Government and Regulations

In 2009, five of the primary-care health centers in Wisconsin-based Dean Health System began to transform into an increasingly popular—but, to many, still somewhat fuzzy—feature of the new healthcare landscape: the “patient-centered medical home.”

The goals are noble: Orient and guide the patient through the healthcare system. Don’t repeat tests already performed. Keep costs down. Prevent illnesses that are, in fact, preventable. And reward doctors for doing so rather than encouraging visit after visit and test after test.

The hospitalists in the Dean system were brought late into the patient-centered medical home, or PCMH, project, but are now more involved:

• They participate in discussions about impending hospitalizations for patients to determine whether hospitalization is really needed;
• They make every effort to assign the same doctor to a patient each time the patient is hospitalized; and
• They also are part of admissions and discharges that are smoother due to efforts to keep information flowing and keep patients in formed.

There have been hiccups, though. Dean hasn’t tracked readmission rates, so it isn’t known whether they’ve improved. And satisfaction ratings from patients haven’t improved—in part, says Kevin Eichhorn, MD, chief of the hospitalist division at Dean, because patients don’t fully appreciate the changes that have been made, although there is an effort to tell them.

I believe the hospitalist will be right at the center of the model, along with the PCPs. In my opinion, the PCMH model will expand the hospitalist’s role outside the four walls of the hospital.

—Ken Simone, DO, SFHM, principal, Hospitalist and Practice Solutions

“But we’ve also only been doing this routinely for about a year,” Dr. Eichhorn says. “My hope is that, as we get better at it, we will see some improvement in terms of patient satisfaction with their hospitalization and improvement in other quality metrics as well.”

If hospitalists already working in a PCMH model are struggling with the changes, imagine the question marks for hospitalists who aren’t familiar with the concept yet (see “The Patient-Centered Medical Home: A Primer,” below). Joseph Ming Wah Li, MD, SFHM, immediate past president of SHM, says most hospitalists are not.

“I think it’s fair to say that most hospitalists lack awareness and insight into what the patient-centered medical home will mean for patients and for hospitalists,” he says.

But it’s a concept HM as a whole should bone up on quickly. As attention to reducing healthcare costs intensifies and the PCMH model becomes more commonplace, hospitalists’ roles within such practices will increase.

Some say hospitalists will be hired by primary-care practices that previously did not employ hospitalists. They might provide extra help during transitions by following patients as they are discharged to skilled rehab units or nursing homes. They also might provide preoperative histories for elective surgeries.

“I believe the hospitalist will be right at the center of the model, along with the PCPs [primary-care physicians],” says Ken Simone, DO, SFHM, a national hospitalist practice management consultant and principal at Maine-based Hospitalist and Practice Solutions. “In my opinion, the PCMH model will expand the hospitalist’s role outside the four walls of the hospital.”

Time to Prepare

Dr. Simone and others say that now is the time for hospitalists to begin exploring the PCMH model and its implications in their locales. HM groups should:

Familiarize themselves with the PCMH concept.

Although the model continues to evolve, the main components can be found in a 2007 joint statement by the American Academy of Family Physicians, American Academy of Pediatrics, American College of Physicians, and American Osteopathic Association.¹ They include the principles of a personal physician with whom the patient has an ongoing relationship; coordinated care across all elements of the healthcare system; better quality and safety; enhanced access to doctors and their teams; and a payment system that factors in the role of physicians and nonphysicians alike, as well as the role of technology and rewards for good outcomes.

“In a patient-centered medical home, there is a strong emphasis on coordination of care and communication between all members of a patient’s healthcare team,” says Jeffrey Cain, MD, president-elect of the American Academy of Family Physicians (AAFP). “Patients receive the highest-quality, patient-centered care when the primary-care physician takes the lead in coordinating care. This means keeping patients, specialists, hospitalists, and other health providers informed of all test results, treatment plans, expectations, progress, and outcomes.”

Find out about the PCMH activity in their own communities.

Dr. Cain said that the degree of PCMH adoption depends on where you work.

“It is spotty throughout the United States,” he notes. “There are areas of tremendous growth and areas that are waiting to have that happen.”

Dr. Simone, a Team Hospitalist member, says the degree to which hospitalists are familiar with PCMH depends on the level of adoption in the area.

“I have found greater hospitalist awareness in communities that have integrated healthcare delivery systems,” he says. “This makes sense, because these are the communities that are aggressively pursing the patient-centered home.”

Forge relationships with primary-care providers.

Dr. Simone encourages hospitalist groups to make marketing visits to local PCP offices. During these visits, hospitalists should discuss the services they provide, their staffing model, admission and communication protocols—and, “most importantly, ask what the hospitalist practice can do to meet the needs of both the patient and the referring providers.”

Dr. Li says it’s always been important to have open lines of communication with your PCPs—but now more than ever.

“If you don’t have this already, you’re already behind in the ballgame,” he says. “But it’s never too late. It’s critically important to have those communication systems in place so that patients get the best care possible.”

Talk to hospital administrators about clinical and financial links with PCMH practices.

The time to do this, Dr. Simone says, is when a local PCMH is being created, or at contract renewal time, if a PCMH is already exists.

“Hospitalists will obviously need to have a voice within the organization and some autonomy for them to commit to such an integrated relationship,” Dr. Simone says.

Prepare for the demands of sicker patients.

If better primary care means fewer hospitalizations, the patients who are admitted will be sicker, posing more challenges to hospitalists.

“Make sure each individual provider has the skill set and schedule that allows them to take care of these patients,” Dr. Li says.

Embrace the possibilities this model offers.

In the PCMH model, the coordination between the hospitalist and the PCP can only help a hospitalist at the time of discharge.

“It will be easier to get their patients into a primary-care office,” says Dr. Cain of AAFP.

David Meyers, MD, director of the Center for Primary Care, Prevention and Clinical Partnerships at the federal Agency for Healthcare Research and Quality (AHRQ), which provides tools and information that support primary care’s redesign and the PCMH, says the model essentially adds a member to the hospitalist’s team.

“If done well, it gives the hospitalist a partner in the community with whom to establish joint accountability,” Dr. Meyers explains. “In addition to establishing accountability, the PCMH helps ensure information flows both into and out of the hospital.”

A Growth Spurt

As of March 1, the nonprofit National Committee on Quality Assurance had recognized 3,979 practices across the country as “patient-centered medical homes.” And that doesn’t include practices that function according to PCMH principles but are not officially recognized.

The Mayo Clinic recently began a three-year pilot PCMH project in Wisconsin, in conjunction with Group Health Cooperative of Eau Claire.

Crucially, insurance companies are coming on board. In January, Indianapolis-based benefits company WellPoint announced a new payment system designed to promote better primary care, with increases to regular fees, payments for “non-visit” services, and shared savings payments based on quality outcomes and reduced medical costs.

Blue Cross and Blue Shield has reported success with PCMH models.

Meanwhile, the Centers for Medicare & Medicaid Services (CMS) is testing a PCMH model to see whether it generates higher quality of care and cost savings. So is the Department of Veterans Affairs.

Primary-care doctors, hospitalists and government officials say the concept is likely here to stay. “We’re in a period of change,” Dr. Meyers says. “I don’t know where we’re going to be in five years from now, but forces are aligning such that this may really work.”

And hospitalists are vital to the success of any PCMH.

“The patient-centered medical home,” he says, “to be effective on what it can do, has to be integrated into a patient-centered medical neighborhood—the partnership between primary care or ambulatory care and inpatient care, and specifically the hospitalists and those folks working in nursing homes and skilled nursing facilities.”

Gordon Chen, MD, a cardiologist and senior vice president of medical affairs at Chen Medical in Miami, where a number of PCMH concepts have been in place for 10 years, says that he works both with hospitalists employed by Chen Medical and some not employed by Chen Medical. And he notices the difference.

“It can be a little bit more difficult to reach and to coordinate and collaborate with other physicians, but we can do it,” he says.

A tighter connection allows information to flow better between the PCPs and the hospitalists, he points out.

“One of the most frustrating things as a physician is to find out that your patient had a prolonged hospitalization and they come to see you in the clinic and you don’t have any information,” Dr. Chen says. “You look at this new medication list and you’re trying to put the pieces together. When a doctor doesn’t have all the information, and is guessing … it leads to poor decisions being made.”

Back at Dean Health System in Wisconsin, Dr. Eichhorn is confident that the concepts behind the patient-centered medical home can only be good for patients. Still, the project there—as at many other places—is a work in progress.

“Emphasizing wellness and preventative health certainly conveys significant benefits,” he says. “The challenge is defining what is a patient-centered medical home. It sounds like every group is struggling what that means and how to define it and then how to track your outcomes. And then does the patient have a sense of that? Are they appreciating something different in what’s happening to their healthcare?”

Thomas R. Collins is a freelance writer in South Florida.

Reference

1. Patient-Centered Primary Care Collaborative. Joint Principles on the Patient-Centered Medical Home. Available at: http://www.pcpcc.net/content/joint-principles-patient-centered-medical-home. Accessed May 31, 2012.

In 2009, five of the primary-care health centers in Wisconsin-based Dean Health System began to transform into an increasingly popular—but, to many, still somewhat fuzzy—feature of the new healthcare landscape: the “patient-centered medical home.”

The goals are noble: Orient and guide the patient through the healthcare system. Don’t repeat tests already performed. Keep costs down. Prevent illnesses that are, in fact, preventable. And reward doctors for doing so rather than encouraging visit after visit and test after test.

The hospitalists in the Dean system were brought late into the patient-centered medical home, or PCMH, project, but are now more involved:

• They participate in discussions about impending hospitalizations for patients to determine whether hospitalization is really needed;
• They make every effort to assign the same doctor to a patient each time the patient is hospitalized; and
• They also are part of admissions and discharges that are smoother due to efforts to keep information flowing and keep patients in formed.

There have been hiccups, though. Dean hasn’t tracked readmission rates, so it isn’t known whether they’ve improved. And satisfaction ratings from patients haven’t improved—in part, says Kevin Eichhorn, MD, chief of the hospitalist division at Dean, because patients don’t fully appreciate the changes that have been made, although there is an effort to tell them.

I believe the hospitalist will be right at the center of the model, along with the PCPs. In my opinion, the PCMH model will expand the hospitalist’s role outside the four walls of the hospital.

—Ken Simone, DO, SFHM, principal, Hospitalist and Practice Solutions

“But we’ve also only been doing this routinely for about a year,” Dr. Eichhorn says. “My hope is that, as we get better at it, we will see some improvement in terms of patient satisfaction with their hospitalization and improvement in other quality metrics as well.”

If hospitalists already working in a PCMH model are struggling with the changes, imagine the question marks for hospitalists who aren’t familiar with the concept yet (see “The Patient-Centered Medical Home: A Primer,” below). Joseph Ming Wah Li, MD, SFHM, immediate past president of SHM, says most hospitalists are not.

“I think it’s fair to say that most hospitalists lack awareness and insight into what the patient-centered medical home will mean for patients and for hospitalists,” he says.

But it’s a concept HM as a whole should bone up on quickly. As attention to reducing healthcare costs intensifies and the PCMH model becomes more commonplace, hospitalists’ roles within such practices will increase.

Some say hospitalists will be hired by primary-care practices that previously did not employ hospitalists. They might provide extra help during transitions by following patients as they are discharged to skilled rehab units or nursing homes. They also might provide preoperative histories for elective surgeries.

“I believe the hospitalist will be right at the center of the model, along with the PCPs [primary-care physicians],” says Ken Simone, DO, SFHM, a national hospitalist practice management consultant and principal at Maine-based Hospitalist and Practice Solutions. “In my opinion, the PCMH model will expand the hospitalist’s role outside the four walls of the hospital.”

Time to Prepare

Dr. Simone and others say that now is the time for hospitalists to begin exploring the PCMH model and its implications in their locales. HM groups should:

Familiarize themselves with the PCMH concept.

Although the model continues to evolve, the main components can be found in a 2007 joint statement by the American Academy of Family Physicians, American Academy of Pediatrics, American College of Physicians, and American Osteopathic Association.¹ They include the principles of a personal physician with whom the patient has an ongoing relationship; coordinated care across all elements of the healthcare system; better quality and safety; enhanced access to doctors and their teams; and a payment system that factors in the role of physicians and nonphysicians alike, as well as the role of technology and rewards for good outcomes.

“In a patient-centered medical home, there is a strong emphasis on coordination of care and communication between all members of a patient’s healthcare team,” says Jeffrey Cain, MD, president-elect of the American Academy of Family Physicians (AAFP). “Patients receive the highest-quality, patient-centered care when the primary-care physician takes the lead in coordinating care. This means keeping patients, specialists, hospitalists, and other health providers informed of all test results, treatment plans, expectations, progress, and outcomes.”

Find out about the PCMH activity in their own communities.

Dr. Cain said that the degree of PCMH adoption depends on where you work.

“It is spotty throughout the United States,” he notes. “There are areas of tremendous growth and areas that are waiting to have that happen.”

Dr. Simone, a Team Hospitalist member, says the degree to which hospitalists are familiar with PCMH depends on the level of adoption in the area.

“I have found greater hospitalist awareness in communities that have integrated healthcare delivery systems,” he says. “This makes sense, because these are the communities that are aggressively pursing the patient-centered home.”

Forge relationships with primary-care providers.

Dr. Simone encourages hospitalist groups to make marketing visits to local PCP offices. During these visits, hospitalists should discuss the services they provide, their staffing model, admission and communication protocols—and, “most importantly, ask what the hospitalist practice can do to meet the needs of both the patient and the referring providers.”

Dr. Li says it’s always been important to have open lines of communication with your PCPs—but now more than ever.

“If you don’t have this already, you’re already behind in the ballgame,” he says. “But it’s never too late. It’s critically important to have those communication systems in place so that patients get the best care possible.”

Talk to hospital administrators about clinical and financial links with PCMH practices.

The time to do this, Dr. Simone says, is when a local PCMH is being created, or at contract renewal time, if a PCMH is already exists.

“Hospitalists will obviously need to have a voice within the organization and some autonomy for them to commit to such an integrated relationship,” Dr. Simone says.

Prepare for the demands of sicker patients.

If better primary care means fewer hospitalizations, the patients who are admitted will be sicker, posing more challenges to hospitalists.

“Make sure each individual provider has the skill set and schedule that allows them to take care of these patients,” Dr. Li says.

Embrace the possibilities this model offers.

In the PCMH model, the coordination between the hospitalist and the PCP can only help a hospitalist at the time of discharge.

“It will be easier to get their patients into a primary-care office,” says Dr. Cain of AAFP.

David Meyers, MD, director of the Center for Primary Care, Prevention and Clinical Partnerships at the federal Agency for Healthcare Research and Quality (AHRQ), which provides tools and information that support primary care’s redesign and the PCMH, says the model essentially adds a member to the hospitalist’s team.

“If done well, it gives the hospitalist a partner in the community with whom to establish joint accountability,” Dr. Meyers explains. “In addition to establishing accountability, the PCMH helps ensure information flows both into and out of the hospital.”

A Growth Spurt

As of March 1, the nonprofit National Committee on Quality Assurance had recognized 3,979 practices across the country as “patient-centered medical homes.” And that doesn’t include practices that function according to PCMH principles but are not officially recognized.

The Mayo Clinic recently began a three-year pilot PCMH project in Wisconsin, in conjunction with Group Health Cooperative of Eau Claire.

Crucially, insurance companies are coming on board. In January, Indianapolis-based benefits company WellPoint announced a new payment system designed to promote better primary care, with increases to regular fees, payments for “non-visit” services, and shared savings payments based on quality outcomes and reduced medical costs.

Blue Cross and Blue Shield has reported success with PCMH models.

Meanwhile, the Centers for Medicare & Medicaid Services (CMS) is testing a PCMH model to see whether it generates higher quality of care and cost savings. So is the Department of Veterans Affairs.

Primary-care doctors, hospitalists and government officials say the concept is likely here to stay. “We’re in a period of change,” Dr. Meyers says. “I don’t know where we’re going to be in five years from now, but forces are aligning such that this may really work.”

And hospitalists are vital to the success of any PCMH.

“The patient-centered medical home,” he says, “to be effective on what it can do, has to be integrated into a patient-centered medical neighborhood—the partnership between primary care or ambulatory care and inpatient care, and specifically the hospitalists and those folks working in nursing homes and skilled nursing facilities.”

Gordon Chen, MD, a cardiologist and senior vice president of medical affairs at Chen Medical in Miami, where a number of PCMH concepts have been in place for 10 years, says that he works both with hospitalists employed by Chen Medical and some not employed by Chen Medical. And he notices the difference.

“It can be a little bit more difficult to reach and to coordinate and collaborate with other physicians, but we can do it,” he says.

A tighter connection allows information to flow better between the PCPs and the hospitalists, he points out.

“One of the most frustrating things as a physician is to find out that your patient had a prolonged hospitalization and they come to see you in the clinic and you don’t have any information,” Dr. Chen says. “You look at this new medication list and you’re trying to put the pieces together. When a doctor doesn’t have all the information, and is guessing … it leads to poor decisions being made.”

Back at Dean Health System in Wisconsin, Dr. Eichhorn is confident that the concepts behind the patient-centered medical home can only be good for patients. Still, the project there—as at many other places—is a work in progress.

“Emphasizing wellness and preventative health certainly conveys significant benefits,” he says. “The challenge is defining what is a patient-centered medical home. It sounds like every group is struggling what that means and how to define it and then how to track your outcomes. And then does the patient have a sense of that? Are they appreciating something different in what’s happening to their healthcare?”

Thomas R. Collins is a freelance writer in South Florida.

Reference

1. Patient-Centered Primary Care Collaborative. Joint Principles on the Patient-Centered Medical Home. Available at: http://www.pcpcc.net/content/joint-principles-patient-centered-medical-home. Accessed May 31, 2012.

In 2009, five of the primary-care health centers in Wisconsin-based Dean Health System began to transform into an increasingly popular—but, to many, still somewhat fuzzy—feature of the new healthcare landscape: the “patient-centered medical home.”

The goals are noble: Orient and guide the patient through the healthcare system. Don’t repeat tests already performed. Keep costs down. Prevent illnesses that are, in fact, preventable. And reward doctors for doing so rather than encouraging visit after visit and test after test.

The hospitalists in the Dean system were brought late into the patient-centered medical home, or PCMH, project, but are now more involved:

• They participate in discussions about impending hospitalizations for patients to determine whether hospitalization is really needed;
• They make every effort to assign the same doctor to a patient each time the patient is hospitalized; and
• They also are part of admissions and discharges that are smoother due to efforts to keep information flowing and keep patients in formed.

There have been hiccups, though. Dean hasn’t tracked readmission rates, so it isn’t known whether they’ve improved. And satisfaction ratings from patients haven’t improved—in part, says Kevin Eichhorn, MD, chief of the hospitalist division at Dean, because patients don’t fully appreciate the changes that have been made, although there is an effort to tell them.

I believe the hospitalist will be right at the center of the model, along with the PCPs. In my opinion, the PCMH model will expand the hospitalist’s role outside the four walls of the hospital.

—Ken Simone, DO, SFHM, principal, Hospitalist and Practice Solutions

“But we’ve also only been doing this routinely for about a year,” Dr. Eichhorn says. “My hope is that, as we get better at it, we will see some improvement in terms of patient satisfaction with their hospitalization and improvement in other quality metrics as well.”

If hospitalists already working in a PCMH model are struggling with the changes, imagine the question marks for hospitalists who aren’t familiar with the concept yet (see “The Patient-Centered Medical Home: A Primer,” below). Joseph Ming Wah Li, MD, SFHM, immediate past president of SHM, says most hospitalists are not.

“I think it’s fair to say that most hospitalists lack awareness and insight into what the patient-centered medical home will mean for patients and for hospitalists,” he says.

But it’s a concept HM as a whole should bone up on quickly. As attention to reducing healthcare costs intensifies and the PCMH model becomes more commonplace, hospitalists’ roles within such practices will increase.

Some say hospitalists will be hired by primary-care practices that previously did not employ hospitalists. They might provide extra help during transitions by following patients as they are discharged to skilled rehab units or nursing homes. They also might provide preoperative histories for elective surgeries.

“I believe the hospitalist will be right at the center of the model, along with the PCPs [primary-care physicians],” says Ken Simone, DO, SFHM, a national hospitalist practice management consultant and principal at Maine-based Hospitalist and Practice Solutions. “In my opinion, the PCMH model will expand the hospitalist’s role outside the four walls of the hospital.”

Time to Prepare

Dr. Simone and others say that now is the time for hospitalists to begin exploring the PCMH model and its implications in their locales. HM groups should:

Familiarize themselves with the PCMH concept.

Although the model continues to evolve, the main components can be found in a 2007 joint statement by the American Academy of Family Physicians, American Academy of Pediatrics, American College of Physicians, and American Osteopathic Association.¹ They include the principles of a personal physician with whom the patient has an ongoing relationship; coordinated care across all elements of the healthcare system; better quality and safety; enhanced access to doctors and their teams; and a payment system that factors in the role of physicians and nonphysicians alike, as well as the role of technology and rewards for good outcomes.

“In a patient-centered medical home, there is a strong emphasis on coordination of care and communication between all members of a patient’s healthcare team,” says Jeffrey Cain, MD, president-elect of the American Academy of Family Physicians (AAFP). “Patients receive the highest-quality, patient-centered care when the primary-care physician takes the lead in coordinating care. This means keeping patients, specialists, hospitalists, and other health providers informed of all test results, treatment plans, expectations, progress, and outcomes.”

Find out about the PCMH activity in their own communities.

Dr. Cain said that the degree of PCMH adoption depends on where you work.

“It is spotty throughout the United States,” he notes. “There are areas of tremendous growth and areas that are waiting to have that happen.”

Dr. Simone, a Team Hospitalist member, says the degree to which hospitalists are familiar with PCMH depends on the level of adoption in the area.

“I have found greater hospitalist awareness in communities that have integrated healthcare delivery systems,” he says. “This makes sense, because these are the communities that are aggressively pursing the patient-centered home.”

Forge relationships with primary-care providers.

Dr. Simone encourages hospitalist groups to make marketing visits to local PCP offices. During these visits, hospitalists should discuss the services they provide, their staffing model, admission and communication protocols—and, “most importantly, ask what the hospitalist practice can do to meet the needs of both the patient and the referring providers.”

Dr. Li says it’s always been important to have open lines of communication with your PCPs—but now more than ever.

“If you don’t have this already, you’re already behind in the ballgame,” he says. “But it’s never too late. It’s critically important to have those communication systems in place so that patients get the best care possible.”

Talk to hospital administrators about clinical and financial links with PCMH practices.

The time to do this, Dr. Simone says, is when a local PCMH is being created, or at contract renewal time, if a PCMH is already exists.

“Hospitalists will obviously need to have a voice within the organization and some autonomy for them to commit to such an integrated relationship,” Dr. Simone says.

Prepare for the demands of sicker patients.

If better primary care means fewer hospitalizations, the patients who are admitted will be sicker, posing more challenges to hospitalists.

“Make sure each individual provider has the skill set and schedule that allows them to take care of these patients,” Dr. Li says.

Embrace the possibilities this model offers.

In the PCMH model, the coordination between the hospitalist and the PCP can only help a hospitalist at the time of discharge.

“It will be easier to get their patients into a primary-care office,” says Dr. Cain of AAFP.

David Meyers, MD, director of the Center for Primary Care, Prevention and Clinical Partnerships at the federal Agency for Healthcare Research and Quality (AHRQ), which provides tools and information that support primary care’s redesign and the PCMH, says the model essentially adds a member to the hospitalist’s team.

“If done well, it gives the hospitalist a partner in the community with whom to establish joint accountability,” Dr. Meyers explains. “In addition to establishing accountability, the PCMH helps ensure information flows both into and out of the hospital.”

A Growth Spurt

As of March 1, the nonprofit National Committee on Quality Assurance had recognized 3,979 practices across the country as “patient-centered medical homes.” And that doesn’t include practices that function according to PCMH principles but are not officially recognized.

The Mayo Clinic recently began a three-year pilot PCMH project in Wisconsin, in conjunction with Group Health Cooperative of Eau Claire.

Crucially, insurance companies are coming on board. In January, Indianapolis-based benefits company WellPoint announced a new payment system designed to promote better primary care, with increases to regular fees, payments for “non-visit” services, and shared savings payments based on quality outcomes and reduced medical costs.

Blue Cross and Blue Shield has reported success with PCMH models.

Meanwhile, the Centers for Medicare & Medicaid Services (CMS) is testing a PCMH model to see whether it generates higher quality of care and cost savings. So is the Department of Veterans Affairs.

Primary-care doctors, hospitalists and government officials say the concept is likely here to stay. “We’re in a period of change,” Dr. Meyers says. “I don’t know where we’re going to be in five years from now, but forces are aligning such that this may really work.”

And hospitalists are vital to the success of any PCMH.

“The patient-centered medical home,” he says, “to be effective on what it can do, has to be integrated into a patient-centered medical neighborhood—the partnership between primary care or ambulatory care and inpatient care, and specifically the hospitalists and those folks working in nursing homes and skilled nursing facilities.”

Gordon Chen, MD, a cardiologist and senior vice president of medical affairs at Chen Medical in Miami, where a number of PCMH concepts have been in place for 10 years, says that he works both with hospitalists employed by Chen Medical and some not employed by Chen Medical. And he notices the difference.

“It can be a little bit more difficult to reach and to coordinate and collaborate with other physicians, but we can do it,” he says.

A tighter connection allows information to flow better between the PCPs and the hospitalists, he points out.

“One of the most frustrating things as a physician is to find out that your patient had a prolonged hospitalization and they come to see you in the clinic and you don’t have any information,” Dr. Chen says. “You look at this new medication list and you’re trying to put the pieces together. When a doctor doesn’t have all the information, and is guessing … it leads to poor decisions being made.”

Back at Dean Health System in Wisconsin, Dr. Eichhorn is confident that the concepts behind the patient-centered medical home can only be good for patients. Still, the project there—as at many other places—is a work in progress.

“Emphasizing wellness and preventative health certainly conveys significant benefits,” he says. “The challenge is defining what is a patient-centered medical home. It sounds like every group is struggling what that means and how to define it and then how to track your outcomes. And then does the patient have a sense of that? Are they appreciating something different in what’s happening to their healthcare?”

Thomas R. Collins is a freelance writer in South Florida.

Reference

1. Patient-Centered Primary Care Collaborative. Joint Principles on the Patient-Centered Medical Home. Available at: http://www.pcpcc.net/content/joint-principles-patient-centered-medical-home. Accessed May 31, 2012.

It’s been one year since the Accreditation Council for Graduate Medical Education’s (ACGME) most recent residency program regulations took effect, updating standards put into place in 2003. The regulations are the latest manifestation of an ongoing challenge in medical training: how to strike the right balance of optimal clinical training with patient safety, resident well-being, and other concerns.

Clearly the most controversial change in the latest regulations is the restriction of first-year residents to a work shift of no more than 16 hours and older residents to 24 hours, with an additional four hours to manage transitions in care (previously, 30-hour shifts were permitted for all residents). ACGME applied the 16-hour restriction after extensive discussions with members of an Institute of Medicine committee that drafted a report at the request of Congress that explored the dangers to patient care of sleep-deprived caregivers. The IOM report argued that revisions to medical residents’ workloads and duty-hours were necessary to better protect patients against fatigue-related errors and to ensure that residents get the best educational experience.¹

This month, the ACGME begins its annual reviews of institutions to gauge the impact of the new regulations. While few expect the ACGME to find decisive answers regarding optimal work-hour regulations for residents, the 16-hour rule has both its opponents and supporters. On balance, HM appears to be well-positioned to benefit from the changes, having been given yet another opportunity to demonstrate value by helping their institutions weather the changes, enhance the residency training experience, and support the patient safety imperative.

Is 16 the Magic Number?

In defending the new rules last year, ACGME CEO Thomas J. Nasca, MD, acknowledged that the evidence linking long duty-hours and patient safety is mixed, while also explaining that another part of the rationale for limiting shifts for the youngest residents was to ease them into the profession. Older residents, he said, must be taught to recognize and manage the fatigue they will encounter regularly in their actual clinical practice, where hours are not regulated.

“It makes sense how ACGME has structured this—giving trainees the chance to learn in a more measured way, while recognizing that more experienced residents have more mature judgment,” says Daniel D. Dressler, MD, MSc, SFHM, FACP, hospital medicine associate division director for education, and associate program director for the J. Willis Hurst Internal Medicine Residency Program at Emory University School of Medicine in Atlanta. “I believe it’s an overall positive move, in terms of morale and work/life balance.”

Others disagree. Patient safety expert Lucian Leape, MD, adjunct professor at Harvard School of Public Health, decried that the ACGME rules did not apply to all residents, just those in their first year, and he rejected the assumption that one can learn to tolerate sleep deprivation.² HM pioneer Bob Wachter, MD, MHM, professor, chief of the division of hospital medicine, and chief of the medical service at University of California San Francisco Medical Center, agrees the work-hour restrictions are here to stay—and are a good thing. At his blog Wachter’s World, he recently posted that research shows “prolonged wakefulness” degrades cognitive skills, and equates to a blood-alcohol level of 0.1, or “legally drunk in every state.”

“Even without strong evidence one way or the other, if it has improved safety, I think 16 hours is probably right for interns, and 24-plus-four hours for second-year residents and above. It’s the ACGME’s best guess, to date, of the right balance,” says Jeffrey G. Wiese, MD, SFHM, FACP, associate dean for graduate medical education, director of the internal medicine program at Tulane University School of Medicine in New Orleans, and former SHM president. “It’s no huge intellectual stretch to say that someone who’s been up for 32 hours is not in the best condition to make optimal patient-care decisions.”

While preserving optimal cognitive abilities is important for all physicians, ACGME’s new work-hour limits matter even more to specialties like surgery, which rely heavily on manual dexterity skills, Dr. Wiese suggests. Ironically, surgical specialty societies have been among the most critical of the new limits.

“My surgical colleagues have been particularly vocal critics of the new work-hour limit,” says Dr. Dressler, noting that Emory’s residency programs are smaller and have greater challenges in adjusting for fewer work hours as they rely more heavily on residents for certain clinical tasks than do other specialties.

Ideally, Dr. Wiese maintains, resident duty-hours should be increased gradually based on progressively demonstrated levels of ability and competence by individual residents, regardless of program year. Such milestone-based accountability is supported by SHM as well as several other medical societies.

Continuity of Care

A downside to the work-hour limit is its potential to disrupt both the continuity of care and the learning process, as fewer patients are likely to be followed by a single resident from admission to resolution of a case. Dr. Wachter, who is chair of the American Board of Internal Medicine (ABIM) and a former SHM president, acknowledges this sacrifice, noting that care teams at his hospital inherit nearly half their patients as handoffs from night admitters, and some never know handed-off patients as well as those they admitted themselves.

“In a system in which half the patients are cared for by two sets of doctors during these crucial stages [early assessment, data gathering, and initial patient response], neither group fully sees this arc play out, and their education suffers,” he wrote on his blog.

New limits means “less flexibility,” says Dr. Dressler, “and it can become a hindrance to completing the work-up of a patient—like not being able to put a central line in at 8:30 p.m. ... Some trainees feel they have less continuity with their patients because of the shorter hours.”

It’s no huge intellectual stretch to say that someone who’s been up for 32 hours is not in the best condition to make optimal patient-care decisions.

—Jeffrey G. Wiese, MD, SFHM, FACP, associate dean, graduate medical education, director, internal medicine program, Tulane University School of Medicine, New Orleans, former SHM president

Thoughtful management is required to minimize schedule disruption and maximize learning opportunities, he adds. “We’ve decided that our interns will have five overnight shifts over 10 days as part of one of their 30-day rotations. It’s important that interns get overnight experience before their second year,” Dr. Dressler says. “We had to incorporate three interns per team instead of two. Any way you slice it, you’re going to need additional manpower from other sources.”

Such workforce issues are hot topics in teaching hospitals across the country, Dr. Wiese says. He also warns that using hospitalists solely as “resident extenders” is not sustainable. “If an academic program is using hospitalists as stopgap labor, they do so at the risk of accelerating burnout,” he says.

Hospitalist Opportunity

Hospitalists can and should, however, take full advantage of a much-needed niche that the new ACGME regulations have called attention to: the need for expertise in minimizing patient-care disruptions resulting from more frequent patient handoffs.

“Hospitalists have an opportunity to get more involved in residency training programs by sharing their knowledge of effective patient handoff protocols,” Dr. Dressler says. “Hospitalists have treaded those waters for over a decade. We’ve learned a lot about structuring handoff information effectively, and we can inform training programs about those issues.”

The increased urgency of effective handoff management might even lead to an increased investment in HM programs, Dr. Dressler believes. “The expectation, of course, is that we are able to demonstrate effective patient handoffs—and show that we’re ‘walking the walk,’ and not just talking about it,” he says.

Christopher Guadagnino is a freelance medical writer in Philadelphia.

References

1. Institute of Medicine. Resident duty hours: enhancing sleep, supervision, and safety. Institute of Medicine website. Available at: http://www.nap.edu/catalog.php?record_id=12508#toc. Accessed May 1, 2012.
2. Krups C. Residency programs scramble to adopt changes. American Medical News website. Available at: http://www.ama-assn.org/amednews/2011/07/11/prsa0711.htm#s1. Accessed May 1, 2012.

It’s been one year since the Accreditation Council for Graduate Medical Education’s (ACGME) most recent residency program regulations took effect, updating standards put into place in 2003. The regulations are the latest manifestation of an ongoing challenge in medical training: how to strike the right balance of optimal clinical training with patient safety, resident well-being, and other concerns.

Clearly the most controversial change in the latest regulations is the restriction of first-year residents to a work shift of no more than 16 hours and older residents to 24 hours, with an additional four hours to manage transitions in care (previously, 30-hour shifts were permitted for all residents). ACGME applied the 16-hour restriction after extensive discussions with members of an Institute of Medicine committee that drafted a report at the request of Congress that explored the dangers to patient care of sleep-deprived caregivers. The IOM report argued that revisions to medical residents’ workloads and duty-hours were necessary to better protect patients against fatigue-related errors and to ensure that residents get the best educational experience.¹

This month, the ACGME begins its annual reviews of institutions to gauge the impact of the new regulations. While few expect the ACGME to find decisive answers regarding optimal work-hour regulations for residents, the 16-hour rule has both its opponents and supporters. On balance, HM appears to be well-positioned to benefit from the changes, having been given yet another opportunity to demonstrate value by helping their institutions weather the changes, enhance the residency training experience, and support the patient safety imperative.

Is 16 the Magic Number?

In defending the new rules last year, ACGME CEO Thomas J. Nasca, MD, acknowledged that the evidence linking long duty-hours and patient safety is mixed, while also explaining that another part of the rationale for limiting shifts for the youngest residents was to ease them into the profession. Older residents, he said, must be taught to recognize and manage the fatigue they will encounter regularly in their actual clinical practice, where hours are not regulated.

“It makes sense how ACGME has structured this—giving trainees the chance to learn in a more measured way, while recognizing that more experienced residents have more mature judgment,” says Daniel D. Dressler, MD, MSc, SFHM, FACP, hospital medicine associate division director for education, and associate program director for the J. Willis Hurst Internal Medicine Residency Program at Emory University School of Medicine in Atlanta. “I believe it’s an overall positive move, in terms of morale and work/life balance.”

Others disagree. Patient safety expert Lucian Leape, MD, adjunct professor at Harvard School of Public Health, decried that the ACGME rules did not apply to all residents, just those in their first year, and he rejected the assumption that one can learn to tolerate sleep deprivation.² HM pioneer Bob Wachter, MD, MHM, professor, chief of the division of hospital medicine, and chief of the medical service at University of California San Francisco Medical Center, agrees the work-hour restrictions are here to stay—and are a good thing. At his blog Wachter’s World, he recently posted that research shows “prolonged wakefulness” degrades cognitive skills, and equates to a blood-alcohol level of 0.1, or “legally drunk in every state.”

“Even without strong evidence one way or the other, if it has improved safety, I think 16 hours is probably right for interns, and 24-plus-four hours for second-year residents and above. It’s the ACGME’s best guess, to date, of the right balance,” says Jeffrey G. Wiese, MD, SFHM, FACP, associate dean for graduate medical education, director of the internal medicine program at Tulane University School of Medicine in New Orleans, and former SHM president. “It’s no huge intellectual stretch to say that someone who’s been up for 32 hours is not in the best condition to make optimal patient-care decisions.”

While preserving optimal cognitive abilities is important for all physicians, ACGME’s new work-hour limits matter even more to specialties like surgery, which rely heavily on manual dexterity skills, Dr. Wiese suggests. Ironically, surgical specialty societies have been among the most critical of the new limits.

“My surgical colleagues have been particularly vocal critics of the new work-hour limit,” says Dr. Dressler, noting that Emory’s residency programs are smaller and have greater challenges in adjusting for fewer work hours as they rely more heavily on residents for certain clinical tasks than do other specialties.

Ideally, Dr. Wiese maintains, resident duty-hours should be increased gradually based on progressively demonstrated levels of ability and competence by individual residents, regardless of program year. Such milestone-based accountability is supported by SHM as well as several other medical societies.

Continuity of Care

A downside to the work-hour limit is its potential to disrupt both the continuity of care and the learning process, as fewer patients are likely to be followed by a single resident from admission to resolution of a case. Dr. Wachter, who is chair of the American Board of Internal Medicine (ABIM) and a former SHM president, acknowledges this sacrifice, noting that care teams at his hospital inherit nearly half their patients as handoffs from night admitters, and some never know handed-off patients as well as those they admitted themselves.

“In a system in which half the patients are cared for by two sets of doctors during these crucial stages [early assessment, data gathering, and initial patient response], neither group fully sees this arc play out, and their education suffers,” he wrote on his blog.

New limits means “less flexibility,” says Dr. Dressler, “and it can become a hindrance to completing the work-up of a patient—like not being able to put a central line in at 8:30 p.m. ... Some trainees feel they have less continuity with their patients because of the shorter hours.”

It’s no huge intellectual stretch to say that someone who’s been up for 32 hours is not in the best condition to make optimal patient-care decisions.

—Jeffrey G. Wiese, MD, SFHM, FACP, associate dean, graduate medical education, director, internal medicine program, Tulane University School of Medicine, New Orleans, former SHM president

Thoughtful management is required to minimize schedule disruption and maximize learning opportunities, he adds. “We’ve decided that our interns will have five overnight shifts over 10 days as part of one of their 30-day rotations. It’s important that interns get overnight experience before their second year,” Dr. Dressler says. “We had to incorporate three interns per team instead of two. Any way you slice it, you’re going to need additional manpower from other sources.”

Such workforce issues are hot topics in teaching hospitals across the country, Dr. Wiese says. He also warns that using hospitalists solely as “resident extenders” is not sustainable. “If an academic program is using hospitalists as stopgap labor, they do so at the risk of accelerating burnout,” he says.

Hospitalist Opportunity

Hospitalists can and should, however, take full advantage of a much-needed niche that the new ACGME regulations have called attention to: the need for expertise in minimizing patient-care disruptions resulting from more frequent patient handoffs.

“Hospitalists have an opportunity to get more involved in residency training programs by sharing their knowledge of effective patient handoff protocols,” Dr. Dressler says. “Hospitalists have treaded those waters for over a decade. We’ve learned a lot about structuring handoff information effectively, and we can inform training programs about those issues.”

The increased urgency of effective handoff management might even lead to an increased investment in HM programs, Dr. Dressler believes. “The expectation, of course, is that we are able to demonstrate effective patient handoffs—and show that we’re ‘walking the walk,’ and not just talking about it,” he says.

Christopher Guadagnino is a freelance medical writer in Philadelphia.

References

1. Institute of Medicine. Resident duty hours: enhancing sleep, supervision, and safety. Institute of Medicine website. Available at: http://www.nap.edu/catalog.php?record_id=12508#toc. Accessed May 1, 2012.
2. Krups C. Residency programs scramble to adopt changes. American Medical News website. Available at: http://www.ama-assn.org/amednews/2011/07/11/prsa0711.htm#s1. Accessed May 1, 2012.

It’s been one year since the Accreditation Council for Graduate Medical Education’s (ACGME) most recent residency program regulations took effect, updating standards put into place in 2003. The regulations are the latest manifestation of an ongoing challenge in medical training: how to strike the right balance of optimal clinical training with patient safety, resident well-being, and other concerns.

Clearly the most controversial change in the latest regulations is the restriction of first-year residents to a work shift of no more than 16 hours and older residents to 24 hours, with an additional four hours to manage transitions in care (previously, 30-hour shifts were permitted for all residents). ACGME applied the 16-hour restriction after extensive discussions with members of an Institute of Medicine committee that drafted a report at the request of Congress that explored the dangers to patient care of sleep-deprived caregivers. The IOM report argued that revisions to medical residents’ workloads and duty-hours were necessary to better protect patients against fatigue-related errors and to ensure that residents get the best educational experience.¹

This month, the ACGME begins its annual reviews of institutions to gauge the impact of the new regulations. While few expect the ACGME to find decisive answers regarding optimal work-hour regulations for residents, the 16-hour rule has both its opponents and supporters. On balance, HM appears to be well-positioned to benefit from the changes, having been given yet another opportunity to demonstrate value by helping their institutions weather the changes, enhance the residency training experience, and support the patient safety imperative.

Is 16 the Magic Number?

In defending the new rules last year, ACGME CEO Thomas J. Nasca, MD, acknowledged that the evidence linking long duty-hours and patient safety is mixed, while also explaining that another part of the rationale for limiting shifts for the youngest residents was to ease them into the profession. Older residents, he said, must be taught to recognize and manage the fatigue they will encounter regularly in their actual clinical practice, where hours are not regulated.

“It makes sense how ACGME has structured this—giving trainees the chance to learn in a more measured way, while recognizing that more experienced residents have more mature judgment,” says Daniel D. Dressler, MD, MSc, SFHM, FACP, hospital medicine associate division director for education, and associate program director for the J. Willis Hurst Internal Medicine Residency Program at Emory University School of Medicine in Atlanta. “I believe it’s an overall positive move, in terms of morale and work/life balance.”

Others disagree. Patient safety expert Lucian Leape, MD, adjunct professor at Harvard School of Public Health, decried that the ACGME rules did not apply to all residents, just those in their first year, and he rejected the assumption that one can learn to tolerate sleep deprivation.² HM pioneer Bob Wachter, MD, MHM, professor, chief of the division of hospital medicine, and chief of the medical service at University of California San Francisco Medical Center, agrees the work-hour restrictions are here to stay—and are a good thing. At his blog Wachter’s World, he recently posted that research shows “prolonged wakefulness” degrades cognitive skills, and equates to a blood-alcohol level of 0.1, or “legally drunk in every state.”

“Even without strong evidence one way or the other, if it has improved safety, I think 16 hours is probably right for interns, and 24-plus-four hours for second-year residents and above. It’s the ACGME’s best guess, to date, of the right balance,” says Jeffrey G. Wiese, MD, SFHM, FACP, associate dean for graduate medical education, director of the internal medicine program at Tulane University School of Medicine in New Orleans, and former SHM president. “It’s no huge intellectual stretch to say that someone who’s been up for 32 hours is not in the best condition to make optimal patient-care decisions.”

While preserving optimal cognitive abilities is important for all physicians, ACGME’s new work-hour limits matter even more to specialties like surgery, which rely heavily on manual dexterity skills, Dr. Wiese suggests. Ironically, surgical specialty societies have been among the most critical of the new limits.

“My surgical colleagues have been particularly vocal critics of the new work-hour limit,” says Dr. Dressler, noting that Emory’s residency programs are smaller and have greater challenges in adjusting for fewer work hours as they rely more heavily on residents for certain clinical tasks than do other specialties.

Ideally, Dr. Wiese maintains, resident duty-hours should be increased gradually based on progressively demonstrated levels of ability and competence by individual residents, regardless of program year. Such milestone-based accountability is supported by SHM as well as several other medical societies.

Continuity of Care

A downside to the work-hour limit is its potential to disrupt both the continuity of care and the learning process, as fewer patients are likely to be followed by a single resident from admission to resolution of a case. Dr. Wachter, who is chair of the American Board of Internal Medicine (ABIM) and a former SHM president, acknowledges this sacrifice, noting that care teams at his hospital inherit nearly half their patients as handoffs from night admitters, and some never know handed-off patients as well as those they admitted themselves.

“In a system in which half the patients are cared for by two sets of doctors during these crucial stages [early assessment, data gathering, and initial patient response], neither group fully sees this arc play out, and their education suffers,” he wrote on his blog.

New limits means “less flexibility,” says Dr. Dressler, “and it can become a hindrance to completing the work-up of a patient—like not being able to put a central line in at 8:30 p.m. ... Some trainees feel they have less continuity with their patients because of the shorter hours.”

It’s no huge intellectual stretch to say that someone who’s been up for 32 hours is not in the best condition to make optimal patient-care decisions.

—Jeffrey G. Wiese, MD, SFHM, FACP, associate dean, graduate medical education, director, internal medicine program, Tulane University School of Medicine, New Orleans, former SHM president

Thoughtful management is required to minimize schedule disruption and maximize learning opportunities, he adds. “We’ve decided that our interns will have five overnight shifts over 10 days as part of one of their 30-day rotations. It’s important that interns get overnight experience before their second year,” Dr. Dressler says. “We had to incorporate three interns per team instead of two. Any way you slice it, you’re going to need additional manpower from other sources.”

Such workforce issues are hot topics in teaching hospitals across the country, Dr. Wiese says. He also warns that using hospitalists solely as “resident extenders” is not sustainable. “If an academic program is using hospitalists as stopgap labor, they do so at the risk of accelerating burnout,” he says.

Hospitalist Opportunity

Hospitalists can and should, however, take full advantage of a much-needed niche that the new ACGME regulations have called attention to: the need for expertise in minimizing patient-care disruptions resulting from more frequent patient handoffs.

“Hospitalists have an opportunity to get more involved in residency training programs by sharing their knowledge of effective patient handoff protocols,” Dr. Dressler says. “Hospitalists have treaded those waters for over a decade. We’ve learned a lot about structuring handoff information effectively, and we can inform training programs about those issues.”

The increased urgency of effective handoff management might even lead to an increased investment in HM programs, Dr. Dressler believes. “The expectation, of course, is that we are able to demonstrate effective patient handoffs—and show that we’re ‘walking the walk,’ and not just talking about it,” he says.

Christopher Guadagnino is a freelance medical writer in Philadelphia.

References

1. Institute of Medicine. Resident duty hours: enhancing sleep, supervision, and safety. Institute of Medicine website. Available at: http://www.nap.edu/catalog.php?record_id=12508#toc. Accessed May 1, 2012.
2. Krups C. Residency programs scramble to adopt changes. American Medical News website. Available at: http://www.ama-assn.org/amednews/2011/07/11/prsa0711.htm#s1. Accessed May 1, 2012.

Danielle Scheurer, MD, MSCR, SFHM

Let’s be honest. How many times in the past (insert any timeline here; month, week, day, minute) have you heard a disparaging comment about a hospital regulatory agency? They usually sound something like, “Well, I’ll be darned if I am going to let CMS tell me how to practice medicine” or “So is this another Joint Commission thing?”

I understand the frustration. The healthcare industry is incredibly regulated. So much so that I, and countless others in hospital administration offices around the country, relinquish an inordinate amount of time figuring out what it is we are supposed to be complying with, then figuring how we are actually going to do it. It often has been equated to Whac-a-Mole, a game that requires more eyeballs and arm strength than an extraterrestrial possesses. There are many reasons that underlie the frustration and lead to the disparaging comments:

• Some requirements are not perfectly evidence-based. Not all process measures actually correlate with any outcomes; just because someone checks an oxygen saturation on every pneumonia patient doesn’t mean anything else improves for the patient.
• Some requirements are poorly implemented. I think we can all agree that counseling patients to stop smoking is a laudable goal. However, “smoking cessation counseling” is often relegated to uttering a short phrase (“you know you should really quit smoking”) while holding the exit-door handle, then checking the box for documentation. This “counseling session” is probably as effective as declaring every day a Great American Smokeout.
• Some regulations result in unintended consequences when implemented into large, complicated organizations. An obvious example is the time to first antibiotic in pneumonia patients, which resulted in frequent and unnecessary antibiotic utilization in patients who did not have pneumonia.
• Some are just extremely difficult to accomplish with high reliability. An example here is time to PCI for heart attacks. It’s clearly the right thing to do, and clearly very difficult to get it completed, on time, on every single patient. And 99% compliance is just not good enough, because the 1% matters.

And as a result of these imperfections, “noncompliance” leads to lots of emails, rework, restructuring, and at times downright bickering—hence, the disparaging comments.

Regulatory Origins and Missions

But let’s back up for a minute and think about why healthcare regulations exist: Many local, state, and federal agencies have enhanced the scrutiny of healthcare over time because, quite frankly, the healthcare industry did not regulate itself very well. We insisted for decades that patients were each too unique to be “cook-booked,” that medicine was an art as much as it was a science, and that “it’s just complicated.”

It took a few (too many) high-profile deaths and a few common-sense publications to incense the public, our payors, and our regulators. Who is not familiar with the 98,000-preventable-deaths-a-year statistic? Not only is that figure sobering, but it also is quite difficult to untether from our reputation. Henceforth, over the course of decades, a multitude of moles have emerged, littering the landscape and sparing no area of the healthcare industry.

So let’s back up another minute and think about what these agencies are trying to do: Could it be that most regulatory agencies really do want to leverage large-scale improvements in patient outcomes, at the best value?

Take this vision statement, as an example: “All people always experience the safest, highest-quality, best-value healthcare across all settings.”

Sounds like the kind of healthcare I want for my kids and my mom. That is the vision statement of the Joint Commission.

How about this vision statement: “CMS is a major force and a trustworthy partner for the continual improvement of health and healthcare for all Americans.”

Not too shabby.

So why do we view regulators like moles? Why do we arm ourselves with big, black mallets ready to strike when we see them emerge from the corner of our eye?

HM-Mole Alliance

Whac-a-Mole is an unwinnable game. No player has ever whacked all the moles. If you have not been to your local arcade lately, the game starts out slow, such that most players can keep pace; it then accelerates, such that several moles are outside the holes simultaneously, and their time above ground becomes consecutively shorter. You can add mallets, even add players, but generally they end up getting in each other’s way, communication breaks down, and one mole gets whacked twice, while another exits unscathed, only to break the soil elsewhere.

Danielle Scheurer, MD, MSCR, SFHM

Maybe a better strategy is to have a strategy—to work with our “trustworthy partners” to align our vision statements, anticipate the vermin’s approach, and fill the holes (or chasms) before anything has a chance to squeeze through. Maybe we should tell them where the moles are, because we actually already know what they look like and where they dwell. Why don’t we tell them which moles are the most dangerous, the most annoying, or are the most likely to tear up the topsoil into an irreparable state?

What about all the issues that no one is telling us we have to comply with—for example, a universal allergy list across the spectrum of care, or a perfectly reliable system to ensure that a patient with an epidural catheter cannot be anticoagulated? Such a list is endless, and no one is telling us we have to address the majority of the items on the list.

It comes down to this: What kind of healthcare do you want for yourself, your family, and the patients who trust you? I’d rather not have a reactive, frantic race to obliterate the next torrid creature that has arisen. I suggest a proactive, strategic pathway of tilling the soil.

In anticipation of a universal vote for the latter, join me in congratulating the healthcare industry in holding ourselves accountable, embracing a new era of transparency and collaboration, and routinely going beyond the expectations of our regulators. And leaving the mallet in the arcade.

Dr. Scheurer is a hospitalist and chief quality officer at the Medical University of South Carolina in Charleston. She is physician editor of The Hospitalist. Email her at scheured@musc.edu.

Danielle Scheurer, MD, MSCR, SFHM

Let’s be honest. How many times in the past (insert any timeline here; month, week, day, minute) have you heard a disparaging comment about a hospital regulatory agency? They usually sound something like, “Well, I’ll be darned if I am going to let CMS tell me how to practice medicine” or “So is this another Joint Commission thing?”

I understand the frustration. The healthcare industry is incredibly regulated. So much so that I, and countless others in hospital administration offices around the country, relinquish an inordinate amount of time figuring out what it is we are supposed to be complying with, then figuring how we are actually going to do it. It often has been equated to Whac-a-Mole, a game that requires more eyeballs and arm strength than an extraterrestrial possesses. There are many reasons that underlie the frustration and lead to the disparaging comments:

• Some requirements are not perfectly evidence-based. Not all process measures actually correlate with any outcomes; just because someone checks an oxygen saturation on every pneumonia patient doesn’t mean anything else improves for the patient.
• Some requirements are poorly implemented. I think we can all agree that counseling patients to stop smoking is a laudable goal. However, “smoking cessation counseling” is often relegated to uttering a short phrase (“you know you should really quit smoking”) while holding the exit-door handle, then checking the box for documentation. This “counseling session” is probably as effective as declaring every day a Great American Smokeout.
• Some regulations result in unintended consequences when implemented into large, complicated organizations. An obvious example is the time to first antibiotic in pneumonia patients, which resulted in frequent and unnecessary antibiotic utilization in patients who did not have pneumonia.
• Some are just extremely difficult to accomplish with high reliability. An example here is time to PCI for heart attacks. It’s clearly the right thing to do, and clearly very difficult to get it completed, on time, on every single patient. And 99% compliance is just not good enough, because the 1% matters.

And as a result of these imperfections, “noncompliance” leads to lots of emails, rework, restructuring, and at times downright bickering—hence, the disparaging comments.

Regulatory Origins and Missions

But let’s back up for a minute and think about why healthcare regulations exist: Many local, state, and federal agencies have enhanced the scrutiny of healthcare over time because, quite frankly, the healthcare industry did not regulate itself very well. We insisted for decades that patients were each too unique to be “cook-booked,” that medicine was an art as much as it was a science, and that “it’s just complicated.”

It took a few (too many) high-profile deaths and a few common-sense publications to incense the public, our payors, and our regulators. Who is not familiar with the 98,000-preventable-deaths-a-year statistic? Not only is that figure sobering, but it also is quite difficult to untether from our reputation. Henceforth, over the course of decades, a multitude of moles have emerged, littering the landscape and sparing no area of the healthcare industry.

So let’s back up another minute and think about what these agencies are trying to do: Could it be that most regulatory agencies really do want to leverage large-scale improvements in patient outcomes, at the best value?

Take this vision statement, as an example: “All people always experience the safest, highest-quality, best-value healthcare across all settings.”

Sounds like the kind of healthcare I want for my kids and my mom. That is the vision statement of the Joint Commission.

How about this vision statement: “CMS is a major force and a trustworthy partner for the continual improvement of health and healthcare for all Americans.”

Not too shabby.

So why do we view regulators like moles? Why do we arm ourselves with big, black mallets ready to strike when we see them emerge from the corner of our eye?

HM-Mole Alliance

Whac-a-Mole is an unwinnable game. No player has ever whacked all the moles. If you have not been to your local arcade lately, the game starts out slow, such that most players can keep pace; it then accelerates, such that several moles are outside the holes simultaneously, and their time above ground becomes consecutively shorter. You can add mallets, even add players, but generally they end up getting in each other’s way, communication breaks down, and one mole gets whacked twice, while another exits unscathed, only to break the soil elsewhere.

Danielle Scheurer, MD, MSCR, SFHM

Maybe a better strategy is to have a strategy—to work with our “trustworthy partners” to align our vision statements, anticipate the vermin’s approach, and fill the holes (or chasms) before anything has a chance to squeeze through. Maybe we should tell them where the moles are, because we actually already know what they look like and where they dwell. Why don’t we tell them which moles are the most dangerous, the most annoying, or are the most likely to tear up the topsoil into an irreparable state?

What about all the issues that no one is telling us we have to comply with—for example, a universal allergy list across the spectrum of care, or a perfectly reliable system to ensure that a patient with an epidural catheter cannot be anticoagulated? Such a list is endless, and no one is telling us we have to address the majority of the items on the list.

It comes down to this: What kind of healthcare do you want for yourself, your family, and the patients who trust you? I’d rather not have a reactive, frantic race to obliterate the next torrid creature that has arisen. I suggest a proactive, strategic pathway of tilling the soil.

In anticipation of a universal vote for the latter, join me in congratulating the healthcare industry in holding ourselves accountable, embracing a new era of transparency and collaboration, and routinely going beyond the expectations of our regulators. And leaving the mallet in the arcade.

Dr. Scheurer is a hospitalist and chief quality officer at the Medical University of South Carolina in Charleston. She is physician editor of The Hospitalist. Email her at scheured@musc.edu.

Danielle Scheurer, MD, MSCR, SFHM

Let’s be honest. How many times in the past (insert any timeline here; month, week, day, minute) have you heard a disparaging comment about a hospital regulatory agency? They usually sound something like, “Well, I’ll be darned if I am going to let CMS tell me how to practice medicine” or “So is this another Joint Commission thing?”

I understand the frustration. The healthcare industry is incredibly regulated. So much so that I, and countless others in hospital administration offices around the country, relinquish an inordinate amount of time figuring out what it is we are supposed to be complying with, then figuring how we are actually going to do it. It often has been equated to Whac-a-Mole, a game that requires more eyeballs and arm strength than an extraterrestrial possesses. There are many reasons that underlie the frustration and lead to the disparaging comments:

• Some requirements are not perfectly evidence-based. Not all process measures actually correlate with any outcomes; just because someone checks an oxygen saturation on every pneumonia patient doesn’t mean anything else improves for the patient.
• Some requirements are poorly implemented. I think we can all agree that counseling patients to stop smoking is a laudable goal. However, “smoking cessation counseling” is often relegated to uttering a short phrase (“you know you should really quit smoking”) while holding the exit-door handle, then checking the box for documentation. This “counseling session” is probably as effective as declaring every day a Great American Smokeout.
• Some regulations result in unintended consequences when implemented into large, complicated organizations. An obvious example is the time to first antibiotic in pneumonia patients, which resulted in frequent and unnecessary antibiotic utilization in patients who did not have pneumonia.
• Some are just extremely difficult to accomplish with high reliability. An example here is time to PCI for heart attacks. It’s clearly the right thing to do, and clearly very difficult to get it completed, on time, on every single patient. And 99% compliance is just not good enough, because the 1% matters.

And as a result of these imperfections, “noncompliance” leads to lots of emails, rework, restructuring, and at times downright bickering—hence, the disparaging comments.

Regulatory Origins and Missions

But let’s back up for a minute and think about why healthcare regulations exist: Many local, state, and federal agencies have enhanced the scrutiny of healthcare over time because, quite frankly, the healthcare industry did not regulate itself very well. We insisted for decades that patients were each too unique to be “cook-booked,” that medicine was an art as much as it was a science, and that “it’s just complicated.”

It took a few (too many) high-profile deaths and a few common-sense publications to incense the public, our payors, and our regulators. Who is not familiar with the 98,000-preventable-deaths-a-year statistic? Not only is that figure sobering, but it also is quite difficult to untether from our reputation. Henceforth, over the course of decades, a multitude of moles have emerged, littering the landscape and sparing no area of the healthcare industry.

So let’s back up another minute and think about what these agencies are trying to do: Could it be that most regulatory agencies really do want to leverage large-scale improvements in patient outcomes, at the best value?

Take this vision statement, as an example: “All people always experience the safest, highest-quality, best-value healthcare across all settings.”

Sounds like the kind of healthcare I want for my kids and my mom. That is the vision statement of the Joint Commission.

How about this vision statement: “CMS is a major force and a trustworthy partner for the continual improvement of health and healthcare for all Americans.”

Not too shabby.

So why do we view regulators like moles? Why do we arm ourselves with big, black mallets ready to strike when we see them emerge from the corner of our eye?

HM-Mole Alliance

Whac-a-Mole is an unwinnable game. No player has ever whacked all the moles. If you have not been to your local arcade lately, the game starts out slow, such that most players can keep pace; it then accelerates, such that several moles are outside the holes simultaneously, and their time above ground becomes consecutively shorter. You can add mallets, even add players, but generally they end up getting in each other’s way, communication breaks down, and one mole gets whacked twice, while another exits unscathed, only to break the soil elsewhere.

Danielle Scheurer, MD, MSCR, SFHM

Maybe a better strategy is to have a strategy—to work with our “trustworthy partners” to align our vision statements, anticipate the vermin’s approach, and fill the holes (or chasms) before anything has a chance to squeeze through. Maybe we should tell them where the moles are, because we actually already know what they look like and where they dwell. Why don’t we tell them which moles are the most dangerous, the most annoying, or are the most likely to tear up the topsoil into an irreparable state?

What about all the issues that no one is telling us we have to comply with—for example, a universal allergy list across the spectrum of care, or a perfectly reliable system to ensure that a patient with an epidural catheter cannot be anticoagulated? Such a list is endless, and no one is telling us we have to address the majority of the items on the list.

It comes down to this: What kind of healthcare do you want for yourself, your family, and the patients who trust you? I’d rather not have a reactive, frantic race to obliterate the next torrid creature that has arisen. I suggest a proactive, strategic pathway of tilling the soil.

In anticipation of a universal vote for the latter, join me in congratulating the healthcare industry in holding ourselves accountable, embracing a new era of transparency and collaboration, and routinely going beyond the expectations of our regulators. And leaving the mallet in the arcade.

Dr. Scheurer is a hospitalist and chief quality officer at the Medical University of South Carolina in Charleston. She is physician editor of The Hospitalist. Email her at scheured@musc.edu.

The term “patient-centered medical home” has a nice ring to it, but what does it really mean? And how does it function in the real world? The model is evolving, but here are the main components of the PCMH and how they’ve been implemented in real practice, at least so far:

“PERSONAL” PHYSICIAN: This is the doctor, usually a family or general practice physician, who shepherds patients through the medical system. In practice, this means things like encouraging patient questions about their care, extra efforts to educate patients on their health, and nurses making detailed follow-up calls with patients to make sure they’ve gotten their medications and know how to take them, and communicating any other steps the patient should be taking.

“Whole-person orientation”: The personal physician is responsible for taking care of all of the patient’s medical needs, either himself or by arranging care with specialists. The care ranges from preventive to chronic to end-of-life. In practice, this often means having appointments made with another doctor, if necessary, before the patient leaves the primary-care doctor, or seeing several doctors of different specialties during the same appointment.

Coordinated or integrated care: Care in the PCMH spans all aspects of the healthcare system, from subspecialists to the hospital to the nursing home. In practice, this means the use of electronic registries and health information exchange systems to make sure every health professional has all the information they should have about the patient.

Quality and safety: In practice, it means the development of a care plan that is bolstered by close relationships between patients, doctors, and family members. Plus, a good PCMH will have a more collegial atmosphere, with regular meetings among doctors of varying specialties. Evidence-based medicine is the guide. And feedback from the patient is sought more aggressively. Practices also can undergo a voluntary recognition process by a non-government-related healthcare quality organization, such as the National Committee for Quality Assurance.

Enhanced access: So that patients get the care when they need it, same-day scheduling is often offered. There are expanded hours, and phone and email communication is used more often.

Payment: The payment system in a PCMH encourages better primary care and prevention of illness. Still, most PCMH practices currently use a blend of fee-for-service, a monthly “care coordination” fee, and incentives for quality care.

Source: Adapted from 2007’s Joint Statement on Patient-Centered Medical Home, Agency for Healthcare Research and Quality

The term “patient-centered medical home” has a nice ring to it, but what does it really mean? And how does it function in the real world? The model is evolving, but here are the main components of the PCMH and how they’ve been implemented in real practice, at least so far:

“PERSONAL” PHYSICIAN: This is the doctor, usually a family or general practice physician, who shepherds patients through the medical system. In practice, this means things like encouraging patient questions about their care, extra efforts to educate patients on their health, and nurses making detailed follow-up calls with patients to make sure they’ve gotten their medications and know how to take them, and communicating any other steps the patient should be taking.

“Whole-person orientation”: The personal physician is responsible for taking care of all of the patient’s medical needs, either himself or by arranging care with specialists. The care ranges from preventive to chronic to end-of-life. In practice, this often means having appointments made with another doctor, if necessary, before the patient leaves the primary-care doctor, or seeing several doctors of different specialties during the same appointment.

Coordinated or integrated care: Care in the PCMH spans all aspects of the healthcare system, from subspecialists to the hospital to the nursing home. In practice, this means the use of electronic registries and health information exchange systems to make sure every health professional has all the information they should have about the patient.

Quality and safety: In practice, it means the development of a care plan that is bolstered by close relationships between patients, doctors, and family members. Plus, a good PCMH will have a more collegial atmosphere, with regular meetings among doctors of varying specialties. Evidence-based medicine is the guide. And feedback from the patient is sought more aggressively. Practices also can undergo a voluntary recognition process by a non-government-related healthcare quality organization, such as the National Committee for Quality Assurance.

Enhanced access: So that patients get the care when they need it, same-day scheduling is often offered. There are expanded hours, and phone and email communication is used more often.

Payment: The payment system in a PCMH encourages better primary care and prevention of illness. Still, most PCMH practices currently use a blend of fee-for-service, a monthly “care coordination” fee, and incentives for quality care.

Source: Adapted from 2007’s Joint Statement on Patient-Centered Medical Home, Agency for Healthcare Research and Quality

The term “patient-centered medical home” has a nice ring to it, but what does it really mean? And how does it function in the real world? The model is evolving, but here are the main components of the PCMH and how they’ve been implemented in real practice, at least so far:

“PERSONAL” PHYSICIAN: This is the doctor, usually a family or general practice physician, who shepherds patients through the medical system. In practice, this means things like encouraging patient questions about their care, extra efforts to educate patients on their health, and nurses making detailed follow-up calls with patients to make sure they’ve gotten their medications and know how to take them, and communicating any other steps the patient should be taking.

“Whole-person orientation”: The personal physician is responsible for taking care of all of the patient’s medical needs, either himself or by arranging care with specialists. The care ranges from preventive to chronic to end-of-life. In practice, this often means having appointments made with another doctor, if necessary, before the patient leaves the primary-care doctor, or seeing several doctors of different specialties during the same appointment.

Coordinated or integrated care: Care in the PCMH spans all aspects of the healthcare system, from subspecialists to the hospital to the nursing home. In practice, this means the use of electronic registries and health information exchange systems to make sure every health professional has all the information they should have about the patient.

Quality and safety: In practice, it means the development of a care plan that is bolstered by close relationships between patients, doctors, and family members. Plus, a good PCMH will have a more collegial atmosphere, with regular meetings among doctors of varying specialties. Evidence-based medicine is the guide. And feedback from the patient is sought more aggressively. Practices also can undergo a voluntary recognition process by a non-government-related healthcare quality organization, such as the National Committee for Quality Assurance.

Enhanced access: So that patients get the care when they need it, same-day scheduling is often offered. There are expanded hours, and phone and email communication is used more often.

Payment: The payment system in a PCMH encourages better primary care and prevention of illness. Still, most PCMH practices currently use a blend of fee-for-service, a monthly “care coordination” fee, and incentives for quality care.

Source: Adapted from 2007’s Joint Statement on Patient-Centered Medical Home, Agency for Healthcare Research and Quality

If the “patient-centered medical home” model does what it intends to do—makes people healthier and limits preventable illness—fewer people will likely be hospitalized. Should hospitalists be worried? Will that mean less work for hospitalists?

“That clearly is one potential implication of many of the different healthcare reform models, including the development of primary-care medical homes and folks out there who are participating in accountable-care organizations [ACOs], all of which are designed to provide better access to patients on an outpatient setting,” SHM immediate past president Joseph Ming Wah Li, MD, SFHM, says. “The rationale is that it should ultimately lead to fewer hospitalizations.”

Dr. Li

Most hospitalists, Dr. Li adds, will say that’s a good thing.

“You’re never going to argue against” fewer hospitalizations, he says. “I think what hospitalists will have to do is they will have to adapt.”

Ultimately, patients who are hospitalized will be sicker, and hospitalists likely will end up seeing those patients several times a day rather than just once or twice, Dr. Li says.

Dr. Meyers, of AHRQ, says inpatient care in the future could become more meaningful, because while there may be fewer patients, those who are hospitalized will need more complex care management.

“I think America’s a big enough country, though, where with an aging population—and we still have lots of chronic disease—there’s going to be no shortage of work, meaningful work, for hospitalists moving forward,” he says.

Dr. Eichhorn, who works in an already up-and-running PCMH system, says patient census shouldn’t be a concern.

“Most hospitalists would probably say that they have plenty of work,” Dr. Eichhorn says. “I think anything that we can do to prevent a hospital stay certainly promotes health and allows us to be better stewards of healthcare resources. And I think it’s a win for everyone.”

If the “patient-centered medical home” model does what it intends to do—makes people healthier and limits preventable illness—fewer people will likely be hospitalized. Should hospitalists be worried? Will that mean less work for hospitalists?

“That clearly is one potential implication of many of the different healthcare reform models, including the development of primary-care medical homes and folks out there who are participating in accountable-care organizations [ACOs], all of which are designed to provide better access to patients on an outpatient setting,” SHM immediate past president Joseph Ming Wah Li, MD, SFHM, says. “The rationale is that it should ultimately lead to fewer hospitalizations.”

Dr. Li

Most hospitalists, Dr. Li adds, will say that’s a good thing.

“You’re never going to argue against” fewer hospitalizations, he says. “I think what hospitalists will have to do is they will have to adapt.”

Ultimately, patients who are hospitalized will be sicker, and hospitalists likely will end up seeing those patients several times a day rather than just once or twice, Dr. Li says.

Dr. Meyers, of AHRQ, says inpatient care in the future could become more meaningful, because while there may be fewer patients, those who are hospitalized will need more complex care management.

“I think America’s a big enough country, though, where with an aging population—and we still have lots of chronic disease—there’s going to be no shortage of work, meaningful work, for hospitalists moving forward,” he says.

Dr. Eichhorn, who works in an already up-and-running PCMH system, says patient census shouldn’t be a concern.

“Most hospitalists would probably say that they have plenty of work,” Dr. Eichhorn says. “I think anything that we can do to prevent a hospital stay certainly promotes health and allows us to be better stewards of healthcare resources. And I think it’s a win for everyone.”

If the “patient-centered medical home” model does what it intends to do—makes people healthier and limits preventable illness—fewer people will likely be hospitalized. Should hospitalists be worried? Will that mean less work for hospitalists?

“That clearly is one potential implication of many of the different healthcare reform models, including the development of primary-care medical homes and folks out there who are participating in accountable-care organizations [ACOs], all of which are designed to provide better access to patients on an outpatient setting,” SHM immediate past president Joseph Ming Wah Li, MD, SFHM, says. “The rationale is that it should ultimately lead to fewer hospitalizations.”

Dr. Li

Most hospitalists, Dr. Li adds, will say that’s a good thing.

“You’re never going to argue against” fewer hospitalizations, he says. “I think what hospitalists will have to do is they will have to adapt.”

Ultimately, patients who are hospitalized will be sicker, and hospitalists likely will end up seeing those patients several times a day rather than just once or twice, Dr. Li says.

Dr. Meyers, of AHRQ, says inpatient care in the future could become more meaningful, because while there may be fewer patients, those who are hospitalized will need more complex care management.

“I think America’s a big enough country, though, where with an aging population—and we still have lots of chronic disease—there’s going to be no shortage of work, meaningful work, for hospitalists moving forward,” he says.

Dr. Eichhorn, who works in an already up-and-running PCMH system, says patient census shouldn’t be a concern.

“Most hospitalists would probably say that they have plenty of work,” Dr. Eichhorn says. “I think anything that we can do to prevent a hospital stay certainly promotes health and allows us to be better stewards of healthcare resources. And I think it’s a win for everyone.”

Medicine in the past 10-20 years has seen major changes driven by changes in payment systems, lifestyle changes, and changes in training patterns. One such change is the hospitalist model of medicine. The advent of hospitalist practice has turned work-life balance on its head, as far as medicine is concerned.

All along, professionalism required that we pay unquestionable attention to the patient, the profession, and the organization—reporting early to work, staying until the work is done, taking work home, and answering the phone on the nights when we were on call. On weekends, finishing pending dictation was normal. The 20-minute mill of outpatient practice has driven primary medicine to a breaking point.

As the pressures of the primary-care job got worse, there came an exit in the form of the hospitalist model. HM provided shift work that could be adjusted to the needs of the physician.

This new kind of job, however, has its own problems. Physicians choosing the normalcy of shift work did not realize that they would give up professional independence. Hospitalists now are governed by the laws of shift work, and at the same time remain governed by the laws of their profession. It is likely when in need they will stay behind and get the work done. And it has been seen that hospitalists do visit the doctors’ lounge, have professional interests outside of direct patient care, and sometimes leave the hospital when their admits and discharges are complete.

And so the shift-work model has, at times, resulted in friction between hospital administration and hospitalists. It could be understood that, from an employer’s perspective, hospitals are paying on an hourly basis and thus expect the hospitalist group to be on site 24/7, sticking around even if there is no work. However, the argument from the hospitalist perspective is that when needed, I stay extra. It should be OK that on low-census days we should be able to leave for a cup of coffee and still be reachable, ready to come in if need arises.

So how do hospitalist-physician professionalism and shift work co-exist? It’s a big question, one that organizations around the country will be looking to solve in the next few years. How this question is answered is going to impact quality of care, recruitment, and staff satisfaction. Each answer will impact the staff and patients.

Keeping in mind outcomes that both parties are looking for, I think a proper plan can be worked out. I suggest hospital administrators adopt the following value-based measurements to evaluate hospitalist clinicians, and establish a compensation system where a minimum amount of production must be met.

Work relative value units (wRVUs). Work RVUs provide a consistent method to measure physician productivity. If one HM clinician’s numbers are below the group average, they might need a lesson in billing, along with a report of their productivity numbers and group expectations.

Patient encounters per day. The average number of patients seen per day (patients seen divided by number of shifts worked) should be measured on a quarterly basis. This metric should provide a measure of the work done by the physician; however, it needs to be offset by your group’s turnover rate (as discussed below).

Length of stay (LOS). Most HM groups are measuring LOS. It is the reason hospitalists exist. Not much more needs to be said about this measure of work performance.

Percentage of patient turnover. A good hospitalist will have a high patient turnover figure (total discharges divided by total encounters per day). This is important to know; it’s even better if accompanied by a short LOS.

New admissions per shift. Again, if there is an outlier, that metric should be detected rather easily.

Patient satisfaction. More and more, this is becoming an important measure of physician quality and is essential for competitive marketplaces. Of course, the quality of medical care will have its own parameters. And it is best left to use the existing, longstanding parameters that are used for the rest of the doctors in your system. There is no need to create an alternative system for the hospitalist.

If all of the above measures are better than the average hospitalist in the locality, then no one should worry about the hospitalist’s other activities, be it involvement in committee work, research, or browsing a newspaper or a cup of coffee in the doctors’ lounge. After all, one of the main reasons physicians opted for HM practice was to have the ability to control their workday.

This will, in my opinion, improve workforce satisfaction and improve productivity. It only makes common sense. It may be a hard pill to swallow for the administrators, but it is the right medicine for the doctor.

Rwoof Reshi, MD, hospitalist, St. Joe’s Hospital, St. Paul, Minn.

Medicine in the past 10-20 years has seen major changes driven by changes in payment systems, lifestyle changes, and changes in training patterns. One such change is the hospitalist model of medicine. The advent of hospitalist practice has turned work-life balance on its head, as far as medicine is concerned.

All along, professionalism required that we pay unquestionable attention to the patient, the profession, and the organization—reporting early to work, staying until the work is done, taking work home, and answering the phone on the nights when we were on call. On weekends, finishing pending dictation was normal. The 20-minute mill of outpatient practice has driven primary medicine to a breaking point.

As the pressures of the primary-care job got worse, there came an exit in the form of the hospitalist model. HM provided shift work that could be adjusted to the needs of the physician.

This new kind of job, however, has its own problems. Physicians choosing the normalcy of shift work did not realize that they would give up professional independence. Hospitalists now are governed by the laws of shift work, and at the same time remain governed by the laws of their profession. It is likely when in need they will stay behind and get the work done. And it has been seen that hospitalists do visit the doctors’ lounge, have professional interests outside of direct patient care, and sometimes leave the hospital when their admits and discharges are complete.

And so the shift-work model has, at times, resulted in friction between hospital administration and hospitalists. It could be understood that, from an employer’s perspective, hospitals are paying on an hourly basis and thus expect the hospitalist group to be on site 24/7, sticking around even if there is no work. However, the argument from the hospitalist perspective is that when needed, I stay extra. It should be OK that on low-census days we should be able to leave for a cup of coffee and still be reachable, ready to come in if need arises.

So how do hospitalist-physician professionalism and shift work co-exist? It’s a big question, one that organizations around the country will be looking to solve in the next few years. How this question is answered is going to impact quality of care, recruitment, and staff satisfaction. Each answer will impact the staff and patients.

Keeping in mind outcomes that both parties are looking for, I think a proper plan can be worked out. I suggest hospital administrators adopt the following value-based measurements to evaluate hospitalist clinicians, and establish a compensation system where a minimum amount of production must be met.

Work relative value units (wRVUs). Work RVUs provide a consistent method to measure physician productivity. If one HM clinician’s numbers are below the group average, they might need a lesson in billing, along with a report of their productivity numbers and group expectations.

Patient encounters per day. The average number of patients seen per day (patients seen divided by number of shifts worked) should be measured on a quarterly basis. This metric should provide a measure of the work done by the physician; however, it needs to be offset by your group’s turnover rate (as discussed below).

Length of stay (LOS). Most HM groups are measuring LOS. It is the reason hospitalists exist. Not much more needs to be said about this measure of work performance.

Percentage of patient turnover. A good hospitalist will have a high patient turnover figure (total discharges divided by total encounters per day). This is important to know; it’s even better if accompanied by a short LOS.

New admissions per shift. Again, if there is an outlier, that metric should be detected rather easily.

Patient satisfaction. More and more, this is becoming an important measure of physician quality and is essential for competitive marketplaces. Of course, the quality of medical care will have its own parameters. And it is best left to use the existing, longstanding parameters that are used for the rest of the doctors in your system. There is no need to create an alternative system for the hospitalist.

If all of the above measures are better than the average hospitalist in the locality, then no one should worry about the hospitalist’s other activities, be it involvement in committee work, research, or browsing a newspaper or a cup of coffee in the doctors’ lounge. After all, one of the main reasons physicians opted for HM practice was to have the ability to control their workday.

This will, in my opinion, improve workforce satisfaction and improve productivity. It only makes common sense. It may be a hard pill to swallow for the administrators, but it is the right medicine for the doctor.

Rwoof Reshi, MD, hospitalist, St. Joe’s Hospital, St. Paul, Minn.

Medicine in the past 10-20 years has seen major changes driven by changes in payment systems, lifestyle changes, and changes in training patterns. One such change is the hospitalist model of medicine. The advent of hospitalist practice has turned work-life balance on its head, as far as medicine is concerned.

All along, professionalism required that we pay unquestionable attention to the patient, the profession, and the organization—reporting early to work, staying until the work is done, taking work home, and answering the phone on the nights when we were on call. On weekends, finishing pending dictation was normal. The 20-minute mill of outpatient practice has driven primary medicine to a breaking point.

As the pressures of the primary-care job got worse, there came an exit in the form of the hospitalist model. HM provided shift work that could be adjusted to the needs of the physician.

This new kind of job, however, has its own problems. Physicians choosing the normalcy of shift work did not realize that they would give up professional independence. Hospitalists now are governed by the laws of shift work, and at the same time remain governed by the laws of their profession. It is likely when in need they will stay behind and get the work done. And it has been seen that hospitalists do visit the doctors’ lounge, have professional interests outside of direct patient care, and sometimes leave the hospital when their admits and discharges are complete.

And so the shift-work model has, at times, resulted in friction between hospital administration and hospitalists. It could be understood that, from an employer’s perspective, hospitals are paying on an hourly basis and thus expect the hospitalist group to be on site 24/7, sticking around even if there is no work. However, the argument from the hospitalist perspective is that when needed, I stay extra. It should be OK that on low-census days we should be able to leave for a cup of coffee and still be reachable, ready to come in if need arises.

So how do hospitalist-physician professionalism and shift work co-exist? It’s a big question, one that organizations around the country will be looking to solve in the next few years. How this question is answered is going to impact quality of care, recruitment, and staff satisfaction. Each answer will impact the staff and patients.

Keeping in mind outcomes that both parties are looking for, I think a proper plan can be worked out. I suggest hospital administrators adopt the following value-based measurements to evaluate hospitalist clinicians, and establish a compensation system where a minimum amount of production must be met.

Work relative value units (wRVUs). Work RVUs provide a consistent method to measure physician productivity. If one HM clinician’s numbers are below the group average, they might need a lesson in billing, along with a report of their productivity numbers and group expectations.

Patient encounters per day. The average number of patients seen per day (patients seen divided by number of shifts worked) should be measured on a quarterly basis. This metric should provide a measure of the work done by the physician; however, it needs to be offset by your group’s turnover rate (as discussed below).

Length of stay (LOS). Most HM groups are measuring LOS. It is the reason hospitalists exist. Not much more needs to be said about this measure of work performance.

Percentage of patient turnover. A good hospitalist will have a high patient turnover figure (total discharges divided by total encounters per day). This is important to know; it’s even better if accompanied by a short LOS.

New admissions per shift. Again, if there is an outlier, that metric should be detected rather easily.

Patient satisfaction. More and more, this is becoming an important measure of physician quality and is essential for competitive marketplaces. Of course, the quality of medical care will have its own parameters. And it is best left to use the existing, longstanding parameters that are used for the rest of the doctors in your system. There is no need to create an alternative system for the hospitalist.

If all of the above measures are better than the average hospitalist in the locality, then no one should worry about the hospitalist’s other activities, be it involvement in committee work, research, or browsing a newspaper or a cup of coffee in the doctors’ lounge. After all, one of the main reasons physicians opted for HM practice was to have the ability to control their workday.

This will, in my opinion, improve workforce satisfaction and improve productivity. It only makes common sense. It may be a hard pill to swallow for the administrators, but it is the right medicine for the doctor.

Rwoof Reshi, MD, hospitalist, St. Joe’s Hospital, St. Paul, Minn.

An evaluation of the Pennsylvania-based Geisinger Health System’s ProvenHealth Navigator, a patient-centered medical home (PCMH) model, found that hospitalizations have been reduced by 18% for all patients.¹

The National Institutes on Aging-sponsored project Geriatric Resources for Assessment and Care of Elders (GRACE), which also functioned according to several PCMH principles, reduced hospitalizations by 40% and 44% in its second and third years, another evaluation showed.^2,3

And in the Veterans Affairs-managed Home-Based Primary Care project, another PCMH-based effort, readmissions were reduced by 22% in the first six months, but the reduction wasn’t sustained for the rest of the year.⁴

Those findings are among the most definitive so far on the effects of the PCMH on hospitalization rates, according to an Agency for Healthcare Research and Quality (AHRQ) report published in February.

The report concluded that among the statistically significant findings in the biggest PCMH evaluations, favorable results far outnumbered unfavorable results—on outcomes, ED use, and patient experience.

But AHRQ also found that most studies have been inconclusive due to problems with their methodologies. For instance, many studies don’t factor in “clustering,” in which patient outcomes within a practice can be expected to be similar to that of other patients at that practice. AHRQ’s report evaluated the results only from studies it determined had methodologies that were sufficiently rigorous.

The evaluation of the GRACE project was the only evaluation that found any evidence of savings, according to the report. But that study was one of only four on the topic that were deemed worth consideration.

David Meyers, MD, director of the Center for Primary Care, Prevention, and Clinical Partnerships at AHRQ, points out that the systems that have been evaluated are the very earliest adopters of PCMH principles. Researchers estimate that it could take 10 years to get reliable results.

“The good news,” Dr. Meyers says, “is that there are a lot more demonstrations happening now, so we soon will have a lot more guidance about how to make this model work.”

Tom Collins is a freelance writer in South Florida.

References

1. Gilfillan RJ, Tomcavage J, Rosenthal MB, et al. Value and the medical home: Effects of transformed primary care. Am J Manag Care. 2010;16(8):607-614.

2. Bielaszka-DuVernay, et al. The “GRACE” model: in-home assessments lead to better care for dual eligibles. Health Aff (Millwood). 2011;30(3):431-434.

3. Counsell SR, Callahan CM, Tu W, Stump TE, Arling GW. Cost analysis of the Geriatric Resources for Assessment and Care of Elders care management intervention. J Am Geriatr Soc. 2009;57(8):1420-1426.

4. Hughes SL, Weaver FM, Giobbie-Hurder A, et al. Effectiveness of team-managed home-based primary care: a randomized multicenter trial. JAMA. 2000;284(22):2877-2885.

An evaluation of the Pennsylvania-based Geisinger Health System’s ProvenHealth Navigator, a patient-centered medical home (PCMH) model, found that hospitalizations have been reduced by 18% for all patients.¹

The National Institutes on Aging-sponsored project Geriatric Resources for Assessment and Care of Elders (GRACE), which also functioned according to several PCMH principles, reduced hospitalizations by 40% and 44% in its second and third years, another evaluation showed.^2,3

And in the Veterans Affairs-managed Home-Based Primary Care project, another PCMH-based effort, readmissions were reduced by 22% in the first six months, but the reduction wasn’t sustained for the rest of the year.⁴

Those findings are among the most definitive so far on the effects of the PCMH on hospitalization rates, according to an Agency for Healthcare Research and Quality (AHRQ) report published in February.

The report concluded that among the statistically significant findings in the biggest PCMH evaluations, favorable results far outnumbered unfavorable results—on outcomes, ED use, and patient experience.

But AHRQ also found that most studies have been inconclusive due to problems with their methodologies. For instance, many studies don’t factor in “clustering,” in which patient outcomes within a practice can be expected to be similar to that of other patients at that practice. AHRQ’s report evaluated the results only from studies it determined had methodologies that were sufficiently rigorous.

The evaluation of the GRACE project was the only evaluation that found any evidence of savings, according to the report. But that study was one of only four on the topic that were deemed worth consideration.

David Meyers, MD, director of the Center for Primary Care, Prevention, and Clinical Partnerships at AHRQ, points out that the systems that have been evaluated are the very earliest adopters of PCMH principles. Researchers estimate that it could take 10 years to get reliable results.

“The good news,” Dr. Meyers says, “is that there are a lot more demonstrations happening now, so we soon will have a lot more guidance about how to make this model work.”

Tom Collins is a freelance writer in South Florida.

References

1. Gilfillan RJ, Tomcavage J, Rosenthal MB, et al. Value and the medical home: Effects of transformed primary care. Am J Manag Care. 2010;16(8):607-614.

2. Bielaszka-DuVernay, et al. The “GRACE” model: in-home assessments lead to better care for dual eligibles. Health Aff (Millwood). 2011;30(3):431-434.

3. Counsell SR, Callahan CM, Tu W, Stump TE, Arling GW. Cost analysis of the Geriatric Resources for Assessment and Care of Elders care management intervention. J Am Geriatr Soc. 2009;57(8):1420-1426.

4. Hughes SL, Weaver FM, Giobbie-Hurder A, et al. Effectiveness of team-managed home-based primary care: a randomized multicenter trial. JAMA. 2000;284(22):2877-2885.

An evaluation of the Pennsylvania-based Geisinger Health System’s ProvenHealth Navigator, a patient-centered medical home (PCMH) model, found that hospitalizations have been reduced by 18% for all patients.¹

The National Institutes on Aging-sponsored project Geriatric Resources for Assessment and Care of Elders (GRACE), which also functioned according to several PCMH principles, reduced hospitalizations by 40% and 44% in its second and third years, another evaluation showed.^2,3

And in the Veterans Affairs-managed Home-Based Primary Care project, another PCMH-based effort, readmissions were reduced by 22% in the first six months, but the reduction wasn’t sustained for the rest of the year.⁴

Those findings are among the most definitive so far on the effects of the PCMH on hospitalization rates, according to an Agency for Healthcare Research and Quality (AHRQ) report published in February.

The report concluded that among the statistically significant findings in the biggest PCMH evaluations, favorable results far outnumbered unfavorable results—on outcomes, ED use, and patient experience.

But AHRQ also found that most studies have been inconclusive due to problems with their methodologies. For instance, many studies don’t factor in “clustering,” in which patient outcomes within a practice can be expected to be similar to that of other patients at that practice. AHRQ’s report evaluated the results only from studies it determined had methodologies that were sufficiently rigorous.

The evaluation of the GRACE project was the only evaluation that found any evidence of savings, according to the report. But that study was one of only four on the topic that were deemed worth consideration.

David Meyers, MD, director of the Center for Primary Care, Prevention, and Clinical Partnerships at AHRQ, points out that the systems that have been evaluated are the very earliest adopters of PCMH principles. Researchers estimate that it could take 10 years to get reliable results.

“The good news,” Dr. Meyers says, “is that there are a lot more demonstrations happening now, so we soon will have a lot more guidance about how to make this model work.”

Tom Collins is a freelance writer in South Florida.

References

1. Gilfillan RJ, Tomcavage J, Rosenthal MB, et al. Value and the medical home: Effects of transformed primary care. Am J Manag Care. 2010;16(8):607-614.

2. Bielaszka-DuVernay, et al. The “GRACE” model: in-home assessments lead to better care for dual eligibles. Health Aff (Millwood). 2011;30(3):431-434.

3. Counsell SR, Callahan CM, Tu W, Stump TE, Arling GW. Cost analysis of the Geriatric Resources for Assessment and Care of Elders care management intervention. J Am Geriatr Soc. 2009;57(8):1420-1426.

4. Hughes SL, Weaver FM, Giobbie-Hurder A, et al. Effectiveness of team-managed home-based primary care: a randomized multicenter trial. JAMA. 2000;284(22):2877-2885.

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