Practice Management

Hospitalists are often perceived as the face of the hospital, whether that is their official responsibility or not. They are on the front lines of hearing, seeing, and understanding where gaps exist in a patient’s experience.

“Whenever I hear a patient complain, I can almost piece together what happened without having to interview other staff,” says Jairy C. Hunter III, MD, MBA, SFHM, associate CMO for care transitions at the Medical University of South Carolina in Charleston.

“Up to this point, there hasn’t been as much accountability regarding customer satisfaction in our industry compared to other industries,” Dr. Hunter says.

The paradigm shift has occurred because payers are demanding it. They want value and satisfaction in what they are paying for. In fact, there is a movement to try to standardize procedures whenever possible, such as the amount of time it takes someone to answer a call bell or the volume of noise in a hallway.

“Patients are being asked questions about such topics in surveys,” Dr. Hunter says. “Although these types of questions don’t involve medical decision-making or a course of treatment, they do include personal interactions that influence how patients feel about their hospital experience.”

Another reason for the shift is the significant increase in the use of electronic communication devices and the explosion of online ratings of consumer products and services. Naturally, consumers want access to accurate and easy-to-use information about the quality of healthcare services.

Patient experience surveys focus on how patients’ experienced or perceived key aspects of their care, not how satisfied they were with their care.¹ One way a hospital can measure patient experience is with the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey, which was developed by the Centers for Medicare and Medicaid Services (CMS) and the Agency for Healthcare Research and Quality (AHRQ).² Although other patient satisfaction/experience vendors offer surveys, the Deficit Reduction Act of 2005 states that all Inpatient Prospective Payment Systems (IPPS) hospitals who wish to receive their full annual payment update must collect and submit HCAHPS data to CMS.

The HCAHPS survey, which employs standardized survey instrument and data collection methodology to measure patients’ perspectives on hospital care, is administered to a random sample of patients throughout the year. CMS cleans, adjusts, and analyzes the data and then publicly reports the results. All CAHPS products are available at no cost at www.cahps.ahrq.gov.²

Christine Crofton, PhD, director of CAHPS in Rockville, Md., notes that the HCAHPS survey focuses on patient experience measures because they are considered more understandable, unambiguous, actionable, and objective compared to general satisfaction ratings. Although CAHPS surveys do ask respondents to provide overall ratings (e.g. rate the physician on a scale of one to 10), their primary focus is to ask patients to report on their experiences with specific aspects of care in order to provide information that is not biased by different expectations.

For example, if a patient doesn’t understand what symptoms or problems to report to his or her provider after leaving the hospital, the lack of understanding could lead to a complication, a worsening condition, or readmission.

“A specific survey question about written discharge instructions will give hospital administrators more actionable information concerning an increase in readmission rates than a response to a 10-point satisfaction scale,” Dr. Crofton explains.

Efforts to Improve

At medical institutions across the nation, hospitalists and their team members are making conscious efforts to improve the patient experience in light of the growing importance of surveys. Baylor Scott and White Health in Round Rock, Texas, offers a lecture series and provider coaching as part of its continuing education program. The training, says Trina E. Dorrah, MD, MPH, a BSWH hospitalist and physician director for quality improvement, encompasses such topics as:

• Dealing with difficult patient scenarios;
• Patient experience improvement tips;
• Tips to improve providers’ explanations; and
• Tips to improve patients’ understanding.

Dr. Dorrah uses one-on-one shadowing to help providers improve the patient experience.

“I accompany the provider when visiting the patient and observe his or her interactions,” she says. “This enables me to help providers to see what skills they can incorporate to positively impact patient experience.”

Interdisciplinary rounds have also helped to improve the patient experience.

“Patients want to know that their entire healthcare team is focused on them and that they are working together to improve their experience,” Dr. Dorrah says. On weekdays, hospitalists lead interdisciplinary rounds with the rest of the care team, including case management, nursing, and therapy. “We discuss our patients and ensure that we are all on the same page regarding the plan.”

In addition, hospitalists round with nurses each morning. “Everyone benefits,” Dr. Dorrah says. “The patient gets more coordinated care and the nurse is better educated about the plan of care for the day. The number of pages from the nurse to the physician is also reduced because the nurse better understands the care plan.”

BSWH, which uses Press Ganey Associates to administer HCAHPS surveys, considers the scores for the doctor communication domain when establishing a hospitalist team goal for the year.

“If our team reaches the goal, the leadership/administrative team rewards the hospitalist team with a financial bonus,” Dr. Dorrah says.

Lawrence General Hospital, in Lawrence, Mass., which also uses Press Ganey Associates to administer and manage its HCAHPS satisfaction surveys, is working to increase the ability of hospitalists and other caregivers to proactively meet and exceed patients’ needs with its Five-to-Thrive program. The program consists of these five strategies:

• Care-Out-Loud: an initiative that charges every clinical and nonclinical staff member to be present, sensitive, and compassionate to the patient and explain each step of the clinical interaction;
• Manager rounding on staff and patients;
• Hourly staff rounding on patients;
• Interdisciplinary bedside rounding; and
• Senior leader rounding.

“It is based on best practice tactics that aim to improve the overall patient and family experience,” says Damaris Valera, MS, CMPE, director of the hospital’s Service Excellence Program.

Cogent Healthcare at University of Florida Health in Jacksonville, Fla., places a large emphasis on AIDET principles—acknowledge, introduce, duration, explanation, and thank you—during each patient encounter, says Larry Sharp, MD, SFHM, system medical director. AIDET principles entail offering a pleasant greeting and introducing yourself to patients, keeping patients abreast of wait times, explaining procedures, and thanking patients for the opportunity to participate in their care.

The medical director makes shadow rounds with providers and then ghost rounds by surveying the patients after rounds to get the patients’ direct feedback about encounters.

“We provide information to our providers from these rounds as a method to improve care,” Dr. Sharp says.

Northwestern University Feinberg School of Medicine in Chicago trains hospitalists on communication skills and consequently saw a trend toward improved satisfaction scores and used physician face cards to improve patients’ knowledge of the names and roles of physicians, which did not impact patient satisfaction, reports Kevin J. O’Leary, MD, MS, SFHM, associate professor of medicine, chief of the division of hospital medicine, and associate chair for quality in the department of medicine at Northwestern.^3,4 Findings were published in the Journal of Hospital Medicine.

“These efforts have reinforced the need for multifaceted interventions,” Dr. O’Leary says. “Alone, each one has had little effect, but combined they may have a greater effect. The data is intended to be formative and to identify opportunities to learn.”

Additional improvements have been made due to a better understanding of drivers of low satisfaction.

“Unit medical directors [hospitalists] have started to visit patients to get a qualitative sense of what things affect patient experience,” Dr. O’Leary says. As a result, two previously unidentified issues—ED personnel making promises that can’t be kept to patients and patients receiving conflicting information from specialist consultants and hospitalists—surfaced which could now be addressed.”

Challenges and Limitations

Despite their best efforts to improve the patient experience, hospitalists face myriad obstacles. First, the HCAHPS survey asks about the collective care delivered by doctors during the hospitalization, as opposed to the care given by one particular hospitalist.

“One challenge hospitalists face by not having individual data is not knowing which hospitalists excel at the patient experience and which ones do not,” Dr. Dorrah says. “When no one feels that he or she is the problem, it is difficult to hold individual hospitalists accountable.”

One challenge hospitalists face by not having individual data is not knowing which hospitalists excel at the patient experience and which ones do not. When no one feels that he or she is the problem, it is difficult to hold individual hospitalists accountable.” —Dr. Dorrah

Another problem, Dr. Dorrah reports, stems from the fact that patients may see more than one physician—perhaps several hospitalists or specialists—during their hospitalization. When the HCAHPS survey asks patients to assess the care given by all physicians, patients consider the care given by multiple different physicians.

“Therefore, it is difficult to hold a particular hospitalist accountable for the physician communication domain when he or she is not the only provider influencing patients’ perceptions.”

Some hospital systems still have chosen to attribute HCAHPS doctor communication scores to individual hospitalists. These health systems address the issue by attributing the survey results to the admitting physician, the discharging physician, or all hospitalists who participated in the patient’s care.

“None of these methods are perfect, but health systems are increasingly wanting to ensure their inpatient providers are as invested in the patient experience as their outpatient physicians,” Dr. Dorrah says.

Another obstacle hospitalist groups face is the fact that more attention is given to raising HCAHPS survey scores than to improving the overall patient experience.

“In an effort to raise survey scores, hospitals often lose sight of what truly matters to patients,” Dr. Dorrah says. “Many things contribute to a positive or negative patient experience that are not necessarily measured by the survey. If you only pay attention to the survey, your hospital may overlook things that truly matter to your patients.”

Finally, with the increasing focus on the patient experience, the focus on maintaining a good provider experience can fall short.

“While it’s tempting to ask hospitalists to do more—see more patients, take on more responsibility, and participate in more committees—if hospitals fail to provide a positive environment for their hospitalists, they will have a difficult time fully engaging their hospitalists with the patient experience,” Dr. Dorrah says.

Some situations are out of the hospitalists’ hands. A patient may get upset or angry, and the cause is outside of anyone’s control.

“They may have to spend a night in the emergency department or have an unfavorable outcome,” Dr. Hunter says. “In those instances, employ the art of personal interaction—try to empathize with patients and let them know that you care about them.”

Another limitation, Dr. Sharp says, is that you can’t specifically script encounters to “teach to the test,” by using verbiage with the patient that is verbatim from the satisfaction survey questions.

“Nor can we directly control the temperature in patients’ rooms or the quality of their food,” he says. “We also do not have direct control over a negative experience in the emergency department before patients are referred to us, and many surveys show that it is very difficult to overcome a bad experience.”

Tools at Your Fingertips

As a result of the growing emphasis on patient-centered care, SHM created a Patient Experience Committee this year. SHM defines patient experience as “everything we say and do that affects our patients’ thoughts, feelings, and well-being.” The committee is looking at the issues at hand and defining the patient experience and what makes it good.

“We are looking at success stories, as well as not so successful stories, from some of our members to identify what seems to work and what doesn’t work,” says Dr. Sharp, a member of the committee. “By identifying best practices, we can then share this knowledge with the rest of the society, along with methods to implement these practices. We can centralize the gathered knowledge and data and then analyze and make it available to SHM members for their implementation and use.”

The hospitalist plays a key role in the patient experience. Now, more than ever, it’s important to do what you can to make it positive. Consider initiatives you might want to participate in—and perhaps even start your own.

Karen Appold is a medical writer in Pennsylvania.

References

1. Consumer Assessment of Healthcare Providers & Systems (CAHPS). CMS.gov. Accessed August 2, 2015.
2. Survey of patients’ experiences (HCAHPS). Medicare.gov/Hospital Compare. Accessed August 2, 2015.
3. O’Leary KJ, Darling TA, Rauworth J, Williams MV. Impact of hospitalist communication-skills training on patient-satisfaction scores. J Hosp Med. 2013;8(6):315-320.
4. Simons Y, Caprio T, Furiasse N, Kriss M, Williams MV, O’Leary KJ. The impact of facecards on patients’ knowledge, satisfaction, trust, and agreement with hospital physicians: a pilot study. J Hosp Med. 2014;9(3):137-141.

Hospitalists are often perceived as the face of the hospital, whether that is their official responsibility or not. They are on the front lines of hearing, seeing, and understanding where gaps exist in a patient’s experience.

“Whenever I hear a patient complain, I can almost piece together what happened without having to interview other staff,” says Jairy C. Hunter III, MD, MBA, SFHM, associate CMO for care transitions at the Medical University of South Carolina in Charleston.

“Up to this point, there hasn’t been as much accountability regarding customer satisfaction in our industry compared to other industries,” Dr. Hunter says.

The paradigm shift has occurred because payers are demanding it. They want value and satisfaction in what they are paying for. In fact, there is a movement to try to standardize procedures whenever possible, such as the amount of time it takes someone to answer a call bell or the volume of noise in a hallway.

“Patients are being asked questions about such topics in surveys,” Dr. Hunter says. “Although these types of questions don’t involve medical decision-making or a course of treatment, they do include personal interactions that influence how patients feel about their hospital experience.”

Another reason for the shift is the significant increase in the use of electronic communication devices and the explosion of online ratings of consumer products and services. Naturally, consumers want access to accurate and easy-to-use information about the quality of healthcare services.

Patient experience surveys focus on how patients’ experienced or perceived key aspects of their care, not how satisfied they were with their care.¹ One way a hospital can measure patient experience is with the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey, which was developed by the Centers for Medicare and Medicaid Services (CMS) and the Agency for Healthcare Research and Quality (AHRQ).² Although other patient satisfaction/experience vendors offer surveys, the Deficit Reduction Act of 2005 states that all Inpatient Prospective Payment Systems (IPPS) hospitals who wish to receive their full annual payment update must collect and submit HCAHPS data to CMS.

The HCAHPS survey, which employs standardized survey instrument and data collection methodology to measure patients’ perspectives on hospital care, is administered to a random sample of patients throughout the year. CMS cleans, adjusts, and analyzes the data and then publicly reports the results. All CAHPS products are available at no cost at www.cahps.ahrq.gov.²

Christine Crofton, PhD, director of CAHPS in Rockville, Md., notes that the HCAHPS survey focuses on patient experience measures because they are considered more understandable, unambiguous, actionable, and objective compared to general satisfaction ratings. Although CAHPS surveys do ask respondents to provide overall ratings (e.g. rate the physician on a scale of one to 10), their primary focus is to ask patients to report on their experiences with specific aspects of care in order to provide information that is not biased by different expectations.

For example, if a patient doesn’t understand what symptoms or problems to report to his or her provider after leaving the hospital, the lack of understanding could lead to a complication, a worsening condition, or readmission.

“A specific survey question about written discharge instructions will give hospital administrators more actionable information concerning an increase in readmission rates than a response to a 10-point satisfaction scale,” Dr. Crofton explains.

Efforts to Improve

At medical institutions across the nation, hospitalists and their team members are making conscious efforts to improve the patient experience in light of the growing importance of surveys. Baylor Scott and White Health in Round Rock, Texas, offers a lecture series and provider coaching as part of its continuing education program. The training, says Trina E. Dorrah, MD, MPH, a BSWH hospitalist and physician director for quality improvement, encompasses such topics as:

• Dealing with difficult patient scenarios;
• Patient experience improvement tips;
• Tips to improve providers’ explanations; and
• Tips to improve patients’ understanding.

Dr. Dorrah uses one-on-one shadowing to help providers improve the patient experience.

“I accompany the provider when visiting the patient and observe his or her interactions,” she says. “This enables me to help providers to see what skills they can incorporate to positively impact patient experience.”

Interdisciplinary rounds have also helped to improve the patient experience.

“Patients want to know that their entire healthcare team is focused on them and that they are working together to improve their experience,” Dr. Dorrah says. On weekdays, hospitalists lead interdisciplinary rounds with the rest of the care team, including case management, nursing, and therapy. “We discuss our patients and ensure that we are all on the same page regarding the plan.”

In addition, hospitalists round with nurses each morning. “Everyone benefits,” Dr. Dorrah says. “The patient gets more coordinated care and the nurse is better educated about the plan of care for the day. The number of pages from the nurse to the physician is also reduced because the nurse better understands the care plan.”

BSWH, which uses Press Ganey Associates to administer HCAHPS surveys, considers the scores for the doctor communication domain when establishing a hospitalist team goal for the year.

“If our team reaches the goal, the leadership/administrative team rewards the hospitalist team with a financial bonus,” Dr. Dorrah says.

Lawrence General Hospital, in Lawrence, Mass., which also uses Press Ganey Associates to administer and manage its HCAHPS satisfaction surveys, is working to increase the ability of hospitalists and other caregivers to proactively meet and exceed patients’ needs with its Five-to-Thrive program. The program consists of these five strategies:

• Care-Out-Loud: an initiative that charges every clinical and nonclinical staff member to be present, sensitive, and compassionate to the patient and explain each step of the clinical interaction;
• Manager rounding on staff and patients;
• Hourly staff rounding on patients;
• Interdisciplinary bedside rounding; and
• Senior leader rounding.

“It is based on best practice tactics that aim to improve the overall patient and family experience,” says Damaris Valera, MS, CMPE, director of the hospital’s Service Excellence Program.

Cogent Healthcare at University of Florida Health in Jacksonville, Fla., places a large emphasis on AIDET principles—acknowledge, introduce, duration, explanation, and thank you—during each patient encounter, says Larry Sharp, MD, SFHM, system medical director. AIDET principles entail offering a pleasant greeting and introducing yourself to patients, keeping patients abreast of wait times, explaining procedures, and thanking patients for the opportunity to participate in their care.

The medical director makes shadow rounds with providers and then ghost rounds by surveying the patients after rounds to get the patients’ direct feedback about encounters.

“We provide information to our providers from these rounds as a method to improve care,” Dr. Sharp says.

Northwestern University Feinberg School of Medicine in Chicago trains hospitalists on communication skills and consequently saw a trend toward improved satisfaction scores and used physician face cards to improve patients’ knowledge of the names and roles of physicians, which did not impact patient satisfaction, reports Kevin J. O’Leary, MD, MS, SFHM, associate professor of medicine, chief of the division of hospital medicine, and associate chair for quality in the department of medicine at Northwestern.^3,4 Findings were published in the Journal of Hospital Medicine.

“These efforts have reinforced the need for multifaceted interventions,” Dr. O’Leary says. “Alone, each one has had little effect, but combined they may have a greater effect. The data is intended to be formative and to identify opportunities to learn.”

Additional improvements have been made due to a better understanding of drivers of low satisfaction.

“Unit medical directors [hospitalists] have started to visit patients to get a qualitative sense of what things affect patient experience,” Dr. O’Leary says. As a result, two previously unidentified issues—ED personnel making promises that can’t be kept to patients and patients receiving conflicting information from specialist consultants and hospitalists—surfaced which could now be addressed.”

Challenges and Limitations

Despite their best efforts to improve the patient experience, hospitalists face myriad obstacles. First, the HCAHPS survey asks about the collective care delivered by doctors during the hospitalization, as opposed to the care given by one particular hospitalist.

“One challenge hospitalists face by not having individual data is not knowing which hospitalists excel at the patient experience and which ones do not,” Dr. Dorrah says. “When no one feels that he or she is the problem, it is difficult to hold individual hospitalists accountable.”

One challenge hospitalists face by not having individual data is not knowing which hospitalists excel at the patient experience and which ones do not. When no one feels that he or she is the problem, it is difficult to hold individual hospitalists accountable.” —Dr. Dorrah

Another problem, Dr. Dorrah reports, stems from the fact that patients may see more than one physician—perhaps several hospitalists or specialists—during their hospitalization. When the HCAHPS survey asks patients to assess the care given by all physicians, patients consider the care given by multiple different physicians.

“Therefore, it is difficult to hold a particular hospitalist accountable for the physician communication domain when he or she is not the only provider influencing patients’ perceptions.”

Some hospital systems still have chosen to attribute HCAHPS doctor communication scores to individual hospitalists. These health systems address the issue by attributing the survey results to the admitting physician, the discharging physician, or all hospitalists who participated in the patient’s care.

“None of these methods are perfect, but health systems are increasingly wanting to ensure their inpatient providers are as invested in the patient experience as their outpatient physicians,” Dr. Dorrah says.

Another obstacle hospitalist groups face is the fact that more attention is given to raising HCAHPS survey scores than to improving the overall patient experience.

“In an effort to raise survey scores, hospitals often lose sight of what truly matters to patients,” Dr. Dorrah says. “Many things contribute to a positive or negative patient experience that are not necessarily measured by the survey. If you only pay attention to the survey, your hospital may overlook things that truly matter to your patients.”

Finally, with the increasing focus on the patient experience, the focus on maintaining a good provider experience can fall short.

“While it’s tempting to ask hospitalists to do more—see more patients, take on more responsibility, and participate in more committees—if hospitals fail to provide a positive environment for their hospitalists, they will have a difficult time fully engaging their hospitalists with the patient experience,” Dr. Dorrah says.

Some situations are out of the hospitalists’ hands. A patient may get upset or angry, and the cause is outside of anyone’s control.

“They may have to spend a night in the emergency department or have an unfavorable outcome,” Dr. Hunter says. “In those instances, employ the art of personal interaction—try to empathize with patients and let them know that you care about them.”

Another limitation, Dr. Sharp says, is that you can’t specifically script encounters to “teach to the test,” by using verbiage with the patient that is verbatim from the satisfaction survey questions.

“Nor can we directly control the temperature in patients’ rooms or the quality of their food,” he says. “We also do not have direct control over a negative experience in the emergency department before patients are referred to us, and many surveys show that it is very difficult to overcome a bad experience.”

Tools at Your Fingertips

As a result of the growing emphasis on patient-centered care, SHM created a Patient Experience Committee this year. SHM defines patient experience as “everything we say and do that affects our patients’ thoughts, feelings, and well-being.” The committee is looking at the issues at hand and defining the patient experience and what makes it good.

“We are looking at success stories, as well as not so successful stories, from some of our members to identify what seems to work and what doesn’t work,” says Dr. Sharp, a member of the committee. “By identifying best practices, we can then share this knowledge with the rest of the society, along with methods to implement these practices. We can centralize the gathered knowledge and data and then analyze and make it available to SHM members for their implementation and use.”

The hospitalist plays a key role in the patient experience. Now, more than ever, it’s important to do what you can to make it positive. Consider initiatives you might want to participate in—and perhaps even start your own.

Karen Appold is a medical writer in Pennsylvania.

References

1. Consumer Assessment of Healthcare Providers & Systems (CAHPS). CMS.gov. Accessed August 2, 2015.
2. Survey of patients’ experiences (HCAHPS). Medicare.gov/Hospital Compare. Accessed August 2, 2015.
3. O’Leary KJ, Darling TA, Rauworth J, Williams MV. Impact of hospitalist communication-skills training on patient-satisfaction scores. J Hosp Med. 2013;8(6):315-320.
4. Simons Y, Caprio T, Furiasse N, Kriss M, Williams MV, O’Leary KJ. The impact of facecards on patients’ knowledge, satisfaction, trust, and agreement with hospital physicians: a pilot study. J Hosp Med. 2014;9(3):137-141.

Hospitalists are often perceived as the face of the hospital, whether that is their official responsibility or not. They are on the front lines of hearing, seeing, and understanding where gaps exist in a patient’s experience.

“Whenever I hear a patient complain, I can almost piece together what happened without having to interview other staff,” says Jairy C. Hunter III, MD, MBA, SFHM, associate CMO for care transitions at the Medical University of South Carolina in Charleston.

“Up to this point, there hasn’t been as much accountability regarding customer satisfaction in our industry compared to other industries,” Dr. Hunter says.

The paradigm shift has occurred because payers are demanding it. They want value and satisfaction in what they are paying for. In fact, there is a movement to try to standardize procedures whenever possible, such as the amount of time it takes someone to answer a call bell or the volume of noise in a hallway.

“Patients are being asked questions about such topics in surveys,” Dr. Hunter says. “Although these types of questions don’t involve medical decision-making or a course of treatment, they do include personal interactions that influence how patients feel about their hospital experience.”

Another reason for the shift is the significant increase in the use of electronic communication devices and the explosion of online ratings of consumer products and services. Naturally, consumers want access to accurate and easy-to-use information about the quality of healthcare services.

Patient experience surveys focus on how patients’ experienced or perceived key aspects of their care, not how satisfied they were with their care.¹ One way a hospital can measure patient experience is with the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey, which was developed by the Centers for Medicare and Medicaid Services (CMS) and the Agency for Healthcare Research and Quality (AHRQ).² Although other patient satisfaction/experience vendors offer surveys, the Deficit Reduction Act of 2005 states that all Inpatient Prospective Payment Systems (IPPS) hospitals who wish to receive their full annual payment update must collect and submit HCAHPS data to CMS.

The HCAHPS survey, which employs standardized survey instrument and data collection methodology to measure patients’ perspectives on hospital care, is administered to a random sample of patients throughout the year. CMS cleans, adjusts, and analyzes the data and then publicly reports the results. All CAHPS products are available at no cost at www.cahps.ahrq.gov.²

Christine Crofton, PhD, director of CAHPS in Rockville, Md., notes that the HCAHPS survey focuses on patient experience measures because they are considered more understandable, unambiguous, actionable, and objective compared to general satisfaction ratings. Although CAHPS surveys do ask respondents to provide overall ratings (e.g. rate the physician on a scale of one to 10), their primary focus is to ask patients to report on their experiences with specific aspects of care in order to provide information that is not biased by different expectations.

For example, if a patient doesn’t understand what symptoms or problems to report to his or her provider after leaving the hospital, the lack of understanding could lead to a complication, a worsening condition, or readmission.

“A specific survey question about written discharge instructions will give hospital administrators more actionable information concerning an increase in readmission rates than a response to a 10-point satisfaction scale,” Dr. Crofton explains.

Efforts to Improve

At medical institutions across the nation, hospitalists and their team members are making conscious efforts to improve the patient experience in light of the growing importance of surveys. Baylor Scott and White Health in Round Rock, Texas, offers a lecture series and provider coaching as part of its continuing education program. The training, says Trina E. Dorrah, MD, MPH, a BSWH hospitalist and physician director for quality improvement, encompasses such topics as:

• Dealing with difficult patient scenarios;
• Patient experience improvement tips;
• Tips to improve providers’ explanations; and
• Tips to improve patients’ understanding.

Dr. Dorrah uses one-on-one shadowing to help providers improve the patient experience.

“I accompany the provider when visiting the patient and observe his or her interactions,” she says. “This enables me to help providers to see what skills they can incorporate to positively impact patient experience.”

Interdisciplinary rounds have also helped to improve the patient experience.

“Patients want to know that their entire healthcare team is focused on them and that they are working together to improve their experience,” Dr. Dorrah says. On weekdays, hospitalists lead interdisciplinary rounds with the rest of the care team, including case management, nursing, and therapy. “We discuss our patients and ensure that we are all on the same page regarding the plan.”

In addition, hospitalists round with nurses each morning. “Everyone benefits,” Dr. Dorrah says. “The patient gets more coordinated care and the nurse is better educated about the plan of care for the day. The number of pages from the nurse to the physician is also reduced because the nurse better understands the care plan.”

BSWH, which uses Press Ganey Associates to administer HCAHPS surveys, considers the scores for the doctor communication domain when establishing a hospitalist team goal for the year.

“If our team reaches the goal, the leadership/administrative team rewards the hospitalist team with a financial bonus,” Dr. Dorrah says.

Lawrence General Hospital, in Lawrence, Mass., which also uses Press Ganey Associates to administer and manage its HCAHPS satisfaction surveys, is working to increase the ability of hospitalists and other caregivers to proactively meet and exceed patients’ needs with its Five-to-Thrive program. The program consists of these five strategies:

• Care-Out-Loud: an initiative that charges every clinical and nonclinical staff member to be present, sensitive, and compassionate to the patient and explain each step of the clinical interaction;
• Manager rounding on staff and patients;
• Hourly staff rounding on patients;
• Interdisciplinary bedside rounding; and
• Senior leader rounding.

“It is based on best practice tactics that aim to improve the overall patient and family experience,” says Damaris Valera, MS, CMPE, director of the hospital’s Service Excellence Program.

Cogent Healthcare at University of Florida Health in Jacksonville, Fla., places a large emphasis on AIDET principles—acknowledge, introduce, duration, explanation, and thank you—during each patient encounter, says Larry Sharp, MD, SFHM, system medical director. AIDET principles entail offering a pleasant greeting and introducing yourself to patients, keeping patients abreast of wait times, explaining procedures, and thanking patients for the opportunity to participate in their care.

The medical director makes shadow rounds with providers and then ghost rounds by surveying the patients after rounds to get the patients’ direct feedback about encounters.

“We provide information to our providers from these rounds as a method to improve care,” Dr. Sharp says.

Northwestern University Feinberg School of Medicine in Chicago trains hospitalists on communication skills and consequently saw a trend toward improved satisfaction scores and used physician face cards to improve patients’ knowledge of the names and roles of physicians, which did not impact patient satisfaction, reports Kevin J. O’Leary, MD, MS, SFHM, associate professor of medicine, chief of the division of hospital medicine, and associate chair for quality in the department of medicine at Northwestern.^3,4 Findings were published in the Journal of Hospital Medicine.

“These efforts have reinforced the need for multifaceted interventions,” Dr. O’Leary says. “Alone, each one has had little effect, but combined they may have a greater effect. The data is intended to be formative and to identify opportunities to learn.”

Additional improvements have been made due to a better understanding of drivers of low satisfaction.

“Unit medical directors [hospitalists] have started to visit patients to get a qualitative sense of what things affect patient experience,” Dr. O’Leary says. As a result, two previously unidentified issues—ED personnel making promises that can’t be kept to patients and patients receiving conflicting information from specialist consultants and hospitalists—surfaced which could now be addressed.”

Challenges and Limitations

Despite their best efforts to improve the patient experience, hospitalists face myriad obstacles. First, the HCAHPS survey asks about the collective care delivered by doctors during the hospitalization, as opposed to the care given by one particular hospitalist.

“One challenge hospitalists face by not having individual data is not knowing which hospitalists excel at the patient experience and which ones do not,” Dr. Dorrah says. “When no one feels that he or she is the problem, it is difficult to hold individual hospitalists accountable.”

One challenge hospitalists face by not having individual data is not knowing which hospitalists excel at the patient experience and which ones do not. When no one feels that he or she is the problem, it is difficult to hold individual hospitalists accountable.” —Dr. Dorrah

Another problem, Dr. Dorrah reports, stems from the fact that patients may see more than one physician—perhaps several hospitalists or specialists—during their hospitalization. When the HCAHPS survey asks patients to assess the care given by all physicians, patients consider the care given by multiple different physicians.

“Therefore, it is difficult to hold a particular hospitalist accountable for the physician communication domain when he or she is not the only provider influencing patients’ perceptions.”

Some hospital systems still have chosen to attribute HCAHPS doctor communication scores to individual hospitalists. These health systems address the issue by attributing the survey results to the admitting physician, the discharging physician, or all hospitalists who participated in the patient’s care.

“None of these methods are perfect, but health systems are increasingly wanting to ensure their inpatient providers are as invested in the patient experience as their outpatient physicians,” Dr. Dorrah says.

Another obstacle hospitalist groups face is the fact that more attention is given to raising HCAHPS survey scores than to improving the overall patient experience.

“In an effort to raise survey scores, hospitals often lose sight of what truly matters to patients,” Dr. Dorrah says. “Many things contribute to a positive or negative patient experience that are not necessarily measured by the survey. If you only pay attention to the survey, your hospital may overlook things that truly matter to your patients.”

Finally, with the increasing focus on the patient experience, the focus on maintaining a good provider experience can fall short.

“While it’s tempting to ask hospitalists to do more—see more patients, take on more responsibility, and participate in more committees—if hospitals fail to provide a positive environment for their hospitalists, they will have a difficult time fully engaging their hospitalists with the patient experience,” Dr. Dorrah says.

Some situations are out of the hospitalists’ hands. A patient may get upset or angry, and the cause is outside of anyone’s control.

“They may have to spend a night in the emergency department or have an unfavorable outcome,” Dr. Hunter says. “In those instances, employ the art of personal interaction—try to empathize with patients and let them know that you care about them.”

Another limitation, Dr. Sharp says, is that you can’t specifically script encounters to “teach to the test,” by using verbiage with the patient that is verbatim from the satisfaction survey questions.

“Nor can we directly control the temperature in patients’ rooms or the quality of their food,” he says. “We also do not have direct control over a negative experience in the emergency department before patients are referred to us, and many surveys show that it is very difficult to overcome a bad experience.”

Tools at Your Fingertips

As a result of the growing emphasis on patient-centered care, SHM created a Patient Experience Committee this year. SHM defines patient experience as “everything we say and do that affects our patients’ thoughts, feelings, and well-being.” The committee is looking at the issues at hand and defining the patient experience and what makes it good.

“We are looking at success stories, as well as not so successful stories, from some of our members to identify what seems to work and what doesn’t work,” says Dr. Sharp, a member of the committee. “By identifying best practices, we can then share this knowledge with the rest of the society, along with methods to implement these practices. We can centralize the gathered knowledge and data and then analyze and make it available to SHM members for their implementation and use.”

The hospitalist plays a key role in the patient experience. Now, more than ever, it’s important to do what you can to make it positive. Consider initiatives you might want to participate in—and perhaps even start your own.

Karen Appold is a medical writer in Pennsylvania.

References

1. Consumer Assessment of Healthcare Providers & Systems (CAHPS). CMS.gov. Accessed August 2, 2015.
2. Survey of patients’ experiences (HCAHPS). Medicare.gov/Hospital Compare. Accessed August 2, 2015.
3. O’Leary KJ, Darling TA, Rauworth J, Williams MV. Impact of hospitalist communication-skills training on patient-satisfaction scores. J Hosp Med. 2013;8(6):315-320.
4. Simons Y, Caprio T, Furiasse N, Kriss M, Williams MV, O’Leary KJ. The impact of facecards on patients’ knowledge, satisfaction, trust, and agreement with hospital physicians: a pilot study. J Hosp Med. 2014;9(3):137-141.

There are two types of memory, the cognitive and the emotional, and the latter is more enduring. Maya Angelou characterized the distinction between these two types of memory most eloquently and succinctly when she said, “I’ve learned that people will forget what you said, people will forget what you did, but people will never forget how you made them feel.” She was ahead of her time, because neurocognitive research has objectified with science what Ms. Angelou captured so elegantly in her prose. Emotional events are processed in the sensory systems and then transmitted to the medial-temporal lobe and the amygdale for the formation of an emotional memory. When the memory is cued and retrieved from the amygdale, it triggers an emotional response. Emotional experiences leave strong traces in the brain. Memories about emotional situations are stored in both the conscious and unconscious memory, which is part of the reason emotional memories are so enduring.¹ Studies of patients with severe anterograde amnesia following circumscribed bilateral hippocampal brain damage showed enduring memories of emotion despite the absence of conscious memories.² This has a demonstrably practical application in patients with dementia, who we now know have feelings of happiness and sadness long after they have forgotten what caused the emotion.³

The distinction is important because patients judge the quality of their medical care based on emotions. The patient satisfaction disconnect arises from the fact that physicians live in their cognitive memory, while patients live in their emotional memory. Being cognitive and objective is a critical skill a physician must bring to the bedside every day; the reason we don’t allow physicians to treat family members is that their ability to remain objective will be impaired. I realized that my emotion, my passion, and my empathy for the dying would impair my judgment when I started medical school, and I launched myself on a conscious and systematic discipline to keep those feelings out of my mind during patient care. The effort worked and, for the most part, I have been able to remain objective and unemotional as I care for my patients. Recently, however, I realized that my focus on objectivity negatively impacts patient experience. As a result, I have expanded my view: While I must stay objective and detached with my thinking, I must be emotionally engaged to provide a great patient experience.

I can remain objective and detached in my clinical judgment as I engage and connect emotionally during my patient encounters. This delicate balancing act has taken years of trial and error, however. I recently cared for a woman in her 60s who had fallen and broke her hip. Everyone was pleased that a top orthopedic surgeon was on call and able to give her the first-rate care she needed to begin walking again. The surgery went smoothly, and she was transferred to the medical/surgical ward, where things took a turn for the worse. She had a lot of anxiety in addition to her osteoporosis. Objectively, she was doing great, and we had a big success on our hands; however, she remained anxious, and she peppered the surgeon with fears that, while unfounded, were very real in her mind. The surgeon brushed them off, saying that her fears were not real and that he didn’t need to address them; his response made her emotional state spiral out of control. Her nurse notified me of the situation, and I came to her bedside. She was very agitated. I sat down at a low level and just started listening. She got all of her anxieties out in words. I held her hand, looked her in the eye, and assured her that I would be there for her and that things were going to be alright. Subsequently, she wrote letters of gratitude and proclaimed to any medical staff who would listen what a talented and great doctor I was. I did not have the skill to fix her broken hip; if it had been left to me alone, she would still be bed-bound. But I did have the human skills to connect with her and fix her agitated mind. If we remember the enduring power of the emotional memory, we can create great patient experiences.

The importance of these experiences was illustrated to me at the 2014 Dignity Health Patient Experience Summit, a powerful event featuring motivational speakers and leaders from across the country. The most powerful speakers, however, were patients. These patients had received terrible diagnoses that committed them to a prolonged interaction with the healthcare system. They were scared of what their diagnoses would mean for their future, they were subjected to uncomfortable procedures in which they struggled to maintain their dignity, and they repeatedly met the indifference of healthcare providers and clerical people who were only there to do a job. They related how the lack of caring and empathy made fears and anxiety much worse. But each of them had a story about that one person, that one care provider, who took the time to reassure them, to show that they cared, and to ensure that the patient did not feel alone. In most of these stories, the stand-out care providers took the time to hold their hands and reassure the patients. They took the time to connect with the patient’s emotional memory in a positive way, and that simple gesture of empathy had a powerful and lasting impact on the patient.

Invariably, the care provider at the heart of the patients’ stories was a nurse. Nurses have the reputation for being angels of mercy because they do the simple, empathetic gestures that let a patient know they are being cared for. These feelings endure in the patients’ memories long after the treatment is over. Doctors can, and should, be that type of care provider. It requires us to recognize that patients are scared and anxious, even though they may do their best not to show it. We, as physicians, often don’t see their anxiety, and we are so focused on the cognitive memory that we don’t address the anxiety and fear that is just under the surface. But taking just a few minutes to acknowledge their emotions, to explore them, and to reassure the patient that we are there for them has a lasting impact. In my group, we talk about the “human-business-human” encounter with patients. We begin all interactions with a human interaction (“Hello, I am Dr. McIlraith…”), conduct the business we came to provide (“Now I am going to examine you…”), and end with a human interaction (“What else can I do for you today?”). Patients expect physical contact with us during the “business” part of that interaction. I find that respectful, reassuring, and appropriate physical contact during the final “human” portion of that interaction helps solidify my patients’ experience. It helps make them feel that they have been cared for, particularly if the visit includes bad news.

Much of the recent focus on patient satisfaction has been driven by financial incentives. In 2013, CMS began penalizing hospitals 1.25% for poor HCAHPS scores as a part of the Affordable Care Act. In 2014, the maximum penalty increased to 2%, and to 3% in 2015. Hospitals have notoriously high overhead costs and slim profit margins, so these penalties can have a profound impact on the financial viability of an institution. But, while hospitals across the country have taken notice (see related article in this edition of The Hospitalist), I find doctors are more motivated by the well-being of their patients than are their hospital administrators. Satisfied patients are more compliant with treatment plans and have better outcomes.^4,5 Hospitalists spend a lot of effort making sure their heart failure patients are on an ACE inhibitor, and their heart attack patients are discharged on aspirin, beta blockers, and statins so that they will have a good outcome following treatment for their acute illness. The same outcome-driven, evidence-based practice of medicine relates to patient satisfaction, however. Success in HCAHPS is as important as core measures when it comes to patient outcomes. And if I can’t convince you patient satisfaction is important because of the good it does for hospitals and patients, think about yourself for a minute. Satisfied patients are much less likely to sue their physicians.⁶ Practicing quality, evidence-based medicine will keep you out of peer review; however, satisfied patients will keep you out of the courtroom.

I frequently hear the comment that “we can do great on patient satisfaction, but then it gets busy, and patient satisfaction goes out the window.” My own experience contradicts this maxim, however. It is not how much time you spend with your patient but, rather, what you do with the time you have. One of the most powerful things we can do is listen. I used to make the mistake that I only wanted to hear the information I needed to figure out my patients’ problems so I could start treating them; however, I have come to learn that being heard is, in itself, therapy for my patients. It is often quoted that physicians interrupt their patients within 18 seconds of starting the interview.⁷ A lot of physicians dispense with attentive listening when they are under time pressure, when they should instead dispense with lengthy discourses on the patient treatment plan. It is important to educate our patients on their illness and treatment, I admit. I find a lot of hospitalists want to impart their knowledge and their treatment rationale to their patients; however, they frequently give patients and families much more information than they can hold in their cognitive memory. And time pressures are not the only anxieties hospitalists carry with them to the bedside. Our increasingly metric-driven profession means that we not only have to worry about morning discharges, interdisciplinary rounds, length of stay, and so on, but we also have to consider patient experience. It is not easy to hide all the stress we are under when we come to the bedside of a patient, but we have to. The easiest way to do that is to take a deep breath, sit next to the patient, ask an open-ended question, and then say nothing until the patient is done speaking. Active listening with good eye contact and encouragement to continue solidifies the patient’s experience of being heard. There are extreme cases when a patient is in a manic phase and won’t ever stop speaking; bend the rules a bit in those circumstances. However, the above rule works very effectively in the majority of physician-patient interactions. Being heard leaves an enduring emotional memory with our patients.

Hospital medicine often looks to other industries for inspiration on how we can improve. The airline industry is often held up as an example of how we can model patient safety, for instance, but these comparisons oversimplify the challenges we face. The same is true with patient satisfaction. In the business world, adages like “The customer is always right” are central to customer satisfaction, yet completely irrelevant to HM practice. Patients and families frequently have inappropriate and unrealistic expectations of their hospitalist physicians. We cannot, and should not, tell the patient addicted to narcotics that they can have as much IV Dilaudid as they would like. We cannot fix the patient with end-stage cancer, heart failure, or dementia. This is where we have to part ways with comparisons to principles that guide other industries if we are going to find a way forward with patient experience in hospital medicine. Because we have to set limits for patients, we often have to give our patients and families bad news, and because we have to tell them things they don’t like to hear, like “You can’t have any salt in your diet,” or “You must quit drinking alcohol,” we must develop our own principles on patient experience and satisfaction. Otherwise our options are either delivering inappropriate medical care or abandoning the pursuit of patient satisfaction all together. This is when we must remember that emotional memories are more enduring. We can’t always give our patients what they want, and we can’t always tell them what they want to hear, but we can always show them that we care. When we show our patients that we care in a palpable way, we leave them with the feeling that they have been cared for regardless of their condition, and the positive memory will endure despite the negative information we may have to convey. Maybe they won’t cut down on their salt or quit drinking alcohol, but they will never forget that their hospitalist physician cared.

And if they remember that the physician cared, it is much more likely that they will cut down on the salt or quit drinking alcohol when they go home. To paraphrase Maya Angelou, “I can’t always tell my patients what they want to hear, I can’t always tell them that their lifestyle is appropriate, but I can always show them that I care.”

Dr. McIlraith is chairman of the department of hospital medicine of Mercy Medical Group in Sacramento, Calif.

References

1. LeDoux JE. Emotional memory. Scholarpedia. Accessed August 2, 2015.
2. Feinstein JS, Duff MC, D Tranel D. Sustained experience of emotion after loss of memory in patients with amnesia. Proc Natl Acad Sci. 2010:107(17):7674-7679.
3. Guzmán-Vélez E, Feinstein JS, Tranel D. Feelings without memory in Alzheimer disease. Cogn Behav Neurol. 2014;27(3):117-129.
4. Institute of Medicine. Crossing the quality chasm: a new health system for the 21st century. March 2001. Accessed August 2, 2015.
5. Bertakis KD, Azari R. Patient-centered care is associated with decreased health care utilization. J Am Board Fam Med. 2011;24(3):229-239.
6. Stelfox HT, Gandhi TK, Orav EJ, Gustafson ML. The relation of patient statisfaction with complaints against physicians and malpractice lawsuits. Am J Med. 2005;118(10):1126-1133.
7. Beckman HB, Frankel RM. The effect of physician behavior on the collection of data. Ann Intern Med. 1984;101(5):692-696.

There are two types of memory, the cognitive and the emotional, and the latter is more enduring. Maya Angelou characterized the distinction between these two types of memory most eloquently and succinctly when she said, “I’ve learned that people will forget what you said, people will forget what you did, but people will never forget how you made them feel.” She was ahead of her time, because neurocognitive research has objectified with science what Ms. Angelou captured so elegantly in her prose. Emotional events are processed in the sensory systems and then transmitted to the medial-temporal lobe and the amygdale for the formation of an emotional memory. When the memory is cued and retrieved from the amygdale, it triggers an emotional response. Emotional experiences leave strong traces in the brain. Memories about emotional situations are stored in both the conscious and unconscious memory, which is part of the reason emotional memories are so enduring.¹ Studies of patients with severe anterograde amnesia following circumscribed bilateral hippocampal brain damage showed enduring memories of emotion despite the absence of conscious memories.² This has a demonstrably practical application in patients with dementia, who we now know have feelings of happiness and sadness long after they have forgotten what caused the emotion.³

The distinction is important because patients judge the quality of their medical care based on emotions. The patient satisfaction disconnect arises from the fact that physicians live in their cognitive memory, while patients live in their emotional memory. Being cognitive and objective is a critical skill a physician must bring to the bedside every day; the reason we don’t allow physicians to treat family members is that their ability to remain objective will be impaired. I realized that my emotion, my passion, and my empathy for the dying would impair my judgment when I started medical school, and I launched myself on a conscious and systematic discipline to keep those feelings out of my mind during patient care. The effort worked and, for the most part, I have been able to remain objective and unemotional as I care for my patients. Recently, however, I realized that my focus on objectivity negatively impacts patient experience. As a result, I have expanded my view: While I must stay objective and detached with my thinking, I must be emotionally engaged to provide a great patient experience.

I can remain objective and detached in my clinical judgment as I engage and connect emotionally during my patient encounters. This delicate balancing act has taken years of trial and error, however. I recently cared for a woman in her 60s who had fallen and broke her hip. Everyone was pleased that a top orthopedic surgeon was on call and able to give her the first-rate care she needed to begin walking again. The surgery went smoothly, and she was transferred to the medical/surgical ward, where things took a turn for the worse. She had a lot of anxiety in addition to her osteoporosis. Objectively, she was doing great, and we had a big success on our hands; however, she remained anxious, and she peppered the surgeon with fears that, while unfounded, were very real in her mind. The surgeon brushed them off, saying that her fears were not real and that he didn’t need to address them; his response made her emotional state spiral out of control. Her nurse notified me of the situation, and I came to her bedside. She was very agitated. I sat down at a low level and just started listening. She got all of her anxieties out in words. I held her hand, looked her in the eye, and assured her that I would be there for her and that things were going to be alright. Subsequently, she wrote letters of gratitude and proclaimed to any medical staff who would listen what a talented and great doctor I was. I did not have the skill to fix her broken hip; if it had been left to me alone, she would still be bed-bound. But I did have the human skills to connect with her and fix her agitated mind. If we remember the enduring power of the emotional memory, we can create great patient experiences.

The importance of these experiences was illustrated to me at the 2014 Dignity Health Patient Experience Summit, a powerful event featuring motivational speakers and leaders from across the country. The most powerful speakers, however, were patients. These patients had received terrible diagnoses that committed them to a prolonged interaction with the healthcare system. They were scared of what their diagnoses would mean for their future, they were subjected to uncomfortable procedures in which they struggled to maintain their dignity, and they repeatedly met the indifference of healthcare providers and clerical people who were only there to do a job. They related how the lack of caring and empathy made fears and anxiety much worse. But each of them had a story about that one person, that one care provider, who took the time to reassure them, to show that they cared, and to ensure that the patient did not feel alone. In most of these stories, the stand-out care providers took the time to hold their hands and reassure the patients. They took the time to connect with the patient’s emotional memory in a positive way, and that simple gesture of empathy had a powerful and lasting impact on the patient.

Invariably, the care provider at the heart of the patients’ stories was a nurse. Nurses have the reputation for being angels of mercy because they do the simple, empathetic gestures that let a patient know they are being cared for. These feelings endure in the patients’ memories long after the treatment is over. Doctors can, and should, be that type of care provider. It requires us to recognize that patients are scared and anxious, even though they may do their best not to show it. We, as physicians, often don’t see their anxiety, and we are so focused on the cognitive memory that we don’t address the anxiety and fear that is just under the surface. But taking just a few minutes to acknowledge their emotions, to explore them, and to reassure the patient that we are there for them has a lasting impact. In my group, we talk about the “human-business-human” encounter with patients. We begin all interactions with a human interaction (“Hello, I am Dr. McIlraith…”), conduct the business we came to provide (“Now I am going to examine you…”), and end with a human interaction (“What else can I do for you today?”). Patients expect physical contact with us during the “business” part of that interaction. I find that respectful, reassuring, and appropriate physical contact during the final “human” portion of that interaction helps solidify my patients’ experience. It helps make them feel that they have been cared for, particularly if the visit includes bad news.

Much of the recent focus on patient satisfaction has been driven by financial incentives. In 2013, CMS began penalizing hospitals 1.25% for poor HCAHPS scores as a part of the Affordable Care Act. In 2014, the maximum penalty increased to 2%, and to 3% in 2015. Hospitals have notoriously high overhead costs and slim profit margins, so these penalties can have a profound impact on the financial viability of an institution. But, while hospitals across the country have taken notice (see related article in this edition of The Hospitalist), I find doctors are more motivated by the well-being of their patients than are their hospital administrators. Satisfied patients are more compliant with treatment plans and have better outcomes.^4,5 Hospitalists spend a lot of effort making sure their heart failure patients are on an ACE inhibitor, and their heart attack patients are discharged on aspirin, beta blockers, and statins so that they will have a good outcome following treatment for their acute illness. The same outcome-driven, evidence-based practice of medicine relates to patient satisfaction, however. Success in HCAHPS is as important as core measures when it comes to patient outcomes. And if I can’t convince you patient satisfaction is important because of the good it does for hospitals and patients, think about yourself for a minute. Satisfied patients are much less likely to sue their physicians.⁶ Practicing quality, evidence-based medicine will keep you out of peer review; however, satisfied patients will keep you out of the courtroom.

I frequently hear the comment that “we can do great on patient satisfaction, but then it gets busy, and patient satisfaction goes out the window.” My own experience contradicts this maxim, however. It is not how much time you spend with your patient but, rather, what you do with the time you have. One of the most powerful things we can do is listen. I used to make the mistake that I only wanted to hear the information I needed to figure out my patients’ problems so I could start treating them; however, I have come to learn that being heard is, in itself, therapy for my patients. It is often quoted that physicians interrupt their patients within 18 seconds of starting the interview.⁷ A lot of physicians dispense with attentive listening when they are under time pressure, when they should instead dispense with lengthy discourses on the patient treatment plan. It is important to educate our patients on their illness and treatment, I admit. I find a lot of hospitalists want to impart their knowledge and their treatment rationale to their patients; however, they frequently give patients and families much more information than they can hold in their cognitive memory. And time pressures are not the only anxieties hospitalists carry with them to the bedside. Our increasingly metric-driven profession means that we not only have to worry about morning discharges, interdisciplinary rounds, length of stay, and so on, but we also have to consider patient experience. It is not easy to hide all the stress we are under when we come to the bedside of a patient, but we have to. The easiest way to do that is to take a deep breath, sit next to the patient, ask an open-ended question, and then say nothing until the patient is done speaking. Active listening with good eye contact and encouragement to continue solidifies the patient’s experience of being heard. There are extreme cases when a patient is in a manic phase and won’t ever stop speaking; bend the rules a bit in those circumstances. However, the above rule works very effectively in the majority of physician-patient interactions. Being heard leaves an enduring emotional memory with our patients.

Hospital medicine often looks to other industries for inspiration on how we can improve. The airline industry is often held up as an example of how we can model patient safety, for instance, but these comparisons oversimplify the challenges we face. The same is true with patient satisfaction. In the business world, adages like “The customer is always right” are central to customer satisfaction, yet completely irrelevant to HM practice. Patients and families frequently have inappropriate and unrealistic expectations of their hospitalist physicians. We cannot, and should not, tell the patient addicted to narcotics that they can have as much IV Dilaudid as they would like. We cannot fix the patient with end-stage cancer, heart failure, or dementia. This is where we have to part ways with comparisons to principles that guide other industries if we are going to find a way forward with patient experience in hospital medicine. Because we have to set limits for patients, we often have to give our patients and families bad news, and because we have to tell them things they don’t like to hear, like “You can’t have any salt in your diet,” or “You must quit drinking alcohol,” we must develop our own principles on patient experience and satisfaction. Otherwise our options are either delivering inappropriate medical care or abandoning the pursuit of patient satisfaction all together. This is when we must remember that emotional memories are more enduring. We can’t always give our patients what they want, and we can’t always tell them what they want to hear, but we can always show them that we care. When we show our patients that we care in a palpable way, we leave them with the feeling that they have been cared for regardless of their condition, and the positive memory will endure despite the negative information we may have to convey. Maybe they won’t cut down on their salt or quit drinking alcohol, but they will never forget that their hospitalist physician cared.

And if they remember that the physician cared, it is much more likely that they will cut down on the salt or quit drinking alcohol when they go home. To paraphrase Maya Angelou, “I can’t always tell my patients what they want to hear, I can’t always tell them that their lifestyle is appropriate, but I can always show them that I care.”

Dr. McIlraith is chairman of the department of hospital medicine of Mercy Medical Group in Sacramento, Calif.

References

1. LeDoux JE. Emotional memory. Scholarpedia. Accessed August 2, 2015.
2. Feinstein JS, Duff MC, D Tranel D. Sustained experience of emotion after loss of memory in patients with amnesia. Proc Natl Acad Sci. 2010:107(17):7674-7679.
3. Guzmán-Vélez E, Feinstein JS, Tranel D. Feelings without memory in Alzheimer disease. Cogn Behav Neurol. 2014;27(3):117-129.
4. Institute of Medicine. Crossing the quality chasm: a new health system for the 21st century. March 2001. Accessed August 2, 2015.
5. Bertakis KD, Azari R. Patient-centered care is associated with decreased health care utilization. J Am Board Fam Med. 2011;24(3):229-239.
6. Stelfox HT, Gandhi TK, Orav EJ, Gustafson ML. The relation of patient statisfaction with complaints against physicians and malpractice lawsuits. Am J Med. 2005;118(10):1126-1133.
7. Beckman HB, Frankel RM. The effect of physician behavior on the collection of data. Ann Intern Med. 1984;101(5):692-696.

There are two types of memory, the cognitive and the emotional, and the latter is more enduring. Maya Angelou characterized the distinction between these two types of memory most eloquently and succinctly when she said, “I’ve learned that people will forget what you said, people will forget what you did, but people will never forget how you made them feel.” She was ahead of her time, because neurocognitive research has objectified with science what Ms. Angelou captured so elegantly in her prose. Emotional events are processed in the sensory systems and then transmitted to the medial-temporal lobe and the amygdale for the formation of an emotional memory. When the memory is cued and retrieved from the amygdale, it triggers an emotional response. Emotional experiences leave strong traces in the brain. Memories about emotional situations are stored in both the conscious and unconscious memory, which is part of the reason emotional memories are so enduring.¹ Studies of patients with severe anterograde amnesia following circumscribed bilateral hippocampal brain damage showed enduring memories of emotion despite the absence of conscious memories.² This has a demonstrably practical application in patients with dementia, who we now know have feelings of happiness and sadness long after they have forgotten what caused the emotion.³

The distinction is important because patients judge the quality of their medical care based on emotions. The patient satisfaction disconnect arises from the fact that physicians live in their cognitive memory, while patients live in their emotional memory. Being cognitive and objective is a critical skill a physician must bring to the bedside every day; the reason we don’t allow physicians to treat family members is that their ability to remain objective will be impaired. I realized that my emotion, my passion, and my empathy for the dying would impair my judgment when I started medical school, and I launched myself on a conscious and systematic discipline to keep those feelings out of my mind during patient care. The effort worked and, for the most part, I have been able to remain objective and unemotional as I care for my patients. Recently, however, I realized that my focus on objectivity negatively impacts patient experience. As a result, I have expanded my view: While I must stay objective and detached with my thinking, I must be emotionally engaged to provide a great patient experience.

I can remain objective and detached in my clinical judgment as I engage and connect emotionally during my patient encounters. This delicate balancing act has taken years of trial and error, however. I recently cared for a woman in her 60s who had fallen and broke her hip. Everyone was pleased that a top orthopedic surgeon was on call and able to give her the first-rate care she needed to begin walking again. The surgery went smoothly, and she was transferred to the medical/surgical ward, where things took a turn for the worse. She had a lot of anxiety in addition to her osteoporosis. Objectively, she was doing great, and we had a big success on our hands; however, she remained anxious, and she peppered the surgeon with fears that, while unfounded, were very real in her mind. The surgeon brushed them off, saying that her fears were not real and that he didn’t need to address them; his response made her emotional state spiral out of control. Her nurse notified me of the situation, and I came to her bedside. She was very agitated. I sat down at a low level and just started listening. She got all of her anxieties out in words. I held her hand, looked her in the eye, and assured her that I would be there for her and that things were going to be alright. Subsequently, she wrote letters of gratitude and proclaimed to any medical staff who would listen what a talented and great doctor I was. I did not have the skill to fix her broken hip; if it had been left to me alone, she would still be bed-bound. But I did have the human skills to connect with her and fix her agitated mind. If we remember the enduring power of the emotional memory, we can create great patient experiences.

The importance of these experiences was illustrated to me at the 2014 Dignity Health Patient Experience Summit, a powerful event featuring motivational speakers and leaders from across the country. The most powerful speakers, however, were patients. These patients had received terrible diagnoses that committed them to a prolonged interaction with the healthcare system. They were scared of what their diagnoses would mean for their future, they were subjected to uncomfortable procedures in which they struggled to maintain their dignity, and they repeatedly met the indifference of healthcare providers and clerical people who were only there to do a job. They related how the lack of caring and empathy made fears and anxiety much worse. But each of them had a story about that one person, that one care provider, who took the time to reassure them, to show that they cared, and to ensure that the patient did not feel alone. In most of these stories, the stand-out care providers took the time to hold their hands and reassure the patients. They took the time to connect with the patient’s emotional memory in a positive way, and that simple gesture of empathy had a powerful and lasting impact on the patient.

Invariably, the care provider at the heart of the patients’ stories was a nurse. Nurses have the reputation for being angels of mercy because they do the simple, empathetic gestures that let a patient know they are being cared for. These feelings endure in the patients’ memories long after the treatment is over. Doctors can, and should, be that type of care provider. It requires us to recognize that patients are scared and anxious, even though they may do their best not to show it. We, as physicians, often don’t see their anxiety, and we are so focused on the cognitive memory that we don’t address the anxiety and fear that is just under the surface. But taking just a few minutes to acknowledge their emotions, to explore them, and to reassure the patient that we are there for them has a lasting impact. In my group, we talk about the “human-business-human” encounter with patients. We begin all interactions with a human interaction (“Hello, I am Dr. McIlraith…”), conduct the business we came to provide (“Now I am going to examine you…”), and end with a human interaction (“What else can I do for you today?”). Patients expect physical contact with us during the “business” part of that interaction. I find that respectful, reassuring, and appropriate physical contact during the final “human” portion of that interaction helps solidify my patients’ experience. It helps make them feel that they have been cared for, particularly if the visit includes bad news.

Much of the recent focus on patient satisfaction has been driven by financial incentives. In 2013, CMS began penalizing hospitals 1.25% for poor HCAHPS scores as a part of the Affordable Care Act. In 2014, the maximum penalty increased to 2%, and to 3% in 2015. Hospitals have notoriously high overhead costs and slim profit margins, so these penalties can have a profound impact on the financial viability of an institution. But, while hospitals across the country have taken notice (see related article in this edition of The Hospitalist), I find doctors are more motivated by the well-being of their patients than are their hospital administrators. Satisfied patients are more compliant with treatment plans and have better outcomes.^4,5 Hospitalists spend a lot of effort making sure their heart failure patients are on an ACE inhibitor, and their heart attack patients are discharged on aspirin, beta blockers, and statins so that they will have a good outcome following treatment for their acute illness. The same outcome-driven, evidence-based practice of medicine relates to patient satisfaction, however. Success in HCAHPS is as important as core measures when it comes to patient outcomes. And if I can’t convince you patient satisfaction is important because of the good it does for hospitals and patients, think about yourself for a minute. Satisfied patients are much less likely to sue their physicians.⁶ Practicing quality, evidence-based medicine will keep you out of peer review; however, satisfied patients will keep you out of the courtroom.

I frequently hear the comment that “we can do great on patient satisfaction, but then it gets busy, and patient satisfaction goes out the window.” My own experience contradicts this maxim, however. It is not how much time you spend with your patient but, rather, what you do with the time you have. One of the most powerful things we can do is listen. I used to make the mistake that I only wanted to hear the information I needed to figure out my patients’ problems so I could start treating them; however, I have come to learn that being heard is, in itself, therapy for my patients. It is often quoted that physicians interrupt their patients within 18 seconds of starting the interview.⁷ A lot of physicians dispense with attentive listening when they are under time pressure, when they should instead dispense with lengthy discourses on the patient treatment plan. It is important to educate our patients on their illness and treatment, I admit. I find a lot of hospitalists want to impart their knowledge and their treatment rationale to their patients; however, they frequently give patients and families much more information than they can hold in their cognitive memory. And time pressures are not the only anxieties hospitalists carry with them to the bedside. Our increasingly metric-driven profession means that we not only have to worry about morning discharges, interdisciplinary rounds, length of stay, and so on, but we also have to consider patient experience. It is not easy to hide all the stress we are under when we come to the bedside of a patient, but we have to. The easiest way to do that is to take a deep breath, sit next to the patient, ask an open-ended question, and then say nothing until the patient is done speaking. Active listening with good eye contact and encouragement to continue solidifies the patient’s experience of being heard. There are extreme cases when a patient is in a manic phase and won’t ever stop speaking; bend the rules a bit in those circumstances. However, the above rule works very effectively in the majority of physician-patient interactions. Being heard leaves an enduring emotional memory with our patients.

Hospital medicine often looks to other industries for inspiration on how we can improve. The airline industry is often held up as an example of how we can model patient safety, for instance, but these comparisons oversimplify the challenges we face. The same is true with patient satisfaction. In the business world, adages like “The customer is always right” are central to customer satisfaction, yet completely irrelevant to HM practice. Patients and families frequently have inappropriate and unrealistic expectations of their hospitalist physicians. We cannot, and should not, tell the patient addicted to narcotics that they can have as much IV Dilaudid as they would like. We cannot fix the patient with end-stage cancer, heart failure, or dementia. This is where we have to part ways with comparisons to principles that guide other industries if we are going to find a way forward with patient experience in hospital medicine. Because we have to set limits for patients, we often have to give our patients and families bad news, and because we have to tell them things they don’t like to hear, like “You can’t have any salt in your diet,” or “You must quit drinking alcohol,” we must develop our own principles on patient experience and satisfaction. Otherwise our options are either delivering inappropriate medical care or abandoning the pursuit of patient satisfaction all together. This is when we must remember that emotional memories are more enduring. We can’t always give our patients what they want, and we can’t always tell them what they want to hear, but we can always show them that we care. When we show our patients that we care in a palpable way, we leave them with the feeling that they have been cared for regardless of their condition, and the positive memory will endure despite the negative information we may have to convey. Maybe they won’t cut down on their salt or quit drinking alcohol, but they will never forget that their hospitalist physician cared.

And if they remember that the physician cared, it is much more likely that they will cut down on the salt or quit drinking alcohol when they go home. To paraphrase Maya Angelou, “I can’t always tell my patients what they want to hear, I can’t always tell them that their lifestyle is appropriate, but I can always show them that I care.”

Dr. McIlraith is chairman of the department of hospital medicine of Mercy Medical Group in Sacramento, Calif.

References

1. LeDoux JE. Emotional memory. Scholarpedia. Accessed August 2, 2015.
2. Feinstein JS, Duff MC, D Tranel D. Sustained experience of emotion after loss of memory in patients with amnesia. Proc Natl Acad Sci. 2010:107(17):7674-7679.
3. Guzmán-Vélez E, Feinstein JS, Tranel D. Feelings without memory in Alzheimer disease. Cogn Behav Neurol. 2014;27(3):117-129.
4. Institute of Medicine. Crossing the quality chasm: a new health system for the 21st century. March 2001. Accessed August 2, 2015.
5. Bertakis KD, Azari R. Patient-centered care is associated with decreased health care utilization. J Am Board Fam Med. 2011;24(3):229-239.
6. Stelfox HT, Gandhi TK, Orav EJ, Gustafson ML. The relation of patient statisfaction with complaints against physicians and malpractice lawsuits. Am J Med. 2005;118(10):1126-1133.
7. Beckman HB, Frankel RM. The effect of physician behavior on the collection of data. Ann Intern Med. 1984;101(5):692-696.

Using quotes to ensure that the results were only those that include the two words adjacent to one another, rather than separated, I entered the following phrases into my Google search engine:

• “hospitalist burnout” = 1,580 results
• “hospitalist morale” = 208 results
• “hospitalist well-being” = 0 results

I think the number of results suggests the level of interest in each topic and, if that is the case, clearly thinking about how hospitalists are doing in their careers is more commonly done through the paradigm of burnout than the other two terms. (Of course, there may be other terms that I didn’t consider.) In fact, there have been a handful of published studies of hospitalist burnout and job satisfaction.^1,2

Those studies generally have shown both reasonably high levels of job satisfaction and troubling levels of burnout.

But I’ve been thinking about hospitalist morale for a while. I think morale is reasonably distinct from both burnout and job satisfaction.

Causes of a National Decline in Hospitalist Morale

I think hospitalist morale has declined some over the past two or three years across the country. This observation is meaningful because it comes from my experience working with a lot of hospitalist groups coast to coast. But I’m the first to admit it is just anecdotal and is subject to my own biases.

I can think of several things contributing to a decline in morale.

EHR adoption. Near the top of the list is the adoption of EHRs in many hospitals, which typically leads doctors in other specialties to seek hospitalist assistance with EHR-related tasks (e.g. medicine reconciliation and order writing) even in cases where there is little or no clinical reason for hospitalist involvement. Lots of hospitalists complain about this. To be clear, in many hospitals the hospitalists are reasonably content with using the EHR, but they experience ongoing frustration and low morale resulting from nonclinical work other doctors pressure them to take over.

Observation status. Many hospitals began classifying a larger portion of patients as observation status over the last few years; at the same time, patients and families have become more aware of how much of a disadvantage this is. In many cases, it is the hospitalist who takes the brunt of patient and family frustration. This can get awfully stressful and frustrating, and I think it is a contributor to allegations of malpractice.

Budgetary stress. Ever since SHM began collecting survey data in the late 1990s, the financial support hospitals have been providing to hospitalists has increased dramatically. The most recent State of Hospital Medicine report, published in 2104, showed median support provided by hospitals of $156,063 per FTE hospitalist, per year. Some hospitals have begun to resist providing more support, and this translates into stress and lower morale for hospitalists. This is far from a universal issue, but it does lead to lower morale for hospitalists who face it.

Many other factors may be contributing to a national decline in morale, but I think these are some of the most important.

What Can Be Done?

Some hospitalist groups have great morale now and don’t need to do much of anything right now, but some groups should think about a deliberate strategy to improve it.

Sadly, there isn’t a prescription that is sure to work. But there are some things you can try.

Self-care. The field of palliative care has thought a lot about caring for caregivers, and hospitalist groups might want to adopt some of their practices. Search the Internet on “self-care” + “palliative care,” and you’ll find a lot of interesting things. The group I’m part of launched a deliberate program of professionally led and facilitated hospitalist self-care, with high hopes that included mindful meditation, among other things. As soon as we had designed our program, the Mayo Clinic published their favorable experience with a program that was very similar to what we had planned, and I thought we would see similar benefits.³

But, while all who attended the sessions thought they were valuable, attendance was so poor that we ended up cancelling the program. The hospitalists were interested in attending but were either on service and busy seeing patients, or were off and didn’t want to drive in to work solely for the purpose of reducing work stress.

I’m convinced a self-care program is valuable but very tricky to schedule effectively. Maybe others have come up with effective ways of overcoming this problem.

Social connections. Some hospitalist groups seem to have little social and personal connection to other physicians and hospital leaders. I think this results in lower hospitalist morale and tends to be self-reinforcing. If you’re in such a group, you and your hospitalist colleagues should deliberately seek better relationships with other doctors and hospital administrative leaders. Ensure that you visit with others at lunch, talk with them at committee meetings, ask about their vacation and personal activities, and pursue activities with them outside of work.

When these sorts of social connections are strong, work is far more satisfying and you’re much more likely to be treated as a peer by other doctors. I think this is really important and shouldn’t be overlooked if your group is suffering from low morale.

Adaptive work. Lastly, you might want to approach changes to your work and morale as “adaptive work,” rather than “technical work.” Space doesn’t permit a description of these, but it is worth reading about how they differ. Many groups will find value in reframing their approach to aspects of work they don’t like as adaptive work.

References

1. Hinami K, Whelan CT, Wolosin RJ, Miller JA, Wetterneck TB. Worklife and satisfaction of hospitalists: toward flourishing careers. J Gen Intern Med. 2012;27(1):28-36.
2. Hoff TH, Whitcomb WF, Williams K, Nelson JR, Cheesman RA. Characteristics and work experiences of hospitalists in the United States. Arch Intern Med. 2001;161(6):851-858.
3. West CP, Dyrbye LN, Rabatin JT, et al. Intervention to promote physician well-being, job satisfaction, and professionalism: a randomized clinical trial. JAMA Intern Med. 2014;174(4):527-533.

Using quotes to ensure that the results were only those that include the two words adjacent to one another, rather than separated, I entered the following phrases into my Google search engine:

• “hospitalist burnout” = 1,580 results
• “hospitalist morale” = 208 results
• “hospitalist well-being” = 0 results

I think the number of results suggests the level of interest in each topic and, if that is the case, clearly thinking about how hospitalists are doing in their careers is more commonly done through the paradigm of burnout than the other two terms. (Of course, there may be other terms that I didn’t consider.) In fact, there have been a handful of published studies of hospitalist burnout and job satisfaction.^1,2

Those studies generally have shown both reasonably high levels of job satisfaction and troubling levels of burnout.

But I’ve been thinking about hospitalist morale for a while. I think morale is reasonably distinct from both burnout and job satisfaction.

Causes of a National Decline in Hospitalist Morale

I think hospitalist morale has declined some over the past two or three years across the country. This observation is meaningful because it comes from my experience working with a lot of hospitalist groups coast to coast. But I’m the first to admit it is just anecdotal and is subject to my own biases.

I can think of several things contributing to a decline in morale.

EHR adoption. Near the top of the list is the adoption of EHRs in many hospitals, which typically leads doctors in other specialties to seek hospitalist assistance with EHR-related tasks (e.g. medicine reconciliation and order writing) even in cases where there is little or no clinical reason for hospitalist involvement. Lots of hospitalists complain about this. To be clear, in many hospitals the hospitalists are reasonably content with using the EHR, but they experience ongoing frustration and low morale resulting from nonclinical work other doctors pressure them to take over.

Observation status. Many hospitals began classifying a larger portion of patients as observation status over the last few years; at the same time, patients and families have become more aware of how much of a disadvantage this is. In many cases, it is the hospitalist who takes the brunt of patient and family frustration. This can get awfully stressful and frustrating, and I think it is a contributor to allegations of malpractice.

Budgetary stress. Ever since SHM began collecting survey data in the late 1990s, the financial support hospitals have been providing to hospitalists has increased dramatically. The most recent State of Hospital Medicine report, published in 2104, showed median support provided by hospitals of $156,063 per FTE hospitalist, per year. Some hospitals have begun to resist providing more support, and this translates into stress and lower morale for hospitalists. This is far from a universal issue, but it does lead to lower morale for hospitalists who face it.

Many other factors may be contributing to a national decline in morale, but I think these are some of the most important.

What Can Be Done?

Some hospitalist groups have great morale now and don’t need to do much of anything right now, but some groups should think about a deliberate strategy to improve it.

Sadly, there isn’t a prescription that is sure to work. But there are some things you can try.

Self-care. The field of palliative care has thought a lot about caring for caregivers, and hospitalist groups might want to adopt some of their practices. Search the Internet on “self-care” + “palliative care,” and you’ll find a lot of interesting things. The group I’m part of launched a deliberate program of professionally led and facilitated hospitalist self-care, with high hopes that included mindful meditation, among other things. As soon as we had designed our program, the Mayo Clinic published their favorable experience with a program that was very similar to what we had planned, and I thought we would see similar benefits.³

But, while all who attended the sessions thought they were valuable, attendance was so poor that we ended up cancelling the program. The hospitalists were interested in attending but were either on service and busy seeing patients, or were off and didn’t want to drive in to work solely for the purpose of reducing work stress.

I’m convinced a self-care program is valuable but very tricky to schedule effectively. Maybe others have come up with effective ways of overcoming this problem.

Social connections. Some hospitalist groups seem to have little social and personal connection to other physicians and hospital leaders. I think this results in lower hospitalist morale and tends to be self-reinforcing. If you’re in such a group, you and your hospitalist colleagues should deliberately seek better relationships with other doctors and hospital administrative leaders. Ensure that you visit with others at lunch, talk with them at committee meetings, ask about their vacation and personal activities, and pursue activities with them outside of work.

When these sorts of social connections are strong, work is far more satisfying and you’re much more likely to be treated as a peer by other doctors. I think this is really important and shouldn’t be overlooked if your group is suffering from low morale.

Adaptive work. Lastly, you might want to approach changes to your work and morale as “adaptive work,” rather than “technical work.” Space doesn’t permit a description of these, but it is worth reading about how they differ. Many groups will find value in reframing their approach to aspects of work they don’t like as adaptive work.

References

1. Hinami K, Whelan CT, Wolosin RJ, Miller JA, Wetterneck TB. Worklife and satisfaction of hospitalists: toward flourishing careers. J Gen Intern Med. 2012;27(1):28-36.
2. Hoff TH, Whitcomb WF, Williams K, Nelson JR, Cheesman RA. Characteristics and work experiences of hospitalists in the United States. Arch Intern Med. 2001;161(6):851-858.
3. West CP, Dyrbye LN, Rabatin JT, et al. Intervention to promote physician well-being, job satisfaction, and professionalism: a randomized clinical trial. JAMA Intern Med. 2014;174(4):527-533.

Using quotes to ensure that the results were only those that include the two words adjacent to one another, rather than separated, I entered the following phrases into my Google search engine:

• “hospitalist burnout” = 1,580 results
• “hospitalist morale” = 208 results
• “hospitalist well-being” = 0 results

I think the number of results suggests the level of interest in each topic and, if that is the case, clearly thinking about how hospitalists are doing in their careers is more commonly done through the paradigm of burnout than the other two terms. (Of course, there may be other terms that I didn’t consider.) In fact, there have been a handful of published studies of hospitalist burnout and job satisfaction.^1,2

Those studies generally have shown both reasonably high levels of job satisfaction and troubling levels of burnout.

But I’ve been thinking about hospitalist morale for a while. I think morale is reasonably distinct from both burnout and job satisfaction.

Causes of a National Decline in Hospitalist Morale

I think hospitalist morale has declined some over the past two or three years across the country. This observation is meaningful because it comes from my experience working with a lot of hospitalist groups coast to coast. But I’m the first to admit it is just anecdotal and is subject to my own biases.

I can think of several things contributing to a decline in morale.

EHR adoption. Near the top of the list is the adoption of EHRs in many hospitals, which typically leads doctors in other specialties to seek hospitalist assistance with EHR-related tasks (e.g. medicine reconciliation and order writing) even in cases where there is little or no clinical reason for hospitalist involvement. Lots of hospitalists complain about this. To be clear, in many hospitals the hospitalists are reasonably content with using the EHR, but they experience ongoing frustration and low morale resulting from nonclinical work other doctors pressure them to take over.

Observation status. Many hospitals began classifying a larger portion of patients as observation status over the last few years; at the same time, patients and families have become more aware of how much of a disadvantage this is. In many cases, it is the hospitalist who takes the brunt of patient and family frustration. This can get awfully stressful and frustrating, and I think it is a contributor to allegations of malpractice.

Budgetary stress. Ever since SHM began collecting survey data in the late 1990s, the financial support hospitals have been providing to hospitalists has increased dramatically. The most recent State of Hospital Medicine report, published in 2104, showed median support provided by hospitals of $156,063 per FTE hospitalist, per year. Some hospitals have begun to resist providing more support, and this translates into stress and lower morale for hospitalists. This is far from a universal issue, but it does lead to lower morale for hospitalists who face it.

Many other factors may be contributing to a national decline in morale, but I think these are some of the most important.

What Can Be Done?

Some hospitalist groups have great morale now and don’t need to do much of anything right now, but some groups should think about a deliberate strategy to improve it.

Sadly, there isn’t a prescription that is sure to work. But there are some things you can try.

Self-care. The field of palliative care has thought a lot about caring for caregivers, and hospitalist groups might want to adopt some of their practices. Search the Internet on “self-care” + “palliative care,” and you’ll find a lot of interesting things. The group I’m part of launched a deliberate program of professionally led and facilitated hospitalist self-care, with high hopes that included mindful meditation, among other things. As soon as we had designed our program, the Mayo Clinic published their favorable experience with a program that was very similar to what we had planned, and I thought we would see similar benefits.³

But, while all who attended the sessions thought they were valuable, attendance was so poor that we ended up cancelling the program. The hospitalists were interested in attending but were either on service and busy seeing patients, or were off and didn’t want to drive in to work solely for the purpose of reducing work stress.

I’m convinced a self-care program is valuable but very tricky to schedule effectively. Maybe others have come up with effective ways of overcoming this problem.

Social connections. Some hospitalist groups seem to have little social and personal connection to other physicians and hospital leaders. I think this results in lower hospitalist morale and tends to be self-reinforcing. If you’re in such a group, you and your hospitalist colleagues should deliberately seek better relationships with other doctors and hospital administrative leaders. Ensure that you visit with others at lunch, talk with them at committee meetings, ask about their vacation and personal activities, and pursue activities with them outside of work.

When these sorts of social connections are strong, work is far more satisfying and you’re much more likely to be treated as a peer by other doctors. I think this is really important and shouldn’t be overlooked if your group is suffering from low morale.

Adaptive work. Lastly, you might want to approach changes to your work and morale as “adaptive work,” rather than “technical work.” Space doesn’t permit a description of these, but it is worth reading about how they differ. Many groups will find value in reframing their approach to aspects of work they don’t like as adaptive work.

References

1. Hinami K, Whelan CT, Wolosin RJ, Miller JA, Wetterneck TB. Worklife and satisfaction of hospitalists: toward flourishing careers. J Gen Intern Med. 2012;27(1):28-36.
2. Hoff TH, Whitcomb WF, Williams K, Nelson JR, Cheesman RA. Characteristics and work experiences of hospitalists in the United States. Arch Intern Med. 2001;161(6):851-858.
3. West CP, Dyrbye LN, Rabatin JT, et al. Intervention to promote physician well-being, job satisfaction, and professionalism: a randomized clinical trial. JAMA Intern Med. 2014;174(4):527-533.

NEW YORK (Reuters Health) - The American Board of Internal Medicine (ABIM) maintenance-of-certification (MOC) program could cost $5.7 billion in physicians' time and fees over the next decade, according to a new model study.

"We estimate that physicians will spend 33 million hours over 10 years to fulfill MOC requirements," Dr. Dhruv S. Kazi from the University of California, San Francisco, told Reuters Health by email.

"This is approximately equivalent to the total clinical work load of 1785 physicians over 10 years," Dr. Kazi said. "This demand on physician time comes during a period of expanding insurance coverage and anticipated physician workforce shortfalls; it may therefore adversely affect access to care, particularly elective care."

The ABIM's substantial expansion in 2014 of its MOC requirements for the more than 250,000 board-certified internists, hospitalists and internal medicine subspecialists ignited an intense debate about the societal value of the program, resulting in temporary suspension of some of the new requirements.

Dr. Kazi's team sought to quantify the costs of the 2015 version of the MOC program and compare them with the costs that would have been incurred had the 2013 version remained unchanged.

The new MOC requirements would cost board-certified internal medicine physicians an average of $23,607 over 10 years, including $2,349 in fees to the ABIM and $21,259 in time costs, the researchers report in Annals of Internal Medicine, online July 28.

Average costs would range from $16,725 for general internists to $40,495 for hematologists-oncologists.

The overall program would cost $5.7 billion ($561 million in fees to ABIM and $5.1 billion in time costs) over the next 10 years, an increase of $1.2 billion over the previous MOC program.

"The ABIM has previously suggested that participation in MOC will cost $200 to $400 per year," the researchers note. "This is a substantial underestimate precisely because it overlooks time costs."

"While we had anticipated that physician time would be an important driver of costs of the program, we were surprised to see that 9 out of every 10 dollars in MOC costs were related to the program's demands on physician time," Dr. Kazi said. "In fact, every additional hour spent by physicians on MOC increased the costs of the program by approximately 13 million dollars."

"The internal medicine community has embraced the principle of evidence-based medicine in clinical practice; expensive policy interventions such as MOC should be held to the same evidentiary standards," Dr. Kazi concluded.

"Instead of piecemeal evaluations, the entire MOC program should be compared head-to-head with other policy interventions or health systems interventions that improve healthcare quality, thus providing an empirical basis for choosing MOC over alternative strategies for quality improvement," Dr. Kazi said.

"We hope that the high costs of MOC catalyze future studies examining the impact of MOC on the quality and economics of care delivered by board-certified physicians in the United States," Dr. Kazi added.

Dr. Robert B. Baron from the American Board of Internal Medicine told Reuters Health by email, "Their analysis is less about time and cost of doing MOC than it is about the time physicians take staying up-to-date. They estimate that it is about an hour a month, and about 40 hours to prepare for the exam every decade. While the researchers attribute that time to MOC, I suspect most physicians would be spending this time staying abreast of the latest developments in their field, with or without MOC. What MOC offers them is a structured framework to keep up and a marker for the public that they are."

"Our MOC program already recognizes so much of what physicians are doing in practice to stay up to date," said Dr. Baron, also of the University of California, San Francisco. "We can and should do more in that area. We are getting a lot of feedback from physicians about how we can improve MOC, and this feedback will help us shape what we know will be an evolving program."

"In conversations we have already had with the community, one thing physicians have shared loud and clear is that they deeply value staying current in their field," he added. "They believe they should spend time staying abreast of the latest updates in their discipline. We are talking with the community to assure that MOC gives them a structured way to stay current, and we all agree it is an important marker for patients that they have done so."

"The researchers make some claims about overall costs to the health care system," Dr. Baron said. "If you accept their methodology, which is a stretch, other research that appeared in JAMA in December showed greater overall savings - 30 times as much as the costs reported here - just in Medicare costs for physicians who participated in MOC. So maybe all those hours spent keeping up are worth it, not just for the physicians and the patients we take care of but for our entire health care system."

NEW YORK (Reuters Health) - The American Board of Internal Medicine (ABIM) maintenance-of-certification (MOC) program could cost $5.7 billion in physicians' time and fees over the next decade, according to a new model study.

"We estimate that physicians will spend 33 million hours over 10 years to fulfill MOC requirements," Dr. Dhruv S. Kazi from the University of California, San Francisco, told Reuters Health by email.

"This is approximately equivalent to the total clinical work load of 1785 physicians over 10 years," Dr. Kazi said. "This demand on physician time comes during a period of expanding insurance coverage and anticipated physician workforce shortfalls; it may therefore adversely affect access to care, particularly elective care."

The ABIM's substantial expansion in 2014 of its MOC requirements for the more than 250,000 board-certified internists, hospitalists and internal medicine subspecialists ignited an intense debate about the societal value of the program, resulting in temporary suspension of some of the new requirements.

Dr. Kazi's team sought to quantify the costs of the 2015 version of the MOC program and compare them with the costs that would have been incurred had the 2013 version remained unchanged.

The new MOC requirements would cost board-certified internal medicine physicians an average of $23,607 over 10 years, including $2,349 in fees to the ABIM and $21,259 in time costs, the researchers report in Annals of Internal Medicine, online July 28.

Average costs would range from $16,725 for general internists to $40,495 for hematologists-oncologists.

The overall program would cost $5.7 billion ($561 million in fees to ABIM and $5.1 billion in time costs) over the next 10 years, an increase of $1.2 billion over the previous MOC program.

"The ABIM has previously suggested that participation in MOC will cost $200 to $400 per year," the researchers note. "This is a substantial underestimate precisely because it overlooks time costs."

"While we had anticipated that physician time would be an important driver of costs of the program, we were surprised to see that 9 out of every 10 dollars in MOC costs were related to the program's demands on physician time," Dr. Kazi said. "In fact, every additional hour spent by physicians on MOC increased the costs of the program by approximately 13 million dollars."

"The internal medicine community has embraced the principle of evidence-based medicine in clinical practice; expensive policy interventions such as MOC should be held to the same evidentiary standards," Dr. Kazi concluded.

"Instead of piecemeal evaluations, the entire MOC program should be compared head-to-head with other policy interventions or health systems interventions that improve healthcare quality, thus providing an empirical basis for choosing MOC over alternative strategies for quality improvement," Dr. Kazi said.

"We hope that the high costs of MOC catalyze future studies examining the impact of MOC on the quality and economics of care delivered by board-certified physicians in the United States," Dr. Kazi added.

Dr. Robert B. Baron from the American Board of Internal Medicine told Reuters Health by email, "Their analysis is less about time and cost of doing MOC than it is about the time physicians take staying up-to-date. They estimate that it is about an hour a month, and about 40 hours to prepare for the exam every decade. While the researchers attribute that time to MOC, I suspect most physicians would be spending this time staying abreast of the latest developments in their field, with or without MOC. What MOC offers them is a structured framework to keep up and a marker for the public that they are."

"Our MOC program already recognizes so much of what physicians are doing in practice to stay up to date," said Dr. Baron, also of the University of California, San Francisco. "We can and should do more in that area. We are getting a lot of feedback from physicians about how we can improve MOC, and this feedback will help us shape what we know will be an evolving program."

"In conversations we have already had with the community, one thing physicians have shared loud and clear is that they deeply value staying current in their field," he added. "They believe they should spend time staying abreast of the latest updates in their discipline. We are talking with the community to assure that MOC gives them a structured way to stay current, and we all agree it is an important marker for patients that they have done so."

"The researchers make some claims about overall costs to the health care system," Dr. Baron said. "If you accept their methodology, which is a stretch, other research that appeared in JAMA in December showed greater overall savings - 30 times as much as the costs reported here - just in Medicare costs for physicians who participated in MOC. So maybe all those hours spent keeping up are worth it, not just for the physicians and the patients we take care of but for our entire health care system."

NEW YORK (Reuters Health) - The American Board of Internal Medicine (ABIM) maintenance-of-certification (MOC) program could cost $5.7 billion in physicians' time and fees over the next decade, according to a new model study.

"We estimate that physicians will spend 33 million hours over 10 years to fulfill MOC requirements," Dr. Dhruv S. Kazi from the University of California, San Francisco, told Reuters Health by email.

"This is approximately equivalent to the total clinical work load of 1785 physicians over 10 years," Dr. Kazi said. "This demand on physician time comes during a period of expanding insurance coverage and anticipated physician workforce shortfalls; it may therefore adversely affect access to care, particularly elective care."

The ABIM's substantial expansion in 2014 of its MOC requirements for the more than 250,000 board-certified internists, hospitalists and internal medicine subspecialists ignited an intense debate about the societal value of the program, resulting in temporary suspension of some of the new requirements.

Dr. Kazi's team sought to quantify the costs of the 2015 version of the MOC program and compare them with the costs that would have been incurred had the 2013 version remained unchanged.

The new MOC requirements would cost board-certified internal medicine physicians an average of $23,607 over 10 years, including $2,349 in fees to the ABIM and $21,259 in time costs, the researchers report in Annals of Internal Medicine, online July 28.

Average costs would range from $16,725 for general internists to $40,495 for hematologists-oncologists.

The overall program would cost $5.7 billion ($561 million in fees to ABIM and $5.1 billion in time costs) over the next 10 years, an increase of $1.2 billion over the previous MOC program.

"The ABIM has previously suggested that participation in MOC will cost $200 to $400 per year," the researchers note. "This is a substantial underestimate precisely because it overlooks time costs."

"While we had anticipated that physician time would be an important driver of costs of the program, we were surprised to see that 9 out of every 10 dollars in MOC costs were related to the program's demands on physician time," Dr. Kazi said. "In fact, every additional hour spent by physicians on MOC increased the costs of the program by approximately 13 million dollars."

"The internal medicine community has embraced the principle of evidence-based medicine in clinical practice; expensive policy interventions such as MOC should be held to the same evidentiary standards," Dr. Kazi concluded.

"Instead of piecemeal evaluations, the entire MOC program should be compared head-to-head with other policy interventions or health systems interventions that improve healthcare quality, thus providing an empirical basis for choosing MOC over alternative strategies for quality improvement," Dr. Kazi said.

"We hope that the high costs of MOC catalyze future studies examining the impact of MOC on the quality and economics of care delivered by board-certified physicians in the United States," Dr. Kazi added.

Dr. Robert B. Baron from the American Board of Internal Medicine told Reuters Health by email, "Their analysis is less about time and cost of doing MOC than it is about the time physicians take staying up-to-date. They estimate that it is about an hour a month, and about 40 hours to prepare for the exam every decade. While the researchers attribute that time to MOC, I suspect most physicians would be spending this time staying abreast of the latest developments in their field, with or without MOC. What MOC offers them is a structured framework to keep up and a marker for the public that they are."

"Our MOC program already recognizes so much of what physicians are doing in practice to stay up to date," said Dr. Baron, also of the University of California, San Francisco. "We can and should do more in that area. We are getting a lot of feedback from physicians about how we can improve MOC, and this feedback will help us shape what we know will be an evolving program."

"In conversations we have already had with the community, one thing physicians have shared loud and clear is that they deeply value staying current in their field," he added. "They believe they should spend time staying abreast of the latest updates in their discipline. We are talking with the community to assure that MOC gives them a structured way to stay current, and we all agree it is an important marker for patients that they have done so."

"The researchers make some claims about overall costs to the health care system," Dr. Baron said. "If you accept their methodology, which is a stretch, other research that appeared in JAMA in December showed greater overall savings - 30 times as much as the costs reported here - just in Medicare costs for physicians who participated in MOC. So maybe all those hours spent keeping up are worth it, not just for the physicians and the patients we take care of but for our entire health care system."

(Reuters Health) - Most older adults who are hospitalized for acute myocardial infarction do not attend even one of the recommended cardiac rehabilitation sessions, according to a new study.

Cardiac rehab increases physical and cardiovascular fitness through structured exercise and education sessions, said lead author Dr. Jacob A. Doll, of Duke Clinical Research Institute in Durham, North Carolina.

Patients may attend individual or group sessions to improve medication adherence, help them quit smoking, lose weight, improve their diet and manage chronic diseases, while also focusing on psychological and social wellbeing, he said.

"Some people will be too sick after a heart attack to exercise safely, but this should be a fairly low percentage," Doll told Reuters Health by email. "Most other people can benefit, especially older adults."

Researchers used data on 58,269 patients 65 years or older who had acute MI between 2007 and 2010.

The researchers found that 36,376 patients, or 62%, were referred to cardiac rehab - but only 11,862 attended at least one rehab session over the year following hospital discharge.

Of those who had not been referred, 1,795 attended at least one session.

Half of those who went to the rehab program attended less than 26 sessions, though insurance usually covers 36 sessions - or two to three sessions per week, as reported August 3 in JAMA Internal Medicine.

Less than a quarter of the total group of MI patients attended at least one rehab session, and only 5% completed 36 sessions.

Younger white male nonsmokers with few other health problems were most likely to attend cardiac rehab.

"Not all (heart attack) patients are referred, some for valid reasons such as inability to exercise, difficulty in scheduling due to their job, lack of transportation, need to care for a sick spouse, etc," said Dr. Jerome L. Fleg of the National Heart, Lung and Blood Institute in Bethesda, Maryland.

Rehab sessions typically involve five to 10 minutes of warm-up, 30 to 40 minutes of walking, stationary cycling, or elliptical machine exercise, followed by five to 10 minutes of cool down, said Fleg, who was not part of the new study.

Hospitals should improve referral rates, and should encourage enrolled patients to actually complete the rehab programs, Doll said.

"Many people might feel that cardiac rehab is not for them, potentially because they feel they are not able to exercise or are too sick," he said.

Medicare recipients, like those in this study, generally have all costs covered for cardiac rehab, Fleg told Reuters Health by email.

Most other insurances cover cardiac rehab, but copayments may be cost-prohibitive for some people, and those living in rural areas may have to drive long distances to find a center, Doll said.

"Health systems and insurers should consider reducing copayments in order to improve access, since cardiac rehabilitation has been shown (to) improve survival and functioning after a heart attack," he said. "For people that cannot attend a traditional program, we may need new ways to deliver rehab services, such as home-based programs."

(Reuters Health) - Most older adults who are hospitalized for acute myocardial infarction do not attend even one of the recommended cardiac rehabilitation sessions, according to a new study.

Cardiac rehab increases physical and cardiovascular fitness through structured exercise and education sessions, said lead author Dr. Jacob A. Doll, of Duke Clinical Research Institute in Durham, North Carolina.

Patients may attend individual or group sessions to improve medication adherence, help them quit smoking, lose weight, improve their diet and manage chronic diseases, while also focusing on psychological and social wellbeing, he said.

"Some people will be too sick after a heart attack to exercise safely, but this should be a fairly low percentage," Doll told Reuters Health by email. "Most other people can benefit, especially older adults."

Researchers used data on 58,269 patients 65 years or older who had acute MI between 2007 and 2010.

The researchers found that 36,376 patients, or 62%, were referred to cardiac rehab - but only 11,862 attended at least one rehab session over the year following hospital discharge.

Of those who had not been referred, 1,795 attended at least one session.

Half of those who went to the rehab program attended less than 26 sessions, though insurance usually covers 36 sessions - or two to three sessions per week, as reported August 3 in JAMA Internal Medicine.

Less than a quarter of the total group of MI patients attended at least one rehab session, and only 5% completed 36 sessions.

Younger white male nonsmokers with few other health problems were most likely to attend cardiac rehab.

"Not all (heart attack) patients are referred, some for valid reasons such as inability to exercise, difficulty in scheduling due to their job, lack of transportation, need to care for a sick spouse, etc," said Dr. Jerome L. Fleg of the National Heart, Lung and Blood Institute in Bethesda, Maryland.

Rehab sessions typically involve five to 10 minutes of warm-up, 30 to 40 minutes of walking, stationary cycling, or elliptical machine exercise, followed by five to 10 minutes of cool down, said Fleg, who was not part of the new study.

Hospitals should improve referral rates, and should encourage enrolled patients to actually complete the rehab programs, Doll said.

"Many people might feel that cardiac rehab is not for them, potentially because they feel they are not able to exercise or are too sick," he said.

Medicare recipients, like those in this study, generally have all costs covered for cardiac rehab, Fleg told Reuters Health by email.

Most other insurances cover cardiac rehab, but copayments may be cost-prohibitive for some people, and those living in rural areas may have to drive long distances to find a center, Doll said.

"Health systems and insurers should consider reducing copayments in order to improve access, since cardiac rehabilitation has been shown (to) improve survival and functioning after a heart attack," he said. "For people that cannot attend a traditional program, we may need new ways to deliver rehab services, such as home-based programs."

(Reuters Health) - Most older adults who are hospitalized for acute myocardial infarction do not attend even one of the recommended cardiac rehabilitation sessions, according to a new study.

Cardiac rehab increases physical and cardiovascular fitness through structured exercise and education sessions, said lead author Dr. Jacob A. Doll, of Duke Clinical Research Institute in Durham, North Carolina.

Patients may attend individual or group sessions to improve medication adherence, help them quit smoking, lose weight, improve their diet and manage chronic diseases, while also focusing on psychological and social wellbeing, he said.

"Some people will be too sick after a heart attack to exercise safely, but this should be a fairly low percentage," Doll told Reuters Health by email. "Most other people can benefit, especially older adults."

Researchers used data on 58,269 patients 65 years or older who had acute MI between 2007 and 2010.

The researchers found that 36,376 patients, or 62%, were referred to cardiac rehab - but only 11,862 attended at least one rehab session over the year following hospital discharge.

Of those who had not been referred, 1,795 attended at least one session.

Half of those who went to the rehab program attended less than 26 sessions, though insurance usually covers 36 sessions - or two to three sessions per week, as reported August 3 in JAMA Internal Medicine.

Less than a quarter of the total group of MI patients attended at least one rehab session, and only 5% completed 36 sessions.

Younger white male nonsmokers with few other health problems were most likely to attend cardiac rehab.

"Not all (heart attack) patients are referred, some for valid reasons such as inability to exercise, difficulty in scheduling due to their job, lack of transportation, need to care for a sick spouse, etc," said Dr. Jerome L. Fleg of the National Heart, Lung and Blood Institute in Bethesda, Maryland.

Rehab sessions typically involve five to 10 minutes of warm-up, 30 to 40 minutes of walking, stationary cycling, or elliptical machine exercise, followed by five to 10 minutes of cool down, said Fleg, who was not part of the new study.

Hospitals should improve referral rates, and should encourage enrolled patients to actually complete the rehab programs, Doll said.

"Many people might feel that cardiac rehab is not for them, potentially because they feel they are not able to exercise or are too sick," he said.

Medicare recipients, like those in this study, generally have all costs covered for cardiac rehab, Fleg told Reuters Health by email.

Most other insurances cover cardiac rehab, but copayments may be cost-prohibitive for some people, and those living in rural areas may have to drive long distances to find a center, Doll said.

"Health systems and insurers should consider reducing copayments in order to improve access, since cardiac rehabilitation has been shown (to) improve survival and functioning after a heart attack," he said. "For people that cannot attend a traditional program, we may need new ways to deliver rehab services, such as home-based programs."

Presenters: Dr. Patrick Brady, Dr. Michele Saysana, Dr. Christine White, and Dr. Mark Shen.

Session analysis:

QI is about making positive changes in the delivery of healthcare. Multiple QI interventions are been implemented daily throughout our hospitals. Some of those interventions result in positive changes and affect specific outcomes the way we want. It is our job, as hospitalists, to share them with our colleagues so patients can benefit from them.

Some of the barriers to publishing QI as identified by the group are: lack of time, resources available and administrative support, lack of mentorship, and unrecognized value of QI in the academic world. The group also identified some strategies to be successful at writing and publishing QI, including: blocking time in the schedule and labeling it "writing days," joining a collaborative, reaching out to Journal editors and becoming familiar with the SQUIRE guidelines. Some key points as discussed by the experts that will aid during the process of writing QI are:

1. A specific goal/aim statement needs to be identified,
2. The measurement needs to match your goal/aim,
3. Always start with writing your methods since you know exactly what you did,
4. Plot data over time using a run chart, and
5. Keep a notebook with documentation of dates all interventions started.

It is also important for everyone to know there are multiple quality and safety journals willing to review QI manuscripts for publication.

Presenters: Dr. Patrick Brady, Dr. Michele Saysana, Dr. Christine White, and Dr. Mark Shen.

Session analysis:

QI is about making positive changes in the delivery of healthcare. Multiple QI interventions are been implemented daily throughout our hospitals. Some of those interventions result in positive changes and affect specific outcomes the way we want. It is our job, as hospitalists, to share them with our colleagues so patients can benefit from them.

Some of the barriers to publishing QI as identified by the group are: lack of time, resources available and administrative support, lack of mentorship, and unrecognized value of QI in the academic world. The group also identified some strategies to be successful at writing and publishing QI, including: blocking time in the schedule and labeling it "writing days," joining a collaborative, reaching out to Journal editors and becoming familiar with the SQUIRE guidelines. Some key points as discussed by the experts that will aid during the process of writing QI are:

1. A specific goal/aim statement needs to be identified,
2. The measurement needs to match your goal/aim,
3. Always start with writing your methods since you know exactly what you did,
4. Plot data over time using a run chart, and
5. Keep a notebook with documentation of dates all interventions started.

It is also important for everyone to know there are multiple quality and safety journals willing to review QI manuscripts for publication.

Presenters: Dr. Patrick Brady, Dr. Michele Saysana, Dr. Christine White, and Dr. Mark Shen.

Session analysis:

QI is about making positive changes in the delivery of healthcare. Multiple QI interventions are been implemented daily throughout our hospitals. Some of those interventions result in positive changes and affect specific outcomes the way we want. It is our job, as hospitalists, to share them with our colleagues so patients can benefit from them.

Some of the barriers to publishing QI as identified by the group are: lack of time, resources available and administrative support, lack of mentorship, and unrecognized value of QI in the academic world. The group also identified some strategies to be successful at writing and publishing QI, including: blocking time in the schedule and labeling it "writing days," joining a collaborative, reaching out to Journal editors and becoming familiar with the SQUIRE guidelines. Some key points as discussed by the experts that will aid during the process of writing QI are:

1. A specific goal/aim statement needs to be identified,
2. The measurement needs to match your goal/aim,
3. Always start with writing your methods since you know exactly what you did,
4. Plot data over time using a run chart, and
5. Keep a notebook with documentation of dates all interventions started.

It is also important for everyone to know there are multiple quality and safety journals willing to review QI manuscripts for publication.

Drs. Pate and Engel presented a hot topic in pediatric hospital medicine, sparking fruitful conversation about current evidence, identified gaps, and controversies regarding the management of febrile infants with urinary tract infections. After the American Academy of Pediatrics published the updated clinical guideline in 2011, controversies about radioimaging, duration of treatment, and pursuit of laboratory evaluations arose. These controversies continue today, and value and gold standard tests are now being questioned. Should urine culture truly be the gold standard to define a UTI?

The current evidence (applying to 2 month-2 years) in a nutshell includes:

• Oral and parental antibiotics are equally efficacious,
• Duration of treatment is a wide range of 7-14 days,
• Positive UA indicating inflammation/infection and a culture >50,000 uropathogens/ml is needed to make the diagnosis, and
• Febrile infants with first UTI should get a renal ultrasound; only if the ultrasound is abnormal should patients get a Voiding Cystourethrogram (VCUG).

Since the guideline was published in 2011, there has been continued disagreement between pediatricians and pediatric urologists. When thinking about high-value care, what value is added by doing the renal ultrasound and/or VCUG? The research over the last couple of years shows that although there is concern that UTIs lead to renal scarring and chronic kidney disease, in the absence of structural kidney abnormalities, recurrent UTIs cause at most 0.3% of chronic kidney disease. The takehome point from the 2014 RIVUR study is:

• The treatment group had significantly higher rates of resistance organisms (63% ppx 19% placebo).
• The NNT with prophylaxis in children with VUR is 9 children for 2 years to prevent 1 UTI, or 6570 days of antibiotics to prevent one 7-14 day course.

The RIVUR study raised more questions:

• Is there a difference in outcome if a child had concurrent bacteremia?

  • There is no significant difference in clinical presentation between an isolated UTI and an infant with bacteremia. Those patients with bacteremia received longer duration of parenteral antibiotics, but the number of days were highly variable and outcomes were excellent overall regardless.

• How accurate is UA in the diagnosis of urinary tract infections in infants less than 3 months of age?

  • Urinalysis in those infants

• Could inflammatory markers accurately identify infants at high risk for more severe disease?

  • Not really.

Guidelines were reviewed, controversies were discussed, and questions were proposed. The session ended with tools to take home to help change hospital practice, and quality-UTI projects metrics were shared, as this is the next AAP VIP project about to launch.

Key Takeaways:

• The guidelines represent a living and dynamic tool that integrates the best evidence we have.
• There is new research evolving and lessons to be learned.

Dr. Hopkins is an academic pediatric hospitalist and instructor at All Children's Hospital Johns Hopkins Medicine, St. Petersburg, Fla.​

Drs. Pate and Engel presented a hot topic in pediatric hospital medicine, sparking fruitful conversation about current evidence, identified gaps, and controversies regarding the management of febrile infants with urinary tract infections. After the American Academy of Pediatrics published the updated clinical guideline in 2011, controversies about radioimaging, duration of treatment, and pursuit of laboratory evaluations arose. These controversies continue today, and value and gold standard tests are now being questioned. Should urine culture truly be the gold standard to define a UTI?

The current evidence (applying to 2 month-2 years) in a nutshell includes:

• Oral and parental antibiotics are equally efficacious,
• Duration of treatment is a wide range of 7-14 days,
• Positive UA indicating inflammation/infection and a culture >50,000 uropathogens/ml is needed to make the diagnosis, and
• Febrile infants with first UTI should get a renal ultrasound; only if the ultrasound is abnormal should patients get a Voiding Cystourethrogram (VCUG).

Since the guideline was published in 2011, there has been continued disagreement between pediatricians and pediatric urologists. When thinking about high-value care, what value is added by doing the renal ultrasound and/or VCUG? The research over the last couple of years shows that although there is concern that UTIs lead to renal scarring and chronic kidney disease, in the absence of structural kidney abnormalities, recurrent UTIs cause at most 0.3% of chronic kidney disease. The takehome point from the 2014 RIVUR study is:

• The treatment group had significantly higher rates of resistance organisms (63% ppx 19% placebo).
• The NNT with prophylaxis in children with VUR is 9 children for 2 years to prevent 1 UTI, or 6570 days of antibiotics to prevent one 7-14 day course.

The RIVUR study raised more questions:

• Is there a difference in outcome if a child had concurrent bacteremia?

  • There is no significant difference in clinical presentation between an isolated UTI and an infant with bacteremia. Those patients with bacteremia received longer duration of parenteral antibiotics, but the number of days were highly variable and outcomes were excellent overall regardless.

• How accurate is UA in the diagnosis of urinary tract infections in infants less than 3 months of age?

  • Urinalysis in those infants

• Could inflammatory markers accurately identify infants at high risk for more severe disease?

  • Not really.

Guidelines were reviewed, controversies were discussed, and questions were proposed. The session ended with tools to take home to help change hospital practice, and quality-UTI projects metrics were shared, as this is the next AAP VIP project about to launch.

Key Takeaways:

• The guidelines represent a living and dynamic tool that integrates the best evidence we have.
• There is new research evolving and lessons to be learned.

Dr. Hopkins is an academic pediatric hospitalist and instructor at All Children's Hospital Johns Hopkins Medicine, St. Petersburg, Fla.​

Drs. Pate and Engel presented a hot topic in pediatric hospital medicine, sparking fruitful conversation about current evidence, identified gaps, and controversies regarding the management of febrile infants with urinary tract infections. After the American Academy of Pediatrics published the updated clinical guideline in 2011, controversies about radioimaging, duration of treatment, and pursuit of laboratory evaluations arose. These controversies continue today, and value and gold standard tests are now being questioned. Should urine culture truly be the gold standard to define a UTI?

The current evidence (applying to 2 month-2 years) in a nutshell includes:

• Oral and parental antibiotics are equally efficacious,
• Duration of treatment is a wide range of 7-14 days,
• Positive UA indicating inflammation/infection and a culture >50,000 uropathogens/ml is needed to make the diagnosis, and
• Febrile infants with first UTI should get a renal ultrasound; only if the ultrasound is abnormal should patients get a Voiding Cystourethrogram (VCUG).

Since the guideline was published in 2011, there has been continued disagreement between pediatricians and pediatric urologists. When thinking about high-value care, what value is added by doing the renal ultrasound and/or VCUG? The research over the last couple of years shows that although there is concern that UTIs lead to renal scarring and chronic kidney disease, in the absence of structural kidney abnormalities, recurrent UTIs cause at most 0.3% of chronic kidney disease. The takehome point from the 2014 RIVUR study is:

• The treatment group had significantly higher rates of resistance organisms (63% ppx 19% placebo).
• The NNT with prophylaxis in children with VUR is 9 children for 2 years to prevent 1 UTI, or 6570 days of antibiotics to prevent one 7-14 day course.

The RIVUR study raised more questions:

• Is there a difference in outcome if a child had concurrent bacteremia?

  • There is no significant difference in clinical presentation between an isolated UTI and an infant with bacteremia. Those patients with bacteremia received longer duration of parenteral antibiotics, but the number of days were highly variable and outcomes were excellent overall regardless.

• How accurate is UA in the diagnosis of urinary tract infections in infants less than 3 months of age?

  • Urinalysis in those infants

• Could inflammatory markers accurately identify infants at high risk for more severe disease?

  • Not really.

Guidelines were reviewed, controversies were discussed, and questions were proposed. The session ended with tools to take home to help change hospital practice, and quality-UTI projects metrics were shared, as this is the next AAP VIP project about to launch.

Key Takeaways:

• The guidelines represent a living and dynamic tool that integrates the best evidence we have.
• There is new research evolving and lessons to be learned.

Dr. Hopkins is an academic pediatric hospitalist and instructor at All Children's Hospital Johns Hopkins Medicine, St. Petersburg, Fla.​

A new book by three leading hospital medicine advocates for maximizing efficiency and outcomes while managing costs and avoiding waste in healthcare—also known as value-based healthcare—offers a primer filled with practical advice for doctors and other clinicians.¹ The hospitalist authors of Understanding Value-Based Healthcare, Christopher Moriates, MD, of the University of California-San Francisco, Vineet Arora, MD, MAPP, of the University of Chicago, and Neel Shah, MD, MPP, of Harvard Medical School, all have leadership positions in Costs of Care, a nonprofit organization formed in 2009 to help empower patients and their caregivers to deflate medical bills.

In a recent op-ed piece at MedPage Today, the book’s authors emphasize the harms for patients when doctors fail to consider the impact of medical bills or screen patients for financial harm.² Doctors should help their patients navigate tradeoffs of lower-cost treatment options. The authors hope to embed principles of value-based care into the apprenticeship of health professional education through initiatives such as Costs of Care’s “Teaching Value & Choosing Wisely Challenge,” which received 80 submissions from medical students and faculty from across the United States and Canada presenting bright ideas and innovations for integrating value into education.

References

1. Moriates C, Arora V, Shah N. Understanding Value-Based Healthcare. New York City: McGraw Hill Education; 2015.
2. Moriates C, Arora V, Shah N. Op-ed: how to rein in out-of-control healthcare costs. May 5, 2015. MedPage Today. Accessed July 2, 2015.

A new book by three leading hospital medicine advocates for maximizing efficiency and outcomes while managing costs and avoiding waste in healthcare—also known as value-based healthcare—offers a primer filled with practical advice for doctors and other clinicians.¹ The hospitalist authors of Understanding Value-Based Healthcare, Christopher Moriates, MD, of the University of California-San Francisco, Vineet Arora, MD, MAPP, of the University of Chicago, and Neel Shah, MD, MPP, of Harvard Medical School, all have leadership positions in Costs of Care, a nonprofit organization formed in 2009 to help empower patients and their caregivers to deflate medical bills.

In a recent op-ed piece at MedPage Today, the book’s authors emphasize the harms for patients when doctors fail to consider the impact of medical bills or screen patients for financial harm.² Doctors should help their patients navigate tradeoffs of lower-cost treatment options. The authors hope to embed principles of value-based care into the apprenticeship of health professional education through initiatives such as Costs of Care’s “Teaching Value & Choosing Wisely Challenge,” which received 80 submissions from medical students and faculty from across the United States and Canada presenting bright ideas and innovations for integrating value into education.

References

1. Moriates C, Arora V, Shah N. Understanding Value-Based Healthcare. New York City: McGraw Hill Education; 2015.
2. Moriates C, Arora V, Shah N. Op-ed: how to rein in out-of-control healthcare costs. May 5, 2015. MedPage Today. Accessed July 2, 2015.

A new book by three leading hospital medicine advocates for maximizing efficiency and outcomes while managing costs and avoiding waste in healthcare—also known as value-based healthcare—offers a primer filled with practical advice for doctors and other clinicians.¹ The hospitalist authors of Understanding Value-Based Healthcare, Christopher Moriates, MD, of the University of California-San Francisco, Vineet Arora, MD, MAPP, of the University of Chicago, and Neel Shah, MD, MPP, of Harvard Medical School, all have leadership positions in Costs of Care, a nonprofit organization formed in 2009 to help empower patients and their caregivers to deflate medical bills.

In a recent op-ed piece at MedPage Today, the book’s authors emphasize the harms for patients when doctors fail to consider the impact of medical bills or screen patients for financial harm.² Doctors should help their patients navigate tradeoffs of lower-cost treatment options. The authors hope to embed principles of value-based care into the apprenticeship of health professional education through initiatives such as Costs of Care’s “Teaching Value & Choosing Wisely Challenge,” which received 80 submissions from medical students and faculty from across the United States and Canada presenting bright ideas and innovations for integrating value into education.

References

1. Moriates C, Arora V, Shah N. Understanding Value-Based Healthcare. New York City: McGraw Hill Education; 2015.
2. Moriates C, Arora V, Shah N. Op-ed: how to rein in out-of-control healthcare costs. May 5, 2015. MedPage Today. Accessed July 2, 2015.