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10 Choosing Wisely Recommendations by Specialists for Hospitalists
When diagnosing a patient, it can be tempting to run all types of tests to expedite the process—and protect yourself from litigation. Patients may push for more tests, too, thinking “the more the better.” But that may not be the best course of action. In fact, according to recommendations of the ABIM Foundations’ Choosing Wisely campaign, more tests can actually bring a host of negative consequences.
In an effort to help hospitalists decide which tests to perform and which to forgo, The Hospitalist asked medical societies that contributed to the Choosing Wisely campaign to tell us which one of their recommendations was the most applicable to hospitalists. Then, we asked some hospitalists to discuss how they might implement each recommendation.
1 American Gastroenterological Association (AGA)
Recommendation: For a patient with functional abdominal pain syndrome (as per Rome criteria), computed tomography (CT) scans should not be repeated unless there is a major change in clinical findings or symptoms.
When a patient first complains of abdominal pain, a CT scan usually is done prior to a gastroenterological consultation. Despite this initial scan, many patients with chronic abdominal pain receive unnecessary repeated CT scans to evaluate their pain even if they have previous negative studies.
“It is important for the hospitalist to know that functional abdominal pain can be managed without additional diagnostic studies,” says John M. Inadomi, MD, head of the division of gastroenterology at the University of Washington School of Medicine in Seattle. “Some doctors are uncomfortable with the uncertainty of a diagnosis of chronic abdominal pain without evidence of biochemical or structural disease [functional abdominal pain syndrome] and fear litigation.”
An abdominal CT scan is one of the higher radiation exposure tests, equivalent to three years of natural background radiation.1
“Due to this risk and the high costs of this procedure, CT scans should be limited to situations in which they are likely to provide useful information that changes patient management,” Dr. Inadomi says.
According to Moises Auron, MD, FAAP, FACP, SFHM, assistant professor of medicine and pediatrics at Cleveland Clinic Lerner College of Medicine of Case Western University in Cleveland, Ohio, it should not be a difficult choice for hospitalists, “as the clinical context provides a safeguard to justify the rationale for a conservative approach. Hospitalists must be educated on the appropriate use of Rome criteria, as well as how to appropriately document it in the chart to justify a decision to avoid unnecessary testing.”
2 American College of Rheumatology (ACR)
Recommendation: Don’t test anti-nuclear antibody (ANA) sub-serologies without a positive ANA and clinical suspicion of immune-mediated disease.
“A fever of unknown origin is among the most common diagnoses the hospitalist encounters,” Dr. Auron says. “Nowadays, given the ease to order tests, as well as the increased awareness of patients with immune-mediated diseases, it may be tempting to order large panels of immunologic tests to minimize the risk of missing a diagnosis; however, because ANA has high sensitivity and poor specificity, it should only be ordered if the clinical context supports its use.”
Jinoos Yazdany, MD, MPH, assistant professor of medicine at the University of California at San Francisco and co-chair of the task force that developed the ACR’s Choosing Wisely list, points out that if you use ANAs as a broad screening test when the pretest probability of specific ANA-associated diseases is low, there is an increased chance of a false positive ANA result. This can lead to unnecessary further testing and additional costs. Furthermore, ANA sub-serologies are usually negative if the ANA (done by immunofluorescence) is negative.
“So it is recommended to order sub-serologies only once it is known that the ANA is positive,” she says. The exceptions to this are anti-SSA and anti-Jo-1 antibodies, which can sometimes be positive when the ANA is negative.
Mangla S. Gulati, MD, FACP, FHM, medical director for clinical effectiveness at the University of Maryland School of Medicine in Baltimore, says a positive ANA in conjunction with clinical information “will help to guide appropriate and cost-conscious testing. Hospitalists could implement this through a clinical decision support approach if using an electronic medical record.”
3 American College of Physicians (ACP)
Recommendation: In patients with low pretest probability of venous thromboembolism (VTE), obtain a high-sensitive D-dimer measurement as the initial diagnostic test; don’t obtain imaging studies as the initial diagnostic test.
VTE, a common problem in hospitalized patients, has high mortality rates. “However, recent statistics suggest that we may be overdiagnosing non-clinically significant disease and exposing large numbers of patients to high doses of radiation unnecessarily in an attempt to rule out VTE disease,” says Cynthia D. Smith, MD, FACP, ACP senior medical associate for content development and adjunct associate professor of medicine at the Perelman School of Medicine in Philadelphia.
Instead, physicians should estimate pretest probability of disease using a validated risk assessment tool (i.e., Wells score). For patients with low clinical probability of VTE, hospitalists should use a negative high-sensitive D-dimer measurement as the initial diagnostic test.
Dr. Auron says the litigious environment of American medicine may trigger clinicians to order testing to minimize the risk of missing potential conditions; however, an adequate, evidence-based approach with appropriate documentation should be sufficient. In this case, that would entail using D-dimer testing to outline the low pretest probability of VTE and explaining to the patient the rationale for not pursuing further imaging.
Dr. Gulati adds that hospitalists should have little difficulty implementing this cost-effective approach.
—Moises Auron, MD, FAAP, FACP, SFHM, assistant professor of medicine and pediatrics, Cleveland Clinic
4 American Geriatrics Society (AGS)
Recommendation: Don’t use antimicrobials to treat bacteriuria in older adults unless specific urinary tract symptoms are present.
Older adults with asymptomatic bacteriuria who received antimicrobial treatment show no benefit, according to multiple studies.2 In fact, increased adverse antimicrobial effects occurred, such as greater resistance patterns and super-infections (e.g. Clostridium difficile).
The truth is that as many as 30% of frail elders (particularly women) have bacterial colonization of the urinary tract without infection, also known as asymptomatic bacteriuria, says Heidi Wald, MD, MSPH, associate professor of medicine and vice chair for quality in the department of medicine at the University of Colorado School of Medicine in Aurora. Therefore, before being prescribed antimicrobials, a patient should exhibit symptoms of urinary tract infection such as fever, frequent urination, urgency to urinate, painful urination, or suprapubic tenderness.
“Without localizing symptoms, you can’t assume bacteriuria equals infection,” Dr. Wald adds. “Too often, we make the urine a scapegoat for unrelated presentations, such as mild confusion.”
If the patient is stable and doesn’t have UTI symptoms, Dr. Wald says hospitalists should consider hydration and monitor the patient without antibiotics.
“This should not be difficult to implement,” Dr. Auron says, “as hospitalists are on the front lines of antibiotic stewardship in hospitals.”
5 American Society of Echocardiography (ASE)
Recommendation: Avoid echocardiograms for pre-operative/peri-operative assessment of patients with no history or symptoms of heart disease.
Echocardiography can diagnose all types of heart disease while being completely safe, inexpensive, and available at the bedside.
“These features may logically lead hospitalists to think, ‘Why not?’ Maybe there’s something going on and an echo can’t hurt,” says James D. Thomas, MD, FASE, FACC, FAHA, FESC, Moore Chair of Cardiovascular Imaging at Cleveland Clinic and ASE past president. “Unfortunately, tests can have false positive findings that lead to other, potentially more hazardous and invasive, tests downstream, as well as unnecessary delays.”
If a patient has no history of heart disease, no positive physical findings, or no symptoms, then an echo probably won’t be helpful. Hospitalists need to be aware of the lack of value of a presumed normal study, Dr. Auron says.
“Having appropriate standards of care allows clinicians in pre-operative areas to use risk stratification tools in an adequate fashion,” he notes.
6 American Society of Nephrology (ASN)
Recommendation: Do not place peripherally inserted central venous catheters (PICC) in stage three to five chronic kidney disease (CKD) patients without consulting nephrology.
Given the increase in patients with CKD in the later stages, as well as end-stage renal disease, clinicians need to protect patients’ upper extremity veins in order to be able to have an adequate vascular substrate for subsequent creation of an arteriovenous fistula (AVF), Dr. Auron maintains.
PICCs, along with other central venous catheters, damage veins and destroy sites for future hemodialysis vascular access, explains Amy W. Williams, MD, medical director of hospital operations and consultant in the division of nephrology and hypertension at Mayo Clinic in Rochester, Minn. If there are no options for AVF or grafts, patients starting or being maintained on hemodialysis will need a tunneled central venous catheter for dialysis access.
Studies have shown that AVFs have better patency rates and fewer complications compared to catheters, and there is a direct correlation of increased mortality and inadequate dialysis with tunneled central catheters.3 In addition, dialysis patients with a tunneled central venous catheter have a five-fold increase of infection compared to those with an AVF.4 The incidence of central venous stenosis associated with PICC lines has been shown to be 42% and the incidence of thrombosis 38%.5,6 There is no significant difference in the rate of central venous complications based on the duration of catheter use or catheter size. In addition, prior PICC use has been shown to be an independent predictor of lack of a functioning AVF (odds ratio 2.8 [95 % CI, 1.5 to 5.5]).7
A better choice for extended venous access in patients with advanced CKD is a tunneled internal jugular vein catheter, which is associated with a lower risk of permanent vascular damage, says Dr. Williams, who is chair of the ASN’s Quality and Patient Safety Task Force.
—James J. O’Callaghan, MD, FAAP, FHM, clinical assistant professor of pediatrics, Seattle Children’s Hospital at the University of Washington, Team Hospitalist member
7 The Society of Thoracic Surgeons (STS)
Recommendation: Patients who have no cardiac history and good functional status do not require pre-operative stress testing prior to non-cardiac thoracic surgery.
By eliminating routine stress testing prior to non-cardiac thoracic surgery for patients without a history of cardiac symptoms, hospitalists can reduce the burden of costs on patients and eliminate the possibility of adverse outcomes due to inappropriate testing.
“Functional status has been shown to be reliable to predict peri-operative and long-term cardiac events,” says Douglas E. Wood, MD, chief of the division of cardiothoracic surgery at the University of Washington in Seattle and president of the STS. “In highly functional asymptomatic patients, management is rarely changed by pre-operative stress testing. Furthermore, abnormalities identified in testing often require additional investigation, with negative consequences related to the risks of more procedures or tests, delays in therapies, and additional costs.”
Pre-operative stress testing should be reserved for patients with low functional capacity or clinical risk factors for cardiac complications. It is important to identify patients pre-operatively who are at risk for these complications by doing a thorough history, physical examination, and resting electrocardiogram.
8 Society of Nuclear Medicine and Molecular Imaging (SNMMI)
Recommendation: Avoid using a CT angiogram to diagnose pulmonary embolism (PE) in young women with a normal chest radiograph; consider a radionuclide lung (V/Q) study instead.
Hospitalists should be knowledgeable of the diagnostic options that will result in the lowest radiation exposure when evaluating young women for PE.
“When a chest radiograph is normal or nearly normal, a computed tomography angiogram or a V/Q lung scan can be used to evaluate these patients. While both exams have low radiation exposure, the V/Q lung scan results in less radiation to the breast tissue,” says society president Gary L. Dillehay, MD, FACNM, FACR, professor of radiology at Northwestern Memorial Hospital in Chicago. “Recent literature cites concerns over radiation exposure from mammography; therefore, reducing radiation exposure to breast tissue, when evaluating patients for suspected PE, is desirable.”
Hospitalists might have difficulty obtaining a V/Q lung scan when nuclear medicine departments are closed.
“The caveat is that CT scans are much more readily available,” Dr. Auron says. In addition, a CT scan provides additional information. But unless the differential diagnosis is much higher for PE than other possibilities, just having a V/Q scan should suffice.
Hospitalists could help implement protocols for chest pain evaluation in premenopausal women by having checklists for risk factors for coronary artery disease, connective tissue disease (essentially aortic dissection), and VTE (e.g. Wells and Geneva scores, use of oral contraceptives, smoking), Dr. Auron says. If the diagnostic branch supports the risk of PE, then nuclear imaging should be available.
“A reasonable way to justify the increased availability of the nuclear medicine department would be to document the number of CT chest scans done after hours in patients who would have instead had a V/Q scan,” he says.
LISTEN NOW to Rahul Shah, MD, FACS, FAAP, associate professor of otolaryngology and pediatrics at Children's National Medical Center in Washington, D.C, and co-chair of the American Academy of Otolaryngology-Head and Neck Surgery Foundation’s Patient Safety Quality Improvement Committee, explain why hospitalists should avoid routine radiographic imaging for patients who meet diagnostic criteria for uncomplicated acute rhinosinusitis.
9 American Academy of Pediatrics (AAP)
Recommendation: Antibiotics should not be used for apparent viral respiratory illnesses (sinusitis, pharyngitis, bronchitis).
Respiratory illnesses are the most common reason for hospitalization in pediatrics. Recent studies and surveys continue to demonstrate antibiotic overuse in the pediatric population, especially when prescribed for apparent viral respiratory illnesses.8,9
“Hospitalists who care for pediatric patients have the potential to significantly impact antibiotic overuse, as hospitalizations for respiratory illnesses due to viruses such as bronchiolitis and croup remain a leading cause of admission,” says James J. O’Callaghan, MD, FAAP, FHM, clinical assistant professor of pediatrics at the University of Washington School of Medicine in Seattle.
Many respiratory problems, such as bronchiolitis, asthma, and even some pneumonias are caused or exacerbated by viruses, points out Ricardo Quiñonez, MD, FAAP, FHM, section head of pediatric hospital medicine at the Children’s Hospital of San Antonio and the Baylor College of Medicine, and chair of the AAP’s section on hospital medicine. In particular, there are national guidelines for bronchiolitis and asthma that recommend against the use of systemic antibiotics.
This recommendation may be difficult for hospitalists to implement, because antibiotics are frequently started by other providers (PCP or ED), Dr. O’Callaghan admits. It can be tricky to change or stop therapy without undermining patients’ or parents’ confidence in their medical decision-making. Hospitalists may need to collaborate with new partners, such as community-wide antibiotic reduction campaigns, in order to affect this culture change.
—James D. Thomas, MD, FASE, FACC, FAHA, FESC, Moore Chair of Cardiovascular Imaging at the Cleveland Clinic in Ohio and past president of the American Society of Echocardiography.
10 American College of Obstetricians and Gynecologists (ACOB)
Recommendation: Don’t schedule elective inductions prior to 39 weeks, and don’t schedule elective inductions of labor after 39 weeks without a favorable cervix.
Studies show an increased risk to newborns that are electively inducted between 37 and 39 weeks. Complications include increased admission to the neonatal intensive care unit, increased risk of respiratory distress and need for respiratory support, and increased incidence of infection and sepsis.
This recommendation may be difficult for hospitalists to implement, because obstetrical providers typically schedule elective inductions. Implementation of this recommendation would involve collaboration with obstetrical providers, with possible support from maternal-fetal and neonatal providers.
“Recent quality measures and initiatives from such organizations such as CMS and the National Quality Forum … may help to galvanize institutional support for its successful implementation,” says Dr. O’Callaghan, a Team Hospitalist member.
Elective surgeries should only be done in cases where there is a medical necessity, such as when the mother is diabetic or has hypertension, adds Rob Olson, MD, FACOG, an OB/GYN hospitalist for PeaceHealth at St. Joseph Medical Center in Bellingham, Wash. “Hospitalists should not give in to pressures from patients who are either tired of the discomforts of pregnancy or have family pressure to end the pregnancy early.”
Karen Appold is a freelance writer in Pennsylvania.
References
- U.S. Food and Drug Administration. Reducing radiation from medical X-rays. Available at: http://www.fda.gov/ForConsumers/ConsumerUpdates/ucm095505.htm. Accessed May 12, 2014.
- Nicolle LE, Bradley S, Colgan R, et al. Infectious Diseases Society of America guidelines for the diagnosis and treatment of asymptomatic bacteriuria in adults. Clin Infect Dis. 2005;40(5):643-654.
- Hoggard J, Saad T, Schon D, et al. Guidelines for venous access in patients with chronic kidney disease. A position statement from the American Society of Diagnostic and Interventional Nephrology, Clinical Practice Committee and the Association for Vascular Access. Semin Dial. 2008;21(2):186-191.
- Rayner HC, Besarab A, Brown WW, Disney A, Saito A, Pisoni RL. Vascular access results from the dialysis outcomes and practice patterns study (DOPPS): Performance against kidney disease outcomes quality initiative (K/DOQI)clinical practice guidelines. Am J Kidney Dis. 2004;44(5 Suppl 2):22-26.
- Gonsalves CF, Eschelman DJ, Sullivan KL, DuBois N, Bonn J. Incidence of central vein stenosis and occlusion following upper extremity PICC and port placement. Cardiovasc Intervent Radiol. 2003;26(2):123-127.
- Allen AW, Megargell JL, Brown DB, et al. Venous thrombosis associated with the placement of peripherally inserted central catheters. J Vasc Interv Radiol. 2000;11(10):1309-1314.
- El Ters M, Schears GJ, Taler SJ, et al. Association between prior peripherally inserted central catheters and lack of functioning ateriovenous fistulas: A case control study in hemodialysis patients. Am J Kidney Dis. 2012;60(4):601-608.
- Hersh AL, Shapiro DJ, Pavia AT, Shah SS. Antibiotic prescribing in ambulatory pediatrics in the United States. Pediatrics. 2011;128(6):1053-1061.
- Knapp JF, Simon SD, Sharma V. Quality of care for common pediatric respiratory illnesses in United States emergency departments: Analysis of 2005 National Hospital Ambulatory Medical Care Survey data. Pediatrics. 2008;122(6):1165-1170.
When diagnosing a patient, it can be tempting to run all types of tests to expedite the process—and protect yourself from litigation. Patients may push for more tests, too, thinking “the more the better.” But that may not be the best course of action. In fact, according to recommendations of the ABIM Foundations’ Choosing Wisely campaign, more tests can actually bring a host of negative consequences.
In an effort to help hospitalists decide which tests to perform and which to forgo, The Hospitalist asked medical societies that contributed to the Choosing Wisely campaign to tell us which one of their recommendations was the most applicable to hospitalists. Then, we asked some hospitalists to discuss how they might implement each recommendation.
1 American Gastroenterological Association (AGA)
Recommendation: For a patient with functional abdominal pain syndrome (as per Rome criteria), computed tomography (CT) scans should not be repeated unless there is a major change in clinical findings or symptoms.
When a patient first complains of abdominal pain, a CT scan usually is done prior to a gastroenterological consultation. Despite this initial scan, many patients with chronic abdominal pain receive unnecessary repeated CT scans to evaluate their pain even if they have previous negative studies.
“It is important for the hospitalist to know that functional abdominal pain can be managed without additional diagnostic studies,” says John M. Inadomi, MD, head of the division of gastroenterology at the University of Washington School of Medicine in Seattle. “Some doctors are uncomfortable with the uncertainty of a diagnosis of chronic abdominal pain without evidence of biochemical or structural disease [functional abdominal pain syndrome] and fear litigation.”
An abdominal CT scan is one of the higher radiation exposure tests, equivalent to three years of natural background radiation.1
“Due to this risk and the high costs of this procedure, CT scans should be limited to situations in which they are likely to provide useful information that changes patient management,” Dr. Inadomi says.
According to Moises Auron, MD, FAAP, FACP, SFHM, assistant professor of medicine and pediatrics at Cleveland Clinic Lerner College of Medicine of Case Western University in Cleveland, Ohio, it should not be a difficult choice for hospitalists, “as the clinical context provides a safeguard to justify the rationale for a conservative approach. Hospitalists must be educated on the appropriate use of Rome criteria, as well as how to appropriately document it in the chart to justify a decision to avoid unnecessary testing.”
2 American College of Rheumatology (ACR)
Recommendation: Don’t test anti-nuclear antibody (ANA) sub-serologies without a positive ANA and clinical suspicion of immune-mediated disease.
“A fever of unknown origin is among the most common diagnoses the hospitalist encounters,” Dr. Auron says. “Nowadays, given the ease to order tests, as well as the increased awareness of patients with immune-mediated diseases, it may be tempting to order large panels of immunologic tests to minimize the risk of missing a diagnosis; however, because ANA has high sensitivity and poor specificity, it should only be ordered if the clinical context supports its use.”
Jinoos Yazdany, MD, MPH, assistant professor of medicine at the University of California at San Francisco and co-chair of the task force that developed the ACR’s Choosing Wisely list, points out that if you use ANAs as a broad screening test when the pretest probability of specific ANA-associated diseases is low, there is an increased chance of a false positive ANA result. This can lead to unnecessary further testing and additional costs. Furthermore, ANA sub-serologies are usually negative if the ANA (done by immunofluorescence) is negative.
“So it is recommended to order sub-serologies only once it is known that the ANA is positive,” she says. The exceptions to this are anti-SSA and anti-Jo-1 antibodies, which can sometimes be positive when the ANA is negative.
Mangla S. Gulati, MD, FACP, FHM, medical director for clinical effectiveness at the University of Maryland School of Medicine in Baltimore, says a positive ANA in conjunction with clinical information “will help to guide appropriate and cost-conscious testing. Hospitalists could implement this through a clinical decision support approach if using an electronic medical record.”
3 American College of Physicians (ACP)
Recommendation: In patients with low pretest probability of venous thromboembolism (VTE), obtain a high-sensitive D-dimer measurement as the initial diagnostic test; don’t obtain imaging studies as the initial diagnostic test.
VTE, a common problem in hospitalized patients, has high mortality rates. “However, recent statistics suggest that we may be overdiagnosing non-clinically significant disease and exposing large numbers of patients to high doses of radiation unnecessarily in an attempt to rule out VTE disease,” says Cynthia D. Smith, MD, FACP, ACP senior medical associate for content development and adjunct associate professor of medicine at the Perelman School of Medicine in Philadelphia.
Instead, physicians should estimate pretest probability of disease using a validated risk assessment tool (i.e., Wells score). For patients with low clinical probability of VTE, hospitalists should use a negative high-sensitive D-dimer measurement as the initial diagnostic test.
Dr. Auron says the litigious environment of American medicine may trigger clinicians to order testing to minimize the risk of missing potential conditions; however, an adequate, evidence-based approach with appropriate documentation should be sufficient. In this case, that would entail using D-dimer testing to outline the low pretest probability of VTE and explaining to the patient the rationale for not pursuing further imaging.
Dr. Gulati adds that hospitalists should have little difficulty implementing this cost-effective approach.
—Moises Auron, MD, FAAP, FACP, SFHM, assistant professor of medicine and pediatrics, Cleveland Clinic
4 American Geriatrics Society (AGS)
Recommendation: Don’t use antimicrobials to treat bacteriuria in older adults unless specific urinary tract symptoms are present.
Older adults with asymptomatic bacteriuria who received antimicrobial treatment show no benefit, according to multiple studies.2 In fact, increased adverse antimicrobial effects occurred, such as greater resistance patterns and super-infections (e.g. Clostridium difficile).
The truth is that as many as 30% of frail elders (particularly women) have bacterial colonization of the urinary tract without infection, also known as asymptomatic bacteriuria, says Heidi Wald, MD, MSPH, associate professor of medicine and vice chair for quality in the department of medicine at the University of Colorado School of Medicine in Aurora. Therefore, before being prescribed antimicrobials, a patient should exhibit symptoms of urinary tract infection such as fever, frequent urination, urgency to urinate, painful urination, or suprapubic tenderness.
“Without localizing symptoms, you can’t assume bacteriuria equals infection,” Dr. Wald adds. “Too often, we make the urine a scapegoat for unrelated presentations, such as mild confusion.”
If the patient is stable and doesn’t have UTI symptoms, Dr. Wald says hospitalists should consider hydration and monitor the patient without antibiotics.
“This should not be difficult to implement,” Dr. Auron says, “as hospitalists are on the front lines of antibiotic stewardship in hospitals.”
5 American Society of Echocardiography (ASE)
Recommendation: Avoid echocardiograms for pre-operative/peri-operative assessment of patients with no history or symptoms of heart disease.
Echocardiography can diagnose all types of heart disease while being completely safe, inexpensive, and available at the bedside.
“These features may logically lead hospitalists to think, ‘Why not?’ Maybe there’s something going on and an echo can’t hurt,” says James D. Thomas, MD, FASE, FACC, FAHA, FESC, Moore Chair of Cardiovascular Imaging at Cleveland Clinic and ASE past president. “Unfortunately, tests can have false positive findings that lead to other, potentially more hazardous and invasive, tests downstream, as well as unnecessary delays.”
If a patient has no history of heart disease, no positive physical findings, or no symptoms, then an echo probably won’t be helpful. Hospitalists need to be aware of the lack of value of a presumed normal study, Dr. Auron says.
“Having appropriate standards of care allows clinicians in pre-operative areas to use risk stratification tools in an adequate fashion,” he notes.
6 American Society of Nephrology (ASN)
Recommendation: Do not place peripherally inserted central venous catheters (PICC) in stage three to five chronic kidney disease (CKD) patients without consulting nephrology.
Given the increase in patients with CKD in the later stages, as well as end-stage renal disease, clinicians need to protect patients’ upper extremity veins in order to be able to have an adequate vascular substrate for subsequent creation of an arteriovenous fistula (AVF), Dr. Auron maintains.
PICCs, along with other central venous catheters, damage veins and destroy sites for future hemodialysis vascular access, explains Amy W. Williams, MD, medical director of hospital operations and consultant in the division of nephrology and hypertension at Mayo Clinic in Rochester, Minn. If there are no options for AVF or grafts, patients starting or being maintained on hemodialysis will need a tunneled central venous catheter for dialysis access.
Studies have shown that AVFs have better patency rates and fewer complications compared to catheters, and there is a direct correlation of increased mortality and inadequate dialysis with tunneled central catheters.3 In addition, dialysis patients with a tunneled central venous catheter have a five-fold increase of infection compared to those with an AVF.4 The incidence of central venous stenosis associated with PICC lines has been shown to be 42% and the incidence of thrombosis 38%.5,6 There is no significant difference in the rate of central venous complications based on the duration of catheter use or catheter size. In addition, prior PICC use has been shown to be an independent predictor of lack of a functioning AVF (odds ratio 2.8 [95 % CI, 1.5 to 5.5]).7
A better choice for extended venous access in patients with advanced CKD is a tunneled internal jugular vein catheter, which is associated with a lower risk of permanent vascular damage, says Dr. Williams, who is chair of the ASN’s Quality and Patient Safety Task Force.
—James J. O’Callaghan, MD, FAAP, FHM, clinical assistant professor of pediatrics, Seattle Children’s Hospital at the University of Washington, Team Hospitalist member
7 The Society of Thoracic Surgeons (STS)
Recommendation: Patients who have no cardiac history and good functional status do not require pre-operative stress testing prior to non-cardiac thoracic surgery.
By eliminating routine stress testing prior to non-cardiac thoracic surgery for patients without a history of cardiac symptoms, hospitalists can reduce the burden of costs on patients and eliminate the possibility of adverse outcomes due to inappropriate testing.
“Functional status has been shown to be reliable to predict peri-operative and long-term cardiac events,” says Douglas E. Wood, MD, chief of the division of cardiothoracic surgery at the University of Washington in Seattle and president of the STS. “In highly functional asymptomatic patients, management is rarely changed by pre-operative stress testing. Furthermore, abnormalities identified in testing often require additional investigation, with negative consequences related to the risks of more procedures or tests, delays in therapies, and additional costs.”
Pre-operative stress testing should be reserved for patients with low functional capacity or clinical risk factors for cardiac complications. It is important to identify patients pre-operatively who are at risk for these complications by doing a thorough history, physical examination, and resting electrocardiogram.
8 Society of Nuclear Medicine and Molecular Imaging (SNMMI)
Recommendation: Avoid using a CT angiogram to diagnose pulmonary embolism (PE) in young women with a normal chest radiograph; consider a radionuclide lung (V/Q) study instead.
Hospitalists should be knowledgeable of the diagnostic options that will result in the lowest radiation exposure when evaluating young women for PE.
“When a chest radiograph is normal or nearly normal, a computed tomography angiogram or a V/Q lung scan can be used to evaluate these patients. While both exams have low radiation exposure, the V/Q lung scan results in less radiation to the breast tissue,” says society president Gary L. Dillehay, MD, FACNM, FACR, professor of radiology at Northwestern Memorial Hospital in Chicago. “Recent literature cites concerns over radiation exposure from mammography; therefore, reducing radiation exposure to breast tissue, when evaluating patients for suspected PE, is desirable.”
Hospitalists might have difficulty obtaining a V/Q lung scan when nuclear medicine departments are closed.
“The caveat is that CT scans are much more readily available,” Dr. Auron says. In addition, a CT scan provides additional information. But unless the differential diagnosis is much higher for PE than other possibilities, just having a V/Q scan should suffice.
Hospitalists could help implement protocols for chest pain evaluation in premenopausal women by having checklists for risk factors for coronary artery disease, connective tissue disease (essentially aortic dissection), and VTE (e.g. Wells and Geneva scores, use of oral contraceptives, smoking), Dr. Auron says. If the diagnostic branch supports the risk of PE, then nuclear imaging should be available.
“A reasonable way to justify the increased availability of the nuclear medicine department would be to document the number of CT chest scans done after hours in patients who would have instead had a V/Q scan,” he says.
LISTEN NOW to Rahul Shah, MD, FACS, FAAP, associate professor of otolaryngology and pediatrics at Children's National Medical Center in Washington, D.C, and co-chair of the American Academy of Otolaryngology-Head and Neck Surgery Foundation’s Patient Safety Quality Improvement Committee, explain why hospitalists should avoid routine radiographic imaging for patients who meet diagnostic criteria for uncomplicated acute rhinosinusitis.
9 American Academy of Pediatrics (AAP)
Recommendation: Antibiotics should not be used for apparent viral respiratory illnesses (sinusitis, pharyngitis, bronchitis).
Respiratory illnesses are the most common reason for hospitalization in pediatrics. Recent studies and surveys continue to demonstrate antibiotic overuse in the pediatric population, especially when prescribed for apparent viral respiratory illnesses.8,9
“Hospitalists who care for pediatric patients have the potential to significantly impact antibiotic overuse, as hospitalizations for respiratory illnesses due to viruses such as bronchiolitis and croup remain a leading cause of admission,” says James J. O’Callaghan, MD, FAAP, FHM, clinical assistant professor of pediatrics at the University of Washington School of Medicine in Seattle.
Many respiratory problems, such as bronchiolitis, asthma, and even some pneumonias are caused or exacerbated by viruses, points out Ricardo Quiñonez, MD, FAAP, FHM, section head of pediatric hospital medicine at the Children’s Hospital of San Antonio and the Baylor College of Medicine, and chair of the AAP’s section on hospital medicine. In particular, there are national guidelines for bronchiolitis and asthma that recommend against the use of systemic antibiotics.
This recommendation may be difficult for hospitalists to implement, because antibiotics are frequently started by other providers (PCP or ED), Dr. O’Callaghan admits. It can be tricky to change or stop therapy without undermining patients’ or parents’ confidence in their medical decision-making. Hospitalists may need to collaborate with new partners, such as community-wide antibiotic reduction campaigns, in order to affect this culture change.
—James D. Thomas, MD, FASE, FACC, FAHA, FESC, Moore Chair of Cardiovascular Imaging at the Cleveland Clinic in Ohio and past president of the American Society of Echocardiography.
10 American College of Obstetricians and Gynecologists (ACOB)
Recommendation: Don’t schedule elective inductions prior to 39 weeks, and don’t schedule elective inductions of labor after 39 weeks without a favorable cervix.
Studies show an increased risk to newborns that are electively inducted between 37 and 39 weeks. Complications include increased admission to the neonatal intensive care unit, increased risk of respiratory distress and need for respiratory support, and increased incidence of infection and sepsis.
This recommendation may be difficult for hospitalists to implement, because obstetrical providers typically schedule elective inductions. Implementation of this recommendation would involve collaboration with obstetrical providers, with possible support from maternal-fetal and neonatal providers.
“Recent quality measures and initiatives from such organizations such as CMS and the National Quality Forum … may help to galvanize institutional support for its successful implementation,” says Dr. O’Callaghan, a Team Hospitalist member.
Elective surgeries should only be done in cases where there is a medical necessity, such as when the mother is diabetic or has hypertension, adds Rob Olson, MD, FACOG, an OB/GYN hospitalist for PeaceHealth at St. Joseph Medical Center in Bellingham, Wash. “Hospitalists should not give in to pressures from patients who are either tired of the discomforts of pregnancy or have family pressure to end the pregnancy early.”
Karen Appold is a freelance writer in Pennsylvania.
References
- U.S. Food and Drug Administration. Reducing radiation from medical X-rays. Available at: http://www.fda.gov/ForConsumers/ConsumerUpdates/ucm095505.htm. Accessed May 12, 2014.
- Nicolle LE, Bradley S, Colgan R, et al. Infectious Diseases Society of America guidelines for the diagnosis and treatment of asymptomatic bacteriuria in adults. Clin Infect Dis. 2005;40(5):643-654.
- Hoggard J, Saad T, Schon D, et al. Guidelines for venous access in patients with chronic kidney disease. A position statement from the American Society of Diagnostic and Interventional Nephrology, Clinical Practice Committee and the Association for Vascular Access. Semin Dial. 2008;21(2):186-191.
- Rayner HC, Besarab A, Brown WW, Disney A, Saito A, Pisoni RL. Vascular access results from the dialysis outcomes and practice patterns study (DOPPS): Performance against kidney disease outcomes quality initiative (K/DOQI)clinical practice guidelines. Am J Kidney Dis. 2004;44(5 Suppl 2):22-26.
- Gonsalves CF, Eschelman DJ, Sullivan KL, DuBois N, Bonn J. Incidence of central vein stenosis and occlusion following upper extremity PICC and port placement. Cardiovasc Intervent Radiol. 2003;26(2):123-127.
- Allen AW, Megargell JL, Brown DB, et al. Venous thrombosis associated with the placement of peripherally inserted central catheters. J Vasc Interv Radiol. 2000;11(10):1309-1314.
- El Ters M, Schears GJ, Taler SJ, et al. Association between prior peripherally inserted central catheters and lack of functioning ateriovenous fistulas: A case control study in hemodialysis patients. Am J Kidney Dis. 2012;60(4):601-608.
- Hersh AL, Shapiro DJ, Pavia AT, Shah SS. Antibiotic prescribing in ambulatory pediatrics in the United States. Pediatrics. 2011;128(6):1053-1061.
- Knapp JF, Simon SD, Sharma V. Quality of care for common pediatric respiratory illnesses in United States emergency departments: Analysis of 2005 National Hospital Ambulatory Medical Care Survey data. Pediatrics. 2008;122(6):1165-1170.
When diagnosing a patient, it can be tempting to run all types of tests to expedite the process—and protect yourself from litigation. Patients may push for more tests, too, thinking “the more the better.” But that may not be the best course of action. In fact, according to recommendations of the ABIM Foundations’ Choosing Wisely campaign, more tests can actually bring a host of negative consequences.
In an effort to help hospitalists decide which tests to perform and which to forgo, The Hospitalist asked medical societies that contributed to the Choosing Wisely campaign to tell us which one of their recommendations was the most applicable to hospitalists. Then, we asked some hospitalists to discuss how they might implement each recommendation.
1 American Gastroenterological Association (AGA)
Recommendation: For a patient with functional abdominal pain syndrome (as per Rome criteria), computed tomography (CT) scans should not be repeated unless there is a major change in clinical findings or symptoms.
When a patient first complains of abdominal pain, a CT scan usually is done prior to a gastroenterological consultation. Despite this initial scan, many patients with chronic abdominal pain receive unnecessary repeated CT scans to evaluate their pain even if they have previous negative studies.
“It is important for the hospitalist to know that functional abdominal pain can be managed without additional diagnostic studies,” says John M. Inadomi, MD, head of the division of gastroenterology at the University of Washington School of Medicine in Seattle. “Some doctors are uncomfortable with the uncertainty of a diagnosis of chronic abdominal pain without evidence of biochemical or structural disease [functional abdominal pain syndrome] and fear litigation.”
An abdominal CT scan is one of the higher radiation exposure tests, equivalent to three years of natural background radiation.1
“Due to this risk and the high costs of this procedure, CT scans should be limited to situations in which they are likely to provide useful information that changes patient management,” Dr. Inadomi says.
According to Moises Auron, MD, FAAP, FACP, SFHM, assistant professor of medicine and pediatrics at Cleveland Clinic Lerner College of Medicine of Case Western University in Cleveland, Ohio, it should not be a difficult choice for hospitalists, “as the clinical context provides a safeguard to justify the rationale for a conservative approach. Hospitalists must be educated on the appropriate use of Rome criteria, as well as how to appropriately document it in the chart to justify a decision to avoid unnecessary testing.”
2 American College of Rheumatology (ACR)
Recommendation: Don’t test anti-nuclear antibody (ANA) sub-serologies without a positive ANA and clinical suspicion of immune-mediated disease.
“A fever of unknown origin is among the most common diagnoses the hospitalist encounters,” Dr. Auron says. “Nowadays, given the ease to order tests, as well as the increased awareness of patients with immune-mediated diseases, it may be tempting to order large panels of immunologic tests to minimize the risk of missing a diagnosis; however, because ANA has high sensitivity and poor specificity, it should only be ordered if the clinical context supports its use.”
Jinoos Yazdany, MD, MPH, assistant professor of medicine at the University of California at San Francisco and co-chair of the task force that developed the ACR’s Choosing Wisely list, points out that if you use ANAs as a broad screening test when the pretest probability of specific ANA-associated diseases is low, there is an increased chance of a false positive ANA result. This can lead to unnecessary further testing and additional costs. Furthermore, ANA sub-serologies are usually negative if the ANA (done by immunofluorescence) is negative.
“So it is recommended to order sub-serologies only once it is known that the ANA is positive,” she says. The exceptions to this are anti-SSA and anti-Jo-1 antibodies, which can sometimes be positive when the ANA is negative.
Mangla S. Gulati, MD, FACP, FHM, medical director for clinical effectiveness at the University of Maryland School of Medicine in Baltimore, says a positive ANA in conjunction with clinical information “will help to guide appropriate and cost-conscious testing. Hospitalists could implement this through a clinical decision support approach if using an electronic medical record.”
3 American College of Physicians (ACP)
Recommendation: In patients with low pretest probability of venous thromboembolism (VTE), obtain a high-sensitive D-dimer measurement as the initial diagnostic test; don’t obtain imaging studies as the initial diagnostic test.
VTE, a common problem in hospitalized patients, has high mortality rates. “However, recent statistics suggest that we may be overdiagnosing non-clinically significant disease and exposing large numbers of patients to high doses of radiation unnecessarily in an attempt to rule out VTE disease,” says Cynthia D. Smith, MD, FACP, ACP senior medical associate for content development and adjunct associate professor of medicine at the Perelman School of Medicine in Philadelphia.
Instead, physicians should estimate pretest probability of disease using a validated risk assessment tool (i.e., Wells score). For patients with low clinical probability of VTE, hospitalists should use a negative high-sensitive D-dimer measurement as the initial diagnostic test.
Dr. Auron says the litigious environment of American medicine may trigger clinicians to order testing to minimize the risk of missing potential conditions; however, an adequate, evidence-based approach with appropriate documentation should be sufficient. In this case, that would entail using D-dimer testing to outline the low pretest probability of VTE and explaining to the patient the rationale for not pursuing further imaging.
Dr. Gulati adds that hospitalists should have little difficulty implementing this cost-effective approach.
—Moises Auron, MD, FAAP, FACP, SFHM, assistant professor of medicine and pediatrics, Cleveland Clinic
4 American Geriatrics Society (AGS)
Recommendation: Don’t use antimicrobials to treat bacteriuria in older adults unless specific urinary tract symptoms are present.
Older adults with asymptomatic bacteriuria who received antimicrobial treatment show no benefit, according to multiple studies.2 In fact, increased adverse antimicrobial effects occurred, such as greater resistance patterns and super-infections (e.g. Clostridium difficile).
The truth is that as many as 30% of frail elders (particularly women) have bacterial colonization of the urinary tract without infection, also known as asymptomatic bacteriuria, says Heidi Wald, MD, MSPH, associate professor of medicine and vice chair for quality in the department of medicine at the University of Colorado School of Medicine in Aurora. Therefore, before being prescribed antimicrobials, a patient should exhibit symptoms of urinary tract infection such as fever, frequent urination, urgency to urinate, painful urination, or suprapubic tenderness.
“Without localizing symptoms, you can’t assume bacteriuria equals infection,” Dr. Wald adds. “Too often, we make the urine a scapegoat for unrelated presentations, such as mild confusion.”
If the patient is stable and doesn’t have UTI symptoms, Dr. Wald says hospitalists should consider hydration and monitor the patient without antibiotics.
“This should not be difficult to implement,” Dr. Auron says, “as hospitalists are on the front lines of antibiotic stewardship in hospitals.”
5 American Society of Echocardiography (ASE)
Recommendation: Avoid echocardiograms for pre-operative/peri-operative assessment of patients with no history or symptoms of heart disease.
Echocardiography can diagnose all types of heart disease while being completely safe, inexpensive, and available at the bedside.
“These features may logically lead hospitalists to think, ‘Why not?’ Maybe there’s something going on and an echo can’t hurt,” says James D. Thomas, MD, FASE, FACC, FAHA, FESC, Moore Chair of Cardiovascular Imaging at Cleveland Clinic and ASE past president. “Unfortunately, tests can have false positive findings that lead to other, potentially more hazardous and invasive, tests downstream, as well as unnecessary delays.”
If a patient has no history of heart disease, no positive physical findings, or no symptoms, then an echo probably won’t be helpful. Hospitalists need to be aware of the lack of value of a presumed normal study, Dr. Auron says.
“Having appropriate standards of care allows clinicians in pre-operative areas to use risk stratification tools in an adequate fashion,” he notes.
6 American Society of Nephrology (ASN)
Recommendation: Do not place peripherally inserted central venous catheters (PICC) in stage three to five chronic kidney disease (CKD) patients without consulting nephrology.
Given the increase in patients with CKD in the later stages, as well as end-stage renal disease, clinicians need to protect patients’ upper extremity veins in order to be able to have an adequate vascular substrate for subsequent creation of an arteriovenous fistula (AVF), Dr. Auron maintains.
PICCs, along with other central venous catheters, damage veins and destroy sites for future hemodialysis vascular access, explains Amy W. Williams, MD, medical director of hospital operations and consultant in the division of nephrology and hypertension at Mayo Clinic in Rochester, Minn. If there are no options for AVF or grafts, patients starting or being maintained on hemodialysis will need a tunneled central venous catheter for dialysis access.
Studies have shown that AVFs have better patency rates and fewer complications compared to catheters, and there is a direct correlation of increased mortality and inadequate dialysis with tunneled central catheters.3 In addition, dialysis patients with a tunneled central venous catheter have a five-fold increase of infection compared to those with an AVF.4 The incidence of central venous stenosis associated with PICC lines has been shown to be 42% and the incidence of thrombosis 38%.5,6 There is no significant difference in the rate of central venous complications based on the duration of catheter use or catheter size. In addition, prior PICC use has been shown to be an independent predictor of lack of a functioning AVF (odds ratio 2.8 [95 % CI, 1.5 to 5.5]).7
A better choice for extended venous access in patients with advanced CKD is a tunneled internal jugular vein catheter, which is associated with a lower risk of permanent vascular damage, says Dr. Williams, who is chair of the ASN’s Quality and Patient Safety Task Force.
—James J. O’Callaghan, MD, FAAP, FHM, clinical assistant professor of pediatrics, Seattle Children’s Hospital at the University of Washington, Team Hospitalist member
7 The Society of Thoracic Surgeons (STS)
Recommendation: Patients who have no cardiac history and good functional status do not require pre-operative stress testing prior to non-cardiac thoracic surgery.
By eliminating routine stress testing prior to non-cardiac thoracic surgery for patients without a history of cardiac symptoms, hospitalists can reduce the burden of costs on patients and eliminate the possibility of adverse outcomes due to inappropriate testing.
“Functional status has been shown to be reliable to predict peri-operative and long-term cardiac events,” says Douglas E. Wood, MD, chief of the division of cardiothoracic surgery at the University of Washington in Seattle and president of the STS. “In highly functional asymptomatic patients, management is rarely changed by pre-operative stress testing. Furthermore, abnormalities identified in testing often require additional investigation, with negative consequences related to the risks of more procedures or tests, delays in therapies, and additional costs.”
Pre-operative stress testing should be reserved for patients with low functional capacity or clinical risk factors for cardiac complications. It is important to identify patients pre-operatively who are at risk for these complications by doing a thorough history, physical examination, and resting electrocardiogram.
8 Society of Nuclear Medicine and Molecular Imaging (SNMMI)
Recommendation: Avoid using a CT angiogram to diagnose pulmonary embolism (PE) in young women with a normal chest radiograph; consider a radionuclide lung (V/Q) study instead.
Hospitalists should be knowledgeable of the diagnostic options that will result in the lowest radiation exposure when evaluating young women for PE.
“When a chest radiograph is normal or nearly normal, a computed tomography angiogram or a V/Q lung scan can be used to evaluate these patients. While both exams have low radiation exposure, the V/Q lung scan results in less radiation to the breast tissue,” says society president Gary L. Dillehay, MD, FACNM, FACR, professor of radiology at Northwestern Memorial Hospital in Chicago. “Recent literature cites concerns over radiation exposure from mammography; therefore, reducing radiation exposure to breast tissue, when evaluating patients for suspected PE, is desirable.”
Hospitalists might have difficulty obtaining a V/Q lung scan when nuclear medicine departments are closed.
“The caveat is that CT scans are much more readily available,” Dr. Auron says. In addition, a CT scan provides additional information. But unless the differential diagnosis is much higher for PE than other possibilities, just having a V/Q scan should suffice.
Hospitalists could help implement protocols for chest pain evaluation in premenopausal women by having checklists for risk factors for coronary artery disease, connective tissue disease (essentially aortic dissection), and VTE (e.g. Wells and Geneva scores, use of oral contraceptives, smoking), Dr. Auron says. If the diagnostic branch supports the risk of PE, then nuclear imaging should be available.
“A reasonable way to justify the increased availability of the nuclear medicine department would be to document the number of CT chest scans done after hours in patients who would have instead had a V/Q scan,” he says.
LISTEN NOW to Rahul Shah, MD, FACS, FAAP, associate professor of otolaryngology and pediatrics at Children's National Medical Center in Washington, D.C, and co-chair of the American Academy of Otolaryngology-Head and Neck Surgery Foundation’s Patient Safety Quality Improvement Committee, explain why hospitalists should avoid routine radiographic imaging for patients who meet diagnostic criteria for uncomplicated acute rhinosinusitis.
9 American Academy of Pediatrics (AAP)
Recommendation: Antibiotics should not be used for apparent viral respiratory illnesses (sinusitis, pharyngitis, bronchitis).
Respiratory illnesses are the most common reason for hospitalization in pediatrics. Recent studies and surveys continue to demonstrate antibiotic overuse in the pediatric population, especially when prescribed for apparent viral respiratory illnesses.8,9
“Hospitalists who care for pediatric patients have the potential to significantly impact antibiotic overuse, as hospitalizations for respiratory illnesses due to viruses such as bronchiolitis and croup remain a leading cause of admission,” says James J. O’Callaghan, MD, FAAP, FHM, clinical assistant professor of pediatrics at the University of Washington School of Medicine in Seattle.
Many respiratory problems, such as bronchiolitis, asthma, and even some pneumonias are caused or exacerbated by viruses, points out Ricardo Quiñonez, MD, FAAP, FHM, section head of pediatric hospital medicine at the Children’s Hospital of San Antonio and the Baylor College of Medicine, and chair of the AAP’s section on hospital medicine. In particular, there are national guidelines for bronchiolitis and asthma that recommend against the use of systemic antibiotics.
This recommendation may be difficult for hospitalists to implement, because antibiotics are frequently started by other providers (PCP or ED), Dr. O’Callaghan admits. It can be tricky to change or stop therapy without undermining patients’ or parents’ confidence in their medical decision-making. Hospitalists may need to collaborate with new partners, such as community-wide antibiotic reduction campaigns, in order to affect this culture change.
—James D. Thomas, MD, FASE, FACC, FAHA, FESC, Moore Chair of Cardiovascular Imaging at the Cleveland Clinic in Ohio and past president of the American Society of Echocardiography.
10 American College of Obstetricians and Gynecologists (ACOB)
Recommendation: Don’t schedule elective inductions prior to 39 weeks, and don’t schedule elective inductions of labor after 39 weeks without a favorable cervix.
Studies show an increased risk to newborns that are electively inducted between 37 and 39 weeks. Complications include increased admission to the neonatal intensive care unit, increased risk of respiratory distress and need for respiratory support, and increased incidence of infection and sepsis.
This recommendation may be difficult for hospitalists to implement, because obstetrical providers typically schedule elective inductions. Implementation of this recommendation would involve collaboration with obstetrical providers, with possible support from maternal-fetal and neonatal providers.
“Recent quality measures and initiatives from such organizations such as CMS and the National Quality Forum … may help to galvanize institutional support for its successful implementation,” says Dr. O’Callaghan, a Team Hospitalist member.
Elective surgeries should only be done in cases where there is a medical necessity, such as when the mother is diabetic or has hypertension, adds Rob Olson, MD, FACOG, an OB/GYN hospitalist for PeaceHealth at St. Joseph Medical Center in Bellingham, Wash. “Hospitalists should not give in to pressures from patients who are either tired of the discomforts of pregnancy or have family pressure to end the pregnancy early.”
Karen Appold is a freelance writer in Pennsylvania.
References
- U.S. Food and Drug Administration. Reducing radiation from medical X-rays. Available at: http://www.fda.gov/ForConsumers/ConsumerUpdates/ucm095505.htm. Accessed May 12, 2014.
- Nicolle LE, Bradley S, Colgan R, et al. Infectious Diseases Society of America guidelines for the diagnosis and treatment of asymptomatic bacteriuria in adults. Clin Infect Dis. 2005;40(5):643-654.
- Hoggard J, Saad T, Schon D, et al. Guidelines for venous access in patients with chronic kidney disease. A position statement from the American Society of Diagnostic and Interventional Nephrology, Clinical Practice Committee and the Association for Vascular Access. Semin Dial. 2008;21(2):186-191.
- Rayner HC, Besarab A, Brown WW, Disney A, Saito A, Pisoni RL. Vascular access results from the dialysis outcomes and practice patterns study (DOPPS): Performance against kidney disease outcomes quality initiative (K/DOQI)clinical practice guidelines. Am J Kidney Dis. 2004;44(5 Suppl 2):22-26.
- Gonsalves CF, Eschelman DJ, Sullivan KL, DuBois N, Bonn J. Incidence of central vein stenosis and occlusion following upper extremity PICC and port placement. Cardiovasc Intervent Radiol. 2003;26(2):123-127.
- Allen AW, Megargell JL, Brown DB, et al. Venous thrombosis associated with the placement of peripherally inserted central catheters. J Vasc Interv Radiol. 2000;11(10):1309-1314.
- El Ters M, Schears GJ, Taler SJ, et al. Association between prior peripherally inserted central catheters and lack of functioning ateriovenous fistulas: A case control study in hemodialysis patients. Am J Kidney Dis. 2012;60(4):601-608.
- Hersh AL, Shapiro DJ, Pavia AT, Shah SS. Antibiotic prescribing in ambulatory pediatrics in the United States. Pediatrics. 2011;128(6):1053-1061.
- Knapp JF, Simon SD, Sharma V. Quality of care for common pediatric respiratory illnesses in United States emergency departments: Analysis of 2005 National Hospital Ambulatory Medical Care Survey data. Pediatrics. 2008;122(6):1165-1170.
Listen Now! American Enterprise Institute's Scott Gottlieb, MD, Talks About the Impact the Affordable Care Act Will Have on Hospitalists
Society of Hospital Medicine’s Hospitalist Program Peak Performance Sets Foundation for Improvement
SHM’s Hospitalist Program Peak Performance, HP3 for short, will conclude at the end of 2014, but it will leave a legacy that will continue to improve HM groups everywhere for years to come.
The product of a unique collaboration among SHM, hospitalist consulting firm Nelson/Flores, and others, HP3 was designed as a key component of the Preventing Readmissions through Effective Partnerships (PREP) collaborative, sponsored by BlueCross BlueShield of Illinois in collaboration with the Illinois Hospital Association and Northwestern University Feinberg School of Medicine. The overall goal of the PREP collaborative is to help move Illinois from the bottom quartile to the upper quartile ranking on readmission rates by providing tools and approaches to improve transitions of care.
“HP3 was designed to be a little like getting a personal trainer at the gym,” says John Nelson, MD, MHM, who helped create the program. “Each hospitalist group was assigned an experienced hospitalist leader as a mentor, who in some ways acted like a personal trainer, guiding and encouraging efforts to complete projects to improve their practice.
“I think most groups were surprised and pleased that they were able to accomplish more than they realized. Our hope is that they will continue ‘working out’ to improve their practice even after their participation in HP3 concludes.”
Today, many of the lessons learned from HP3—including the idea that a healthy, high-functioning hospitalist practice is an important part of improving care—have been carried into other important SHM projects, like the recent “Key Principles and Characteristics of an Effective Hospital Medicine Group,” an assessment guide developed by SHM and published in the February 2014 Journal of Hospital Medicine.
Among the ideas presented in the “Key Principles and Characteristics” guide is the concept of hospitalist engagement, which is what Dr. Mark Williams thinks hospitals can also take away from HP3.
“Engaging hospitalists is key to improving care for hospitalized patients,” says Dr. Williams, who notes that engaging hospitalists means engaging much of the entire hospital. “Hospitalists are fully integrated into hospital care delivery for general medicine patients and many—if not most—specialty and surgical patients.”
HP3 faculty Leslie Flores, MHA, SFHM, saw a two-fold benefit from HP3: an outside perspective and an introduction to techniques that will continue beyond HP3.
“It caused them to look critically at their hospitalist program and assess its organization and performance against an objective benchmark. For many, it was the first time they had been challenged to think about their hospitalist program in this way,” Flores says.
She noticed that HP3 “also taught the participants how to use basic quality improvement and project management techniques to improve their own group’s performance—these are skills they can use again and again going forward.”
Flores thinks that HP3 also benefited from another core piece of SHM’s DNA: its award-winning Mentored Implementation (MI) model, which pairs hospital sites with national experts in hospital medicine. But, instead of being focused solely on quality improvement, it broadened the MI approach to operational improvement, opening up the possibility of improved quality outcomes.
As with many SHM educational programs, the learning went in both directions and may continue after the end of HP3, according to Flores.
“I think we [the faculty and mentors], in some cases, learned as much from our participants as they learned from us,” she says. “Some of them are doing some really great things that we can add to our fund of practice management ‘best practices’ and share with others!”
SHM’s Hospitalist Program Peak Performance, HP3 for short, will conclude at the end of 2014, but it will leave a legacy that will continue to improve HM groups everywhere for years to come.
The product of a unique collaboration among SHM, hospitalist consulting firm Nelson/Flores, and others, HP3 was designed as a key component of the Preventing Readmissions through Effective Partnerships (PREP) collaborative, sponsored by BlueCross BlueShield of Illinois in collaboration with the Illinois Hospital Association and Northwestern University Feinberg School of Medicine. The overall goal of the PREP collaborative is to help move Illinois from the bottom quartile to the upper quartile ranking on readmission rates by providing tools and approaches to improve transitions of care.
“HP3 was designed to be a little like getting a personal trainer at the gym,” says John Nelson, MD, MHM, who helped create the program. “Each hospitalist group was assigned an experienced hospitalist leader as a mentor, who in some ways acted like a personal trainer, guiding and encouraging efforts to complete projects to improve their practice.
“I think most groups were surprised and pleased that they were able to accomplish more than they realized. Our hope is that they will continue ‘working out’ to improve their practice even after their participation in HP3 concludes.”
Today, many of the lessons learned from HP3—including the idea that a healthy, high-functioning hospitalist practice is an important part of improving care—have been carried into other important SHM projects, like the recent “Key Principles and Characteristics of an Effective Hospital Medicine Group,” an assessment guide developed by SHM and published in the February 2014 Journal of Hospital Medicine.
Among the ideas presented in the “Key Principles and Characteristics” guide is the concept of hospitalist engagement, which is what Dr. Mark Williams thinks hospitals can also take away from HP3.
“Engaging hospitalists is key to improving care for hospitalized patients,” says Dr. Williams, who notes that engaging hospitalists means engaging much of the entire hospital. “Hospitalists are fully integrated into hospital care delivery for general medicine patients and many—if not most—specialty and surgical patients.”
HP3 faculty Leslie Flores, MHA, SFHM, saw a two-fold benefit from HP3: an outside perspective and an introduction to techniques that will continue beyond HP3.
“It caused them to look critically at their hospitalist program and assess its organization and performance against an objective benchmark. For many, it was the first time they had been challenged to think about their hospitalist program in this way,” Flores says.
She noticed that HP3 “also taught the participants how to use basic quality improvement and project management techniques to improve their own group’s performance—these are skills they can use again and again going forward.”
Flores thinks that HP3 also benefited from another core piece of SHM’s DNA: its award-winning Mentored Implementation (MI) model, which pairs hospital sites with national experts in hospital medicine. But, instead of being focused solely on quality improvement, it broadened the MI approach to operational improvement, opening up the possibility of improved quality outcomes.
As with many SHM educational programs, the learning went in both directions and may continue after the end of HP3, according to Flores.
“I think we [the faculty and mentors], in some cases, learned as much from our participants as they learned from us,” she says. “Some of them are doing some really great things that we can add to our fund of practice management ‘best practices’ and share with others!”
SHM’s Hospitalist Program Peak Performance, HP3 for short, will conclude at the end of 2014, but it will leave a legacy that will continue to improve HM groups everywhere for years to come.
The product of a unique collaboration among SHM, hospitalist consulting firm Nelson/Flores, and others, HP3 was designed as a key component of the Preventing Readmissions through Effective Partnerships (PREP) collaborative, sponsored by BlueCross BlueShield of Illinois in collaboration with the Illinois Hospital Association and Northwestern University Feinberg School of Medicine. The overall goal of the PREP collaborative is to help move Illinois from the bottom quartile to the upper quartile ranking on readmission rates by providing tools and approaches to improve transitions of care.
“HP3 was designed to be a little like getting a personal trainer at the gym,” says John Nelson, MD, MHM, who helped create the program. “Each hospitalist group was assigned an experienced hospitalist leader as a mentor, who in some ways acted like a personal trainer, guiding and encouraging efforts to complete projects to improve their practice.
“I think most groups were surprised and pleased that they were able to accomplish more than they realized. Our hope is that they will continue ‘working out’ to improve their practice even after their participation in HP3 concludes.”
Today, many of the lessons learned from HP3—including the idea that a healthy, high-functioning hospitalist practice is an important part of improving care—have been carried into other important SHM projects, like the recent “Key Principles and Characteristics of an Effective Hospital Medicine Group,” an assessment guide developed by SHM and published in the February 2014 Journal of Hospital Medicine.
Among the ideas presented in the “Key Principles and Characteristics” guide is the concept of hospitalist engagement, which is what Dr. Mark Williams thinks hospitals can also take away from HP3.
“Engaging hospitalists is key to improving care for hospitalized patients,” says Dr. Williams, who notes that engaging hospitalists means engaging much of the entire hospital. “Hospitalists are fully integrated into hospital care delivery for general medicine patients and many—if not most—specialty and surgical patients.”
HP3 faculty Leslie Flores, MHA, SFHM, saw a two-fold benefit from HP3: an outside perspective and an introduction to techniques that will continue beyond HP3.
“It caused them to look critically at their hospitalist program and assess its organization and performance against an objective benchmark. For many, it was the first time they had been challenged to think about their hospitalist program in this way,” Flores says.
She noticed that HP3 “also taught the participants how to use basic quality improvement and project management techniques to improve their own group’s performance—these are skills they can use again and again going forward.”
Flores thinks that HP3 also benefited from another core piece of SHM’s DNA: its award-winning Mentored Implementation (MI) model, which pairs hospital sites with national experts in hospital medicine. But, instead of being focused solely on quality improvement, it broadened the MI approach to operational improvement, opening up the possibility of improved quality outcomes.
As with many SHM educational programs, the learning went in both directions and may continue after the end of HP3, according to Flores.
“I think we [the faculty and mentors], in some cases, learned as much from our participants as they learned from us,” she says. “Some of them are doing some really great things that we can add to our fund of practice management ‘best practices’ and share with others!”
Hospital Medicine Movement Grows in Scope, Impact
SHM estimates that there are more than 44,000 hospitalists in 2014. Here are some other facts and figures about the specialty:
- In 2014, it is estimated that hospitalists have a presence at 72% of U.S. hospitals, with an average group size of 12.3 physicians.
- In the 10-year period between 2003 and 2012, the percentage of hospitals with hospitalists has more than doubled. The overall penetration of hospitals with HM groups grew from 29% to 66%.
- In same 10-year period, the number of hospitalists grew from 11,159 to 38,114.
- Since the development of SHM’s award-winning mentored implementation program, 423 hospitals nationwide have adopted the model to address some of the most pressing hospital-based healthcare issues, such as readmissions, VTE, and glycemic control. SHM’s implementation guides on these issues have been downloaded more than 9,500 times.
- Research published in the Journal of Hospital Medicine in 2013 showed that SHM’s Project BOOST has helped reduce readmissions among hospitals collecting and reporting data.
SHM estimates that there are more than 44,000 hospitalists in 2014. Here are some other facts and figures about the specialty:
- In 2014, it is estimated that hospitalists have a presence at 72% of U.S. hospitals, with an average group size of 12.3 physicians.
- In the 10-year period between 2003 and 2012, the percentage of hospitals with hospitalists has more than doubled. The overall penetration of hospitals with HM groups grew from 29% to 66%.
- In same 10-year period, the number of hospitalists grew from 11,159 to 38,114.
- Since the development of SHM’s award-winning mentored implementation program, 423 hospitals nationwide have adopted the model to address some of the most pressing hospital-based healthcare issues, such as readmissions, VTE, and glycemic control. SHM’s implementation guides on these issues have been downloaded more than 9,500 times.
- Research published in the Journal of Hospital Medicine in 2013 showed that SHM’s Project BOOST has helped reduce readmissions among hospitals collecting and reporting data.
SHM estimates that there are more than 44,000 hospitalists in 2014. Here are some other facts and figures about the specialty:
- In 2014, it is estimated that hospitalists have a presence at 72% of U.S. hospitals, with an average group size of 12.3 physicians.
- In the 10-year period between 2003 and 2012, the percentage of hospitals with hospitalists has more than doubled. The overall penetration of hospitals with HM groups grew from 29% to 66%.
- In same 10-year period, the number of hospitalists grew from 11,159 to 38,114.
- Since the development of SHM’s award-winning mentored implementation program, 423 hospitals nationwide have adopted the model to address some of the most pressing hospital-based healthcare issues, such as readmissions, VTE, and glycemic control. SHM’s implementation guides on these issues have been downloaded more than 9,500 times.
- Research published in the Journal of Hospital Medicine in 2013 showed that SHM’s Project BOOST has helped reduce readmissions among hospitals collecting and reporting data.
Healthcare Changes Under Affordable Care Act Raise Concerns for Hospital Chief Financial Officers
The changes launched by the Affordable Care Act are upon us and have created considerable trepidation among many in healthcare, particularly our chief financial officers (CFOs). The CFOs’ core responsibilities include financial planning, contracting, and setting budgets. Although finance teams and clinical leaders sometimes feel like they are speaking different languages—and, in fact, many physicians couldn’t pick their hospital’s CFO out of a police lineup—successful healthcare systems bridge that gap, enabling clinical and finance leaders to work together toward common goals.
It’s easy for us doctor types to be leery of our hospital’s financial team. If you’ve ever been in direct conversation with your CFO, you may have found the discussion was packed with terms like “EBIDA,” “capital allocation,” and “operating margin,” and seemed to imply that the organization is prioritizing its bond rating over its composite PSI [patient safety indicators] performance. But the truth is that our finance teams are frustrated, too. In fact, they are more than frustrated—they are scared.
They really haven’t been sleeping well lately. They’d feel better if doctors could try to see the world that they see. A CFO’s core responsibility is ensuring a responsible, long-range financial plan that meets the needs of their hospital stakeholders—to paraphrase Tom Wolfe paraphrasing astronaut Gus Grissom, “no bucks, no Buck Rogers”—and that responsibility got a lot harder in 2014. By understanding their perspective, we clinicians should be able to take actions that result in better care of our patients today—and ensure a sustainable hospital that can take care of patients tomorrow. So that we can better empathize with our green-visored colleagues, here are a few of the thoughts going through their heads as they toss and turn at 3 a.m.
Change Is All Around
There are many urgent pressures on hospital, physician, and healthcare revenues. Keep in mind that a hospital’s costs in terms of pharmaceuticals, equipment, and labor (the average hospital has nearly 60% of its cost in labor) are not really going down to offset that revenue loss. While we’ve become uncomfortably familiar with RAC audits, value-based purchasing, the sustainable growth rate, and sequestration, I’d suggest that these revenue challenges pale in comparison to the insomnia created by the rapid rise of healthcare consumerism. Lost, or at least buried, in the stories about ACA politics, coverage of the uninsured, website malfunctions, and dropped insurance plans is the fact that the nature of insurance is changing.
Although offerings like medical savings accounts and high-deductible plans have been around for years, they are increasingly mainstream, because the plans offered through the insurance exchanges, which have surpassed the seven million mark in enrollment as of the time of this writing, all carry substantial patient commitments. The great majority of these plans—81% through February—are either “bronze” or “silver” level—and keep in mind that the average “gold” plan, in covering 80% of anticipated expenses, leaves patients with higher commitments than most large-employer group plans probably do. From that standpoint, they require patients, doctors, and hospitals to manage healthcare differently than they have in the past: We have to be mindful that patients are paying more of the “first dollar.”
The problem, from a CFO’s perspective, is at least twofold: First, a lot of patients don’t pay the portion of their bill for which they are responsible. Many doctors, hospitals, and healthcare systems are moving toward more assertive and up-front collections for non-emergency care; unfortunately, at best, we don’t do a very good job and, at worst, we create an uncomfortable space where we either channel the practices of collection agencies or leave much-needed funds on the table. As the deductibles, co-pays, and co-insurance obligations rise, so do the uncollected accounts. Our advocacy for patients increasingly requires us to be better stewards of their resources.
The second insomnia-inducing aspect of consumerism is transparency of pricing. As the exchanges move to create a “Priceline.com”-like approach to selecting an insurance plan, a similar transformation is occurring in how payers—and, with the spread of plans with higher patient obligations, patients themselves—are looking at how we set prices for everything from MRIs and laboratory services to hospitalization and physician charges. While we as individuals are used to price transparency in purchasing consumer goods, the third-party payment system in healthcare has insulated us, and our hospitals, from the consequences of the market system. (Please note, dear reader: I’m not defending either the past practices or current policy. I’m simply diagnosing why your CFO has black circles under his or her eyes.)
So, prices are increasingly published and available for comparison shopping by both insurers and individuals with those high deductibles or co-insurance amounts. As charges hit their pocketbooks, there is good reason to believe that patients will be “brand loyal” only to the point where they stop appreciating value. Systems with a reliable advantage in pricing (think: academic medical centers) run a great risk of losing business quickly if they cannot demonstrate value for those prices. Hospital-based physicians have been in the position of being the “translators” of value-based care—by always advocating for measurably better care, we help both our patients and our organizations.
Variation in Care
Perhaps most befuddling to our CFO friends are the variations in costs, outcomes, and clinical processes that seemingly similar patients with seemingly similar problems incur. Wide variations might occur based on just about any parameter, from the name of the attending physician to the day of the week of admission. Of course, at times, this variation could be explainable by, say, clinically relevant features that are simply not adjusted for, or the absence of literature to guide decisions. But, all too often, no reasonable explanation exists, and underneath that is a simmering concern that wide variations reflect failure to adhere to known guidelines, uneven distribution of resources, and “waste” deeply embedded in the healthcare value stream.
Less widely understood to clinicians is that, from the CFO’s perspective, the movement toward “value over volume” and risk-bearing systems such as accountable care organizations (ACOs) requires healthcare organizations to think like insurance companies. They must be able to accurately predict clinical outcomes within a population so that they can assess their actuarial risk and manage appropriately. Wide variations in care make those predictions less valid and outcomes more unpredictable, greatly raising the stakes for an ACO or other risk-bearing model.
From the CFO’s perspective, a key advantage to the move toward systems directly employing physicians is that a management structure can be created to decrease this variation; however, I’d question whether many physician groups, much less employed-group practices, have the appropriate management culture or the sophistication with data to do this effectively.
The Cost of Recapitalization
Most of the hospitals I’ve worked in are a jumble of incrementally newer additions built on a decades-old core facility. Clinicians tend to see the consequences as patients see them: not enough private rooms, outdated technology and equipment, poorly integrated computer and health IT systems, and inadequate storage for equipment. Your CFO certainly sees these same things, but has the additional challenge of trying to keep up with the demands for new facilities and capital purchases while maintaining the older physical plant and preserving the long-term financial strength of the organization. Even though roofing, HVAC, and new flooring are rarely as sexy as a new surgical robot, it won’t do much good to invest in that new OR equipment if the roof is leaking. And healthcare construction is really expensive, even more so because of entirely appropriate requirements that renovations bring older structures up to modern codes.
In the healthcare world, these expenses are formidable. Hospitals, like other businesses, sometimes borrow money to fund projects—particularly new construction projects. Nonprofit hospitals can be attractive to lenders because of their tax-advantaged nature. But, like our personal credit ratings, a healthcare system that enters into the bond market has specific metrics at which lenders look carefully to determine the cost of such lending, such as payer mix, income margin, debt ratios, and earnings before interest, depreciation, and amortization (EBIDA). And that’s where we come full circle to that latest conversation with the CFO.
So in order to preserve the ability to meet the needs of stakeholders, our friends in finance need to make sure a long-range plan is in place that continues to fund operations, growth, and ongoing maintenance, including the ability to borrow money when appropriate. Going forward, thriving healthcare organizations will have to be consumer-minded and successful in managing the risks of population health. The uncertainty created by the exchanges and transparency, and the inability to accurately gauge and manage the risk of adverse outcomes, has our CFO colleagues pleading with us for a prescription that will ease their restless nights. Here’s how we can help:
- Focus on working with your group to measure and minimize variations in care processes and outcomes among patients and doctors;
- Be mindful that in a value-based world, CMS and insurers now look at both inpatient and outpatient utilization and costs, and we need to do the same in our transitional care planning; and
- Be conscious that our prescriptions for care are increasingly impacting patients’ wallets, so we need to articulate and demonstrate the clinical value that underlies each decision.
In Sum
The next time you or your nocturnist is admitting that nth patient at 3 a.m., consider that your CFO may also be wide awake, struggling with his or her own version of a management challenge. As physicians who practice in hospitals, which are perhaps the most costly environments in the healthcare world, you and your colleagues may be well positioned to help make your hospitals more efficient, to better manage and improve those outcomes, and to help identify and prioritize the most pressing capital needs.
In short, just what the doctor ordered for your CFO to finally get a good night’s sleep.
Dr. Harte is president of Hillcrest Hospital in Mayfield Heights, Ohio, part of the Cleveland Clinic Health System. He is associate professor of medicine at the Lerner College of Medicine in Cleveland and an SHM board member.
The changes launched by the Affordable Care Act are upon us and have created considerable trepidation among many in healthcare, particularly our chief financial officers (CFOs). The CFOs’ core responsibilities include financial planning, contracting, and setting budgets. Although finance teams and clinical leaders sometimes feel like they are speaking different languages—and, in fact, many physicians couldn’t pick their hospital’s CFO out of a police lineup—successful healthcare systems bridge that gap, enabling clinical and finance leaders to work together toward common goals.
It’s easy for us doctor types to be leery of our hospital’s financial team. If you’ve ever been in direct conversation with your CFO, you may have found the discussion was packed with terms like “EBIDA,” “capital allocation,” and “operating margin,” and seemed to imply that the organization is prioritizing its bond rating over its composite PSI [patient safety indicators] performance. But the truth is that our finance teams are frustrated, too. In fact, they are more than frustrated—they are scared.
They really haven’t been sleeping well lately. They’d feel better if doctors could try to see the world that they see. A CFO’s core responsibility is ensuring a responsible, long-range financial plan that meets the needs of their hospital stakeholders—to paraphrase Tom Wolfe paraphrasing astronaut Gus Grissom, “no bucks, no Buck Rogers”—and that responsibility got a lot harder in 2014. By understanding their perspective, we clinicians should be able to take actions that result in better care of our patients today—and ensure a sustainable hospital that can take care of patients tomorrow. So that we can better empathize with our green-visored colleagues, here are a few of the thoughts going through their heads as they toss and turn at 3 a.m.
Change Is All Around
There are many urgent pressures on hospital, physician, and healthcare revenues. Keep in mind that a hospital’s costs in terms of pharmaceuticals, equipment, and labor (the average hospital has nearly 60% of its cost in labor) are not really going down to offset that revenue loss. While we’ve become uncomfortably familiar with RAC audits, value-based purchasing, the sustainable growth rate, and sequestration, I’d suggest that these revenue challenges pale in comparison to the insomnia created by the rapid rise of healthcare consumerism. Lost, or at least buried, in the stories about ACA politics, coverage of the uninsured, website malfunctions, and dropped insurance plans is the fact that the nature of insurance is changing.
Although offerings like medical savings accounts and high-deductible plans have been around for years, they are increasingly mainstream, because the plans offered through the insurance exchanges, which have surpassed the seven million mark in enrollment as of the time of this writing, all carry substantial patient commitments. The great majority of these plans—81% through February—are either “bronze” or “silver” level—and keep in mind that the average “gold” plan, in covering 80% of anticipated expenses, leaves patients with higher commitments than most large-employer group plans probably do. From that standpoint, they require patients, doctors, and hospitals to manage healthcare differently than they have in the past: We have to be mindful that patients are paying more of the “first dollar.”
The problem, from a CFO’s perspective, is at least twofold: First, a lot of patients don’t pay the portion of their bill for which they are responsible. Many doctors, hospitals, and healthcare systems are moving toward more assertive and up-front collections for non-emergency care; unfortunately, at best, we don’t do a very good job and, at worst, we create an uncomfortable space where we either channel the practices of collection agencies or leave much-needed funds on the table. As the deductibles, co-pays, and co-insurance obligations rise, so do the uncollected accounts. Our advocacy for patients increasingly requires us to be better stewards of their resources.
The second insomnia-inducing aspect of consumerism is transparency of pricing. As the exchanges move to create a “Priceline.com”-like approach to selecting an insurance plan, a similar transformation is occurring in how payers—and, with the spread of plans with higher patient obligations, patients themselves—are looking at how we set prices for everything from MRIs and laboratory services to hospitalization and physician charges. While we as individuals are used to price transparency in purchasing consumer goods, the third-party payment system in healthcare has insulated us, and our hospitals, from the consequences of the market system. (Please note, dear reader: I’m not defending either the past practices or current policy. I’m simply diagnosing why your CFO has black circles under his or her eyes.)
So, prices are increasingly published and available for comparison shopping by both insurers and individuals with those high deductibles or co-insurance amounts. As charges hit their pocketbooks, there is good reason to believe that patients will be “brand loyal” only to the point where they stop appreciating value. Systems with a reliable advantage in pricing (think: academic medical centers) run a great risk of losing business quickly if they cannot demonstrate value for those prices. Hospital-based physicians have been in the position of being the “translators” of value-based care—by always advocating for measurably better care, we help both our patients and our organizations.
Variation in Care
Perhaps most befuddling to our CFO friends are the variations in costs, outcomes, and clinical processes that seemingly similar patients with seemingly similar problems incur. Wide variations might occur based on just about any parameter, from the name of the attending physician to the day of the week of admission. Of course, at times, this variation could be explainable by, say, clinically relevant features that are simply not adjusted for, or the absence of literature to guide decisions. But, all too often, no reasonable explanation exists, and underneath that is a simmering concern that wide variations reflect failure to adhere to known guidelines, uneven distribution of resources, and “waste” deeply embedded in the healthcare value stream.
Less widely understood to clinicians is that, from the CFO’s perspective, the movement toward “value over volume” and risk-bearing systems such as accountable care organizations (ACOs) requires healthcare organizations to think like insurance companies. They must be able to accurately predict clinical outcomes within a population so that they can assess their actuarial risk and manage appropriately. Wide variations in care make those predictions less valid and outcomes more unpredictable, greatly raising the stakes for an ACO or other risk-bearing model.
From the CFO’s perspective, a key advantage to the move toward systems directly employing physicians is that a management structure can be created to decrease this variation; however, I’d question whether many physician groups, much less employed-group practices, have the appropriate management culture or the sophistication with data to do this effectively.
The Cost of Recapitalization
Most of the hospitals I’ve worked in are a jumble of incrementally newer additions built on a decades-old core facility. Clinicians tend to see the consequences as patients see them: not enough private rooms, outdated technology and equipment, poorly integrated computer and health IT systems, and inadequate storage for equipment. Your CFO certainly sees these same things, but has the additional challenge of trying to keep up with the demands for new facilities and capital purchases while maintaining the older physical plant and preserving the long-term financial strength of the organization. Even though roofing, HVAC, and new flooring are rarely as sexy as a new surgical robot, it won’t do much good to invest in that new OR equipment if the roof is leaking. And healthcare construction is really expensive, even more so because of entirely appropriate requirements that renovations bring older structures up to modern codes.
In the healthcare world, these expenses are formidable. Hospitals, like other businesses, sometimes borrow money to fund projects—particularly new construction projects. Nonprofit hospitals can be attractive to lenders because of their tax-advantaged nature. But, like our personal credit ratings, a healthcare system that enters into the bond market has specific metrics at which lenders look carefully to determine the cost of such lending, such as payer mix, income margin, debt ratios, and earnings before interest, depreciation, and amortization (EBIDA). And that’s where we come full circle to that latest conversation with the CFO.
So in order to preserve the ability to meet the needs of stakeholders, our friends in finance need to make sure a long-range plan is in place that continues to fund operations, growth, and ongoing maintenance, including the ability to borrow money when appropriate. Going forward, thriving healthcare organizations will have to be consumer-minded and successful in managing the risks of population health. The uncertainty created by the exchanges and transparency, and the inability to accurately gauge and manage the risk of adverse outcomes, has our CFO colleagues pleading with us for a prescription that will ease their restless nights. Here’s how we can help:
- Focus on working with your group to measure and minimize variations in care processes and outcomes among patients and doctors;
- Be mindful that in a value-based world, CMS and insurers now look at both inpatient and outpatient utilization and costs, and we need to do the same in our transitional care planning; and
- Be conscious that our prescriptions for care are increasingly impacting patients’ wallets, so we need to articulate and demonstrate the clinical value that underlies each decision.
In Sum
The next time you or your nocturnist is admitting that nth patient at 3 a.m., consider that your CFO may also be wide awake, struggling with his or her own version of a management challenge. As physicians who practice in hospitals, which are perhaps the most costly environments in the healthcare world, you and your colleagues may be well positioned to help make your hospitals more efficient, to better manage and improve those outcomes, and to help identify and prioritize the most pressing capital needs.
In short, just what the doctor ordered for your CFO to finally get a good night’s sleep.
Dr. Harte is president of Hillcrest Hospital in Mayfield Heights, Ohio, part of the Cleveland Clinic Health System. He is associate professor of medicine at the Lerner College of Medicine in Cleveland and an SHM board member.
The changes launched by the Affordable Care Act are upon us and have created considerable trepidation among many in healthcare, particularly our chief financial officers (CFOs). The CFOs’ core responsibilities include financial planning, contracting, and setting budgets. Although finance teams and clinical leaders sometimes feel like they are speaking different languages—and, in fact, many physicians couldn’t pick their hospital’s CFO out of a police lineup—successful healthcare systems bridge that gap, enabling clinical and finance leaders to work together toward common goals.
It’s easy for us doctor types to be leery of our hospital’s financial team. If you’ve ever been in direct conversation with your CFO, you may have found the discussion was packed with terms like “EBIDA,” “capital allocation,” and “operating margin,” and seemed to imply that the organization is prioritizing its bond rating over its composite PSI [patient safety indicators] performance. But the truth is that our finance teams are frustrated, too. In fact, they are more than frustrated—they are scared.
They really haven’t been sleeping well lately. They’d feel better if doctors could try to see the world that they see. A CFO’s core responsibility is ensuring a responsible, long-range financial plan that meets the needs of their hospital stakeholders—to paraphrase Tom Wolfe paraphrasing astronaut Gus Grissom, “no bucks, no Buck Rogers”—and that responsibility got a lot harder in 2014. By understanding their perspective, we clinicians should be able to take actions that result in better care of our patients today—and ensure a sustainable hospital that can take care of patients tomorrow. So that we can better empathize with our green-visored colleagues, here are a few of the thoughts going through their heads as they toss and turn at 3 a.m.
Change Is All Around
There are many urgent pressures on hospital, physician, and healthcare revenues. Keep in mind that a hospital’s costs in terms of pharmaceuticals, equipment, and labor (the average hospital has nearly 60% of its cost in labor) are not really going down to offset that revenue loss. While we’ve become uncomfortably familiar with RAC audits, value-based purchasing, the sustainable growth rate, and sequestration, I’d suggest that these revenue challenges pale in comparison to the insomnia created by the rapid rise of healthcare consumerism. Lost, or at least buried, in the stories about ACA politics, coverage of the uninsured, website malfunctions, and dropped insurance plans is the fact that the nature of insurance is changing.
Although offerings like medical savings accounts and high-deductible plans have been around for years, they are increasingly mainstream, because the plans offered through the insurance exchanges, which have surpassed the seven million mark in enrollment as of the time of this writing, all carry substantial patient commitments. The great majority of these plans—81% through February—are either “bronze” or “silver” level—and keep in mind that the average “gold” plan, in covering 80% of anticipated expenses, leaves patients with higher commitments than most large-employer group plans probably do. From that standpoint, they require patients, doctors, and hospitals to manage healthcare differently than they have in the past: We have to be mindful that patients are paying more of the “first dollar.”
The problem, from a CFO’s perspective, is at least twofold: First, a lot of patients don’t pay the portion of their bill for which they are responsible. Many doctors, hospitals, and healthcare systems are moving toward more assertive and up-front collections for non-emergency care; unfortunately, at best, we don’t do a very good job and, at worst, we create an uncomfortable space where we either channel the practices of collection agencies or leave much-needed funds on the table. As the deductibles, co-pays, and co-insurance obligations rise, so do the uncollected accounts. Our advocacy for patients increasingly requires us to be better stewards of their resources.
The second insomnia-inducing aspect of consumerism is transparency of pricing. As the exchanges move to create a “Priceline.com”-like approach to selecting an insurance plan, a similar transformation is occurring in how payers—and, with the spread of plans with higher patient obligations, patients themselves—are looking at how we set prices for everything from MRIs and laboratory services to hospitalization and physician charges. While we as individuals are used to price transparency in purchasing consumer goods, the third-party payment system in healthcare has insulated us, and our hospitals, from the consequences of the market system. (Please note, dear reader: I’m not defending either the past practices or current policy. I’m simply diagnosing why your CFO has black circles under his or her eyes.)
So, prices are increasingly published and available for comparison shopping by both insurers and individuals with those high deductibles or co-insurance amounts. As charges hit their pocketbooks, there is good reason to believe that patients will be “brand loyal” only to the point where they stop appreciating value. Systems with a reliable advantage in pricing (think: academic medical centers) run a great risk of losing business quickly if they cannot demonstrate value for those prices. Hospital-based physicians have been in the position of being the “translators” of value-based care—by always advocating for measurably better care, we help both our patients and our organizations.
Variation in Care
Perhaps most befuddling to our CFO friends are the variations in costs, outcomes, and clinical processes that seemingly similar patients with seemingly similar problems incur. Wide variations might occur based on just about any parameter, from the name of the attending physician to the day of the week of admission. Of course, at times, this variation could be explainable by, say, clinically relevant features that are simply not adjusted for, or the absence of literature to guide decisions. But, all too often, no reasonable explanation exists, and underneath that is a simmering concern that wide variations reflect failure to adhere to known guidelines, uneven distribution of resources, and “waste” deeply embedded in the healthcare value stream.
Less widely understood to clinicians is that, from the CFO’s perspective, the movement toward “value over volume” and risk-bearing systems such as accountable care organizations (ACOs) requires healthcare organizations to think like insurance companies. They must be able to accurately predict clinical outcomes within a population so that they can assess their actuarial risk and manage appropriately. Wide variations in care make those predictions less valid and outcomes more unpredictable, greatly raising the stakes for an ACO or other risk-bearing model.
From the CFO’s perspective, a key advantage to the move toward systems directly employing physicians is that a management structure can be created to decrease this variation; however, I’d question whether many physician groups, much less employed-group practices, have the appropriate management culture or the sophistication with data to do this effectively.
The Cost of Recapitalization
Most of the hospitals I’ve worked in are a jumble of incrementally newer additions built on a decades-old core facility. Clinicians tend to see the consequences as patients see them: not enough private rooms, outdated technology and equipment, poorly integrated computer and health IT systems, and inadequate storage for equipment. Your CFO certainly sees these same things, but has the additional challenge of trying to keep up with the demands for new facilities and capital purchases while maintaining the older physical plant and preserving the long-term financial strength of the organization. Even though roofing, HVAC, and new flooring are rarely as sexy as a new surgical robot, it won’t do much good to invest in that new OR equipment if the roof is leaking. And healthcare construction is really expensive, even more so because of entirely appropriate requirements that renovations bring older structures up to modern codes.
In the healthcare world, these expenses are formidable. Hospitals, like other businesses, sometimes borrow money to fund projects—particularly new construction projects. Nonprofit hospitals can be attractive to lenders because of their tax-advantaged nature. But, like our personal credit ratings, a healthcare system that enters into the bond market has specific metrics at which lenders look carefully to determine the cost of such lending, such as payer mix, income margin, debt ratios, and earnings before interest, depreciation, and amortization (EBIDA). And that’s where we come full circle to that latest conversation with the CFO.
So in order to preserve the ability to meet the needs of stakeholders, our friends in finance need to make sure a long-range plan is in place that continues to fund operations, growth, and ongoing maintenance, including the ability to borrow money when appropriate. Going forward, thriving healthcare organizations will have to be consumer-minded and successful in managing the risks of population health. The uncertainty created by the exchanges and transparency, and the inability to accurately gauge and manage the risk of adverse outcomes, has our CFO colleagues pleading with us for a prescription that will ease their restless nights. Here’s how we can help:
- Focus on working with your group to measure and minimize variations in care processes and outcomes among patients and doctors;
- Be mindful that in a value-based world, CMS and insurers now look at both inpatient and outpatient utilization and costs, and we need to do the same in our transitional care planning; and
- Be conscious that our prescriptions for care are increasingly impacting patients’ wallets, so we need to articulate and demonstrate the clinical value that underlies each decision.
In Sum
The next time you or your nocturnist is admitting that nth patient at 3 a.m., consider that your CFO may also be wide awake, struggling with his or her own version of a management challenge. As physicians who practice in hospitals, which are perhaps the most costly environments in the healthcare world, you and your colleagues may be well positioned to help make your hospitals more efficient, to better manage and improve those outcomes, and to help identify and prioritize the most pressing capital needs.
In short, just what the doctor ordered for your CFO to finally get a good night’s sleep.
Dr. Harte is president of Hillcrest Hospital in Mayfield Heights, Ohio, part of the Cleveland Clinic Health System. He is associate professor of medicine at the Lerner College of Medicine in Cleveland and an SHM board member.
Bill to Clarify Three-Midnight Rule for Medicare Patients Gains Support from Congress, Hospitalists
In 2010, my office received a call from a Norwich, Conn., family whose 89-year-old father had fallen and broken his hip. After he was treated in the local hospital for four days, his doctor prescribed follow-on skilled nursing facility (SNF) care. Upon his arrival at the nursing home, his family was informed that they would have to pay more than $10,000 up front to cover the cost of his care: Because he had never been admitted to the hospital as an inpatient, Medicare would not cover the prescribed rehabilitative care that he needed to return home safely.
I know that hospitalists are already far too familiar with stories like this. Together, we can work to make sure it doesn’t happen again.
Support Is Growing
For me, that family’s story was a call for action. Shortly after speaking with the family, I introduced the Improving Access to Medicare Coverage Act (H.R. 1179). The bill is simple: It would restore the three-day hospital stay standard for SNF coverage, whether the stay is coded as inpatient under Part A or outpatient observation under Part B. Two Congresses later, support for the proposal is growing. In the 113th Congress, the bill has 137 bipartisan cosponsors, an indication of how widespread this problem is for Medicare beneficiaries.
The outdated Medicare law on skilled nursing care coverage is creating financial and healthcare dilemmas for families across the country. Under current law, beneficiaries must have a hospital inpatient stay of at least three days in order to qualify for Medicare coverage SNF benefits; however, more and more patients are being coded under observation status, and access to post-acute SNF care is diminishing. Patients are suffering, and healthcare providers are caught in the middle.
In fact, the Office of the Inspector General at the Department of Health and Human Services released a report last fall that showed that Medicare beneficiaries in 2012 had more than 600,000 hospital stays that lasted three nights, yet none were admitted as inpatients. Even though these beneficiaries likely received the same care inpatients received, their observation status designation disqualified them from Medicare coverage of the SNF benefit. For their families, prescribed follow-on SNF care would have an out-of-pocket cost averaging more than $10,000. For seniors on fixed incomes, that is a devastating financial penalty for a service that should be covered by their health plans.
—Rep. Joe Courtney
Administrative Oversight
There are many reasons for the growth in observation status treatments, but a primary driver is increasing scrutiny of admitting practices by recovery audit contractors (RACs). The consequences of RAC review processes have created difficult situations for hospitals, because admitting decisions are reviewable for three years, and hospitals can be hit with claw-back penalties for payments on behalf of patients RACs determine were incorrectly admitted. To prevent costly penalties and protracted appeals of individual cases, many hospitals feel an understandable amount of pressure to err on the side of treating patients under outpatient observation status covered under Part B.
The original intent of the three-day inpatient stay requirement was to serve as a tangible measure of medical necessity of SNF care. And, when the three-day inpatient stay prerequisite was written into law, long-term hospital observation stays were nonexistent. This intent has been lost in a changing system of hospital oversight under RACs and admitting practices.
The impact on patients and families is tragic.
Ann Sheehy, MD, MS, FHM, a hospitalist speaking on behalf of the Society of Hospital Medicine on a recent conference call I hosted, detailed the scenes she sees every day with her own patients. She described how doctors, knowing that a patient lacks the means to pay for rehabilitative care out of pocket and the support system to recover safely at home, sometimes keep the patient in the hospital longer, at a higher cost to Medicare. In other cases, Dr. Sheehy noted that patients end up back in the hospital soon after being discharged, having foregone expensive SNF care and subsequently suffered preventable injuries and illnesses. Both of these outcomes are bad for patients—and bad for Medicare expenditures.
Three-Day Fix
While the problem of observation status treatment is complex, the solution is simple.
As observation status becomes more ingrained in the healthcare lexicon, a legislative fix to restore the three-day hospital stay standard is needed now more than ever. Three days in the hospital—whether as an inpatient or under outpatient observation—should count for three days in the hospital when Medicare determines eligibility for SNF coverage.
My bill, H.R. 1179, is the most direct solution to rectify the flaw that leaves hundreds of thousands of beneficiaries wondering how their stay in the hospital does not “count” and scrambling to figure out how to pay for care—or foregoing it entirely. The strong support in the advocacy community for this legislation—especially from SHM—and the sway of outside groups cannot be overstated. In Washington’s current climate, the only thing that moves bipartisan issues forward is outside pressure.
Together, I hope hospitalists and members of Congress will reach the critical mass needed to pass this legislation and ensure that Medicare beneficiaries are covered for medically necessary care.
Joseph “Joe” Courtney is the U.S. Representative for Connecticut’s second congressional district, serving since 2007. The district includes most of the eastern third of the state, including Norwich and New London.
In 2010, my office received a call from a Norwich, Conn., family whose 89-year-old father had fallen and broken his hip. After he was treated in the local hospital for four days, his doctor prescribed follow-on skilled nursing facility (SNF) care. Upon his arrival at the nursing home, his family was informed that they would have to pay more than $10,000 up front to cover the cost of his care: Because he had never been admitted to the hospital as an inpatient, Medicare would not cover the prescribed rehabilitative care that he needed to return home safely.
I know that hospitalists are already far too familiar with stories like this. Together, we can work to make sure it doesn’t happen again.
Support Is Growing
For me, that family’s story was a call for action. Shortly after speaking with the family, I introduced the Improving Access to Medicare Coverage Act (H.R. 1179). The bill is simple: It would restore the three-day hospital stay standard for SNF coverage, whether the stay is coded as inpatient under Part A or outpatient observation under Part B. Two Congresses later, support for the proposal is growing. In the 113th Congress, the bill has 137 bipartisan cosponsors, an indication of how widespread this problem is for Medicare beneficiaries.
The outdated Medicare law on skilled nursing care coverage is creating financial and healthcare dilemmas for families across the country. Under current law, beneficiaries must have a hospital inpatient stay of at least three days in order to qualify for Medicare coverage SNF benefits; however, more and more patients are being coded under observation status, and access to post-acute SNF care is diminishing. Patients are suffering, and healthcare providers are caught in the middle.
In fact, the Office of the Inspector General at the Department of Health and Human Services released a report last fall that showed that Medicare beneficiaries in 2012 had more than 600,000 hospital stays that lasted three nights, yet none were admitted as inpatients. Even though these beneficiaries likely received the same care inpatients received, their observation status designation disqualified them from Medicare coverage of the SNF benefit. For their families, prescribed follow-on SNF care would have an out-of-pocket cost averaging more than $10,000. For seniors on fixed incomes, that is a devastating financial penalty for a service that should be covered by their health plans.
—Rep. Joe Courtney
Administrative Oversight
There are many reasons for the growth in observation status treatments, but a primary driver is increasing scrutiny of admitting practices by recovery audit contractors (RACs). The consequences of RAC review processes have created difficult situations for hospitals, because admitting decisions are reviewable for three years, and hospitals can be hit with claw-back penalties for payments on behalf of patients RACs determine were incorrectly admitted. To prevent costly penalties and protracted appeals of individual cases, many hospitals feel an understandable amount of pressure to err on the side of treating patients under outpatient observation status covered under Part B.
The original intent of the three-day inpatient stay requirement was to serve as a tangible measure of medical necessity of SNF care. And, when the three-day inpatient stay prerequisite was written into law, long-term hospital observation stays were nonexistent. This intent has been lost in a changing system of hospital oversight under RACs and admitting practices.
The impact on patients and families is tragic.
Ann Sheehy, MD, MS, FHM, a hospitalist speaking on behalf of the Society of Hospital Medicine on a recent conference call I hosted, detailed the scenes she sees every day with her own patients. She described how doctors, knowing that a patient lacks the means to pay for rehabilitative care out of pocket and the support system to recover safely at home, sometimes keep the patient in the hospital longer, at a higher cost to Medicare. In other cases, Dr. Sheehy noted that patients end up back in the hospital soon after being discharged, having foregone expensive SNF care and subsequently suffered preventable injuries and illnesses. Both of these outcomes are bad for patients—and bad for Medicare expenditures.
Three-Day Fix
While the problem of observation status treatment is complex, the solution is simple.
As observation status becomes more ingrained in the healthcare lexicon, a legislative fix to restore the three-day hospital stay standard is needed now more than ever. Three days in the hospital—whether as an inpatient or under outpatient observation—should count for three days in the hospital when Medicare determines eligibility for SNF coverage.
My bill, H.R. 1179, is the most direct solution to rectify the flaw that leaves hundreds of thousands of beneficiaries wondering how their stay in the hospital does not “count” and scrambling to figure out how to pay for care—or foregoing it entirely. The strong support in the advocacy community for this legislation—especially from SHM—and the sway of outside groups cannot be overstated. In Washington’s current climate, the only thing that moves bipartisan issues forward is outside pressure.
Together, I hope hospitalists and members of Congress will reach the critical mass needed to pass this legislation and ensure that Medicare beneficiaries are covered for medically necessary care.
Joseph “Joe” Courtney is the U.S. Representative for Connecticut’s second congressional district, serving since 2007. The district includes most of the eastern third of the state, including Norwich and New London.
In 2010, my office received a call from a Norwich, Conn., family whose 89-year-old father had fallen and broken his hip. After he was treated in the local hospital for four days, his doctor prescribed follow-on skilled nursing facility (SNF) care. Upon his arrival at the nursing home, his family was informed that they would have to pay more than $10,000 up front to cover the cost of his care: Because he had never been admitted to the hospital as an inpatient, Medicare would not cover the prescribed rehabilitative care that he needed to return home safely.
I know that hospitalists are already far too familiar with stories like this. Together, we can work to make sure it doesn’t happen again.
Support Is Growing
For me, that family’s story was a call for action. Shortly after speaking with the family, I introduced the Improving Access to Medicare Coverage Act (H.R. 1179). The bill is simple: It would restore the three-day hospital stay standard for SNF coverage, whether the stay is coded as inpatient under Part A or outpatient observation under Part B. Two Congresses later, support for the proposal is growing. In the 113th Congress, the bill has 137 bipartisan cosponsors, an indication of how widespread this problem is for Medicare beneficiaries.
The outdated Medicare law on skilled nursing care coverage is creating financial and healthcare dilemmas for families across the country. Under current law, beneficiaries must have a hospital inpatient stay of at least three days in order to qualify for Medicare coverage SNF benefits; however, more and more patients are being coded under observation status, and access to post-acute SNF care is diminishing. Patients are suffering, and healthcare providers are caught in the middle.
In fact, the Office of the Inspector General at the Department of Health and Human Services released a report last fall that showed that Medicare beneficiaries in 2012 had more than 600,000 hospital stays that lasted three nights, yet none were admitted as inpatients. Even though these beneficiaries likely received the same care inpatients received, their observation status designation disqualified them from Medicare coverage of the SNF benefit. For their families, prescribed follow-on SNF care would have an out-of-pocket cost averaging more than $10,000. For seniors on fixed incomes, that is a devastating financial penalty for a service that should be covered by their health plans.
—Rep. Joe Courtney
Administrative Oversight
There are many reasons for the growth in observation status treatments, but a primary driver is increasing scrutiny of admitting practices by recovery audit contractors (RACs). The consequences of RAC review processes have created difficult situations for hospitals, because admitting decisions are reviewable for three years, and hospitals can be hit with claw-back penalties for payments on behalf of patients RACs determine were incorrectly admitted. To prevent costly penalties and protracted appeals of individual cases, many hospitals feel an understandable amount of pressure to err on the side of treating patients under outpatient observation status covered under Part B.
The original intent of the three-day inpatient stay requirement was to serve as a tangible measure of medical necessity of SNF care. And, when the three-day inpatient stay prerequisite was written into law, long-term hospital observation stays were nonexistent. This intent has been lost in a changing system of hospital oversight under RACs and admitting practices.
The impact on patients and families is tragic.
Ann Sheehy, MD, MS, FHM, a hospitalist speaking on behalf of the Society of Hospital Medicine on a recent conference call I hosted, detailed the scenes she sees every day with her own patients. She described how doctors, knowing that a patient lacks the means to pay for rehabilitative care out of pocket and the support system to recover safely at home, sometimes keep the patient in the hospital longer, at a higher cost to Medicare. In other cases, Dr. Sheehy noted that patients end up back in the hospital soon after being discharged, having foregone expensive SNF care and subsequently suffered preventable injuries and illnesses. Both of these outcomes are bad for patients—and bad for Medicare expenditures.
Three-Day Fix
While the problem of observation status treatment is complex, the solution is simple.
As observation status becomes more ingrained in the healthcare lexicon, a legislative fix to restore the three-day hospital stay standard is needed now more than ever. Three days in the hospital—whether as an inpatient or under outpatient observation—should count for three days in the hospital when Medicare determines eligibility for SNF coverage.
My bill, H.R. 1179, is the most direct solution to rectify the flaw that leaves hundreds of thousands of beneficiaries wondering how their stay in the hospital does not “count” and scrambling to figure out how to pay for care—or foregoing it entirely. The strong support in the advocacy community for this legislation—especially from SHM—and the sway of outside groups cannot be overstated. In Washington’s current climate, the only thing that moves bipartisan issues forward is outside pressure.
Together, I hope hospitalists and members of Congress will reach the critical mass needed to pass this legislation and ensure that Medicare beneficiaries are covered for medically necessary care.
Joseph “Joe” Courtney is the U.S. Representative for Connecticut’s second congressional district, serving since 2007. The district includes most of the eastern third of the state, including Norwich and New London.
State of the Art
It has been a couple of years since Jason Stein, MD, SFHM, a hospitalist at Emory University School of Medicine in Atlanta, first reported on his experience with accountable care units (ACUs) and structured interdisciplinary bedside rounds (SIBR). With ACUs, Jason and his team undertook an “extreme makeover” of care on the hospital ward. Because most hospitalist groups are endeavoring to address team-based care, I took the opportunity to catch up with and learn from Jason, who has created an exciting and compelling approach to multidisciplinary, collaborative care in the hospital.
In 2012, Jason’s team won SHM’s Excellence in Teamwork in Quality Improvement Award, and Jason was selected as an innovation advisor to the Center for Medicare and Medicaid Innovation. Since then, ACUs and SIBR have been implemented at a number of sites in the U.S. and abroad, and the work has been referenced by the Agency for Healthcare Research and Quality and the Harvard Business Review. Jason has created Centripital, a nonprofit that trains members of the hospital team to collaborate optimally around the patient and family, the central focus of care.
Here are some excerpts from my interview with Jason:
Question: What is an accountable care unit (ACU)?
Answer: We defined an ACU as a geographic inpatient care area consistently responsible for the clinical, service, and cost outcomes it produces. There are four essential design features of ACUs: 1) unit-based physician teams; 2) structured interdisciplinary bedside rounds, or SIBR; 3) unit-level performance reports; and 4) unit co-management by nurse and physician directors.
Q: What were you observing in the care of the hospitalized patient that led you to create ACUs?
A: We saw fragmentation. We saw weak cohesiveness and poor communication among doctors, nurses, and allied health professionals. HM physicians who travel all over the hospital seeing patients are living with an illusion of teamwork. In reality, to be a high-functioning team, physicians have to share time, space, and a standard way to work together with nurses, patients, and families. When we embraced this way of thinking, we realized we could be so much better than we were. The key was to re-engineer a way to really work together.
Q: What makes an ACU successful?
A: In a word, control. An ACU creates new control levers for all of the key players to have greater influence on other members of the team—nurses with doctors, doctors with nurses, patients with everyone, and vice versa. It’s actually quite simple how this happens. The ACU clinical team spends the day together, caring for the same group of patients. Everyone communicates face to face, rather than by page, text, or phone. Stronger relationships are built, and clinicians are more respectful of one another. A different level of responsiveness and accountability is created. The feeling that every person is accountable to the patient and to the other team members allows the team to gain greater control over what happens on the unit. That’s a very powerful dynamic.
SIBR further reinforces the mutual accountability on an ACU. During SIBR, each person has a chance to hear and be heard, to share their perspective, and to contribute to the care plan. Day after day, SIBR creates a positive, collaborative culture of patient care. Once clinicians realize how much control and how much self-actualization they gain on an ACU, it seems impossible to go back to the old way.
—Jason Stein, MD, SFHM
Q: What is the biggest challenge in implementing and sustaining an ACU?
A: The first challenge, of course, is that this is change. And up front—before they realize they will actually gain greater control from the ACU-SIBR model—nurses and, particularly, doctors can perceive this change as a loss of control. “You’re telling me I have to SIBR every morning? At what time? And I have to do all my primary data gathering, including a patient interview and physical exam, before SIBR? Let me stop you right there. I’m way too busy for that.”
Naturally, not everyone immediately sees that they can gain rather than lose efficiency.
Another challenge is the logistics of implementing and then maintaining unit-based physician teams. There are multiple forces that can make geographic units a challenge to create and sustain, but all the logistics are manageable.
Q: How have you helped hospitals transition from a physician-centric model to the geographic-based model?
A: The most important factor in transitioning to an ACU model is for physicians to come to terms with the reality that geography must be the primary driver of physician assignments to patients. Nurses figured this out a long time ago. Do any of us know, bedside nurses who care for patients on multiple different units? As physicians, we’re due for the same realization.
But this means sacrificing long-practiced physician-centric methods of assigning ourselves to patients: call schedules, load balancing across practice partners—even the cherished concept of continuity is a force that can be at odds with geography as the driver. The way to approach the transition to unit-based teams is to have an honest dialogue. Why do we come to work in the hospital every day? If it’s to serve physician needs first, the old model deserves our loyalty. But if the needs of our patients and families are our focus, then we should embrace models that enable us to work effectively together, to become a great team.
Q: How have ACUs performed so far?
A: In the highest-acuity ACUs, we’ve seen mortality reductions of nearly 50%. In addition, there is a wide range of anecdotal outcomes reported. Most ACUs appear to be seeing reductions in length of stay and improvements in patient satisfaction and employee engagement. One ACU reports significant reductions in average cost per patient per day. Another ACU in a geriatric unit has seen dramatic reductions in falls. Some ACUs have seen improvements in glycemic control and VTE prophylaxis, and reductions in catheter utilization.
The benefits of the model seem to be many and probably depend on the patient population, severity of illness, baseline level of performance, and the focus and ability of the unit leadership team to get the most out of the model.
Q: Will ACUs or ACU features become de rigueur in a transformed healthcare landscape?
A: It’s hard to imagine a reality where features of ACUs do not become the standard of care. Once patients and professionals experience the impact of the ACU model, there’ll be no going back. It feels like exactly what we should be doing together. Several ACU design features are reinforced pretty cogently by Richard Bohmer in a New England Journal of Medicine perspective called “The Four Habits of High-Value Health Care Organizations.”1
Q: Any final thoughts?
A: I did not imagine my career as a QI practitioner at Emory becoming so immersed in social and industrial engineering. Of course, it’s obvious to me now that it’s happened, but six years ago when I first started directing SHM’s quality course, I thought the future in HM was health IT and real-time dashboards. Now I know those things will be important, but only if we first figure out how to get our frontline interdisciplinary clinicians to work as an effective team.
Dr. Whitcomb is Chief Medical Officer of Remedy Partners. He is co-founder and past president of SHM. Email him at wfwhit@comcast.net.
Reference
It has been a couple of years since Jason Stein, MD, SFHM, a hospitalist at Emory University School of Medicine in Atlanta, first reported on his experience with accountable care units (ACUs) and structured interdisciplinary bedside rounds (SIBR). With ACUs, Jason and his team undertook an “extreme makeover” of care on the hospital ward. Because most hospitalist groups are endeavoring to address team-based care, I took the opportunity to catch up with and learn from Jason, who has created an exciting and compelling approach to multidisciplinary, collaborative care in the hospital.
In 2012, Jason’s team won SHM’s Excellence in Teamwork in Quality Improvement Award, and Jason was selected as an innovation advisor to the Center for Medicare and Medicaid Innovation. Since then, ACUs and SIBR have been implemented at a number of sites in the U.S. and abroad, and the work has been referenced by the Agency for Healthcare Research and Quality and the Harvard Business Review. Jason has created Centripital, a nonprofit that trains members of the hospital team to collaborate optimally around the patient and family, the central focus of care.
Here are some excerpts from my interview with Jason:
Question: What is an accountable care unit (ACU)?
Answer: We defined an ACU as a geographic inpatient care area consistently responsible for the clinical, service, and cost outcomes it produces. There are four essential design features of ACUs: 1) unit-based physician teams; 2) structured interdisciplinary bedside rounds, or SIBR; 3) unit-level performance reports; and 4) unit co-management by nurse and physician directors.
Q: What were you observing in the care of the hospitalized patient that led you to create ACUs?
A: We saw fragmentation. We saw weak cohesiveness and poor communication among doctors, nurses, and allied health professionals. HM physicians who travel all over the hospital seeing patients are living with an illusion of teamwork. In reality, to be a high-functioning team, physicians have to share time, space, and a standard way to work together with nurses, patients, and families. When we embraced this way of thinking, we realized we could be so much better than we were. The key was to re-engineer a way to really work together.
Q: What makes an ACU successful?
A: In a word, control. An ACU creates new control levers for all of the key players to have greater influence on other members of the team—nurses with doctors, doctors with nurses, patients with everyone, and vice versa. It’s actually quite simple how this happens. The ACU clinical team spends the day together, caring for the same group of patients. Everyone communicates face to face, rather than by page, text, or phone. Stronger relationships are built, and clinicians are more respectful of one another. A different level of responsiveness and accountability is created. The feeling that every person is accountable to the patient and to the other team members allows the team to gain greater control over what happens on the unit. That’s a very powerful dynamic.
SIBR further reinforces the mutual accountability on an ACU. During SIBR, each person has a chance to hear and be heard, to share their perspective, and to contribute to the care plan. Day after day, SIBR creates a positive, collaborative culture of patient care. Once clinicians realize how much control and how much self-actualization they gain on an ACU, it seems impossible to go back to the old way.
—Jason Stein, MD, SFHM
Q: What is the biggest challenge in implementing and sustaining an ACU?
A: The first challenge, of course, is that this is change. And up front—before they realize they will actually gain greater control from the ACU-SIBR model—nurses and, particularly, doctors can perceive this change as a loss of control. “You’re telling me I have to SIBR every morning? At what time? And I have to do all my primary data gathering, including a patient interview and physical exam, before SIBR? Let me stop you right there. I’m way too busy for that.”
Naturally, not everyone immediately sees that they can gain rather than lose efficiency.
Another challenge is the logistics of implementing and then maintaining unit-based physician teams. There are multiple forces that can make geographic units a challenge to create and sustain, but all the logistics are manageable.
Q: How have you helped hospitals transition from a physician-centric model to the geographic-based model?
A: The most important factor in transitioning to an ACU model is for physicians to come to terms with the reality that geography must be the primary driver of physician assignments to patients. Nurses figured this out a long time ago. Do any of us know, bedside nurses who care for patients on multiple different units? As physicians, we’re due for the same realization.
But this means sacrificing long-practiced physician-centric methods of assigning ourselves to patients: call schedules, load balancing across practice partners—even the cherished concept of continuity is a force that can be at odds with geography as the driver. The way to approach the transition to unit-based teams is to have an honest dialogue. Why do we come to work in the hospital every day? If it’s to serve physician needs first, the old model deserves our loyalty. But if the needs of our patients and families are our focus, then we should embrace models that enable us to work effectively together, to become a great team.
Q: How have ACUs performed so far?
A: In the highest-acuity ACUs, we’ve seen mortality reductions of nearly 50%. In addition, there is a wide range of anecdotal outcomes reported. Most ACUs appear to be seeing reductions in length of stay and improvements in patient satisfaction and employee engagement. One ACU reports significant reductions in average cost per patient per day. Another ACU in a geriatric unit has seen dramatic reductions in falls. Some ACUs have seen improvements in glycemic control and VTE prophylaxis, and reductions in catheter utilization.
The benefits of the model seem to be many and probably depend on the patient population, severity of illness, baseline level of performance, and the focus and ability of the unit leadership team to get the most out of the model.
Q: Will ACUs or ACU features become de rigueur in a transformed healthcare landscape?
A: It’s hard to imagine a reality where features of ACUs do not become the standard of care. Once patients and professionals experience the impact of the ACU model, there’ll be no going back. It feels like exactly what we should be doing together. Several ACU design features are reinforced pretty cogently by Richard Bohmer in a New England Journal of Medicine perspective called “The Four Habits of High-Value Health Care Organizations.”1
Q: Any final thoughts?
A: I did not imagine my career as a QI practitioner at Emory becoming so immersed in social and industrial engineering. Of course, it’s obvious to me now that it’s happened, but six years ago when I first started directing SHM’s quality course, I thought the future in HM was health IT and real-time dashboards. Now I know those things will be important, but only if we first figure out how to get our frontline interdisciplinary clinicians to work as an effective team.
Dr. Whitcomb is Chief Medical Officer of Remedy Partners. He is co-founder and past president of SHM. Email him at wfwhit@comcast.net.
Reference
It has been a couple of years since Jason Stein, MD, SFHM, a hospitalist at Emory University School of Medicine in Atlanta, first reported on his experience with accountable care units (ACUs) and structured interdisciplinary bedside rounds (SIBR). With ACUs, Jason and his team undertook an “extreme makeover” of care on the hospital ward. Because most hospitalist groups are endeavoring to address team-based care, I took the opportunity to catch up with and learn from Jason, who has created an exciting and compelling approach to multidisciplinary, collaborative care in the hospital.
In 2012, Jason’s team won SHM’s Excellence in Teamwork in Quality Improvement Award, and Jason was selected as an innovation advisor to the Center for Medicare and Medicaid Innovation. Since then, ACUs and SIBR have been implemented at a number of sites in the U.S. and abroad, and the work has been referenced by the Agency for Healthcare Research and Quality and the Harvard Business Review. Jason has created Centripital, a nonprofit that trains members of the hospital team to collaborate optimally around the patient and family, the central focus of care.
Here are some excerpts from my interview with Jason:
Question: What is an accountable care unit (ACU)?
Answer: We defined an ACU as a geographic inpatient care area consistently responsible for the clinical, service, and cost outcomes it produces. There are four essential design features of ACUs: 1) unit-based physician teams; 2) structured interdisciplinary bedside rounds, or SIBR; 3) unit-level performance reports; and 4) unit co-management by nurse and physician directors.
Q: What were you observing in the care of the hospitalized patient that led you to create ACUs?
A: We saw fragmentation. We saw weak cohesiveness and poor communication among doctors, nurses, and allied health professionals. HM physicians who travel all over the hospital seeing patients are living with an illusion of teamwork. In reality, to be a high-functioning team, physicians have to share time, space, and a standard way to work together with nurses, patients, and families. When we embraced this way of thinking, we realized we could be so much better than we were. The key was to re-engineer a way to really work together.
Q: What makes an ACU successful?
A: In a word, control. An ACU creates new control levers for all of the key players to have greater influence on other members of the team—nurses with doctors, doctors with nurses, patients with everyone, and vice versa. It’s actually quite simple how this happens. The ACU clinical team spends the day together, caring for the same group of patients. Everyone communicates face to face, rather than by page, text, or phone. Stronger relationships are built, and clinicians are more respectful of one another. A different level of responsiveness and accountability is created. The feeling that every person is accountable to the patient and to the other team members allows the team to gain greater control over what happens on the unit. That’s a very powerful dynamic.
SIBR further reinforces the mutual accountability on an ACU. During SIBR, each person has a chance to hear and be heard, to share their perspective, and to contribute to the care plan. Day after day, SIBR creates a positive, collaborative culture of patient care. Once clinicians realize how much control and how much self-actualization they gain on an ACU, it seems impossible to go back to the old way.
—Jason Stein, MD, SFHM
Q: What is the biggest challenge in implementing and sustaining an ACU?
A: The first challenge, of course, is that this is change. And up front—before they realize they will actually gain greater control from the ACU-SIBR model—nurses and, particularly, doctors can perceive this change as a loss of control. “You’re telling me I have to SIBR every morning? At what time? And I have to do all my primary data gathering, including a patient interview and physical exam, before SIBR? Let me stop you right there. I’m way too busy for that.”
Naturally, not everyone immediately sees that they can gain rather than lose efficiency.
Another challenge is the logistics of implementing and then maintaining unit-based physician teams. There are multiple forces that can make geographic units a challenge to create and sustain, but all the logistics are manageable.
Q: How have you helped hospitals transition from a physician-centric model to the geographic-based model?
A: The most important factor in transitioning to an ACU model is for physicians to come to terms with the reality that geography must be the primary driver of physician assignments to patients. Nurses figured this out a long time ago. Do any of us know, bedside nurses who care for patients on multiple different units? As physicians, we’re due for the same realization.
But this means sacrificing long-practiced physician-centric methods of assigning ourselves to patients: call schedules, load balancing across practice partners—even the cherished concept of continuity is a force that can be at odds with geography as the driver. The way to approach the transition to unit-based teams is to have an honest dialogue. Why do we come to work in the hospital every day? If it’s to serve physician needs first, the old model deserves our loyalty. But if the needs of our patients and families are our focus, then we should embrace models that enable us to work effectively together, to become a great team.
Q: How have ACUs performed so far?
A: In the highest-acuity ACUs, we’ve seen mortality reductions of nearly 50%. In addition, there is a wide range of anecdotal outcomes reported. Most ACUs appear to be seeing reductions in length of stay and improvements in patient satisfaction and employee engagement. One ACU reports significant reductions in average cost per patient per day. Another ACU in a geriatric unit has seen dramatic reductions in falls. Some ACUs have seen improvements in glycemic control and VTE prophylaxis, and reductions in catheter utilization.
The benefits of the model seem to be many and probably depend on the patient population, severity of illness, baseline level of performance, and the focus and ability of the unit leadership team to get the most out of the model.
Q: Will ACUs or ACU features become de rigueur in a transformed healthcare landscape?
A: It’s hard to imagine a reality where features of ACUs do not become the standard of care. Once patients and professionals experience the impact of the ACU model, there’ll be no going back. It feels like exactly what we should be doing together. Several ACU design features are reinforced pretty cogently by Richard Bohmer in a New England Journal of Medicine perspective called “The Four Habits of High-Value Health Care Organizations.”1
Q: Any final thoughts?
A: I did not imagine my career as a QI practitioner at Emory becoming so immersed in social and industrial engineering. Of course, it’s obvious to me now that it’s happened, but six years ago when I first started directing SHM’s quality course, I thought the future in HM was health IT and real-time dashboards. Now I know those things will be important, but only if we first figure out how to get our frontline interdisciplinary clinicians to work as an effective team.
Dr. Whitcomb is Chief Medical Officer of Remedy Partners. He is co-founder and past president of SHM. Email him at wfwhit@comcast.net.
Reference
Hospital Medicine Leaders Share Practice Management Pearls at HM14
LAS VEGAS—Susan Eschenburg, practice program manager at Independent Hospitalist Practice in Jackson, Mich., sat in the practice management pre-course at HM14 and listened to a panel of experts discuss hospitalists’ growing role in post-acute care centers such as skilled nursing facilities.
You could almost hear the bell go off in her head.
“We work in an underserved area, and we’ve just [been asked] if we would be interested in supplying a hospitalist in some of these nursing homes,” Eschenburg said. “We’re going to listen to a spiel next month about that. That was real-time and interesting to listen to.”
That was the point of the practice management sessions at SHM’s annual meeting here at the Mandalay Bay Resort and Casino: to give the most current updates available to administrators, group leaders, and rank-and-file hospitalists about best practices in the day-to-day operation of a group.
For Eschenburg, the lessons learned here are particularly helpful; her group just launched its hospitalist program in September and is dealing with a variety of implementation questions, including whether to use scribes to enhance patient-physician interaction, improve documentation, save physician time, and reduce technology-related errors. Other issues that resonate with her include scheduling and the amount of time that administrative leaders should spend in the clinical setting.
The meeting helped “[us] to see if there’s anything out there that we haven’t thought about or talked about,” Eschenburg said. “We’re not this big corporate giant that can’t make quick movements.”
Whether a hospitalist is working at a new practice in an underserved area or as a department head at a massive academic institution, a new white paper from SHM can provide information on how to move toward those best practices. “The Key Principles and Characteristics of an Effective Hospital Medicine Group: An Assessment Guide for Hospitals and Hospitalists” (http://onlinelibrary.wiley.com/doi/10.1002/jhm.2119/full), published in February in the Journal of Hospital Medicine, lists 10 guiding principles and 47 individual characteristics as a launching point for best practices.
Although the white paper is a first-of-its-kind initiative, SHM isn’t stopping there. Society staff and committee members are working to roll out a pilot program later this year that will ask group leaders to validate the key characteristics. SHM will provide back-up documentation, such as sample business plans or other toolkits, to implement some of the recommendations. Group leaders will be asked to use the documentation to determine whether or not it helps them achieve the goals.
–Dr. Wellikson
“One valuable thing that could come out of the pilot is not just feedback from you that will help us refine the key characteristics, but also ideas about resources that SHM can provide to help you better accomplish the things the key characteristics set forth,” said Leslie Flores, MHA, a partner in Nelson Flores Hospital Medicine Consultants, a member of SHM’s Practice Analysis Committee, and a co-director for the popular practice management pre-course, “Where the Rubber Meets the Road: Managing in the Era of Healthcare Reform.”
Put more simply by Flores’ consulting colleague, John Nelson, MD, MHM, FACP: “We’ll learn from each other the best ways to do this.”
SHM senior vice president Joe Miller added that the white paper “simply identifies the characteristics and includes a rationale as to why they’re included.” The pilot program, however, will produce “a more enriched tool that you can use in a more directed fashion,” Miller said, “but we felt it was important to get this out right now and get the sense that we’ve identified the right issues.”
SHM CEO Larry Wellikson, MD, SFHM, said the initiative is “bold” and encouraged HM groups that are below standard in any area to step up their games.
“What we’re saying to you and your colleagues is that some of you aren’t performing necessarily at the best level you can,” Dr. Wellikson said. “We want to give you a pathway to get better, because at the end of the day, we’re all in this to deliver the best care we can to our patients. So we recognize where we aren’t perfect, and we try to improve.”
Those seeking practice management advice said they’re always thinking about ways to improve, and being with 3,600 like-minded folks often helps tease out tidbits and strategies to get better.
Sunil Kartham, MD, a hospitalist at Altru Health System in Grand Forks, N.D., said he enjoys hearing HM leaders give advice, whether they’re practice administrators in individual sessions or keynote speakers in large ballrooms.
“When you’re [an] individual physician, you don’t know what to expect in the future,” Dr. Kartham said. “When the leaders come and speak, they lay out a map for you…so you can prepare yourself.”
Preparing for what the future might bring is what drew Angelo Barile, MD, to the meeting. As the head of the hospitalist group at Cleveland Clinic Lorain Family Health and Surgery Center in Lorain, Ohio, he’s always looking for tips on how to improve the practical side of running a 12-FTE group.
“It helps to see how other people do it, and you get a nice framework of how to do it,” said Dr. Barile. “As busy as we are, running the group [and] seeing patients, it’s nice to get away from the pager [and] get away from my administrators and my bosses and say, ‘I want to try to learn something here.’ It is refreshing.”
Education doesn’t end with the meeting’s finale. Dr. Barile traditionally holds a sit-down with his staff as soon as he returns home. The doctors discuss the new ideas Dr. Barile learned and determine as a group what could work in their practice.
Eschenburg, the nascent program manager in Michigan, said she gets the same reaction when she returns from professional meetings.
“It’s certainly something that people are looking for when you get back,” she said. “What did you learn? What can you share with us?”
LAS VEGAS—Susan Eschenburg, practice program manager at Independent Hospitalist Practice in Jackson, Mich., sat in the practice management pre-course at HM14 and listened to a panel of experts discuss hospitalists’ growing role in post-acute care centers such as skilled nursing facilities.
You could almost hear the bell go off in her head.
“We work in an underserved area, and we’ve just [been asked] if we would be interested in supplying a hospitalist in some of these nursing homes,” Eschenburg said. “We’re going to listen to a spiel next month about that. That was real-time and interesting to listen to.”
That was the point of the practice management sessions at SHM’s annual meeting here at the Mandalay Bay Resort and Casino: to give the most current updates available to administrators, group leaders, and rank-and-file hospitalists about best practices in the day-to-day operation of a group.
For Eschenburg, the lessons learned here are particularly helpful; her group just launched its hospitalist program in September and is dealing with a variety of implementation questions, including whether to use scribes to enhance patient-physician interaction, improve documentation, save physician time, and reduce technology-related errors. Other issues that resonate with her include scheduling and the amount of time that administrative leaders should spend in the clinical setting.
The meeting helped “[us] to see if there’s anything out there that we haven’t thought about or talked about,” Eschenburg said. “We’re not this big corporate giant that can’t make quick movements.”
Whether a hospitalist is working at a new practice in an underserved area or as a department head at a massive academic institution, a new white paper from SHM can provide information on how to move toward those best practices. “The Key Principles and Characteristics of an Effective Hospital Medicine Group: An Assessment Guide for Hospitals and Hospitalists” (http://onlinelibrary.wiley.com/doi/10.1002/jhm.2119/full), published in February in the Journal of Hospital Medicine, lists 10 guiding principles and 47 individual characteristics as a launching point for best practices.
Although the white paper is a first-of-its-kind initiative, SHM isn’t stopping there. Society staff and committee members are working to roll out a pilot program later this year that will ask group leaders to validate the key characteristics. SHM will provide back-up documentation, such as sample business plans or other toolkits, to implement some of the recommendations. Group leaders will be asked to use the documentation to determine whether or not it helps them achieve the goals.
–Dr. Wellikson
“One valuable thing that could come out of the pilot is not just feedback from you that will help us refine the key characteristics, but also ideas about resources that SHM can provide to help you better accomplish the things the key characteristics set forth,” said Leslie Flores, MHA, a partner in Nelson Flores Hospital Medicine Consultants, a member of SHM’s Practice Analysis Committee, and a co-director for the popular practice management pre-course, “Where the Rubber Meets the Road: Managing in the Era of Healthcare Reform.”
Put more simply by Flores’ consulting colleague, John Nelson, MD, MHM, FACP: “We’ll learn from each other the best ways to do this.”
SHM senior vice president Joe Miller added that the white paper “simply identifies the characteristics and includes a rationale as to why they’re included.” The pilot program, however, will produce “a more enriched tool that you can use in a more directed fashion,” Miller said, “but we felt it was important to get this out right now and get the sense that we’ve identified the right issues.”
SHM CEO Larry Wellikson, MD, SFHM, said the initiative is “bold” and encouraged HM groups that are below standard in any area to step up their games.
“What we’re saying to you and your colleagues is that some of you aren’t performing necessarily at the best level you can,” Dr. Wellikson said. “We want to give you a pathway to get better, because at the end of the day, we’re all in this to deliver the best care we can to our patients. So we recognize where we aren’t perfect, and we try to improve.”
Those seeking practice management advice said they’re always thinking about ways to improve, and being with 3,600 like-minded folks often helps tease out tidbits and strategies to get better.
Sunil Kartham, MD, a hospitalist at Altru Health System in Grand Forks, N.D., said he enjoys hearing HM leaders give advice, whether they’re practice administrators in individual sessions or keynote speakers in large ballrooms.
“When you’re [an] individual physician, you don’t know what to expect in the future,” Dr. Kartham said. “When the leaders come and speak, they lay out a map for you…so you can prepare yourself.”
Preparing for what the future might bring is what drew Angelo Barile, MD, to the meeting. As the head of the hospitalist group at Cleveland Clinic Lorain Family Health and Surgery Center in Lorain, Ohio, he’s always looking for tips on how to improve the practical side of running a 12-FTE group.
“It helps to see how other people do it, and you get a nice framework of how to do it,” said Dr. Barile. “As busy as we are, running the group [and] seeing patients, it’s nice to get away from the pager [and] get away from my administrators and my bosses and say, ‘I want to try to learn something here.’ It is refreshing.”
Education doesn’t end with the meeting’s finale. Dr. Barile traditionally holds a sit-down with his staff as soon as he returns home. The doctors discuss the new ideas Dr. Barile learned and determine as a group what could work in their practice.
Eschenburg, the nascent program manager in Michigan, said she gets the same reaction when she returns from professional meetings.
“It’s certainly something that people are looking for when you get back,” she said. “What did you learn? What can you share with us?”
LAS VEGAS—Susan Eschenburg, practice program manager at Independent Hospitalist Practice in Jackson, Mich., sat in the practice management pre-course at HM14 and listened to a panel of experts discuss hospitalists’ growing role in post-acute care centers such as skilled nursing facilities.
You could almost hear the bell go off in her head.
“We work in an underserved area, and we’ve just [been asked] if we would be interested in supplying a hospitalist in some of these nursing homes,” Eschenburg said. “We’re going to listen to a spiel next month about that. That was real-time and interesting to listen to.”
That was the point of the practice management sessions at SHM’s annual meeting here at the Mandalay Bay Resort and Casino: to give the most current updates available to administrators, group leaders, and rank-and-file hospitalists about best practices in the day-to-day operation of a group.
For Eschenburg, the lessons learned here are particularly helpful; her group just launched its hospitalist program in September and is dealing with a variety of implementation questions, including whether to use scribes to enhance patient-physician interaction, improve documentation, save physician time, and reduce technology-related errors. Other issues that resonate with her include scheduling and the amount of time that administrative leaders should spend in the clinical setting.
The meeting helped “[us] to see if there’s anything out there that we haven’t thought about or talked about,” Eschenburg said. “We’re not this big corporate giant that can’t make quick movements.”
Whether a hospitalist is working at a new practice in an underserved area or as a department head at a massive academic institution, a new white paper from SHM can provide information on how to move toward those best practices. “The Key Principles and Characteristics of an Effective Hospital Medicine Group: An Assessment Guide for Hospitals and Hospitalists” (http://onlinelibrary.wiley.com/doi/10.1002/jhm.2119/full), published in February in the Journal of Hospital Medicine, lists 10 guiding principles and 47 individual characteristics as a launching point for best practices.
Although the white paper is a first-of-its-kind initiative, SHM isn’t stopping there. Society staff and committee members are working to roll out a pilot program later this year that will ask group leaders to validate the key characteristics. SHM will provide back-up documentation, such as sample business plans or other toolkits, to implement some of the recommendations. Group leaders will be asked to use the documentation to determine whether or not it helps them achieve the goals.
–Dr. Wellikson
“One valuable thing that could come out of the pilot is not just feedback from you that will help us refine the key characteristics, but also ideas about resources that SHM can provide to help you better accomplish the things the key characteristics set forth,” said Leslie Flores, MHA, a partner in Nelson Flores Hospital Medicine Consultants, a member of SHM’s Practice Analysis Committee, and a co-director for the popular practice management pre-course, “Where the Rubber Meets the Road: Managing in the Era of Healthcare Reform.”
Put more simply by Flores’ consulting colleague, John Nelson, MD, MHM, FACP: “We’ll learn from each other the best ways to do this.”
SHM senior vice president Joe Miller added that the white paper “simply identifies the characteristics and includes a rationale as to why they’re included.” The pilot program, however, will produce “a more enriched tool that you can use in a more directed fashion,” Miller said, “but we felt it was important to get this out right now and get the sense that we’ve identified the right issues.”
SHM CEO Larry Wellikson, MD, SFHM, said the initiative is “bold” and encouraged HM groups that are below standard in any area to step up their games.
“What we’re saying to you and your colleagues is that some of you aren’t performing necessarily at the best level you can,” Dr. Wellikson said. “We want to give you a pathway to get better, because at the end of the day, we’re all in this to deliver the best care we can to our patients. So we recognize where we aren’t perfect, and we try to improve.”
Those seeking practice management advice said they’re always thinking about ways to improve, and being with 3,600 like-minded folks often helps tease out tidbits and strategies to get better.
Sunil Kartham, MD, a hospitalist at Altru Health System in Grand Forks, N.D., said he enjoys hearing HM leaders give advice, whether they’re practice administrators in individual sessions or keynote speakers in large ballrooms.
“When you’re [an] individual physician, you don’t know what to expect in the future,” Dr. Kartham said. “When the leaders come and speak, they lay out a map for you…so you can prepare yourself.”
Preparing for what the future might bring is what drew Angelo Barile, MD, to the meeting. As the head of the hospitalist group at Cleveland Clinic Lorain Family Health and Surgery Center in Lorain, Ohio, he’s always looking for tips on how to improve the practical side of running a 12-FTE group.
“It helps to see how other people do it, and you get a nice framework of how to do it,” said Dr. Barile. “As busy as we are, running the group [and] seeing patients, it’s nice to get away from the pager [and] get away from my administrators and my bosses and say, ‘I want to try to learn something here.’ It is refreshing.”
Education doesn’t end with the meeting’s finale. Dr. Barile traditionally holds a sit-down with his staff as soon as he returns home. The doctors discuss the new ideas Dr. Barile learned and determine as a group what could work in their practice.
Eschenburg, the nascent program manager in Michigan, said she gets the same reaction when she returns from professional meetings.
“It’s certainly something that people are looking for when you get back,” she said. “What did you learn? What can you share with us?”
How Hospitalists Can Improve Efficiency on Inpatient Wards
At some point in residency, we all learn that time management and multitasking are vital to ward efficiency; however, it is important to note that efficiency as a hospitalist is as much about providing high quality clinical care as it is about maximizing resources, reducing waste, and avoiding redundancy in the process.
This article examines the pre-rounding, rounding, and follow-up phases of a hospitalist’s typical workday and provides suggestions to help streamline your work—and enhance both personal and system efficiency.
Pre-Rounding
While most would agree that preparing for rounds is essential to making them effective, longer patient lists may lead to hours of pre-rounding. Often, by the time you get to the “rounding stage,” things change. To make this a more productive exercise, we recommend “focused pre-rounding,” which allows you to organize your efforts as follows:
- For overnight admissions, skim through such data as presenting complaint, relevant past medical history, exam, labs, and radiology, looking for any critical values or findings that may need immediate attention. As you prioritize your order of rounding, you are also familiarizing yourself with the cases, which will reassure your new patients.
- For patients who are already on service, do a quick review of any acute overnight events or important management needs. For example, you may have to follow up on a CT head for a patient who fell overnight or check fasting blood sugars to modify a diabetic ketoacidosis patient’s morning insulin dose. These are time-sensitive issues that may need your attention before you actually lay eyes on the patient.
- Prioritize visits and learn to manage patient expectations. Organize your patient visits based on the data gathered from pre-rounding. Seeing potential discharges first helps the hospital open up beds early and facilitates patient throughput. As appealing as early discharge is to any hospital administrator, those working in a teaching setting might argue that first priority should go to night float admissions that have not been “staffed” by an attending yet.
Barring urgent patient care issues, we would recommend that patients who are ready for discharge pending a face-to-face visit or a morning lab should be seen first. You can attend to the new admissions next. In contrast, there is no rush to see potential discharges undergoing a procedure such as an esophagogastroduodenoscopy or stress test. Furthermore, if your decision-making hinges on these test results, timing your visit so that it occurs after the procedure makes your rounding even more efficient. In these situations, informing the patient the evening prior to rounding that you will be visiting them late the next day is not only professionally courteous, but also goes a long way in managing their expectations and enhancing patient satisfaction.
Rounding (The Patient Encounter)
Be professional. Introduce yourself and, if necessary, explain your role as a hospitalist. Sit down when possible. Studies have shown that just the act of sitting makes patients feel that you are communicating better and spending more time with them. If you normally walk or talk quickly, try to slow down temporarily while in the room. The art is for you to be cognizant of the time while avoiding the appearance of impatience.
Engage the patient and/or family. Interact with patients in a way that makes them feel included in their care. For example, show patients X-rays or use diagrams to explain their disease pathophysiology or any upcoming procedures. We feel that even the less educated patient will have a better understanding of her illness when it’s less abstract and more visually defined.
Set reasonable expectations. The patient or family may have many questions during rounds. If time does not permit, especially when you are rounding with housestaff, it is more efficient to say, “We need to move on for now, but one of us will return later to discuss all of this in more depth.”
For particularly demanding patients and families, manage expectations by communicating honestly about your other patient care responsibilities, while still acknowledging their needs. In these situations, setting up a family meeting to discuss plans of care early in the hospital course can be very productive.
Integrate inter-professional care when possible: Rounding with a care coordinator or the patient’s nurse allows you to share clinical information and plans of care in real time. This can help minimize interruptions and pages later in the day, while enhancing patient safety by limiting communication failures.
Perform tasks “as you go.” Entering orders and calling urgent consults as you round not only provides timely medical care but, by limiting unfinished tasks, also reduces the chances of medical errors.
Post Rounds (Follow-Up Care and Planning)
Start discharge planning on day 1. As you gain experience, predicting patients’ hospital stays and anticipating their discharge needs becomes part of your hospitalist “sixth sense.” Obtaining timely therapy, social work, and case management consults is fundamental to your efficiency as a hospitalist. It is also prudent to keep patients and their families updated on discharge plans.
Delegate responsibilities when possible. Efficiency can be fueled by sharing your workload, especially non-clinical tasks such as obtaining occupational safety and health records, completing SNF forms, or scheduling follow-up appointments. Potential resources include ward secretaries, nurses, or, for more clinical tasks, housestaff, nurse practitioners, or physician assistants. The availability of this support varies substantially between institutions. Still, your goal should be to advocate for a collaborative work environment where support staff are expected to contribute to team efficiency and, by corollary, patient satisfaction.
Document succinctly and in a timely manner. Your notes should reflect the patient’s clinical progress and your thought process. You don’t need to import every detail that can be found elsewhere in the EHR, and you should refrain from long, cut and pasted notes that are often meaningless “note bloat.” Likewise, discharge summaries should be high quality informative documents that list key elements, including discharge diagnoses, discharge medications, follow-up appointments, procedures, and a brief hospital course. These are best done in real time or even the day before, when the case is fresh in your memory. Spending an extra 15 - 30 minutes on this important task is well worth it. Do not let records pile up!
“Run the list.” Among the million other things you’re doing all day, this quick end-of-the-day review of your patient list helps you prepare for the next day. It’s an opportunity to ready things for potential next day discharges, discontinue redundant lab testing, remove unnecessary Foley catheters and lines, and identify any medication order errors.
In Sum
Many personal habits can improve the quality and efficiency of patient care, and hospitalist efficiency is intimately related to system performance. As hospitalists, each one of us can enhance the system, whether we do so by facilitating patient throughput, improving communication, or utilizing resources in a cost-conscious manner. Volunteering to serve on information technology or quality assurance committees is also a “big picture” way of contributing. It is our hope that the tips in this article will have a qualitative impact on both your work habits and your organization’s performance, thereby improving patient care and, ultimately, your own career satisfaction.
Dr. Chandra is assistant professor of medicine at Case Western Reserve University and chief of the division of general internal medicine, University Hospitals Case Medical Center in Cleveland, Ohio. Dr. Donahue is assistant professor of medicine at the University of Massachusetts Medical School in Worcester. Dr. Smith is a hospitalist at Aurora Medical Center in Summit, Wis.
At some point in residency, we all learn that time management and multitasking are vital to ward efficiency; however, it is important to note that efficiency as a hospitalist is as much about providing high quality clinical care as it is about maximizing resources, reducing waste, and avoiding redundancy in the process.
This article examines the pre-rounding, rounding, and follow-up phases of a hospitalist’s typical workday and provides suggestions to help streamline your work—and enhance both personal and system efficiency.
Pre-Rounding
While most would agree that preparing for rounds is essential to making them effective, longer patient lists may lead to hours of pre-rounding. Often, by the time you get to the “rounding stage,” things change. To make this a more productive exercise, we recommend “focused pre-rounding,” which allows you to organize your efforts as follows:
- For overnight admissions, skim through such data as presenting complaint, relevant past medical history, exam, labs, and radiology, looking for any critical values or findings that may need immediate attention. As you prioritize your order of rounding, you are also familiarizing yourself with the cases, which will reassure your new patients.
- For patients who are already on service, do a quick review of any acute overnight events or important management needs. For example, you may have to follow up on a CT head for a patient who fell overnight or check fasting blood sugars to modify a diabetic ketoacidosis patient’s morning insulin dose. These are time-sensitive issues that may need your attention before you actually lay eyes on the patient.
- Prioritize visits and learn to manage patient expectations. Organize your patient visits based on the data gathered from pre-rounding. Seeing potential discharges first helps the hospital open up beds early and facilitates patient throughput. As appealing as early discharge is to any hospital administrator, those working in a teaching setting might argue that first priority should go to night float admissions that have not been “staffed” by an attending yet.
Barring urgent patient care issues, we would recommend that patients who are ready for discharge pending a face-to-face visit or a morning lab should be seen first. You can attend to the new admissions next. In contrast, there is no rush to see potential discharges undergoing a procedure such as an esophagogastroduodenoscopy or stress test. Furthermore, if your decision-making hinges on these test results, timing your visit so that it occurs after the procedure makes your rounding even more efficient. In these situations, informing the patient the evening prior to rounding that you will be visiting them late the next day is not only professionally courteous, but also goes a long way in managing their expectations and enhancing patient satisfaction.
Rounding (The Patient Encounter)
Be professional. Introduce yourself and, if necessary, explain your role as a hospitalist. Sit down when possible. Studies have shown that just the act of sitting makes patients feel that you are communicating better and spending more time with them. If you normally walk or talk quickly, try to slow down temporarily while in the room. The art is for you to be cognizant of the time while avoiding the appearance of impatience.
Engage the patient and/or family. Interact with patients in a way that makes them feel included in their care. For example, show patients X-rays or use diagrams to explain their disease pathophysiology or any upcoming procedures. We feel that even the less educated patient will have a better understanding of her illness when it’s less abstract and more visually defined.
Set reasonable expectations. The patient or family may have many questions during rounds. If time does not permit, especially when you are rounding with housestaff, it is more efficient to say, “We need to move on for now, but one of us will return later to discuss all of this in more depth.”
For particularly demanding patients and families, manage expectations by communicating honestly about your other patient care responsibilities, while still acknowledging their needs. In these situations, setting up a family meeting to discuss plans of care early in the hospital course can be very productive.
Integrate inter-professional care when possible: Rounding with a care coordinator or the patient’s nurse allows you to share clinical information and plans of care in real time. This can help minimize interruptions and pages later in the day, while enhancing patient safety by limiting communication failures.
Perform tasks “as you go.” Entering orders and calling urgent consults as you round not only provides timely medical care but, by limiting unfinished tasks, also reduces the chances of medical errors.
Post Rounds (Follow-Up Care and Planning)
Start discharge planning on day 1. As you gain experience, predicting patients’ hospital stays and anticipating their discharge needs becomes part of your hospitalist “sixth sense.” Obtaining timely therapy, social work, and case management consults is fundamental to your efficiency as a hospitalist. It is also prudent to keep patients and their families updated on discharge plans.
Delegate responsibilities when possible. Efficiency can be fueled by sharing your workload, especially non-clinical tasks such as obtaining occupational safety and health records, completing SNF forms, or scheduling follow-up appointments. Potential resources include ward secretaries, nurses, or, for more clinical tasks, housestaff, nurse practitioners, or physician assistants. The availability of this support varies substantially between institutions. Still, your goal should be to advocate for a collaborative work environment where support staff are expected to contribute to team efficiency and, by corollary, patient satisfaction.
Document succinctly and in a timely manner. Your notes should reflect the patient’s clinical progress and your thought process. You don’t need to import every detail that can be found elsewhere in the EHR, and you should refrain from long, cut and pasted notes that are often meaningless “note bloat.” Likewise, discharge summaries should be high quality informative documents that list key elements, including discharge diagnoses, discharge medications, follow-up appointments, procedures, and a brief hospital course. These are best done in real time or even the day before, when the case is fresh in your memory. Spending an extra 15 - 30 minutes on this important task is well worth it. Do not let records pile up!
“Run the list.” Among the million other things you’re doing all day, this quick end-of-the-day review of your patient list helps you prepare for the next day. It’s an opportunity to ready things for potential next day discharges, discontinue redundant lab testing, remove unnecessary Foley catheters and lines, and identify any medication order errors.
In Sum
Many personal habits can improve the quality and efficiency of patient care, and hospitalist efficiency is intimately related to system performance. As hospitalists, each one of us can enhance the system, whether we do so by facilitating patient throughput, improving communication, or utilizing resources in a cost-conscious manner. Volunteering to serve on information technology or quality assurance committees is also a “big picture” way of contributing. It is our hope that the tips in this article will have a qualitative impact on both your work habits and your organization’s performance, thereby improving patient care and, ultimately, your own career satisfaction.
Dr. Chandra is assistant professor of medicine at Case Western Reserve University and chief of the division of general internal medicine, University Hospitals Case Medical Center in Cleveland, Ohio. Dr. Donahue is assistant professor of medicine at the University of Massachusetts Medical School in Worcester. Dr. Smith is a hospitalist at Aurora Medical Center in Summit, Wis.
At some point in residency, we all learn that time management and multitasking are vital to ward efficiency; however, it is important to note that efficiency as a hospitalist is as much about providing high quality clinical care as it is about maximizing resources, reducing waste, and avoiding redundancy in the process.
This article examines the pre-rounding, rounding, and follow-up phases of a hospitalist’s typical workday and provides suggestions to help streamline your work—and enhance both personal and system efficiency.
Pre-Rounding
While most would agree that preparing for rounds is essential to making them effective, longer patient lists may lead to hours of pre-rounding. Often, by the time you get to the “rounding stage,” things change. To make this a more productive exercise, we recommend “focused pre-rounding,” which allows you to organize your efforts as follows:
- For overnight admissions, skim through such data as presenting complaint, relevant past medical history, exam, labs, and radiology, looking for any critical values or findings that may need immediate attention. As you prioritize your order of rounding, you are also familiarizing yourself with the cases, which will reassure your new patients.
- For patients who are already on service, do a quick review of any acute overnight events or important management needs. For example, you may have to follow up on a CT head for a patient who fell overnight or check fasting blood sugars to modify a diabetic ketoacidosis patient’s morning insulin dose. These are time-sensitive issues that may need your attention before you actually lay eyes on the patient.
- Prioritize visits and learn to manage patient expectations. Organize your patient visits based on the data gathered from pre-rounding. Seeing potential discharges first helps the hospital open up beds early and facilitates patient throughput. As appealing as early discharge is to any hospital administrator, those working in a teaching setting might argue that first priority should go to night float admissions that have not been “staffed” by an attending yet.
Barring urgent patient care issues, we would recommend that patients who are ready for discharge pending a face-to-face visit or a morning lab should be seen first. You can attend to the new admissions next. In contrast, there is no rush to see potential discharges undergoing a procedure such as an esophagogastroduodenoscopy or stress test. Furthermore, if your decision-making hinges on these test results, timing your visit so that it occurs after the procedure makes your rounding even more efficient. In these situations, informing the patient the evening prior to rounding that you will be visiting them late the next day is not only professionally courteous, but also goes a long way in managing their expectations and enhancing patient satisfaction.
Rounding (The Patient Encounter)
Be professional. Introduce yourself and, if necessary, explain your role as a hospitalist. Sit down when possible. Studies have shown that just the act of sitting makes patients feel that you are communicating better and spending more time with them. If you normally walk or talk quickly, try to slow down temporarily while in the room. The art is for you to be cognizant of the time while avoiding the appearance of impatience.
Engage the patient and/or family. Interact with patients in a way that makes them feel included in their care. For example, show patients X-rays or use diagrams to explain their disease pathophysiology or any upcoming procedures. We feel that even the less educated patient will have a better understanding of her illness when it’s less abstract and more visually defined.
Set reasonable expectations. The patient or family may have many questions during rounds. If time does not permit, especially when you are rounding with housestaff, it is more efficient to say, “We need to move on for now, but one of us will return later to discuss all of this in more depth.”
For particularly demanding patients and families, manage expectations by communicating honestly about your other patient care responsibilities, while still acknowledging their needs. In these situations, setting up a family meeting to discuss plans of care early in the hospital course can be very productive.
Integrate inter-professional care when possible: Rounding with a care coordinator or the patient’s nurse allows you to share clinical information and plans of care in real time. This can help minimize interruptions and pages later in the day, while enhancing patient safety by limiting communication failures.
Perform tasks “as you go.” Entering orders and calling urgent consults as you round not only provides timely medical care but, by limiting unfinished tasks, also reduces the chances of medical errors.
Post Rounds (Follow-Up Care and Planning)
Start discharge planning on day 1. As you gain experience, predicting patients’ hospital stays and anticipating their discharge needs becomes part of your hospitalist “sixth sense.” Obtaining timely therapy, social work, and case management consults is fundamental to your efficiency as a hospitalist. It is also prudent to keep patients and their families updated on discharge plans.
Delegate responsibilities when possible. Efficiency can be fueled by sharing your workload, especially non-clinical tasks such as obtaining occupational safety and health records, completing SNF forms, or scheduling follow-up appointments. Potential resources include ward secretaries, nurses, or, for more clinical tasks, housestaff, nurse practitioners, or physician assistants. The availability of this support varies substantially between institutions. Still, your goal should be to advocate for a collaborative work environment where support staff are expected to contribute to team efficiency and, by corollary, patient satisfaction.
Document succinctly and in a timely manner. Your notes should reflect the patient’s clinical progress and your thought process. You don’t need to import every detail that can be found elsewhere in the EHR, and you should refrain from long, cut and pasted notes that are often meaningless “note bloat.” Likewise, discharge summaries should be high quality informative documents that list key elements, including discharge diagnoses, discharge medications, follow-up appointments, procedures, and a brief hospital course. These are best done in real time or even the day before, when the case is fresh in your memory. Spending an extra 15 - 30 minutes on this important task is well worth it. Do not let records pile up!
“Run the list.” Among the million other things you’re doing all day, this quick end-of-the-day review of your patient list helps you prepare for the next day. It’s an opportunity to ready things for potential next day discharges, discontinue redundant lab testing, remove unnecessary Foley catheters and lines, and identify any medication order errors.
In Sum
Many personal habits can improve the quality and efficiency of patient care, and hospitalist efficiency is intimately related to system performance. As hospitalists, each one of us can enhance the system, whether we do so by facilitating patient throughput, improving communication, or utilizing resources in a cost-conscious manner. Volunteering to serve on information technology or quality assurance committees is also a “big picture” way of contributing. It is our hope that the tips in this article will have a qualitative impact on both your work habits and your organization’s performance, thereby improving patient care and, ultimately, your own career satisfaction.
Dr. Chandra is assistant professor of medicine at Case Western Reserve University and chief of the division of general internal medicine, University Hospitals Case Medical Center in Cleveland, Ohio. Dr. Donahue is assistant professor of medicine at the University of Massachusetts Medical School in Worcester. Dr. Smith is a hospitalist at Aurora Medical Center in Summit, Wis.
Listen Now! Patrick Torcson, MD, MMM, SFHM, discusses how being a hospitalist prepared him for the C-suite
Click here to listen to more of our interview with Dr. Torcson
Click here to listen to more of our interview with Dr. Torcson
Click here to listen to more of our interview with Dr. Torcson