Larry Beresford

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

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

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

Christine Lum Lung, MD, SFHM

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

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

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

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

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

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

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

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

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

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

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

Christine Lum Lung, MD, SFHM

Christine Lum Lung, MD, SFHM

Title: Medical director, Northern Colorado Hospitalists, Fort Collins

Program: VTE Prevention Collaborative

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

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

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

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

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

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

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

Jordan Messler, MD, SFHM

Jordan Messler, MD, SFHM

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

Program: GCMI; Project BOOST

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

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

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

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

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

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

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

Stephanie Rennke, MD

Stephanie Rennke, MD

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

Program: Project BOOST

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

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

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

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

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

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

Jennifer Quartarolo, MD, SFHM

Jennifer Quartarolo, MD, SFHM

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

Program: Project BOOST

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

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

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

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

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

Rich Balaban, MD

Rich Balaban, MD

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

Program: Project BOOST

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Cheryl O’Malley, MD, FHM

Cheryl O’Malley, MD, FHM

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

Program: GCMI

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

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

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

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

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

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

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

Cheryl O’Malley, MD, FHM

Christopher Kim, MD, MBA, SFHM

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

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

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

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

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

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

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

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

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

Larry Beresford is a freelance writer in Alameda, Calif.

Christine Lum Lung, MD, SFHM

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

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

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

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

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

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

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

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

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

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

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

Christine Lum Lung, MD, SFHM

Christine Lum Lung, MD, SFHM

Title: Medical director, Northern Colorado Hospitalists, Fort Collins

Program: VTE Prevention Collaborative

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

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

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

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

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

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

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

Jordan Messler, MD, SFHM

Jordan Messler, MD, SFHM

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

Program: GCMI; Project BOOST

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

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

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

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

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

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

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

Stephanie Rennke, MD

Stephanie Rennke, MD

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

Program: Project BOOST

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

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

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

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

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

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

Jennifer Quartarolo, MD, SFHM

Jennifer Quartarolo, MD, SFHM

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

Program: Project BOOST

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

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

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

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

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

Rich Balaban, MD

Rich Balaban, MD

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

Program: Project BOOST

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Cheryl O’Malley, MD, FHM

Cheryl O’Malley, MD, FHM

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

Program: GCMI

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

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

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

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

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

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

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

Cheryl O’Malley, MD, FHM

Christopher Kim, MD, MBA, SFHM

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

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

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

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

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

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

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

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

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

Larry Beresford is a freelance writer in Alameda, Calif.

Christine Lum Lung, MD, SFHM

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

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

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

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

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

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

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

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

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

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

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

Christine Lum Lung, MD, SFHM

Christine Lum Lung, MD, SFHM

Title: Medical director, Northern Colorado Hospitalists, Fort Collins

Program: VTE Prevention Collaborative

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

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

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

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

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

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

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

Jordan Messler, MD, SFHM

Jordan Messler, MD, SFHM

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

Program: GCMI; Project BOOST

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

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

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

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

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

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

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

Stephanie Rennke, MD

Stephanie Rennke, MD

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

Program: Project BOOST

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

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

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

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

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

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

Jennifer Quartarolo, MD, SFHM

Jennifer Quartarolo, MD, SFHM

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

Program: Project BOOST

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

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

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

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

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

Rich Balaban, MD

Rich Balaban, MD

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

Program: Project BOOST

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Cheryl O’Malley, MD, FHM

Cheryl O’Malley, MD, FHM

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

Program: GCMI

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

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

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

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

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

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

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

Cheryl O’Malley, MD, FHM

Christopher Kim, MD, MBA, SFHM

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

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

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

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

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

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

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

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

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

Larry Beresford is a freelance writer in Alameda, Calif.

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

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

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

Dollar value of uncompensated care provided by U.S. hospitals in 2012, expressed in terms of actual costs, according to data from the American Hospital Association’s Annual Survey of Hospitals^.6 This figure represents 6.1% of total costs, an increase of 11.7% from 2011. The total includes both bad debt and charity care provided to patients unable to pay for their care, AHA says, but does not include underpayments by Medicare and Medicaid.

Larry Beresford is a freelance writer in Alameda, Calif.

References

1. Bailey FA, Williams BR, Woodby LL, et al. Intervention to improve care at life's end in inpatient settings: The BEACON trial. J Gen Intern Med. 2014;29(6):836-843.
2. Burling S. Yogurt a solution to hospital infection? Philadelphia Inquirer website. December 10, 2013. Available at: http://articles.philly.com/2013-12-10/news/44946926_1_holy-redeemer-probiotics-yogurt. Accessed June 5, 2014.
3. Landelle C, Verachten M, Legrand P, Girou E, Barbut F, Buisson CB. Contamination of healthcare workers’ hands with Clostridium difficile spores after caring for patients with C. difficile infection. Infect Control Hosp Epidemiol. 2014;35(1):10-15.
4. Lewis K, Walker C. Development and application of information technology solutions to improve the quality and availability of discharge summaries. Journal of Hospital Medicine RIV abstracts website. Available at: http://www.shmabstracts.com/abstract.asp?MeetingID=793&id=104276&meeting=JHM201305. Published May 2013. Accessed June 14, 2014.
5. Snow V, Beck D, Budnitz T, et al. Transitions of Care Consensus Policy Statement. American College of Physicians; Society of General Internal Medicine; Society of Hospital Medicine; American Geriatrics Society; American College of Emergency Physicians; Society of Academic Emergency Medicine. J Gen Intern Med. 2009;24(8):971-976.
6. American Hospital Association: Uncompensated hospital care cost fact sheet. January 2014. Available at: http://www.aha.org/content/14/14uncompensatedcare.pdf. Accessed June 5, 2014.

Dollar value of uncompensated care provided by U.S. hospitals in 2012, expressed in terms of actual costs, according to data from the American Hospital Association’s Annual Survey of Hospitals^.6 This figure represents 6.1% of total costs, an increase of 11.7% from 2011. The total includes both bad debt and charity care provided to patients unable to pay for their care, AHA says, but does not include underpayments by Medicare and Medicaid.

Larry Beresford is a freelance writer in Alameda, Calif.

References

1. Bailey FA, Williams BR, Woodby LL, et al. Intervention to improve care at life's end in inpatient settings: The BEACON trial. J Gen Intern Med. 2014;29(6):836-843.
2. Burling S. Yogurt a solution to hospital infection? Philadelphia Inquirer website. December 10, 2013. Available at: http://articles.philly.com/2013-12-10/news/44946926_1_holy-redeemer-probiotics-yogurt. Accessed June 5, 2014.
3. Landelle C, Verachten M, Legrand P, Girou E, Barbut F, Buisson CB. Contamination of healthcare workers’ hands with Clostridium difficile spores after caring for patients with C. difficile infection. Infect Control Hosp Epidemiol. 2014;35(1):10-15.
4. Lewis K, Walker C. Development and application of information technology solutions to improve the quality and availability of discharge summaries. Journal of Hospital Medicine RIV abstracts website. Available at: http://www.shmabstracts.com/abstract.asp?MeetingID=793&id=104276&meeting=JHM201305. Published May 2013. Accessed June 14, 2014.
5. Snow V, Beck D, Budnitz T, et al. Transitions of Care Consensus Policy Statement. American College of Physicians; Society of General Internal Medicine; Society of Hospital Medicine; American Geriatrics Society; American College of Emergency Physicians; Society of Academic Emergency Medicine. J Gen Intern Med. 2009;24(8):971-976.
6. American Hospital Association: Uncompensated hospital care cost fact sheet. January 2014. Available at: http://www.aha.org/content/14/14uncompensatedcare.pdf. Accessed June 5, 2014.

Dollar value of uncompensated care provided by U.S. hospitals in 2012, expressed in terms of actual costs, according to data from the American Hospital Association’s Annual Survey of Hospitals^.6 This figure represents 6.1% of total costs, an increase of 11.7% from 2011. The total includes both bad debt and charity care provided to patients unable to pay for their care, AHA says, but does not include underpayments by Medicare and Medicaid.

Larry Beresford is a freelance writer in Alameda, Calif.

References

1. Bailey FA, Williams BR, Woodby LL, et al. Intervention to improve care at life's end in inpatient settings: The BEACON trial. J Gen Intern Med. 2014;29(6):836-843.
2. Burling S. Yogurt a solution to hospital infection? Philadelphia Inquirer website. December 10, 2013. Available at: http://articles.philly.com/2013-12-10/news/44946926_1_holy-redeemer-probiotics-yogurt. Accessed June 5, 2014.
3. Landelle C, Verachten M, Legrand P, Girou E, Barbut F, Buisson CB. Contamination of healthcare workers’ hands with Clostridium difficile spores after caring for patients with C. difficile infection. Infect Control Hosp Epidemiol. 2014;35(1):10-15.
4. Lewis K, Walker C. Development and application of information technology solutions to improve the quality and availability of discharge summaries. Journal of Hospital Medicine RIV abstracts website. Available at: http://www.shmabstracts.com/abstract.asp?MeetingID=793&id=104276&meeting=JHM201305. Published May 2013. Accessed June 14, 2014.
5. Snow V, Beck D, Budnitz T, et al. Transitions of Care Consensus Policy Statement. American College of Physicians; Society of General Internal Medicine; Society of Hospital Medicine; American Geriatrics Society; American College of Emergency Physicians; Society of Academic Emergency Medicine. J Gen Intern Med. 2009;24(8):971-976.
6. American Hospital Association: Uncompensated hospital care cost fact sheet. January 2014. Available at: http://www.aha.org/content/14/14uncompensatedcare.pdf. Accessed June 5, 2014.

An RIV poster presented at SHM’s annual meeting describes the application of health information technology to improve the quality of hospital discharge summaries.⁴ Lead author Kristen Lewis, MD, in the clinical division of hospital medicine at The Ohio State University (OSU) Wexner Medical Center in Columbus, described how SHM’s 2009 “Transitions of Care Consensus Policy Statement” was adopted as the medical center’s standard of care—although at baseline this standard was being fully met at the hospital only 4% of the time^.5 Discharge summaries frequently lacked important information, including tests pending at discharge, and were not made available to those clinicians who needed them following discharge.

“We developed, piloted, and implemented an innovative electronic discharge summary template that incorporated prompts and automatically populated core components of a quality discharge summary,” Dr. Lewis says, adding that the process also offered opportunities for customization and free-text entries. Initial experience following a series of multidisciplinary educational initiatives to help physicians and case managers understand these mechanisms found full compliance rising to 75%.

Next steps for the project include improving the availability of discharge data for primary care providers, specialist physicians, and extended care facilities not affiliated with OSU; inclusion of the discharge summary in the “After Visit Summary” given to patients; and assessment of outpatient providers’ satisfaction with the process.

For more information about the electronic discharge template, contact Dr. Lewis at kristen.lewis@osumc.edu.

Larry Beresford is a freelance writer in Alameda, Calif.

References

1. Bailey FA, Williams BR, Woodby LL, et al. Intervention to improve care at life's end in inpatient settings: The BEACON trial. J Gen Intern Med. 2014;29(6):836-843.
2. Burling S. Yogurt a solution to hospital infection? Philadelphia Inquirer website. December 10, 2013. Available at: http://articles.philly.com/2013-12-10/news/44946926_1_holy-redeemer-probiotics-yogurt. Accessed June 5, 2014.
3. Landelle C, Verachten M, Legrand P, Girou E, Barbut F, Buisson CB. Contamination of healthcare workers’ hands with Clostridium difficile spores after caring for patients with C. difficile infection. Infect Control Hosp Epidemiol. 2014;35(1):10-15.
4. Lewis K, Walker C. Development and application of information technology solutions to improve the quality and availability of discharge summaries. Journal of Hospital Medicine RIV abstracts website. Available at: http://www.shmabstracts.com/abstract.asp?MeetingID=793&id=104276&meeting=JHM201305. Published May 2013. Accessed June 14, 2014.
5. Snow V, Beck D, Budnitz T, et al. Transitions of Care Consensus Policy Statement. American College of Physicians; Society of General Internal Medicine; Society of Hospital Medicine; American Geriatrics Society; American College of Emergency Physicians; Society of Academic Emergency Medicine. J Gen Intern Med. 2009;24(8):971-976.
6. American Hospital Association: Uncompensated hospital care cost fact sheet. January 2014. Available at: http://www.aha.org/content/14/14uncompensatedcare.pdf. Accessed June 5, 2014.

An RIV poster presented at SHM’s annual meeting describes the application of health information technology to improve the quality of hospital discharge summaries.⁴ Lead author Kristen Lewis, MD, in the clinical division of hospital medicine at The Ohio State University (OSU) Wexner Medical Center in Columbus, described how SHM’s 2009 “Transitions of Care Consensus Policy Statement” was adopted as the medical center’s standard of care—although at baseline this standard was being fully met at the hospital only 4% of the time^.5 Discharge summaries frequently lacked important information, including tests pending at discharge, and were not made available to those clinicians who needed them following discharge.

“We developed, piloted, and implemented an innovative electronic discharge summary template that incorporated prompts and automatically populated core components of a quality discharge summary,” Dr. Lewis says, adding that the process also offered opportunities for customization and free-text entries. Initial experience following a series of multidisciplinary educational initiatives to help physicians and case managers understand these mechanisms found full compliance rising to 75%.

Next steps for the project include improving the availability of discharge data for primary care providers, specialist physicians, and extended care facilities not affiliated with OSU; inclusion of the discharge summary in the “After Visit Summary” given to patients; and assessment of outpatient providers’ satisfaction with the process.

For more information about the electronic discharge template, contact Dr. Lewis at kristen.lewis@osumc.edu.

Larry Beresford is a freelance writer in Alameda, Calif.

References

1. Bailey FA, Williams BR, Woodby LL, et al. Intervention to improve care at life's end in inpatient settings: The BEACON trial. J Gen Intern Med. 2014;29(6):836-843.
2. Burling S. Yogurt a solution to hospital infection? Philadelphia Inquirer website. December 10, 2013. Available at: http://articles.philly.com/2013-12-10/news/44946926_1_holy-redeemer-probiotics-yogurt. Accessed June 5, 2014.
3. Landelle C, Verachten M, Legrand P, Girou E, Barbut F, Buisson CB. Contamination of healthcare workers’ hands with Clostridium difficile spores after caring for patients with C. difficile infection. Infect Control Hosp Epidemiol. 2014;35(1):10-15.
4. Lewis K, Walker C. Development and application of information technology solutions to improve the quality and availability of discharge summaries. Journal of Hospital Medicine RIV abstracts website. Available at: http://www.shmabstracts.com/abstract.asp?MeetingID=793&id=104276&meeting=JHM201305. Published May 2013. Accessed June 14, 2014.
5. Snow V, Beck D, Budnitz T, et al. Transitions of Care Consensus Policy Statement. American College of Physicians; Society of General Internal Medicine; Society of Hospital Medicine; American Geriatrics Society; American College of Emergency Physicians; Society of Academic Emergency Medicine. J Gen Intern Med. 2009;24(8):971-976.
6. American Hospital Association: Uncompensated hospital care cost fact sheet. January 2014. Available at: http://www.aha.org/content/14/14uncompensatedcare.pdf. Accessed June 5, 2014.

An RIV poster presented at SHM’s annual meeting describes the application of health information technology to improve the quality of hospital discharge summaries.⁴ Lead author Kristen Lewis, MD, in the clinical division of hospital medicine at The Ohio State University (OSU) Wexner Medical Center in Columbus, described how SHM’s 2009 “Transitions of Care Consensus Policy Statement” was adopted as the medical center’s standard of care—although at baseline this standard was being fully met at the hospital only 4% of the time^.5 Discharge summaries frequently lacked important information, including tests pending at discharge, and were not made available to those clinicians who needed them following discharge.

“We developed, piloted, and implemented an innovative electronic discharge summary template that incorporated prompts and automatically populated core components of a quality discharge summary,” Dr. Lewis says, adding that the process also offered opportunities for customization and free-text entries. Initial experience following a series of multidisciplinary educational initiatives to help physicians and case managers understand these mechanisms found full compliance rising to 75%.

Next steps for the project include improving the availability of discharge data for primary care providers, specialist physicians, and extended care facilities not affiliated with OSU; inclusion of the discharge summary in the “After Visit Summary” given to patients; and assessment of outpatient providers’ satisfaction with the process.

For more information about the electronic discharge template, contact Dr. Lewis at kristen.lewis@osumc.edu.

Larry Beresford is a freelance writer in Alameda, Calif.

References

1. Bailey FA, Williams BR, Woodby LL, et al. Intervention to improve care at life's end in inpatient settings: The BEACON trial. J Gen Intern Med. 2014;29(6):836-843.
2. Burling S. Yogurt a solution to hospital infection? Philadelphia Inquirer website. December 10, 2013. Available at: http://articles.philly.com/2013-12-10/news/44946926_1_holy-redeemer-probiotics-yogurt. Accessed June 5, 2014.
3. Landelle C, Verachten M, Legrand P, Girou E, Barbut F, Buisson CB. Contamination of healthcare workers’ hands with Clostridium difficile spores after caring for patients with C. difficile infection. Infect Control Hosp Epidemiol. 2014;35(1):10-15.
4. Lewis K, Walker C. Development and application of information technology solutions to improve the quality and availability of discharge summaries. Journal of Hospital Medicine RIV abstracts website. Available at: http://www.shmabstracts.com/abstract.asp?MeetingID=793&id=104276&meeting=JHM201305. Published May 2013. Accessed June 14, 2014.
5. Snow V, Beck D, Budnitz T, et al. Transitions of Care Consensus Policy Statement. American College of Physicians; Society of General Internal Medicine; Society of Hospital Medicine; American Geriatrics Society; American College of Emergency Physicians; Society of Academic Emergency Medicine. J Gen Intern Med. 2009;24(8):971-976.
6. American Hospital Association: Uncompensated hospital care cost fact sheet. January 2014. Available at: http://www.aha.org/content/14/14uncompensatedcare.pdf. Accessed June 5, 2014.

The Philadelphia Inquirer recently reported that Holy Redeemer Hospital in Meadowbrook, Pa., cut its incidence of Clostridium difficile by two-thirds after its nutritionists began encouraging hospitalized patients with orders for antibiotics for more than one day to eat a widely available brand of yogurt.² Seventy-five C. diff cases were reported in the hospital during 2011 and only 23 in 2012. The facility won an innovation award for the program from the Hospital and Healthsystem Association of Pennsylvania.

Other hospitals dispense probiotic dietary supplements, shown to have benefits against C. diff, in granular form. Medical experts have expressed skepticism that dispensing yogurt made the difference in cutting C. diff infections, arguing that there has not been enough research yet to support its widespread implementation in hospital settings.

Nationally, 337,000 cases of C. diff are reported in hospitals each year. A recent study reports that its spores are still commonly carried on the hands of healthcare workers who rubbed alcohol on their hands shortly after providing routine care to patients.³ Risk factors independently associated with hand contamination among healthcare workers in the exposed group included high-risk contacts and at least one contact without the use of gloves.

Larry Beresford is a freelance writer in Alameda, Calif.

References

1. Bailey FA, Williams BR, Woodby LL, et al. Intervention to improve care at life's end in inpatient settings: The BEACON trial. J Gen Intern Med. 2014;29(6):836-843.
2. Burling S. Yogurt a solution to hospital infection? Philadelphia Inquirer website. December 10, 2013. Available at: http://articles.philly.com/2013-12-10/news/44946926_1_holy-redeemer-probiotics-yogurt. Accessed June 5, 2014.
3. Landelle C, Verachten M, Legrand P, Girou E, Barbut F, Buisson CB. Contamination of healthcare workers’ hands with Clostridium difficile spores after caring for patients with C. difficile infection. Infect Control Hosp Epidemiol. 2014;35(1):10-15.
4. Lewis K, Walker C. Development and application of information technology solutions to improve the quality and availability of discharge summaries. Journal of Hospital Medicine RIV abstracts website. Available at: http://www.shmabstracts.com/abstract.asp?MeetingID=793&id=104276&meeting=JHM201305. Published May 2013. Accessed June 14, 2014.
5. Snow V, Beck D, Budnitz T, et al. Transitions of Care Consensus Policy Statement. American College of Physicians; Society of General Internal Medicine; Society of Hospital Medicine; American Geriatrics Society; American College of Emergency Physicians; Society of Academic Emergency Medicine. J Gen Intern Med. 2009;24(8):971-976.
6. American Hospital Association: Uncompensated hospital care cost fact sheet. January 2014. Available at: http://www.aha.org/content/14/14uncompensatedcare.pdf. Accessed June 5, 2014.

The Philadelphia Inquirer recently reported that Holy Redeemer Hospital in Meadowbrook, Pa., cut its incidence of Clostridium difficile by two-thirds after its nutritionists began encouraging hospitalized patients with orders for antibiotics for more than one day to eat a widely available brand of yogurt.² Seventy-five C. diff cases were reported in the hospital during 2011 and only 23 in 2012. The facility won an innovation award for the program from the Hospital and Healthsystem Association of Pennsylvania.

Other hospitals dispense probiotic dietary supplements, shown to have benefits against C. diff, in granular form. Medical experts have expressed skepticism that dispensing yogurt made the difference in cutting C. diff infections, arguing that there has not been enough research yet to support its widespread implementation in hospital settings.

Nationally, 337,000 cases of C. diff are reported in hospitals each year. A recent study reports that its spores are still commonly carried on the hands of healthcare workers who rubbed alcohol on their hands shortly after providing routine care to patients.³ Risk factors independently associated with hand contamination among healthcare workers in the exposed group included high-risk contacts and at least one contact without the use of gloves.

Larry Beresford is a freelance writer in Alameda, Calif.

References

1. Bailey FA, Williams BR, Woodby LL, et al. Intervention to improve care at life's end in inpatient settings: The BEACON trial. J Gen Intern Med. 2014;29(6):836-843.
2. Burling S. Yogurt a solution to hospital infection? Philadelphia Inquirer website. December 10, 2013. Available at: http://articles.philly.com/2013-12-10/news/44946926_1_holy-redeemer-probiotics-yogurt. Accessed June 5, 2014.
3. Landelle C, Verachten M, Legrand P, Girou E, Barbut F, Buisson CB. Contamination of healthcare workers’ hands with Clostridium difficile spores after caring for patients with C. difficile infection. Infect Control Hosp Epidemiol. 2014;35(1):10-15.
4. Lewis K, Walker C. Development and application of information technology solutions to improve the quality and availability of discharge summaries. Journal of Hospital Medicine RIV abstracts website. Available at: http://www.shmabstracts.com/abstract.asp?MeetingID=793&id=104276&meeting=JHM201305. Published May 2013. Accessed June 14, 2014.
5. Snow V, Beck D, Budnitz T, et al. Transitions of Care Consensus Policy Statement. American College of Physicians; Society of General Internal Medicine; Society of Hospital Medicine; American Geriatrics Society; American College of Emergency Physicians; Society of Academic Emergency Medicine. J Gen Intern Med. 2009;24(8):971-976.
6. American Hospital Association: Uncompensated hospital care cost fact sheet. January 2014. Available at: http://www.aha.org/content/14/14uncompensatedcare.pdf. Accessed June 5, 2014.

The Philadelphia Inquirer recently reported that Holy Redeemer Hospital in Meadowbrook, Pa., cut its incidence of Clostridium difficile by two-thirds after its nutritionists began encouraging hospitalized patients with orders for antibiotics for more than one day to eat a widely available brand of yogurt.² Seventy-five C. diff cases were reported in the hospital during 2011 and only 23 in 2012. The facility won an innovation award for the program from the Hospital and Healthsystem Association of Pennsylvania.

Other hospitals dispense probiotic dietary supplements, shown to have benefits against C. diff, in granular form. Medical experts have expressed skepticism that dispensing yogurt made the difference in cutting C. diff infections, arguing that there has not been enough research yet to support its widespread implementation in hospital settings.

Nationally, 337,000 cases of C. diff are reported in hospitals each year. A recent study reports that its spores are still commonly carried on the hands of healthcare workers who rubbed alcohol on their hands shortly after providing routine care to patients.³ Risk factors independently associated with hand contamination among healthcare workers in the exposed group included high-risk contacts and at least one contact without the use of gloves.

Larry Beresford is a freelance writer in Alameda, Calif.

References

1. Bailey FA, Williams BR, Woodby LL, et al. Intervention to improve care at life's end in inpatient settings: The BEACON trial. J Gen Intern Med. 2014;29(6):836-843.
2. Burling S. Yogurt a solution to hospital infection? Philadelphia Inquirer website. December 10, 2013. Available at: http://articles.philly.com/2013-12-10/news/44946926_1_holy-redeemer-probiotics-yogurt. Accessed June 5, 2014.
3. Landelle C, Verachten M, Legrand P, Girou E, Barbut F, Buisson CB. Contamination of healthcare workers’ hands with Clostridium difficile spores after caring for patients with C. difficile infection. Infect Control Hosp Epidemiol. 2014;35(1):10-15.
4. Lewis K, Walker C. Development and application of information technology solutions to improve the quality and availability of discharge summaries. Journal of Hospital Medicine RIV abstracts website. Available at: http://www.shmabstracts.com/abstract.asp?MeetingID=793&id=104276&meeting=JHM201305. Published May 2013. Accessed June 14, 2014.
5. Snow V, Beck D, Budnitz T, et al. Transitions of Care Consensus Policy Statement. American College of Physicians; Society of General Internal Medicine; Society of Hospital Medicine; American Geriatrics Society; American College of Emergency Physicians; Society of Academic Emergency Medicine. J Gen Intern Med. 2009;24(8):971-976.
6. American Hospital Association: Uncompensated hospital care cost fact sheet. January 2014. Available at: http://www.aha.org/content/14/14uncompensatedcare.pdf. Accessed June 5, 2014.

New research from the Birmingham, Ala., Veterans Affairs Medical Center and the University of Alabama-Birmingham, published in the Journal of General Internal Medicine, finds that clinical techniques and care processes imported from home-based hospice professionals improved outcomes for hospitalized patients approaching the end of their lives.¹

The project, conducted in six VA medical centers, employed a multi-modal strategy for improving end-of-life care processes, with staff training for all hospital providers in how to identify actively dying patients and then communicate this information to their families. Best clinical practices, supported by electronic order sets and paper-based educational materials, were implemented. Patients also were encouraged to eat what—and when—they wanted, to sit up in bed, and to receive family visitors at all hours.

“I started the project years ago, when I noticed that patients on hospice care at home often seemed more comfortable, while if I brought them into the hospital, they sometimes got worse,” says lead author F. Amos Bailey, MD. “We went out to the home to observe what the hospice nurses were doing and then came back to the hospital to write order sets to reflect that practice.”

Key quality endpoints included:

• Rates of orders for opioid pain medications;
• Anti-psychotic medications and scopolamine for death rattle;
• Completion of advance directives; and
• Consultations for palliative care and pastoral care.

Patients were more likely to have their pain relieved and symptoms addressed, according to chart reviews of 6,066 patients who died before or after the intervention was launched.

“All of the processes we measured moved in the direction of increased comfort,” Dr. Bailey says.

This is the first study to show that palliative care techniques developed in the home setting can have an impact on end-of-life care. That’s important, he adds, because most patients die in hospitals or nursing homes.

Larry Beresford is a freelance writer in Alameda, Calif.

References

1. Bailey FA, Williams BR, Woodby LL, et al. Intervention to improve care at life's end in inpatient settings: The BEACON trial. J Gen Intern Med. 2014;29(6):836-843.
2. Burling S. Yogurt a solution to hospital infection? Philadelphia Inquirer website. December 10, 2013. Available at: http://articles.philly.com/2013-12-10/news/44946926_1_holy-redeemer-probiotics-yogurt. Accessed June 5, 2014.
3. Landelle C, Verachten M, Legrand P, Girou E, Barbut F, Buisson CB. Contamination of healthcare workers’ hands with Clostridium difficile spores after caring for patients with C. difficile infection. Infect Control Hosp Epidemiol. 2014;35(1):10-15.
4. Lewis K, Walker C. Development and application of information technology solutions to improve the quality and availability of discharge summaries. Journal of Hospital Medicine RIV abstracts website. Available at: http://www.shmabstracts.com/abstract.asp?MeetingID=793&id=104276&meeting=JHM201305. Published May 2013. Accessed June 14, 2014.
5. Snow V, Beck D, Budnitz T, et al. Transitions of Care Consensus Policy Statement. American College of Physicians; Society of General Internal Medicine; Society of Hospital Medicine; American Geriatrics Society; American College of Emergency Physicians; Society of Academic Emergency Medicine. J Gen Intern Med. 2009;24(8):971-976.
6. American Hospital Association: Uncompensated hospital care cost fact sheet. January 2014. Available at: http://www.aha.org/content/14/14uncompensatedcare.pdf. Accessed June 5, 2014.

New research from the Birmingham, Ala., Veterans Affairs Medical Center and the University of Alabama-Birmingham, published in the Journal of General Internal Medicine, finds that clinical techniques and care processes imported from home-based hospice professionals improved outcomes for hospitalized patients approaching the end of their lives.¹

The project, conducted in six VA medical centers, employed a multi-modal strategy for improving end-of-life care processes, with staff training for all hospital providers in how to identify actively dying patients and then communicate this information to their families. Best clinical practices, supported by electronic order sets and paper-based educational materials, were implemented. Patients also were encouraged to eat what—and when—they wanted, to sit up in bed, and to receive family visitors at all hours.

“I started the project years ago, when I noticed that patients on hospice care at home often seemed more comfortable, while if I brought them into the hospital, they sometimes got worse,” says lead author F. Amos Bailey, MD. “We went out to the home to observe what the hospice nurses were doing and then came back to the hospital to write order sets to reflect that practice.”

Key quality endpoints included:

• Rates of orders for opioid pain medications;
• Anti-psychotic medications and scopolamine for death rattle;
• Completion of advance directives; and
• Consultations for palliative care and pastoral care.

Patients were more likely to have their pain relieved and symptoms addressed, according to chart reviews of 6,066 patients who died before or after the intervention was launched.

“All of the processes we measured moved in the direction of increased comfort,” Dr. Bailey says.

This is the first study to show that palliative care techniques developed in the home setting can have an impact on end-of-life care. That’s important, he adds, because most patients die in hospitals or nursing homes.

Larry Beresford is a freelance writer in Alameda, Calif.

References

1. Bailey FA, Williams BR, Woodby LL, et al. Intervention to improve care at life's end in inpatient settings: The BEACON trial. J Gen Intern Med. 2014;29(6):836-843.
2. Burling S. Yogurt a solution to hospital infection? Philadelphia Inquirer website. December 10, 2013. Available at: http://articles.philly.com/2013-12-10/news/44946926_1_holy-redeemer-probiotics-yogurt. Accessed June 5, 2014.
3. Landelle C, Verachten M, Legrand P, Girou E, Barbut F, Buisson CB. Contamination of healthcare workers’ hands with Clostridium difficile spores after caring for patients with C. difficile infection. Infect Control Hosp Epidemiol. 2014;35(1):10-15.
4. Lewis K, Walker C. Development and application of information technology solutions to improve the quality and availability of discharge summaries. Journal of Hospital Medicine RIV abstracts website. Available at: http://www.shmabstracts.com/abstract.asp?MeetingID=793&id=104276&meeting=JHM201305. Published May 2013. Accessed June 14, 2014.
5. Snow V, Beck D, Budnitz T, et al. Transitions of Care Consensus Policy Statement. American College of Physicians; Society of General Internal Medicine; Society of Hospital Medicine; American Geriatrics Society; American College of Emergency Physicians; Society of Academic Emergency Medicine. J Gen Intern Med. 2009;24(8):971-976.
6. American Hospital Association: Uncompensated hospital care cost fact sheet. January 2014. Available at: http://www.aha.org/content/14/14uncompensatedcare.pdf. Accessed June 5, 2014.

New research from the Birmingham, Ala., Veterans Affairs Medical Center and the University of Alabama-Birmingham, published in the Journal of General Internal Medicine, finds that clinical techniques and care processes imported from home-based hospice professionals improved outcomes for hospitalized patients approaching the end of their lives.¹

The project, conducted in six VA medical centers, employed a multi-modal strategy for improving end-of-life care processes, with staff training for all hospital providers in how to identify actively dying patients and then communicate this information to their families. Best clinical practices, supported by electronic order sets and paper-based educational materials, were implemented. Patients also were encouraged to eat what—and when—they wanted, to sit up in bed, and to receive family visitors at all hours.

“I started the project years ago, when I noticed that patients on hospice care at home often seemed more comfortable, while if I brought them into the hospital, they sometimes got worse,” says lead author F. Amos Bailey, MD. “We went out to the home to observe what the hospice nurses were doing and then came back to the hospital to write order sets to reflect that practice.”

Key quality endpoints included:

• Rates of orders for opioid pain medications;
• Anti-psychotic medications and scopolamine for death rattle;
• Completion of advance directives; and
• Consultations for palliative care and pastoral care.

Patients were more likely to have their pain relieved and symptoms addressed, according to chart reviews of 6,066 patients who died before or after the intervention was launched.

“All of the processes we measured moved in the direction of increased comfort,” Dr. Bailey says.

This is the first study to show that palliative care techniques developed in the home setting can have an impact on end-of-life care. That’s important, he adds, because most patients die in hospitals or nursing homes.

Larry Beresford is a freelance writer in Alameda, Calif.

References

1. Bailey FA, Williams BR, Woodby LL, et al. Intervention to improve care at life's end in inpatient settings: The BEACON trial. J Gen Intern Med. 2014;29(6):836-843.
2. Burling S. Yogurt a solution to hospital infection? Philadelphia Inquirer website. December 10, 2013. Available at: http://articles.philly.com/2013-12-10/news/44946926_1_holy-redeemer-probiotics-yogurt. Accessed June 5, 2014.
3. Landelle C, Verachten M, Legrand P, Girou E, Barbut F, Buisson CB. Contamination of healthcare workers’ hands with Clostridium difficile spores after caring for patients with C. difficile infection. Infect Control Hosp Epidemiol. 2014;35(1):10-15.
4. Lewis K, Walker C. Development and application of information technology solutions to improve the quality and availability of discharge summaries. Journal of Hospital Medicine RIV abstracts website. Available at: http://www.shmabstracts.com/abstract.asp?MeetingID=793&id=104276&meeting=JHM201305. Published May 2013. Accessed June 14, 2014.
5. Snow V, Beck D, Budnitz T, et al. Transitions of Care Consensus Policy Statement. American College of Physicians; Society of General Internal Medicine; Society of Hospital Medicine; American Geriatrics Society; American College of Emergency Physicians; Society of Academic Emergency Medicine. J Gen Intern Med. 2009;24(8):971-976.
6. American Hospital Association: Uncompensated hospital care cost fact sheet. January 2014. Available at: http://www.aha.org/content/14/14uncompensatedcare.pdf. Accessed June 5, 2014.

When she presents information to hospitalists about the little-known revision to Medicare’s condition of participation for discharge planning by hospitals, most hospitalists have no idea what Amy Boutwell, MD, MPP, is talking about. Even hospitalists who are active in their institutions’ efforts to improve transitions of care out of the hospital setting are unaware of the change, which was published in the Centers for Medicare & Medicaid Services’ Transmittal 87 and became effective July 19, 2013.

“I just don’t hear hospital professionals talking about it,” says Dr. Boutwell, a hospitalist at Newton-Wellesley Hospital and president of Collaborative Healthcare Strategies in Lexington, Mass. “When I say, ‘There are new rules of the road for discharge planning and evaluation,’ many are not aware of it.”

The revised condition states that the hospital must have a discharge planning process that applies to all patients—not just Medicare beneficiaries. Not every patient needs to have a written discharge plan—although this is recommended—but all patients should be screened and, if indicated, evaluated at an early stage of their hospitalization for risk of adverse post-discharge outcomes. Observation patients are not included in this requirement.

The discharge plan is different from a discharge summary document, which must be completed by the inpatient attending physician, not the hospital, and is not directly addressed in the regulation. The regulation does address the need for transfer of essential information to the next provider of care and says the hospital should have a written policy and procedure in place for discharge planning. The policy and procedure should be developed with input from medical staff and approved by the hospital’s governing body.

Any hospitalist participating with a hospital QI team involved in Project BOOST is helping their hospital comply with this condition of participation.

—Mark Williams, MD, FACP, SFHM, principal investigator of SHM’s Project BOOST

Transmittal 87 represents the first major update of the discharge planning regulation (Standard 482.43) and accompanying interpretive guidelines in more than a decade, Dr. Boutwell says. It consolidates and reorganizes 24 “tags” of regulatory language down to 13 and contains blue advisory boxes recommending best practices in discharge planning, drawn from the suggestions of a technical expert panel convened by CMS.

That panel included many of the country’s recognized thought leaders on improving care transitions, such as Mark Williams, MD, FACP, SFHM, principal investigator of SHM’s Project BOOST; Eric Coleman, MD, MPH, head of the University of Colorado’s division of health care policy and research and creator of the widely-adopted Care Transitions Program (caretransitions.org), and Dr. Boutwell, co-founder of the STAAR initiative (www.ihi.org/engage/Initiatives/completed/STAAR).

The new condition raises baseline expectations for discharge planning and elevates care transitions efforts from a quality improvement issue to the realm of regulatory compliance, Dr. Boutwell says.

“This goes way beyond case review,” she adds. “It represents an evolution from discharge planning case by case to a system for improving transitions of care [for the hospital]. I’m impressed.”

The recommendations are consistent with best practices promoted by Project BOOST, STAAR, Project RED [Re-Engineered Discharge], and other national quality initiatives for improving care transitions.

“Any hospitalist participating with a hospital QI team involved in Project BOOST is helping their hospital comply with this condition of participation,” Dr. Williams says.

In the Byzantine structure of federal regulations, Medicare’s conditions of participation are the regulations providers must meet in order to participate in the Medicare program and bill for their services. Condition-level citations, if not resolved, can cause hospitals to be decertified from Medicare. The accompanying interpretive guidelines, with survey protocols, are the playbook to help state auditors and providers know how to interpret and apply the language of the regulations. The suggestions and examples of best practices contained in the new condition are not required of hospitals but, if followed, could increase their likelihood of achieving better patient outcomes and staying in compliance with the regulations on surveys.

“If hospitals were to actually implement all of the CMS advisory practice recommendations contained in this 35-page document, they’d be in really good shape for effectively managing transitions of care,” says Teresa L. Hamblin, RN, MS, a CMS consultant with Joint Commission Resources. “The government has provided robust practice recommendations that are a model for what hospitals can do. I’d advise doing your best to implement these recommendations. Check your current processes using this detailed document for reference.”

Discharge planning starts at admission, Hamblin says. If the hospitalist assumes that responsibility, it becomes easier to leave a paper trail in the patient’s chart. Other important lessons for hospitalists include participation in a multidisciplinary approach to discharge planning (i.e., interdisciplinary rounding) and development of policies and procedures in this area.

“If the hospital has not elected to do a discharge plan on every patient, request this for your own patients and recommend it as a policy,” Hamblin says. “Go the extra mile, making follow-up appointments for your patients, filling prescriptions in house, and calling the patient 24 to 72 hours after discharge.”

Weekend coverage, when case managers typically are not present, is a particular challenge in care transitions.

“Encourage your hospital to provide reliable weekend coverage for discharge planning. Involve the nurses,” Hamblin says. “Anything the hospitalist can do to help the hospital close this gap is important.”

Larry Beresford is a freelance writer in Alameda, Calif.

When she presents information to hospitalists about the little-known revision to Medicare’s condition of participation for discharge planning by hospitals, most hospitalists have no idea what Amy Boutwell, MD, MPP, is talking about. Even hospitalists who are active in their institutions’ efforts to improve transitions of care out of the hospital setting are unaware of the change, which was published in the Centers for Medicare & Medicaid Services’ Transmittal 87 and became effective July 19, 2013.

“I just don’t hear hospital professionals talking about it,” says Dr. Boutwell, a hospitalist at Newton-Wellesley Hospital and president of Collaborative Healthcare Strategies in Lexington, Mass. “When I say, ‘There are new rules of the road for discharge planning and evaluation,’ many are not aware of it.”

The revised condition states that the hospital must have a discharge planning process that applies to all patients—not just Medicare beneficiaries. Not every patient needs to have a written discharge plan—although this is recommended—but all patients should be screened and, if indicated, evaluated at an early stage of their hospitalization for risk of adverse post-discharge outcomes. Observation patients are not included in this requirement.

The discharge plan is different from a discharge summary document, which must be completed by the inpatient attending physician, not the hospital, and is not directly addressed in the regulation. The regulation does address the need for transfer of essential information to the next provider of care and says the hospital should have a written policy and procedure in place for discharge planning. The policy and procedure should be developed with input from medical staff and approved by the hospital’s governing body.

Any hospitalist participating with a hospital QI team involved in Project BOOST is helping their hospital comply with this condition of participation.

—Mark Williams, MD, FACP, SFHM, principal investigator of SHM’s Project BOOST

Transmittal 87 represents the first major update of the discharge planning regulation (Standard 482.43) and accompanying interpretive guidelines in more than a decade, Dr. Boutwell says. It consolidates and reorganizes 24 “tags” of regulatory language down to 13 and contains blue advisory boxes recommending best practices in discharge planning, drawn from the suggestions of a technical expert panel convened by CMS.

That panel included many of the country’s recognized thought leaders on improving care transitions, such as Mark Williams, MD, FACP, SFHM, principal investigator of SHM’s Project BOOST; Eric Coleman, MD, MPH, head of the University of Colorado’s division of health care policy and research and creator of the widely-adopted Care Transitions Program (caretransitions.org), and Dr. Boutwell, co-founder of the STAAR initiative (www.ihi.org/engage/Initiatives/completed/STAAR).

The new condition raises baseline expectations for discharge planning and elevates care transitions efforts from a quality improvement issue to the realm of regulatory compliance, Dr. Boutwell says.

“This goes way beyond case review,” she adds. “It represents an evolution from discharge planning case by case to a system for improving transitions of care [for the hospital]. I’m impressed.”

The recommendations are consistent with best practices promoted by Project BOOST, STAAR, Project RED [Re-Engineered Discharge], and other national quality initiatives for improving care transitions.

“Any hospitalist participating with a hospital QI team involved in Project BOOST is helping their hospital comply with this condition of participation,” Dr. Williams says.

In the Byzantine structure of federal regulations, Medicare’s conditions of participation are the regulations providers must meet in order to participate in the Medicare program and bill for their services. Condition-level citations, if not resolved, can cause hospitals to be decertified from Medicare. The accompanying interpretive guidelines, with survey protocols, are the playbook to help state auditors and providers know how to interpret and apply the language of the regulations. The suggestions and examples of best practices contained in the new condition are not required of hospitals but, if followed, could increase their likelihood of achieving better patient outcomes and staying in compliance with the regulations on surveys.

“If hospitals were to actually implement all of the CMS advisory practice recommendations contained in this 35-page document, they’d be in really good shape for effectively managing transitions of care,” says Teresa L. Hamblin, RN, MS, a CMS consultant with Joint Commission Resources. “The government has provided robust practice recommendations that are a model for what hospitals can do. I’d advise doing your best to implement these recommendations. Check your current processes using this detailed document for reference.”

Discharge planning starts at admission, Hamblin says. If the hospitalist assumes that responsibility, it becomes easier to leave a paper trail in the patient’s chart. Other important lessons for hospitalists include participation in a multidisciplinary approach to discharge planning (i.e., interdisciplinary rounding) and development of policies and procedures in this area.

“If the hospital has not elected to do a discharge plan on every patient, request this for your own patients and recommend it as a policy,” Hamblin says. “Go the extra mile, making follow-up appointments for your patients, filling prescriptions in house, and calling the patient 24 to 72 hours after discharge.”

Weekend coverage, when case managers typically are not present, is a particular challenge in care transitions.

“Encourage your hospital to provide reliable weekend coverage for discharge planning. Involve the nurses,” Hamblin says. “Anything the hospitalist can do to help the hospital close this gap is important.”

Larry Beresford is a freelance writer in Alameda, Calif.

When she presents information to hospitalists about the little-known revision to Medicare’s condition of participation for discharge planning by hospitals, most hospitalists have no idea what Amy Boutwell, MD, MPP, is talking about. Even hospitalists who are active in their institutions’ efforts to improve transitions of care out of the hospital setting are unaware of the change, which was published in the Centers for Medicare & Medicaid Services’ Transmittal 87 and became effective July 19, 2013.

“I just don’t hear hospital professionals talking about it,” says Dr. Boutwell, a hospitalist at Newton-Wellesley Hospital and president of Collaborative Healthcare Strategies in Lexington, Mass. “When I say, ‘There are new rules of the road for discharge planning and evaluation,’ many are not aware of it.”

The revised condition states that the hospital must have a discharge planning process that applies to all patients—not just Medicare beneficiaries. Not every patient needs to have a written discharge plan—although this is recommended—but all patients should be screened and, if indicated, evaluated at an early stage of their hospitalization for risk of adverse post-discharge outcomes. Observation patients are not included in this requirement.

The discharge plan is different from a discharge summary document, which must be completed by the inpatient attending physician, not the hospital, and is not directly addressed in the regulation. The regulation does address the need for transfer of essential information to the next provider of care and says the hospital should have a written policy and procedure in place for discharge planning. The policy and procedure should be developed with input from medical staff and approved by the hospital’s governing body.

Any hospitalist participating with a hospital QI team involved in Project BOOST is helping their hospital comply with this condition of participation.

—Mark Williams, MD, FACP, SFHM, principal investigator of SHM’s Project BOOST

Transmittal 87 represents the first major update of the discharge planning regulation (Standard 482.43) and accompanying interpretive guidelines in more than a decade, Dr. Boutwell says. It consolidates and reorganizes 24 “tags” of regulatory language down to 13 and contains blue advisory boxes recommending best practices in discharge planning, drawn from the suggestions of a technical expert panel convened by CMS.

That panel included many of the country’s recognized thought leaders on improving care transitions, such as Mark Williams, MD, FACP, SFHM, principal investigator of SHM’s Project BOOST; Eric Coleman, MD, MPH, head of the University of Colorado’s division of health care policy and research and creator of the widely-adopted Care Transitions Program (caretransitions.org), and Dr. Boutwell, co-founder of the STAAR initiative (www.ihi.org/engage/Initiatives/completed/STAAR).

The new condition raises baseline expectations for discharge planning and elevates care transitions efforts from a quality improvement issue to the realm of regulatory compliance, Dr. Boutwell says.

“This goes way beyond case review,” she adds. “It represents an evolution from discharge planning case by case to a system for improving transitions of care [for the hospital]. I’m impressed.”

The recommendations are consistent with best practices promoted by Project BOOST, STAAR, Project RED [Re-Engineered Discharge], and other national quality initiatives for improving care transitions.

“Any hospitalist participating with a hospital QI team involved in Project BOOST is helping their hospital comply with this condition of participation,” Dr. Williams says.

In the Byzantine structure of federal regulations, Medicare’s conditions of participation are the regulations providers must meet in order to participate in the Medicare program and bill for their services. Condition-level citations, if not resolved, can cause hospitals to be decertified from Medicare. The accompanying interpretive guidelines, with survey protocols, are the playbook to help state auditors and providers know how to interpret and apply the language of the regulations. The suggestions and examples of best practices contained in the new condition are not required of hospitals but, if followed, could increase their likelihood of achieving better patient outcomes and staying in compliance with the regulations on surveys.

“If hospitals were to actually implement all of the CMS advisory practice recommendations contained in this 35-page document, they’d be in really good shape for effectively managing transitions of care,” says Teresa L. Hamblin, RN, MS, a CMS consultant with Joint Commission Resources. “The government has provided robust practice recommendations that are a model for what hospitals can do. I’d advise doing your best to implement these recommendations. Check your current processes using this detailed document for reference.”

Discharge planning starts at admission, Hamblin says. If the hospitalist assumes that responsibility, it becomes easier to leave a paper trail in the patient’s chart. Other important lessons for hospitalists include participation in a multidisciplinary approach to discharge planning (i.e., interdisciplinary rounding) and development of policies and procedures in this area.

“If the hospital has not elected to do a discharge plan on every patient, request this for your own patients and recommend it as a policy,” Hamblin says. “Go the extra mile, making follow-up appointments for your patients, filling prescriptions in house, and calling the patient 24 to 72 hours after discharge.”

Weekend coverage, when case managers typically are not present, is a particular challenge in care transitions.

“Encourage your hospital to provide reliable weekend coverage for discharge planning. Involve the nurses,” Hamblin says. “Anything the hospitalist can do to help the hospital close this gap is important.”

Larry Beresford is a freelance writer in Alameda, Calif.

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

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

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

Larry Beresford is a freelance writer in Alameda, Calif.

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

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

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

Larry Beresford is a freelance writer in Alameda, Calif.

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

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

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

Larry Beresford is a freelance writer in Alameda, Calif.

A recent article in the Journal of Internal Medicine draws a strong link between readmission rates and the degree to which patients are activated—possessing the knowledge, skills, and confidence to manage their own health post-discharge.² Co-author Judith Hibbard, DrPh, professor of health policy at the University of Oregon, is the lead inventor of the Patient Activation Measure (PAM), an eight-item tool that assigns patients to one of four levels of activation.

In a sample of 700 patients discharged from Boston Medical Center, those with the lowest levels of activation had 1.75 times the risk of 30-day readmissions, more ED visits, and greater utilization of health services, even after adjusting for severity of illness and demographics.

“Contrary to what some may assume, patients who demonstrate a lower level of activation do not fall into any specific racial, economic, or educational demographic,” Dr. Hibbard says, adding that providers should not expect to be able to reliably judge their patients’ ability to self-manage outside of the hospital. “We know that people who measure low tend to have little confidence in their ability to manage their own health. They feel overwhelmed, show poor problem-solving skills, don’t understand what professionals are telling them, and, as a result, may not pay close attention.”

Dr. Hibbard says higher activation scores reflect greater focus on personal health and the effort to monitor it—with more confidence.

The take-home message for hospitalists, she says, is to understand the importance of their patients’ activation level and to tailor interventions accordingly.

“Those with low activation may need more support,” such as post-discharge home visits instead of just a phone call. Low-activation patients should not be overwhelmed with information but should instead be given just a few prioritized key points, combined with the use of reinforcing communications techniques such as teach-back.

“Someone should sit with them and help negotiate their health behaviors,” she adds. “That’s how they get more activated. It doesn’t have to be a doctor going through these things. But just using the clinical lens to understand your patients is not enough.”

Larry Beresford is a freelance writer in Alameda, Calif.

A recent article in the Journal of Internal Medicine draws a strong link between readmission rates and the degree to which patients are activated—possessing the knowledge, skills, and confidence to manage their own health post-discharge.² Co-author Judith Hibbard, DrPh, professor of health policy at the University of Oregon, is the lead inventor of the Patient Activation Measure (PAM), an eight-item tool that assigns patients to one of four levels of activation.

In a sample of 700 patients discharged from Boston Medical Center, those with the lowest levels of activation had 1.75 times the risk of 30-day readmissions, more ED visits, and greater utilization of health services, even after adjusting for severity of illness and demographics.

“Contrary to what some may assume, patients who demonstrate a lower level of activation do not fall into any specific racial, economic, or educational demographic,” Dr. Hibbard says, adding that providers should not expect to be able to reliably judge their patients’ ability to self-manage outside of the hospital. “We know that people who measure low tend to have little confidence in their ability to manage their own health. They feel overwhelmed, show poor problem-solving skills, don’t understand what professionals are telling them, and, as a result, may not pay close attention.”

Dr. Hibbard says higher activation scores reflect greater focus on personal health and the effort to monitor it—with more confidence.

The take-home message for hospitalists, she says, is to understand the importance of their patients’ activation level and to tailor interventions accordingly.

“Those with low activation may need more support,” such as post-discharge home visits instead of just a phone call. Low-activation patients should not be overwhelmed with information but should instead be given just a few prioritized key points, combined with the use of reinforcing communications techniques such as teach-back.

“Someone should sit with them and help negotiate their health behaviors,” she adds. “That’s how they get more activated. It doesn’t have to be a doctor going through these things. But just using the clinical lens to understand your patients is not enough.”

Larry Beresford is a freelance writer in Alameda, Calif.

A recent article in the Journal of Internal Medicine draws a strong link between readmission rates and the degree to which patients are activated—possessing the knowledge, skills, and confidence to manage their own health post-discharge.² Co-author Judith Hibbard, DrPh, professor of health policy at the University of Oregon, is the lead inventor of the Patient Activation Measure (PAM), an eight-item tool that assigns patients to one of four levels of activation.

In a sample of 700 patients discharged from Boston Medical Center, those with the lowest levels of activation had 1.75 times the risk of 30-day readmissions, more ED visits, and greater utilization of health services, even after adjusting for severity of illness and demographics.

“Contrary to what some may assume, patients who demonstrate a lower level of activation do not fall into any specific racial, economic, or educational demographic,” Dr. Hibbard says, adding that providers should not expect to be able to reliably judge their patients’ ability to self-manage outside of the hospital. “We know that people who measure low tend to have little confidence in their ability to manage their own health. They feel overwhelmed, show poor problem-solving skills, don’t understand what professionals are telling them, and, as a result, may not pay close attention.”

Dr. Hibbard says higher activation scores reflect greater focus on personal health and the effort to monitor it—with more confidence.

The take-home message for hospitalists, she says, is to understand the importance of their patients’ activation level and to tailor interventions accordingly.

“Those with low activation may need more support,” such as post-discharge home visits instead of just a phone call. Low-activation patients should not be overwhelmed with information but should instead be given just a few prioritized key points, combined with the use of reinforcing communications techniques such as teach-back.

“Someone should sit with them and help negotiate their health behaviors,” she adds. “That’s how they get more activated. It doesn’t have to be a doctor going through these things. But just using the clinical lens to understand your patients is not enough.”

Larry Beresford is a freelance writer in Alameda, Calif.