Transitions of Care

Sometimes a hospitalist is put in the difficult position of communicating information that involves bad news—for instance, a poor prognosis to a patient or clarifying treatment options and goals for care to a family member of a patient with an advanced illness. A workshop at HM12 offered a technique that hospitalists can use to convey such difficult messages.

“Ask-Tell-Ask” is a back-and-forth cycle between the patient and health professional that addresses four essential components: the patient’s perspective, information that needs to be delivered, response to the patient’s emotions, and recommendations by the professional.

“In the setting of an advanced illness, the patient’s perspective needs to be more fully explored so that we can figure out what information they need and want,” says Kristen Schaefer, MD, a palliative-care physician and director of residency education at Brigham and Women’s Hospital in Boston who spoke at an HM12 workshop. “That communication needs to be multidirectional to promote shared decision-making. All of these communication techniques are based on a better understanding of the patient’s perspective, but with Ask-Tell-Ask, you are clarifying their emotional response to illness, their values and personal goals in life, and how they cope with setbacks.”

Physicians should always start in an open-ended way, asking questions and listening to the response, Dr. Schaefer explains. “Then you can tailor the information you provide to what they have told you. There’s always emotional content around these issues, and you need to clarify that emotion,” she says. “If there is a big emotion in the room, and it hasn’t been addressed, it doesn’t matter what you teach the patient. You’ll never get to the underlying problems.”

Another effective technique, Dr. Schaefer says, is the judicious use of silence. She says healthcare providers can learn to listen more, talk less, and always start with the patient’s perspective as the basis for communication.

“It makes for more satisfying work—and it’s also more effective,” she says.

Larry Beresford is a freelance writer in Oakland, Calif.

Sometimes a hospitalist is put in the difficult position of communicating information that involves bad news—for instance, a poor prognosis to a patient or clarifying treatment options and goals for care to a family member of a patient with an advanced illness. A workshop at HM12 offered a technique that hospitalists can use to convey such difficult messages.

“Ask-Tell-Ask” is a back-and-forth cycle between the patient and health professional that addresses four essential components: the patient’s perspective, information that needs to be delivered, response to the patient’s emotions, and recommendations by the professional.

“In the setting of an advanced illness, the patient’s perspective needs to be more fully explored so that we can figure out what information they need and want,” says Kristen Schaefer, MD, a palliative-care physician and director of residency education at Brigham and Women’s Hospital in Boston who spoke at an HM12 workshop. “That communication needs to be multidirectional to promote shared decision-making. All of these communication techniques are based on a better understanding of the patient’s perspective, but with Ask-Tell-Ask, you are clarifying their emotional response to illness, their values and personal goals in life, and how they cope with setbacks.”

Physicians should always start in an open-ended way, asking questions and listening to the response, Dr. Schaefer explains. “Then you can tailor the information you provide to what they have told you. There’s always emotional content around these issues, and you need to clarify that emotion,” she says. “If there is a big emotion in the room, and it hasn’t been addressed, it doesn’t matter what you teach the patient. You’ll never get to the underlying problems.”

Another effective technique, Dr. Schaefer says, is the judicious use of silence. She says healthcare providers can learn to listen more, talk less, and always start with the patient’s perspective as the basis for communication.

“It makes for more satisfying work—and it’s also more effective,” she says.

Larry Beresford is a freelance writer in Oakland, Calif.

Sometimes a hospitalist is put in the difficult position of communicating information that involves bad news—for instance, a poor prognosis to a patient or clarifying treatment options and goals for care to a family member of a patient with an advanced illness. A workshop at HM12 offered a technique that hospitalists can use to convey such difficult messages.

“Ask-Tell-Ask” is a back-and-forth cycle between the patient and health professional that addresses four essential components: the patient’s perspective, information that needs to be delivered, response to the patient’s emotions, and recommendations by the professional.

“In the setting of an advanced illness, the patient’s perspective needs to be more fully explored so that we can figure out what information they need and want,” says Kristen Schaefer, MD, a palliative-care physician and director of residency education at Brigham and Women’s Hospital in Boston who spoke at an HM12 workshop. “That communication needs to be multidirectional to promote shared decision-making. All of these communication techniques are based on a better understanding of the patient’s perspective, but with Ask-Tell-Ask, you are clarifying their emotional response to illness, their values and personal goals in life, and how they cope with setbacks.”

Physicians should always start in an open-ended way, asking questions and listening to the response, Dr. Schaefer explains. “Then you can tailor the information you provide to what they have told you. There’s always emotional content around these issues, and you need to clarify that emotion,” she says. “If there is a big emotion in the room, and it hasn’t been addressed, it doesn’t matter what you teach the patient. You’ll never get to the underlying problems.”

Another effective technique, Dr. Schaefer says, is the judicious use of silence. She says healthcare providers can learn to listen more, talk less, and always start with the patient’s perspective as the basis for communication.

“It makes for more satisfying work—and it’s also more effective,” she says.

Larry Beresford is a freelance writer in Oakland, Calif.

Earlier this month CMS announced 17 additional awards under its Community-Based Care Transitions Program (CCTP), which now encompasses 200 acute-care hospitals and their hospitalists partnering with community agencies and coalitions to improve transitions of care in advance of the Oct. 1 start for excessive readmissions penalties. Innovative solutions to the readmissions dilemma are being tested at the local level by a variety of partnerships with hospitals and hospitalists.

For example, William C. Cook, DO, chief of hospital medicine for the Ohio Permanente Medical Group in Cleveland, is part of a community-wide quality coalition called Better Health Greater Cleveland, one of 17 such groups in the Robert Wood Johnson Foundation's Aligning Forces for Quality collaborative. The program includes 150 quality teams in 100 hospitals posting readmissions reductions and other quality metrics. Dr. Cook, who co-chairs Better Health's Steering Committee for Transitions of Care, is spearheading a transitions pilot with two local nursing homes.

"From the hospitalist perspective, our role is to make care transitions safe and predictable," Dr. Cook says. "The way I can contribute most to these transitions is by thinking ahead about what's going to happen next—and how do I prepare the patient and the next provider." One key step is taking time to complete the real-time discharge summary for each patient, he adds.

The idea, Dr. Cook explains, is to identify and communicate with collaborators across care settings so that the "coaching baton" can be passed in a manner that appears seamless to the patient.

Nearly a third of the 17 new CCTP sites participate in SHM's Project BOOST, including three hospitals in California and one each in Illinois and Pennsylvania. Project BOOST is accepting applications for its next round of sites through September.

Earlier this month CMS announced 17 additional awards under its Community-Based Care Transitions Program (CCTP), which now encompasses 200 acute-care hospitals and their hospitalists partnering with community agencies and coalitions to improve transitions of care in advance of the Oct. 1 start for excessive readmissions penalties. Innovative solutions to the readmissions dilemma are being tested at the local level by a variety of partnerships with hospitals and hospitalists.

For example, William C. Cook, DO, chief of hospital medicine for the Ohio Permanente Medical Group in Cleveland, is part of a community-wide quality coalition called Better Health Greater Cleveland, one of 17 such groups in the Robert Wood Johnson Foundation's Aligning Forces for Quality collaborative. The program includes 150 quality teams in 100 hospitals posting readmissions reductions and other quality metrics. Dr. Cook, who co-chairs Better Health's Steering Committee for Transitions of Care, is spearheading a transitions pilot with two local nursing homes.

"From the hospitalist perspective, our role is to make care transitions safe and predictable," Dr. Cook says. "The way I can contribute most to these transitions is by thinking ahead about what's going to happen next—and how do I prepare the patient and the next provider." One key step is taking time to complete the real-time discharge summary for each patient, he adds.

The idea, Dr. Cook explains, is to identify and communicate with collaborators across care settings so that the "coaching baton" can be passed in a manner that appears seamless to the patient.

Nearly a third of the 17 new CCTP sites participate in SHM's Project BOOST, including three hospitals in California and one each in Illinois and Pennsylvania. Project BOOST is accepting applications for its next round of sites through September.

Earlier this month CMS announced 17 additional awards under its Community-Based Care Transitions Program (CCTP), which now encompasses 200 acute-care hospitals and their hospitalists partnering with community agencies and coalitions to improve transitions of care in advance of the Oct. 1 start for excessive readmissions penalties. Innovative solutions to the readmissions dilemma are being tested at the local level by a variety of partnerships with hospitals and hospitalists.

For example, William C. Cook, DO, chief of hospital medicine for the Ohio Permanente Medical Group in Cleveland, is part of a community-wide quality coalition called Better Health Greater Cleveland, one of 17 such groups in the Robert Wood Johnson Foundation's Aligning Forces for Quality collaborative. The program includes 150 quality teams in 100 hospitals posting readmissions reductions and other quality metrics. Dr. Cook, who co-chairs Better Health's Steering Committee for Transitions of Care, is spearheading a transitions pilot with two local nursing homes.

"From the hospitalist perspective, our role is to make care transitions safe and predictable," Dr. Cook says. "The way I can contribute most to these transitions is by thinking ahead about what's going to happen next—and how do I prepare the patient and the next provider." One key step is taking time to complete the real-time discharge summary for each patient, he adds.

The idea, Dr. Cook explains, is to identify and communicate with collaborators across care settings so that the "coaching baton" can be passed in a manner that appears seamless to the patient.

Nearly a third of the 17 new CCTP sites participate in SHM's Project BOOST, including three hospitals in California and one each in Illinois and Pennsylvania. Project BOOST is accepting applications for its next round of sites through September.

Hospitalists coordinate the care of large numbers of very sick, very complicated patients, making patient-hospitalist communication very important. When done effectively, communication can help hospitalists improve their patients’ sense of well-being and reinforce their adherence to medical treatments post-discharge. It also can build trust and help patients better understand their illnesses.

Nonetheless, communication gaps do occur. The main culprits include time pressures, the lack of a pre-existing patient relationship, patient emotions, medical jargon, and physicians’ tendencies to lecture.

The following five examples outline common communication pitfalls, followed by fundamental skills that can be used to solve communication problems.

Tick, Tock Goes the Clock

Scenario: A hospitalist mentions a medication change during a brief patient visit in the midst of a hectic day. The hospitalist pauses for a moment, glances at his watch, and reaches for the room’s door handle. When no question is forthcoming, he excuses himself to visit the next patient.

The patient has questions about the new medication but feels guilty about taking up the hospitalist’s time. The patient decides she can ask about the medication and the reason for the change when the hospitalist isn’t in such a hurry.

Skill: Creating an environment in which patients are encouraged to ask questions need not result in lengthy conversations. The key is having a clear framework for directing conversations, says Cindy Lien, MD, an academic hospitalist at Beth Israel Deaconess Medical Center in Boston. Dr. Lien uses “Ask-Tell-Ask” as a mnemonic when teaching communication skills to internal-medicine trainees.

“We have a tendency to just tell, tell, tell information,” she says. “Ask-Tell-Ask reminds you that one of the most important things to do is to ask the patient to describe what their understanding is of the situation so you have a sense of where they’re coming from.”

Opening questions can include “What is the most important issue on your mind today?” and “What do you understand about your medications?”

After listening to the patient’s response, tell the patient in a few straightforward sentences the information you need to communicate, Dr. Lien says. Then ask the patient if they understand the information conveyed to them, which will give them a chance to ask questions. Additional questions for the patient can include “Do you need further information at this point?” and “How do you feel about what we’ve discussed?”

The way our brains are built, emotion will trump cognition every time. If you as the doctor keep talking when someone is having an emotional moment, they will generally miss all the information you provided.

—Anthony Back, MD, professor of medicine, University of Washington, Seattle

What’s Your Name Again?

Scenario: A hospitalist wearing professional dress with no nametag enters a patient room and introduces herself before informing the patient that she’s ordered additional tests. The hospitalist visits the patient several times during his hospital stay to discuss test results and self-care instructions upon discharge but never reintroduces herself.

The patient was exhausted and in discomfort when the clinician first introduced herself as a hospitalist. She said her name so quickly that the patient didn’t catch it. The patient sees the hospitalist more often than other providers during his admission, but he’s not sure what her role is and he finds it too awkward to ask.

Skill: First impressions are lasting, so make a solid introduction, says David Meltzer, MD, PhD, FHM, associate professor in the department of medicine at the University of Chicago. Because patients are more likely to identify a hospitalist if they understand the hospitalist has a relationship with their primary-care physician (PCP), the initial greeting should be stated clearly, slowly, and include a reference to the PCP.

“After providing your name, you can say something like, ‘I see you’re Dr. Smith’s patient. I’ve worked with Dr. Smith for many years. We’ll make sure we communicate what happens during your hospitalization. I hope to develop a good relationship with you while you’re in the hospital,’” Dr. Meltzer says.

The hospitalist team should also consider providing brochures with photos of the hospitalists and an explanation of what hospitalists do, says Michael Pistoria, DO, FACP, SFHM, associate chief of the division of general internal medicine at Lehigh Valley Health Network in Allentown, Pa.

“Brochures can be handed to patients at the time of admission with the hospitalist explaining, ‘I’m going to be the doctor in charge of coordinating your care,’” he explains.

Mind Over Matter

Scenario: A hospitalist explains to the patient that her illness is getting worse and more aggressive treatment is advised. While reviewing treatment options, the hospitalist notices the patient is staring out the window, her chin quivering. The hospitalist presses on with what she has to say.

The patient can hear the hospitalist talking, but she’s thinking about how this setback will affect her family. She’s doing all she can to keep from crying and nods her head out of politeness to feign understanding of the information being provided.

Skill: Acknowledging patient emotion is imperative, because doctors who ignore these signals do so at their own professional peril, says Anthony Back, MD, professor of medicine at the University of Washington in Seattle.

“The way our brains are built, emotion will trump cognition every time,” he says. “If you as the doctor keep talking when someone is having an emotional moment, they will generally miss all the information you provided.

“If you see the patient has a lot of emotion, you can say, ‘I notice you are really concerned about this. Can you tell me more?’” Dr. Back says. “Just the act of getting it out in the open will often enable a patient to process the emotion enough so that you can go on to medical issues that are important for the patient to know.”

In most cases, respectfully acknowledging the emotion won’t take long. He says most patients recognize they have limited time with the doctor, and they want to get to the important medical information, too.

It’s Gibberish to Me

Dr. Meltzer

Scenario: A hospitalist believes a patient has a solid understanding of his diagnosis. The hospitalist sends the patient for several tests and discusses with him the risks and benefits of various medications and interventions, sometimes using complex terminology.

The patient doesn’t know why he’s had to undergo so many tests. He’s tried to follow along as the hospitalist talks about treatment options and has even asked his daughter to look up medical terminology on her smartphone so he can better understand what is going on. He wishes the hospitalist would explain his condition in basic terms.

Skill: Simplify the language used to communicate with patients by speaking in plain English, says Jeff Greenwald, MD, SFHM, associate professor of medicine at Harvard Medical School and a teaching hospitalist at Massachusetts General Hospital in Boston. Hospitalists should be aware that words and terminology they think are commonplace many times are medical jargon and confusing to patients, he adds.

“For example, when I say ‘take this medication orally,’ that doesn’t strike me as technical language. But ‘orally’ is a word that is not understood by a significant percentage of the population,” Dr. Greenwald says.

Dr. Greenwald

A good rule of thumb is to continually check in with patients about the words and terms being used, Dr. Meltzer adds.

“Ask patients if they would like you to explain a term,” he says. “You can say something like, ‘I know this is a term many people aren’t familiar with. Would you like me to tell you more about what it means?’”

Data-Dumping

Scenario: A hospitalist checks in on a patient with atrial fibrillation and uses the visit to talk about Coumadin. She instructs the patient on how the drug works in the body, how it increases the chance of bleeding, and how the medication should be taken and monitored.

Later that day, the patient tells her daughter about the hospitalist’s instructions regarding her new medication. The patient remembers that she should avoid certain foods and beverages while on Coumadin but can’t immediately recall what they are. The patient also has trouble recounting what danger signs she should look out for when taking Coumadin.

Skill: Teach-back is an effective tool that can—and should—be used anytime a hospitalist is providing important information to a patient, Dr. Greenwald says. The hospitalist asks the patient to explain back the information in his or her own words in order to determine the patient’s understanding. If errors are identified, the hospitalist can explain the information again to ensure the patient’s comprehension.

“You might say, ‘How are you going to explain to your primary-care doctor about why you’re on an antibiotic?’ or ‘What are you going to tell your son about how your diet has to change?’” Dr. Greenwald says.

He outlines three important elements of teach-back:

• Concentrate on the critical information that patients need to know in order to function;
• Provide information in small bites that the patient can digest; and
• Repeat and reinforce the information with the help of all the members of the care team.

Teach-back should be used consistently, he says, so hospitalists can build on the information taught previously by adding layers to the patient’s knowledge.

Lisa Ryan is a freelance writer in New Jersey.

Hospitalists coordinate the care of large numbers of very sick, very complicated patients, making patient-hospitalist communication very important. When done effectively, communication can help hospitalists improve their patients’ sense of well-being and reinforce their adherence to medical treatments post-discharge. It also can build trust and help patients better understand their illnesses.

Nonetheless, communication gaps do occur. The main culprits include time pressures, the lack of a pre-existing patient relationship, patient emotions, medical jargon, and physicians’ tendencies to lecture.

The following five examples outline common communication pitfalls, followed by fundamental skills that can be used to solve communication problems.

Tick, Tock Goes the Clock

Scenario: A hospitalist mentions a medication change during a brief patient visit in the midst of a hectic day. The hospitalist pauses for a moment, glances at his watch, and reaches for the room’s door handle. When no question is forthcoming, he excuses himself to visit the next patient.

The patient has questions about the new medication but feels guilty about taking up the hospitalist’s time. The patient decides she can ask about the medication and the reason for the change when the hospitalist isn’t in such a hurry.

Skill: Creating an environment in which patients are encouraged to ask questions need not result in lengthy conversations. The key is having a clear framework for directing conversations, says Cindy Lien, MD, an academic hospitalist at Beth Israel Deaconess Medical Center in Boston. Dr. Lien uses “Ask-Tell-Ask” as a mnemonic when teaching communication skills to internal-medicine trainees.

“We have a tendency to just tell, tell, tell information,” she says. “Ask-Tell-Ask reminds you that one of the most important things to do is to ask the patient to describe what their understanding is of the situation so you have a sense of where they’re coming from.”

Opening questions can include “What is the most important issue on your mind today?” and “What do you understand about your medications?”

After listening to the patient’s response, tell the patient in a few straightforward sentences the information you need to communicate, Dr. Lien says. Then ask the patient if they understand the information conveyed to them, which will give them a chance to ask questions. Additional questions for the patient can include “Do you need further information at this point?” and “How do you feel about what we’ve discussed?”

The way our brains are built, emotion will trump cognition every time. If you as the doctor keep talking when someone is having an emotional moment, they will generally miss all the information you provided.

—Anthony Back, MD, professor of medicine, University of Washington, Seattle

What’s Your Name Again?

Scenario: A hospitalist wearing professional dress with no nametag enters a patient room and introduces herself before informing the patient that she’s ordered additional tests. The hospitalist visits the patient several times during his hospital stay to discuss test results and self-care instructions upon discharge but never reintroduces herself.

The patient was exhausted and in discomfort when the clinician first introduced herself as a hospitalist. She said her name so quickly that the patient didn’t catch it. The patient sees the hospitalist more often than other providers during his admission, but he’s not sure what her role is and he finds it too awkward to ask.

Skill: First impressions are lasting, so make a solid introduction, says David Meltzer, MD, PhD, FHM, associate professor in the department of medicine at the University of Chicago. Because patients are more likely to identify a hospitalist if they understand the hospitalist has a relationship with their primary-care physician (PCP), the initial greeting should be stated clearly, slowly, and include a reference to the PCP.

“After providing your name, you can say something like, ‘I see you’re Dr. Smith’s patient. I’ve worked with Dr. Smith for many years. We’ll make sure we communicate what happens during your hospitalization. I hope to develop a good relationship with you while you’re in the hospital,’” Dr. Meltzer says.

The hospitalist team should also consider providing brochures with photos of the hospitalists and an explanation of what hospitalists do, says Michael Pistoria, DO, FACP, SFHM, associate chief of the division of general internal medicine at Lehigh Valley Health Network in Allentown, Pa.

“Brochures can be handed to patients at the time of admission with the hospitalist explaining, ‘I’m going to be the doctor in charge of coordinating your care,’” he explains.

Mind Over Matter

Scenario: A hospitalist explains to the patient that her illness is getting worse and more aggressive treatment is advised. While reviewing treatment options, the hospitalist notices the patient is staring out the window, her chin quivering. The hospitalist presses on with what she has to say.

The patient can hear the hospitalist talking, but she’s thinking about how this setback will affect her family. She’s doing all she can to keep from crying and nods her head out of politeness to feign understanding of the information being provided.

Skill: Acknowledging patient emotion is imperative, because doctors who ignore these signals do so at their own professional peril, says Anthony Back, MD, professor of medicine at the University of Washington in Seattle.

“The way our brains are built, emotion will trump cognition every time,” he says. “If you as the doctor keep talking when someone is having an emotional moment, they will generally miss all the information you provided.

“If you see the patient has a lot of emotion, you can say, ‘I notice you are really concerned about this. Can you tell me more?’” Dr. Back says. “Just the act of getting it out in the open will often enable a patient to process the emotion enough so that you can go on to medical issues that are important for the patient to know.”

In most cases, respectfully acknowledging the emotion won’t take long. He says most patients recognize they have limited time with the doctor, and they want to get to the important medical information, too.

It’s Gibberish to Me

Dr. Meltzer

Scenario: A hospitalist believes a patient has a solid understanding of his diagnosis. The hospitalist sends the patient for several tests and discusses with him the risks and benefits of various medications and interventions, sometimes using complex terminology.

The patient doesn’t know why he’s had to undergo so many tests. He’s tried to follow along as the hospitalist talks about treatment options and has even asked his daughter to look up medical terminology on her smartphone so he can better understand what is going on. He wishes the hospitalist would explain his condition in basic terms.

Skill: Simplify the language used to communicate with patients by speaking in plain English, says Jeff Greenwald, MD, SFHM, associate professor of medicine at Harvard Medical School and a teaching hospitalist at Massachusetts General Hospital in Boston. Hospitalists should be aware that words and terminology they think are commonplace many times are medical jargon and confusing to patients, he adds.

“For example, when I say ‘take this medication orally,’ that doesn’t strike me as technical language. But ‘orally’ is a word that is not understood by a significant percentage of the population,” Dr. Greenwald says.

Dr. Greenwald

A good rule of thumb is to continually check in with patients about the words and terms being used, Dr. Meltzer adds.

“Ask patients if they would like you to explain a term,” he says. “You can say something like, ‘I know this is a term many people aren’t familiar with. Would you like me to tell you more about what it means?’”

Data-Dumping

Scenario: A hospitalist checks in on a patient with atrial fibrillation and uses the visit to talk about Coumadin. She instructs the patient on how the drug works in the body, how it increases the chance of bleeding, and how the medication should be taken and monitored.

Later that day, the patient tells her daughter about the hospitalist’s instructions regarding her new medication. The patient remembers that she should avoid certain foods and beverages while on Coumadin but can’t immediately recall what they are. The patient also has trouble recounting what danger signs she should look out for when taking Coumadin.

Skill: Teach-back is an effective tool that can—and should—be used anytime a hospitalist is providing important information to a patient, Dr. Greenwald says. The hospitalist asks the patient to explain back the information in his or her own words in order to determine the patient’s understanding. If errors are identified, the hospitalist can explain the information again to ensure the patient’s comprehension.

“You might say, ‘How are you going to explain to your primary-care doctor about why you’re on an antibiotic?’ or ‘What are you going to tell your son about how your diet has to change?’” Dr. Greenwald says.

He outlines three important elements of teach-back:

• Concentrate on the critical information that patients need to know in order to function;
• Provide information in small bites that the patient can digest; and
• Repeat and reinforce the information with the help of all the members of the care team.

Teach-back should be used consistently, he says, so hospitalists can build on the information taught previously by adding layers to the patient’s knowledge.

Lisa Ryan is a freelance writer in New Jersey.

Hospitalists coordinate the care of large numbers of very sick, very complicated patients, making patient-hospitalist communication very important. When done effectively, communication can help hospitalists improve their patients’ sense of well-being and reinforce their adherence to medical treatments post-discharge. It also can build trust and help patients better understand their illnesses.

Nonetheless, communication gaps do occur. The main culprits include time pressures, the lack of a pre-existing patient relationship, patient emotions, medical jargon, and physicians’ tendencies to lecture.

The following five examples outline common communication pitfalls, followed by fundamental skills that can be used to solve communication problems.

Tick, Tock Goes the Clock

Scenario: A hospitalist mentions a medication change during a brief patient visit in the midst of a hectic day. The hospitalist pauses for a moment, glances at his watch, and reaches for the room’s door handle. When no question is forthcoming, he excuses himself to visit the next patient.

The patient has questions about the new medication but feels guilty about taking up the hospitalist’s time. The patient decides she can ask about the medication and the reason for the change when the hospitalist isn’t in such a hurry.

Skill: Creating an environment in which patients are encouraged to ask questions need not result in lengthy conversations. The key is having a clear framework for directing conversations, says Cindy Lien, MD, an academic hospitalist at Beth Israel Deaconess Medical Center in Boston. Dr. Lien uses “Ask-Tell-Ask” as a mnemonic when teaching communication skills to internal-medicine trainees.

“We have a tendency to just tell, tell, tell information,” she says. “Ask-Tell-Ask reminds you that one of the most important things to do is to ask the patient to describe what their understanding is of the situation so you have a sense of where they’re coming from.”

Opening questions can include “What is the most important issue on your mind today?” and “What do you understand about your medications?”

After listening to the patient’s response, tell the patient in a few straightforward sentences the information you need to communicate, Dr. Lien says. Then ask the patient if they understand the information conveyed to them, which will give them a chance to ask questions. Additional questions for the patient can include “Do you need further information at this point?” and “How do you feel about what we’ve discussed?”

The way our brains are built, emotion will trump cognition every time. If you as the doctor keep talking when someone is having an emotional moment, they will generally miss all the information you provided.

—Anthony Back, MD, professor of medicine, University of Washington, Seattle

What’s Your Name Again?

Scenario: A hospitalist wearing professional dress with no nametag enters a patient room and introduces herself before informing the patient that she’s ordered additional tests. The hospitalist visits the patient several times during his hospital stay to discuss test results and self-care instructions upon discharge but never reintroduces herself.

The patient was exhausted and in discomfort when the clinician first introduced herself as a hospitalist. She said her name so quickly that the patient didn’t catch it. The patient sees the hospitalist more often than other providers during his admission, but he’s not sure what her role is and he finds it too awkward to ask.

Skill: First impressions are lasting, so make a solid introduction, says David Meltzer, MD, PhD, FHM, associate professor in the department of medicine at the University of Chicago. Because patients are more likely to identify a hospitalist if they understand the hospitalist has a relationship with their primary-care physician (PCP), the initial greeting should be stated clearly, slowly, and include a reference to the PCP.

“After providing your name, you can say something like, ‘I see you’re Dr. Smith’s patient. I’ve worked with Dr. Smith for many years. We’ll make sure we communicate what happens during your hospitalization. I hope to develop a good relationship with you while you’re in the hospital,’” Dr. Meltzer says.

The hospitalist team should also consider providing brochures with photos of the hospitalists and an explanation of what hospitalists do, says Michael Pistoria, DO, FACP, SFHM, associate chief of the division of general internal medicine at Lehigh Valley Health Network in Allentown, Pa.

“Brochures can be handed to patients at the time of admission with the hospitalist explaining, ‘I’m going to be the doctor in charge of coordinating your care,’” he explains.

Mind Over Matter

Scenario: A hospitalist explains to the patient that her illness is getting worse and more aggressive treatment is advised. While reviewing treatment options, the hospitalist notices the patient is staring out the window, her chin quivering. The hospitalist presses on with what she has to say.

The patient can hear the hospitalist talking, but she’s thinking about how this setback will affect her family. She’s doing all she can to keep from crying and nods her head out of politeness to feign understanding of the information being provided.

Skill: Acknowledging patient emotion is imperative, because doctors who ignore these signals do so at their own professional peril, says Anthony Back, MD, professor of medicine at the University of Washington in Seattle.

“The way our brains are built, emotion will trump cognition every time,” he says. “If you as the doctor keep talking when someone is having an emotional moment, they will generally miss all the information you provided.

“If you see the patient has a lot of emotion, you can say, ‘I notice you are really concerned about this. Can you tell me more?’” Dr. Back says. “Just the act of getting it out in the open will often enable a patient to process the emotion enough so that you can go on to medical issues that are important for the patient to know.”

In most cases, respectfully acknowledging the emotion won’t take long. He says most patients recognize they have limited time with the doctor, and they want to get to the important medical information, too.

It’s Gibberish to Me

Dr. Meltzer

Scenario: A hospitalist believes a patient has a solid understanding of his diagnosis. The hospitalist sends the patient for several tests and discusses with him the risks and benefits of various medications and interventions, sometimes using complex terminology.

The patient doesn’t know why he’s had to undergo so many tests. He’s tried to follow along as the hospitalist talks about treatment options and has even asked his daughter to look up medical terminology on her smartphone so he can better understand what is going on. He wishes the hospitalist would explain his condition in basic terms.

Skill: Simplify the language used to communicate with patients by speaking in plain English, says Jeff Greenwald, MD, SFHM, associate professor of medicine at Harvard Medical School and a teaching hospitalist at Massachusetts General Hospital in Boston. Hospitalists should be aware that words and terminology they think are commonplace many times are medical jargon and confusing to patients, he adds.

“For example, when I say ‘take this medication orally,’ that doesn’t strike me as technical language. But ‘orally’ is a word that is not understood by a significant percentage of the population,” Dr. Greenwald says.

Dr. Greenwald

A good rule of thumb is to continually check in with patients about the words and terms being used, Dr. Meltzer adds.

“Ask patients if they would like you to explain a term,” he says. “You can say something like, ‘I know this is a term many people aren’t familiar with. Would you like me to tell you more about what it means?’”

Data-Dumping

Scenario: A hospitalist checks in on a patient with atrial fibrillation and uses the visit to talk about Coumadin. She instructs the patient on how the drug works in the body, how it increases the chance of bleeding, and how the medication should be taken and monitored.

Later that day, the patient tells her daughter about the hospitalist’s instructions regarding her new medication. The patient remembers that she should avoid certain foods and beverages while on Coumadin but can’t immediately recall what they are. The patient also has trouble recounting what danger signs she should look out for when taking Coumadin.

Skill: Teach-back is an effective tool that can—and should—be used anytime a hospitalist is providing important information to a patient, Dr. Greenwald says. The hospitalist asks the patient to explain back the information in his or her own words in order to determine the patient’s understanding. If errors are identified, the hospitalist can explain the information again to ensure the patient’s comprehension.

“You might say, ‘How are you going to explain to your primary-care doctor about why you’re on an antibiotic?’ or ‘What are you going to tell your son about how your diet has to change?’” Dr. Greenwald says.

He outlines three important elements of teach-back:

• Concentrate on the critical information that patients need to know in order to function;
• Provide information in small bites that the patient can digest; and
• Repeat and reinforce the information with the help of all the members of the care team.

Teach-back should be used consistently, he says, so hospitalists can build on the information taught previously by adding layers to the patient’s knowledge.

Lisa Ryan is a freelance writer in New Jersey.

Chithra Perumalswami, MD, knew early on what she wanted to do with her life. As a teenager, she volunteered in an ED and with a hospice group, volunteerism that continued throughout her education. When she graduated from high school, she was tapped for Brown University’s Program in Liberal Medical Education, which calls itself the only baccalaureate-MD program in the Ivy League. And though she eventually turned down the offer, she pursued dual majors in cellular and molecular biology and English at the University of Michigan, where she earned her medical degree in 2004 and completed her residency.

In 2009, she participated in the Palliative Care Education and Practice Program at Harvard Medical School in Boston, a two-week post-graduate course aimed at professional development for physicians dedicated to careers in palliative-care education. “I really found that there were just so many aspects to caring for a patient as a palliative-care specialist and as a hospitalist that really strike at the heart of what being a doctor is,” says Dr. Perumalswami, assistant professor of medicine in the Division of Hospital Medicine at Northwestern Memorial Hospital in Chicago and one of four new members of Team Hospitalist. “I think it’s been an interest I’ve always had. During my residency training, I definitely experienced quite a few patient cases where I felt that we really needed to help patients and their families, and I didn’t necessarily have the best skill set to do that until I had more experience and more training.”

Dr. Perumalswami now wants to get better at her craft.

“As an academic hospitalist, it’s not just about doing research and writing papers and seeing papers,” she says, “but it’s also developing those leadership skills and helping that become an integral part of the educational experience.”

Question: What drew you to a career in HM?

Answer: I chose a career in academic hospital medicine primarily because I enjoy taking care of acutely ill, hospitalized, adult patients. I also really enjoy teaching medical students, residents, and fellows, and I enjoy doing that in the hospital setting. I think that there’s great satisfaction from taking care of a patient from admission to discharge.… I enjoyed every aspect of internal medicine, and when I graduated, I thought I could choose a subspecialty, but I felt that my skills and my expertise was really in taking care of the hospitalized patient.

Q: You have sought out extra training in palliative care and pain management. How has that impacted your career?

A: It’s not something that I necessarily started out thinking that I would specialize in, but the more I took care of hospitalized patients, the more I realized that we actually take care of a fair number of patients who have really complex symptom needs, and also really have a lot of needs with regard to recognizing when their prognosis is poor and understanding what their options are, if they’re even amenable to a palliative approach. I really felt that that was a skill that I needed to fine-tune. So I ended up gaining enough clinical experience and participating with hospice patients to the point where that’s really supplemented my hospitalist career, because what I found is that it’s made me a better hospitalist, and being a hospitalist has made me a better palliative-care doc.

Q: Working in academia, there’s no way to escape talk of the duty-hour rules recently put in place. What’s your view on the issue?

A: My view is that the work hours are here to stay. I think that there are some definite benefits that we’ve gained from having work hours. I’d say first and foremost of those gains is public trust. I think most physicians will tell you that they don’t want a physician who’s in the 36th hour of their day taking care of them when we know that studies actually can demonstrate that when you’ve been awake that long, that your cognitive abilities decline.

Q: But?

A: I think we have a lot of challenges, though, because a lot of things require creative solutions. And I think the first on that list is education, because that’s the first thing that I think has the potential to drop to the bottom of the list.

Q: In terms of HM’s growth, as you see residents coming through your program, how popular do you think the model is going to be with them moving forward?

A: I do, actually, because as an academic hospitalist, I’ve had several medical students and residents tell me, “Watching you, I think that I want to go into this field.” Or they’ll say, “What do you think about doing this for a year or two?” Or, “What do you think about subspecializing, and then being a hospitalist?” And my answer to all of them is it’s a dynamic specialty, and if you’re up for creating change and being a leader, it’s a good field, because we need people in a lot of different buckets, so to speak. We need people who have done other things in their career to contribute to our field.

Q: How do you prepare trainees for all the challenges coming down the pike?

A: A lot of the people who are doing work in medical education are starting to look to other fields to see if there are other models that we can adapt, or that we can somehow absorb into our practice. I think that there are some parts of our education which are not really formalized early on, but I think we have a lot to learn from organizational behavior circles, and systems that actually look at teams and leadership.

Q: What do the next five to 10 years hold for you?

A: All physician leaders have to stay somewhat in the clinical world. I think if you lose sight of that, you can’t be a very effective leader, or a very effective agent for change. Because part of my work is with palliative care, and I really feel that it’s affected my work as a hospitalist in a positive way, I don’t think I ever see myself leaving the clinical world completely. But I do see myself becoming, ideally, more involved with leadership and more involved with helping to train the next set of leaders.

Q: What do you see as SHM’s role specific to academic HM?

A: HM is changing the way healthcare is delivered in the U.S., and I think having an organization to represent us is vital to our success in other arenas of change—including healthcare policy and innovative care models. I see SHM as a large umbrella group, of which academic HM is one part. Academic hospitalists are increasingly involved in the education of future generations of physicians, and are uniquely poised for facilitating cascading leadership. The traditional, hierarchical model of attending-fellow-resident-medical student is shifting, and academic hospitalists are well-suited to study and explore this leadership structure and how it affects patient care, feedback, and mentoring.

Richard Quinn is a freelance writer based in New Jersey.

Chithra Perumalswami, MD, knew early on what she wanted to do with her life. As a teenager, she volunteered in an ED and with a hospice group, volunteerism that continued throughout her education. When she graduated from high school, she was tapped for Brown University’s Program in Liberal Medical Education, which calls itself the only baccalaureate-MD program in the Ivy League. And though she eventually turned down the offer, she pursued dual majors in cellular and molecular biology and English at the University of Michigan, where she earned her medical degree in 2004 and completed her residency.

In 2009, she participated in the Palliative Care Education and Practice Program at Harvard Medical School in Boston, a two-week post-graduate course aimed at professional development for physicians dedicated to careers in palliative-care education. “I really found that there were just so many aspects to caring for a patient as a palliative-care specialist and as a hospitalist that really strike at the heart of what being a doctor is,” says Dr. Perumalswami, assistant professor of medicine in the Division of Hospital Medicine at Northwestern Memorial Hospital in Chicago and one of four new members of Team Hospitalist. “I think it’s been an interest I’ve always had. During my residency training, I definitely experienced quite a few patient cases where I felt that we really needed to help patients and their families, and I didn’t necessarily have the best skill set to do that until I had more experience and more training.”

Dr. Perumalswami now wants to get better at her craft.

“As an academic hospitalist, it’s not just about doing research and writing papers and seeing papers,” she says, “but it’s also developing those leadership skills and helping that become an integral part of the educational experience.”

Question: What drew you to a career in HM?

Answer: I chose a career in academic hospital medicine primarily because I enjoy taking care of acutely ill, hospitalized, adult patients. I also really enjoy teaching medical students, residents, and fellows, and I enjoy doing that in the hospital setting. I think that there’s great satisfaction from taking care of a patient from admission to discharge.… I enjoyed every aspect of internal medicine, and when I graduated, I thought I could choose a subspecialty, but I felt that my skills and my expertise was really in taking care of the hospitalized patient.

Q: You have sought out extra training in palliative care and pain management. How has that impacted your career?

A: It’s not something that I necessarily started out thinking that I would specialize in, but the more I took care of hospitalized patients, the more I realized that we actually take care of a fair number of patients who have really complex symptom needs, and also really have a lot of needs with regard to recognizing when their prognosis is poor and understanding what their options are, if they’re even amenable to a palliative approach. I really felt that that was a skill that I needed to fine-tune. So I ended up gaining enough clinical experience and participating with hospice patients to the point where that’s really supplemented my hospitalist career, because what I found is that it’s made me a better hospitalist, and being a hospitalist has made me a better palliative-care doc.

Q: Working in academia, there’s no way to escape talk of the duty-hour rules recently put in place. What’s your view on the issue?

A: My view is that the work hours are here to stay. I think that there are some definite benefits that we’ve gained from having work hours. I’d say first and foremost of those gains is public trust. I think most physicians will tell you that they don’t want a physician who’s in the 36th hour of their day taking care of them when we know that studies actually can demonstrate that when you’ve been awake that long, that your cognitive abilities decline.

Q: But?

A: I think we have a lot of challenges, though, because a lot of things require creative solutions. And I think the first on that list is education, because that’s the first thing that I think has the potential to drop to the bottom of the list.

Q: In terms of HM’s growth, as you see residents coming through your program, how popular do you think the model is going to be with them moving forward?

A: I do, actually, because as an academic hospitalist, I’ve had several medical students and residents tell me, “Watching you, I think that I want to go into this field.” Or they’ll say, “What do you think about doing this for a year or two?” Or, “What do you think about subspecializing, and then being a hospitalist?” And my answer to all of them is it’s a dynamic specialty, and if you’re up for creating change and being a leader, it’s a good field, because we need people in a lot of different buckets, so to speak. We need people who have done other things in their career to contribute to our field.

Q: How do you prepare trainees for all the challenges coming down the pike?

A: A lot of the people who are doing work in medical education are starting to look to other fields to see if there are other models that we can adapt, or that we can somehow absorb into our practice. I think that there are some parts of our education which are not really formalized early on, but I think we have a lot to learn from organizational behavior circles, and systems that actually look at teams and leadership.

Q: What do the next five to 10 years hold for you?

A: All physician leaders have to stay somewhat in the clinical world. I think if you lose sight of that, you can’t be a very effective leader, or a very effective agent for change. Because part of my work is with palliative care, and I really feel that it’s affected my work as a hospitalist in a positive way, I don’t think I ever see myself leaving the clinical world completely. But I do see myself becoming, ideally, more involved with leadership and more involved with helping to train the next set of leaders.

Q: What do you see as SHM’s role specific to academic HM?

A: HM is changing the way healthcare is delivered in the U.S., and I think having an organization to represent us is vital to our success in other arenas of change—including healthcare policy and innovative care models. I see SHM as a large umbrella group, of which academic HM is one part. Academic hospitalists are increasingly involved in the education of future generations of physicians, and are uniquely poised for facilitating cascading leadership. The traditional, hierarchical model of attending-fellow-resident-medical student is shifting, and academic hospitalists are well-suited to study and explore this leadership structure and how it affects patient care, feedback, and mentoring.

Richard Quinn is a freelance writer based in New Jersey.

Chithra Perumalswami, MD, knew early on what she wanted to do with her life. As a teenager, she volunteered in an ED and with a hospice group, volunteerism that continued throughout her education. When she graduated from high school, she was tapped for Brown University’s Program in Liberal Medical Education, which calls itself the only baccalaureate-MD program in the Ivy League. And though she eventually turned down the offer, she pursued dual majors in cellular and molecular biology and English at the University of Michigan, where she earned her medical degree in 2004 and completed her residency.

In 2009, she participated in the Palliative Care Education and Practice Program at Harvard Medical School in Boston, a two-week post-graduate course aimed at professional development for physicians dedicated to careers in palliative-care education. “I really found that there were just so many aspects to caring for a patient as a palliative-care specialist and as a hospitalist that really strike at the heart of what being a doctor is,” says Dr. Perumalswami, assistant professor of medicine in the Division of Hospital Medicine at Northwestern Memorial Hospital in Chicago and one of four new members of Team Hospitalist. “I think it’s been an interest I’ve always had. During my residency training, I definitely experienced quite a few patient cases where I felt that we really needed to help patients and their families, and I didn’t necessarily have the best skill set to do that until I had more experience and more training.”

Dr. Perumalswami now wants to get better at her craft.

“As an academic hospitalist, it’s not just about doing research and writing papers and seeing papers,” she says, “but it’s also developing those leadership skills and helping that become an integral part of the educational experience.”

Question: What drew you to a career in HM?

Answer: I chose a career in academic hospital medicine primarily because I enjoy taking care of acutely ill, hospitalized, adult patients. I also really enjoy teaching medical students, residents, and fellows, and I enjoy doing that in the hospital setting. I think that there’s great satisfaction from taking care of a patient from admission to discharge.… I enjoyed every aspect of internal medicine, and when I graduated, I thought I could choose a subspecialty, but I felt that my skills and my expertise was really in taking care of the hospitalized patient.

Q: You have sought out extra training in palliative care and pain management. How has that impacted your career?

A: It’s not something that I necessarily started out thinking that I would specialize in, but the more I took care of hospitalized patients, the more I realized that we actually take care of a fair number of patients who have really complex symptom needs, and also really have a lot of needs with regard to recognizing when their prognosis is poor and understanding what their options are, if they’re even amenable to a palliative approach. I really felt that that was a skill that I needed to fine-tune. So I ended up gaining enough clinical experience and participating with hospice patients to the point where that’s really supplemented my hospitalist career, because what I found is that it’s made me a better hospitalist, and being a hospitalist has made me a better palliative-care doc.

Q: Working in academia, there’s no way to escape talk of the duty-hour rules recently put in place. What’s your view on the issue?

A: My view is that the work hours are here to stay. I think that there are some definite benefits that we’ve gained from having work hours. I’d say first and foremost of those gains is public trust. I think most physicians will tell you that they don’t want a physician who’s in the 36th hour of their day taking care of them when we know that studies actually can demonstrate that when you’ve been awake that long, that your cognitive abilities decline.

Q: But?

A: I think we have a lot of challenges, though, because a lot of things require creative solutions. And I think the first on that list is education, because that’s the first thing that I think has the potential to drop to the bottom of the list.

Q: In terms of HM’s growth, as you see residents coming through your program, how popular do you think the model is going to be with them moving forward?

A: I do, actually, because as an academic hospitalist, I’ve had several medical students and residents tell me, “Watching you, I think that I want to go into this field.” Or they’ll say, “What do you think about doing this for a year or two?” Or, “What do you think about subspecializing, and then being a hospitalist?” And my answer to all of them is it’s a dynamic specialty, and if you’re up for creating change and being a leader, it’s a good field, because we need people in a lot of different buckets, so to speak. We need people who have done other things in their career to contribute to our field.

Q: How do you prepare trainees for all the challenges coming down the pike?

A: A lot of the people who are doing work in medical education are starting to look to other fields to see if there are other models that we can adapt, or that we can somehow absorb into our practice. I think that there are some parts of our education which are not really formalized early on, but I think we have a lot to learn from organizational behavior circles, and systems that actually look at teams and leadership.

Q: What do the next five to 10 years hold for you?

A: All physician leaders have to stay somewhat in the clinical world. I think if you lose sight of that, you can’t be a very effective leader, or a very effective agent for change. Because part of my work is with palliative care, and I really feel that it’s affected my work as a hospitalist in a positive way, I don’t think I ever see myself leaving the clinical world completely. But I do see myself becoming, ideally, more involved with leadership and more involved with helping to train the next set of leaders.

Q: What do you see as SHM’s role specific to academic HM?

A: HM is changing the way healthcare is delivered in the U.S., and I think having an organization to represent us is vital to our success in other arenas of change—including healthcare policy and innovative care models. I see SHM as a large umbrella group, of which academic HM is one part. Academic hospitalists are increasingly involved in the education of future generations of physicians, and are uniquely poised for facilitating cascading leadership. The traditional, hierarchical model of attending-fellow-resident-medical student is shifting, and academic hospitalists are well-suited to study and explore this leadership structure and how it affects patient care, feedback, and mentoring.

Richard Quinn is a freelance writer based in New Jersey.

Dr. Frost

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

The Process

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

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

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

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

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

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

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

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

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

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

Conclusion

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

Dr. Frost is president of SHM.

Reference

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

Dr. Frost

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

The Process

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

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

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

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

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

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

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

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

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

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

Conclusion

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

Dr. Frost is president of SHM.

Reference

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

Dr. Frost

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

The Process

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

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

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

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

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

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

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

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

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

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

Conclusion

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

Dr. Frost is president of SHM.

Reference

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

Dr. Hospitalist

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

—Libby Gardner

Dr. Hospitalist responds:

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

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

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

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

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

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

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

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

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

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

Dr. Hospitalist

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

—Libby Gardner

Dr. Hospitalist responds:

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

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

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

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

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

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

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

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

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

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

Dr. Hospitalist

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

—Libby Gardner

Dr. Hospitalist responds:

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Six out of 7 respondents to an unscientific survey at the-hospitalist.org correctly answered the question "Which patient being discharged DOES NOT require VTE prophylaxis?" while 14% of respondents answered incorrectly, according to veteran hospitalists who reviewed survey results.

Nearly 200 people responded to the survey, which provided the following answers:

• Hip/knee replacement patients;

• Hip-fracture surgery patients;

• Patients with advanced solid tumors;

• Patients with congestive heart failure; and

• Immobile or bed-bound patients.

The survey ran from June 29 to July 27 and was not limited to physicians. Sixty-six percent of respondents chose "patients with congestive heart failure" as their answer; 20% of respondents chose "patients with advanced solid tumors." Both types of discharged patients do not require VTE prophylaxis, according to the new American College of Chest Physicians (ACCP) guidelines, says Joseph Ming Wah Li, MD, SFHM, FACP, past president of SHM, associate professor of medicine at Harvard Medical School, and hospitalist at Beth Israel Deaconess Medical Center in Boston.

"Hospitalists are familiar with the fact that patients with advanced solid tumors without additional risk factors do not need extended prophylaxis, as per the guidelines put out by ACCP," Dr. Li says. "And patients with congestive heart failure being discharged from the hospital do not need extended thromboprophylaxis, either."

As for the 14% of respondents who chose incorrectly, Gregory Maynard, MD, MSc, SFHM, health sciences professor of medicine at the University of California at San Diego, says extended prophylaxis "may not be on their radar."

"Hospitalists are still struggling to get a consistent approach to inpatient VTE prophylaxis, especially since the ACCP 9 guidelines changed methodologies and provided weaker support for prophylaxis," says Dr. Maynard, senior vice president of SHM's Center for Hospital Innovation and Improvement.

For more information, check out our "Key Clinical Question" outlining VTE prophylaxis guidelines.

Six out of 7 respondents to an unscientific survey at the-hospitalist.org correctly answered the question "Which patient being discharged DOES NOT require VTE prophylaxis?" while 14% of respondents answered incorrectly, according to veteran hospitalists who reviewed survey results.

Nearly 200 people responded to the survey, which provided the following answers:

• Hip/knee replacement patients;

• Hip-fracture surgery patients;

• Patients with advanced solid tumors;

• Patients with congestive heart failure; and

• Immobile or bed-bound patients.

The survey ran from June 29 to July 27 and was not limited to physicians. Sixty-six percent of respondents chose "patients with congestive heart failure" as their answer; 20% of respondents chose "patients with advanced solid tumors." Both types of discharged patients do not require VTE prophylaxis, according to the new American College of Chest Physicians (ACCP) guidelines, says Joseph Ming Wah Li, MD, SFHM, FACP, past president of SHM, associate professor of medicine at Harvard Medical School, and hospitalist at Beth Israel Deaconess Medical Center in Boston.

"Hospitalists are familiar with the fact that patients with advanced solid tumors without additional risk factors do not need extended prophylaxis, as per the guidelines put out by ACCP," Dr. Li says. "And patients with congestive heart failure being discharged from the hospital do not need extended thromboprophylaxis, either."

As for the 14% of respondents who chose incorrectly, Gregory Maynard, MD, MSc, SFHM, health sciences professor of medicine at the University of California at San Diego, says extended prophylaxis "may not be on their radar."

"Hospitalists are still struggling to get a consistent approach to inpatient VTE prophylaxis, especially since the ACCP 9 guidelines changed methodologies and provided weaker support for prophylaxis," says Dr. Maynard, senior vice president of SHM's Center for Hospital Innovation and Improvement.

For more information, check out our "Key Clinical Question" outlining VTE prophylaxis guidelines.

Six out of 7 respondents to an unscientific survey at the-hospitalist.org correctly answered the question "Which patient being discharged DOES NOT require VTE prophylaxis?" while 14% of respondents answered incorrectly, according to veteran hospitalists who reviewed survey results.

Nearly 200 people responded to the survey, which provided the following answers:

• Hip/knee replacement patients;

• Hip-fracture surgery patients;

• Patients with advanced solid tumors;

• Patients with congestive heart failure; and

• Immobile or bed-bound patients.

The survey ran from June 29 to July 27 and was not limited to physicians. Sixty-six percent of respondents chose "patients with congestive heart failure" as their answer; 20% of respondents chose "patients with advanced solid tumors." Both types of discharged patients do not require VTE prophylaxis, according to the new American College of Chest Physicians (ACCP) guidelines, says Joseph Ming Wah Li, MD, SFHM, FACP, past president of SHM, associate professor of medicine at Harvard Medical School, and hospitalist at Beth Israel Deaconess Medical Center in Boston.

"Hospitalists are familiar with the fact that patients with advanced solid tumors without additional risk factors do not need extended prophylaxis, as per the guidelines put out by ACCP," Dr. Li says. "And patients with congestive heart failure being discharged from the hospital do not need extended thromboprophylaxis, either."

As for the 14% of respondents who chose incorrectly, Gregory Maynard, MD, MSc, SFHM, health sciences professor of medicine at the University of California at San Diego, says extended prophylaxis "may not be on their radar."

"Hospitalists are still struggling to get a consistent approach to inpatient VTE prophylaxis, especially since the ACCP 9 guidelines changed methodologies and provided weaker support for prophylaxis," says Dr. Maynard, senior vice president of SHM's Center for Hospital Innovation and Improvement.

For more information, check out our "Key Clinical Question" outlining VTE prophylaxis guidelines.

Discordant antibiotic therapy for urinary tract infections (UTIs) is common and associated with higher length of stay (LOS) in hospitalized children, according to a study published online last month in the Journal of Hospital Medicine. But lead author Karen Jerardi, MD, division of hospital medicine at Cincinnati Children's Hospital Medical Center says the reason might be related to physicians, not their patients.

"First, use our knowledge of local resistance patterns and patient factors to select an antibiotic likely to be concordant," she says. "The second thing is [that] we probably need to analyze our practice a little bit more and try to figure out if we are just keeping patients in the hospital because we want to see them be on the concordant antibiotic for X number of hours before we send them home. Does that benefit the patient more, or are we keeping them in the hospital longer for our own peace of mind?"

The report, "Discordant Antibiotic Therapy and Length of Stay in Children Hospitalized for Urinary Tract Infection," found that discordant therapy occurred in 10% of cases in which patients had laboratory-confirmed UTIs and, in adjusted analyses, was associated with a 1.8-day increase in LOS.

Dr. Jerardi says that future studies are needed to determine whether pediatric hospitalists are extending LOS by keeping patients longer than absolutely necessary. She cautions, though, that how long a child is kept in the hospital should be determined by case-specific circumstances.

"Hopefully, this will make people analyze how they do things," she adds, "and think to themselves, 'Would I keep that patient an extra day longer because I had to switch their antibiotic—even if their fever went away, they were drinking great, and Mom and Dad were ready to go home—just for my peace of mind?'"

Discordant antibiotic therapy for urinary tract infections (UTIs) is common and associated with higher length of stay (LOS) in hospitalized children, according to a study published online last month in the Journal of Hospital Medicine. But lead author Karen Jerardi, MD, division of hospital medicine at Cincinnati Children's Hospital Medical Center says the reason might be related to physicians, not their patients.

"First, use our knowledge of local resistance patterns and patient factors to select an antibiotic likely to be concordant," she says. "The second thing is [that] we probably need to analyze our practice a little bit more and try to figure out if we are just keeping patients in the hospital because we want to see them be on the concordant antibiotic for X number of hours before we send them home. Does that benefit the patient more, or are we keeping them in the hospital longer for our own peace of mind?"

The report, "Discordant Antibiotic Therapy and Length of Stay in Children Hospitalized for Urinary Tract Infection," found that discordant therapy occurred in 10% of cases in which patients had laboratory-confirmed UTIs and, in adjusted analyses, was associated with a 1.8-day increase in LOS.

Dr. Jerardi says that future studies are needed to determine whether pediatric hospitalists are extending LOS by keeping patients longer than absolutely necessary. She cautions, though, that how long a child is kept in the hospital should be determined by case-specific circumstances.

"Hopefully, this will make people analyze how they do things," she adds, "and think to themselves, 'Would I keep that patient an extra day longer because I had to switch their antibiotic—even if their fever went away, they were drinking great, and Mom and Dad were ready to go home—just for my peace of mind?'"

Discordant antibiotic therapy for urinary tract infections (UTIs) is common and associated with higher length of stay (LOS) in hospitalized children, according to a study published online last month in the Journal of Hospital Medicine. But lead author Karen Jerardi, MD, division of hospital medicine at Cincinnati Children's Hospital Medical Center says the reason might be related to physicians, not their patients.

"First, use our knowledge of local resistance patterns and patient factors to select an antibiotic likely to be concordant," she says. "The second thing is [that] we probably need to analyze our practice a little bit more and try to figure out if we are just keeping patients in the hospital because we want to see them be on the concordant antibiotic for X number of hours before we send them home. Does that benefit the patient more, or are we keeping them in the hospital longer for our own peace of mind?"

The report, "Discordant Antibiotic Therapy and Length of Stay in Children Hospitalized for Urinary Tract Infection," found that discordant therapy occurred in 10% of cases in which patients had laboratory-confirmed UTIs and, in adjusted analyses, was associated with a 1.8-day increase in LOS.

Dr. Jerardi says that future studies are needed to determine whether pediatric hospitalists are extending LOS by keeping patients longer than absolutely necessary. She cautions, though, that how long a child is kept in the hospital should be determined by case-specific circumstances.

"Hopefully, this will make people analyze how they do things," she adds, "and think to themselves, 'Would I keep that patient an extra day longer because I had to switch their antibiotic—even if their fever went away, they were drinking great, and Mom and Dad were ready to go home—just for my peace of mind?'"

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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