Practice Management

I think every hospitalist group should diligently try to maximize hospitalist-patient continuity, but many seem to adopt schedules and other operational practices that erode it. Let’s walk through the issue of continuity, starting with some history.

Inpatient Continuity in Old Healthcare System

Proudly carrying a pager nearly the size of a loaf of bread and wearing a white shirt and pants with Converse All Stars, I served as a hospital orderly in the 1970s. This position involved things like getting patients out of bed, placing Foley catheters, performing chest compressions during codes, and transporting the bodies of the deceased to the morgue. I really enjoyed the work, and the experience serves as one of my historical frames of reference for how hospital care has evolved since then.

The way I remember it, nearly everyone at the hospital worked a predictable schedule. RN staffing was the same each day; it didn’t vary based on census. Each full-time RN worked five shifts a week, eight hours each. Most or all would work alternate weekends and would have two compensatory days off during the following work week. This resulted in terrific continuity between nurse and patient, and the long length of stays meant patients and nurses got to know one another really well.

Continuity Takes a Hit

But things have changed. Nurse-patient continuity seems to have declined significantly as a result of two main forces: the hospital’s efforts to reduce staffing costs by varying nurse staffing to match daily patient volume, and nurses’ desire for a wide variety of work schedules. Asking a bedside nurse in today’s hospital whether the patient’s confusion, diarrhea, or appetite is meaningfully different today than yesterday typically yields the same reply. “This is my first day with the patient; I’ll have to look at the chart.”

I couldn’t find many research articles or editorials regarding hospital nurse-patient continuity from one day to the next. But several researchers seem to have begun studying this issue and have recently published a proposed framework for assessing it, and I found one study showing it wasn’t correlated with rates of pressure ulcers.^1,2.

My anecdotal experience tells me continuity between the patient and caregivers of all stripes matters a lot. Research will be valuable in helping us to better understand its most significant costs and benefits, but I’m already convinced “Continuity is King” and should be one of the most important factors in the design of work schedules and patient allocation models for nurses and hospitalists alike.

While some might say we should wait for randomized trials of continuity to determine its importance, I’m inclined to see it like the authors of “Parachute use to prevent death and major trauma related to gravitational challenge: systematic review of randomised controlled trials.” As a ding against those who insist on research data when common sense may be sufficient, they concluded “…that everyone might benefit if the most radical protagonists of evidence-based medicine organised and participated in a double-blind, randomised, placebo-controlled, crossover trial of the parachute.³

Continuity and Hospitalists

On top of what I see as erosion in nurse-patient continuity, the arrival of hospitalists disrupted doctor-patient continuity across the inpatient and outpatient setting. While there was significant concern about this when our field first took off in the 1990s, it seems to be getting a great deal less attention over the last few years. In many hospitalist groups I work with, it is one of the last factors considered when creating a work schedule. Factors that are examined include the following:

• Solely for provider convenience, a group might regularly schedule a provider for only two or three consecutive daytime shifts, or sometimes only single days;
• Groups that use unit-based hospital (a.k.a. “geographic”) staffing might have a patient transfer to a different attending hospitalist solely as a result of moving to a room in a different nursing unit; and
• As part of morning load leveling, some groups reassign existing patients to a new hospitalist.

I think all groups should work hard to avoid doing these things. And while I seem to be a real outlier on this one, I think the benefits of a separate daytime hospitalist admitter shift are not worth the cost of having different doctors always do the admission and first follow-up visit. Most groups should consider moving the admitter into an additional rounder position and allocating daytime admissions across all hospitalists.

One study found that hospitalist discontinuity was not associated with adverse events, and another found it was associated with higher length of stay for selected diagnoses.^4,5 But there is too little research to draw hard conclusions. I’m convinced poor continuity increases the possibility of handoff-related errors, likely results in lower patient satisfaction, and increases the overall work of the hospitalist group, because more providers have to take the time to get to know the patient.

Although there will always be some tension between terrific continuity and a sustainable hospitalist lifestyle—a person can work only so many consecutive days before wearing out—every group should thoughtfully consider whether they are doing everything reasonable to maximize continuity. After all, continuity is king.

References

1. Stifter J, Yao Y, Lopez KC, Khokhar A, Wilkie DJ, Keenan GM. Proposing a new conceptual model and an exemplar measure using health information technology to examine the impact of relational nurse continuity on hospital-acquired pressure ulcers. ANS Adv Nurs Sci. 2015;38(3):241-251.
2. Stifter J, Yao Y, Lodhi MK, et al. Nurse continuity and hospital-acquired pressure ulcers: a comparative analysis using an electronic health record “big data” set. Nurs Res. 2015;64(5):361-371.
3. Smith GC, Pell JP. Parachute use to prevent death and major trauma related to gravitational challenge: systematic review of randomised controlled trials. BMJ. 2003;327(7429):1459-1461.
4. O’Leary KJ, Turner J, Christensen N, et al. The effect of hospitalist discontinuity on adverse events. J Hosp Med. 2015;10(3):147-151.
5. Epstein K, Juarez E, Epstein A, Loya K, Singer A. The impact of fragmentation of hospitalist care on length of stay. J Hosp Med. 2010;5(6):335-338.

I think every hospitalist group should diligently try to maximize hospitalist-patient continuity, but many seem to adopt schedules and other operational practices that erode it. Let’s walk through the issue of continuity, starting with some history.

Inpatient Continuity in Old Healthcare System

Proudly carrying a pager nearly the size of a loaf of bread and wearing a white shirt and pants with Converse All Stars, I served as a hospital orderly in the 1970s. This position involved things like getting patients out of bed, placing Foley catheters, performing chest compressions during codes, and transporting the bodies of the deceased to the morgue. I really enjoyed the work, and the experience serves as one of my historical frames of reference for how hospital care has evolved since then.

The way I remember it, nearly everyone at the hospital worked a predictable schedule. RN staffing was the same each day; it didn’t vary based on census. Each full-time RN worked five shifts a week, eight hours each. Most or all would work alternate weekends and would have two compensatory days off during the following work week. This resulted in terrific continuity between nurse and patient, and the long length of stays meant patients and nurses got to know one another really well.

Continuity Takes a Hit

But things have changed. Nurse-patient continuity seems to have declined significantly as a result of two main forces: the hospital’s efforts to reduce staffing costs by varying nurse staffing to match daily patient volume, and nurses’ desire for a wide variety of work schedules. Asking a bedside nurse in today’s hospital whether the patient’s confusion, diarrhea, or appetite is meaningfully different today than yesterday typically yields the same reply. “This is my first day with the patient; I’ll have to look at the chart.”

I couldn’t find many research articles or editorials regarding hospital nurse-patient continuity from one day to the next. But several researchers seem to have begun studying this issue and have recently published a proposed framework for assessing it, and I found one study showing it wasn’t correlated with rates of pressure ulcers.^1,2.

My anecdotal experience tells me continuity between the patient and caregivers of all stripes matters a lot. Research will be valuable in helping us to better understand its most significant costs and benefits, but I’m already convinced “Continuity is King” and should be one of the most important factors in the design of work schedules and patient allocation models for nurses and hospitalists alike.

While some might say we should wait for randomized trials of continuity to determine its importance, I’m inclined to see it like the authors of “Parachute use to prevent death and major trauma related to gravitational challenge: systematic review of randomised controlled trials.” As a ding against those who insist on research data when common sense may be sufficient, they concluded “…that everyone might benefit if the most radical protagonists of evidence-based medicine organised and participated in a double-blind, randomised, placebo-controlled, crossover trial of the parachute.³

Continuity and Hospitalists

On top of what I see as erosion in nurse-patient continuity, the arrival of hospitalists disrupted doctor-patient continuity across the inpatient and outpatient setting. While there was significant concern about this when our field first took off in the 1990s, it seems to be getting a great deal less attention over the last few years. In many hospitalist groups I work with, it is one of the last factors considered when creating a work schedule. Factors that are examined include the following:

• Solely for provider convenience, a group might regularly schedule a provider for only two or three consecutive daytime shifts, or sometimes only single days;
• Groups that use unit-based hospital (a.k.a. “geographic”) staffing might have a patient transfer to a different attending hospitalist solely as a result of moving to a room in a different nursing unit; and
• As part of morning load leveling, some groups reassign existing patients to a new hospitalist.

I think all groups should work hard to avoid doing these things. And while I seem to be a real outlier on this one, I think the benefits of a separate daytime hospitalist admitter shift are not worth the cost of having different doctors always do the admission and first follow-up visit. Most groups should consider moving the admitter into an additional rounder position and allocating daytime admissions across all hospitalists.

One study found that hospitalist discontinuity was not associated with adverse events, and another found it was associated with higher length of stay for selected diagnoses.^4,5 But there is too little research to draw hard conclusions. I’m convinced poor continuity increases the possibility of handoff-related errors, likely results in lower patient satisfaction, and increases the overall work of the hospitalist group, because more providers have to take the time to get to know the patient.

Although there will always be some tension between terrific continuity and a sustainable hospitalist lifestyle—a person can work only so many consecutive days before wearing out—every group should thoughtfully consider whether they are doing everything reasonable to maximize continuity. After all, continuity is king.

References

1. Stifter J, Yao Y, Lopez KC, Khokhar A, Wilkie DJ, Keenan GM. Proposing a new conceptual model and an exemplar measure using health information technology to examine the impact of relational nurse continuity on hospital-acquired pressure ulcers. ANS Adv Nurs Sci. 2015;38(3):241-251.
2. Stifter J, Yao Y, Lodhi MK, et al. Nurse continuity and hospital-acquired pressure ulcers: a comparative analysis using an electronic health record “big data” set. Nurs Res. 2015;64(5):361-371.
3. Smith GC, Pell JP. Parachute use to prevent death and major trauma related to gravitational challenge: systematic review of randomised controlled trials. BMJ. 2003;327(7429):1459-1461.
4. O’Leary KJ, Turner J, Christensen N, et al. The effect of hospitalist discontinuity on adverse events. J Hosp Med. 2015;10(3):147-151.
5. Epstein K, Juarez E, Epstein A, Loya K, Singer A. The impact of fragmentation of hospitalist care on length of stay. J Hosp Med. 2010;5(6):335-338.

I think every hospitalist group should diligently try to maximize hospitalist-patient continuity, but many seem to adopt schedules and other operational practices that erode it. Let’s walk through the issue of continuity, starting with some history.

Inpatient Continuity in Old Healthcare System

Proudly carrying a pager nearly the size of a loaf of bread and wearing a white shirt and pants with Converse All Stars, I served as a hospital orderly in the 1970s. This position involved things like getting patients out of bed, placing Foley catheters, performing chest compressions during codes, and transporting the bodies of the deceased to the morgue. I really enjoyed the work, and the experience serves as one of my historical frames of reference for how hospital care has evolved since then.

The way I remember it, nearly everyone at the hospital worked a predictable schedule. RN staffing was the same each day; it didn’t vary based on census. Each full-time RN worked five shifts a week, eight hours each. Most or all would work alternate weekends and would have two compensatory days off during the following work week. This resulted in terrific continuity between nurse and patient, and the long length of stays meant patients and nurses got to know one another really well.

Continuity Takes a Hit

But things have changed. Nurse-patient continuity seems to have declined significantly as a result of two main forces: the hospital’s efforts to reduce staffing costs by varying nurse staffing to match daily patient volume, and nurses’ desire for a wide variety of work schedules. Asking a bedside nurse in today’s hospital whether the patient’s confusion, diarrhea, or appetite is meaningfully different today than yesterday typically yields the same reply. “This is my first day with the patient; I’ll have to look at the chart.”

I couldn’t find many research articles or editorials regarding hospital nurse-patient continuity from one day to the next. But several researchers seem to have begun studying this issue and have recently published a proposed framework for assessing it, and I found one study showing it wasn’t correlated with rates of pressure ulcers.^1,2.

My anecdotal experience tells me continuity between the patient and caregivers of all stripes matters a lot. Research will be valuable in helping us to better understand its most significant costs and benefits, but I’m already convinced “Continuity is King” and should be one of the most important factors in the design of work schedules and patient allocation models for nurses and hospitalists alike.

While some might say we should wait for randomized trials of continuity to determine its importance, I’m inclined to see it like the authors of “Parachute use to prevent death and major trauma related to gravitational challenge: systematic review of randomised controlled trials.” As a ding against those who insist on research data when common sense may be sufficient, they concluded “…that everyone might benefit if the most radical protagonists of evidence-based medicine organised and participated in a double-blind, randomised, placebo-controlled, crossover trial of the parachute.³

Continuity and Hospitalists

On top of what I see as erosion in nurse-patient continuity, the arrival of hospitalists disrupted doctor-patient continuity across the inpatient and outpatient setting. While there was significant concern about this when our field first took off in the 1990s, it seems to be getting a great deal less attention over the last few years. In many hospitalist groups I work with, it is one of the last factors considered when creating a work schedule. Factors that are examined include the following:

• Solely for provider convenience, a group might regularly schedule a provider for only two or three consecutive daytime shifts, or sometimes only single days;
• Groups that use unit-based hospital (a.k.a. “geographic”) staffing might have a patient transfer to a different attending hospitalist solely as a result of moving to a room in a different nursing unit; and
• As part of morning load leveling, some groups reassign existing patients to a new hospitalist.

I think all groups should work hard to avoid doing these things. And while I seem to be a real outlier on this one, I think the benefits of a separate daytime hospitalist admitter shift are not worth the cost of having different doctors always do the admission and first follow-up visit. Most groups should consider moving the admitter into an additional rounder position and allocating daytime admissions across all hospitalists.

One study found that hospitalist discontinuity was not associated with adverse events, and another found it was associated with higher length of stay for selected diagnoses.^4,5 But there is too little research to draw hard conclusions. I’m convinced poor continuity increases the possibility of handoff-related errors, likely results in lower patient satisfaction, and increases the overall work of the hospitalist group, because more providers have to take the time to get to know the patient.

Although there will always be some tension between terrific continuity and a sustainable hospitalist lifestyle—a person can work only so many consecutive days before wearing out—every group should thoughtfully consider whether they are doing everything reasonable to maximize continuity. After all, continuity is king.

References

1. Stifter J, Yao Y, Lopez KC, Khokhar A, Wilkie DJ, Keenan GM. Proposing a new conceptual model and an exemplar measure using health information technology to examine the impact of relational nurse continuity on hospital-acquired pressure ulcers. ANS Adv Nurs Sci. 2015;38(3):241-251.
2. Stifter J, Yao Y, Lodhi MK, et al. Nurse continuity and hospital-acquired pressure ulcers: a comparative analysis using an electronic health record “big data” set. Nurs Res. 2015;64(5):361-371.
3. Smith GC, Pell JP. Parachute use to prevent death and major trauma related to gravitational challenge: systematic review of randomised controlled trials. BMJ. 2003;327(7429):1459-1461.
4. O’Leary KJ, Turner J, Christensen N, et al. The effect of hospitalist discontinuity on adverse events. J Hosp Med. 2015;10(3):147-151.
5. Epstein K, Juarez E, Epstein A, Loya K, Singer A. The impact of fragmentation of hospitalist care on length of stay. J Hosp Med. 2010;5(6):335-338.

NEW YORK - While the new International Classification of Diseases, Tenth Revision, Clinical

Modification (ICD-10-CM) codes offer greater diagnostic precision, their implementation will require training of clinicians, coders, and other staff to minimize payment denials or delays from both public and private payers.

Brian Outland and colleagues from the American College of Physicians in Washington, D.C., outline some of the promises and challenges of ICD-10-CM implementation in a report online Sept. 22 in Annals of Internal Medicine.

Although completed and endorsed by the World Health Assembly in 1990, ICD-10-CM's implementation date has repeatedly been delayed, and was scheduled to take effect on Oct. 1.

The authors suggest that "the newer coding system will produce data that will indicate the clinical trajectory and other factors that will enable the data to be used in meaningful ways to better understand complications, design robust algorithms for clinical decision support, and track outcomes. Having these details built into the codes will decrease the need for health care providers to include supporting documentation with claims."

The new ICD-10-CM alphanumeric codes will contain as many as seven characters that specify categories, subcategories, laterality, severity and other features.

The use of codes that are not specific enough can result in payment denials or delays, so practices will need to keep current on payer reimbursement policies to ensure the reporting of ICD-10-CM codes that support reimbursement, the authors note.

The cost for the training of clinicians and staffs will depend on practice size, specialty, the method of training, current documentation quality, and technology readiness and availability.

Dr. Susan H. Fenton from UTHealth School of Biomedical Informatics in Houston, Texas, said by email, "One of the thoughts I cannot get away from is that the U.S. is trying to manage a 21st-century, rapidly evolving healthcare system with a 1970s technology. I can think of little else in healthcare that has remained as static since the 1970s."

"The diagnostic system added lots of codes, but the basic structure is the same," she said.

"Certainly, with more detail such as laterality, as well as first encounter, subsequent encounter, and sequelae, it will be much easier to track care for specific conditions across providers," Dr. Fenton said. "I think the issue of claims denials will have to play out over time."

Resources and tools from the Centers for Medicare & Medicaid Services (CMS) can be found online at www.roadto10.org.

The American College of Physicians also has helpful information available at www.acponline.org/ICD10.

Outland did not respond to a request for comment.

NEW YORK - While the new International Classification of Diseases, Tenth Revision, Clinical

Modification (ICD-10-CM) codes offer greater diagnostic precision, their implementation will require training of clinicians, coders, and other staff to minimize payment denials or delays from both public and private payers.

Brian Outland and colleagues from the American College of Physicians in Washington, D.C., outline some of the promises and challenges of ICD-10-CM implementation in a report online Sept. 22 in Annals of Internal Medicine.

Although completed and endorsed by the World Health Assembly in 1990, ICD-10-CM's implementation date has repeatedly been delayed, and was scheduled to take effect on Oct. 1.

The authors suggest that "the newer coding system will produce data that will indicate the clinical trajectory and other factors that will enable the data to be used in meaningful ways to better understand complications, design robust algorithms for clinical decision support, and track outcomes. Having these details built into the codes will decrease the need for health care providers to include supporting documentation with claims."

The new ICD-10-CM alphanumeric codes will contain as many as seven characters that specify categories, subcategories, laterality, severity and other features.

The use of codes that are not specific enough can result in payment denials or delays, so practices will need to keep current on payer reimbursement policies to ensure the reporting of ICD-10-CM codes that support reimbursement, the authors note.

The cost for the training of clinicians and staffs will depend on practice size, specialty, the method of training, current documentation quality, and technology readiness and availability.

Dr. Susan H. Fenton from UTHealth School of Biomedical Informatics in Houston, Texas, said by email, "One of the thoughts I cannot get away from is that the U.S. is trying to manage a 21st-century, rapidly evolving healthcare system with a 1970s technology. I can think of little else in healthcare that has remained as static since the 1970s."

"The diagnostic system added lots of codes, but the basic structure is the same," she said.

"Certainly, with more detail such as laterality, as well as first encounter, subsequent encounter, and sequelae, it will be much easier to track care for specific conditions across providers," Dr. Fenton said. "I think the issue of claims denials will have to play out over time."

Resources and tools from the Centers for Medicare & Medicaid Services (CMS) can be found online at www.roadto10.org.

The American College of Physicians also has helpful information available at www.acponline.org/ICD10.

Outland did not respond to a request for comment.

NEW YORK - While the new International Classification of Diseases, Tenth Revision, Clinical

Modification (ICD-10-CM) codes offer greater diagnostic precision, their implementation will require training of clinicians, coders, and other staff to minimize payment denials or delays from both public and private payers.

Brian Outland and colleagues from the American College of Physicians in Washington, D.C., outline some of the promises and challenges of ICD-10-CM implementation in a report online Sept. 22 in Annals of Internal Medicine.

Although completed and endorsed by the World Health Assembly in 1990, ICD-10-CM's implementation date has repeatedly been delayed, and was scheduled to take effect on Oct. 1.

The authors suggest that "the newer coding system will produce data that will indicate the clinical trajectory and other factors that will enable the data to be used in meaningful ways to better understand complications, design robust algorithms for clinical decision support, and track outcomes. Having these details built into the codes will decrease the need for health care providers to include supporting documentation with claims."

The new ICD-10-CM alphanumeric codes will contain as many as seven characters that specify categories, subcategories, laterality, severity and other features.

The use of codes that are not specific enough can result in payment denials or delays, so practices will need to keep current on payer reimbursement policies to ensure the reporting of ICD-10-CM codes that support reimbursement, the authors note.

The cost for the training of clinicians and staffs will depend on practice size, specialty, the method of training, current documentation quality, and technology readiness and availability.

Dr. Susan H. Fenton from UTHealth School of Biomedical Informatics in Houston, Texas, said by email, "One of the thoughts I cannot get away from is that the U.S. is trying to manage a 21st-century, rapidly evolving healthcare system with a 1970s technology. I can think of little else in healthcare that has remained as static since the 1970s."

"The diagnostic system added lots of codes, but the basic structure is the same," she said.

"Certainly, with more detail such as laterality, as well as first encounter, subsequent encounter, and sequelae, it will be much easier to track care for specific conditions across providers," Dr. Fenton said. "I think the issue of claims denials will have to play out over time."

Resources and tools from the Centers for Medicare & Medicaid Services (CMS) can be found online at www.roadto10.org.

The American College of Physicians also has helpful information available at www.acponline.org/ICD10.

Outland did not respond to a request for comment.

During a facility stay, a patient could be attended to by more than one hospitalist. For example, perhaps one hospitalist is the admitting physician, but the patient has a three-day stay and may be seen by three different hospitalists. Are there any guidelines as to which physician should be billed on the facility claim? Thank you for any remarks, suggestions, or references.

—Anonymous

Dr. Hospitalist responds:

Most of us can definitely relate to the concerns you have about properly billing during the patient’s hospital stay. By facility claim, I’m assuming you mean the physician’s bill for services rendered to a hospitalized patient. After querying the Centers for Medicare and Medicaid (CMS) website and discussing the question with several of our coding and billing gurus, as far as I can tell, there are no specific guidelines pertaining to which physician in a multiphysician group should bill. CMS guidelines are clear that you should only bill for the services you provide. CMS is very specific about allowing only one physician of the same specialty billing per day (reference the CMS Manual, Chapter 12, 30.6.9-Payment for Inpatient Hospital Visits).

In our very large group, we bill daily for the individual inpatient services we provide. That way, when the bill goes out, the clinician author is responsible for its validity and can support the level of care as documented.

Billing and coding is such an arduous process, I can’t imagine attempting it without an electronic interface. Most hospitalist groups have some form of electronic billing software that has integrated checks and balances to catch the common mistakes. Improper billing done by anyone in the group can expose the entire group to an audit. With ICD-10 now upon us, this becomes ever more important.

Good luck!

Do you have a problem or concern that you’d like Dr. Hospitalist to address? Email your questions to drhospit@wiley.com.

During a facility stay, a patient could be attended to by more than one hospitalist. For example, perhaps one hospitalist is the admitting physician, but the patient has a three-day stay and may be seen by three different hospitalists. Are there any guidelines as to which physician should be billed on the facility claim? Thank you for any remarks, suggestions, or references.

—Anonymous

Dr. Hospitalist responds:

Most of us can definitely relate to the concerns you have about properly billing during the patient’s hospital stay. By facility claim, I’m assuming you mean the physician’s bill for services rendered to a hospitalized patient. After querying the Centers for Medicare and Medicaid (CMS) website and discussing the question with several of our coding and billing gurus, as far as I can tell, there are no specific guidelines pertaining to which physician in a multiphysician group should bill. CMS guidelines are clear that you should only bill for the services you provide. CMS is very specific about allowing only one physician of the same specialty billing per day (reference the CMS Manual, Chapter 12, 30.6.9-Payment for Inpatient Hospital Visits).

In our very large group, we bill daily for the individual inpatient services we provide. That way, when the bill goes out, the clinician author is responsible for its validity and can support the level of care as documented.

Billing and coding is such an arduous process, I can’t imagine attempting it without an electronic interface. Most hospitalist groups have some form of electronic billing software that has integrated checks and balances to catch the common mistakes. Improper billing done by anyone in the group can expose the entire group to an audit. With ICD-10 now upon us, this becomes ever more important.

Good luck!

Do you have a problem or concern that you’d like Dr. Hospitalist to address? Email your questions to drhospit@wiley.com.

During a facility stay, a patient could be attended to by more than one hospitalist. For example, perhaps one hospitalist is the admitting physician, but the patient has a three-day stay and may be seen by three different hospitalists. Are there any guidelines as to which physician should be billed on the facility claim? Thank you for any remarks, suggestions, or references.

—Anonymous

Dr. Hospitalist responds:

Most of us can definitely relate to the concerns you have about properly billing during the patient’s hospital stay. By facility claim, I’m assuming you mean the physician’s bill for services rendered to a hospitalized patient. After querying the Centers for Medicare and Medicaid (CMS) website and discussing the question with several of our coding and billing gurus, as far as I can tell, there are no specific guidelines pertaining to which physician in a multiphysician group should bill. CMS guidelines are clear that you should only bill for the services you provide. CMS is very specific about allowing only one physician of the same specialty billing per day (reference the CMS Manual, Chapter 12, 30.6.9-Payment for Inpatient Hospital Visits).

In our very large group, we bill daily for the individual inpatient services we provide. That way, when the bill goes out, the clinician author is responsible for its validity and can support the level of care as documented.

Billing and coding is such an arduous process, I can’t imagine attempting it without an electronic interface. Most hospitalist groups have some form of electronic billing software that has integrated checks and balances to catch the common mistakes. Improper billing done by anyone in the group can expose the entire group to an audit. With ICD-10 now upon us, this becomes ever more important.

Good luck!

Do you have a problem or concern that you’d like Dr. Hospitalist to address? Email your questions to drhospit@wiley.com.

Editor’s note: Second in a continuing series of articles exploring ways hospitalist groups can cut back.

In last month’s column, I made the case that most hospitalist groups should think about doing away with a morning meeting to distribute overnight admissions and changing a daytime admitter shift into another rounder and having all of the day rounders share admissions. Here I’ll describe additional things in place at some hospitalist groups that should probably be eliminated.

Obscuring Attending Hospitalist Name

Some hospitalist groups admit patients to the “blue team” or “gold team” or use a similar system. I encountered one place that had a fuchsia team. Such designations typically take the place of the attending physician’s name and can be convenient when one hospitalist goes off service and is replaced by another; the team name stays the same. Even if the attending hospitalist makes up the entire team (i.e., no residents or students), some groups use the “team” name rather than the attending hospitalist name.

But when the patient’s chart, sign on the door, and other identifying materials all refer only to the team that is caring for the patient, the patients, their families, and most hospital staff don’t have an easy way to identify the responsible physician. Say a worried daughter steps into the hall to ask the nurse, “Which doctor is taking care of my dad?” The nurse might readily see that the blue team is responsible but may not know which hospitalist is working on the blue team today and might have to walk back to the nursing station to look over a sheet of paper (a “decoder ring”) to figure out the hospitalist’s name.

This scenario has all kinds of drawbacks. To the daughter, the name of the doctor in charge is a big deal. It doesn’t inspire confidence if the nurse can’t readily say who that is. And the busy nurse might forget to investigate and provide the name to the daughter in a timely way.

I think groups using a system like this should seriously consider replacing team names with the attending hospitalist name and updating that name in the medical record, whether that is an EHR, a paper chart, or some other form, every time that doctor rotates off service and is replaced by another. Hospital staff, patients, and families should always see the name of the attending physician and not an uninformative color or nondescript team name.

It will require work for someone, the hospitalist in many cases, to go into the EHR and write an order or send a message to ensure that the hospitalist name is kept current every time one doctor replaces another. But it’s worth the effort.

Day Hospitalists Should Round on Patients Admitted after Midnight

Although not exactly common, I’ve come across this scenario often enough that it’s worth mentioning.

Hospitalists, sometimes with a hint of indignity or even chest thumping, have told me they don’t visit or round on patients admitted after midnight by their night doctor. “You can’t bill for a second visit on the same calendar day,” they explain, firmly. “So if I can’t get paid to see the patient, then I won’t.”

This is just crazy.

For one thing, these same doctors are typically employed by the hospital and are being paid to provide whatever care patients need. I think they’ve just latched onto the “can’t bill another visit” as an excuse to get out of some work.

Don’t forget that many of these patients may wait over 30 hours from their admitting visit to the first follow-up visit; this delay is at the beginning of their hospital stay, when they might be most unstable. And it delays initiation of discharge planning and other important steps in patient care.

I don’t see any room for meaningful debate on this. The rounder who picks up a patient admitted the night before should always make a full rounding visit, even if the admission was after midnight.

But if the visit isn’t billable, you are freed from the typical billing-related documentation requirements. No need to document detail in the note that doesn’t meaningfully contribute to the care of the patient. For example, you might omit a chief complaint for this encounter.

Daytime Triage Doctor

Practices larger than about 20 full-time equivalents often have one daytime doctor hold a “triage” or “hot” pager, which others call to make a new referral. This triage doctor will hear about all referrals and keep track of and contact the hospitalist responsible for the next new patient. This can be a very busy job and often comes on top of a full clinical load for that doctor.

As I mentioned in my July 2015 and December 2010 articles, in many or most groups, a clerical person could take over this function, at least during business hours.

Vacation Time

In many or most cases, hospitalists that have specified vacation time are not getting a better deal than those that have no vacation time. What really matters is how many shifts you’re responsible for in a year. For the days you aren’t on shift, in most hospitalist groups it really doesn’t matter whether you label some of them as vacation days or CME days.

I discussed this issue in greater detail in my March 2007 article.

But if you’re in the 30% of hospitalist groups that have a vacation (or PTO) provision currently and it works well, then there certainly isn’t a compelling reason to change or do away with it.

Editor’s note: Second in a continuing series of articles exploring ways hospitalist groups can cut back.

In last month’s column, I made the case that most hospitalist groups should think about doing away with a morning meeting to distribute overnight admissions and changing a daytime admitter shift into another rounder and having all of the day rounders share admissions. Here I’ll describe additional things in place at some hospitalist groups that should probably be eliminated.

Obscuring Attending Hospitalist Name

Some hospitalist groups admit patients to the “blue team” or “gold team” or use a similar system. I encountered one place that had a fuchsia team. Such designations typically take the place of the attending physician’s name and can be convenient when one hospitalist goes off service and is replaced by another; the team name stays the same. Even if the attending hospitalist makes up the entire team (i.e., no residents or students), some groups use the “team” name rather than the attending hospitalist name.

But when the patient’s chart, sign on the door, and other identifying materials all refer only to the team that is caring for the patient, the patients, their families, and most hospital staff don’t have an easy way to identify the responsible physician. Say a worried daughter steps into the hall to ask the nurse, “Which doctor is taking care of my dad?” The nurse might readily see that the blue team is responsible but may not know which hospitalist is working on the blue team today and might have to walk back to the nursing station to look over a sheet of paper (a “decoder ring”) to figure out the hospitalist’s name.

This scenario has all kinds of drawbacks. To the daughter, the name of the doctor in charge is a big deal. It doesn’t inspire confidence if the nurse can’t readily say who that is. And the busy nurse might forget to investigate and provide the name to the daughter in a timely way.

I think groups using a system like this should seriously consider replacing team names with the attending hospitalist name and updating that name in the medical record, whether that is an EHR, a paper chart, or some other form, every time that doctor rotates off service and is replaced by another. Hospital staff, patients, and families should always see the name of the attending physician and not an uninformative color or nondescript team name.

It will require work for someone, the hospitalist in many cases, to go into the EHR and write an order or send a message to ensure that the hospitalist name is kept current every time one doctor replaces another. But it’s worth the effort.

Day Hospitalists Should Round on Patients Admitted after Midnight

Although not exactly common, I’ve come across this scenario often enough that it’s worth mentioning.

Hospitalists, sometimes with a hint of indignity or even chest thumping, have told me they don’t visit or round on patients admitted after midnight by their night doctor. “You can’t bill for a second visit on the same calendar day,” they explain, firmly. “So if I can’t get paid to see the patient, then I won’t.”

This is just crazy.

For one thing, these same doctors are typically employed by the hospital and are being paid to provide whatever care patients need. I think they’ve just latched onto the “can’t bill another visit” as an excuse to get out of some work.

Don’t forget that many of these patients may wait over 30 hours from their admitting visit to the first follow-up visit; this delay is at the beginning of their hospital stay, when they might be most unstable. And it delays initiation of discharge planning and other important steps in patient care.

I don’t see any room for meaningful debate on this. The rounder who picks up a patient admitted the night before should always make a full rounding visit, even if the admission was after midnight.

But if the visit isn’t billable, you are freed from the typical billing-related documentation requirements. No need to document detail in the note that doesn’t meaningfully contribute to the care of the patient. For example, you might omit a chief complaint for this encounter.

Daytime Triage Doctor

Practices larger than about 20 full-time equivalents often have one daytime doctor hold a “triage” or “hot” pager, which others call to make a new referral. This triage doctor will hear about all referrals and keep track of and contact the hospitalist responsible for the next new patient. This can be a very busy job and often comes on top of a full clinical load for that doctor.

As I mentioned in my July 2015 and December 2010 articles, in many or most groups, a clerical person could take over this function, at least during business hours.

Vacation Time

In many or most cases, hospitalists that have specified vacation time are not getting a better deal than those that have no vacation time. What really matters is how many shifts you’re responsible for in a year. For the days you aren’t on shift, in most hospitalist groups it really doesn’t matter whether you label some of them as vacation days or CME days.

I discussed this issue in greater detail in my March 2007 article.

But if you’re in the 30% of hospitalist groups that have a vacation (or PTO) provision currently and it works well, then there certainly isn’t a compelling reason to change or do away with it.

Editor’s note: Second in a continuing series of articles exploring ways hospitalist groups can cut back.

In last month’s column, I made the case that most hospitalist groups should think about doing away with a morning meeting to distribute overnight admissions and changing a daytime admitter shift into another rounder and having all of the day rounders share admissions. Here I’ll describe additional things in place at some hospitalist groups that should probably be eliminated.

Obscuring Attending Hospitalist Name

Some hospitalist groups admit patients to the “blue team” or “gold team” or use a similar system. I encountered one place that had a fuchsia team. Such designations typically take the place of the attending physician’s name and can be convenient when one hospitalist goes off service and is replaced by another; the team name stays the same. Even if the attending hospitalist makes up the entire team (i.e., no residents or students), some groups use the “team” name rather than the attending hospitalist name.

But when the patient’s chart, sign on the door, and other identifying materials all refer only to the team that is caring for the patient, the patients, their families, and most hospital staff don’t have an easy way to identify the responsible physician. Say a worried daughter steps into the hall to ask the nurse, “Which doctor is taking care of my dad?” The nurse might readily see that the blue team is responsible but may not know which hospitalist is working on the blue team today and might have to walk back to the nursing station to look over a sheet of paper (a “decoder ring”) to figure out the hospitalist’s name.

This scenario has all kinds of drawbacks. To the daughter, the name of the doctor in charge is a big deal. It doesn’t inspire confidence if the nurse can’t readily say who that is. And the busy nurse might forget to investigate and provide the name to the daughter in a timely way.

I think groups using a system like this should seriously consider replacing team names with the attending hospitalist name and updating that name in the medical record, whether that is an EHR, a paper chart, or some other form, every time that doctor rotates off service and is replaced by another. Hospital staff, patients, and families should always see the name of the attending physician and not an uninformative color or nondescript team name.

It will require work for someone, the hospitalist in many cases, to go into the EHR and write an order or send a message to ensure that the hospitalist name is kept current every time one doctor replaces another. But it’s worth the effort.

Day Hospitalists Should Round on Patients Admitted after Midnight

Although not exactly common, I’ve come across this scenario often enough that it’s worth mentioning.

Hospitalists, sometimes with a hint of indignity or even chest thumping, have told me they don’t visit or round on patients admitted after midnight by their night doctor. “You can’t bill for a second visit on the same calendar day,” they explain, firmly. “So if I can’t get paid to see the patient, then I won’t.”

This is just crazy.

For one thing, these same doctors are typically employed by the hospital and are being paid to provide whatever care patients need. I think they’ve just latched onto the “can’t bill another visit” as an excuse to get out of some work.

Don’t forget that many of these patients may wait over 30 hours from their admitting visit to the first follow-up visit; this delay is at the beginning of their hospital stay, when they might be most unstable. And it delays initiation of discharge planning and other important steps in patient care.

I don’t see any room for meaningful debate on this. The rounder who picks up a patient admitted the night before should always make a full rounding visit, even if the admission was after midnight.

But if the visit isn’t billable, you are freed from the typical billing-related documentation requirements. No need to document detail in the note that doesn’t meaningfully contribute to the care of the patient. For example, you might omit a chief complaint for this encounter.

Daytime Triage Doctor

Practices larger than about 20 full-time equivalents often have one daytime doctor hold a “triage” or “hot” pager, which others call to make a new referral. This triage doctor will hear about all referrals and keep track of and contact the hospitalist responsible for the next new patient. This can be a very busy job and often comes on top of a full clinical load for that doctor.

As I mentioned in my July 2015 and December 2010 articles, in many or most groups, a clerical person could take over this function, at least during business hours.

Vacation Time

In many or most cases, hospitalists that have specified vacation time are not getting a better deal than those that have no vacation time. What really matters is how many shifts you’re responsible for in a year. For the days you aren’t on shift, in most hospitalist groups it really doesn’t matter whether you label some of them as vacation days or CME days.

I discussed this issue in greater detail in my March 2007 article.

But if you’re in the 30% of hospitalist groups that have a vacation (or PTO) provision currently and it works well, then there certainly isn’t a compelling reason to change or do away with it.

Michael Murphy, MD, the co-founder and CEO of ScribeAmerica, talks about the business model that has led to the growing use of medical scribes.

Michael Murphy, MD, the co-founder and CEO of ScribeAmerica, talks about the business model that has led to the growing use of medical scribes.

Michael Murphy, MD, the co-founder and CEO of ScribeAmerica, talks about the business model that has led to the growing use of medical scribes.

The electronic health record (EHR) has many benefits:

• Improved patient care;
• Improved care coordination;
• Improved diagnostics and patient outcomes;
• Increased patient participation; and
• Increased practice efficiencies and cost savings.¹

EHRs also introduce risks, however. Heightened concern about EHR misuse and vulnerability elevates the level of scrutiny placed on provider documentation as it relates to billing and coding. Without clear guidelines from the Centers for Medicare and Medicaid Services (CMS) or other payers, the potential for unintentional misapplication exists. Auditor misinterpretation is also possible. Providers should utilize simple defensive documentation principles to support their services and minimize their risks.

Reason for Encounter

Under section 1862 (a)(1)(A) of the Social Security Act, the Medicare Program may only pay for items and services that are “reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member,” unless there is another statutory authorization for payment (e.g. colorectal cancer screening).²

A payer can determine if a service is “reasonable and necessary” based on the service indication. The reason for the patient encounter, otherwise known as the chief complaint, must be evident. This can be a symptom, problem, condition, diagnosis, physician-recommended return, or another factor that necessitates the encounter.¹ It cannot be inferred and must be clearly stated in the documentation. Without it, a payer may question the medical necessity of the service, especially if it involves hospital-based services in the course of which multiple specialists will see the patient on any given date. Payers are likely to deny services that cannot be easily differentiated (e.g. “no c/o”). Furthermore, payers can deny concurrent care services for the following reasons:³

• Services exceed normal frequency or duration for a given condition without documented circumstances requiring additional care; or
• Services by one physician duplicate/overlap those of the other provider without any recognizable distinction.

Providers should be specific in identifying the encounter reason, as in the following examples: “Patient seen for shortness of breath” or “Patient with COPD, feeling improved with 3L O2 NC.”

Assessment and Plan

Accurately representing patient complexity for every visit throughout the hospitalization presents its challenges. Although the problem list may not dramatically change day to day, providers must formulate an assessment of the patient’s condition with a corresponding plan of care for each encounter. Documenting problems without a corresponding plan of care does not substantiate physician participation in the management of that problem. Providing a brief, generalized comment (e.g. “DM, CKD, CHF: Continue current treatment plan”) minimizes the complexity and effort put forth in the encounter and could result in auditor downgrading upon documentation review.

Developing shortcuts might falsely minimize the provider’s documentation burden. An electronic documentation system might make it possible to copy previous progress notes into the current encounter to save time; however, the previously entered information could include elements that do not require reassessment during a subsequent encounter or contain information about conditions that are being managed concurrently by another specialist (e.g. CKD being managed by the nephrologist). Leaving the copied information unmodified may not accurately reflect the patient’s current condition or the care provided by the hospitalist during the current encounter. Information that is pulled forward or copied and pasted from a previous entry should be modified to demonstrate updated content and nonoverlapping care relevant to that date.

According to the Office of Inspector General (OIG), “inappropriate copy-pasting could facilitate attempts to inflate claims and duplicate or create fraudulent claims.”⁴

An equally problematic EHR function involves “overdocumentation,” the practice of inserting false or irrelevant documentation to create the appearance of support for billing higher level services.4 EHR technology has the ability to auto-populate fields using templates built into the system or generate extensive documentation on the basis of a single click. The OIG cautions providers to use these features carefully, because they can produce information suggesting the practitioner performed more comprehensive services than were actually rendered.⁴

An example is the inclusion of the same lab results more than once. Although clinicians include this information as a reference to avoid having to “find it somewhere in the chart” when it is needed—as a basis for comparison, for example—auditors mistake this as an attempt to gain credit for the daily review of the same “old” information. Including only relevant data will mitigate this concern.

Authorship

Dates and signatures are essential to each encounter. Medicare requires services provided/ordered to be authenticated by the author.⁵ A reviewer must be able to identify each individual who performs, documents, and bills for a service on a given date. Progress notes that fail to identify the service date or service provider will likely result in denial.

Additionally, a service is questioned when two different sets of handwriting appear on a note, yet only one signature is provided. Since the reviewer cannot confirm the credentials of the unidentified individual and cannot be sure which portion belongs to the identified individual, the entire note is disregarded.

Notes that contain an illegible signature are equally problematic. If the legibility of the signature prevents the reviewer from correctly identifying the rendering provider, the service may be denied.

CMS has instructed Medicare contractors to request a signed provider attestation before issuing a denial.⁵ The provider should print his/her name beside the signature or include a separate signature sheet with the requested documentation to assist the reviewer in provider identification. Stamped signatures are not acceptable under any circumstance. Medicare accepts only handwritten or electronic signatures.⁵

Carol Pohlig is a billing and coding expert with the University of Pennsylvania Medical Center, Philadelphia. She is also on the faculty of SHM’s inpatient coding course.

References

1. HealthIT.gov. Benefits of electronic health records (EHRs). Accessed August 1, 2015.
2. Social Security Administration. Exclusions from coverage and Medicare as secondary payer. Accessed August 1, 2015.
3. Centers for Medicare and Medicaid Services. Medicare Benefit Policy Manual: Chapter 15—Covered medical and other health services. Chapter 15, Section 30.E. Concurrent care. Accessed August 1, 2015.
4. Department of Health and Human Services. Office of Inspector General. CMS and its contractors have adopted few program integrity practices to address vulnerabilities in EHRs. Accessed August 1, 2015.
5. Centers for Medicare and Medicaid Services. Signature guidelines for medical review purposes. Accessed August 1, 2015.
6. Centers for Medicare and Medicaid Services. 1995 documentation guidelines for evaluation and management services. Accessed August 1, 2015.

The electronic health record (EHR) has many benefits:

• Improved patient care;
• Improved care coordination;
• Improved diagnostics and patient outcomes;
• Increased patient participation; and
• Increased practice efficiencies and cost savings.¹

EHRs also introduce risks, however. Heightened concern about EHR misuse and vulnerability elevates the level of scrutiny placed on provider documentation as it relates to billing and coding. Without clear guidelines from the Centers for Medicare and Medicaid Services (CMS) or other payers, the potential for unintentional misapplication exists. Auditor misinterpretation is also possible. Providers should utilize simple defensive documentation principles to support their services and minimize their risks.

Reason for Encounter

Under section 1862 (a)(1)(A) of the Social Security Act, the Medicare Program may only pay for items and services that are “reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member,” unless there is another statutory authorization for payment (e.g. colorectal cancer screening).²

A payer can determine if a service is “reasonable and necessary” based on the service indication. The reason for the patient encounter, otherwise known as the chief complaint, must be evident. This can be a symptom, problem, condition, diagnosis, physician-recommended return, or another factor that necessitates the encounter.¹ It cannot be inferred and must be clearly stated in the documentation. Without it, a payer may question the medical necessity of the service, especially if it involves hospital-based services in the course of which multiple specialists will see the patient on any given date. Payers are likely to deny services that cannot be easily differentiated (e.g. “no c/o”). Furthermore, payers can deny concurrent care services for the following reasons:³

• Services exceed normal frequency or duration for a given condition without documented circumstances requiring additional care; or
• Services by one physician duplicate/overlap those of the other provider without any recognizable distinction.

Providers should be specific in identifying the encounter reason, as in the following examples: “Patient seen for shortness of breath” or “Patient with COPD, feeling improved with 3L O2 NC.”

Assessment and Plan

Accurately representing patient complexity for every visit throughout the hospitalization presents its challenges. Although the problem list may not dramatically change day to day, providers must formulate an assessment of the patient’s condition with a corresponding plan of care for each encounter. Documenting problems without a corresponding plan of care does not substantiate physician participation in the management of that problem. Providing a brief, generalized comment (e.g. “DM, CKD, CHF: Continue current treatment plan”) minimizes the complexity and effort put forth in the encounter and could result in auditor downgrading upon documentation review.

Developing shortcuts might falsely minimize the provider’s documentation burden. An electronic documentation system might make it possible to copy previous progress notes into the current encounter to save time; however, the previously entered information could include elements that do not require reassessment during a subsequent encounter or contain information about conditions that are being managed concurrently by another specialist (e.g. CKD being managed by the nephrologist). Leaving the copied information unmodified may not accurately reflect the patient’s current condition or the care provided by the hospitalist during the current encounter. Information that is pulled forward or copied and pasted from a previous entry should be modified to demonstrate updated content and nonoverlapping care relevant to that date.

According to the Office of Inspector General (OIG), “inappropriate copy-pasting could facilitate attempts to inflate claims and duplicate or create fraudulent claims.”⁴

An equally problematic EHR function involves “overdocumentation,” the practice of inserting false or irrelevant documentation to create the appearance of support for billing higher level services.4 EHR technology has the ability to auto-populate fields using templates built into the system or generate extensive documentation on the basis of a single click. The OIG cautions providers to use these features carefully, because they can produce information suggesting the practitioner performed more comprehensive services than were actually rendered.⁴

An example is the inclusion of the same lab results more than once. Although clinicians include this information as a reference to avoid having to “find it somewhere in the chart” when it is needed—as a basis for comparison, for example—auditors mistake this as an attempt to gain credit for the daily review of the same “old” information. Including only relevant data will mitigate this concern.

Authorship

Dates and signatures are essential to each encounter. Medicare requires services provided/ordered to be authenticated by the author.⁵ A reviewer must be able to identify each individual who performs, documents, and bills for a service on a given date. Progress notes that fail to identify the service date or service provider will likely result in denial.

Additionally, a service is questioned when two different sets of handwriting appear on a note, yet only one signature is provided. Since the reviewer cannot confirm the credentials of the unidentified individual and cannot be sure which portion belongs to the identified individual, the entire note is disregarded.

Notes that contain an illegible signature are equally problematic. If the legibility of the signature prevents the reviewer from correctly identifying the rendering provider, the service may be denied.

CMS has instructed Medicare contractors to request a signed provider attestation before issuing a denial.⁵ The provider should print his/her name beside the signature or include a separate signature sheet with the requested documentation to assist the reviewer in provider identification. Stamped signatures are not acceptable under any circumstance. Medicare accepts only handwritten or electronic signatures.⁵

Carol Pohlig is a billing and coding expert with the University of Pennsylvania Medical Center, Philadelphia. She is also on the faculty of SHM’s inpatient coding course.

References

1. HealthIT.gov. Benefits of electronic health records (EHRs). Accessed August 1, 2015.
2. Social Security Administration. Exclusions from coverage and Medicare as secondary payer. Accessed August 1, 2015.
3. Centers for Medicare and Medicaid Services. Medicare Benefit Policy Manual: Chapter 15—Covered medical and other health services. Chapter 15, Section 30.E. Concurrent care. Accessed August 1, 2015.
4. Department of Health and Human Services. Office of Inspector General. CMS and its contractors have adopted few program integrity practices to address vulnerabilities in EHRs. Accessed August 1, 2015.
5. Centers for Medicare and Medicaid Services. Signature guidelines for medical review purposes. Accessed August 1, 2015.
6. Centers for Medicare and Medicaid Services. 1995 documentation guidelines for evaluation and management services. Accessed August 1, 2015.

The electronic health record (EHR) has many benefits:

• Improved patient care;
• Improved care coordination;
• Improved diagnostics and patient outcomes;
• Increased patient participation; and
• Increased practice efficiencies and cost savings.¹

EHRs also introduce risks, however. Heightened concern about EHR misuse and vulnerability elevates the level of scrutiny placed on provider documentation as it relates to billing and coding. Without clear guidelines from the Centers for Medicare and Medicaid Services (CMS) or other payers, the potential for unintentional misapplication exists. Auditor misinterpretation is also possible. Providers should utilize simple defensive documentation principles to support their services and minimize their risks.

Reason for Encounter

Under section 1862 (a)(1)(A) of the Social Security Act, the Medicare Program may only pay for items and services that are “reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member,” unless there is another statutory authorization for payment (e.g. colorectal cancer screening).²

A payer can determine if a service is “reasonable and necessary” based on the service indication. The reason for the patient encounter, otherwise known as the chief complaint, must be evident. This can be a symptom, problem, condition, diagnosis, physician-recommended return, or another factor that necessitates the encounter.¹ It cannot be inferred and must be clearly stated in the documentation. Without it, a payer may question the medical necessity of the service, especially if it involves hospital-based services in the course of which multiple specialists will see the patient on any given date. Payers are likely to deny services that cannot be easily differentiated (e.g. “no c/o”). Furthermore, payers can deny concurrent care services for the following reasons:³

• Services exceed normal frequency or duration for a given condition without documented circumstances requiring additional care; or
• Services by one physician duplicate/overlap those of the other provider without any recognizable distinction.

Providers should be specific in identifying the encounter reason, as in the following examples: “Patient seen for shortness of breath” or “Patient with COPD, feeling improved with 3L O2 NC.”

Assessment and Plan

Accurately representing patient complexity for every visit throughout the hospitalization presents its challenges. Although the problem list may not dramatically change day to day, providers must formulate an assessment of the patient’s condition with a corresponding plan of care for each encounter. Documenting problems without a corresponding plan of care does not substantiate physician participation in the management of that problem. Providing a brief, generalized comment (e.g. “DM, CKD, CHF: Continue current treatment plan”) minimizes the complexity and effort put forth in the encounter and could result in auditor downgrading upon documentation review.

Developing shortcuts might falsely minimize the provider’s documentation burden. An electronic documentation system might make it possible to copy previous progress notes into the current encounter to save time; however, the previously entered information could include elements that do not require reassessment during a subsequent encounter or contain information about conditions that are being managed concurrently by another specialist (e.g. CKD being managed by the nephrologist). Leaving the copied information unmodified may not accurately reflect the patient’s current condition or the care provided by the hospitalist during the current encounter. Information that is pulled forward or copied and pasted from a previous entry should be modified to demonstrate updated content and nonoverlapping care relevant to that date.

According to the Office of Inspector General (OIG), “inappropriate copy-pasting could facilitate attempts to inflate claims and duplicate or create fraudulent claims.”⁴

An equally problematic EHR function involves “overdocumentation,” the practice of inserting false or irrelevant documentation to create the appearance of support for billing higher level services.4 EHR technology has the ability to auto-populate fields using templates built into the system or generate extensive documentation on the basis of a single click. The OIG cautions providers to use these features carefully, because they can produce information suggesting the practitioner performed more comprehensive services than were actually rendered.⁴

An example is the inclusion of the same lab results more than once. Although clinicians include this information as a reference to avoid having to “find it somewhere in the chart” when it is needed—as a basis for comparison, for example—auditors mistake this as an attempt to gain credit for the daily review of the same “old” information. Including only relevant data will mitigate this concern.

Authorship

Dates and signatures are essential to each encounter. Medicare requires services provided/ordered to be authenticated by the author.⁵ A reviewer must be able to identify each individual who performs, documents, and bills for a service on a given date. Progress notes that fail to identify the service date or service provider will likely result in denial.

Additionally, a service is questioned when two different sets of handwriting appear on a note, yet only one signature is provided. Since the reviewer cannot confirm the credentials of the unidentified individual and cannot be sure which portion belongs to the identified individual, the entire note is disregarded.

Notes that contain an illegible signature are equally problematic. If the legibility of the signature prevents the reviewer from correctly identifying the rendering provider, the service may be denied.

CMS has instructed Medicare contractors to request a signed provider attestation before issuing a denial.⁵ The provider should print his/her name beside the signature or include a separate signature sheet with the requested documentation to assist the reviewer in provider identification. Stamped signatures are not acceptable under any circumstance. Medicare accepts only handwritten or electronic signatures.⁵

Carol Pohlig is a billing and coding expert with the University of Pennsylvania Medical Center, Philadelphia. She is also on the faculty of SHM’s inpatient coding course.

References

1. HealthIT.gov. Benefits of electronic health records (EHRs). Accessed August 1, 2015.
2. Social Security Administration. Exclusions from coverage and Medicare as secondary payer. Accessed August 1, 2015.
3. Centers for Medicare and Medicaid Services. Medicare Benefit Policy Manual: Chapter 15—Covered medical and other health services. Chapter 15, Section 30.E. Concurrent care. Accessed August 1, 2015.
4. Department of Health and Human Services. Office of Inspector General. CMS and its contractors have adopted few program integrity practices to address vulnerabilities in EHRs. Accessed August 1, 2015.
5. Centers for Medicare and Medicaid Services. Signature guidelines for medical review purposes. Accessed August 1, 2015.
6. Centers for Medicare and Medicaid Services. 1995 documentation guidelines for evaluation and management services. Accessed August 1, 2015.

You shouldn’t maintain things that do not deliver the value you anticipated when you first put them in place. For example, I thought Netflix streaming would be terrific, but I have used it so infrequently that it probably costs me $50 per movie or show watched. I should probably dump it.

Your hospitalist group might have some operational practices that are not as valuable as they seem and could be replaced with something better. For many groups, this might include doing away with a separate daytime admitter shift and a morning meeting to distribute the overnight admissions.

Daytime Admission Shift

My experience is that hospitalist groups with more than about five daytime doctors almost always have a day-shift person dedicated to seeing new admissions. In most cases, this procedure is implemented with the idea of reducing the stress of other day-shift doctors, who don’t have to interrupt rounds to admit a new patient. Some see a dedicated admitter as a tool to improve ED throughput, because this doctor isn’t tied up with rounds and can immediately start seeing a new admission.

I think an admitter shift does deliver both of these benefits, but its costs make it suboptimal in most settings. For example, a single admitter will impede ED throughput any time more than one new admission is waiting to be seen, and for most groups that will be much of the day. In fact, improved ED throughput is best achieved by having many hospitalists available for admissions, not just a single admitter. (There are many other factors influencing ED throughput, such as whether ED doctors simply send patients to their “floor” bed prior to being seen by a hospitalist. But for this article, I’m just considering the influence of a dedicated admitter.)

I think “silo-ing” work into different roles, such as separating rounding and admitting, makes it more difficult to ensure that each is always working productively. There are likely to be times when the admitter has little or nothing to do, even though the rounders are very busy. Or perhaps the rounders aren’t very busy, but the admitter has just been asked to admit four ED patients at the same time.

While protecting rounders from the stress of admissions is valuable, it comes at the cost of a net increase in hospitalist work, because a new doctor must get to know the patient on the day following admission. And this admitter-to-rounder handoff serves as another opportunity for errors—and probably lowers patient satisfaction.

I think most groups should consider moving the admitter shift into an additional rounder position, dividing admissions across all of the doctors working during the daytime. For example, a group that has six rounders and a separate admitter would change to seven rounders, each available to admit every seventh daytime admission. Each would bear the meaningful stress of having rounds interrupted to admit a new patient, but accepting every seventh daytime admission shouldn’t be too difficult on most days.

Don’t forget that eliminating the admitter means that the list of new patients you take on each morning will be shorter. Mornings may be a little less stressful.

A.M. Distribution

The daytime doctors at many hospitalist groups meet each morning to discuss how the new admissions from the prior night (or even the last 24 hours) will be distributed. Or perhaps one person, sometimes a nurse or clerical staff, arrives very early each day to do this.

Although it might take some careful planning, I think most groups that use this sort of morning distribution should abandon it for a better system. Consider a group in which all six daytime doctors spend an average of 20 minutes distributing patients each morning. Twenty minutes (0.33 hours) times six doctors times 365 days comes to 730 hours annually.

Assuming these doctors are compensated at typical rates, the practice is spending more than $100,000 annually just so the doctors can distribute patients each morning. On top of this, nurses and others at the hospital are usually delayed in learning which daytime hospitalist is caring for each patient. These costs seem unreasonably high.

An alternative is to develop a system by which any admitter, such as a night doctor, who will not be providing subsequent care to a patient can identify by name the doctor who will be providing that care. During the admission encounter, the admitter can tell patient/family, “Dr. Boswell will be taking over your care starting tomorrow. He’s a great guy and has been named one of Portland’s best doctors.” This seems so much better than saying, “One of my partners will be taking over tomorrow. I don’t know which of my partners it will be, but they’re all good doctors.” And Dr. Boswell’s name can be entered into the attending physician field of the EHR so that all hospital staff will know without delay.

MedAptus has recently launched software they call “Assign” that may be able to replace the morning meeting and automate assigning new admissions to each hospitalist. I haven’t seen it in operation, so I can’t speak for its effectiveness, but it might be worthwhile for some groups.

Practical Considerations

The changes I’ve described above might not be optimal for every group, and they may take meaningful work to implement. But I don’t think the difficulty of these things is the biggest barrier. The biggest barrier is probably just inertia in most cases, the same reason I’m still a Netflix streaming subscriber even though I almost never watch it. I did, however, really enjoy the Nexflix original series Lilyhammer.

You shouldn’t maintain things that do not deliver the value you anticipated when you first put them in place. For example, I thought Netflix streaming would be terrific, but I have used it so infrequently that it probably costs me $50 per movie or show watched. I should probably dump it.

Your hospitalist group might have some operational practices that are not as valuable as they seem and could be replaced with something better. For many groups, this might include doing away with a separate daytime admitter shift and a morning meeting to distribute the overnight admissions.

Daytime Admission Shift

My experience is that hospitalist groups with more than about five daytime doctors almost always have a day-shift person dedicated to seeing new admissions. In most cases, this procedure is implemented with the idea of reducing the stress of other day-shift doctors, who don’t have to interrupt rounds to admit a new patient. Some see a dedicated admitter as a tool to improve ED throughput, because this doctor isn’t tied up with rounds and can immediately start seeing a new admission.

I think an admitter shift does deliver both of these benefits, but its costs make it suboptimal in most settings. For example, a single admitter will impede ED throughput any time more than one new admission is waiting to be seen, and for most groups that will be much of the day. In fact, improved ED throughput is best achieved by having many hospitalists available for admissions, not just a single admitter. (There are many other factors influencing ED throughput, such as whether ED doctors simply send patients to their “floor” bed prior to being seen by a hospitalist. But for this article, I’m just considering the influence of a dedicated admitter.)

I think “silo-ing” work into different roles, such as separating rounding and admitting, makes it more difficult to ensure that each is always working productively. There are likely to be times when the admitter has little or nothing to do, even though the rounders are very busy. Or perhaps the rounders aren’t very busy, but the admitter has just been asked to admit four ED patients at the same time.

While protecting rounders from the stress of admissions is valuable, it comes at the cost of a net increase in hospitalist work, because a new doctor must get to know the patient on the day following admission. And this admitter-to-rounder handoff serves as another opportunity for errors—and probably lowers patient satisfaction.

I think most groups should consider moving the admitter shift into an additional rounder position, dividing admissions across all of the doctors working during the daytime. For example, a group that has six rounders and a separate admitter would change to seven rounders, each available to admit every seventh daytime admission. Each would bear the meaningful stress of having rounds interrupted to admit a new patient, but accepting every seventh daytime admission shouldn’t be too difficult on most days.

Don’t forget that eliminating the admitter means that the list of new patients you take on each morning will be shorter. Mornings may be a little less stressful.

A.M. Distribution

The daytime doctors at many hospitalist groups meet each morning to discuss how the new admissions from the prior night (or even the last 24 hours) will be distributed. Or perhaps one person, sometimes a nurse or clerical staff, arrives very early each day to do this.

Although it might take some careful planning, I think most groups that use this sort of morning distribution should abandon it for a better system. Consider a group in which all six daytime doctors spend an average of 20 minutes distributing patients each morning. Twenty minutes (0.33 hours) times six doctors times 365 days comes to 730 hours annually.

Assuming these doctors are compensated at typical rates, the practice is spending more than $100,000 annually just so the doctors can distribute patients each morning. On top of this, nurses and others at the hospital are usually delayed in learning which daytime hospitalist is caring for each patient. These costs seem unreasonably high.

An alternative is to develop a system by which any admitter, such as a night doctor, who will not be providing subsequent care to a patient can identify by name the doctor who will be providing that care. During the admission encounter, the admitter can tell patient/family, “Dr. Boswell will be taking over your care starting tomorrow. He’s a great guy and has been named one of Portland’s best doctors.” This seems so much better than saying, “One of my partners will be taking over tomorrow. I don’t know which of my partners it will be, but they’re all good doctors.” And Dr. Boswell’s name can be entered into the attending physician field of the EHR so that all hospital staff will know without delay.

MedAptus has recently launched software they call “Assign” that may be able to replace the morning meeting and automate assigning new admissions to each hospitalist. I haven’t seen it in operation, so I can’t speak for its effectiveness, but it might be worthwhile for some groups.

Practical Considerations

The changes I’ve described above might not be optimal for every group, and they may take meaningful work to implement. But I don’t think the difficulty of these things is the biggest barrier. The biggest barrier is probably just inertia in most cases, the same reason I’m still a Netflix streaming subscriber even though I almost never watch it. I did, however, really enjoy the Nexflix original series Lilyhammer.

You shouldn’t maintain things that do not deliver the value you anticipated when you first put them in place. For example, I thought Netflix streaming would be terrific, but I have used it so infrequently that it probably costs me $50 per movie or show watched. I should probably dump it.

Your hospitalist group might have some operational practices that are not as valuable as they seem and could be replaced with something better. For many groups, this might include doing away with a separate daytime admitter shift and a morning meeting to distribute the overnight admissions.

Daytime Admission Shift

My experience is that hospitalist groups with more than about five daytime doctors almost always have a day-shift person dedicated to seeing new admissions. In most cases, this procedure is implemented with the idea of reducing the stress of other day-shift doctors, who don’t have to interrupt rounds to admit a new patient. Some see a dedicated admitter as a tool to improve ED throughput, because this doctor isn’t tied up with rounds and can immediately start seeing a new admission.

I think an admitter shift does deliver both of these benefits, but its costs make it suboptimal in most settings. For example, a single admitter will impede ED throughput any time more than one new admission is waiting to be seen, and for most groups that will be much of the day. In fact, improved ED throughput is best achieved by having many hospitalists available for admissions, not just a single admitter. (There are many other factors influencing ED throughput, such as whether ED doctors simply send patients to their “floor” bed prior to being seen by a hospitalist. But for this article, I’m just considering the influence of a dedicated admitter.)

I think “silo-ing” work into different roles, such as separating rounding and admitting, makes it more difficult to ensure that each is always working productively. There are likely to be times when the admitter has little or nothing to do, even though the rounders are very busy. Or perhaps the rounders aren’t very busy, but the admitter has just been asked to admit four ED patients at the same time.

While protecting rounders from the stress of admissions is valuable, it comes at the cost of a net increase in hospitalist work, because a new doctor must get to know the patient on the day following admission. And this admitter-to-rounder handoff serves as another opportunity for errors—and probably lowers patient satisfaction.

I think most groups should consider moving the admitter shift into an additional rounder position, dividing admissions across all of the doctors working during the daytime. For example, a group that has six rounders and a separate admitter would change to seven rounders, each available to admit every seventh daytime admission. Each would bear the meaningful stress of having rounds interrupted to admit a new patient, but accepting every seventh daytime admission shouldn’t be too difficult on most days.

Don’t forget that eliminating the admitter means that the list of new patients you take on each morning will be shorter. Mornings may be a little less stressful.

A.M. Distribution

The daytime doctors at many hospitalist groups meet each morning to discuss how the new admissions from the prior night (or even the last 24 hours) will be distributed. Or perhaps one person, sometimes a nurse or clerical staff, arrives very early each day to do this.

Although it might take some careful planning, I think most groups that use this sort of morning distribution should abandon it for a better system. Consider a group in which all six daytime doctors spend an average of 20 minutes distributing patients each morning. Twenty minutes (0.33 hours) times six doctors times 365 days comes to 730 hours annually.

Assuming these doctors are compensated at typical rates, the practice is spending more than $100,000 annually just so the doctors can distribute patients each morning. On top of this, nurses and others at the hospital are usually delayed in learning which daytime hospitalist is caring for each patient. These costs seem unreasonably high.

An alternative is to develop a system by which any admitter, such as a night doctor, who will not be providing subsequent care to a patient can identify by name the doctor who will be providing that care. During the admission encounter, the admitter can tell patient/family, “Dr. Boswell will be taking over your care starting tomorrow. He’s a great guy and has been named one of Portland’s best doctors.” This seems so much better than saying, “One of my partners will be taking over tomorrow. I don’t know which of my partners it will be, but they’re all good doctors.” And Dr. Boswell’s name can be entered into the attending physician field of the EHR so that all hospital staff will know without delay.

MedAptus has recently launched software they call “Assign” that may be able to replace the morning meeting and automate assigning new admissions to each hospitalist. I haven’t seen it in operation, so I can’t speak for its effectiveness, but it might be worthwhile for some groups.

Practical Considerations

The changes I’ve described above might not be optimal for every group, and they may take meaningful work to implement. But I don’t think the difficulty of these things is the biggest barrier. The biggest barrier is probably just inertia in most cases, the same reason I’m still a Netflix streaming subscriber even though I almost never watch it. I did, however, really enjoy the Nexflix original series Lilyhammer.

Understanding and improving the patient care experience has become a vital component of delivering high quality care. According to a new survey of American Society for Quality (ASQ) healthcare quality experts, more than 80% of respondents said improving communications between caregivers and patients and easing access to treatment across the entire continuum of care should be top priorities for improving patient experience. For Hill Country Memorial (HCM) in Fredericksburg, Texas, winner of the Malcolm Baldrige National Quality Award, accomplishing this kind of top-level patient experience performance involved engaging physicians—particularly hospitalists—using voice of the customer (VOC) input.

HCM did not achieve overnight success, however; instead, the facility achieved year-over-year improvement in finance and growth, patient experience, quality of care, and workforce environment and engagement (see Figure 1).

HCM developed a systematic VOC input-to-action process in which listening and learning methods during annual planning led them to institute a hospitalist program. Results included:

• Improved access to primary care, achieved by increasing the physicians’ hours of availability in their clinics, and improved work-life balance, enhancing engagement and alignment of the medical staff and HCM;
• Reductions in delays in admissions, discharges, and length of stay; and
• Real-time review and management of clinical data, not just during the daily rounding as had been done previously.

One of the major hurdles in the way of achieving patient satisfaction, according to the ASQ patient experience survey, is care that is fragmented and uncoordinated because of communication issues. HCM has overcome those hurdles using strategies such as a daily afternoon huddle in which hospitalists meet with a multidisciplinary team so that everyone understands patient action plans and current concerns. The process of discharge planning begins in these huddles so that more complex issues are initiated on day one of the hospital stay.

A new rounding communication process, called GIFT for greet, inform, find out, and time, has dramatically improved patient satisfaction and engagement. GIFT enables hospitalists to greet a patient with a personal introduction and an explanation of their position and responsibilities. Hospitalists always sit while engaging the patient, and they make it a point to acknowledge not only the patient but everyone present in the room. Personalized “baseball cards” featuring the hospitalist’s background, including personal interests and hobbies, are handed out to patients or family members. Hospitalists take time to inform the patient and appropriate family members and caregivers of all diagnostic test results and the clinical response of treatment to date. Treatment plans and further diagnostic tests or procedures are discussed. A report of all consultants who have joined or will be joining in the care, along with their roles in the treatment planned, is fully vetted.

One key to a successful patient experience is discovering the concerns of the patient, family members, friends, and caregivers. Emotional issues become as important as the physical needs of the patient; these are openly addressed. Ask not “What’s the matter?” but instead “What matters to you?”

Timing the hospitalist’s return to see the patient and the anticipated date of transition of care is the last item in the rounding interaction. The date should be as accurate as possible to reduce patient anxiety and help the patient understand that the hospitalist really cares.

The hospitalist program has also strengthened the relationship between nurses and physicians. Nurses know the hospitalists’ practice patterns well, which allows them to help manage patient interactions and minimize patient anxiety and frustration. The physician-patient relationship is reinforced when nurse leaders include hospitalist satisfaction questions during daily rounding to identify concerns that can be clarified or resolved in real time.

The systematic VOC approach has enabled HCM to design, manage, and improve its key work process at multiple levels of the organization. These processes are reviewed and refined periodically to respond to the changing healthcare environment and stay focused on creating value for customers.

Chip Caldwell is chairman of Caldwell Butler, a firm specializing in coaching organizations to achieve world class performance in margin improvement, patient experience, physician/clinical enterprise, and capacity optimization. Jayne Pope, MBA, RN, is CEO of Hill Country Memorial Hospital in Fredericksburg, Texas. James Partin, MD, is CMO at Hill Country Memorial.

Understanding and improving the patient care experience has become a vital component of delivering high quality care. According to a new survey of American Society for Quality (ASQ) healthcare quality experts, more than 80% of respondents said improving communications between caregivers and patients and easing access to treatment across the entire continuum of care should be top priorities for improving patient experience. For Hill Country Memorial (HCM) in Fredericksburg, Texas, winner of the Malcolm Baldrige National Quality Award, accomplishing this kind of top-level patient experience performance involved engaging physicians—particularly hospitalists—using voice of the customer (VOC) input.

HCM did not achieve overnight success, however; instead, the facility achieved year-over-year improvement in finance and growth, patient experience, quality of care, and workforce environment and engagement (see Figure 1).

HCM developed a systematic VOC input-to-action process in which listening and learning methods during annual planning led them to institute a hospitalist program. Results included:

• Improved access to primary care, achieved by increasing the physicians’ hours of availability in their clinics, and improved work-life balance, enhancing engagement and alignment of the medical staff and HCM;
• Reductions in delays in admissions, discharges, and length of stay; and
• Real-time review and management of clinical data, not just during the daily rounding as had been done previously.

One of the major hurdles in the way of achieving patient satisfaction, according to the ASQ patient experience survey, is care that is fragmented and uncoordinated because of communication issues. HCM has overcome those hurdles using strategies such as a daily afternoon huddle in which hospitalists meet with a multidisciplinary team so that everyone understands patient action plans and current concerns. The process of discharge planning begins in these huddles so that more complex issues are initiated on day one of the hospital stay.

A new rounding communication process, called GIFT for greet, inform, find out, and time, has dramatically improved patient satisfaction and engagement. GIFT enables hospitalists to greet a patient with a personal introduction and an explanation of their position and responsibilities. Hospitalists always sit while engaging the patient, and they make it a point to acknowledge not only the patient but everyone present in the room. Personalized “baseball cards” featuring the hospitalist’s background, including personal interests and hobbies, are handed out to patients or family members. Hospitalists take time to inform the patient and appropriate family members and caregivers of all diagnostic test results and the clinical response of treatment to date. Treatment plans and further diagnostic tests or procedures are discussed. A report of all consultants who have joined or will be joining in the care, along with their roles in the treatment planned, is fully vetted.

One key to a successful patient experience is discovering the concerns of the patient, family members, friends, and caregivers. Emotional issues become as important as the physical needs of the patient; these are openly addressed. Ask not “What’s the matter?” but instead “What matters to you?”

Timing the hospitalist’s return to see the patient and the anticipated date of transition of care is the last item in the rounding interaction. The date should be as accurate as possible to reduce patient anxiety and help the patient understand that the hospitalist really cares.

The hospitalist program has also strengthened the relationship between nurses and physicians. Nurses know the hospitalists’ practice patterns well, which allows them to help manage patient interactions and minimize patient anxiety and frustration. The physician-patient relationship is reinforced when nurse leaders include hospitalist satisfaction questions during daily rounding to identify concerns that can be clarified or resolved in real time.

The systematic VOC approach has enabled HCM to design, manage, and improve its key work process at multiple levels of the organization. These processes are reviewed and refined periodically to respond to the changing healthcare environment and stay focused on creating value for customers.

Chip Caldwell is chairman of Caldwell Butler, a firm specializing in coaching organizations to achieve world class performance in margin improvement, patient experience, physician/clinical enterprise, and capacity optimization. Jayne Pope, MBA, RN, is CEO of Hill Country Memorial Hospital in Fredericksburg, Texas. James Partin, MD, is CMO at Hill Country Memorial.

Understanding and improving the patient care experience has become a vital component of delivering high quality care. According to a new survey of American Society for Quality (ASQ) healthcare quality experts, more than 80% of respondents said improving communications between caregivers and patients and easing access to treatment across the entire continuum of care should be top priorities for improving patient experience. For Hill Country Memorial (HCM) in Fredericksburg, Texas, winner of the Malcolm Baldrige National Quality Award, accomplishing this kind of top-level patient experience performance involved engaging physicians—particularly hospitalists—using voice of the customer (VOC) input.

HCM did not achieve overnight success, however; instead, the facility achieved year-over-year improvement in finance and growth, patient experience, quality of care, and workforce environment and engagement (see Figure 1).

HCM developed a systematic VOC input-to-action process in which listening and learning methods during annual planning led them to institute a hospitalist program. Results included:

• Improved access to primary care, achieved by increasing the physicians’ hours of availability in their clinics, and improved work-life balance, enhancing engagement and alignment of the medical staff and HCM;
• Reductions in delays in admissions, discharges, and length of stay; and
• Real-time review and management of clinical data, not just during the daily rounding as had been done previously.

One of the major hurdles in the way of achieving patient satisfaction, according to the ASQ patient experience survey, is care that is fragmented and uncoordinated because of communication issues. HCM has overcome those hurdles using strategies such as a daily afternoon huddle in which hospitalists meet with a multidisciplinary team so that everyone understands patient action plans and current concerns. The process of discharge planning begins in these huddles so that more complex issues are initiated on day one of the hospital stay.

A new rounding communication process, called GIFT for greet, inform, find out, and time, has dramatically improved patient satisfaction and engagement. GIFT enables hospitalists to greet a patient with a personal introduction and an explanation of their position and responsibilities. Hospitalists always sit while engaging the patient, and they make it a point to acknowledge not only the patient but everyone present in the room. Personalized “baseball cards” featuring the hospitalist’s background, including personal interests and hobbies, are handed out to patients or family members. Hospitalists take time to inform the patient and appropriate family members and caregivers of all diagnostic test results and the clinical response of treatment to date. Treatment plans and further diagnostic tests or procedures are discussed. A report of all consultants who have joined or will be joining in the care, along with their roles in the treatment planned, is fully vetted.

One key to a successful patient experience is discovering the concerns of the patient, family members, friends, and caregivers. Emotional issues become as important as the physical needs of the patient; these are openly addressed. Ask not “What’s the matter?” but instead “What matters to you?”

Timing the hospitalist’s return to see the patient and the anticipated date of transition of care is the last item in the rounding interaction. The date should be as accurate as possible to reduce patient anxiety and help the patient understand that the hospitalist really cares.

The hospitalist program has also strengthened the relationship between nurses and physicians. Nurses know the hospitalists’ practice patterns well, which allows them to help manage patient interactions and minimize patient anxiety and frustration. The physician-patient relationship is reinforced when nurse leaders include hospitalist satisfaction questions during daily rounding to identify concerns that can be clarified or resolved in real time.

The systematic VOC approach has enabled HCM to design, manage, and improve its key work process at multiple levels of the organization. These processes are reviewed and refined periodically to respond to the changing healthcare environment and stay focused on creating value for customers.

Chip Caldwell is chairman of Caldwell Butler, a firm specializing in coaching organizations to achieve world class performance in margin improvement, patient experience, physician/clinical enterprise, and capacity optimization. Jayne Pope, MBA, RN, is CEO of Hill Country Memorial Hospital in Fredericksburg, Texas. James Partin, MD, is CMO at Hill Country Memorial.

At A Glance

Series: Hospital Medicine: Current Concepts

Title: Clinical Care Conundrums: Challenging Diagnoses in Hospital Medicine

Edited by: James C. Pile, Thomas E. Baudendistel, Brian Harte

Series Editors: Scott Flanders, Sanjay Saint

Pages: 208

Clinical Care Conundrums is written in 22 chapters, each discussing a clinical case presentation in a format similar to the series by the same name, published frequently in the Journal of Hospital Medicine.

An expert clinician’s approach to the “clinical conundrums” is disclosed using the presentation of an actual patient case in a prototypical “morning report” style. As in a patient care situation, sequential pieces of information are provided to the expert clinician, who is unfamiliar with the case. The focus of each case is the thought processes of both the clinical team caring for the patient and the commentator.

Each case provides great learning potential, not only in the unusual presentation of common diseases or more typical presentations of unusual diseases, but also in discussions of the possibilities in differential diagnoses. The range of information is wide. Readers are taken through discussions of conditions infrequently encountered but potentially fatal in the event of missed or delayed diagnosis, such as strongyloides hyperinfection, a condition that we are reminded is not always accompanied by eosinophilia. Some discussions of the more common conditions include:

• Evaluation of confusion;
• Etiologies of cirrhosis;
• Malignancies associated with hypercalcemia; and
• Work-up for new-onset seizures.

My interest remained high throughout the book, because I never knew what to expect. For example, a patient presenting with acute chest pain caused by esophageal perforation resulting in delayed diagnosis might follow the index case presentation of Whipple’s disease. We are also reminded that, despite the insistence of Gregory House, MD, (Dr. House is the titular character from the television series “House”) that “it’s never lupus,” it sometimes is actually lupus. A couple of interesting lupus cases are presented in a realistically perplexing manner, followed by beneficial discussion.

Analysis

The real value in this book lies in continued reminders of how and why clinicians make diagnostic errors. In fact, an early chapter in the book deals explicitly with improving diagnostic safety.

Robert Wachter, MD, MHM, reminds us in the introductory chapter that diagnostic errors comprise nearly one in five preventable adverse events. Until recently, diagnostic errors have been given relatively little attention, most likely because they are difficult to measure and harder to fix.

As hospital-based providers, the more awareness we have about the “anatomy and physiology” of both good and faulty decision making, the more likely we are to make better decisions. This book can be a crucial resource for any hospital-based care provider.

Dr. Lindsey is medical director of hospital-based physician services at Hospital Corporation of America (HCA).

At A Glance

Series: Hospital Medicine: Current Concepts

Title: Clinical Care Conundrums: Challenging Diagnoses in Hospital Medicine

Edited by: James C. Pile, Thomas E. Baudendistel, Brian Harte

Series Editors: Scott Flanders, Sanjay Saint

Pages: 208

Clinical Care Conundrums is written in 22 chapters, each discussing a clinical case presentation in a format similar to the series by the same name, published frequently in the Journal of Hospital Medicine.

An expert clinician’s approach to the “clinical conundrums” is disclosed using the presentation of an actual patient case in a prototypical “morning report” style. As in a patient care situation, sequential pieces of information are provided to the expert clinician, who is unfamiliar with the case. The focus of each case is the thought processes of both the clinical team caring for the patient and the commentator.

Each case provides great learning potential, not only in the unusual presentation of common diseases or more typical presentations of unusual diseases, but also in discussions of the possibilities in differential diagnoses. The range of information is wide. Readers are taken through discussions of conditions infrequently encountered but potentially fatal in the event of missed or delayed diagnosis, such as strongyloides hyperinfection, a condition that we are reminded is not always accompanied by eosinophilia. Some discussions of the more common conditions include:

• Evaluation of confusion;
• Etiologies of cirrhosis;
• Malignancies associated with hypercalcemia; and
• Work-up for new-onset seizures.

My interest remained high throughout the book, because I never knew what to expect. For example, a patient presenting with acute chest pain caused by esophageal perforation resulting in delayed diagnosis might follow the index case presentation of Whipple’s disease. We are also reminded that, despite the insistence of Gregory House, MD, (Dr. House is the titular character from the television series “House”) that “it’s never lupus,” it sometimes is actually lupus. A couple of interesting lupus cases are presented in a realistically perplexing manner, followed by beneficial discussion.

Analysis

The real value in this book lies in continued reminders of how and why clinicians make diagnostic errors. In fact, an early chapter in the book deals explicitly with improving diagnostic safety.

Robert Wachter, MD, MHM, reminds us in the introductory chapter that diagnostic errors comprise nearly one in five preventable adverse events. Until recently, diagnostic errors have been given relatively little attention, most likely because they are difficult to measure and harder to fix.

As hospital-based providers, the more awareness we have about the “anatomy and physiology” of both good and faulty decision making, the more likely we are to make better decisions. This book can be a crucial resource for any hospital-based care provider.

Dr. Lindsey is medical director of hospital-based physician services at Hospital Corporation of America (HCA).

At A Glance

Series: Hospital Medicine: Current Concepts

Title: Clinical Care Conundrums: Challenging Diagnoses in Hospital Medicine

Edited by: James C. Pile, Thomas E. Baudendistel, Brian Harte

Series Editors: Scott Flanders, Sanjay Saint

Pages: 208

Clinical Care Conundrums is written in 22 chapters, each discussing a clinical case presentation in a format similar to the series by the same name, published frequently in the Journal of Hospital Medicine.

An expert clinician’s approach to the “clinical conundrums” is disclosed using the presentation of an actual patient case in a prototypical “morning report” style. As in a patient care situation, sequential pieces of information are provided to the expert clinician, who is unfamiliar with the case. The focus of each case is the thought processes of both the clinical team caring for the patient and the commentator.

Each case provides great learning potential, not only in the unusual presentation of common diseases or more typical presentations of unusual diseases, but also in discussions of the possibilities in differential diagnoses. The range of information is wide. Readers are taken through discussions of conditions infrequently encountered but potentially fatal in the event of missed or delayed diagnosis, such as strongyloides hyperinfection, a condition that we are reminded is not always accompanied by eosinophilia. Some discussions of the more common conditions include:

• Evaluation of confusion;
• Etiologies of cirrhosis;
• Malignancies associated with hypercalcemia; and
• Work-up for new-onset seizures.

My interest remained high throughout the book, because I never knew what to expect. For example, a patient presenting with acute chest pain caused by esophageal perforation resulting in delayed diagnosis might follow the index case presentation of Whipple’s disease. We are also reminded that, despite the insistence of Gregory House, MD, (Dr. House is the titular character from the television series “House”) that “it’s never lupus,” it sometimes is actually lupus. A couple of interesting lupus cases are presented in a realistically perplexing manner, followed by beneficial discussion.

Analysis

The real value in this book lies in continued reminders of how and why clinicians make diagnostic errors. In fact, an early chapter in the book deals explicitly with improving diagnostic safety.

Robert Wachter, MD, MHM, reminds us in the introductory chapter that diagnostic errors comprise nearly one in five preventable adverse events. Until recently, diagnostic errors have been given relatively little attention, most likely because they are difficult to measure and harder to fix.

As hospital-based providers, the more awareness we have about the “anatomy and physiology” of both good and faulty decision making, the more likely we are to make better decisions. This book can be a crucial resource for any hospital-based care provider.

Dr. Lindsey is medical director of hospital-based physician services at Hospital Corporation of America (HCA).

Community hospitals offer multiple opportunities for hospitalists to become involved in both quality assurance and quality improvement. To help steer the right approach and avoid possible missteps, it’s important to acknowledge the differences between the community and academic settings, according to two medical directors with whom we spoke.

For example, in the rural, 47-bed Riverside Tappahannock Hospital where Randy Ferrance, DC, MD, SFHM, is medical director for hospital-based quality, cost effectiveness is king.

“We live on a thin margin, and being sure we provide cost-effective care is the difference between having adequate nursing and not,” he says. It’s a critical difference from academic institutions, he notes, where “there is protected time to do QI, research, and administrative tasks.”

Dr. Ferrance advises those interested in tackling quality projects to “make sure that the project is tied to quality measures and that you’re being cognizant of the cost impact.”

Although much of the work around quality assurance and quality improvement in the community hospital setting is being tackled by nonphysician administrative partners, “those people are usually more than happy to develop a physician partner,” says Colleen A. McCoy, MD, PhD, medical director for hospital medicine at Williamsport (Pa.) Regional Medical Center, a part of the Susquehanna Health System.

“The idea is to look for quality projects where there is a quantifiable financial payoff to the hospital,” she says. That could be a Centers for Medicare and Medicaid Services (CMS) core measure or helping to rewrite an order set for new inpatient guidelines on stroke, as Dr. McCoy did at her hospital.

First Order of Business

Dr. McCoy has been actively engaged in quality initiatives since she joined Williams-port in 2012. She cautions new hospitalists to spend the first six months at their new job developing a reputation for clinical excellence and attention to detail.

“Having a reputation that is respected clinically opens many doors,” she says. As generalists, hospitalists interact with a wider variety of staff than specialists. This leads to broad early exposure to a diverse group of decision makers in your institution. “As a hospitalist, you can get a lot of credibility in your organization much sooner than, for example, a young cardiologist or a young gastroenterologist,” she notes.

It is also important for new hospitalists to be mindful of their position in the organization and to watch how their institutions work and operate, so that when they propose a project they are not doing so from a critical standpoint.

“Unrequested input is often seen as criticism,” she says.

Dr. Ferrance agrees. “It’s always a good idea to make sure we focus on processes and not on people in the process.”

Meeting the Mark

“If you want to leapfrog into doing things quickly, you have to be very savvy about the cost impact of your quality improvement,” continues Dr. McCoy. She and Dr. Ferrance advise those just getting started to consider tackling core measures that are reported to CMS or to identify other quality improvement projects that can be financially quantified.

Early on at Riverside Tappahannock Hospital, Dr. Ferrance participated in root cause analyses and developed (at that time) paper-based standard order sets with quality measures attached to them.

The idea is to look for quality projects where there is a quantifiable financial payoff to the hospital. —Colleen A. McCoy, MD, PhD, medical director, hospital medicine, Williamsport (Pa.) Regional Medical Center

Because of her attention to detail during her orientation at Williamsport, Dr. McCoy, who had been a clinical instructor at Emory University and worked for Kaiser Permanente, quickly spotted some necessary omissions regarding DVT prophylaxis. She helped rewrite the ICU admission order sets, inserting a query for DVT prophylaxis. That one intervention helped to increase compliance on a CMS core measure.

Assess Advancement Ops

Is your community hospital open to QI projects? Dr. McCoy says candidates should ask direct questions during job interviews to assess a prospective employer’s approach to quality. She suggests two fair questions:

1. Is it possible, within my first two years here as a junior staff member, to participate in a QI project?
2. If I were successful in that venture, is this organization open and able to give me more opportunities in that field?

It is key for the medical director to know who in the administrative organization of the hospital would really appreciate a physician partner or physician champion for new projects. If young hospitalists are interested in such projects, they should make that known to their medical directors.

“Having the senior person in your group make a connection with your [administrative] partner is how things get done in the community medical center,” Dr. McCoy says.

Dr. Ferrance’s HM group comprises four physicians and one nurse practitioner, so “there are plenty of QI projects to go around.”

“I would be more than happy to give them [junior staff hospitalists] any QI project they are interested in taking on,” he adds. “With medicine evolving as it does, we need to revisit processes every two to three years.” For example, drug shortages and cost increases often necessitate formulary cutbacks and the need for a change in administration protocols.

When selecting a QI project, it pays to stay ahead of the game, Dr. McCoy says. She encourages hospitalists to be aware of the next core measures and volunteer to help develop guidelines. She helped create a new protocol for inpatient tissue plasminogen activator (tPa) evaluation for acute stroke, which was a recent recommendation for stroke center certification. This approach was key in helping Williamsport retain its accreditation as a stroke center. The hospital has garnered multiple accolades from the Joint Commission, U.S. News and World Report, and other reporting agencies.

“The community setting is a much smaller world than academia,” she says. But smaller can be good for one’s career advancement. “If you hit a project out of the park and it makes your hospital look better, you can very quickly get a promotion or an increase in other opportunities. These types of projects may lead to the hospital asking, ‘Have you thought about being director of the hospital medicine group or taking a leadership role in hospital operations?’”

Gretchen Henkel is a freelance writer in California.

Community hospitals offer multiple opportunities for hospitalists to become involved in both quality assurance and quality improvement. To help steer the right approach and avoid possible missteps, it’s important to acknowledge the differences between the community and academic settings, according to two medical directors with whom we spoke.

For example, in the rural, 47-bed Riverside Tappahannock Hospital where Randy Ferrance, DC, MD, SFHM, is medical director for hospital-based quality, cost effectiveness is king.

“We live on a thin margin, and being sure we provide cost-effective care is the difference between having adequate nursing and not,” he says. It’s a critical difference from academic institutions, he notes, where “there is protected time to do QI, research, and administrative tasks.”

Dr. Ferrance advises those interested in tackling quality projects to “make sure that the project is tied to quality measures and that you’re being cognizant of the cost impact.”

Although much of the work around quality assurance and quality improvement in the community hospital setting is being tackled by nonphysician administrative partners, “those people are usually more than happy to develop a physician partner,” says Colleen A. McCoy, MD, PhD, medical director for hospital medicine at Williamsport (Pa.) Regional Medical Center, a part of the Susquehanna Health System.

“The idea is to look for quality projects where there is a quantifiable financial payoff to the hospital,” she says. That could be a Centers for Medicare and Medicaid Services (CMS) core measure or helping to rewrite an order set for new inpatient guidelines on stroke, as Dr. McCoy did at her hospital.

First Order of Business

Dr. McCoy has been actively engaged in quality initiatives since she joined Williams-port in 2012. She cautions new hospitalists to spend the first six months at their new job developing a reputation for clinical excellence and attention to detail.

“Having a reputation that is respected clinically opens many doors,” she says. As generalists, hospitalists interact with a wider variety of staff than specialists. This leads to broad early exposure to a diverse group of decision makers in your institution. “As a hospitalist, you can get a lot of credibility in your organization much sooner than, for example, a young cardiologist or a young gastroenterologist,” she notes.

It is also important for new hospitalists to be mindful of their position in the organization and to watch how their institutions work and operate, so that when they propose a project they are not doing so from a critical standpoint.

“Unrequested input is often seen as criticism,” she says.

Dr. Ferrance agrees. “It’s always a good idea to make sure we focus on processes and not on people in the process.”

Meeting the Mark

“If you want to leapfrog into doing things quickly, you have to be very savvy about the cost impact of your quality improvement,” continues Dr. McCoy. She and Dr. Ferrance advise those just getting started to consider tackling core measures that are reported to CMS or to identify other quality improvement projects that can be financially quantified.

Early on at Riverside Tappahannock Hospital, Dr. Ferrance participated in root cause analyses and developed (at that time) paper-based standard order sets with quality measures attached to them.

The idea is to look for quality projects where there is a quantifiable financial payoff to the hospital. —Colleen A. McCoy, MD, PhD, medical director, hospital medicine, Williamsport (Pa.) Regional Medical Center

Because of her attention to detail during her orientation at Williamsport, Dr. McCoy, who had been a clinical instructor at Emory University and worked for Kaiser Permanente, quickly spotted some necessary omissions regarding DVT prophylaxis. She helped rewrite the ICU admission order sets, inserting a query for DVT prophylaxis. That one intervention helped to increase compliance on a CMS core measure.

Assess Advancement Ops

Is your community hospital open to QI projects? Dr. McCoy says candidates should ask direct questions during job interviews to assess a prospective employer’s approach to quality. She suggests two fair questions:

1. Is it possible, within my first two years here as a junior staff member, to participate in a QI project?
2. If I were successful in that venture, is this organization open and able to give me more opportunities in that field?

It is key for the medical director to know who in the administrative organization of the hospital would really appreciate a physician partner or physician champion for new projects. If young hospitalists are interested in such projects, they should make that known to their medical directors.

“Having the senior person in your group make a connection with your [administrative] partner is how things get done in the community medical center,” Dr. McCoy says.

Dr. Ferrance’s HM group comprises four physicians and one nurse practitioner, so “there are plenty of QI projects to go around.”

“I would be more than happy to give them [junior staff hospitalists] any QI project they are interested in taking on,” he adds. “With medicine evolving as it does, we need to revisit processes every two to three years.” For example, drug shortages and cost increases often necessitate formulary cutbacks and the need for a change in administration protocols.

When selecting a QI project, it pays to stay ahead of the game, Dr. McCoy says. She encourages hospitalists to be aware of the next core measures and volunteer to help develop guidelines. She helped create a new protocol for inpatient tissue plasminogen activator (tPa) evaluation for acute stroke, which was a recent recommendation for stroke center certification. This approach was key in helping Williamsport retain its accreditation as a stroke center. The hospital has garnered multiple accolades from the Joint Commission, U.S. News and World Report, and other reporting agencies.

“The community setting is a much smaller world than academia,” she says. But smaller can be good for one’s career advancement. “If you hit a project out of the park and it makes your hospital look better, you can very quickly get a promotion or an increase in other opportunities. These types of projects may lead to the hospital asking, ‘Have you thought about being director of the hospital medicine group or taking a leadership role in hospital operations?’”

Gretchen Henkel is a freelance writer in California.

Community hospitals offer multiple opportunities for hospitalists to become involved in both quality assurance and quality improvement. To help steer the right approach and avoid possible missteps, it’s important to acknowledge the differences between the community and academic settings, according to two medical directors with whom we spoke.

For example, in the rural, 47-bed Riverside Tappahannock Hospital where Randy Ferrance, DC, MD, SFHM, is medical director for hospital-based quality, cost effectiveness is king.

“We live on a thin margin, and being sure we provide cost-effective care is the difference between having adequate nursing and not,” he says. It’s a critical difference from academic institutions, he notes, where “there is protected time to do QI, research, and administrative tasks.”

Dr. Ferrance advises those interested in tackling quality projects to “make sure that the project is tied to quality measures and that you’re being cognizant of the cost impact.”

Although much of the work around quality assurance and quality improvement in the community hospital setting is being tackled by nonphysician administrative partners, “those people are usually more than happy to develop a physician partner,” says Colleen A. McCoy, MD, PhD, medical director for hospital medicine at Williamsport (Pa.) Regional Medical Center, a part of the Susquehanna Health System.

“The idea is to look for quality projects where there is a quantifiable financial payoff to the hospital,” she says. That could be a Centers for Medicare and Medicaid Services (CMS) core measure or helping to rewrite an order set for new inpatient guidelines on stroke, as Dr. McCoy did at her hospital.

First Order of Business

Dr. McCoy has been actively engaged in quality initiatives since she joined Williams-port in 2012. She cautions new hospitalists to spend the first six months at their new job developing a reputation for clinical excellence and attention to detail.

“Having a reputation that is respected clinically opens many doors,” she says. As generalists, hospitalists interact with a wider variety of staff than specialists. This leads to broad early exposure to a diverse group of decision makers in your institution. “As a hospitalist, you can get a lot of credibility in your organization much sooner than, for example, a young cardiologist or a young gastroenterologist,” she notes.

It is also important for new hospitalists to be mindful of their position in the organization and to watch how their institutions work and operate, so that when they propose a project they are not doing so from a critical standpoint.

“Unrequested input is often seen as criticism,” she says.

Dr. Ferrance agrees. “It’s always a good idea to make sure we focus on processes and not on people in the process.”

Meeting the Mark

“If you want to leapfrog into doing things quickly, you have to be very savvy about the cost impact of your quality improvement,” continues Dr. McCoy. She and Dr. Ferrance advise those just getting started to consider tackling core measures that are reported to CMS or to identify other quality improvement projects that can be financially quantified.

Early on at Riverside Tappahannock Hospital, Dr. Ferrance participated in root cause analyses and developed (at that time) paper-based standard order sets with quality measures attached to them.

The idea is to look for quality projects where there is a quantifiable financial payoff to the hospital. —Colleen A. McCoy, MD, PhD, medical director, hospital medicine, Williamsport (Pa.) Regional Medical Center

Because of her attention to detail during her orientation at Williamsport, Dr. McCoy, who had been a clinical instructor at Emory University and worked for Kaiser Permanente, quickly spotted some necessary omissions regarding DVT prophylaxis. She helped rewrite the ICU admission order sets, inserting a query for DVT prophylaxis. That one intervention helped to increase compliance on a CMS core measure.

Assess Advancement Ops

Is your community hospital open to QI projects? Dr. McCoy says candidates should ask direct questions during job interviews to assess a prospective employer’s approach to quality. She suggests two fair questions:

1. Is it possible, within my first two years here as a junior staff member, to participate in a QI project?
2. If I were successful in that venture, is this organization open and able to give me more opportunities in that field?

It is key for the medical director to know who in the administrative organization of the hospital would really appreciate a physician partner or physician champion for new projects. If young hospitalists are interested in such projects, they should make that known to their medical directors.

“Having the senior person in your group make a connection with your [administrative] partner is how things get done in the community medical center,” Dr. McCoy says.

Dr. Ferrance’s HM group comprises four physicians and one nurse practitioner, so “there are plenty of QI projects to go around.”

“I would be more than happy to give them [junior staff hospitalists] any QI project they are interested in taking on,” he adds. “With medicine evolving as it does, we need to revisit processes every two to three years.” For example, drug shortages and cost increases often necessitate formulary cutbacks and the need for a change in administration protocols.

When selecting a QI project, it pays to stay ahead of the game, Dr. McCoy says. She encourages hospitalists to be aware of the next core measures and volunteer to help develop guidelines. She helped create a new protocol for inpatient tissue plasminogen activator (tPa) evaluation for acute stroke, which was a recent recommendation for stroke center certification. This approach was key in helping Williamsport retain its accreditation as a stroke center. The hospital has garnered multiple accolades from the Joint Commission, U.S. News and World Report, and other reporting agencies.

“The community setting is a much smaller world than academia,” she says. But smaller can be good for one’s career advancement. “If you hit a project out of the park and it makes your hospital look better, you can very quickly get a promotion or an increase in other opportunities. These types of projects may lead to the hospital asking, ‘Have you thought about being director of the hospital medicine group or taking a leadership role in hospital operations?’”

Gretchen Henkel is a freelance writer in California.