Larry Beresford

Two RIV posters presented at HM13 from University of California at San Francisco (UCSF) hospitalists analyzed outcomes from post-discharge phone calls to patients and found that those who were reached and interviewed by a call nurse had a 33% lower all-cause readmission rate.

UCSF joined SHM’s Project BOOST quality initiative in 2009 and adopted its recommendation to call patients within 72 hours of their hospital discharge, according to co-author Michelle Mourad, MD, assistant professor of clinical medicine and a UCSF hospitalist. “We reached out to about 60% to 70% of our patients with a standard script to address issues associated with readmissions,” Dr. Mourad explains. “We were also lucky enough to build a computer program with quantifiable outcomes in the database.”¹

Researchers broke the data down into three categories: those called and interviewed by the nurse; those called who didn’t answer the phone or had a wrong number; and those who were never called due to errors in the administrative list of discharged patients. Interpreting the results is complicated, Dr. Mourad says, because of the challenges of separating factors leading to patients answering the survey from those that affect their readmission risk.

“These phone calls weren’t done in isolation and were part of our overall bridging interventions for patients going home from the hospital,” she says. “We designed the intervention to help people, and we found that 43% of those reached had at least one issue identified in the call for which the nurse tried to help.”

However, whether patients reported post-discharge issues and their responses to specific questions within the interview were not associated with readmission rates. “Does that mean the nurses’ calls are not helping? It either means the nurses are effectively managing these issues to prevent readmissions or that the factors affecting readmissions are more complicated than we currently understand,” Dr. Mourad says.

---

Larry Beresford is a freelance writer in San Francisco.

References

1. Harrison J, Quinn K, Mourad M. Is anyone home? The association between being reached for a post-discharge telephone call and 30-day hospital readmission. Harrison J, Quinn K, Mourad M. Any questions? The relationship between responses to post-discharge call questions and 30-day hospital readmissions [abstracts]. Journal of Hospital Medicine, 2013, 8 Suppl 1.
2. Institute of Medicine. Crossing the quality chasm: a new health system for the 21st century. Institute of Medicine website. Available at: http://www.iom.edu/~/media/Files/Report%20Files/2001/Crossing-the-Quality-Chasm/Quality%20Chasm%202001%20%20report%20brief.pdf. Accessed Sept. 9, 2013.
3. Shlaes DM, Sahm D, Opiela C, Spellberg B. Commentary: the FDA reboot of antibiotic development. Antimicrob Agents Chemother. 29 Jul 2013 [Epub ahead of print].
4. Alliance for Aging Research. HAIs growing problem, group says. Alliance for Aging Research website. Available at: http://www.agingresearch.org/content/article/detail/33504. Accessed Sept. 9, 2013.
5. Huang SS, Septimus E, Kleinman K, et al. Targeted versus universal decolonization to prevent ICU infection. N Engl J Med. 2013;368:2255-2265.
6. Hospitals in Pursuit of Excellence. Eliminating catheter-associated urinary tract infections. Hospitals in Pursuit of Excellence website. Available at: http://www.hpoe.org/Reports-HPOE/eliminating_catheter_associated_urinary_tract_infection.pdf. Accessed Sept. 9, 2013.
7. Center to Advance Palliative Care. Growth of palliative care in U.S. hospitals 2013 snapshot. Center to Advance Palliative Care website. Available at: http://www.capc.org/capc-growth-analysis-snapshot-2013.pdf. Accessed Sept. 9, 2013.

Two RIV posters presented at HM13 from University of California at San Francisco (UCSF) hospitalists analyzed outcomes from post-discharge phone calls to patients and found that those who were reached and interviewed by a call nurse had a 33% lower all-cause readmission rate.

UCSF joined SHM’s Project BOOST quality initiative in 2009 and adopted its recommendation to call patients within 72 hours of their hospital discharge, according to co-author Michelle Mourad, MD, assistant professor of clinical medicine and a UCSF hospitalist. “We reached out to about 60% to 70% of our patients with a standard script to address issues associated with readmissions,” Dr. Mourad explains. “We were also lucky enough to build a computer program with quantifiable outcomes in the database.”¹

Researchers broke the data down into three categories: those called and interviewed by the nurse; those called who didn’t answer the phone or had a wrong number; and those who were never called due to errors in the administrative list of discharged patients. Interpreting the results is complicated, Dr. Mourad says, because of the challenges of separating factors leading to patients answering the survey from those that affect their readmission risk.

“These phone calls weren’t done in isolation and were part of our overall bridging interventions for patients going home from the hospital,” she says. “We designed the intervention to help people, and we found that 43% of those reached had at least one issue identified in the call for which the nurse tried to help.”

However, whether patients reported post-discharge issues and their responses to specific questions within the interview were not associated with readmission rates. “Does that mean the nurses’ calls are not helping? It either means the nurses are effectively managing these issues to prevent readmissions or that the factors affecting readmissions are more complicated than we currently understand,” Dr. Mourad says.

---

Larry Beresford is a freelance writer in San Francisco.

References

1. Harrison J, Quinn K, Mourad M. Is anyone home? The association between being reached for a post-discharge telephone call and 30-day hospital readmission. Harrison J, Quinn K, Mourad M. Any questions? The relationship between responses to post-discharge call questions and 30-day hospital readmissions [abstracts]. Journal of Hospital Medicine, 2013, 8 Suppl 1.
2. Institute of Medicine. Crossing the quality chasm: a new health system for the 21st century. Institute of Medicine website. Available at: http://www.iom.edu/~/media/Files/Report%20Files/2001/Crossing-the-Quality-Chasm/Quality%20Chasm%202001%20%20report%20brief.pdf. Accessed Sept. 9, 2013.
3. Shlaes DM, Sahm D, Opiela C, Spellberg B. Commentary: the FDA reboot of antibiotic development. Antimicrob Agents Chemother. 29 Jul 2013 [Epub ahead of print].
4. Alliance for Aging Research. HAIs growing problem, group says. Alliance for Aging Research website. Available at: http://www.agingresearch.org/content/article/detail/33504. Accessed Sept. 9, 2013.
5. Huang SS, Septimus E, Kleinman K, et al. Targeted versus universal decolonization to prevent ICU infection. N Engl J Med. 2013;368:2255-2265.
6. Hospitals in Pursuit of Excellence. Eliminating catheter-associated urinary tract infections. Hospitals in Pursuit of Excellence website. Available at: http://www.hpoe.org/Reports-HPOE/eliminating_catheter_associated_urinary_tract_infection.pdf. Accessed Sept. 9, 2013.
7. Center to Advance Palliative Care. Growth of palliative care in U.S. hospitals 2013 snapshot. Center to Advance Palliative Care website. Available at: http://www.capc.org/capc-growth-analysis-snapshot-2013.pdf. Accessed Sept. 9, 2013.

Two RIV posters presented at HM13 from University of California at San Francisco (UCSF) hospitalists analyzed outcomes from post-discharge phone calls to patients and found that those who were reached and interviewed by a call nurse had a 33% lower all-cause readmission rate.

UCSF joined SHM’s Project BOOST quality initiative in 2009 and adopted its recommendation to call patients within 72 hours of their hospital discharge, according to co-author Michelle Mourad, MD, assistant professor of clinical medicine and a UCSF hospitalist. “We reached out to about 60% to 70% of our patients with a standard script to address issues associated with readmissions,” Dr. Mourad explains. “We were also lucky enough to build a computer program with quantifiable outcomes in the database.”¹

Researchers broke the data down into three categories: those called and interviewed by the nurse; those called who didn’t answer the phone or had a wrong number; and those who were never called due to errors in the administrative list of discharged patients. Interpreting the results is complicated, Dr. Mourad says, because of the challenges of separating factors leading to patients answering the survey from those that affect their readmission risk.

“These phone calls weren’t done in isolation and were part of our overall bridging interventions for patients going home from the hospital,” she says. “We designed the intervention to help people, and we found that 43% of those reached had at least one issue identified in the call for which the nurse tried to help.”

However, whether patients reported post-discharge issues and their responses to specific questions within the interview were not associated with readmission rates. “Does that mean the nurses’ calls are not helping? It either means the nurses are effectively managing these issues to prevent readmissions or that the factors affecting readmissions are more complicated than we currently understand,” Dr. Mourad says.

---

Larry Beresford is a freelance writer in San Francisco.

References

1. Harrison J, Quinn K, Mourad M. Is anyone home? The association between being reached for a post-discharge telephone call and 30-day hospital readmission. Harrison J, Quinn K, Mourad M. Any questions? The relationship between responses to post-discharge call questions and 30-day hospital readmissions [abstracts]. Journal of Hospital Medicine, 2013, 8 Suppl 1.
2. Institute of Medicine. Crossing the quality chasm: a new health system for the 21st century. Institute of Medicine website. Available at: http://www.iom.edu/~/media/Files/Report%20Files/2001/Crossing-the-Quality-Chasm/Quality%20Chasm%202001%20%20report%20brief.pdf. Accessed Sept. 9, 2013.
3. Shlaes DM, Sahm D, Opiela C, Spellberg B. Commentary: the FDA reboot of antibiotic development. Antimicrob Agents Chemother. 29 Jul 2013 [Epub ahead of print].
4. Alliance for Aging Research. HAIs growing problem, group says. Alliance for Aging Research website. Available at: http://www.agingresearch.org/content/article/detail/33504. Accessed Sept. 9, 2013.
5. Huang SS, Septimus E, Kleinman K, et al. Targeted versus universal decolonization to prevent ICU infection. N Engl J Med. 2013;368:2255-2265.
6. Hospitals in Pursuit of Excellence. Eliminating catheter-associated urinary tract infections. Hospitals in Pursuit of Excellence website. Available at: http://www.hpoe.org/Reports-HPOE/eliminating_catheter_associated_urinary_tract_infection.pdf. Accessed Sept. 9, 2013.
7. Center to Advance Palliative Care. Growth of palliative care in U.S. hospitals 2013 snapshot. Center to Advance Palliative Care website. Available at: http://www.capc.org/capc-growth-analysis-snapshot-2013.pdf. Accessed Sept. 9, 2013.

When it comes to controlling healthcare costs, only 36% of physicians agree that practicing physicians have a “major responsibility” to participate in cost containment, according to a recently published Journal of the American Medical Association study, "Views of U.S. Physicians About Controlling Health Care Costs.”

More than half of the 2,556 physicians who responded to a survey said trial lawyers, health insurance companies, hospitals and health systems, pharmaceutical and device manufacturers, and patients have a major responsibility for controlling healthcare costs.

In an accompanying editorial, Ezekiel Emanuel, MD, PhD, and Andrew Steinmetz, BA, of the department of medical ethics and health policy at the Perelman School of Medicine at the University of Pennsylvania in Philadelphia, labeled the responses as “somewhat discouraging” and “a denial of responsibility” by physicians about their role in bringing costs under control.

Christopher Moriates, MD, a hospitalist at the University of California at San Francisco (UCSF) who developed a cost-awareness curriculum for physicians and serves as co-chair of UCSF’s High Value Care Committee, calls the survey a snapshot of changing attitudes in medicine because it does not include medical students or residents who, he says, are more engaged in fighting wasteful spending.

“Younger physicians are growing up in a medical world that has stressed systems-thinking and teamwork,” Dr. Moriates says. “They are ready to take that major responsibility for our healthcare system. We just need to make sure that we are teaching them how.”

 

Visit our website for more information on controlling healthcare costs.

 

 

When it comes to controlling healthcare costs, only 36% of physicians agree that practicing physicians have a “major responsibility” to participate in cost containment, according to a recently published Journal of the American Medical Association study, "Views of U.S. Physicians About Controlling Health Care Costs.”

More than half of the 2,556 physicians who responded to a survey said trial lawyers, health insurance companies, hospitals and health systems, pharmaceutical and device manufacturers, and patients have a major responsibility for controlling healthcare costs.

In an accompanying editorial, Ezekiel Emanuel, MD, PhD, and Andrew Steinmetz, BA, of the department of medical ethics and health policy at the Perelman School of Medicine at the University of Pennsylvania in Philadelphia, labeled the responses as “somewhat discouraging” and “a denial of responsibility” by physicians about their role in bringing costs under control.

Christopher Moriates, MD, a hospitalist at the University of California at San Francisco (UCSF) who developed a cost-awareness curriculum for physicians and serves as co-chair of UCSF’s High Value Care Committee, calls the survey a snapshot of changing attitudes in medicine because it does not include medical students or residents who, he says, are more engaged in fighting wasteful spending.

“Younger physicians are growing up in a medical world that has stressed systems-thinking and teamwork,” Dr. Moriates says. “They are ready to take that major responsibility for our healthcare system. We just need to make sure that we are teaching them how.”

 

Visit our website for more information on controlling healthcare costs.

 

 

When it comes to controlling healthcare costs, only 36% of physicians agree that practicing physicians have a “major responsibility” to participate in cost containment, according to a recently published Journal of the American Medical Association study, "Views of U.S. Physicians About Controlling Health Care Costs.”

More than half of the 2,556 physicians who responded to a survey said trial lawyers, health insurance companies, hospitals and health systems, pharmaceutical and device manufacturers, and patients have a major responsibility for controlling healthcare costs.

In an accompanying editorial, Ezekiel Emanuel, MD, PhD, and Andrew Steinmetz, BA, of the department of medical ethics and health policy at the Perelman School of Medicine at the University of Pennsylvania in Philadelphia, labeled the responses as “somewhat discouraging” and “a denial of responsibility” by physicians about their role in bringing costs under control.

Christopher Moriates, MD, a hospitalist at the University of California at San Francisco (UCSF) who developed a cost-awareness curriculum for physicians and serves as co-chair of UCSF’s High Value Care Committee, calls the survey a snapshot of changing attitudes in medicine because it does not include medical students or residents who, he says, are more engaged in fighting wasteful spending.

“Younger physicians are growing up in a medical world that has stressed systems-thinking and teamwork,” Dr. Moriates says. “They are ready to take that major responsibility for our healthcare system. We just need to make sure that we are teaching them how.”

 

Visit our website for more information on controlling healthcare costs.

 

 

What is the best possible medication history? How is it done? Who should do it? When should it be done during a patient’s journey in and out of the hospital? What medication discrepancies—and potential adverse drug events—are most likely?

Those are questions veteran hospitalist Jason Stein, MD, tried to answer during an HM13 breakout session on medication reconciliation at the Gaylord National Resort and Conference Center in National Harbor, Md.

"How do you know as the discharging provider if the medication list you’re looking at is gold or garbage?" said Dr. Stein, associate director for quality improvement (QI) at Emory University in Atlanta and a mentor for SHM’s Multi-Center Medication Reconciliation Quality Improvement Study (MARQUIS) quality-research initiative.

The concept of the “best possible medication history” (BPMH) originated with patient-safety expert Edward Etchells, MD, MSc, at Sunnybrook Health Sciences Centre in Toronto. The concept is outlined on a pocket reminder card for MARQUIS participants, explained co-presenter and principal investigator Jeffrey Schnipper MD, MPH, FHM, a hospitalist at Brigham & Women’s Hospital in Boston.

“Sometimes it’s impossible to know what the patient was or wasn’t taking, but it doesn’t mean you don’t do your best,” he said, adding that hospitalists should attempt to get at least one reliable, corroborating source of information for a patient’s medical history.

Sometimes it is necessary to speak to family members or the community pharmacy, Dr. Schnipper said, because many patients can’t remember all of the drugs they are taking. Trying to do medication reconciliation at the time of discharge when BPMH has not been done can lead to more work for the provider, medication errors, or rehospitalizations. Ideally, knowledge of what the patient was taking before admission, as well as the patient’s health literacy and adherence history, should be gathered and documented once, early, and well during the hospitalization by a trained provider, according to Dr. Schnipper.

An SHM survey, however, showed 50% to 70% percent of front-line providers have never received BPMH training, and 60% say they are not given the time.¹

“Not knowing means a diligent provider would need to take a BPMH at discharge, which is a waste,” Dr. Stein said. It would be nice to tell from the electronic health record whether a true BPMH had been taken for every hospitalized patient—or at least every high-risk patient—but this goal is not well-supported by current information technology, MARQUIS investigators said they have learned.

The MARQUIS program was launched in 2011 with a grant from the federal Agency for Healthcare Research and Quality. It began with a thorough review of the literature on medication reconciliation and the development of a toolkit of best practices. In 2012, six pilot sites were offered a menu of 11 MARQUIS medication-reconciliation interventions to choose from and help in implementing them from an SHM mentor, with expertise in both QI and medication safety.

Listen to more of our interview with MARQUIS principal investigator Jeffrey Schnipper MD, MPH, FHM.

Participating sites have mobilized high-level hospital leadership and utilize a local champion, usually a hospitalist, tools for assessing high-risk patients, medication-reconciliation assistants or counselors, and pharmacist involvement. Different sites have employed different professional staff to take medication histories.

Dr. Schnipper said he expects another round of MARQUIS-mentored implementation, probably in 2014, after data from the first round have been analyzed. The program is tracking such outcomes as the number of potentially harmful, unintentional medication discrepancies per patient at participating sites.

The MARQUIS toolkit is available on the SHM website. TH

Larry Beresford is a freelance writer in San Francisco.

 

Reference

1. Schnipper JL, Mueller SK, Salanitro AH, Stein J. Got Med Wreck? Targeted Repairs from the Multi-Center Medication Reconciliation Quality Improvement Study (MARQUIS). PowerPoint presentation at Society of Hospital Medicine annual meeting, May 16-19, 2013, National Harbor, Md.

 

What is the best possible medication history? How is it done? Who should do it? When should it be done during a patient’s journey in and out of the hospital? What medication discrepancies—and potential adverse drug events—are most likely?

Those are questions veteran hospitalist Jason Stein, MD, tried to answer during an HM13 breakout session on medication reconciliation at the Gaylord National Resort and Conference Center in National Harbor, Md.

"How do you know as the discharging provider if the medication list you’re looking at is gold or garbage?" said Dr. Stein, associate director for quality improvement (QI) at Emory University in Atlanta and a mentor for SHM’s Multi-Center Medication Reconciliation Quality Improvement Study (MARQUIS) quality-research initiative.

The concept of the “best possible medication history” (BPMH) originated with patient-safety expert Edward Etchells, MD, MSc, at Sunnybrook Health Sciences Centre in Toronto. The concept is outlined on a pocket reminder card for MARQUIS participants, explained co-presenter and principal investigator Jeffrey Schnipper MD, MPH, FHM, a hospitalist at Brigham & Women’s Hospital in Boston.

“Sometimes it’s impossible to know what the patient was or wasn’t taking, but it doesn’t mean you don’t do your best,” he said, adding that hospitalists should attempt to get at least one reliable, corroborating source of information for a patient’s medical history.

Sometimes it is necessary to speak to family members or the community pharmacy, Dr. Schnipper said, because many patients can’t remember all of the drugs they are taking. Trying to do medication reconciliation at the time of discharge when BPMH has not been done can lead to more work for the provider, medication errors, or rehospitalizations. Ideally, knowledge of what the patient was taking before admission, as well as the patient’s health literacy and adherence history, should be gathered and documented once, early, and well during the hospitalization by a trained provider, according to Dr. Schnipper.

An SHM survey, however, showed 50% to 70% percent of front-line providers have never received BPMH training, and 60% say they are not given the time.¹

“Not knowing means a diligent provider would need to take a BPMH at discharge, which is a waste,” Dr. Stein said. It would be nice to tell from the electronic health record whether a true BPMH had been taken for every hospitalized patient—or at least every high-risk patient—but this goal is not well-supported by current information technology, MARQUIS investigators said they have learned.

The MARQUIS program was launched in 2011 with a grant from the federal Agency for Healthcare Research and Quality. It began with a thorough review of the literature on medication reconciliation and the development of a toolkit of best practices. In 2012, six pilot sites were offered a menu of 11 MARQUIS medication-reconciliation interventions to choose from and help in implementing them from an SHM mentor, with expertise in both QI and medication safety.

Listen to more of our interview with MARQUIS principal investigator Jeffrey Schnipper MD, MPH, FHM.

Participating sites have mobilized high-level hospital leadership and utilize a local champion, usually a hospitalist, tools for assessing high-risk patients, medication-reconciliation assistants or counselors, and pharmacist involvement. Different sites have employed different professional staff to take medication histories.

Dr. Schnipper said he expects another round of MARQUIS-mentored implementation, probably in 2014, after data from the first round have been analyzed. The program is tracking such outcomes as the number of potentially harmful, unintentional medication discrepancies per patient at participating sites.

The MARQUIS toolkit is available on the SHM website. TH

Larry Beresford is a freelance writer in San Francisco.

 

Reference

1. Schnipper JL, Mueller SK, Salanitro AH, Stein J. Got Med Wreck? Targeted Repairs from the Multi-Center Medication Reconciliation Quality Improvement Study (MARQUIS). PowerPoint presentation at Society of Hospital Medicine annual meeting, May 16-19, 2013, National Harbor, Md.

 

What is the best possible medication history? How is it done? Who should do it? When should it be done during a patient’s journey in and out of the hospital? What medication discrepancies—and potential adverse drug events—are most likely?

Those are questions veteran hospitalist Jason Stein, MD, tried to answer during an HM13 breakout session on medication reconciliation at the Gaylord National Resort and Conference Center in National Harbor, Md.

"How do you know as the discharging provider if the medication list you’re looking at is gold or garbage?" said Dr. Stein, associate director for quality improvement (QI) at Emory University in Atlanta and a mentor for SHM’s Multi-Center Medication Reconciliation Quality Improvement Study (MARQUIS) quality-research initiative.

The concept of the “best possible medication history” (BPMH) originated with patient-safety expert Edward Etchells, MD, MSc, at Sunnybrook Health Sciences Centre in Toronto. The concept is outlined on a pocket reminder card for MARQUIS participants, explained co-presenter and principal investigator Jeffrey Schnipper MD, MPH, FHM, a hospitalist at Brigham & Women’s Hospital in Boston.

“Sometimes it’s impossible to know what the patient was or wasn’t taking, but it doesn’t mean you don’t do your best,” he said, adding that hospitalists should attempt to get at least one reliable, corroborating source of information for a patient’s medical history.

Sometimes it is necessary to speak to family members or the community pharmacy, Dr. Schnipper said, because many patients can’t remember all of the drugs they are taking. Trying to do medication reconciliation at the time of discharge when BPMH has not been done can lead to more work for the provider, medication errors, or rehospitalizations. Ideally, knowledge of what the patient was taking before admission, as well as the patient’s health literacy and adherence history, should be gathered and documented once, early, and well during the hospitalization by a trained provider, according to Dr. Schnipper.

An SHM survey, however, showed 50% to 70% percent of front-line providers have never received BPMH training, and 60% say they are not given the time.¹

“Not knowing means a diligent provider would need to take a BPMH at discharge, which is a waste,” Dr. Stein said. It would be nice to tell from the electronic health record whether a true BPMH had been taken for every hospitalized patient—or at least every high-risk patient—but this goal is not well-supported by current information technology, MARQUIS investigators said they have learned.

The MARQUIS program was launched in 2011 with a grant from the federal Agency for Healthcare Research and Quality. It began with a thorough review of the literature on medication reconciliation and the development of a toolkit of best practices. In 2012, six pilot sites were offered a menu of 11 MARQUIS medication-reconciliation interventions to choose from and help in implementing them from an SHM mentor, with expertise in both QI and medication safety.

Listen to more of our interview with MARQUIS principal investigator Jeffrey Schnipper MD, MPH, FHM.

Participating sites have mobilized high-level hospital leadership and utilize a local champion, usually a hospitalist, tools for assessing high-risk patients, medication-reconciliation assistants or counselors, and pharmacist involvement. Different sites have employed different professional staff to take medication histories.

Dr. Schnipper said he expects another round of MARQUIS-mentored implementation, probably in 2014, after data from the first round have been analyzed. The program is tracking such outcomes as the number of potentially harmful, unintentional medication discrepancies per patient at participating sites.

The MARQUIS toolkit is available on the SHM website. TH

Larry Beresford is a freelance writer in San Francisco.

 

Reference

1. Schnipper JL, Mueller SK, Salanitro AH, Stein J. Got Med Wreck? Targeted Repairs from the Multi-Center Medication Reconciliation Quality Improvement Study (MARQUIS). PowerPoint presentation at Society of Hospital Medicine annual meeting, May 16-19, 2013, National Harbor, Md.

 

Hospitalists and ED physicians at Newton Medical Center in New Jersey recently participated in an improvised, interactive learning experience with actors who portrayed problematic patients. “Developing Doctor-Patient Relations through Better Communication” is a curriculum to test and teach communication skills for doctors that was created by Anthony Orsini, MD, a neonatologist at Morristown Medical Center, Newton’s sister facility in the Atlantic Health System. Dr. Orsini founded the Breaking Bad News Foundation (www.bbnfoundation.org) more than a decade ago to help health professionals impart bad medical news to patients and families.

Physicians role-play with actors in such difficult scenarios as imparting a troubling diagnosis to a patient who does not want to hear it. This interaction is viewed remotely by instructors from the foundation and by peers, who then meet with the doctor to go over the videotaped encounter regarding its effectiveness, spoken messages, body language, and other communications.

The project to improve staff communication skills is enhancing teamwork between Newton’s hospitalists and emergency doctors, according to David Stuhlmiller, MD, the hospital’s director of emergency medicine.

---

Larry Beresford is a freelance writer in San Francisco.

References

1. Hartocollis A. With money at risk, hospitals push staff to wash hands. The New York Times website. Available at: http://www.nytimes.com/2013/05/29/nyregion/hospitals-struggle-to-get-workers-to-wash-their-hands.html?pagewanted=all&_r=0. Accessed May 28, 2013.
2. Cumbler E, Castillo L, Satorie L, et al. Culture change in infection control: applying psychological principles to improve hand hygiene. J Nurs Care Qual. 2013 May 10 [Epub ahead of print].
3. Bernhard B. High tech hand washing comes to St. Louis hospital. St. Louis Post-Dispatch website. Available at: http://www.stltoday.com/lifestyles/health-med-fit/health/high-tech-hand-washing-comes-to-st-louis-hospital/article_9379065d-85ff-5643-bae2-899254cb22fa.html. Accessed June 27, 2013.
4. Lowe TJ, Partovian C, Kroch E, Martin J, Bankowitz R. Measuring cardiac waste: the Premier cardiac waste measures. Am J Med Qual. 2013 May 29 [Epub ahead of print].
5. Elixhauser A, Steiner C. Readmissions to U.S. hospitals by diagnosis, 2010. Healthcare Cost and Utilization Project website. Available at: http://www.hcup-us.ahrq.gov/reports/statbriefs/sb153.pdf. Accessed July 15, 2013.
6. Jackson Healthcare. Filling the void: 2013 physician outlook & practice trends. Jackson Healthcare website. Available at: http://www.jacksonhealthcare.com/media/193525/jc-2013physiciantrends-void_ebk0513.pdf. Accessed July 15, 2013.

Hospitalists and ED physicians at Newton Medical Center in New Jersey recently participated in an improvised, interactive learning experience with actors who portrayed problematic patients. “Developing Doctor-Patient Relations through Better Communication” is a curriculum to test and teach communication skills for doctors that was created by Anthony Orsini, MD, a neonatologist at Morristown Medical Center, Newton’s sister facility in the Atlantic Health System. Dr. Orsini founded the Breaking Bad News Foundation (www.bbnfoundation.org) more than a decade ago to help health professionals impart bad medical news to patients and families.

Physicians role-play with actors in such difficult scenarios as imparting a troubling diagnosis to a patient who does not want to hear it. This interaction is viewed remotely by instructors from the foundation and by peers, who then meet with the doctor to go over the videotaped encounter regarding its effectiveness, spoken messages, body language, and other communications.

The project to improve staff communication skills is enhancing teamwork between Newton’s hospitalists and emergency doctors, according to David Stuhlmiller, MD, the hospital’s director of emergency medicine.

---

Larry Beresford is a freelance writer in San Francisco.

References

1. Hartocollis A. With money at risk, hospitals push staff to wash hands. The New York Times website. Available at: http://www.nytimes.com/2013/05/29/nyregion/hospitals-struggle-to-get-workers-to-wash-their-hands.html?pagewanted=all&_r=0. Accessed May 28, 2013.
2. Cumbler E, Castillo L, Satorie L, et al. Culture change in infection control: applying psychological principles to improve hand hygiene. J Nurs Care Qual. 2013 May 10 [Epub ahead of print].
3. Bernhard B. High tech hand washing comes to St. Louis hospital. St. Louis Post-Dispatch website. Available at: http://www.stltoday.com/lifestyles/health-med-fit/health/high-tech-hand-washing-comes-to-st-louis-hospital/article_9379065d-85ff-5643-bae2-899254cb22fa.html. Accessed June 27, 2013.
4. Lowe TJ, Partovian C, Kroch E, Martin J, Bankowitz R. Measuring cardiac waste: the Premier cardiac waste measures. Am J Med Qual. 2013 May 29 [Epub ahead of print].
5. Elixhauser A, Steiner C. Readmissions to U.S. hospitals by diagnosis, 2010. Healthcare Cost and Utilization Project website. Available at: http://www.hcup-us.ahrq.gov/reports/statbriefs/sb153.pdf. Accessed July 15, 2013.
6. Jackson Healthcare. Filling the void: 2013 physician outlook & practice trends. Jackson Healthcare website. Available at: http://www.jacksonhealthcare.com/media/193525/jc-2013physiciantrends-void_ebk0513.pdf. Accessed July 15, 2013.

Hospitalists and ED physicians at Newton Medical Center in New Jersey recently participated in an improvised, interactive learning experience with actors who portrayed problematic patients. “Developing Doctor-Patient Relations through Better Communication” is a curriculum to test and teach communication skills for doctors that was created by Anthony Orsini, MD, a neonatologist at Morristown Medical Center, Newton’s sister facility in the Atlantic Health System. Dr. Orsini founded the Breaking Bad News Foundation (www.bbnfoundation.org) more than a decade ago to help health professionals impart bad medical news to patients and families.

Physicians role-play with actors in such difficult scenarios as imparting a troubling diagnosis to a patient who does not want to hear it. This interaction is viewed remotely by instructors from the foundation and by peers, who then meet with the doctor to go over the videotaped encounter regarding its effectiveness, spoken messages, body language, and other communications.

The project to improve staff communication skills is enhancing teamwork between Newton’s hospitalists and emergency doctors, according to David Stuhlmiller, MD, the hospital’s director of emergency medicine.

---

Larry Beresford is a freelance writer in San Francisco.

References

1. Hartocollis A. With money at risk, hospitals push staff to wash hands. The New York Times website. Available at: http://www.nytimes.com/2013/05/29/nyregion/hospitals-struggle-to-get-workers-to-wash-their-hands.html?pagewanted=all&_r=0. Accessed May 28, 2013.
2. Cumbler E, Castillo L, Satorie L, et al. Culture change in infection control: applying psychological principles to improve hand hygiene. J Nurs Care Qual. 2013 May 10 [Epub ahead of print].
3. Bernhard B. High tech hand washing comes to St. Louis hospital. St. Louis Post-Dispatch website. Available at: http://www.stltoday.com/lifestyles/health-med-fit/health/high-tech-hand-washing-comes-to-st-louis-hospital/article_9379065d-85ff-5643-bae2-899254cb22fa.html. Accessed June 27, 2013.
4. Lowe TJ, Partovian C, Kroch E, Martin J, Bankowitz R. Measuring cardiac waste: the Premier cardiac waste measures. Am J Med Qual. 2013 May 29 [Epub ahead of print].
5. Elixhauser A, Steiner C. Readmissions to U.S. hospitals by diagnosis, 2010. Healthcare Cost and Utilization Project website. Available at: http://www.hcup-us.ahrq.gov/reports/statbriefs/sb153.pdf. Accessed July 15, 2013.
6. Jackson Healthcare. Filling the void: 2013 physician outlook & practice trends. Jackson Healthcare website. Available at: http://www.jacksonhealthcare.com/media/193525/jc-2013physiciantrends-void_ebk0513.pdf. Accessed July 15, 2013.

Percentage of practicing physicians who would not recommend a medical career to a young person, according to Filling The Void: 2013 Physician Outlook Practice Trends, a national physician practice survey conducted by health-care staffing firm Jackson Healthcare.⁶ “Physician discontent appears to be creating a void in the health-care field,” with dissatisfaction and burnout leading to early retirement, the report stated. Discontent is driven by decreased autonomy, decreased reimbursement, administrative and regulatory distractions, corporatization of medicine, and fear of litigation, according to the report. Thirty-six percent of the respondents reported a generally negative outlook about their career, compared with only 16% who had a generally favorable outlook.

---

Larry Beresford is a freelance writer in San Francisco.

References

1. Hartocollis A. With money at risk, hospitals push staff to wash hands. The New York Times website. Available at: http://www.nytimes.com/2013/05/29/nyregion/hospitals-struggle-to-get-workers-to-wash-their-hands.html?pagewanted=all&_r=0. Accessed May 28, 2013.
2. Cumbler E, Castillo L, Satorie L, et al. Culture change in infection control: applying psychological principles to improve hand hygiene. J Nurs Care Qual. 2013 May 10 [Epub ahead of print].
3. Bernhard B. High tech hand washing comes to St. Louis hospital. St. Louis Post-Dispatch website. Available at: http://www.stltoday.com/lifestyles/health-med-fit/health/high-tech-hand-washing-comes-to-st-louis-hospital/article_9379065d-85ff-5643-bae2-899254cb22fa.html. Accessed June 27, 2013.
4. Lowe TJ, Partovian C, Kroch E, Martin J, Bankowitz R. Measuring cardiac waste: the Premier cardiac waste measures. Am J Med Qual. 2013 May 29 [Epub ahead of print].
5. Elixhauser A, Steiner C. Readmissions to U.S. hospitals by diagnosis, 2010. Healthcare Cost and Utilization Project website. Available at: http://www.hcup-us.ahrq.gov/reports/statbriefs/sb153.pdf. Accessed July 15, 2013.
6. Jackson Healthcare. Filling the void: 2013 physician outlook & practice trends. Jackson Healthcare website. Available at: http://www.jacksonhealthcare.com/media/193525/jc-2013physiciantrends-void_ebk0513.pdf. Accessed July 15, 2013.

Percentage of practicing physicians who would not recommend a medical career to a young person, according to Filling The Void: 2013 Physician Outlook Practice Trends, a national physician practice survey conducted by health-care staffing firm Jackson Healthcare.⁶ “Physician discontent appears to be creating a void in the health-care field,” with dissatisfaction and burnout leading to early retirement, the report stated. Discontent is driven by decreased autonomy, decreased reimbursement, administrative and regulatory distractions, corporatization of medicine, and fear of litigation, according to the report. Thirty-six percent of the respondents reported a generally negative outlook about their career, compared with only 16% who had a generally favorable outlook.

---

Larry Beresford is a freelance writer in San Francisco.

References

1. Hartocollis A. With money at risk, hospitals push staff to wash hands. The New York Times website. Available at: http://www.nytimes.com/2013/05/29/nyregion/hospitals-struggle-to-get-workers-to-wash-their-hands.html?pagewanted=all&_r=0. Accessed May 28, 2013.
2. Cumbler E, Castillo L, Satorie L, et al. Culture change in infection control: applying psychological principles to improve hand hygiene. J Nurs Care Qual. 2013 May 10 [Epub ahead of print].
3. Bernhard B. High tech hand washing comes to St. Louis hospital. St. Louis Post-Dispatch website. Available at: http://www.stltoday.com/lifestyles/health-med-fit/health/high-tech-hand-washing-comes-to-st-louis-hospital/article_9379065d-85ff-5643-bae2-899254cb22fa.html. Accessed June 27, 2013.
4. Lowe TJ, Partovian C, Kroch E, Martin J, Bankowitz R. Measuring cardiac waste: the Premier cardiac waste measures. Am J Med Qual. 2013 May 29 [Epub ahead of print].
5. Elixhauser A, Steiner C. Readmissions to U.S. hospitals by diagnosis, 2010. Healthcare Cost and Utilization Project website. Available at: http://www.hcup-us.ahrq.gov/reports/statbriefs/sb153.pdf. Accessed July 15, 2013.
6. Jackson Healthcare. Filling the void: 2013 physician outlook & practice trends. Jackson Healthcare website. Available at: http://www.jacksonhealthcare.com/media/193525/jc-2013physiciantrends-void_ebk0513.pdf. Accessed July 15, 2013.

Percentage of practicing physicians who would not recommend a medical career to a young person, according to Filling The Void: 2013 Physician Outlook Practice Trends, a national physician practice survey conducted by health-care staffing firm Jackson Healthcare.⁶ “Physician discontent appears to be creating a void in the health-care field,” with dissatisfaction and burnout leading to early retirement, the report stated. Discontent is driven by decreased autonomy, decreased reimbursement, administrative and regulatory distractions, corporatization of medicine, and fear of litigation, according to the report. Thirty-six percent of the respondents reported a generally negative outlook about their career, compared with only 16% who had a generally favorable outlook.

---

Larry Beresford is a freelance writer in San Francisco.

References

1. Hartocollis A. With money at risk, hospitals push staff to wash hands. The New York Times website. Available at: http://www.nytimes.com/2013/05/29/nyregion/hospitals-struggle-to-get-workers-to-wash-their-hands.html?pagewanted=all&_r=0. Accessed May 28, 2013.
2. Cumbler E, Castillo L, Satorie L, et al. Culture change in infection control: applying psychological principles to improve hand hygiene. J Nurs Care Qual. 2013 May 10 [Epub ahead of print].
3. Bernhard B. High tech hand washing comes to St. Louis hospital. St. Louis Post-Dispatch website. Available at: http://www.stltoday.com/lifestyles/health-med-fit/health/high-tech-hand-washing-comes-to-st-louis-hospital/article_9379065d-85ff-5643-bae2-899254cb22fa.html. Accessed June 27, 2013.
4. Lowe TJ, Partovian C, Kroch E, Martin J, Bankowitz R. Measuring cardiac waste: the Premier cardiac waste measures. Am J Med Qual. 2013 May 29 [Epub ahead of print].
5. Elixhauser A, Steiner C. Readmissions to U.S. hospitals by diagnosis, 2010. Healthcare Cost and Utilization Project website. Available at: http://www.hcup-us.ahrq.gov/reports/statbriefs/sb153.pdf. Accessed July 15, 2013.
6. Jackson Healthcare. Filling the void: 2013 physician outlook & practice trends. Jackson Healthcare website. Available at: http://www.jacksonhealthcare.com/media/193525/jc-2013physiciantrends-void_ebk0513.pdf. Accessed July 15, 2013.

Hospital readmission rate for sickle cell anemia, the diagnosis that is most likely to land a patient back in the hospital within 30 days, according to a report by the federal Healthcare Cost and Utilization Project.⁵ The authors list the top 10 diagnoses for readmissions, with gangrene as No. 2 at 31.6%, followed by hepatitis (30.9%), diseases of white blood cells (30.6%), and chronic renal failure (27.4%).

---

Larry Beresford is a freelance writer in San Francisco.

References

1. Hartocollis A. With money at risk, hospitals push staff to wash hands. The New York Times website. Available at: http://www.nytimes.com/2013/05/29/nyregion/hospitals-struggle-to-get-workers-to-wash-their-hands.html?pagewanted=all&_r=0. Accessed May 28, 2013.
2. Cumbler E, Castillo L, Satorie L, et al. Culture change in infection control: applying psychological principles to improve hand hygiene. J Nurs Care Qual. 2013 May 10 [Epub ahead of print].
3. Bernhard B. High tech hand washing comes to St. Louis hospital. St. Louis Post-Dispatch website. Available at: http://www.stltoday.com/lifestyles/health-med-fit/health/high-tech-hand-washing-comes-to-st-louis-hospital/article_9379065d-85ff-5643-bae2-899254cb22fa.html. Accessed June 27, 2013.
4. Lowe TJ, Partovian C, Kroch E, Martin J, Bankowitz R. Measuring cardiac waste: the Premier cardiac waste measures. Am J Med Qual. 2013 May 29 [Epub ahead of print].
5. Elixhauser A, Steiner C. Readmissions to U.S. hospitals by diagnosis, 2010. Healthcare Cost and Utilization Project website. Available at: http://www.hcup-us.ahrq.gov/reports/statbriefs/sb153.pdf. Accessed July 15, 2013.
6. Jackson Healthcare. Filling the void: 2013 physician outlook & practice trends. Jackson Healthcare website. Available at: http://www.jacksonhealthcare.com/media/193525/jc-2013physiciantrends-void_ebk0513.pdf. Accessed July 15, 2013.

Hospital readmission rate for sickle cell anemia, the diagnosis that is most likely to land a patient back in the hospital within 30 days, according to a report by the federal Healthcare Cost and Utilization Project.⁵ The authors list the top 10 diagnoses for readmissions, with gangrene as No. 2 at 31.6%, followed by hepatitis (30.9%), diseases of white blood cells (30.6%), and chronic renal failure (27.4%).

---

Larry Beresford is a freelance writer in San Francisco.

References

1. Hartocollis A. With money at risk, hospitals push staff to wash hands. The New York Times website. Available at: http://www.nytimes.com/2013/05/29/nyregion/hospitals-struggle-to-get-workers-to-wash-their-hands.html?pagewanted=all&_r=0. Accessed May 28, 2013.
2. Cumbler E, Castillo L, Satorie L, et al. Culture change in infection control: applying psychological principles to improve hand hygiene. J Nurs Care Qual. 2013 May 10 [Epub ahead of print].
3. Bernhard B. High tech hand washing comes to St. Louis hospital. St. Louis Post-Dispatch website. Available at: http://www.stltoday.com/lifestyles/health-med-fit/health/high-tech-hand-washing-comes-to-st-louis-hospital/article_9379065d-85ff-5643-bae2-899254cb22fa.html. Accessed June 27, 2013.
4. Lowe TJ, Partovian C, Kroch E, Martin J, Bankowitz R. Measuring cardiac waste: the Premier cardiac waste measures. Am J Med Qual. 2013 May 29 [Epub ahead of print].
5. Elixhauser A, Steiner C. Readmissions to U.S. hospitals by diagnosis, 2010. Healthcare Cost and Utilization Project website. Available at: http://www.hcup-us.ahrq.gov/reports/statbriefs/sb153.pdf. Accessed July 15, 2013.
6. Jackson Healthcare. Filling the void: 2013 physician outlook & practice trends. Jackson Healthcare website. Available at: http://www.jacksonhealthcare.com/media/193525/jc-2013physiciantrends-void_ebk0513.pdf. Accessed July 15, 2013.

Hospital readmission rate for sickle cell anemia, the diagnosis that is most likely to land a patient back in the hospital within 30 days, according to a report by the federal Healthcare Cost and Utilization Project.⁵ The authors list the top 10 diagnoses for readmissions, with gangrene as No. 2 at 31.6%, followed by hepatitis (30.9%), diseases of white blood cells (30.6%), and chronic renal failure (27.4%).

---

Larry Beresford is a freelance writer in San Francisco.

References

1. Hartocollis A. With money at risk, hospitals push staff to wash hands. The New York Times website. Available at: http://www.nytimes.com/2013/05/29/nyregion/hospitals-struggle-to-get-workers-to-wash-their-hands.html?pagewanted=all&_r=0. Accessed May 28, 2013.
2. Cumbler E, Castillo L, Satorie L, et al. Culture change in infection control: applying psychological principles to improve hand hygiene. J Nurs Care Qual. 2013 May 10 [Epub ahead of print].
3. Bernhard B. High tech hand washing comes to St. Louis hospital. St. Louis Post-Dispatch website. Available at: http://www.stltoday.com/lifestyles/health-med-fit/health/high-tech-hand-washing-comes-to-st-louis-hospital/article_9379065d-85ff-5643-bae2-899254cb22fa.html. Accessed June 27, 2013.
4. Lowe TJ, Partovian C, Kroch E, Martin J, Bankowitz R. Measuring cardiac waste: the Premier cardiac waste measures. Am J Med Qual. 2013 May 29 [Epub ahead of print].
5. Elixhauser A, Steiner C. Readmissions to U.S. hospitals by diagnosis, 2010. Healthcare Cost and Utilization Project website. Available at: http://www.hcup-us.ahrq.gov/reports/statbriefs/sb153.pdf. Accessed July 15, 2013.
6. Jackson Healthcare. Filling the void: 2013 physician outlook & practice trends. Jackson Healthcare website. Available at: http://www.jacksonhealthcare.com/media/193525/jc-2013physiciantrends-void_ebk0513.pdf. Accessed July 15, 2013.

Click here to listen to more of our interview with Dr. Arora

Click here to listen to more of our interview with Dr. Grant

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

Click here to listen to more of our interview with Dr. Wise

 

Click here to listen to more of our interview with Dr. Arora

Click here to listen to more of our interview with Dr. Grant

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

Click here to listen to more of our interview with Dr. Wise

 

Click here to listen to more of our interview with Dr. Arora

Click here to listen to more of our interview with Dr. Grant

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

Click here to listen to more of our interview with Dr. Wise

 

Initial research on outcomes following Project BOOST (Better Outcomes for Older Adults through Safe Transitions) implementation shows modest improvement in rehospitalization rates. Moreover, some experts suggest the real problem might lie in using 30-day hospital readmissions, now a target for Medicare reimbursement penalties, as the quality metric for care transitions out of the hospital.

Study data showed a 2% absolute reduction in all-patient, 30-day readmission rates at 11 of the original 30 BOOST sites (to 12.7% from 14.7%), according to an article in the August issue of the Journal of Hospital Medicine.¹

“Everybody has talked about readmissions as the quality target, but really it should be about improving transitions of care for the patient going home,” says Ashish Jha, MD, MPH, of the Harvard School of Public Health, Health Policy and Management. “If we’re going to use readmissions as our quality measure, maybe we’re set up to fail. Can we do care transitions better? Yes, we can. Can we do better quality measures? Yes. My take-home message is that we should get clearer on what we are trying to achieve.”

Project BOOST (www.hospitalmedicine.org/boost) has been a major quality initiative for SHM since 2008 and one of several national programs aimed at helping hospitals improve care-transitions processes and patient outcomes. BOOST offers participating sites an online toolkit of strategies and interventions, along with the support of an expert mentor.

“Participation in Project BOOST appeared to be associated with a decrease in readmission rates,” the authors conclude. But two accompanying editorials in the journal expressed disappointment with a lack of “robustness” to these results and lack of participation by BOOST sites.^2,3 The editorials also acknowledge the challenges of multisite, voluntary research on a topic that, so far, has largely resisted validated, generalizable research outcomes demonstrating what really works in preventing readmissions.

“I think people want a silver bullet on this issue,” says lead author Luke Hansen, MD, MHS, of the division of hospital medicine at Northwestern University Feinberg School of Medicine in Chicago. “They want to be able to define an intervention to take care of all of the avoidable fraction of rehospitalizations. But I don’t think that’s possible. The disappointment may come from the fact that this is a more complicated issue than we thought.”

Dr. Hansen says data reporting was voluntary and uncompensated, and the BOOST research team is trying to facilitate better reporting from subsequent cohorts. He says one of BOOST’s unique aspects—tailoring interventions to local circumstances—could be a drawback to outcomes research. “We have to incorporate the diversity of experience into our research methods and our expectations,” he says.

Hospitalist Bradley Flansbaum, DO, MPH, FACP, SFHM, of Lenox Hill Hospital in New York City says BOOST reinforces many of things hospitalists should be doing to provide optimal discharges and transitions

.

“Like appropriate teaching and patient education, medication reconciliation, and setting up follow-up appointments,” says Dr. Flansbaum, a member of SHM’s Public Policy Committee and regular contributor to SHM’s Practice Management blog. “But if there was one thing I’d like hospitalists to take home from this research, it’s the cognitive dissonance—the challenge of matching the evidence with what the regulatory bodies expect from us and knowing that the evidence is falling short.

“As much as we might be held accountable for outcomes like readmissions, the reality is that we can’t control them. What we’re learning is that this is really hard to do.”

 

Amy Boutwell, MD, MPP, a hospitalist in Newton, Mass., and founder of Collaborative Healthcare Strategies, agrees transitions of care are difficult. However, she also thinks hospitals and hospitalists cannot wait for conclusive research that proves what works in preventing readmissions.

“The BOOST results reflect my own experience working with more than a hundred STAAR [State Action on Avoidable Readmissions] hospitals. We haven’t yet been able to sufficiently extract the data about readmissions from the field—and we need to figure out how to do that,” she says. “But when you look at the issue from a patient’s perspective and their desire for a safe transition, why would you not do the things recommended by Project BOOST and similar initiatives?”

Primary-care physicians (PCPs) need to know about major changes in a discharged patient’s plan of care in a timely manner, along with any results from pending lab tests, Dr. Boutwell explains. She emphasizes that patients and their caregivers need to be given clear discharge instructions when they leave the hospital.

“We have an obligation to do what we know to be best practices and standards of care. The BOOST toolkit of recommendations is very comprehensive and gives hospitals a lot of options to improve their internal processes,” Dr. Boutwell says. “It’s hard to argue against any of them, even if it’s hard to draw clear links between them and readmissions rates. These are the self-evident, basic tasks that I would want done for myself or my child or my parent, if we were in the hospital.”

---

Larry Beresford is a freelance writer in San Francisco.

References

1. Hansen L, Greenwald J, Budnitz T, et al. Project BOOST: Effectiveness of a multihospital effort to reduce rehospitalization. J Hosp Med. 2013;8(8):421-427. doi: 10.1002/jhm.2054. Epub 2013 Jul 22.
2. Auerbach A, Fang M, Glasheen J, Brotman D, O’Leary KJ, Horwitz LJ. BOOST: Evidence needing a lift. J Hosp Med. 2013;8(8):468-469. doi: 10.1002/jhm.2065. Epub 2013 Jul 22.
3. Jha A. BOOST and readmissions: Thinking beyond the walls of the hospital. J Hosp Med. 2013;8(8):470-471. doi: 10.1002/jhm.2069. Epub 2013 Jul 22.

Initial research on outcomes following Project BOOST (Better Outcomes for Older Adults through Safe Transitions) implementation shows modest improvement in rehospitalization rates. Moreover, some experts suggest the real problem might lie in using 30-day hospital readmissions, now a target for Medicare reimbursement penalties, as the quality metric for care transitions out of the hospital.

Study data showed a 2% absolute reduction in all-patient, 30-day readmission rates at 11 of the original 30 BOOST sites (to 12.7% from 14.7%), according to an article in the August issue of the Journal of Hospital Medicine.¹

“Everybody has talked about readmissions as the quality target, but really it should be about improving transitions of care for the patient going home,” says Ashish Jha, MD, MPH, of the Harvard School of Public Health, Health Policy and Management. “If we’re going to use readmissions as our quality measure, maybe we’re set up to fail. Can we do care transitions better? Yes, we can. Can we do better quality measures? Yes. My take-home message is that we should get clearer on what we are trying to achieve.”

Project BOOST (www.hospitalmedicine.org/boost) has been a major quality initiative for SHM since 2008 and one of several national programs aimed at helping hospitals improve care-transitions processes and patient outcomes. BOOST offers participating sites an online toolkit of strategies and interventions, along with the support of an expert mentor.

“Participation in Project BOOST appeared to be associated with a decrease in readmission rates,” the authors conclude. But two accompanying editorials in the journal expressed disappointment with a lack of “robustness” to these results and lack of participation by BOOST sites.^2,3 The editorials also acknowledge the challenges of multisite, voluntary research on a topic that, so far, has largely resisted validated, generalizable research outcomes demonstrating what really works in preventing readmissions.

“I think people want a silver bullet on this issue,” says lead author Luke Hansen, MD, MHS, of the division of hospital medicine at Northwestern University Feinberg School of Medicine in Chicago. “They want to be able to define an intervention to take care of all of the avoidable fraction of rehospitalizations. But I don’t think that’s possible. The disappointment may come from the fact that this is a more complicated issue than we thought.”

Dr. Hansen says data reporting was voluntary and uncompensated, and the BOOST research team is trying to facilitate better reporting from subsequent cohorts. He says one of BOOST’s unique aspects—tailoring interventions to local circumstances—could be a drawback to outcomes research. “We have to incorporate the diversity of experience into our research methods and our expectations,” he says.

Hospitalist Bradley Flansbaum, DO, MPH, FACP, SFHM, of Lenox Hill Hospital in New York City says BOOST reinforces many of things hospitalists should be doing to provide optimal discharges and transitions

.

“Like appropriate teaching and patient education, medication reconciliation, and setting up follow-up appointments,” says Dr. Flansbaum, a member of SHM’s Public Policy Committee and regular contributor to SHM’s Practice Management blog. “But if there was one thing I’d like hospitalists to take home from this research, it’s the cognitive dissonance—the challenge of matching the evidence with what the regulatory bodies expect from us and knowing that the evidence is falling short.

“As much as we might be held accountable for outcomes like readmissions, the reality is that we can’t control them. What we’re learning is that this is really hard to do.”

 

Amy Boutwell, MD, MPP, a hospitalist in Newton, Mass., and founder of Collaborative Healthcare Strategies, agrees transitions of care are difficult. However, she also thinks hospitals and hospitalists cannot wait for conclusive research that proves what works in preventing readmissions.

“The BOOST results reflect my own experience working with more than a hundred STAAR [State Action on Avoidable Readmissions] hospitals. We haven’t yet been able to sufficiently extract the data about readmissions from the field—and we need to figure out how to do that,” she says. “But when you look at the issue from a patient’s perspective and their desire for a safe transition, why would you not do the things recommended by Project BOOST and similar initiatives?”

Primary-care physicians (PCPs) need to know about major changes in a discharged patient’s plan of care in a timely manner, along with any results from pending lab tests, Dr. Boutwell explains. She emphasizes that patients and their caregivers need to be given clear discharge instructions when they leave the hospital.

“We have an obligation to do what we know to be best practices and standards of care. The BOOST toolkit of recommendations is very comprehensive and gives hospitals a lot of options to improve their internal processes,” Dr. Boutwell says. “It’s hard to argue against any of them, even if it’s hard to draw clear links between them and readmissions rates. These are the self-evident, basic tasks that I would want done for myself or my child or my parent, if we were in the hospital.”

---

Larry Beresford is a freelance writer in San Francisco.

References

1. Hansen L, Greenwald J, Budnitz T, et al. Project BOOST: Effectiveness of a multihospital effort to reduce rehospitalization. J Hosp Med. 2013;8(8):421-427. doi: 10.1002/jhm.2054. Epub 2013 Jul 22.
2. Auerbach A, Fang M, Glasheen J, Brotman D, O’Leary KJ, Horwitz LJ. BOOST: Evidence needing a lift. J Hosp Med. 2013;8(8):468-469. doi: 10.1002/jhm.2065. Epub 2013 Jul 22.
3. Jha A. BOOST and readmissions: Thinking beyond the walls of the hospital. J Hosp Med. 2013;8(8):470-471. doi: 10.1002/jhm.2069. Epub 2013 Jul 22.

Initial research on outcomes following Project BOOST (Better Outcomes for Older Adults through Safe Transitions) implementation shows modest improvement in rehospitalization rates. Moreover, some experts suggest the real problem might lie in using 30-day hospital readmissions, now a target for Medicare reimbursement penalties, as the quality metric for care transitions out of the hospital.

Study data showed a 2% absolute reduction in all-patient, 30-day readmission rates at 11 of the original 30 BOOST sites (to 12.7% from 14.7%), according to an article in the August issue of the Journal of Hospital Medicine.¹

“Everybody has talked about readmissions as the quality target, but really it should be about improving transitions of care for the patient going home,” says Ashish Jha, MD, MPH, of the Harvard School of Public Health, Health Policy and Management. “If we’re going to use readmissions as our quality measure, maybe we’re set up to fail. Can we do care transitions better? Yes, we can. Can we do better quality measures? Yes. My take-home message is that we should get clearer on what we are trying to achieve.”

Project BOOST (www.hospitalmedicine.org/boost) has been a major quality initiative for SHM since 2008 and one of several national programs aimed at helping hospitals improve care-transitions processes and patient outcomes. BOOST offers participating sites an online toolkit of strategies and interventions, along with the support of an expert mentor.

“Participation in Project BOOST appeared to be associated with a decrease in readmission rates,” the authors conclude. But two accompanying editorials in the journal expressed disappointment with a lack of “robustness” to these results and lack of participation by BOOST sites.^2,3 The editorials also acknowledge the challenges of multisite, voluntary research on a topic that, so far, has largely resisted validated, generalizable research outcomes demonstrating what really works in preventing readmissions.

“I think people want a silver bullet on this issue,” says lead author Luke Hansen, MD, MHS, of the division of hospital medicine at Northwestern University Feinberg School of Medicine in Chicago. “They want to be able to define an intervention to take care of all of the avoidable fraction of rehospitalizations. But I don’t think that’s possible. The disappointment may come from the fact that this is a more complicated issue than we thought.”

Dr. Hansen says data reporting was voluntary and uncompensated, and the BOOST research team is trying to facilitate better reporting from subsequent cohorts. He says one of BOOST’s unique aspects—tailoring interventions to local circumstances—could be a drawback to outcomes research. “We have to incorporate the diversity of experience into our research methods and our expectations,” he says.

Hospitalist Bradley Flansbaum, DO, MPH, FACP, SFHM, of Lenox Hill Hospital in New York City says BOOST reinforces many of things hospitalists should be doing to provide optimal discharges and transitions

.

“Like appropriate teaching and patient education, medication reconciliation, and setting up follow-up appointments,” says Dr. Flansbaum, a member of SHM’s Public Policy Committee and regular contributor to SHM’s Practice Management blog. “But if there was one thing I’d like hospitalists to take home from this research, it’s the cognitive dissonance—the challenge of matching the evidence with what the regulatory bodies expect from us and knowing that the evidence is falling short.

“As much as we might be held accountable for outcomes like readmissions, the reality is that we can’t control them. What we’re learning is that this is really hard to do.”

 

Amy Boutwell, MD, MPP, a hospitalist in Newton, Mass., and founder of Collaborative Healthcare Strategies, agrees transitions of care are difficult. However, she also thinks hospitals and hospitalists cannot wait for conclusive research that proves what works in preventing readmissions.

“The BOOST results reflect my own experience working with more than a hundred STAAR [State Action on Avoidable Readmissions] hospitals. We haven’t yet been able to sufficiently extract the data about readmissions from the field—and we need to figure out how to do that,” she says. “But when you look at the issue from a patient’s perspective and their desire for a safe transition, why would you not do the things recommended by Project BOOST and similar initiatives?”

Primary-care physicians (PCPs) need to know about major changes in a discharged patient’s plan of care in a timely manner, along with any results from pending lab tests, Dr. Boutwell explains. She emphasizes that patients and their caregivers need to be given clear discharge instructions when they leave the hospital.

“We have an obligation to do what we know to be best practices and standards of care. The BOOST toolkit of recommendations is very comprehensive and gives hospitals a lot of options to improve their internal processes,” Dr. Boutwell says. “It’s hard to argue against any of them, even if it’s hard to draw clear links between them and readmissions rates. These are the self-evident, basic tasks that I would want done for myself or my child or my parent, if we were in the hospital.”

---

Larry Beresford is a freelance writer in San Francisco.

References

1. Hansen L, Greenwald J, Budnitz T, et al. Project BOOST: Effectiveness of a multihospital effort to reduce rehospitalization. J Hosp Med. 2013;8(8):421-427. doi: 10.1002/jhm.2054. Epub 2013 Jul 22.
2. Auerbach A, Fang M, Glasheen J, Brotman D, O’Leary KJ, Horwitz LJ. BOOST: Evidence needing a lift. J Hosp Med. 2013;8(8):468-469. doi: 10.1002/jhm.2065. Epub 2013 Jul 22.
3. Jha A. BOOST and readmissions: Thinking beyond the walls of the hospital. J Hosp Med. 2013;8(8):470-471. doi: 10.1002/jhm.2069. Epub 2013 Jul 22.

A recent article in the American Journal of Medical Quality reviewed 366 cardiac-related medical studies and 21 practice guidelines to identify eight measures of potential waste in hospital cardiac services.⁴ The wasteful measures included excess use of higher-cost implantable cardioverter-defibrillators and similar cardiac devices, the use of dual-chamber defibrillators rather than single-chamber devices, and excess lengths of stay in the hospital. The eight measures were validated with data from 261 hospitals.

The authors emphasize that their set of measures is not designed to determine clinical appropriateness but to highlight areas of potential overutilization that can be benchmarked with other hospitals.

---

Larry Beresford is a freelance writer in San Francisco.

References

1. Hartocollis A. With money at risk, hospitals push staff to wash hands. The New York Times website. Available at: http://www.nytimes.com/2013/05/29/nyregion/hospitals-struggle-to-get-workers-to-wash-their-hands.html?pagewanted=all&_r=0. Accessed May 28, 2013.
2. Cumbler E, Castillo L, Satorie L, et al. Culture change in infection control: applying psychological principles to improve hand hygiene. J Nurs Care Qual. 2013 May 10 [Epub ahead of print].
3. Bernhard B. High tech hand washing comes to St. Louis hospital. St. Louis Post-Dispatch website. Available at: http://www.stltoday.com/lifestyles/health-med-fit/health/high-tech-hand-washing-comes-to-st-louis-hospital/article_9379065d-85ff-5643-bae2-899254cb22fa.html. Accessed June 27, 2013.
4. Lowe TJ, Partovian C, Kroch E, Martin J, Bankowitz R. Measuring cardiac waste: the Premier cardiac waste measures. Am J Med Qual. 2013 May 29 [Epub ahead of print].
5. Elixhauser A, Steiner C. Readmissions to U.S. hospitals by diagnosis, 2010. Healthcare Cost and Utilization Project website. Available at: http://www.hcup-us.ahrq.gov/reports/statbriefs/sb153.pdf. Accessed July 15, 2013.
6. Jackson Healthcare. Filling the void: 2013 physician outlook & practice trends. Jackson Healthcare website. Available at: http://www.jacksonhealthcare.com/media/193525/jc-2013physiciantrends-void_ebk0513.pdf. Accessed July 15, 2013.

A recent article in the American Journal of Medical Quality reviewed 366 cardiac-related medical studies and 21 practice guidelines to identify eight measures of potential waste in hospital cardiac services.⁴ The wasteful measures included excess use of higher-cost implantable cardioverter-defibrillators and similar cardiac devices, the use of dual-chamber defibrillators rather than single-chamber devices, and excess lengths of stay in the hospital. The eight measures were validated with data from 261 hospitals.

The authors emphasize that their set of measures is not designed to determine clinical appropriateness but to highlight areas of potential overutilization that can be benchmarked with other hospitals.

---

Larry Beresford is a freelance writer in San Francisco.

References

1. Hartocollis A. With money at risk, hospitals push staff to wash hands. The New York Times website. Available at: http://www.nytimes.com/2013/05/29/nyregion/hospitals-struggle-to-get-workers-to-wash-their-hands.html?pagewanted=all&_r=0. Accessed May 28, 2013.
2. Cumbler E, Castillo L, Satorie L, et al. Culture change in infection control: applying psychological principles to improve hand hygiene. J Nurs Care Qual. 2013 May 10 [Epub ahead of print].
3. Bernhard B. High tech hand washing comes to St. Louis hospital. St. Louis Post-Dispatch website. Available at: http://www.stltoday.com/lifestyles/health-med-fit/health/high-tech-hand-washing-comes-to-st-louis-hospital/article_9379065d-85ff-5643-bae2-899254cb22fa.html. Accessed June 27, 2013.
4. Lowe TJ, Partovian C, Kroch E, Martin J, Bankowitz R. Measuring cardiac waste: the Premier cardiac waste measures. Am J Med Qual. 2013 May 29 [Epub ahead of print].
5. Elixhauser A, Steiner C. Readmissions to U.S. hospitals by diagnosis, 2010. Healthcare Cost and Utilization Project website. Available at: http://www.hcup-us.ahrq.gov/reports/statbriefs/sb153.pdf. Accessed July 15, 2013.
6. Jackson Healthcare. Filling the void: 2013 physician outlook & practice trends. Jackson Healthcare website. Available at: http://www.jacksonhealthcare.com/media/193525/jc-2013physiciantrends-void_ebk0513.pdf. Accessed July 15, 2013.

A recent article in the American Journal of Medical Quality reviewed 366 cardiac-related medical studies and 21 practice guidelines to identify eight measures of potential waste in hospital cardiac services.⁴ The wasteful measures included excess use of higher-cost implantable cardioverter-defibrillators and similar cardiac devices, the use of dual-chamber defibrillators rather than single-chamber devices, and excess lengths of stay in the hospital. The eight measures were validated with data from 261 hospitals.

The authors emphasize that their set of measures is not designed to determine clinical appropriateness but to highlight areas of potential overutilization that can be benchmarked with other hospitals.

---

Larry Beresford is a freelance writer in San Francisco.

References

1. Hartocollis A. With money at risk, hospitals push staff to wash hands. The New York Times website. Available at: http://www.nytimes.com/2013/05/29/nyregion/hospitals-struggle-to-get-workers-to-wash-their-hands.html?pagewanted=all&_r=0. Accessed May 28, 2013.
2. Cumbler E, Castillo L, Satorie L, et al. Culture change in infection control: applying psychological principles to improve hand hygiene. J Nurs Care Qual. 2013 May 10 [Epub ahead of print].
3. Bernhard B. High tech hand washing comes to St. Louis hospital. St. Louis Post-Dispatch website. Available at: http://www.stltoday.com/lifestyles/health-med-fit/health/high-tech-hand-washing-comes-to-st-louis-hospital/article_9379065d-85ff-5643-bae2-899254cb22fa.html. Accessed June 27, 2013.
4. Lowe TJ, Partovian C, Kroch E, Martin J, Bankowitz R. Measuring cardiac waste: the Premier cardiac waste measures. Am J Med Qual. 2013 May 29 [Epub ahead of print].
5. Elixhauser A, Steiner C. Readmissions to U.S. hospitals by diagnosis, 2010. Healthcare Cost and Utilization Project website. Available at: http://www.hcup-us.ahrq.gov/reports/statbriefs/sb153.pdf. Accessed July 15, 2013.
6. Jackson Healthcare. Filling the void: 2013 physician outlook & practice trends. Jackson Healthcare website. Available at: http://www.jacksonhealthcare.com/media/193525/jc-2013physiciantrends-void_ebk0513.pdf. Accessed July 15, 2013.

According to a recent New York Times report, hand-hygiene compliance in hospitals can be as low as 30%, with serious implications regarding hospital-acquired infections.¹ While many initiatives have employed secret observers, vibrating badges, or hand-washing coaches, a Research, Innovations, and Clinical Vignettes (RIV) poster at HM13 outlined how a multidisciplinary committee at University of Colorado Hospital in Aurora applied principles of psychology to the challenge of compliance.²

The initiative focused on behavioral changes: surreptitiously auditing staff behaviors, real-time feedback, and immediate public corrections for observed nonadherence on the test unit from an infection-control champion. The study randomly assigned daily auditing responsibilities across all members of the nursing staff, including aides. Taking a page from soccer referees, auditors handed out red tickets to hygiene violators—and individually wrapped Life Savers to reinforce adherence.

When unprofessional behavior is the response to a verbal correction, leadership has to be prepared to act, explains hospitalist and lead author Ethan Cumbler, MD, FACP.

“We need to stop thinking about hospital staff and physicians as rational actors when it comes to hand hygiene, but as social animals who will respond to positive and negative reinforcements and group culture,” he says.

Noncompliant hand hygiene is largely unconscious behavior that needs to be brought to conscious attention but is amenable to change, Dr. Cumbler says, adding that “unit leadership steps in for repeated nonadherence or an unprofessional response to correction. We have never needed to intervene more than once with the same person.”

Hand-hygiene adherence reached 97% on the pilot unit in the second quarter of 2012 and has remained at that level, Dr. Cumbler says. Additionally, iatrogenic infections dropped to zero from 4.8 per 1,000 urinary catheter days, with bloodstream infections falling at a similar rate.

Similar results with hand-hygiene compliance have been reported at St. Mary’s Health Center in St. Louis, which has been testing a system that reminds nurses to wash their hands at various checkpoints in the hospital, tracking their compliance with a badge that turns green when registering the presence of hand sanitizer, thereby informing patients that the nurse’s hands are clean.

The system, developed by Biovigil Hygiene Technologies of Ann Arbor, Mich., started on two pilot units last year, where compliance has grown to 97% and 99%, respectively. System set-up can cost about $2,000 per patient room, plus monthly subscriptions per employee, but more hospitals in the system could sign on next year, reports the St. Louis Post-Dispatch.³

---

Larry Beresford is a freelance writer in San Francisco.

References

1. Hartocollis A. With money at risk, hospitals push staff to wash hands. The New York Times website. Available at: http://www.nytimes.com/2013/05/29/nyregion/hospitals-struggle-to-get-workers-to-wash-their-hands.html?pagewanted=all&_r=0. Accessed May 28, 2013.
2. Cumbler E, Castillo L, Satorie L, et al. Culture change in infection control: applying psychological principles to improve hand hygiene. J Nurs Care Qual. 2013 May 10 [Epub ahead of print].
3. Bernhard B. High tech hand washing comes to St. Louis hospital. St. Louis Post-Dispatch website. Available at: http://www.stltoday.com/lifestyles/health-med-fit/health/high-tech-hand-washing-comes-to-st-louis-hospital/article_9379065d-85ff-5643-bae2-899254cb22fa.html. Accessed June 27, 2013.
4. Lowe TJ, Partovian C, Kroch E, Martin J, Bankowitz R. Measuring cardiac waste: the Premier cardiac waste measures. Am J Med Qual. 2013 May 29 [Epub ahead of print].
5. Elixhauser A, Steiner C. Readmissions to U.S. hospitals by diagnosis, 2010. Healthcare Cost and Utilization Project website. Available at: http://www.hcup-us.ahrq.gov/reports/statbriefs/sb153.pdf. Accessed July 15, 2013.
6. Jackson Healthcare. Filling the void: 2013 physician outlook & practice trends. Jackson Healthcare website. Available at: http://www.jacksonhealthcare.com/media/193525/jc-2013physiciantrends-void_ebk0513.pdf. Accessed July 15, 2013.

According to a recent New York Times report, hand-hygiene compliance in hospitals can be as low as 30%, with serious implications regarding hospital-acquired infections.¹ While many initiatives have employed secret observers, vibrating badges, or hand-washing coaches, a Research, Innovations, and Clinical Vignettes (RIV) poster at HM13 outlined how a multidisciplinary committee at University of Colorado Hospital in Aurora applied principles of psychology to the challenge of compliance.²

The initiative focused on behavioral changes: surreptitiously auditing staff behaviors, real-time feedback, and immediate public corrections for observed nonadherence on the test unit from an infection-control champion. The study randomly assigned daily auditing responsibilities across all members of the nursing staff, including aides. Taking a page from soccer referees, auditors handed out red tickets to hygiene violators—and individually wrapped Life Savers to reinforce adherence.

When unprofessional behavior is the response to a verbal correction, leadership has to be prepared to act, explains hospitalist and lead author Ethan Cumbler, MD, FACP.

“We need to stop thinking about hospital staff and physicians as rational actors when it comes to hand hygiene, but as social animals who will respond to positive and negative reinforcements and group culture,” he says.

Noncompliant hand hygiene is largely unconscious behavior that needs to be brought to conscious attention but is amenable to change, Dr. Cumbler says, adding that “unit leadership steps in for repeated nonadherence or an unprofessional response to correction. We have never needed to intervene more than once with the same person.”

Hand-hygiene adherence reached 97% on the pilot unit in the second quarter of 2012 and has remained at that level, Dr. Cumbler says. Additionally, iatrogenic infections dropped to zero from 4.8 per 1,000 urinary catheter days, with bloodstream infections falling at a similar rate.

Similar results with hand-hygiene compliance have been reported at St. Mary’s Health Center in St. Louis, which has been testing a system that reminds nurses to wash their hands at various checkpoints in the hospital, tracking their compliance with a badge that turns green when registering the presence of hand sanitizer, thereby informing patients that the nurse’s hands are clean.

The system, developed by Biovigil Hygiene Technologies of Ann Arbor, Mich., started on two pilot units last year, where compliance has grown to 97% and 99%, respectively. System set-up can cost about $2,000 per patient room, plus monthly subscriptions per employee, but more hospitals in the system could sign on next year, reports the St. Louis Post-Dispatch.³

---

Larry Beresford is a freelance writer in San Francisco.

References

1. Hartocollis A. With money at risk, hospitals push staff to wash hands. The New York Times website. Available at: http://www.nytimes.com/2013/05/29/nyregion/hospitals-struggle-to-get-workers-to-wash-their-hands.html?pagewanted=all&_r=0. Accessed May 28, 2013.
2. Cumbler E, Castillo L, Satorie L, et al. Culture change in infection control: applying psychological principles to improve hand hygiene. J Nurs Care Qual. 2013 May 10 [Epub ahead of print].
3. Bernhard B. High tech hand washing comes to St. Louis hospital. St. Louis Post-Dispatch website. Available at: http://www.stltoday.com/lifestyles/health-med-fit/health/high-tech-hand-washing-comes-to-st-louis-hospital/article_9379065d-85ff-5643-bae2-899254cb22fa.html. Accessed June 27, 2013.
4. Lowe TJ, Partovian C, Kroch E, Martin J, Bankowitz R. Measuring cardiac waste: the Premier cardiac waste measures. Am J Med Qual. 2013 May 29 [Epub ahead of print].
5. Elixhauser A, Steiner C. Readmissions to U.S. hospitals by diagnosis, 2010. Healthcare Cost and Utilization Project website. Available at: http://www.hcup-us.ahrq.gov/reports/statbriefs/sb153.pdf. Accessed July 15, 2013.
6. Jackson Healthcare. Filling the void: 2013 physician outlook & practice trends. Jackson Healthcare website. Available at: http://www.jacksonhealthcare.com/media/193525/jc-2013physiciantrends-void_ebk0513.pdf. Accessed July 15, 2013.

According to a recent New York Times report, hand-hygiene compliance in hospitals can be as low as 30%, with serious implications regarding hospital-acquired infections.¹ While many initiatives have employed secret observers, vibrating badges, or hand-washing coaches, a Research, Innovations, and Clinical Vignettes (RIV) poster at HM13 outlined how a multidisciplinary committee at University of Colorado Hospital in Aurora applied principles of psychology to the challenge of compliance.²

The initiative focused on behavioral changes: surreptitiously auditing staff behaviors, real-time feedback, and immediate public corrections for observed nonadherence on the test unit from an infection-control champion. The study randomly assigned daily auditing responsibilities across all members of the nursing staff, including aides. Taking a page from soccer referees, auditors handed out red tickets to hygiene violators—and individually wrapped Life Savers to reinforce adherence.

When unprofessional behavior is the response to a verbal correction, leadership has to be prepared to act, explains hospitalist and lead author Ethan Cumbler, MD, FACP.

“We need to stop thinking about hospital staff and physicians as rational actors when it comes to hand hygiene, but as social animals who will respond to positive and negative reinforcements and group culture,” he says.

Noncompliant hand hygiene is largely unconscious behavior that needs to be brought to conscious attention but is amenable to change, Dr. Cumbler says, adding that “unit leadership steps in for repeated nonadherence or an unprofessional response to correction. We have never needed to intervene more than once with the same person.”

Hand-hygiene adherence reached 97% on the pilot unit in the second quarter of 2012 and has remained at that level, Dr. Cumbler says. Additionally, iatrogenic infections dropped to zero from 4.8 per 1,000 urinary catheter days, with bloodstream infections falling at a similar rate.

Similar results with hand-hygiene compliance have been reported at St. Mary’s Health Center in St. Louis, which has been testing a system that reminds nurses to wash their hands at various checkpoints in the hospital, tracking their compliance with a badge that turns green when registering the presence of hand sanitizer, thereby informing patients that the nurse’s hands are clean.

The system, developed by Biovigil Hygiene Technologies of Ann Arbor, Mich., started on two pilot units last year, where compliance has grown to 97% and 99%, respectively. System set-up can cost about $2,000 per patient room, plus monthly subscriptions per employee, but more hospitals in the system could sign on next year, reports the St. Louis Post-Dispatch.³

---

Larry Beresford is a freelance writer in San Francisco.

References

1. Hartocollis A. With money at risk, hospitals push staff to wash hands. The New York Times website. Available at: http://www.nytimes.com/2013/05/29/nyregion/hospitals-struggle-to-get-workers-to-wash-their-hands.html?pagewanted=all&_r=0. Accessed May 28, 2013.
2. Cumbler E, Castillo L, Satorie L, et al. Culture change in infection control: applying psychological principles to improve hand hygiene. J Nurs Care Qual. 2013 May 10 [Epub ahead of print].
3. Bernhard B. High tech hand washing comes to St. Louis hospital. St. Louis Post-Dispatch website. Available at: http://www.stltoday.com/lifestyles/health-med-fit/health/high-tech-hand-washing-comes-to-st-louis-hospital/article_9379065d-85ff-5643-bae2-899254cb22fa.html. Accessed June 27, 2013.
4. Lowe TJ, Partovian C, Kroch E, Martin J, Bankowitz R. Measuring cardiac waste: the Premier cardiac waste measures. Am J Med Qual. 2013 May 29 [Epub ahead of print].
5. Elixhauser A, Steiner C. Readmissions to U.S. hospitals by diagnosis, 2010. Healthcare Cost and Utilization Project website. Available at: http://www.hcup-us.ahrq.gov/reports/statbriefs/sb153.pdf. Accessed July 15, 2013.
6. Jackson Healthcare. Filling the void: 2013 physician outlook & practice trends. Jackson Healthcare website. Available at: http://www.jacksonhealthcare.com/media/193525/jc-2013physiciantrends-void_ebk0513.pdf. Accessed July 15, 2013.