardization of care is necessary for Choosing Wisely to work, homogeneity doesn’t mean everybody does everything exactly the same way. It means ensuring that hospitalists adopt “agreed upon best practices” before local variations are added. He compared it to a cookbook of apple pie recipes. All apple pies contain apples and crust, but the tasty treats are tailored differently from there.

“When you come up with guidelines in your hospital, that’s what you’re doing,” Dr. Bulger says. “You’re writing the cookbook and coming up with what works at your hospital. It might not work at [my hospital] at all, but I can look at it and learn.”

In the long-term, SHM hopes to create resources beyond the recommendations themselves—perhaps including a mentored implementation program akin to Project BOOST or pre-packaged order sets and checklists. Whatever the society does, it needs to engage the younger generation of physicians to ensure that quality and safety stay a priority for them, says Darlene Tad-y, MD, chair of SHM’s Physicians in Training Committee.

An assistant professor of medicine and a hospitalist at the University of Colorado Denver, Dr. Tad-y says that getting residents and students involved in quality and safety measures is critical for HM’s future.

“Especially since we want to have hospital medicine be at the forefront,” she explains. “It’s vital for us to have our students and residents taking the lead.”

Younger physicians already see the role quality and safety take in day-to-day practice. So, for them, according to Dr. Tad-y, a focus on making sure patient care is delivered better and more safely isn’t a renewed effort—it’s what they’re taught from the beginning.

“They haven’t been trained in the old way yet,” she says. “They still have an open mind. They see that things can change and things can be better. We don’t have to change old habits. We are just evolving good new habits for them.”

One new perspective was a first-time pre-course, “Cardiology: What Hospitalists Need to Know as Front-Line Providers.” The eight-hour seminar was led by cardiologist Matthews Chacko, MD, of Johns Hopkins Hospital in Baltimore, who says the time is right for quality-focused hospitalists to devote a full-day pre-course to cardiology.

“Cardiovascular disease is the most common reason we die,” he says. “It’s something hospital-based practitioners see often. Providing a comprehensive, yet simplified, overview of the way to manage some of these diseases with talks given by some of the leading experts in the field seemed very appropriate for this meeting.”

The sheer scale of QI initiatives can be daunting, says Michelle Mourad, MD, director of quality and safety at the University of California at San Francisco (UCSF) School of Medicine. She urges her peers to take the proverbial step back, identify a single issue—sepsis mortality or hand hygiene, for example—and then focus on understanding that issue intimately. That way, a hospitalist or HM group can convince other physicians that there is a problem and that it’s worth the work to fix it. Once that’s done, a hospitalist can launch a QI project that devises a measurement strategy to see if change is occurring.

And, while sustaining that change beyond the initial start-up can be difficult, Dr. Mourad believes success breeds success.

“When you work hard at a quality gap that’s in your organization, [when you] actually see the care you provide get better—not just for the patient in front of you, but for all the patients in your organization—it’s extremely powerful and motivating,” she says. “It changes the culture in your institution and convinces other people that they can do the same.”

LAS VEGAS—Hospitalist Ijeoma “Carol” Nwelue, MD, has been more focused on patient readmissions over the past year at her practice in Lansing, Mich. So when the directors at Sparrow Hospitalists told her she had a meeting a few weeks after HM14 to discuss different risk assessment tools that might be used to pre-identify patients at high risk for readmission, she wasn’t nervous.

Instead, she prepped at SHM’s annual meeting at Mandalay Bay Resort and Casino—a veritable three-day crash course in the latest and greatest approaches to preventing readmissions.

“It’s very helpful,” she says. “It helps to see things that I haven’t thought about in our practice that other people are looking into.”

Quality improvement (QI) and patient safety are at the core of what hospitalists do, and the HM14 organizers understand that. From multiple pre-courses on the topics trending today to a dedicated educational track of breakout sessions and expert speakers to hundreds of posters identifying HM-specific QI projects, SHM’s annual meeting is a veritable QI opportunity of its own.

Take the annual pre-course, “ABIM Maintenance of Certification Facilitated Modules.” One attendee told presenter Read Pierce, MD, director of quality improvement and clinical innovation for the hospitalist group at the University of Colorado Denver, that before the session in Las Vegas he had always had “the sense that quality and safety is soft science or fuzzy stuff around the edges, and if you were a smart clinician, that was good enough.”

After some time in the session, Dr. Pierce recounts, the man “realized it’s not just enough to have great intellectual horsepower. You have to have some approach for dealing with these complex systems. And I think that’s the really fun thing....It’s not just about the discreet concepts; it’s about understanding the environment in which we practice, the importance of engaging systems and of using the tools of quality and safety to augment what physicians have always been good at doing.”

John Coppes, MD, FHM, a hospitalist at Mount Nittany Medical Center in State College, Pa., says quality and patient safety are the “most important things that we do.”

“It’s our responsibility to our patients to do the best job we can,” he notes. “It’s our responsibility to society to do it as efficiently as we can.”

Veteran meeting faculty John Bulger, DO, MBA, FACP, SFHM, hospitalist and chief quality officer at Geisinger Health System in Pennsylvania, agrees completely and is one of HM’s biggest proponents of the American Board of Internal Medicine (ABIM) Foundation’s Choosing Wisely (www.hospitalmedicine.org/choosingwisely) campaign. The national initiative, aimed at educating physicians—and patients—about wasteful medical tests, procedures, and treatments, launched in 2012, but SHM joined the chorus as a strategic partner last year.

“Choosing Wisely is about bending the cost curve,” Dr. Bulger says.

He added that although standardization of care is necessary for Choosing Wisely to work, homogeneity doesn’t mean everybody does everything exactly the same way. It means ensuring that hospitalists adopt “agreed upon best practices” before local variations are added. He compared it to a cookbook of apple pie recipes. All apple pies contain apples and crust, but the tasty treats are tailored differently from there.

“When you come up with guidelines in your hospital, that’s what you’re doing,” Dr. Bulger says. “You’re writing the cookbook and coming up with what works at your hospital. It might not work at [my hospital] at all, but I can look at it and learn.”

In the long-term, SHM hopes to create resources beyond the recommendations themselves—perhaps including a mentored implementation program akin to Project BOOST or pre-packaged order sets and checklists. Whatever the society does, it needs to engage the younger generation of physicians to ensure that quality and safety stay a priority for them, says Darlene Tad-y, MD, chair of SHM’s Physicians in Training Committee.

An assistant professor of medicine and a hospitalist at the University of Colorado Denver, Dr. Tad-y says that getting residents and students involved in quality and safety measures is critical for HM’s future.

“Especially since we want to have hospital medicine be at the forefront,” she explains. “It’s vital for us to have our students and residents taking the lead.”

Younger physicians already see the role quality and safety take in day-to-day practice. So, for them, according to Dr. Tad-y, a focus on making sure patient care is delivered better and more safely isn’t a renewed effort—it’s what they’re taught from the beginning.

“They haven’t been trained in the old way yet,” she says. “They still have an open mind. They see that things can change and things can be better. We don’t have to change old habits. We are just evolving good new habits for them.”

One new perspective was a first-time pre-course, “Cardiology: What Hospitalists Need to Know as Front-Line Providers.” The eight-hour seminar was led by cardiologist Matthews Chacko, MD, of Johns Hopkins Hospital in Baltimore, who says the time is right for quality-focused hospitalists to devote a full-day pre-course to cardiology.

“Cardiovascular disease is the most common reason we die,” he says. “It’s something hospital-based practitioners see often. Providing a comprehensive, yet simplified, overview of the way to manage some of these diseases with talks given by some of the leading experts in the field seemed very appropriate for this meeting.”

The sheer scale of QI initiatives can be daunting, says Michelle Mourad, MD, director of quality and safety at the University of California at San Francisco (UCSF) School of Medicine. She urges her peers to take the proverbial step back, identify a single issue—sepsis mortality or hand hygiene, for example—and then focus on understanding that issue intimately. That way, a hospitalist or HM group can convince other physicians that there is a problem and that it’s worth the work to fix it. Once that’s done, a hospitalist can launch a QI project that devises a measurement strategy to see if change is occurring.

And, while sustaining that change beyond the initial start-up can be difficult, Dr. Mourad believes success breeds success.

“When you work hard at a quality gap that’s in your organization, [when you] actually see the care you provide get better—not just for the patient in front of you, but for all the patients in your organization—it’s extremely powerful and motivating,” she says. “It changes the culture in your institution and convinces other people that they can do the same.”

LAS VEGAS—Hospitalist Ijeoma “Carol” Nwelue, MD, has been more focused on patient readmissions over the past year at her practice in Lansing, Mich. So when the directors at Sparrow Hospitalists told her she had a meeting a few weeks after HM14 to discuss different risk assessment tools that might be used to pre-identify patients at high risk for readmission, she wasn’t nervous.

Instead, she prepped at SHM’s annual meeting at Mandalay Bay Resort and Casino—a veritable three-day crash course in the latest and greatest approaches to preventing readmissions.

“It’s very helpful,” she says. “It helps to see things that I haven’t thought about in our practice that other people are looking into.”

Quality improvement (QI) and patient safety are at the core of what hospitalists do, and the HM14 organizers understand that. From multiple pre-courses on the topics trending today to a dedicated educational track of breakout sessions and expert speakers to hundreds of posters identifying HM-specific QI projects, SHM’s annual meeting is a veritable QI opportunity of its own.

Take the annual pre-course, “ABIM Maintenance of Certification Facilitated Modules.” One attendee told presenter Read Pierce, MD, director of quality improvement and clinical innovation for the hospitalist group at the University of Colorado Denver, that before the session in Las Vegas he had always had “the sense that quality and safety is soft science or fuzzy stuff around the edges, and if you were a smart clinician, that was good enough.”

After some time in the session, Dr. Pierce recounts, the man “realized it’s not just enough to have great intellectual horsepower. You have to have some approach for dealing with these complex systems. And I think that’s the really fun thing....It’s not just about the discreet concepts; it’s about understanding the environment in which we practice, the importance of engaging systems and of using the tools of quality and safety to augment what physicians have always been good at doing.”

John Coppes, MD, FHM, a hospitalist at Mount Nittany Medical Center in State College, Pa., says quality and patient safety are the “most important things that we do.”

“It’s our responsibility to our patients to do the best job we can,” he notes. “It’s our responsibility to society to do it as efficiently as we can.”

Veteran meeting faculty John Bulger, DO, MBA, FACP, SFHM, hospitalist and chief quality officer at Geisinger Health System in Pennsylvania, agrees completely and is one of HM’s biggest proponents of the American Board of Internal Medicine (ABIM) Foundation’s Choosing Wisely (www.hospitalmedicine.org/choosingwisely) campaign. The national initiative, aimed at educating physicians—and patients—about wasteful medical tests, procedures, and treatments, launched in 2012, but SHM joined the chorus as a strategic partner last year.

“Choosing Wisely is about bending the cost curve,” Dr. Bulger says.

He added that although standardization of care is necessary for Choosing Wisely to work, homogeneity doesn’t mean everybody does everything exactly the same way. It means ensuring that hospitalists adopt “agreed upon best practices” before local variations are added. He compared it to a cookbook of apple pie recipes. All apple pies contain apples and crust, but the tasty treats are tailored differently from there.

“When you come up with guidelines in your hospital, that’s what you’re doing,” Dr. Bulger says. “You’re writing the cookbook and coming up with what works at your hospital. It might not work at [my hospital] at all, but I can look at it and learn.”

In the long-term, SHM hopes to create resources beyond the recommendations themselves—perhaps including a mentored implementation program akin to Project BOOST or pre-packaged order sets and checklists. Whatever the society does, it needs to engage the younger generation of physicians to ensure that quality and safety stay a priority for them, says Darlene Tad-y, MD, chair of SHM’s Physicians in Training Committee.

An assistant professor of medicine and a hospitalist at the University of Colorado Denver, Dr. Tad-y says that getting residents and students involved in quality and safety measures is critical for HM’s future.

“Especially since we want to have hospital medicine be at the forefront,” she explains. “It’s vital for us to have our students and residents taking the lead.”

Younger physicians already see the role quality and safety take in day-to-day practice. So, for them, according to Dr. Tad-y, a focus on making sure patient care is delivered better and more safely isn’t a renewed effort—it’s what they’re taught from the beginning.

“They haven’t been trained in the old way yet,” she says. “They still have an open mind. They see that things can change and things can be better. We don’t have to change old habits. We are just evolving good new habits for them.”

One new perspective was a first-time pre-course, “Cardiology: What Hospitalists Need to Know as Front-Line Providers.” The eight-hour seminar was led by cardiologist Matthews Chacko, MD, of Johns Hopkins Hospital in Baltimore, who says the time is right for quality-focused hospitalists to devote a full-day pre-course to cardiology.

“Cardiovascular disease is the most common reason we die,” he says. “It’s something hospital-based practitioners see often. Providing a comprehensive, yet simplified, overview of the way to manage some of these diseases with talks given by some of the leading experts in the field seemed very appropriate for this meeting.”

The sheer scale of QI initiatives can be daunting, says Michelle Mourad, MD, director of quality and safety at the University of California at San Francisco (UCSF) School of Medicine. She urges her peers to take the proverbial step back, identify a single issue—sepsis mortality or hand hygiene, for example—and then focus on understanding that issue intimately. That way, a hospitalist or HM group can convince other physicians that there is a problem and that it’s worth the work to fix it. Once that’s done, a hospitalist can launch a QI project that devises a measurement strategy to see if change is occurring.

And, while sustaining that change beyond the initial start-up can be difficult, Dr. Mourad believes success breeds success.

“When you work hard at a quality gap that’s in your organization, [when you] actually see the care you provide get better—not just for the patient in front of you, but for all the patients in your organization—it’s extremely powerful and motivating,” she says. “It changes the culture in your institution and convinces other people that they can do the same.”

Many potential Project BOOST candidate sites apply, but not all are accepted into the program. What makes for a successful application? Ask one of the founding members of Project BOOST and a current mentor, Dr. Jeffrey Greenwald.

• A strong letter of support. Qualified candidates can demonstrate that the hospital’s leadership is already behind their interest to reduce readmission rates through a program like Project BOOST.
• Demonstrate the existing support of the team. Good applications show that it’s not just a good idea to a few people. Good Project BOOST candidates can illustrate that their hospital has an “institutional prioritization for transitions of care.”
• An honest assessment on organizing change. Project BOOST has helped high-performing sites and beginners alike, but a thoughtful assessment of your site’s prior experience in organizing change and process improvement helps program leaders better understand your needs.

Apply Now Project BOOST is accepting applications now through August 30. Visit www.hospitalmedicine.org/projectboost.

Many potential Project BOOST candidate sites apply, but not all are accepted into the program. What makes for a successful application? Ask one of the founding members of Project BOOST and a current mentor, Dr. Jeffrey Greenwald.

• A strong letter of support. Qualified candidates can demonstrate that the hospital’s leadership is already behind their interest to reduce readmission rates through a program like Project BOOST.
• Demonstrate the existing support of the team. Good applications show that it’s not just a good idea to a few people. Good Project BOOST candidates can illustrate that their hospital has an “institutional prioritization for transitions of care.”
• An honest assessment on organizing change. Project BOOST has helped high-performing sites and beginners alike, but a thoughtful assessment of your site’s prior experience in organizing change and process improvement helps program leaders better understand your needs.

Apply Now Project BOOST is accepting applications now through August 30. Visit www.hospitalmedicine.org/projectboost.

Many potential Project BOOST candidate sites apply, but not all are accepted into the program. What makes for a successful application? Ask one of the founding members of Project BOOST and a current mentor, Dr. Jeffrey Greenwald.

• A strong letter of support. Qualified candidates can demonstrate that the hospital’s leadership is already behind their interest to reduce readmission rates through a program like Project BOOST.
• Demonstrate the existing support of the team. Good applications show that it’s not just a good idea to a few people. Good Project BOOST candidates can illustrate that their hospital has an “institutional prioritization for transitions of care.”
• An honest assessment on organizing change. Project BOOST has helped high-performing sites and beginners alike, but a thoughtful assessment of your site’s prior experience in organizing change and process improvement helps program leaders better understand your needs.

Apply Now Project BOOST is accepting applications now through August 30. Visit www.hospitalmedicine.org/projectboost.

Change doesn’t always come easily to hospitals, but once a catalyst comes along, one positive change can set the stage for the next one—and the one after that. At least that’s the lesson from Houston Methodist Hospital (HMH) and their work with SHM’s Project BOOST, a yearlong, mentored implementation program designed to help hospitals nationwide reduce readmission rates.

As the saying goes, every journey begins with a single step. For hospitals ready to start their journey to reduce readmissions rates and tackle other quality improvement challenges, the first step is the application to Project BOOST, which is due at the end of August. Details on the application and fees are available at www.hospitalmedicine.org/boost.

At Houston Methodist Hospital—a hospital U.S. News & World Report ranked one of “America’s Best Hospitals” in a dozen specialties and designated as a magnet hospital for excellence in nursing—taking that first step toward reducing readmissions by applying to Project BOOST has been well worth it.

“I recommend Project BOOST enthusiastically and unequivocally. If implemented efficiently, it could result in a ‘win-win’ situation for patients, the hospital, and the healthcare providers,” says Manasi Kekan, MD, MS, FACP, who serves as HMH’s medical director. “As a hospitalist, at times, I have found it challenging to ration my times between patient contact and documentation to meet the goals set by the healthcare industry. Being involved in BOOST and watching tangible improvements for my patients has provided me with immense personal and professional gratification!”

In fact, Dr. Kekan and her team have been so pleased with the results, both quantitative and qualitative, from their participation in Project BOOST that they enrolled twice: first in 2012 and again in 2013. She cites the program’s adaptability “that would help us develop a higher quality discharge process for our patients.”

Like many fruitful journeys, though, this one did not find Dr. Kekan and the caregivers at HMH alone: They had a guide who made all the difference.

Change implementation can be difficult, says Houston Methodist’s Janice Finder, RN, MSN. “Everyone knows how they want to design the house, so to speak,” she says, “but if you have someone who has done it before and can lead and direct, it goes much smoother.”

That was the true value of their Project BOOST mentor, Jeffrey Greenwald, MD, SFHM, one of the founding developers of Project BOOST.

“Dr. Greenwald gave us great mentorship and guidance,” Finder says. “The guidance about leadership is essential. If you do not have full support and a person who has ‘been there, done that,’ it is hard to envision.”

From his perspective, Dr. Greenwald saw that HMH had many of the critical elements in place to be successful.

“They had a good set of experiences already. They had the will and leadership and skill on the ground in process improvement,” he says, calling HMH an “incredibly well-oiled machine” with buy-in from the kind of inter-professional team that can make Project BOOST a success.

Overall, Dr. Greenwald calls HMH a “good example of a hospital that has married Project BOOST with the hospital’s existing priorities.”

Other Project BOOST sites start at different levels, in terms of basic interventions and process improvement, Dr. Greenwald explains. Many are able to address more advanced challenges, like how to implement change across broader areas in the hospital, working with leadership, addressing political issues, and improving waning interest in groups.

Dr. Greenwald’s interest in mentorship of Project BOOST sites stems from his own experiences early on—and the need for mentors in quality improvement projects.

“I wish I would have had someone like that when I got started,” says Dr. Greenwald, who tries to fill that role for others now. “Hopefully, each group moves down the path of making sure they have the right stakeholders, the right communications styles and skills in how to look at data and work with front-end staff.”

While Project BOOST focuses teams on reducing readmissions rates, Dr. Kekan has found that the skills learned from Project BOOST have created a blueprint that is applicable to many other team-based challenges in the hospital.

“We describe BOOST as a patient-centric quality initiative that mainly helps improve care transitions and encourages patients to stay informed about their health, which, in turn, helps reduce readmissions,” she says. “BOOST can be used as a framework to enhance other disease-specific discharge initiatives, like CHF [congestive heart failure] and delirium.”

Still, the core elements of reducing readmission rates and making a qualitative impact on her, her team, and the hospital resonate the most with Dr. Kekan.

“Providing a good transition plan to our patients provides satisfaction like none other.”

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

Change doesn’t always come easily to hospitals, but once a catalyst comes along, one positive change can set the stage for the next one—and the one after that. At least that’s the lesson from Houston Methodist Hospital (HMH) and their work with SHM’s Project BOOST, a yearlong, mentored implementation program designed to help hospitals nationwide reduce readmission rates.

As the saying goes, every journey begins with a single step. For hospitals ready to start their journey to reduce readmissions rates and tackle other quality improvement challenges, the first step is the application to Project BOOST, which is due at the end of August. Details on the application and fees are available at www.hospitalmedicine.org/boost.

At Houston Methodist Hospital—a hospital U.S. News & World Report ranked one of “America’s Best Hospitals” in a dozen specialties and designated as a magnet hospital for excellence in nursing—taking that first step toward reducing readmissions by applying to Project BOOST has been well worth it.

“I recommend Project BOOST enthusiastically and unequivocally. If implemented efficiently, it could result in a ‘win-win’ situation for patients, the hospital, and the healthcare providers,” says Manasi Kekan, MD, MS, FACP, who serves as HMH’s medical director. “As a hospitalist, at times, I have found it challenging to ration my times between patient contact and documentation to meet the goals set by the healthcare industry. Being involved in BOOST and watching tangible improvements for my patients has provided me with immense personal and professional gratification!”

In fact, Dr. Kekan and her team have been so pleased with the results, both quantitative and qualitative, from their participation in Project BOOST that they enrolled twice: first in 2012 and again in 2013. She cites the program’s adaptability “that would help us develop a higher quality discharge process for our patients.”

Like many fruitful journeys, though, this one did not find Dr. Kekan and the caregivers at HMH alone: They had a guide who made all the difference.

Change implementation can be difficult, says Houston Methodist’s Janice Finder, RN, MSN. “Everyone knows how they want to design the house, so to speak,” she says, “but if you have someone who has done it before and can lead and direct, it goes much smoother.”

That was the true value of their Project BOOST mentor, Jeffrey Greenwald, MD, SFHM, one of the founding developers of Project BOOST.

“Dr. Greenwald gave us great mentorship and guidance,” Finder says. “The guidance about leadership is essential. If you do not have full support and a person who has ‘been there, done that,’ it is hard to envision.”

From his perspective, Dr. Greenwald saw that HMH had many of the critical elements in place to be successful.

“They had a good set of experiences already. They had the will and leadership and skill on the ground in process improvement,” he says, calling HMH an “incredibly well-oiled machine” with buy-in from the kind of inter-professional team that can make Project BOOST a success.

Overall, Dr. Greenwald calls HMH a “good example of a hospital that has married Project BOOST with the hospital’s existing priorities.”

Other Project BOOST sites start at different levels, in terms of basic interventions and process improvement, Dr. Greenwald explains. Many are able to address more advanced challenges, like how to implement change across broader areas in the hospital, working with leadership, addressing political issues, and improving waning interest in groups.

Dr. Greenwald’s interest in mentorship of Project BOOST sites stems from his own experiences early on—and the need for mentors in quality improvement projects.

“I wish I would have had someone like that when I got started,” says Dr. Greenwald, who tries to fill that role for others now. “Hopefully, each group moves down the path of making sure they have the right stakeholders, the right communications styles and skills in how to look at data and work with front-end staff.”

While Project BOOST focuses teams on reducing readmissions rates, Dr. Kekan has found that the skills learned from Project BOOST have created a blueprint that is applicable to many other team-based challenges in the hospital.

“We describe BOOST as a patient-centric quality initiative that mainly helps improve care transitions and encourages patients to stay informed about their health, which, in turn, helps reduce readmissions,” she says. “BOOST can be used as a framework to enhance other disease-specific discharge initiatives, like CHF [congestive heart failure] and delirium.”

Still, the core elements of reducing readmission rates and making a qualitative impact on her, her team, and the hospital resonate the most with Dr. Kekan.

“Providing a good transition plan to our patients provides satisfaction like none other.”

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

Change doesn’t always come easily to hospitals, but once a catalyst comes along, one positive change can set the stage for the next one—and the one after that. At least that’s the lesson from Houston Methodist Hospital (HMH) and their work with SHM’s Project BOOST, a yearlong, mentored implementation program designed to help hospitals nationwide reduce readmission rates.

As the saying goes, every journey begins with a single step. For hospitals ready to start their journey to reduce readmissions rates and tackle other quality improvement challenges, the first step is the application to Project BOOST, which is due at the end of August. Details on the application and fees are available at www.hospitalmedicine.org/boost.

At Houston Methodist Hospital—a hospital U.S. News & World Report ranked one of “America’s Best Hospitals” in a dozen specialties and designated as a magnet hospital for excellence in nursing—taking that first step toward reducing readmissions by applying to Project BOOST has been well worth it.

“I recommend Project BOOST enthusiastically and unequivocally. If implemented efficiently, it could result in a ‘win-win’ situation for patients, the hospital, and the healthcare providers,” says Manasi Kekan, MD, MS, FACP, who serves as HMH’s medical director. “As a hospitalist, at times, I have found it challenging to ration my times between patient contact and documentation to meet the goals set by the healthcare industry. Being involved in BOOST and watching tangible improvements for my patients has provided me with immense personal and professional gratification!”

In fact, Dr. Kekan and her team have been so pleased with the results, both quantitative and qualitative, from their participation in Project BOOST that they enrolled twice: first in 2012 and again in 2013. She cites the program’s adaptability “that would help us develop a higher quality discharge process for our patients.”

Like many fruitful journeys, though, this one did not find Dr. Kekan and the caregivers at HMH alone: They had a guide who made all the difference.

Change implementation can be difficult, says Houston Methodist’s Janice Finder, RN, MSN. “Everyone knows how they want to design the house, so to speak,” she says, “but if you have someone who has done it before and can lead and direct, it goes much smoother.”

That was the true value of their Project BOOST mentor, Jeffrey Greenwald, MD, SFHM, one of the founding developers of Project BOOST.

“Dr. Greenwald gave us great mentorship and guidance,” Finder says. “The guidance about leadership is essential. If you do not have full support and a person who has ‘been there, done that,’ it is hard to envision.”

From his perspective, Dr. Greenwald saw that HMH had many of the critical elements in place to be successful.

“They had a good set of experiences already. They had the will and leadership and skill on the ground in process improvement,” he says, calling HMH an “incredibly well-oiled machine” with buy-in from the kind of inter-professional team that can make Project BOOST a success.

Overall, Dr. Greenwald calls HMH a “good example of a hospital that has married Project BOOST with the hospital’s existing priorities.”

Other Project BOOST sites start at different levels, in terms of basic interventions and process improvement, Dr. Greenwald explains. Many are able to address more advanced challenges, like how to implement change across broader areas in the hospital, working with leadership, addressing political issues, and improving waning interest in groups.

Dr. Greenwald’s interest in mentorship of Project BOOST sites stems from his own experiences early on—and the need for mentors in quality improvement projects.

“I wish I would have had someone like that when I got started,” says Dr. Greenwald, who tries to fill that role for others now. “Hopefully, each group moves down the path of making sure they have the right stakeholders, the right communications styles and skills in how to look at data and work with front-end staff.”

While Project BOOST focuses teams on reducing readmissions rates, Dr. Kekan has found that the skills learned from Project BOOST have created a blueprint that is applicable to many other team-based challenges in the hospital.

“We describe BOOST as a patient-centric quality initiative that mainly helps improve care transitions and encourages patients to stay informed about their health, which, in turn, helps reduce readmissions,” she says. “BOOST can be used as a framework to enhance other disease-specific discharge initiatives, like CHF [congestive heart failure] and delirium.”

Still, the core elements of reducing readmission rates and making a qualitative impact on her, her team, and the hospital resonate the most with Dr. Kekan.

“Providing a good transition plan to our patients provides satisfaction like none other.”

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

The American Hospital Association’s Health Research and Educational Trust (HRET) recently obtained a grant from the federal Agency for Healthcare Research and Quality to expand CUSP, the Comprehensive Unit-based Safety Program for reducing catheter-associated urinary tract infections (CAUTI) and other healthcare-associated infections, to nursing homes and skilled nursing facilities nationwide.

CUSP has posted a 40% reduction in central line-associated bloodstream infections (CLABSI) in 1,000 participating hospitals by providing education and support and an evidence-based protocol. The grant will be administered by HRET in partnership with others, including the University of Michigan Health System, the Association for Professionals in Infection Control and Epidemiology, and SHM.

Meanwhile, a study published in the American Journal of Infection Control found that rates of catheter-associated urinary tract infections in adult patients given urinary catheter placements dropped nationwide to 5.3% in 2010 from 9.4% in 2001.³ The retrospective analysis of data from the National Hospital Discharge Survey found that CAUTI-related mortality and associated length of hospital stay also declined during the same period.

Larry Beresford is a freelance writer in Alameda, Calif.

The American Hospital Association’s Health Research and Educational Trust (HRET) recently obtained a grant from the federal Agency for Healthcare Research and Quality to expand CUSP, the Comprehensive Unit-based Safety Program for reducing catheter-associated urinary tract infections (CAUTI) and other healthcare-associated infections, to nursing homes and skilled nursing facilities nationwide.

CUSP has posted a 40% reduction in central line-associated bloodstream infections (CLABSI) in 1,000 participating hospitals by providing education and support and an evidence-based protocol. The grant will be administered by HRET in partnership with others, including the University of Michigan Health System, the Association for Professionals in Infection Control and Epidemiology, and SHM.

Meanwhile, a study published in the American Journal of Infection Control found that rates of catheter-associated urinary tract infections in adult patients given urinary catheter placements dropped nationwide to 5.3% in 2010 from 9.4% in 2001.³ The retrospective analysis of data from the National Hospital Discharge Survey found that CAUTI-related mortality and associated length of hospital stay also declined during the same period.

Larry Beresford is a freelance writer in Alameda, Calif.

The American Hospital Association’s Health Research and Educational Trust (HRET) recently obtained a grant from the federal Agency for Healthcare Research and Quality to expand CUSP, the Comprehensive Unit-based Safety Program for reducing catheter-associated urinary tract infections (CAUTI) and other healthcare-associated infections, to nursing homes and skilled nursing facilities nationwide.

CUSP has posted a 40% reduction in central line-associated bloodstream infections (CLABSI) in 1,000 participating hospitals by providing education and support and an evidence-based protocol. The grant will be administered by HRET in partnership with others, including the University of Michigan Health System, the Association for Professionals in Infection Control and Epidemiology, and SHM.

Meanwhile, a study published in the American Journal of Infection Control found that rates of catheter-associated urinary tract infections in adult patients given urinary catheter placements dropped nationwide to 5.3% in 2010 from 9.4% in 2001.³ The retrospective analysis of data from the National Hospital Discharge Survey found that CAUTI-related mortality and associated length of hospital stay also declined during the same period.

Larry Beresford is a freelance writer in Alameda, Calif.

HMX in 3 Minutes or Less

More than 2,500 hospitalists have logged into HMX to share their experiences and ask questions on a wide variety of topics, from HM group practice management to clinical details about glycemic control.

New communities are being added regularly, so be sure to set up your account, sign up for customizable e-mail notifications, and check back regularly to follow your favorite discussions.

Have a question or idea for other hospitalists? Share it today.

Here’s how to get started. All you need are your SHM login credentials.

1. Go to www.hmxchange.org.
2. In the top right-hand corner, click the link that reads, “Login to see members only content.”
3. Enter your SHM login credentials and click login.
4. Now you’re logged in. On the right-hand side, you will find a box with a list of the various communities. Click on the community you would like to view and/or post in.
5. Click the “Discussions” tab and, on the right, click the square button that says “+ Post New Message.”
6. Compose your message with subject and body (and you can include an attachment if you want).
7. Click “Send.”

Hospitalists can now follow their favorite discussions on the go with the Member Centric app for HMX.

1. Go to your preferred app store and download “MemberCentric.”
2. Search for “Society of Hospital Medicine” in the list of organizations.
3. Log in with your SHM/HMX username and password.
4. Get access to your discussions, contacts, private message inbox, and events calendar.

HMX in 3 Minutes or Less

More than 2,500 hospitalists have logged into HMX to share their experiences and ask questions on a wide variety of topics, from HM group practice management to clinical details about glycemic control.

New communities are being added regularly, so be sure to set up your account, sign up for customizable e-mail notifications, and check back regularly to follow your favorite discussions.

Have a question or idea for other hospitalists? Share it today.

Here’s how to get started. All you need are your SHM login credentials.

1. Go to www.hmxchange.org.
2. In the top right-hand corner, click the link that reads, “Login to see members only content.”
3. Enter your SHM login credentials and click login.
4. Now you’re logged in. On the right-hand side, you will find a box with a list of the various communities. Click on the community you would like to view and/or post in.
5. Click the “Discussions” tab and, on the right, click the square button that says “+ Post New Message.”
6. Compose your message with subject and body (and you can include an attachment if you want).
7. Click “Send.”

Hospitalists can now follow their favorite discussions on the go with the Member Centric app for HMX.

1. Go to your preferred app store and download “MemberCentric.”
2. Search for “Society of Hospital Medicine” in the list of organizations.
3. Log in with your SHM/HMX username and password.
4. Get access to your discussions, contacts, private message inbox, and events calendar.

HMX in 3 Minutes or Less

More than 2,500 hospitalists have logged into HMX to share their experiences and ask questions on a wide variety of topics, from HM group practice management to clinical details about glycemic control.

New communities are being added regularly, so be sure to set up your account, sign up for customizable e-mail notifications, and check back regularly to follow your favorite discussions.

Have a question or idea for other hospitalists? Share it today.

Here’s how to get started. All you need are your SHM login credentials.

1. Go to www.hmxchange.org.
2. In the top right-hand corner, click the link that reads, “Login to see members only content.”
3. Enter your SHM login credentials and click login.
4. Now you’re logged in. On the right-hand side, you will find a box with a list of the various communities. Click on the community you would like to view and/or post in.
5. Click the “Discussions” tab and, on the right, click the square button that says “+ Post New Message.”
6. Compose your message with subject and body (and you can include an attachment if you want).
7. Click “Send.”

Hospitalists can now follow their favorite discussions on the go with the Member Centric app for HMX.

1. Go to your preferred app store and download “MemberCentric.”
2. Search for “Society of Hospital Medicine” in the list of organizations.
3. Log in with your SHM/HMX username and password.
4. Get access to your discussions, contacts, private message inbox, and events calendar.

SHM asked leaders of the Hospital-Based Quality Improvement in Stroke Prevention for Patients with Atrial Fibrillation (AF) Project, Hiren Shah, MD, MBA, SFHM, and Andrew Masica, MD, SFHM, to provide an overview of the program.

“AF is a disease state that is highly prevalent, and the numbers are rising yearly. We also know that it is one of the most common inpatient diagnoses,” Dr. Shah says. “However, when you look at the quality of care provided to our AF patients, it is quite variable and has implications for other hospital performance metrics such as 30-day readmission rates. This makes AF a high-impact target for inpatient quality improvement initiatives.”

Dr. Shah is assistant professor of medicine at Northwestern University’s Feinberg School of Medicine and medical director at Northwestern Memorial Hospital in Chicago. Dr. Masica is vice president of clinical effectiveness at Baylor Health Care System in Dallas.

The implementation guide for SHM’s AF project will be available later in December at www.hospitalmedicine.org/afib.

Question: What is the scope of your project?

Dr. Masica

Dr. Masica: That is a question we wrestled with. Numerous care processes related to AF are amenable to inpatient quality improvement. We chose to focus our efforts on stroke prevention in AF and the development of a toolkit to help hospital-based practitioners to assess stroke and bleeding risk consistently and, if indicated, to initiate antithrombotic therapy.

Dr. Shah: Along those lines, we know that at least 25% of AF-related strokes are potentially preventable with adherence to evidence-based care; however, current data indicate that only 50% to 60% of patients with AF who are eligible to receive antithrombotic therapy are on active stroke prophylaxis.

Q: Why do you think there are such large gaps in stroke prophylaxis for AF patients?

Dr. Masica: The prophylaxis decision requires the clinician to do an anticoagulation net-benefit and risk assessment, and although there are validated tools to do this type of assessment, use of these tools hasn’t yet become hardwired into daily hospital practice. Empiric clinical assessments often overestimate the bleed risk and underestimate stroke risk, so the ultimate result can be underuse of antithrombotic therapy.

“Ideally, we would like to start anticoagulation during the hospital stay or on discharge, if indicated, but even if we clearly communicate a patient’s stroke and bleed risk to the PCP on discharge, we can help ensure that this issue will be addressed on outpatient follow-up.”

–Dr. Shah

Dr. Shah: Another barrier is that in many hospitals, there are not reminders in place in our workflow for this assessment to happen at all. Hospitalists may think that the anticoagulation decision is an outpatient issue, better addressed by their primary care doctor, so it is sometimes even intentionally bypassed. Another barrier is that it takes time to discuss a patient’s values and preferences in the anticoagulation decision.

Q: But isn’t stroke prevention in AF more of an outpatient issue?

Dr. Shah: We think the hospital is a great place to start this evaluation and to make the anticoagulation decision. Of course, we should discuss these issues with the primary care doctor. Ideally, we would like to start anticoagulation during the hospital stay or on discharge, if indicated, but even if we clearly communicate a patient’s stroke and bleed risk to the PCP on discharge, we can help ensure that this issue will be addressed on outpatient follow-up.

Q: What specific tools for stroke and bleed risk are you referring to?

Dr. Shah: The CHADS2 scoring system is a well-validated tool for estimating the risk of stroke in AF patients, one that most clinicians may be aware of. The CHA2DS2-VASc is a slightly more refined scoring system. When it comes to bleeding, however, fewer clinicians are aware of the HAS-BLED bleeding risk assessment method.

Dr. Masica: The scoring systems represent a consistent, reproducible approach by which to evaluate inpatients with AF. Of course, there is some discretion for other patient-specific factors (e.g. fall risk) that are not captured in the scoring systems, but they are good starting points in the decision-making process. Finally and most importantly, although it is often overlooked, shared decision-making should take place with the patients, because their values in facing the risk of stroke versus bleeding often tip the balance one way or the other.

Q: How will the project help hospitals in this process?

Dr. Shah: We have written a QI Implementation Guide for hospitals with tools intended to improve the care of patients with AF in the hospital setting. This book will be similar to SHM’s VTE Prevention Implementation Guide, published a few years ago. We also will have an upcoming AF QI resource room within the SHM website. Additionally, similar to VTE, there are likely to be future mentored implementation projects where we will be working directly with hospitals and coaching them in this initiative.

Dr. Masica: We also have given a recent SHM-sponsored webinar that outlines some content of the guide. It can be accessed on the SHM website. This webinar reviews how to start a QI project in AF, assess your current state of care, build an interdisciplinary team, use validated tools, and deploy interventions to help make the stroke risk assessment and prophylaxis decision. I would note that the intended audience for these tools is broad and includes frontline hospitalists, QI directors, CMOs, and COOs, as well as nursing leadership, NPs, PAs, pharmacists, and other care providers.

Q: Does healthcare reform impact your efforts in this area?

Dr. Shah: Value-based purchasing, preventing readmissions, accountable care organizations, and bundled payments are all aspects of reform that will involve this therapeutic area, as their scope will impact the quality of care we deliver, how our cost structures are, and how we improve fragmentation of care across care transitions.

Dr. Masica: In addition, market forces, healthcare legislation, conceptual shifts regarding the need for systematic approaches to healthcare improvement, and new rules that may impact hospital reimbursement will continue to make AF an important healthcare quality issue. Thus, we think the discussion around delivering patient-centered care in AF is really just beginning.

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

SHM asked leaders of the Hospital-Based Quality Improvement in Stroke Prevention for Patients with Atrial Fibrillation (AF) Project, Hiren Shah, MD, MBA, SFHM, and Andrew Masica, MD, SFHM, to provide an overview of the program.

“AF is a disease state that is highly prevalent, and the numbers are rising yearly. We also know that it is one of the most common inpatient diagnoses,” Dr. Shah says. “However, when you look at the quality of care provided to our AF patients, it is quite variable and has implications for other hospital performance metrics such as 30-day readmission rates. This makes AF a high-impact target for inpatient quality improvement initiatives.”

Dr. Shah is assistant professor of medicine at Northwestern University’s Feinberg School of Medicine and medical director at Northwestern Memorial Hospital in Chicago. Dr. Masica is vice president of clinical effectiveness at Baylor Health Care System in Dallas.

The implementation guide for SHM’s AF project will be available later in December at www.hospitalmedicine.org/afib.

Question: What is the scope of your project?

Dr. Masica

Dr. Masica: That is a question we wrestled with. Numerous care processes related to AF are amenable to inpatient quality improvement. We chose to focus our efforts on stroke prevention in AF and the development of a toolkit to help hospital-based practitioners to assess stroke and bleeding risk consistently and, if indicated, to initiate antithrombotic therapy.

Dr. Shah: Along those lines, we know that at least 25% of AF-related strokes are potentially preventable with adherence to evidence-based care; however, current data indicate that only 50% to 60% of patients with AF who are eligible to receive antithrombotic therapy are on active stroke prophylaxis.

Q: Why do you think there are such large gaps in stroke prophylaxis for AF patients?

Dr. Masica: The prophylaxis decision requires the clinician to do an anticoagulation net-benefit and risk assessment, and although there are validated tools to do this type of assessment, use of these tools hasn’t yet become hardwired into daily hospital practice. Empiric clinical assessments often overestimate the bleed risk and underestimate stroke risk, so the ultimate result can be underuse of antithrombotic therapy.

“Ideally, we would like to start anticoagulation during the hospital stay or on discharge, if indicated, but even if we clearly communicate a patient’s stroke and bleed risk to the PCP on discharge, we can help ensure that this issue will be addressed on outpatient follow-up.”

–Dr. Shah

Dr. Shah: Another barrier is that in many hospitals, there are not reminders in place in our workflow for this assessment to happen at all. Hospitalists may think that the anticoagulation decision is an outpatient issue, better addressed by their primary care doctor, so it is sometimes even intentionally bypassed. Another barrier is that it takes time to discuss a patient’s values and preferences in the anticoagulation decision.

Q: But isn’t stroke prevention in AF more of an outpatient issue?

Dr. Shah: We think the hospital is a great place to start this evaluation and to make the anticoagulation decision. Of course, we should discuss these issues with the primary care doctor. Ideally, we would like to start anticoagulation during the hospital stay or on discharge, if indicated, but even if we clearly communicate a patient’s stroke and bleed risk to the PCP on discharge, we can help ensure that this issue will be addressed on outpatient follow-up.

Q: What specific tools for stroke and bleed risk are you referring to?

Dr. Shah: The CHADS2 scoring system is a well-validated tool for estimating the risk of stroke in AF patients, one that most clinicians may be aware of. The CHA2DS2-VASc is a slightly more refined scoring system. When it comes to bleeding, however, fewer clinicians are aware of the HAS-BLED bleeding risk assessment method.

Dr. Masica: The scoring systems represent a consistent, reproducible approach by which to evaluate inpatients with AF. Of course, there is some discretion for other patient-specific factors (e.g. fall risk) that are not captured in the scoring systems, but they are good starting points in the decision-making process. Finally and most importantly, although it is often overlooked, shared decision-making should take place with the patients, because their values in facing the risk of stroke versus bleeding often tip the balance one way or the other.

Q: How will the project help hospitals in this process?

Dr. Shah: We have written a QI Implementation Guide for hospitals with tools intended to improve the care of patients with AF in the hospital setting. This book will be similar to SHM’s VTE Prevention Implementation Guide, published a few years ago. We also will have an upcoming AF QI resource room within the SHM website. Additionally, similar to VTE, there are likely to be future mentored implementation projects where we will be working directly with hospitals and coaching them in this initiative.

Dr. Masica: We also have given a recent SHM-sponsored webinar that outlines some content of the guide. It can be accessed on the SHM website. This webinar reviews how to start a QI project in AF, assess your current state of care, build an interdisciplinary team, use validated tools, and deploy interventions to help make the stroke risk assessment and prophylaxis decision. I would note that the intended audience for these tools is broad and includes frontline hospitalists, QI directors, CMOs, and COOs, as well as nursing leadership, NPs, PAs, pharmacists, and other care providers.

Q: Does healthcare reform impact your efforts in this area?

Dr. Shah: Value-based purchasing, preventing readmissions, accountable care organizations, and bundled payments are all aspects of reform that will involve this therapeutic area, as their scope will impact the quality of care we deliver, how our cost structures are, and how we improve fragmentation of care across care transitions.

Dr. Masica: In addition, market forces, healthcare legislation, conceptual shifts regarding the need for systematic approaches to healthcare improvement, and new rules that may impact hospital reimbursement will continue to make AF an important healthcare quality issue. Thus, we think the discussion around delivering patient-centered care in AF is really just beginning.

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

SHM asked leaders of the Hospital-Based Quality Improvement in Stroke Prevention for Patients with Atrial Fibrillation (AF) Project, Hiren Shah, MD, MBA, SFHM, and Andrew Masica, MD, SFHM, to provide an overview of the program.

“AF is a disease state that is highly prevalent, and the numbers are rising yearly. We also know that it is one of the most common inpatient diagnoses,” Dr. Shah says. “However, when you look at the quality of care provided to our AF patients, it is quite variable and has implications for other hospital performance metrics such as 30-day readmission rates. This makes AF a high-impact target for inpatient quality improvement initiatives.”

Dr. Shah is assistant professor of medicine at Northwestern University’s Feinberg School of Medicine and medical director at Northwestern Memorial Hospital in Chicago. Dr. Masica is vice president of clinical effectiveness at Baylor Health Care System in Dallas.

The implementation guide for SHM’s AF project will be available later in December at www.hospitalmedicine.org/afib.

Question: What is the scope of your project?

Dr. Masica

Dr. Masica: That is a question we wrestled with. Numerous care processes related to AF are amenable to inpatient quality improvement. We chose to focus our efforts on stroke prevention in AF and the development of a toolkit to help hospital-based practitioners to assess stroke and bleeding risk consistently and, if indicated, to initiate antithrombotic therapy.

Dr. Shah: Along those lines, we know that at least 25% of AF-related strokes are potentially preventable with adherence to evidence-based care; however, current data indicate that only 50% to 60% of patients with AF who are eligible to receive antithrombotic therapy are on active stroke prophylaxis.

Q: Why do you think there are such large gaps in stroke prophylaxis for AF patients?

Dr. Masica: The prophylaxis decision requires the clinician to do an anticoagulation net-benefit and risk assessment, and although there are validated tools to do this type of assessment, use of these tools hasn’t yet become hardwired into daily hospital practice. Empiric clinical assessments often overestimate the bleed risk and underestimate stroke risk, so the ultimate result can be underuse of antithrombotic therapy.

“Ideally, we would like to start anticoagulation during the hospital stay or on discharge, if indicated, but even if we clearly communicate a patient’s stroke and bleed risk to the PCP on discharge, we can help ensure that this issue will be addressed on outpatient follow-up.”

–Dr. Shah

Dr. Shah: Another barrier is that in many hospitals, there are not reminders in place in our workflow for this assessment to happen at all. Hospitalists may think that the anticoagulation decision is an outpatient issue, better addressed by their primary care doctor, so it is sometimes even intentionally bypassed. Another barrier is that it takes time to discuss a patient’s values and preferences in the anticoagulation decision.

Q: But isn’t stroke prevention in AF more of an outpatient issue?

Dr. Shah: We think the hospital is a great place to start this evaluation and to make the anticoagulation decision. Of course, we should discuss these issues with the primary care doctor. Ideally, we would like to start anticoagulation during the hospital stay or on discharge, if indicated, but even if we clearly communicate a patient’s stroke and bleed risk to the PCP on discharge, we can help ensure that this issue will be addressed on outpatient follow-up.

Q: What specific tools for stroke and bleed risk are you referring to?

Dr. Shah: The CHADS2 scoring system is a well-validated tool for estimating the risk of stroke in AF patients, one that most clinicians may be aware of. The CHA2DS2-VASc is a slightly more refined scoring system. When it comes to bleeding, however, fewer clinicians are aware of the HAS-BLED bleeding risk assessment method.

Dr. Masica: The scoring systems represent a consistent, reproducible approach by which to evaluate inpatients with AF. Of course, there is some discretion for other patient-specific factors (e.g. fall risk) that are not captured in the scoring systems, but they are good starting points in the decision-making process. Finally and most importantly, although it is often overlooked, shared decision-making should take place with the patients, because their values in facing the risk of stroke versus bleeding often tip the balance one way or the other.

Q: How will the project help hospitals in this process?

Dr. Shah: We have written a QI Implementation Guide for hospitals with tools intended to improve the care of patients with AF in the hospital setting. This book will be similar to SHM’s VTE Prevention Implementation Guide, published a few years ago. We also will have an upcoming AF QI resource room within the SHM website. Additionally, similar to VTE, there are likely to be future mentored implementation projects where we will be working directly with hospitals and coaching them in this initiative.

Dr. Masica: We also have given a recent SHM-sponsored webinar that outlines some content of the guide. It can be accessed on the SHM website. This webinar reviews how to start a QI project in AF, assess your current state of care, build an interdisciplinary team, use validated tools, and deploy interventions to help make the stroke risk assessment and prophylaxis decision. I would note that the intended audience for these tools is broad and includes frontline hospitalists, QI directors, CMOs, and COOs, as well as nursing leadership, NPs, PAs, pharmacists, and other care providers.

Q: Does healthcare reform impact your efforts in this area?

Dr. Shah: Value-based purchasing, preventing readmissions, accountable care organizations, and bundled payments are all aspects of reform that will involve this therapeutic area, as their scope will impact the quality of care we deliver, how our cost structures are, and how we improve fragmentation of care across care transitions.

Dr. Masica: In addition, market forces, healthcare legislation, conceptual shifts regarding the need for systematic approaches to healthcare improvement, and new rules that may impact hospital reimbursement will continue to make AF an important healthcare quality issue. Thus, we think the discussion around delivering patient-centered care in AF is really just beginning.

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

Clinical question: What steps can hospitals take to reduce readmission rates in patients with heart failure?

Background: Evidence about various hospital strategies to decrease readmissions in patients with heart failure is limited.

Study Design: Cross-sectional study using a web-based survey.

Setting: Survey of 599 hospitals participating in quality initiatives to reduce readmissions.

Synopsis: Readmission of patients with heart failure is common and costly. Hospitals with high readmissions can lose up to 3% of their Medicare reimbursements by 2015.

This study found six strategies associated with lower risk-standardized 30-day readmission rates.

1. Partnering with community physicians and physician groups (0.33%; P=0.017);
2. Partnering with local hospitals (0.34%; P=0.020);
3. Having nurses responsible for medication reconciliation (0.18%; P=0.002);
4. Arranging follow-up visit before discharge (0.19%; P=0.037);
5. Having a process in place to send all discharge summaries directly to the patient’s primary care physician (0.21%; P=0.004); and
6. Assigning staff to follow up on test results after the patient is discharged (0.26%; P=0.049).

Individually, the magnitude of the effects was modest, but implementing multiple strategies was more beneficial (0.34% additional benefit for each additional strategy). Only 7% of the hospitals surveyed implemented all six strategies, highlighting substantial opportunities for improvement.

Bottom line: Implementing multiple strategies may help reduce readmission in patients with heart failure.

Citation: Bradley EH, Curry L, Horwitz LI, et al. Hospital strategies associated with 30-day readmission rates for patients with heart failure. Circ Cardiovasc Qual Outcomes. 2013;6:444-450.

Clinical question: What steps can hospitals take to reduce readmission rates in patients with heart failure?

Background: Evidence about various hospital strategies to decrease readmissions in patients with heart failure is limited.

Study Design: Cross-sectional study using a web-based survey.

Setting: Survey of 599 hospitals participating in quality initiatives to reduce readmissions.

Synopsis: Readmission of patients with heart failure is common and costly. Hospitals with high readmissions can lose up to 3% of their Medicare reimbursements by 2015.

This study found six strategies associated with lower risk-standardized 30-day readmission rates.

1. Partnering with community physicians and physician groups (0.33%; P=0.017);
2. Partnering with local hospitals (0.34%; P=0.020);
3. Having nurses responsible for medication reconciliation (0.18%; P=0.002);
4. Arranging follow-up visit before discharge (0.19%; P=0.037);
5. Having a process in place to send all discharge summaries directly to the patient’s primary care physician (0.21%; P=0.004); and
6. Assigning staff to follow up on test results after the patient is discharged (0.26%; P=0.049).

Individually, the magnitude of the effects was modest, but implementing multiple strategies was more beneficial (0.34% additional benefit for each additional strategy). Only 7% of the hospitals surveyed implemented all six strategies, highlighting substantial opportunities for improvement.

Bottom line: Implementing multiple strategies may help reduce readmission in patients with heart failure.

Citation: Bradley EH, Curry L, Horwitz LI, et al. Hospital strategies associated with 30-day readmission rates for patients with heart failure. Circ Cardiovasc Qual Outcomes. 2013;6:444-450.

Clinical question: What steps can hospitals take to reduce readmission rates in patients with heart failure?

Background: Evidence about various hospital strategies to decrease readmissions in patients with heart failure is limited.

Study Design: Cross-sectional study using a web-based survey.

Setting: Survey of 599 hospitals participating in quality initiatives to reduce readmissions.

Synopsis: Readmission of patients with heart failure is common and costly. Hospitals with high readmissions can lose up to 3% of their Medicare reimbursements by 2015.

This study found six strategies associated with lower risk-standardized 30-day readmission rates.

1. Partnering with community physicians and physician groups (0.33%; P=0.017);
2. Partnering with local hospitals (0.34%; P=0.020);
3. Having nurses responsible for medication reconciliation (0.18%; P=0.002);
4. Arranging follow-up visit before discharge (0.19%; P=0.037);
5. Having a process in place to send all discharge summaries directly to the patient’s primary care physician (0.21%; P=0.004); and
6. Assigning staff to follow up on test results after the patient is discharged (0.26%; P=0.049).

Individually, the magnitude of the effects was modest, but implementing multiple strategies was more beneficial (0.34% additional benefit for each additional strategy). Only 7% of the hospitals surveyed implemented all six strategies, highlighting substantial opportunities for improvement.

Bottom line: Implementing multiple strategies may help reduce readmission in patients with heart failure.

Citation: Bradley EH, Curry L, Horwitz LI, et al. Hospital strategies associated with 30-day readmission rates for patients with heart failure. Circ Cardiovasc Qual Outcomes. 2013;6:444-450.