Meadowview Regional Medical Center in Maysville, Ky., recently added a hospitalist program as part of its renovation campaign. Jeff Dickerson, MD, Ignacio Calvo, MD, and nurse practitioner Abe Keating are heading up the new hospitalist team.

Eric McFarling, MD, a hospitalist at St. Cloud Hospital in St. Cloud, Minn., received the Physician of Excellence Award from employees and peers. The award recognizes commitment to patient satisfaction and teamwork.

Emily Hebert, MD, an internal-medicine hospitalist at Baylor University Medical Center in Waco, Texas, was awarded the 2011 Texas Medical Association’s Anson Jones, MD, Award in the Physician Excellence in Reporting category for her work as medical expert for the local ABC affiliate. She recently joined the staff at The Cooper Clinic in Dallas as a preventive- medicine physician, specializing in internal medicine and pediatrics.

Business Moves

IPC: the Hospitalist Co. has signed agreements to acquire Inpatient Clinical Solutions Inc. (ICS), an acute-care practice headquartered in Coral Springs, Fla., and the hospitalist practice of Lionel J. Gatien, DO, PA, based in Jacksonville, Fla. IPC expects to add approximately 116,000 patient visits on an annual basis from these acquisitions.

Glendale, Calif.-based Apollo Medical Holdings Inc., a hospitalist-, critical-care and multi-disciplinary care-management service, has appointed Edward “Ted” Schreck chairman of the board. Schreck is a senior healthcare executive with 37 years of experience in both the private and public healthcare sectors.

Carlisle (Pa.) Regional Medical Center has added a 12-member hospitalist team to its list of medical departments. The team will be known as Hospitalists of Central Pennsylvania. Michael Hilden, MD, will serve as group director.

—Alexandra Schultz

Meadowview Regional Medical Center in Maysville, Ky., recently added a hospitalist program as part of its renovation campaign. Jeff Dickerson, MD, Ignacio Calvo, MD, and nurse practitioner Abe Keating are heading up the new hospitalist team.

Eric McFarling, MD, a hospitalist at St. Cloud Hospital in St. Cloud, Minn., received the Physician of Excellence Award from employees and peers. The award recognizes commitment to patient satisfaction and teamwork.

Emily Hebert, MD, an internal-medicine hospitalist at Baylor University Medical Center in Waco, Texas, was awarded the 2011 Texas Medical Association’s Anson Jones, MD, Award in the Physician Excellence in Reporting category for her work as medical expert for the local ABC affiliate. She recently joined the staff at The Cooper Clinic in Dallas as a preventive- medicine physician, specializing in internal medicine and pediatrics.

Business Moves

IPC: the Hospitalist Co. has signed agreements to acquire Inpatient Clinical Solutions Inc. (ICS), an acute-care practice headquartered in Coral Springs, Fla., and the hospitalist practice of Lionel J. Gatien, DO, PA, based in Jacksonville, Fla. IPC expects to add approximately 116,000 patient visits on an annual basis from these acquisitions.

Glendale, Calif.-based Apollo Medical Holdings Inc., a hospitalist-, critical-care and multi-disciplinary care-management service, has appointed Edward “Ted” Schreck chairman of the board. Schreck is a senior healthcare executive with 37 years of experience in both the private and public healthcare sectors.

Carlisle (Pa.) Regional Medical Center has added a 12-member hospitalist team to its list of medical departments. The team will be known as Hospitalists of Central Pennsylvania. Michael Hilden, MD, will serve as group director.

—Alexandra Schultz

Meadowview Regional Medical Center in Maysville, Ky., recently added a hospitalist program as part of its renovation campaign. Jeff Dickerson, MD, Ignacio Calvo, MD, and nurse practitioner Abe Keating are heading up the new hospitalist team.

Eric McFarling, MD, a hospitalist at St. Cloud Hospital in St. Cloud, Minn., received the Physician of Excellence Award from employees and peers. The award recognizes commitment to patient satisfaction and teamwork.

Emily Hebert, MD, an internal-medicine hospitalist at Baylor University Medical Center in Waco, Texas, was awarded the 2011 Texas Medical Association’s Anson Jones, MD, Award in the Physician Excellence in Reporting category for her work as medical expert for the local ABC affiliate. She recently joined the staff at The Cooper Clinic in Dallas as a preventive- medicine physician, specializing in internal medicine and pediatrics.

Business Moves

IPC: the Hospitalist Co. has signed agreements to acquire Inpatient Clinical Solutions Inc. (ICS), an acute-care practice headquartered in Coral Springs, Fla., and the hospitalist practice of Lionel J. Gatien, DO, PA, based in Jacksonville, Fla. IPC expects to add approximately 116,000 patient visits on an annual basis from these acquisitions.

Glendale, Calif.-based Apollo Medical Holdings Inc., a hospitalist-, critical-care and multi-disciplinary care-management service, has appointed Edward “Ted” Schreck chairman of the board. Schreck is a senior healthcare executive with 37 years of experience in both the private and public healthcare sectors.

Carlisle (Pa.) Regional Medical Center has added a 12-member hospitalist team to its list of medical departments. The team will be known as Hospitalists of Central Pennsylvania. Michael Hilden, MD, will serve as group director.

—Alexandra Schultz

On March 7, the Centers for Medicare & Medicaid Services (CMS) released a proposed rule: Medicare and Medicaid Programs; Electronic Health Record Incentive Program—Stage 2. This rule is more commonly known as “Stage 2 of meaningful use.” At more than 130 pages, the rule builds upon Stage 1 of the program mainly by increasing measurement thresholds and requiring higher levels of system functionality.

Although there are no major surprises within the proposed rule, there is always one very basic yet very important question that surfaces when meaningful use makes headlines: Are hospitalists eligible for health information technology (HIT) incentives and thus subject to the meaningful use requirements?

“No” is the short answer to this question. Although physicians, including hospitalists, are considered eligible professionals (EPs) under the HIT incentive program, a subset of EPs are defined as hospital-based EPs and, therefore, are not subject to the program’s requirements. CMS defines a hospital-based eligible professional as an EP who furnishes 90% or more of their covered professional services in either the inpatient division or ED of a hospital.

While some may call this an exemption for hospitalists, it is not that definitive. Hospitalists are still “eligible,” and the determination is not made by specialty, but by pattern of practice. This means that hospitalists could find themselves on the hook for future penalties if their practice patterns expand beyond CMS’ 90% threshold.

An example of this would be a hospitalist who spends time doing rounds at a nursing home. Today, this might constitute only a small percentage of a hospitalist’s practice, but with an increasingly aging population, it is not inconceivable that this small percentage could exceed 10% within five or 10 years.

With this in mind, and a similar scenario also present in the Electronic Prescribing Incentive Program (eRx), SHM has consistently pointed out the issue to CMS and is working to find an acceptable solution.

Although hospitalists are not currently subject to physician meaningful-use requirements, the program has another category of eligibility that will certainly affect hospitalists: the eligible hospital, or EH. Many hospitalists are directly involved with HIT implementation efforts at their institutions or are indirectly working with these systems as they are implemented and expanded in hospitals across the country.

Given the 90% eligibility threshold and the role of HIT in hospitals, it is important for hospitalists to stay current and informed on meaningful use and HIT policy. Involvement with one of SHM’s HIT related committees is a clear way to stay informed in this ever-evolving area, and SHM’s efforts can be reviewed on the Advocacy page of SHM’s website: www.hospitalmedicine.org/advocacy.

For the most up-to-date information on what is being done at the federal level, the Office of the National Coordinator (ONC) has a wealth of information available at www.healthit.gov/.

SHM will continue to monitor and analyze developments and changes to EHR policy, but it also looks to you, its members, for experience and insight.

On March 7, the Centers for Medicare & Medicaid Services (CMS) released a proposed rule: Medicare and Medicaid Programs; Electronic Health Record Incentive Program—Stage 2. This rule is more commonly known as “Stage 2 of meaningful use.” At more than 130 pages, the rule builds upon Stage 1 of the program mainly by increasing measurement thresholds and requiring higher levels of system functionality.

Although there are no major surprises within the proposed rule, there is always one very basic yet very important question that surfaces when meaningful use makes headlines: Are hospitalists eligible for health information technology (HIT) incentives and thus subject to the meaningful use requirements?

“No” is the short answer to this question. Although physicians, including hospitalists, are considered eligible professionals (EPs) under the HIT incentive program, a subset of EPs are defined as hospital-based EPs and, therefore, are not subject to the program’s requirements. CMS defines a hospital-based eligible professional as an EP who furnishes 90% or more of their covered professional services in either the inpatient division or ED of a hospital.

While some may call this an exemption for hospitalists, it is not that definitive. Hospitalists are still “eligible,” and the determination is not made by specialty, but by pattern of practice. This means that hospitalists could find themselves on the hook for future penalties if their practice patterns expand beyond CMS’ 90% threshold.

An example of this would be a hospitalist who spends time doing rounds at a nursing home. Today, this might constitute only a small percentage of a hospitalist’s practice, but with an increasingly aging population, it is not inconceivable that this small percentage could exceed 10% within five or 10 years.

With this in mind, and a similar scenario also present in the Electronic Prescribing Incentive Program (eRx), SHM has consistently pointed out the issue to CMS and is working to find an acceptable solution.

Although hospitalists are not currently subject to physician meaningful-use requirements, the program has another category of eligibility that will certainly affect hospitalists: the eligible hospital, or EH. Many hospitalists are directly involved with HIT implementation efforts at their institutions or are indirectly working with these systems as they are implemented and expanded in hospitals across the country.

Given the 90% eligibility threshold and the role of HIT in hospitals, it is important for hospitalists to stay current and informed on meaningful use and HIT policy. Involvement with one of SHM’s HIT related committees is a clear way to stay informed in this ever-evolving area, and SHM’s efforts can be reviewed on the Advocacy page of SHM’s website: www.hospitalmedicine.org/advocacy.

For the most up-to-date information on what is being done at the federal level, the Office of the National Coordinator (ONC) has a wealth of information available at www.healthit.gov/.

SHM will continue to monitor and analyze developments and changes to EHR policy, but it also looks to you, its members, for experience and insight.

On March 7, the Centers for Medicare & Medicaid Services (CMS) released a proposed rule: Medicare and Medicaid Programs; Electronic Health Record Incentive Program—Stage 2. This rule is more commonly known as “Stage 2 of meaningful use.” At more than 130 pages, the rule builds upon Stage 1 of the program mainly by increasing measurement thresholds and requiring higher levels of system functionality.

Although there are no major surprises within the proposed rule, there is always one very basic yet very important question that surfaces when meaningful use makes headlines: Are hospitalists eligible for health information technology (HIT) incentives and thus subject to the meaningful use requirements?

“No” is the short answer to this question. Although physicians, including hospitalists, are considered eligible professionals (EPs) under the HIT incentive program, a subset of EPs are defined as hospital-based EPs and, therefore, are not subject to the program’s requirements. CMS defines a hospital-based eligible professional as an EP who furnishes 90% or more of their covered professional services in either the inpatient division or ED of a hospital.

While some may call this an exemption for hospitalists, it is not that definitive. Hospitalists are still “eligible,” and the determination is not made by specialty, but by pattern of practice. This means that hospitalists could find themselves on the hook for future penalties if their practice patterns expand beyond CMS’ 90% threshold.

An example of this would be a hospitalist who spends time doing rounds at a nursing home. Today, this might constitute only a small percentage of a hospitalist’s practice, but with an increasingly aging population, it is not inconceivable that this small percentage could exceed 10% within five or 10 years.

With this in mind, and a similar scenario also present in the Electronic Prescribing Incentive Program (eRx), SHM has consistently pointed out the issue to CMS and is working to find an acceptable solution.

Although hospitalists are not currently subject to physician meaningful-use requirements, the program has another category of eligibility that will certainly affect hospitalists: the eligible hospital, or EH. Many hospitalists are directly involved with HIT implementation efforts at their institutions or are indirectly working with these systems as they are implemented and expanded in hospitals across the country.

Given the 90% eligibility threshold and the role of HIT in hospitals, it is important for hospitalists to stay current and informed on meaningful use and HIT policy. Involvement with one of SHM’s HIT related committees is a clear way to stay informed in this ever-evolving area, and SHM’s efforts can be reviewed on the Advocacy page of SHM’s website: www.hospitalmedicine.org/advocacy.

For the most up-to-date information on what is being done at the federal level, the Office of the National Coordinator (ONC) has a wealth of information available at www.healthit.gov/.

SHM will continue to monitor and analyze developments and changes to EHR policy, but it also looks to you, its members, for experience and insight.

To get where we want to go in American healthcare, we need a more thoroughly supported measure development infrastructure.

—Anne-Marie J. Audet, MD, MSc, SM, vice president, Health System Quality and Efficiency, Commonwealth Fund

The Centers for Medicare & Medicaid Services (CMS) has been publicly reporting performance measures on its Hospital Compare website (www.hospitalcompare.hhs.gov) since 2005, focusing on processes of care, patient outcomes, patient satisfaction, patient safety, and other measures. A recent addition of patient-safety metrics has rekindled skeptical questions about the validity, purpose, and effectiveness of public healthcare quality report cards, while highlighting the need for hospitalists and their institutions to remain vigilant in the struggle to ensure that they are compared and rewarded fairly and appropriately.

Provocative Measures

Last fall, CMS began posting “Serious Complications and Deaths” measures, developed by the Agency for Healthcare Research and Quality (AHRQ). The measures score individual hospitals according to the rates at which their patients suffer from:

• Pneumothorax due to medical treatment;
• Post-operative VTE;
• Post-operative abdominal or pelvic dehiscence; and
• Accidental lacerations from medical treatment.

Four other serious complication measures (pressure ulcers, catheter and bloodstream infections, and hip fractures from falling after surgery) are folded into a separate composite score for each hospital, while another composite score for “Deaths for Certain Conditions” is based on a hospital’s post-admission mortality rate for hip fractures, acute MI, heart failure, stroke, GI bleed, and pneumonia.

National and local media reports have thrust these dramatic metrics into the public eye, putting many hospitals on the spot to explain their putative breaches of patient safety. A closer inspection of the metrics, however, reveals plausible criticisms of their shortcomings.

Methodological Weakness

The new metrics are derived from Medicare claims data instead of medical chart abstractions, which experts say weakens their validity significantly and makes their use for provider profiling questionable. Moreover, claims data are based on records that were never designed to capture the sort of clinical nuances needed for valid and equitable risk adjustment (see “Methodological Challenges to Quality Metrics,” below). “Serious Complications and Deaths” rates based on these data, critics maintain, lack validity for meaningful hospital comparisons because they can exaggerate problems at hospitals that treat a high volume of complicated patients and use more invasive procedures to do so, such as teaching hospitals in academic medical centers.¹

The ante gets upped when CMS eventually begins adding patient-safety measures to the Hospital Value-Based Purchasing (HVBP) program, which rewards or punishes hospitals financially, depending on their performance on the metrics. CMS is considering adding the Serious Complications and Deaths measures to the HVPB program in the near future.

As the science of documenting and reporting patient harm struggles to find its footing, physicians and hospitals have to be more vigilant than ever to adopt a unified, organized approach to advocate the most appropriate processes and outcomes for which they will be held accountable, and avoid being cast in a reactive mode when metrics are imposed on them, says Patrick J. Torcson, MD, MMM, FACP, SFHM, chair of SHM’s Performance Measurement and Reporting Committee, and director of hospital medicine at St. Tammany Parish Hospital in Shreveport, La.

Last year, SHM sent comments to then-CMS administrator Don Berwick, expressing concern that the patient-safety measures CMS proposes to include in the HVBP program in fiscal-year 2014 are not endorsed by the National Quality Forum (NQF), that they are derived from billing and payment data that are not intended to be used primarily for clinical purposes, that the outcome measures are not entirely preventable even with the best of care, and that they are not adequately risk-adjusted.

“While it’s easy to agree with the experts that Hospital Compare’s patient-safety measures are not ready for prime time, it’s no longer acceptable simply to say, ‘These metrics are irrelevant,’” Dr. Torcson cautions. “We also must be aware of the evolution and inexorable movement of the nation’s healthcare quality and safety agenda. SHM embraces the triple aim of providing better care to our patients, promoting better health of patient populations, and doing so at a lower cost.”

The Power of “Why?”

Despite its imperfections, Hospital Compare’s greatest value is the power of its transparency, which fosters healthy discussion among providers, patients, and payors, according to Anne-Marie J. Audet, MD, MSc, SM, vice president for Health System Quality and Efficiency for the Commonwealth Fund. “That transparency gets providers’ attention and leads them to make changes that can translate into better performance,” she says, noting how hospital care for patients with heart attack, heart failure, and pneumonia has steadily improved in recent years, with the worst performers in 2009 doing as well or better than the best performers in 2004.

“There are also examples of hospitals that have gone from a median of four central line-associated bloodstream infections (CLABSI) per 1,000 line-days to zero because they decided not to take the status quo as acceptable,” says Stephen C. Schoenbaum, MD, MPH, special advisor to the president of the Josiah Macy Jr. Foundation. Dr. Schoenbaum played a significant role in the development of the Healthcare Effectiveness Data and Information Set, or HEDIS.

“There is no such thing as a perfect measure in which some adjustment or better collection method would not affect the numbers,” he notes. “Ideally, you want any publicly reported measure to get the poorer performers to come up with a way to explain their result. Or, even better, to improve their result.”

Methodological criticisms of CMS’ new “Serious Complications and Deaths” measures may be justified, Dr. Audet concedes, but she also notes that rigorous validation and reliability testing of quality measures is an expensive process. “To get where we want to go in American healthcare, we need a more thoroughly supported measure development infrastructure,” she says.

“In the meantime, providers will be probing the implications of their numbers, asking why they got the numbers they did, and what can be done about it. This attention can only lead to improvement, both in the measures themselves and in the care delivered.”

Indeed, one of the hospitals that was listed as having a high rate of accidental cuts and lacerations in the new measures found most of those cuts had been intended by the surgeon but erroneously billed to Medicare under the code for an accidental cut. Even with its methodological flaws, the Hospital Compare data led to root-cause analysis and improvement in coding.

Hospitalists’ Role

Hospitalists, according to Dr. Torcson, will be critical to the successful performance of hospitals under the HVPB program, as experts in quality and quality-measurement adherence. Hospitalists care for more hospitalized patients than any other physician group, and many believe they are uniquely positioned to lead the system-level changes and quality-improvement (QI) efforts that will be required.

“Hospitalists and their hospitals, practicing in alignment, become champions for their patients,” Dr. Torcson says. “SHM supported the HVBP program, and we foresee that the alignment of performance and payment within the program will inevitably result in better clinical outcomes for our patients.”

Chris Guadagnino is a freelance writer in Philadelphia.

References

1. Experts question Medicare’s effort to rate hospitals’ patient safety records. Kaiser Health News website. Available at: http://www.kaiserhealthnews.org/Stories/2012/February/13/medicare-hospital-patient-safety-records.aspx. Accessed March 12, 2012.
2. Shahian DM, Iezzoni LI, Meyer GS, Kirle L, Normand ST. Hospital-wide mortality as a quality metric: conceptual and methodological challenges. Am J Med Qual. 2012;27:112.

To get where we want to go in American healthcare, we need a more thoroughly supported measure development infrastructure.

—Anne-Marie J. Audet, MD, MSc, SM, vice president, Health System Quality and Efficiency, Commonwealth Fund

The Centers for Medicare & Medicaid Services (CMS) has been publicly reporting performance measures on its Hospital Compare website (www.hospitalcompare.hhs.gov) since 2005, focusing on processes of care, patient outcomes, patient satisfaction, patient safety, and other measures. A recent addition of patient-safety metrics has rekindled skeptical questions about the validity, purpose, and effectiveness of public healthcare quality report cards, while highlighting the need for hospitalists and their institutions to remain vigilant in the struggle to ensure that they are compared and rewarded fairly and appropriately.

Provocative Measures

Last fall, CMS began posting “Serious Complications and Deaths” measures, developed by the Agency for Healthcare Research and Quality (AHRQ). The measures score individual hospitals according to the rates at which their patients suffer from:

• Pneumothorax due to medical treatment;
• Post-operative VTE;
• Post-operative abdominal or pelvic dehiscence; and
• Accidental lacerations from medical treatment.

Four other serious complication measures (pressure ulcers, catheter and bloodstream infections, and hip fractures from falling after surgery) are folded into a separate composite score for each hospital, while another composite score for “Deaths for Certain Conditions” is based on a hospital’s post-admission mortality rate for hip fractures, acute MI, heart failure, stroke, GI bleed, and pneumonia.

National and local media reports have thrust these dramatic metrics into the public eye, putting many hospitals on the spot to explain their putative breaches of patient safety. A closer inspection of the metrics, however, reveals plausible criticisms of their shortcomings.

Methodological Weakness

The new metrics are derived from Medicare claims data instead of medical chart abstractions, which experts say weakens their validity significantly and makes their use for provider profiling questionable. Moreover, claims data are based on records that were never designed to capture the sort of clinical nuances needed for valid and equitable risk adjustment (see “Methodological Challenges to Quality Metrics,” below). “Serious Complications and Deaths” rates based on these data, critics maintain, lack validity for meaningful hospital comparisons because they can exaggerate problems at hospitals that treat a high volume of complicated patients and use more invasive procedures to do so, such as teaching hospitals in academic medical centers.¹

The ante gets upped when CMS eventually begins adding patient-safety measures to the Hospital Value-Based Purchasing (HVBP) program, which rewards or punishes hospitals financially, depending on their performance on the metrics. CMS is considering adding the Serious Complications and Deaths measures to the HVPB program in the near future.

As the science of documenting and reporting patient harm struggles to find its footing, physicians and hospitals have to be more vigilant than ever to adopt a unified, organized approach to advocate the most appropriate processes and outcomes for which they will be held accountable, and avoid being cast in a reactive mode when metrics are imposed on them, says Patrick J. Torcson, MD, MMM, FACP, SFHM, chair of SHM’s Performance Measurement and Reporting Committee, and director of hospital medicine at St. Tammany Parish Hospital in Shreveport, La.

Last year, SHM sent comments to then-CMS administrator Don Berwick, expressing concern that the patient-safety measures CMS proposes to include in the HVBP program in fiscal-year 2014 are not endorsed by the National Quality Forum (NQF), that they are derived from billing and payment data that are not intended to be used primarily for clinical purposes, that the outcome measures are not entirely preventable even with the best of care, and that they are not adequately risk-adjusted.

“While it’s easy to agree with the experts that Hospital Compare’s patient-safety measures are not ready for prime time, it’s no longer acceptable simply to say, ‘These metrics are irrelevant,’” Dr. Torcson cautions. “We also must be aware of the evolution and inexorable movement of the nation’s healthcare quality and safety agenda. SHM embraces the triple aim of providing better care to our patients, promoting better health of patient populations, and doing so at a lower cost.”

The Power of “Why?”

Despite its imperfections, Hospital Compare’s greatest value is the power of its transparency, which fosters healthy discussion among providers, patients, and payors, according to Anne-Marie J. Audet, MD, MSc, SM, vice president for Health System Quality and Efficiency for the Commonwealth Fund. “That transparency gets providers’ attention and leads them to make changes that can translate into better performance,” she says, noting how hospital care for patients with heart attack, heart failure, and pneumonia has steadily improved in recent years, with the worst performers in 2009 doing as well or better than the best performers in 2004.

“There are also examples of hospitals that have gone from a median of four central line-associated bloodstream infections (CLABSI) per 1,000 line-days to zero because they decided not to take the status quo as acceptable,” says Stephen C. Schoenbaum, MD, MPH, special advisor to the president of the Josiah Macy Jr. Foundation. Dr. Schoenbaum played a significant role in the development of the Healthcare Effectiveness Data and Information Set, or HEDIS.

“There is no such thing as a perfect measure in which some adjustment or better collection method would not affect the numbers,” he notes. “Ideally, you want any publicly reported measure to get the poorer performers to come up with a way to explain their result. Or, even better, to improve their result.”

Methodological criticisms of CMS’ new “Serious Complications and Deaths” measures may be justified, Dr. Audet concedes, but she also notes that rigorous validation and reliability testing of quality measures is an expensive process. “To get where we want to go in American healthcare, we need a more thoroughly supported measure development infrastructure,” she says.

“In the meantime, providers will be probing the implications of their numbers, asking why they got the numbers they did, and what can be done about it. This attention can only lead to improvement, both in the measures themselves and in the care delivered.”

Indeed, one of the hospitals that was listed as having a high rate of accidental cuts and lacerations in the new measures found most of those cuts had been intended by the surgeon but erroneously billed to Medicare under the code for an accidental cut. Even with its methodological flaws, the Hospital Compare data led to root-cause analysis and improvement in coding.

Hospitalists’ Role

Hospitalists, according to Dr. Torcson, will be critical to the successful performance of hospitals under the HVPB program, as experts in quality and quality-measurement adherence. Hospitalists care for more hospitalized patients than any other physician group, and many believe they are uniquely positioned to lead the system-level changes and quality-improvement (QI) efforts that will be required.

“Hospitalists and their hospitals, practicing in alignment, become champions for their patients,” Dr. Torcson says. “SHM supported the HVBP program, and we foresee that the alignment of performance and payment within the program will inevitably result in better clinical outcomes for our patients.”

Chris Guadagnino is a freelance writer in Philadelphia.

References

1. Experts question Medicare’s effort to rate hospitals’ patient safety records. Kaiser Health News website. Available at: http://www.kaiserhealthnews.org/Stories/2012/February/13/medicare-hospital-patient-safety-records.aspx. Accessed March 12, 2012.
2. Shahian DM, Iezzoni LI, Meyer GS, Kirle L, Normand ST. Hospital-wide mortality as a quality metric: conceptual and methodological challenges. Am J Med Qual. 2012;27:112.

To get where we want to go in American healthcare, we need a more thoroughly supported measure development infrastructure.

—Anne-Marie J. Audet, MD, MSc, SM, vice president, Health System Quality and Efficiency, Commonwealth Fund

The Centers for Medicare & Medicaid Services (CMS) has been publicly reporting performance measures on its Hospital Compare website (www.hospitalcompare.hhs.gov) since 2005, focusing on processes of care, patient outcomes, patient satisfaction, patient safety, and other measures. A recent addition of patient-safety metrics has rekindled skeptical questions about the validity, purpose, and effectiveness of public healthcare quality report cards, while highlighting the need for hospitalists and their institutions to remain vigilant in the struggle to ensure that they are compared and rewarded fairly and appropriately.

Provocative Measures

Last fall, CMS began posting “Serious Complications and Deaths” measures, developed by the Agency for Healthcare Research and Quality (AHRQ). The measures score individual hospitals according to the rates at which their patients suffer from:

• Pneumothorax due to medical treatment;
• Post-operative VTE;
• Post-operative abdominal or pelvic dehiscence; and
• Accidental lacerations from medical treatment.

Four other serious complication measures (pressure ulcers, catheter and bloodstream infections, and hip fractures from falling after surgery) are folded into a separate composite score for each hospital, while another composite score for “Deaths for Certain Conditions” is based on a hospital’s post-admission mortality rate for hip fractures, acute MI, heart failure, stroke, GI bleed, and pneumonia.

National and local media reports have thrust these dramatic metrics into the public eye, putting many hospitals on the spot to explain their putative breaches of patient safety. A closer inspection of the metrics, however, reveals plausible criticisms of their shortcomings.

Methodological Weakness

The new metrics are derived from Medicare claims data instead of medical chart abstractions, which experts say weakens their validity significantly and makes their use for provider profiling questionable. Moreover, claims data are based on records that were never designed to capture the sort of clinical nuances needed for valid and equitable risk adjustment (see “Methodological Challenges to Quality Metrics,” below). “Serious Complications and Deaths” rates based on these data, critics maintain, lack validity for meaningful hospital comparisons because they can exaggerate problems at hospitals that treat a high volume of complicated patients and use more invasive procedures to do so, such as teaching hospitals in academic medical centers.¹

The ante gets upped when CMS eventually begins adding patient-safety measures to the Hospital Value-Based Purchasing (HVBP) program, which rewards or punishes hospitals financially, depending on their performance on the metrics. CMS is considering adding the Serious Complications and Deaths measures to the HVPB program in the near future.

As the science of documenting and reporting patient harm struggles to find its footing, physicians and hospitals have to be more vigilant than ever to adopt a unified, organized approach to advocate the most appropriate processes and outcomes for which they will be held accountable, and avoid being cast in a reactive mode when metrics are imposed on them, says Patrick J. Torcson, MD, MMM, FACP, SFHM, chair of SHM’s Performance Measurement and Reporting Committee, and director of hospital medicine at St. Tammany Parish Hospital in Shreveport, La.

Last year, SHM sent comments to then-CMS administrator Don Berwick, expressing concern that the patient-safety measures CMS proposes to include in the HVBP program in fiscal-year 2014 are not endorsed by the National Quality Forum (NQF), that they are derived from billing and payment data that are not intended to be used primarily for clinical purposes, that the outcome measures are not entirely preventable even with the best of care, and that they are not adequately risk-adjusted.

“While it’s easy to agree with the experts that Hospital Compare’s patient-safety measures are not ready for prime time, it’s no longer acceptable simply to say, ‘These metrics are irrelevant,’” Dr. Torcson cautions. “We also must be aware of the evolution and inexorable movement of the nation’s healthcare quality and safety agenda. SHM embraces the triple aim of providing better care to our patients, promoting better health of patient populations, and doing so at a lower cost.”

The Power of “Why?”

Despite its imperfections, Hospital Compare’s greatest value is the power of its transparency, which fosters healthy discussion among providers, patients, and payors, according to Anne-Marie J. Audet, MD, MSc, SM, vice president for Health System Quality and Efficiency for the Commonwealth Fund. “That transparency gets providers’ attention and leads them to make changes that can translate into better performance,” she says, noting how hospital care for patients with heart attack, heart failure, and pneumonia has steadily improved in recent years, with the worst performers in 2009 doing as well or better than the best performers in 2004.

“There are also examples of hospitals that have gone from a median of four central line-associated bloodstream infections (CLABSI) per 1,000 line-days to zero because they decided not to take the status quo as acceptable,” says Stephen C. Schoenbaum, MD, MPH, special advisor to the president of the Josiah Macy Jr. Foundation. Dr. Schoenbaum played a significant role in the development of the Healthcare Effectiveness Data and Information Set, or HEDIS.

“There is no such thing as a perfect measure in which some adjustment or better collection method would not affect the numbers,” he notes. “Ideally, you want any publicly reported measure to get the poorer performers to come up with a way to explain their result. Or, even better, to improve their result.”

Methodological criticisms of CMS’ new “Serious Complications and Deaths” measures may be justified, Dr. Audet concedes, but she also notes that rigorous validation and reliability testing of quality measures is an expensive process. “To get where we want to go in American healthcare, we need a more thoroughly supported measure development infrastructure,” she says.

“In the meantime, providers will be probing the implications of their numbers, asking why they got the numbers they did, and what can be done about it. This attention can only lead to improvement, both in the measures themselves and in the care delivered.”

Indeed, one of the hospitals that was listed as having a high rate of accidental cuts and lacerations in the new measures found most of those cuts had been intended by the surgeon but erroneously billed to Medicare under the code for an accidental cut. Even with its methodological flaws, the Hospital Compare data led to root-cause analysis and improvement in coding.

Hospitalists’ Role

Hospitalists, according to Dr. Torcson, will be critical to the successful performance of hospitals under the HVPB program, as experts in quality and quality-measurement adherence. Hospitalists care for more hospitalized patients than any other physician group, and many believe they are uniquely positioned to lead the system-level changes and quality-improvement (QI) efforts that will be required.

“Hospitalists and their hospitals, practicing in alignment, become champions for their patients,” Dr. Torcson says. “SHM supported the HVBP program, and we foresee that the alignment of performance and payment within the program will inevitably result in better clinical outcomes for our patients.”

Chris Guadagnino is a freelance writer in Philadelphia.

References

1. Experts question Medicare’s effort to rate hospitals’ patient safety records. Kaiser Health News website. Available at: http://www.kaiserhealthnews.org/Stories/2012/February/13/medicare-hospital-patient-safety-records.aspx. Accessed March 12, 2012.
2. Shahian DM, Iezzoni LI, Meyer GS, Kirle L, Normand ST. Hospital-wide mortality as a quality metric: conceptual and methodological challenges. Am J Med Qual. 2012;27:112.

Efforts to create a greater sense of urgency over patient satisfaction within the hospitalist service at the Cleveland Clinic using an eight-step model for changing organizational culture were outlined in an abstract presented at HM11.

“Attention to the doctor-patient experience should be our guiding principle,” explains lead author and hospitalist Vicente Velez, MD. “No matter how complex the science of medicine gets, the art is equally important.” Physicians can be taught skills in effective communication with their patients and families, Dr. Velez adds.

The initiative began four years ago after the department identified low patient satisfaction scores as a “credibility crisis.” Leadership sprung into action, promoting a vision that HM should be known for its ability to communicate. “Regardless of individual communication style, a proper self-introduction, eliciting the patient’s perspective, and an explanation of the daily plan of care were things we all had to develop as habits,” he says.

Individual projects to advance the agenda included:

• Communication training offered to all physicians at the Cleveland Clinic;
• New business cards with the hospitalists’ pictures on them;
• A pre-discharge “fly-by” visit from the hospitalist;
• Post-discharge callbacks to patients; and
• Joint physician-nurse rounding.

The service now shares its Hospital Consumer Assessment of Healthcare Providers and Systems Survey (HCAHPS) satisfaction scores for individual physicians in small groups or one-on-one meetings. The department recognizes high performers. Overall satisfaction scores rose to between 76% and 86%, up from 69% at the start of the project, Dr. Velez says.

Reference

1. Accenture. U.S. among leaders in healthcare IT use and adoption, Accenture eight-country study reports. Accenture website. Available at: http://newsroom.accenture.com/news/us-among-leaders-in-healthcare-it-use-and-adoption-accenture-eight-country-study-reports.htm. Accessed March 29, 2012.

Efforts to create a greater sense of urgency over patient satisfaction within the hospitalist service at the Cleveland Clinic using an eight-step model for changing organizational culture were outlined in an abstract presented at HM11.

“Attention to the doctor-patient experience should be our guiding principle,” explains lead author and hospitalist Vicente Velez, MD. “No matter how complex the science of medicine gets, the art is equally important.” Physicians can be taught skills in effective communication with their patients and families, Dr. Velez adds.

The initiative began four years ago after the department identified low patient satisfaction scores as a “credibility crisis.” Leadership sprung into action, promoting a vision that HM should be known for its ability to communicate. “Regardless of individual communication style, a proper self-introduction, eliciting the patient’s perspective, and an explanation of the daily plan of care were things we all had to develop as habits,” he says.

Individual projects to advance the agenda included:

• Communication training offered to all physicians at the Cleveland Clinic;
• New business cards with the hospitalists’ pictures on them;
• A pre-discharge “fly-by” visit from the hospitalist;
• Post-discharge callbacks to patients; and
• Joint physician-nurse rounding.

The service now shares its Hospital Consumer Assessment of Healthcare Providers and Systems Survey (HCAHPS) satisfaction scores for individual physicians in small groups or one-on-one meetings. The department recognizes high performers. Overall satisfaction scores rose to between 76% and 86%, up from 69% at the start of the project, Dr. Velez says.

Reference

1. Accenture. U.S. among leaders in healthcare IT use and adoption, Accenture eight-country study reports. Accenture website. Available at: http://newsroom.accenture.com/news/us-among-leaders-in-healthcare-it-use-and-adoption-accenture-eight-country-study-reports.htm. Accessed March 29, 2012.

Efforts to create a greater sense of urgency over patient satisfaction within the hospitalist service at the Cleveland Clinic using an eight-step model for changing organizational culture were outlined in an abstract presented at HM11.

“Attention to the doctor-patient experience should be our guiding principle,” explains lead author and hospitalist Vicente Velez, MD. “No matter how complex the science of medicine gets, the art is equally important.” Physicians can be taught skills in effective communication with their patients and families, Dr. Velez adds.

The initiative began four years ago after the department identified low patient satisfaction scores as a “credibility crisis.” Leadership sprung into action, promoting a vision that HM should be known for its ability to communicate. “Regardless of individual communication style, a proper self-introduction, eliciting the patient’s perspective, and an explanation of the daily plan of care were things we all had to develop as habits,” he says.

Individual projects to advance the agenda included:

• Communication training offered to all physicians at the Cleveland Clinic;
• New business cards with the hospitalists’ pictures on them;
• A pre-discharge “fly-by” visit from the hospitalist;
• Post-discharge callbacks to patients; and
• Joint physician-nurse rounding.

The service now shares its Hospital Consumer Assessment of Healthcare Providers and Systems Survey (HCAHPS) satisfaction scores for individual physicians in small groups or one-on-one meetings. The department recognizes high performers. Overall satisfaction scores rose to between 76% and 86%, up from 69% at the start of the project, Dr. Velez says.

Reference

1. Accenture. U.S. among leaders in healthcare IT use and adoption, Accenture eight-country study reports. Accenture website. Available at: http://newsroom.accenture.com/news/us-among-leaders-in-healthcare-it-use-and-adoption-accenture-eight-country-study-reports.htm. Accessed March 29, 2012.

Approximate number of million-dollar hospitalization bills in Northern California hospitals in 2010, up from 430 a decade earlier, according to statistics from the Office of Statewide Health Planning and Development.¹ More than 20% of the giant bills—typically for complicated, life-saving procedures and lengthy hospital stays following critical illness or trauma—went to the parents of newborn babies with catastrophic illnesses. Organ transplants were also associated with extended hospital stays and million-dollar price tags.

Medical bills are a major factor in two-thirds of personal bankruptcy cases, although most of the largest bills will be lowered significantly, as much as 80%, after negotiations between hospitals and insurers.

Reference

1. Reese P, Smith D. Million-dollar hospital bills rise sharply in Northern California. Sacramento Bee website. Available at: http://www.sacbee.com/2012/03/11/4328036/million-dollar-hospital-bills.html. Accessed March 29, 2012.

Approximate number of million-dollar hospitalization bills in Northern California hospitals in 2010, up from 430 a decade earlier, according to statistics from the Office of Statewide Health Planning and Development.¹ More than 20% of the giant bills—typically for complicated, life-saving procedures and lengthy hospital stays following critical illness or trauma—went to the parents of newborn babies with catastrophic illnesses. Organ transplants were also associated with extended hospital stays and million-dollar price tags.

Medical bills are a major factor in two-thirds of personal bankruptcy cases, although most of the largest bills will be lowered significantly, as much as 80%, after negotiations between hospitals and insurers.

Reference

1. Reese P, Smith D. Million-dollar hospital bills rise sharply in Northern California. Sacramento Bee website. Available at: http://www.sacbee.com/2012/03/11/4328036/million-dollar-hospital-bills.html. Accessed March 29, 2012.

Approximate number of million-dollar hospitalization bills in Northern California hospitals in 2010, up from 430 a decade earlier, according to statistics from the Office of Statewide Health Planning and Development.¹ More than 20% of the giant bills—typically for complicated, life-saving procedures and lengthy hospital stays following critical illness or trauma—went to the parents of newborn babies with catastrophic illnesses. Organ transplants were also associated with extended hospital stays and million-dollar price tags.

Medical bills are a major factor in two-thirds of personal bankruptcy cases, although most of the largest bills will be lowered significantly, as much as 80%, after negotiations between hospitals and insurers.

Reference

1. Reese P, Smith D. Million-dollar hospital bills rise sharply in Northern California. Sacramento Bee website. Available at: http://www.sacbee.com/2012/03/11/4328036/million-dollar-hospital-bills.html. Accessed March 29, 2012.

Both incidence and deaths related to the bacterial infection Clostridium difficile have reached an all-time high, according to the federal Centers for Disease Control and Prevention (CDC), which calls C. diff “a formidable opponent” and a widespread safety issue. A total of 14,000 deaths related to C. diff were reported during the period of 2006-2007, compared with 3,000 in 1999-2000. A quarter of infections now appear first in hospitalized patients, with the rest in nursing home residents or patients in doctors’ offices.

L. Clifford McDonald, MD, CDC epidemiologist and lead author of a recent CDC Vital Signs report on the subject, recommended several steps for reducing C. diff infections, starting with better antibiotic stewardship, early detection and isolation for those who test positive, use of gloves and gowns when treating them, and informing the receiving medical team when those patients are transferred.¹ Dr. McDonald also noted that state-led hospital collaboratives in Illinois, Massachusetts, and New York have reduced infection rates by 20%.

Another recent example of successful antibiotic stewardship comes from the University of Maryland Medical Center (UMMC) and Health Day News, summarizing a study in the journal Infection Control and Hospital Epidemiology.²

A seven-year stewardship program using an anti-microbial monitoring team generated a $3 million reduction in the hospital’s annual budget for antibiotics by its third year, with no increase in death rates, hospital readmissions, or length of stay. After seven years, antibiotic spending per patient per day had been cut by nearly half. The antibiotic stewardship program was canceled in 2008 in favor of providing more infectious-disease consulting as an alternative mode of stewardship. Over the subsequent two years, antibiotic costs went back up 32%, reports lead author Harold Standiford, MD.

“Our results clearly show that an antimicrobial stewardship program like the one at UMMC is safe, effective, and makes good financial sense,” he says, adding physicians should eliminate wasteful healthcare spending.

References

1. Centers for Disease Control and Prevention. Vital signs: preventing Clostridium difficile infections. Centers for Disease Control and Prevention website. Available at: http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6109a3.htm. Accessed March 29, 2012.
2. Standiford HC, Chan S, Tripoli M, Weekes E, Forrest GN. Antimicrobial stewardship at a large tertiary care academic medical center: cost analysis before, during, and after a 7-year program. Infect Control Hosp Epidemiol. 2012;33(4);338-345.

Both incidence and deaths related to the bacterial infection Clostridium difficile have reached an all-time high, according to the federal Centers for Disease Control and Prevention (CDC), which calls C. diff “a formidable opponent” and a widespread safety issue. A total of 14,000 deaths related to C. diff were reported during the period of 2006-2007, compared with 3,000 in 1999-2000. A quarter of infections now appear first in hospitalized patients, with the rest in nursing home residents or patients in doctors’ offices.

L. Clifford McDonald, MD, CDC epidemiologist and lead author of a recent CDC Vital Signs report on the subject, recommended several steps for reducing C. diff infections, starting with better antibiotic stewardship, early detection and isolation for those who test positive, use of gloves and gowns when treating them, and informing the receiving medical team when those patients are transferred.¹ Dr. McDonald also noted that state-led hospital collaboratives in Illinois, Massachusetts, and New York have reduced infection rates by 20%.

Another recent example of successful antibiotic stewardship comes from the University of Maryland Medical Center (UMMC) and Health Day News, summarizing a study in the journal Infection Control and Hospital Epidemiology.²

A seven-year stewardship program using an anti-microbial monitoring team generated a $3 million reduction in the hospital’s annual budget for antibiotics by its third year, with no increase in death rates, hospital readmissions, or length of stay. After seven years, antibiotic spending per patient per day had been cut by nearly half. The antibiotic stewardship program was canceled in 2008 in favor of providing more infectious-disease consulting as an alternative mode of stewardship. Over the subsequent two years, antibiotic costs went back up 32%, reports lead author Harold Standiford, MD.

“Our results clearly show that an antimicrobial stewardship program like the one at UMMC is safe, effective, and makes good financial sense,” he says, adding physicians should eliminate wasteful healthcare spending.

References

1. Centers for Disease Control and Prevention. Vital signs: preventing Clostridium difficile infections. Centers for Disease Control and Prevention website. Available at: http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6109a3.htm. Accessed March 29, 2012.
2. Standiford HC, Chan S, Tripoli M, Weekes E, Forrest GN. Antimicrobial stewardship at a large tertiary care academic medical center: cost analysis before, during, and after a 7-year program. Infect Control Hosp Epidemiol. 2012;33(4);338-345.

Both incidence and deaths related to the bacterial infection Clostridium difficile have reached an all-time high, according to the federal Centers for Disease Control and Prevention (CDC), which calls C. diff “a formidable opponent” and a widespread safety issue. A total of 14,000 deaths related to C. diff were reported during the period of 2006-2007, compared with 3,000 in 1999-2000. A quarter of infections now appear first in hospitalized patients, with the rest in nursing home residents or patients in doctors’ offices.

L. Clifford McDonald, MD, CDC epidemiologist and lead author of a recent CDC Vital Signs report on the subject, recommended several steps for reducing C. diff infections, starting with better antibiotic stewardship, early detection and isolation for those who test positive, use of gloves and gowns when treating them, and informing the receiving medical team when those patients are transferred.¹ Dr. McDonald also noted that state-led hospital collaboratives in Illinois, Massachusetts, and New York have reduced infection rates by 20%.

Another recent example of successful antibiotic stewardship comes from the University of Maryland Medical Center (UMMC) and Health Day News, summarizing a study in the journal Infection Control and Hospital Epidemiology.²

A seven-year stewardship program using an anti-microbial monitoring team generated a $3 million reduction in the hospital’s annual budget for antibiotics by its third year, with no increase in death rates, hospital readmissions, or length of stay. After seven years, antibiotic spending per patient per day had been cut by nearly half. The antibiotic stewardship program was canceled in 2008 in favor of providing more infectious-disease consulting as an alternative mode of stewardship. Over the subsequent two years, antibiotic costs went back up 32%, reports lead author Harold Standiford, MD.

“Our results clearly show that an antimicrobial stewardship program like the one at UMMC is safe, effective, and makes good financial sense,” he says, adding physicians should eliminate wasteful healthcare spending.

References

1. Centers for Disease Control and Prevention. Vital signs: preventing Clostridium difficile infections. Centers for Disease Control and Prevention website. Available at: http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6109a3.htm. Accessed March 29, 2012.
2. Standiford HC, Chan S, Tripoli M, Weekes E, Forrest GN. Antimicrobial stewardship at a large tertiary care academic medical center: cost analysis before, during, and after a 7-year program. Infect Control Hosp Epidemiol. 2012;33(4);338-345.

In January, the American Medical Association (AMA) announced a redesigned website for its Practice Management Center (PMC), a resource designed to help physicians manage their practice more effectively. The PMC includes an online library of tools to help physicians streamline their administrative and business practices, with new sections on practice operations, claims revenue cycle management, and health insurer relations.

An estimated 7,000 visitors access the center each month. Physicians can sign up for practice management alerts or join an online community.

One particular resource that might be useful to hospitalists is a sample hospital-physician employment agreement.

In January, the American Medical Association (AMA) announced a redesigned website for its Practice Management Center (PMC), a resource designed to help physicians manage their practice more effectively. The PMC includes an online library of tools to help physicians streamline their administrative and business practices, with new sections on practice operations, claims revenue cycle management, and health insurer relations.

An estimated 7,000 visitors access the center each month. Physicians can sign up for practice management alerts or join an online community.

One particular resource that might be useful to hospitalists is a sample hospital-physician employment agreement.

In January, the American Medical Association (AMA) announced a redesigned website for its Practice Management Center (PMC), a resource designed to help physicians manage their practice more effectively. The PMC includes an online library of tools to help physicians streamline their administrative and business practices, with new sections on practice operations, claims revenue cycle management, and health insurer relations.

An estimated 7,000 visitors access the center each month. Physicians can sign up for practice management alerts or join an online community.

One particular resource that might be useful to hospitalists is a sample hospital-physician employment agreement.

A study in the March issue of Health Affairs concludes that Hospital Compare, the government’s national hospital quality data reporting system, has produced no reductions in 30-day mortality rates for heart attacks and pneumonia, beyond what would be expected due to existing trends and ongoing innovations in care.¹ The data were inconclusive on the impact of reporting on heart failure.

The survey covers Medicare claims data from 2000 to 2008. Its authors say it is one of the strongest studies yet, suggesting that Medicare’s public reporting has little or no impact on actual hospital quality—at least according to current metrics. The jury is still out on Medicare’s efforts to improve hospital quality of care with public reporting, with more study needed, according to lead author Andrew Ryan, MD, of Weill Cornell Medical College in New York City.

Reference

1. Ryan AM, Nallamothu BK, Dimick JB. Medicare’s public reporting initiative on hospital quality had modest or no impact on mortality from three key conditions. Health Aff (Millwood). 2012;31(3):585-592.

A study in the March issue of Health Affairs concludes that Hospital Compare, the government’s national hospital quality data reporting system, has produced no reductions in 30-day mortality rates for heart attacks and pneumonia, beyond what would be expected due to existing trends and ongoing innovations in care.¹ The data were inconclusive on the impact of reporting on heart failure.

The survey covers Medicare claims data from 2000 to 2008. Its authors say it is one of the strongest studies yet, suggesting that Medicare’s public reporting has little or no impact on actual hospital quality—at least according to current metrics. The jury is still out on Medicare’s efforts to improve hospital quality of care with public reporting, with more study needed, according to lead author Andrew Ryan, MD, of Weill Cornell Medical College in New York City.

Reference

1. Ryan AM, Nallamothu BK, Dimick JB. Medicare’s public reporting initiative on hospital quality had modest or no impact on mortality from three key conditions. Health Aff (Millwood). 2012;31(3):585-592.

A study in the March issue of Health Affairs concludes that Hospital Compare, the government’s national hospital quality data reporting system, has produced no reductions in 30-day mortality rates for heart attacks and pneumonia, beyond what would be expected due to existing trends and ongoing innovations in care.¹ The data were inconclusive on the impact of reporting on heart failure.

The survey covers Medicare claims data from 2000 to 2008. Its authors say it is one of the strongest studies yet, suggesting that Medicare’s public reporting has little or no impact on actual hospital quality—at least according to current metrics. The jury is still out on Medicare’s efforts to improve hospital quality of care with public reporting, with more study needed, according to lead author Andrew Ryan, MD, of Weill Cornell Medical College in New York City.

Reference

1. Ryan AM, Nallamothu BK, Dimick JB. Medicare’s public reporting initiative on hospital quality had modest or no impact on mortality from three key conditions. Health Aff (Millwood). 2012;31(3):585-592.

Jan. 1 marked the official start of the Accountable Care Organization (ACO) era, with 32 Pioneer ACOs across the country beginning a three-year program embracing the “three-part aim” of improving the health of the population, enhancing patient experience, and making costs sustainable. Later this year, many more ACOs will come on line around the country under the Medicare Shared Savings Program. Perhaps the biggest challenge to ACOs will be the management of the complex medically ill, or those individuals with two or more concurrent chronic conditions that require ongoing medical attention and/or limit activities of daily living.

In 2011, SHM embarked on a groundbreaking project to improve care coordination between hospitalists and primary-care physicians (PCPs). The Complex Medically Ill Project is being carried out at three health systems and has already had a positive impact. As part of the project, SHM is working with a mobile and online physician community, QuantiaMD, to both learn and teach during the one-year project. Parenthetically, in a short time, the collaboration has yielded glimpses of the potential of mobile technology to improve healthcare, or at least learn about physician attitudes and preferences.

In November 2011, SHM queried hospitalists and PCPs about communication and care coordination between the two specialties regarding treatment of the complex medically ill patient. Remarkably, 4,000 PCPs and hospitalists responded to the survey. In less than a month, we collected more information on this crucial topic than at any other time in the past.

SHM has prepared a white paper that will provide a full picture of what we learned. Here is a preview of the survey findings:

• Improvement efforts in hospitalist-PCP communication should focus on 1) the hospital discharge and 2) the “black hole” —the time between hospital discharge and first follow-up with a PCP;
• Hospitalists and PCPs feel that the telephone currently is the best communication tool, but both groups agree that technology solutions will improve care coordination more than human resources (e.g. a transitions coach) or process improvement (e.g. checklists or discharge bundles);
• PCPs should be more involved in the inpatient care of the complex medically ill; and
• There is a high degree of alignment between PCPs and hospitalists regarding the importance of robust communication for complex medically ill patients.

As ACOs and other approaches to payment innovation expand to effectively manage the health of a population, HM must evolve its focus away from just managing the individual patient during an acute hospitalization and toward a true collaboration with PCPs and the medical home. What will this look like? In pockets across the country, there are hospitalist systems that have enabled 1990s-style managed care to survive and thrive under Medicare Advantage programs (physician groups and hospitals that have aligned incentives under capitated or global payments). They provide some of the best insight into how HM can embrace population health management. The key elements of these hospitalist programs include:

• Aligned incentives with PCPs (and in some cases specialists) and the hospital under a global payment for a population of patients;
• Active participation in disease-management programs for patients, especially the complex medically ill, across the care continuum, including the home and post-acute-care venues;
• Use of “front-end” technology to coordinate care with the PCP and other members of the care team; and
• Use of “back-end” technology to 1) track key measures of healthcare quality and population health, 2) measure and manage utilization of resources, and 3) accurately capture severity of population illness.

SHM’s Complex Medically Ill Project will be one of a number of “test tubes” for care coordination in HM as it transitions from fee-for-service to global payment and population health management. The coming months will see the start of the ACO voyage for a few hundred health systems and their hospitalist programs.

Additionally, Medicare Advantage programs continue to grow, fueling efforts at better coordination and disease management, with hospitalists squarely in the mix. Surely, each of these will represent an experiment in the design of systems for population health management.

While it is anyone’s guess as to whether these policy initiatives will have a major impact on cost containment while maintaining quality and access, it is hard to imagine the brave new world without a retooled hospitalist model that plays an integral role in population health.

Win Whitcomb, MD, MHM is medical director of healthcare quality at Baystate Medical Center in Springfield, Mass. He is a co-founder and past president of SHM. Email him at wfwhit@comcast.net.

Jan. 1 marked the official start of the Accountable Care Organization (ACO) era, with 32 Pioneer ACOs across the country beginning a three-year program embracing the “three-part aim” of improving the health of the population, enhancing patient experience, and making costs sustainable. Later this year, many more ACOs will come on line around the country under the Medicare Shared Savings Program. Perhaps the biggest challenge to ACOs will be the management of the complex medically ill, or those individuals with two or more concurrent chronic conditions that require ongoing medical attention and/or limit activities of daily living.

In 2011, SHM embarked on a groundbreaking project to improve care coordination between hospitalists and primary-care physicians (PCPs). The Complex Medically Ill Project is being carried out at three health systems and has already had a positive impact. As part of the project, SHM is working with a mobile and online physician community, QuantiaMD, to both learn and teach during the one-year project. Parenthetically, in a short time, the collaboration has yielded glimpses of the potential of mobile technology to improve healthcare, or at least learn about physician attitudes and preferences.

In November 2011, SHM queried hospitalists and PCPs about communication and care coordination between the two specialties regarding treatment of the complex medically ill patient. Remarkably, 4,000 PCPs and hospitalists responded to the survey. In less than a month, we collected more information on this crucial topic than at any other time in the past.

SHM has prepared a white paper that will provide a full picture of what we learned. Here is a preview of the survey findings:

• Improvement efforts in hospitalist-PCP communication should focus on 1) the hospital discharge and 2) the “black hole” —the time between hospital discharge and first follow-up with a PCP;
• Hospitalists and PCPs feel that the telephone currently is the best communication tool, but both groups agree that technology solutions will improve care coordination more than human resources (e.g. a transitions coach) or process improvement (e.g. checklists or discharge bundles);
• PCPs should be more involved in the inpatient care of the complex medically ill; and
• There is a high degree of alignment between PCPs and hospitalists regarding the importance of robust communication for complex medically ill patients.

As ACOs and other approaches to payment innovation expand to effectively manage the health of a population, HM must evolve its focus away from just managing the individual patient during an acute hospitalization and toward a true collaboration with PCPs and the medical home. What will this look like? In pockets across the country, there are hospitalist systems that have enabled 1990s-style managed care to survive and thrive under Medicare Advantage programs (physician groups and hospitals that have aligned incentives under capitated or global payments). They provide some of the best insight into how HM can embrace population health management. The key elements of these hospitalist programs include:

• Aligned incentives with PCPs (and in some cases specialists) and the hospital under a global payment for a population of patients;
• Active participation in disease-management programs for patients, especially the complex medically ill, across the care continuum, including the home and post-acute-care venues;
• Use of “front-end” technology to coordinate care with the PCP and other members of the care team; and
• Use of “back-end” technology to 1) track key measures of healthcare quality and population health, 2) measure and manage utilization of resources, and 3) accurately capture severity of population illness.

SHM’s Complex Medically Ill Project will be one of a number of “test tubes” for care coordination in HM as it transitions from fee-for-service to global payment and population health management. The coming months will see the start of the ACO voyage for a few hundred health systems and their hospitalist programs.

Additionally, Medicare Advantage programs continue to grow, fueling efforts at better coordination and disease management, with hospitalists squarely in the mix. Surely, each of these will represent an experiment in the design of systems for population health management.

While it is anyone’s guess as to whether these policy initiatives will have a major impact on cost containment while maintaining quality and access, it is hard to imagine the brave new world without a retooled hospitalist model that plays an integral role in population health.

Win Whitcomb, MD, MHM is medical director of healthcare quality at Baystate Medical Center in Springfield, Mass. He is a co-founder and past president of SHM. Email him at wfwhit@comcast.net.

Jan. 1 marked the official start of the Accountable Care Organization (ACO) era, with 32 Pioneer ACOs across the country beginning a three-year program embracing the “three-part aim” of improving the health of the population, enhancing patient experience, and making costs sustainable. Later this year, many more ACOs will come on line around the country under the Medicare Shared Savings Program. Perhaps the biggest challenge to ACOs will be the management of the complex medically ill, or those individuals with two or more concurrent chronic conditions that require ongoing medical attention and/or limit activities of daily living.

In 2011, SHM embarked on a groundbreaking project to improve care coordination between hospitalists and primary-care physicians (PCPs). The Complex Medically Ill Project is being carried out at three health systems and has already had a positive impact. As part of the project, SHM is working with a mobile and online physician community, QuantiaMD, to both learn and teach during the one-year project. Parenthetically, in a short time, the collaboration has yielded glimpses of the potential of mobile technology to improve healthcare, or at least learn about physician attitudes and preferences.

In November 2011, SHM queried hospitalists and PCPs about communication and care coordination between the two specialties regarding treatment of the complex medically ill patient. Remarkably, 4,000 PCPs and hospitalists responded to the survey. In less than a month, we collected more information on this crucial topic than at any other time in the past.

SHM has prepared a white paper that will provide a full picture of what we learned. Here is a preview of the survey findings:

• Improvement efforts in hospitalist-PCP communication should focus on 1) the hospital discharge and 2) the “black hole” —the time between hospital discharge and first follow-up with a PCP;
• Hospitalists and PCPs feel that the telephone currently is the best communication tool, but both groups agree that technology solutions will improve care coordination more than human resources (e.g. a transitions coach) or process improvement (e.g. checklists or discharge bundles);
• PCPs should be more involved in the inpatient care of the complex medically ill; and
• There is a high degree of alignment between PCPs and hospitalists regarding the importance of robust communication for complex medically ill patients.

As ACOs and other approaches to payment innovation expand to effectively manage the health of a population, HM must evolve its focus away from just managing the individual patient during an acute hospitalization and toward a true collaboration with PCPs and the medical home. What will this look like? In pockets across the country, there are hospitalist systems that have enabled 1990s-style managed care to survive and thrive under Medicare Advantage programs (physician groups and hospitals that have aligned incentives under capitated or global payments). They provide some of the best insight into how HM can embrace population health management. The key elements of these hospitalist programs include:

• Aligned incentives with PCPs (and in some cases specialists) and the hospital under a global payment for a population of patients;
• Active participation in disease-management programs for patients, especially the complex medically ill, across the care continuum, including the home and post-acute-care venues;
• Use of “front-end” technology to coordinate care with the PCP and other members of the care team; and
• Use of “back-end” technology to 1) track key measures of healthcare quality and population health, 2) measure and manage utilization of resources, and 3) accurately capture severity of population illness.

SHM’s Complex Medically Ill Project will be one of a number of “test tubes” for care coordination in HM as it transitions from fee-for-service to global payment and population health management. The coming months will see the start of the ACO voyage for a few hundred health systems and their hospitalist programs.

Additionally, Medicare Advantage programs continue to grow, fueling efforts at better coordination and disease management, with hospitalists squarely in the mix. Surely, each of these will represent an experiment in the design of systems for population health management.

While it is anyone’s guess as to whether these policy initiatives will have a major impact on cost containment while maintaining quality and access, it is hard to imagine the brave new world without a retooled hospitalist model that plays an integral role in population health.

Win Whitcomb, MD, MHM is medical director of healthcare quality at Baystate Medical Center in Springfield, Mass. He is a co-founder and past president of SHM. Email him at wfwhit@comcast.net.

As the train of healthcare reform has undeniably left the station and presently is barreling down the tracks with unstoppable momentum, the need for the specialty of hospital medicine to truly perform as an agent of high-quality, cost-effective care delivery is of paramount importance. By perform, I mean deliver measurable results, and truly realize expectations that we have set for ourselves as a profession—a profession that has claimed since its infancy that a core justification for its existence is the ability for it to realize the goals of healthcare quality improvement (QI).

We have done much in our short history to position ourselves to realize these goals, and in many of our hospitals and communities, we are delivering tangible results. In some settings, however, we could do more. Essential to capitalizing on these performance-improvement opportunities is ensuring every hospitalist and every HM professional commits personally to making high-quality care delivery a non-negotiable proposition.

Accountability is at issue here. We all must strive to consistently hold ourselves, and each other, personally accountable for embracing the work necessary to realize HM’s potential to be a true healthcare reform effector. We have to “put our money where our mouth is” by delivering tangible performance results.

The Accountability Imperative

If there are any doubts about the need for accountability to drive performance in today’s healthcare climate, one need not look further than work ongoing to redesign the manner in which healthcare is delivered through the creation of Accountable Care Organizations (ACOs). The ACO concept is complicated and confusing, and it is doubtful that anyone knows with certainty how it will work. One thing though that should be clear is that ACOs will not be successful unless each of their members is accountable for delivering high-value healthcare—the “A” in the acronym, after all, stands for “accountable.”

Advancing the accountability imperative further is a New England Journal of Medicine sounding board article by Wachter and Pronovost, where it is eloquently argued that the time has come to hold individuals accountable for sub-optimal performance on those quality imperatives for which broken systems have been successfully redesigned.¹ The authors propose that it is no longer appropriate to blame systems failures as the reason for inadequate performance, because clinicians who fail to hold themselves accountable for working within the context of successfully redesigned systems is often the relevant problem.

The authors use hand hygiene as an example, noting that despite such efforts as extensive education, increased access to hand-washing materials, and creative auditing efforts to measure performance, hospitals continue to have unacceptably low hand hygiene rates. They argue that “low hand hygiene rates are generally not a systems problem anymore; they are largely an accountability problem.” They also cite “following an institution’s guidelines regarding provider-to-provider signout at the end of a shift” as an issue of unique importance to hospitalist practice.

Emphasizing that disciplinary action is in order for poor-performing individuals, Wachter and Pronovost conclude that it is time for us to place accountability for the delivery of high-quality care at the top of our agenda. If we do not, the authors believe, regulators “are likely to judge” our lack of accountability “as an example of guild behavior,” that will result in “further intrusion on the practice of medicine.” They go on to suggest that “having our own profession unblinkingly deem some behaviors as unacceptable, with clear consequences, will serve as a vivid example of our professionalism, and thus represent our best protection against such outside intrusions.”1

Avoiding outside intrusions, however, should not be the primary motivator. We should hold ourselves accountable for high-quality care delivery because it is the right thing to do, and our patients deserve nothing less. It is time for HM to get serious by not tolerating performance failures due to accountability lapses. We must define clear, non-negotiable performance imperatives (e.g. hand hygiene and adequate end-of-shift signouts), and demand accountability by not being afraid to enforce penalties for habitual failure to meet expectations.

Accountability and Autonomy

Accountability is hard, and in healthcare it is tempting to avoid responsibility by invoking myriad excuses as to why we cannot or should not be held individually accountable. An oft-cited excuse for why physicians should not be expected to comply with QI initiatives is that doing so threatens a physician’s ability to customize care in situations in which unique circumstances necessitate customization. The argument advanced is that “medicine is an art,” and as such physicians must be permitted to act autonomously. Inevitably, these arguments proceed by invoking problems created by a decline in the degree of physician decision-making independence, and further lament a loss of autonomy.

Reinertsen has written about why the medical profession has witnessed a decline in autonomy over the past decades.² He notes that physicians have done a poor job in holding themselves accountable for consistently practicing the science of medicine, thus necessitating the imposition of rules and regulations to ensure that every patient always receives the best care. While calling this out, Reinertsen acknowledges a place for autonomy in the practice of medicine by writing: “If clinical autonomy is good for the art of medicine … we should do a better job of policing our profession by dealing firmly and effectively with those of our colleagues who do not fulfill their professional obligations of quality and integrity.”

Reinertsen’s argument is beautiful in its simplicity. Furthermore, it emphasizes the accountability imperative considered above by Wachter and Pronovost. We cannot ignore that accountability failures by some of our physician predecessors are directly responsible for the quality problems that we currently face, and we must accept this as a legitimate reason for our diminishing professional autonomy. To correct this going forward, we have to hold each other and ourselves accountable for doing what is right, for it is only then that we will regain our autonomy by earning the trust and respect of the patients and the system that we serve.

Failure to Perform Not an Option

It is undeniable that in its brief history, HM has done fabulous things for patients through redesigning faulty healthcare systems that compromise our ability to consistently deliver high-quality care. It also is true, however, that we have made promises that we have yet to decisively deliver on. The time is now to definitively perform by delivering tangible results that realize those promises.

Former Notre Dame University football coach Lou Holtz once said, “When all is said and done, a lot more is said than done.” Unfortunately, this is often true in our society, and should cause hospitalists to pause and reflect on how to prevent this from happening. After national healthcare reform is complete, we must be able to say “it has been said and done, and we did it all.”

Our legacy and the future success of HM depend on this. To guarantee we reach our full potential tomorrow, we must hold ourselves accountable today for executing on what is expected of us as agents of high-quality, cost-effective care delivery.

Dr. Frost is president of SHM.

References

1. Wachter RM, Pronovost PJ. Balancing “no blame” with accountability in patient safety. N Engl J Med. 2009;361;14:1401-1406.
2. Reinertsen J. Zen and the art of physician autonomy maintenance. Ann Intern Med. 2003;138:992-995.

As the train of healthcare reform has undeniably left the station and presently is barreling down the tracks with unstoppable momentum, the need for the specialty of hospital medicine to truly perform as an agent of high-quality, cost-effective care delivery is of paramount importance. By perform, I mean deliver measurable results, and truly realize expectations that we have set for ourselves as a profession—a profession that has claimed since its infancy that a core justification for its existence is the ability for it to realize the goals of healthcare quality improvement (QI).

We have done much in our short history to position ourselves to realize these goals, and in many of our hospitals and communities, we are delivering tangible results. In some settings, however, we could do more. Essential to capitalizing on these performance-improvement opportunities is ensuring every hospitalist and every HM professional commits personally to making high-quality care delivery a non-negotiable proposition.

Accountability is at issue here. We all must strive to consistently hold ourselves, and each other, personally accountable for embracing the work necessary to realize HM’s potential to be a true healthcare reform effector. We have to “put our money where our mouth is” by delivering tangible performance results.

The Accountability Imperative

If there are any doubts about the need for accountability to drive performance in today’s healthcare climate, one need not look further than work ongoing to redesign the manner in which healthcare is delivered through the creation of Accountable Care Organizations (ACOs). The ACO concept is complicated and confusing, and it is doubtful that anyone knows with certainty how it will work. One thing though that should be clear is that ACOs will not be successful unless each of their members is accountable for delivering high-value healthcare—the “A” in the acronym, after all, stands for “accountable.”

Advancing the accountability imperative further is a New England Journal of Medicine sounding board article by Wachter and Pronovost, where it is eloquently argued that the time has come to hold individuals accountable for sub-optimal performance on those quality imperatives for which broken systems have been successfully redesigned.¹ The authors propose that it is no longer appropriate to blame systems failures as the reason for inadequate performance, because clinicians who fail to hold themselves accountable for working within the context of successfully redesigned systems is often the relevant problem.

The authors use hand hygiene as an example, noting that despite such efforts as extensive education, increased access to hand-washing materials, and creative auditing efforts to measure performance, hospitals continue to have unacceptably low hand hygiene rates. They argue that “low hand hygiene rates are generally not a systems problem anymore; they are largely an accountability problem.” They also cite “following an institution’s guidelines regarding provider-to-provider signout at the end of a shift” as an issue of unique importance to hospitalist practice.

Emphasizing that disciplinary action is in order for poor-performing individuals, Wachter and Pronovost conclude that it is time for us to place accountability for the delivery of high-quality care at the top of our agenda. If we do not, the authors believe, regulators “are likely to judge” our lack of accountability “as an example of guild behavior,” that will result in “further intrusion on the practice of medicine.” They go on to suggest that “having our own profession unblinkingly deem some behaviors as unacceptable, with clear consequences, will serve as a vivid example of our professionalism, and thus represent our best protection against such outside intrusions.”1

Avoiding outside intrusions, however, should not be the primary motivator. We should hold ourselves accountable for high-quality care delivery because it is the right thing to do, and our patients deserve nothing less. It is time for HM to get serious by not tolerating performance failures due to accountability lapses. We must define clear, non-negotiable performance imperatives (e.g. hand hygiene and adequate end-of-shift signouts), and demand accountability by not being afraid to enforce penalties for habitual failure to meet expectations.

Accountability and Autonomy

Accountability is hard, and in healthcare it is tempting to avoid responsibility by invoking myriad excuses as to why we cannot or should not be held individually accountable. An oft-cited excuse for why physicians should not be expected to comply with QI initiatives is that doing so threatens a physician’s ability to customize care in situations in which unique circumstances necessitate customization. The argument advanced is that “medicine is an art,” and as such physicians must be permitted to act autonomously. Inevitably, these arguments proceed by invoking problems created by a decline in the degree of physician decision-making independence, and further lament a loss of autonomy.

Reinertsen has written about why the medical profession has witnessed a decline in autonomy over the past decades.² He notes that physicians have done a poor job in holding themselves accountable for consistently practicing the science of medicine, thus necessitating the imposition of rules and regulations to ensure that every patient always receives the best care. While calling this out, Reinertsen acknowledges a place for autonomy in the practice of medicine by writing: “If clinical autonomy is good for the art of medicine … we should do a better job of policing our profession by dealing firmly and effectively with those of our colleagues who do not fulfill their professional obligations of quality and integrity.”

Reinertsen’s argument is beautiful in its simplicity. Furthermore, it emphasizes the accountability imperative considered above by Wachter and Pronovost. We cannot ignore that accountability failures by some of our physician predecessors are directly responsible for the quality problems that we currently face, and we must accept this as a legitimate reason for our diminishing professional autonomy. To correct this going forward, we have to hold each other and ourselves accountable for doing what is right, for it is only then that we will regain our autonomy by earning the trust and respect of the patients and the system that we serve.

Failure to Perform Not an Option

It is undeniable that in its brief history, HM has done fabulous things for patients through redesigning faulty healthcare systems that compromise our ability to consistently deliver high-quality care. It also is true, however, that we have made promises that we have yet to decisively deliver on. The time is now to definitively perform by delivering tangible results that realize those promises.

Former Notre Dame University football coach Lou Holtz once said, “When all is said and done, a lot more is said than done.” Unfortunately, this is often true in our society, and should cause hospitalists to pause and reflect on how to prevent this from happening. After national healthcare reform is complete, we must be able to say “it has been said and done, and we did it all.”

Our legacy and the future success of HM depend on this. To guarantee we reach our full potential tomorrow, we must hold ourselves accountable today for executing on what is expected of us as agents of high-quality, cost-effective care delivery.

Dr. Frost is president of SHM.

References

1. Wachter RM, Pronovost PJ. Balancing “no blame” with accountability in patient safety. N Engl J Med. 2009;361;14:1401-1406.
2. Reinertsen J. Zen and the art of physician autonomy maintenance. Ann Intern Med. 2003;138:992-995.

As the train of healthcare reform has undeniably left the station and presently is barreling down the tracks with unstoppable momentum, the need for the specialty of hospital medicine to truly perform as an agent of high-quality, cost-effective care delivery is of paramount importance. By perform, I mean deliver measurable results, and truly realize expectations that we have set for ourselves as a profession—a profession that has claimed since its infancy that a core justification for its existence is the ability for it to realize the goals of healthcare quality improvement (QI).

We have done much in our short history to position ourselves to realize these goals, and in many of our hospitals and communities, we are delivering tangible results. In some settings, however, we could do more. Essential to capitalizing on these performance-improvement opportunities is ensuring every hospitalist and every HM professional commits personally to making high-quality care delivery a non-negotiable proposition.

Accountability is at issue here. We all must strive to consistently hold ourselves, and each other, personally accountable for embracing the work necessary to realize HM’s potential to be a true healthcare reform effector. We have to “put our money where our mouth is” by delivering tangible performance results.

The Accountability Imperative

If there are any doubts about the need for accountability to drive performance in today’s healthcare climate, one need not look further than work ongoing to redesign the manner in which healthcare is delivered through the creation of Accountable Care Organizations (ACOs). The ACO concept is complicated and confusing, and it is doubtful that anyone knows with certainty how it will work. One thing though that should be clear is that ACOs will not be successful unless each of their members is accountable for delivering high-value healthcare—the “A” in the acronym, after all, stands for “accountable.”

Advancing the accountability imperative further is a New England Journal of Medicine sounding board article by Wachter and Pronovost, where it is eloquently argued that the time has come to hold individuals accountable for sub-optimal performance on those quality imperatives for which broken systems have been successfully redesigned.¹ The authors propose that it is no longer appropriate to blame systems failures as the reason for inadequate performance, because clinicians who fail to hold themselves accountable for working within the context of successfully redesigned systems is often the relevant problem.

The authors use hand hygiene as an example, noting that despite such efforts as extensive education, increased access to hand-washing materials, and creative auditing efforts to measure performance, hospitals continue to have unacceptably low hand hygiene rates. They argue that “low hand hygiene rates are generally not a systems problem anymore; they are largely an accountability problem.” They also cite “following an institution’s guidelines regarding provider-to-provider signout at the end of a shift” as an issue of unique importance to hospitalist practice.

Emphasizing that disciplinary action is in order for poor-performing individuals, Wachter and Pronovost conclude that it is time for us to place accountability for the delivery of high-quality care at the top of our agenda. If we do not, the authors believe, regulators “are likely to judge” our lack of accountability “as an example of guild behavior,” that will result in “further intrusion on the practice of medicine.” They go on to suggest that “having our own profession unblinkingly deem some behaviors as unacceptable, with clear consequences, will serve as a vivid example of our professionalism, and thus represent our best protection against such outside intrusions.”1

Avoiding outside intrusions, however, should not be the primary motivator. We should hold ourselves accountable for high-quality care delivery because it is the right thing to do, and our patients deserve nothing less. It is time for HM to get serious by not tolerating performance failures due to accountability lapses. We must define clear, non-negotiable performance imperatives (e.g. hand hygiene and adequate end-of-shift signouts), and demand accountability by not being afraid to enforce penalties for habitual failure to meet expectations.

Accountability and Autonomy

Accountability is hard, and in healthcare it is tempting to avoid responsibility by invoking myriad excuses as to why we cannot or should not be held individually accountable. An oft-cited excuse for why physicians should not be expected to comply with QI initiatives is that doing so threatens a physician’s ability to customize care in situations in which unique circumstances necessitate customization. The argument advanced is that “medicine is an art,” and as such physicians must be permitted to act autonomously. Inevitably, these arguments proceed by invoking problems created by a decline in the degree of physician decision-making independence, and further lament a loss of autonomy.

Reinertsen has written about why the medical profession has witnessed a decline in autonomy over the past decades.² He notes that physicians have done a poor job in holding themselves accountable for consistently practicing the science of medicine, thus necessitating the imposition of rules and regulations to ensure that every patient always receives the best care. While calling this out, Reinertsen acknowledges a place for autonomy in the practice of medicine by writing: “If clinical autonomy is good for the art of medicine … we should do a better job of policing our profession by dealing firmly and effectively with those of our colleagues who do not fulfill their professional obligations of quality and integrity.”

Reinertsen’s argument is beautiful in its simplicity. Furthermore, it emphasizes the accountability imperative considered above by Wachter and Pronovost. We cannot ignore that accountability failures by some of our physician predecessors are directly responsible for the quality problems that we currently face, and we must accept this as a legitimate reason for our diminishing professional autonomy. To correct this going forward, we have to hold each other and ourselves accountable for doing what is right, for it is only then that we will regain our autonomy by earning the trust and respect of the patients and the system that we serve.

Failure to Perform Not an Option

It is undeniable that in its brief history, HM has done fabulous things for patients through redesigning faulty healthcare systems that compromise our ability to consistently deliver high-quality care. It also is true, however, that we have made promises that we have yet to decisively deliver on. The time is now to definitively perform by delivering tangible results that realize those promises.

Former Notre Dame University football coach Lou Holtz once said, “When all is said and done, a lot more is said than done.” Unfortunately, this is often true in our society, and should cause hospitalists to pause and reflect on how to prevent this from happening. After national healthcare reform is complete, we must be able to say “it has been said and done, and we did it all.”

Our legacy and the future success of HM depend on this. To guarantee we reach our full potential tomorrow, we must hold ourselves accountable today for executing on what is expected of us as agents of high-quality, cost-effective care delivery.

Dr. Frost is president of SHM.

References

1. Wachter RM, Pronovost PJ. Balancing “no blame” with accountability in patient safety. N Engl J Med. 2009;361;14:1401-1406.
2. Reinertsen J. Zen and the art of physician autonomy maintenance. Ann Intern Med. 2003;138:992-995.