Quality

The tiresome cycle of the sustainable growth rate (SGR) continues and, as a result, providers are facing a pay cut of approximately 25% at the end of 2013. With virtually universal agreement that something must be done to permanently repeal the SGR, the insurmountable barrier to a solution has been the cost, which is estimated at $245 billion.

However, a bright spot has emerged.

Several months ago, the Congressional Budget Office produced an anomalous, revised SGR repeal estimate of $138 billion. At nearly half the cost of previous estimates, this is a much less daunting budgetary hole to fill. Needless to say, this revised estimate has breathed new life into the potential to permanently fix the SGR this year. The only catch is that this low estimate is unlikely to persist, so a flurry of activity is expected to last throughout the summer months before the window of opportunity closes.

One of the earliest proposals to move away from fee-for-service to a payment system rooted in quality and value came from the reintroduction of legislation by U.S. Reps. Allyson Schwartz (D-Pa.) and Joe Heck (R-Nev.). SHM is actively supporting this legislation and will continue to do so, but it will give the same attention to other reasonable plans designed to move away from the SGR by incorporating the concepts of quality and value as laid out by Schwartz and Heck.

Along these lines, a joint effort by House Energy and Commerce Committee chairman

Fred Upton (R-Mich.) and House Ways and Means Committee chairman Dave Camp (R-Mich.) would repeal the SGR and replace it with a more sustainable payment system. The plan is being developed iteratively, with opportunities for specialty societies, such as SHM, to provide input along the way. Clear details have yet to emerge because the plan is still in its early stages, but broadly, it will repeal the SGR, replacing it with quality and resource use metrics coupled with value-based payment, and somehow incorporate alternative payment models, such as accountable-care organizations (ACOs). This may sound familiar

because much of it is.

The Centers for Medicare & Medicaid Services (CMS) is developing programs, guided by the Affordable Care Act (ACA), to meet many of these systemic needs in the absence of a repeal of the SGR. The Physician Quality Reporting System (PQRS) is transitioning into a mandatory program, and it’s coupling with Quality and Resource Use Reports (QRURs) brings value into the equation. Both of these programs are a part of the ACA-mandated Physician Value-Based Payment Modifier (VBPM), which implements a level of value-based payment to all physicians by 2017. Additionally, the Center for Medicare & Medicaid Innovation, along with Medicare itself, is developing and testing many alternative models, such as ACOs, bundled payments, and patient-centered medical homes, to name a few.

Upton and Camp have expressed that their goal is to not only repeal the SGR, but also to establish a system that pays for value and is less piecemeal and confusing than what is currently being implemented. For example, they are looking at ways to potentially unify the often disparate yet overlapping reporting requirements placed on physicians through such programs as PQRS, Meaningful Use, and VBPM. This is a great opportunity to take the knowledge and experience hospitalists have with these current CMS programs and advocate for aligning programs, ensuring the usefulness of quality measurement, and reducing administrative barriers and burdens.

Ultimately, the repeal of the SGR will take much thought and legislative will to accomplish. With a broad framework in place, the process has at least begun. It remains to be seen whether Congress will act now on the SGR “sale” and help the health-care system transition into something more sustainable and stable.

Josh Boswell is SHM’s senior manager of government relations

The tiresome cycle of the sustainable growth rate (SGR) continues and, as a result, providers are facing a pay cut of approximately 25% at the end of 2013. With virtually universal agreement that something must be done to permanently repeal the SGR, the insurmountable barrier to a solution has been the cost, which is estimated at $245 billion.

However, a bright spot has emerged.

Several months ago, the Congressional Budget Office produced an anomalous, revised SGR repeal estimate of $138 billion. At nearly half the cost of previous estimates, this is a much less daunting budgetary hole to fill. Needless to say, this revised estimate has breathed new life into the potential to permanently fix the SGR this year. The only catch is that this low estimate is unlikely to persist, so a flurry of activity is expected to last throughout the summer months before the window of opportunity closes.

One of the earliest proposals to move away from fee-for-service to a payment system rooted in quality and value came from the reintroduction of legislation by U.S. Reps. Allyson Schwartz (D-Pa.) and Joe Heck (R-Nev.). SHM is actively supporting this legislation and will continue to do so, but it will give the same attention to other reasonable plans designed to move away from the SGR by incorporating the concepts of quality and value as laid out by Schwartz and Heck.

Along these lines, a joint effort by House Energy and Commerce Committee chairman

Fred Upton (R-Mich.) and House Ways and Means Committee chairman Dave Camp (R-Mich.) would repeal the SGR and replace it with a more sustainable payment system. The plan is being developed iteratively, with opportunities for specialty societies, such as SHM, to provide input along the way. Clear details have yet to emerge because the plan is still in its early stages, but broadly, it will repeal the SGR, replacing it with quality and resource use metrics coupled with value-based payment, and somehow incorporate alternative payment models, such as accountable-care organizations (ACOs). This may sound familiar

because much of it is.

The Centers for Medicare & Medicaid Services (CMS) is developing programs, guided by the Affordable Care Act (ACA), to meet many of these systemic needs in the absence of a repeal of the SGR. The Physician Quality Reporting System (PQRS) is transitioning into a mandatory program, and it’s coupling with Quality and Resource Use Reports (QRURs) brings value into the equation. Both of these programs are a part of the ACA-mandated Physician Value-Based Payment Modifier (VBPM), which implements a level of value-based payment to all physicians by 2017. Additionally, the Center for Medicare & Medicaid Innovation, along with Medicare itself, is developing and testing many alternative models, such as ACOs, bundled payments, and patient-centered medical homes, to name a few.

Upton and Camp have expressed that their goal is to not only repeal the SGR, but also to establish a system that pays for value and is less piecemeal and confusing than what is currently being implemented. For example, they are looking at ways to potentially unify the often disparate yet overlapping reporting requirements placed on physicians through such programs as PQRS, Meaningful Use, and VBPM. This is a great opportunity to take the knowledge and experience hospitalists have with these current CMS programs and advocate for aligning programs, ensuring the usefulness of quality measurement, and reducing administrative barriers and burdens.

Ultimately, the repeal of the SGR will take much thought and legislative will to accomplish. With a broad framework in place, the process has at least begun. It remains to be seen whether Congress will act now on the SGR “sale” and help the health-care system transition into something more sustainable and stable.

Josh Boswell is SHM’s senior manager of government relations

The tiresome cycle of the sustainable growth rate (SGR) continues and, as a result, providers are facing a pay cut of approximately 25% at the end of 2013. With virtually universal agreement that something must be done to permanently repeal the SGR, the insurmountable barrier to a solution has been the cost, which is estimated at $245 billion.

However, a bright spot has emerged.

Several months ago, the Congressional Budget Office produced an anomalous, revised SGR repeal estimate of $138 billion. At nearly half the cost of previous estimates, this is a much less daunting budgetary hole to fill. Needless to say, this revised estimate has breathed new life into the potential to permanently fix the SGR this year. The only catch is that this low estimate is unlikely to persist, so a flurry of activity is expected to last throughout the summer months before the window of opportunity closes.

One of the earliest proposals to move away from fee-for-service to a payment system rooted in quality and value came from the reintroduction of legislation by U.S. Reps. Allyson Schwartz (D-Pa.) and Joe Heck (R-Nev.). SHM is actively supporting this legislation and will continue to do so, but it will give the same attention to other reasonable plans designed to move away from the SGR by incorporating the concepts of quality and value as laid out by Schwartz and Heck.

Along these lines, a joint effort by House Energy and Commerce Committee chairman

Fred Upton (R-Mich.) and House Ways and Means Committee chairman Dave Camp (R-Mich.) would repeal the SGR and replace it with a more sustainable payment system. The plan is being developed iteratively, with opportunities for specialty societies, such as SHM, to provide input along the way. Clear details have yet to emerge because the plan is still in its early stages, but broadly, it will repeal the SGR, replacing it with quality and resource use metrics coupled with value-based payment, and somehow incorporate alternative payment models, such as accountable-care organizations (ACOs). This may sound familiar

because much of it is.

The Centers for Medicare & Medicaid Services (CMS) is developing programs, guided by the Affordable Care Act (ACA), to meet many of these systemic needs in the absence of a repeal of the SGR. The Physician Quality Reporting System (PQRS) is transitioning into a mandatory program, and it’s coupling with Quality and Resource Use Reports (QRURs) brings value into the equation. Both of these programs are a part of the ACA-mandated Physician Value-Based Payment Modifier (VBPM), which implements a level of value-based payment to all physicians by 2017. Additionally, the Center for Medicare & Medicaid Innovation, along with Medicare itself, is developing and testing many alternative models, such as ACOs, bundled payments, and patient-centered medical homes, to name a few.

Upton and Camp have expressed that their goal is to not only repeal the SGR, but also to establish a system that pays for value and is less piecemeal and confusing than what is currently being implemented. For example, they are looking at ways to potentially unify the often disparate yet overlapping reporting requirements placed on physicians through such programs as PQRS, Meaningful Use, and VBPM. This is a great opportunity to take the knowledge and experience hospitalists have with these current CMS programs and advocate for aligning programs, ensuring the usefulness of quality measurement, and reducing administrative barriers and burdens.

Ultimately, the repeal of the SGR will take much thought and legislative will to accomplish. With a broad framework in place, the process has at least begun. It remains to be seen whether Congress will act now on the SGR “sale” and help the health-care system transition into something more sustainable and stable.

Josh Boswell is SHM’s senior manager of government relations

Two oral research poster presentations at HM13 explored malpractice concerns of hospitalists and the issue of defensive-medicine-related overutilization—popular topics considering how policymakers are attempting to bend the cost curve in the direction of greater efficiency and value.

Hospitalist Alan Kachalia, MD, JD, and colleagues at Brigham and Women’s Hospital in Boston conducted a randomized national survey of 1,020 hospitalists and analyzed their responses to common clinical scenarios. They found evidence of inappropriate overutilization and deviance from scientific evidence or recognized treatment guidelines, which the research team pegged to the practice of defensive medicine.

Dr. Kachalia’s presentation, “Overutilization and Defensive Medicine in U.S. Hospitals: A Randomized National Survey of Hospitalists,” was named best of the oral presentations in the research category.

“Our survey found substantial overutilization, frequently caused by defensive medicine,” in response to questions about practice patterns for two common clinical scenarios: preoperative evaluation and syncope, Dr. Kachalia said. Physicians who practiced at Veterans Affairs medical centers had less association with defensive medicine, while those who paid for their own liability insurance reported more. Overall, defensive medicine was reported for 37% of preoperative evaluations and 58% of the syncope scenarios.

More than 800 abstracts were submitted for HM13’s Research, Innovations, and Clinical Vignettes (RIV) competition. Nearly 600 were accepted, put on display at the annual meeting, and published online (www.shmabstracts.com). More than 100 abstracts were judged, with 15 of the Research and Innovations entries invited to make oral presentations of their projects. Three others gave “Best of RIV” plenary presentations at the conference.

The diversity and richness of HM13’s oral and poster presentations also will be highlighted in the Innovations department of The Hospitalist over the next year.

Asked to suggest policy responses to these findings, Dr. Kachalia said reform of the malpractice system is needed. “What a lot of us argue is that to get physicians to follow treatment guidelines, make them more clear and practical,” he said. “We’d also like to see safe harbors [from lawsuits] for following recognized guidelines.”

Adam Schaffer, MD, also a hospitalist at Brigham and Women’s Hospital in Boston, and colleagues reviewed a medical liability insurance carrier’s database of more than 30,000 closed claims for those in which a hospitalist was the attending of record. Dr. Schaffer’s retrospective, observational analysis, “Medical Malpractice: Causes and Outcomes of Claims Against Hospitalists,” of the claims database from 1997 to 2011 found 272 claims—almost 1%—for which the attending was a hospitalist.

“The claims rate was almost four times lower for hospitalists than for nonhospitalist internal-medicine physicians,” he said.

The average payment for claims against hospitalists also was smaller. He noted that the types of claims were similar and tended to fall in three general categories: errors in medical treatment, missed or delayed diagnoses, and medication-related errors (although claims also tended to have multiple contributing factors).

Research like Dr. Schaffer’s could help to inform patient-safety efforts and reduce legal malpractice risk, he said. If hospitalists have fewer malpractice claims, that information might also be used to argue for lower malpractice premium rates.

Larry Beresford is a freelance writer in Oakland, Calif.

Two oral research poster presentations at HM13 explored malpractice concerns of hospitalists and the issue of defensive-medicine-related overutilization—popular topics considering how policymakers are attempting to bend the cost curve in the direction of greater efficiency and value.

Hospitalist Alan Kachalia, MD, JD, and colleagues at Brigham and Women’s Hospital in Boston conducted a randomized national survey of 1,020 hospitalists and analyzed their responses to common clinical scenarios. They found evidence of inappropriate overutilization and deviance from scientific evidence or recognized treatment guidelines, which the research team pegged to the practice of defensive medicine.

Dr. Kachalia’s presentation, “Overutilization and Defensive Medicine in U.S. Hospitals: A Randomized National Survey of Hospitalists,” was named best of the oral presentations in the research category.

“Our survey found substantial overutilization, frequently caused by defensive medicine,” in response to questions about practice patterns for two common clinical scenarios: preoperative evaluation and syncope, Dr. Kachalia said. Physicians who practiced at Veterans Affairs medical centers had less association with defensive medicine, while those who paid for their own liability insurance reported more. Overall, defensive medicine was reported for 37% of preoperative evaluations and 58% of the syncope scenarios.

More than 800 abstracts were submitted for HM13’s Research, Innovations, and Clinical Vignettes (RIV) competition. Nearly 600 were accepted, put on display at the annual meeting, and published online (www.shmabstracts.com). More than 100 abstracts were judged, with 15 of the Research and Innovations entries invited to make oral presentations of their projects. Three others gave “Best of RIV” plenary presentations at the conference.

The diversity and richness of HM13’s oral and poster presentations also will be highlighted in the Innovations department of The Hospitalist over the next year.

Asked to suggest policy responses to these findings, Dr. Kachalia said reform of the malpractice system is needed. “What a lot of us argue is that to get physicians to follow treatment guidelines, make them more clear and practical,” he said. “We’d also like to see safe harbors [from lawsuits] for following recognized guidelines.”

Adam Schaffer, MD, also a hospitalist at Brigham and Women’s Hospital in Boston, and colleagues reviewed a medical liability insurance carrier’s database of more than 30,000 closed claims for those in which a hospitalist was the attending of record. Dr. Schaffer’s retrospective, observational analysis, “Medical Malpractice: Causes and Outcomes of Claims Against Hospitalists,” of the claims database from 1997 to 2011 found 272 claims—almost 1%—for which the attending was a hospitalist.

“The claims rate was almost four times lower for hospitalists than for nonhospitalist internal-medicine physicians,” he said.

The average payment for claims against hospitalists also was smaller. He noted that the types of claims were similar and tended to fall in three general categories: errors in medical treatment, missed or delayed diagnoses, and medication-related errors (although claims also tended to have multiple contributing factors).

Research like Dr. Schaffer’s could help to inform patient-safety efforts and reduce legal malpractice risk, he said. If hospitalists have fewer malpractice claims, that information might also be used to argue for lower malpractice premium rates.

Larry Beresford is a freelance writer in Oakland, Calif.

Two oral research poster presentations at HM13 explored malpractice concerns of hospitalists and the issue of defensive-medicine-related overutilization—popular topics considering how policymakers are attempting to bend the cost curve in the direction of greater efficiency and value.

Hospitalist Alan Kachalia, MD, JD, and colleagues at Brigham and Women’s Hospital in Boston conducted a randomized national survey of 1,020 hospitalists and analyzed their responses to common clinical scenarios. They found evidence of inappropriate overutilization and deviance from scientific evidence or recognized treatment guidelines, which the research team pegged to the practice of defensive medicine.

Dr. Kachalia’s presentation, “Overutilization and Defensive Medicine in U.S. Hospitals: A Randomized National Survey of Hospitalists,” was named best of the oral presentations in the research category.

“Our survey found substantial overutilization, frequently caused by defensive medicine,” in response to questions about practice patterns for two common clinical scenarios: preoperative evaluation and syncope, Dr. Kachalia said. Physicians who practiced at Veterans Affairs medical centers had less association with defensive medicine, while those who paid for their own liability insurance reported more. Overall, defensive medicine was reported for 37% of preoperative evaluations and 58% of the syncope scenarios.

More than 800 abstracts were submitted for HM13’s Research, Innovations, and Clinical Vignettes (RIV) competition. Nearly 600 were accepted, put on display at the annual meeting, and published online (www.shmabstracts.com). More than 100 abstracts were judged, with 15 of the Research and Innovations entries invited to make oral presentations of their projects. Three others gave “Best of RIV” plenary presentations at the conference.

The diversity and richness of HM13’s oral and poster presentations also will be highlighted in the Innovations department of The Hospitalist over the next year.

Asked to suggest policy responses to these findings, Dr. Kachalia said reform of the malpractice system is needed. “What a lot of us argue is that to get physicians to follow treatment guidelines, make them more clear and practical,” he said. “We’d also like to see safe harbors [from lawsuits] for following recognized guidelines.”

Adam Schaffer, MD, also a hospitalist at Brigham and Women’s Hospital in Boston, and colleagues reviewed a medical liability insurance carrier’s database of more than 30,000 closed claims for those in which a hospitalist was the attending of record. Dr. Schaffer’s retrospective, observational analysis, “Medical Malpractice: Causes and Outcomes of Claims Against Hospitalists,” of the claims database from 1997 to 2011 found 272 claims—almost 1%—for which the attending was a hospitalist.

“The claims rate was almost four times lower for hospitalists than for nonhospitalist internal-medicine physicians,” he said.

The average payment for claims against hospitalists also was smaller. He noted that the types of claims were similar and tended to fall in three general categories: errors in medical treatment, missed or delayed diagnoses, and medication-related errors (although claims also tended to have multiple contributing factors).

Research like Dr. Schaffer’s could help to inform patient-safety efforts and reduce legal malpractice risk, he said. If hospitalists have fewer malpractice claims, that information might also be used to argue for lower malpractice premium rates.

Larry Beresford is a freelance writer in Oakland, Calif.

One of the busiest times of HM13—and, come to think of it, every recent annual meeting—is the poster session for the Research, Innovations, and Clinical Vignettes (RIV) competition. This year, more than 800 abstracts were submitted and reviewed, with nearly 600 being accepted for presentation at HM13. That meant thousands of hospitalists thumbtacking posters to rows and rows of portable bulletin boards in the Gaylord National Resort & Convention Center’s massive exhibit hall.

With all those posters and accompanying oral presentations, it’s impossible for RIV judges to chat with everybody, so they choose finalists based on the abstracts, then listen to quick-hit summaries before choosing a winner on site. And meeting attendees are just as strapped for time, so they do the best they can to see as many posters as they can, taking time to network with old connections and make new ones.

So with all the limitations on how many people will interact with your poster, the small chance of winning Best in Show, and the hundreds of work hours that go into a poster presentation, why do it?

“To share is what I think is really important,” says Todd Hecht, MD, FACP, SFHM, associate professor of clinical medicine at the Perelman School of Medicine at the University of Pennsylvania in Philadelphia. “If you don’t let other people know what you’re doing, they can’t bring it to their institutions, nor can you learn from others and bring their innovations to your own hospital.”

Dr. Hecht, director of the Anticoagulation Management Center and Anticoagulation Management Program at the Hospital of the University of Pennsylvania, takes the poster sessions very seriously. This year, he entered a poster in both the Innovations and Vignette categories. His Innovations poster, “Impact of a Multidisciplinary Safety Checklist on the Rate of Preventable Hospital Complications and Standardization of Care,” was a finalist.

That meant that, at the very least, he’d be able to explain to at least two judges what motivated his research team’s project. And what was the inspiration? A 90-year-old male patient with metastatic melanoma who, in the fall of 2011, refused to take medication for VTE prophylaxis, as lesions on his skin made the process rather painful. After refusing the doses for a bit, though, the high-risk patient unsurprisingly developed a pulmonary embolism (PE).

The man survived the PE, but Dr. Hecht and his colleagues began to wonder how many patients refuse VTE prophylaxis. So they investigated, and it turned out that from December 2010 to February 2011, 26.4% of the prescribed doses of prophylaxis on the medicine floors they studied were missed. Moreover, nearly 80% of all missed doses on the medicine floors were due to patient refusal.

“It was astonishing to me that it was that high,” Dr. Hecht says. “If there were 1,000 doses in a month, 260 of them were not being given—and 205 of them were not given because they were refused.”

Checklist Integration

So Dr. Hecht and colleagues set out to create a checklist that could be used daily on multidisciplinary rounds to help reduce the risk of VTE. First question on the list: Has prophylaxis been ordered, and if so, is the patient refusing it? Knowing that patients are “refusing” medication can lead to discussions about why that is happening, which in turn can lead to ways to convince the patient that the preventative measure is a good idea.

Dr. Hecht says the team also realized a checklist creates the opportunity to improve other quality metrics, such as hospital-associated infections (HAIs). Two questions on the checklist ask whether indwelling urinary catheters (IUCs) and central venous catheters (CVCs) can be removed. Two questions ask if telemetry can be stopped and whether there are any pain-management concerns. A final query asks whether there are any nursing, social work, or discharge-related questions—a step that, according to Dr. Hecht, loops the entire multidisciplinary team into the care-plan discussion.

“An ongoing challenge is making sure it’s not just questions being asked and being answered by rote,” Dr. Hecht says. “Just pause and think for just a second for each question. You can get through the checklist in 10 seconds, but you can’t go through the checklist in two seconds.”

The project’s results are what made it a finalist. After the checklist intervention, the number of missed doses of VTE prophylaxis plummeted 59% to just 10.9% (P<0.001) from September to November 2012; the number of “patient refused” doses dropped to 6.3% (P<0.001).

Not only was Dr. Hecht caught off guard by his findings, but so were the judges who visited his poster—Mangla Gulati, MD, FHM, of the University of Maryland School of Medicine and Rachel George, MD, MBA, FHM, of Cogent HMG.

“I wonder if it’s like that in every hospital,” Dr. George says. “I’d like to know.”

The positive reaction and feedback to Dr. Hecht’s poster, however, was not enough to win the Innovations category. That honor went to “SEPTRIS: Improving Sepsis Recognition and Management Through a Mobile Educational Game,” which was developed by a team of researchers at Stanford University in Palo Alto, Calif. The video game

(http://med.stanford.edu/septris/)—a mashup of sepsis and the once-popular Tetris puzzle game—already has been played 17,000 times and is on its way to being shared in other languages.

“Win or lose, it doesn’t matter,” Dr. Hecht says. “The goal is to share your information with other people and learn from them.”

Peter Watson, MD, FACP, FHM, sees it the same way. That’s why this year he was both judge and judged. The division head of hospital medicine for Henry Ford Medical Group in Detroit was part of a group presenting “Feasibility and Efficacy of a Specialized Pilot Training Program to Enhance Inpatient Communication Skills of Hospitalists.” He was a judge for the Research portion of the contest. He says he’s hard-pressed to say which process he enjoyed more, but one trick of the poster trade he passes along is that “judging actually makes you a better presenter on the back end,” especially when it comes to describing in less than five minutes a poster whose work may date back 12 to 18 months.

“In your brain,” he says, “you have a Tolstoy novel of information, but you have to break that down into a paragraph of CliffsNotes, and actually convince the people that are judging you that you have a really cool project that either is going to have a big impact in the field or may lead to other big studies or is going to impress somebody so much that they’re going to go back to their institution and say, ‘Hey, I’m going to do that.’”

Dr. Watson also urges people not to be discouraged by not winning the poster contest. First, all of the accepted abstracts get published online (www.shmabstracts.com) by the Journal of Hospital Medicine, a high point for medical students, residents, and early-career physicians looking to make a mark. Second, presenting information of value to one’s peers is the definition of a specialty that prides itself on collaboration.

“To see a second-year medical student presenting all the way up to a very senior division chief and everything in between is a really good example for our profession,” he says. “That’s really the magic of this meeting.”

Richard Quinn is a freelance writer in New Jersey.

One of the busiest times of HM13—and, come to think of it, every recent annual meeting—is the poster session for the Research, Innovations, and Clinical Vignettes (RIV) competition. This year, more than 800 abstracts were submitted and reviewed, with nearly 600 being accepted for presentation at HM13. That meant thousands of hospitalists thumbtacking posters to rows and rows of portable bulletin boards in the Gaylord National Resort & Convention Center’s massive exhibit hall.

With all those posters and accompanying oral presentations, it’s impossible for RIV judges to chat with everybody, so they choose finalists based on the abstracts, then listen to quick-hit summaries before choosing a winner on site. And meeting attendees are just as strapped for time, so they do the best they can to see as many posters as they can, taking time to network with old connections and make new ones.

So with all the limitations on how many people will interact with your poster, the small chance of winning Best in Show, and the hundreds of work hours that go into a poster presentation, why do it?

“To share is what I think is really important,” says Todd Hecht, MD, FACP, SFHM, associate professor of clinical medicine at the Perelman School of Medicine at the University of Pennsylvania in Philadelphia. “If you don’t let other people know what you’re doing, they can’t bring it to their institutions, nor can you learn from others and bring their innovations to your own hospital.”

Dr. Hecht, director of the Anticoagulation Management Center and Anticoagulation Management Program at the Hospital of the University of Pennsylvania, takes the poster sessions very seriously. This year, he entered a poster in both the Innovations and Vignette categories. His Innovations poster, “Impact of a Multidisciplinary Safety Checklist on the Rate of Preventable Hospital Complications and Standardization of Care,” was a finalist.

That meant that, at the very least, he’d be able to explain to at least two judges what motivated his research team’s project. And what was the inspiration? A 90-year-old male patient with metastatic melanoma who, in the fall of 2011, refused to take medication for VTE prophylaxis, as lesions on his skin made the process rather painful. After refusing the doses for a bit, though, the high-risk patient unsurprisingly developed a pulmonary embolism (PE).

The man survived the PE, but Dr. Hecht and his colleagues began to wonder how many patients refuse VTE prophylaxis. So they investigated, and it turned out that from December 2010 to February 2011, 26.4% of the prescribed doses of prophylaxis on the medicine floors they studied were missed. Moreover, nearly 80% of all missed doses on the medicine floors were due to patient refusal.

“It was astonishing to me that it was that high,” Dr. Hecht says. “If there were 1,000 doses in a month, 260 of them were not being given—and 205 of them were not given because they were refused.”

Checklist Integration

So Dr. Hecht and colleagues set out to create a checklist that could be used daily on multidisciplinary rounds to help reduce the risk of VTE. First question on the list: Has prophylaxis been ordered, and if so, is the patient refusing it? Knowing that patients are “refusing” medication can lead to discussions about why that is happening, which in turn can lead to ways to convince the patient that the preventative measure is a good idea.

Dr. Hecht says the team also realized a checklist creates the opportunity to improve other quality metrics, such as hospital-associated infections (HAIs). Two questions on the checklist ask whether indwelling urinary catheters (IUCs) and central venous catheters (CVCs) can be removed. Two questions ask if telemetry can be stopped and whether there are any pain-management concerns. A final query asks whether there are any nursing, social work, or discharge-related questions—a step that, according to Dr. Hecht, loops the entire multidisciplinary team into the care-plan discussion.

“An ongoing challenge is making sure it’s not just questions being asked and being answered by rote,” Dr. Hecht says. “Just pause and think for just a second for each question. You can get through the checklist in 10 seconds, but you can’t go through the checklist in two seconds.”

The project’s results are what made it a finalist. After the checklist intervention, the number of missed doses of VTE prophylaxis plummeted 59% to just 10.9% (P<0.001) from September to November 2012; the number of “patient refused” doses dropped to 6.3% (P<0.001).

Not only was Dr. Hecht caught off guard by his findings, but so were the judges who visited his poster—Mangla Gulati, MD, FHM, of the University of Maryland School of Medicine and Rachel George, MD, MBA, FHM, of Cogent HMG.

“I wonder if it’s like that in every hospital,” Dr. George says. “I’d like to know.”

The positive reaction and feedback to Dr. Hecht’s poster, however, was not enough to win the Innovations category. That honor went to “SEPTRIS: Improving Sepsis Recognition and Management Through a Mobile Educational Game,” which was developed by a team of researchers at Stanford University in Palo Alto, Calif. The video game

(http://med.stanford.edu/septris/)—a mashup of sepsis and the once-popular Tetris puzzle game—already has been played 17,000 times and is on its way to being shared in other languages.

“Win or lose, it doesn’t matter,” Dr. Hecht says. “The goal is to share your information with other people and learn from them.”

Peter Watson, MD, FACP, FHM, sees it the same way. That’s why this year he was both judge and judged. The division head of hospital medicine for Henry Ford Medical Group in Detroit was part of a group presenting “Feasibility and Efficacy of a Specialized Pilot Training Program to Enhance Inpatient Communication Skills of Hospitalists.” He was a judge for the Research portion of the contest. He says he’s hard-pressed to say which process he enjoyed more, but one trick of the poster trade he passes along is that “judging actually makes you a better presenter on the back end,” especially when it comes to describing in less than five minutes a poster whose work may date back 12 to 18 months.

“In your brain,” he says, “you have a Tolstoy novel of information, but you have to break that down into a paragraph of CliffsNotes, and actually convince the people that are judging you that you have a really cool project that either is going to have a big impact in the field or may lead to other big studies or is going to impress somebody so much that they’re going to go back to their institution and say, ‘Hey, I’m going to do that.’”

Dr. Watson also urges people not to be discouraged by not winning the poster contest. First, all of the accepted abstracts get published online (www.shmabstracts.com) by the Journal of Hospital Medicine, a high point for medical students, residents, and early-career physicians looking to make a mark. Second, presenting information of value to one’s peers is the definition of a specialty that prides itself on collaboration.

“To see a second-year medical student presenting all the way up to a very senior division chief and everything in between is a really good example for our profession,” he says. “That’s really the magic of this meeting.”

Richard Quinn is a freelance writer in New Jersey.

One of the busiest times of HM13—and, come to think of it, every recent annual meeting—is the poster session for the Research, Innovations, and Clinical Vignettes (RIV) competition. This year, more than 800 abstracts were submitted and reviewed, with nearly 600 being accepted for presentation at HM13. That meant thousands of hospitalists thumbtacking posters to rows and rows of portable bulletin boards in the Gaylord National Resort & Convention Center’s massive exhibit hall.

With all those posters and accompanying oral presentations, it’s impossible for RIV judges to chat with everybody, so they choose finalists based on the abstracts, then listen to quick-hit summaries before choosing a winner on site. And meeting attendees are just as strapped for time, so they do the best they can to see as many posters as they can, taking time to network with old connections and make new ones.

So with all the limitations on how many people will interact with your poster, the small chance of winning Best in Show, and the hundreds of work hours that go into a poster presentation, why do it?

“To share is what I think is really important,” says Todd Hecht, MD, FACP, SFHM, associate professor of clinical medicine at the Perelman School of Medicine at the University of Pennsylvania in Philadelphia. “If you don’t let other people know what you’re doing, they can’t bring it to their institutions, nor can you learn from others and bring their innovations to your own hospital.”

Dr. Hecht, director of the Anticoagulation Management Center and Anticoagulation Management Program at the Hospital of the University of Pennsylvania, takes the poster sessions very seriously. This year, he entered a poster in both the Innovations and Vignette categories. His Innovations poster, “Impact of a Multidisciplinary Safety Checklist on the Rate of Preventable Hospital Complications and Standardization of Care,” was a finalist.

That meant that, at the very least, he’d be able to explain to at least two judges what motivated his research team’s project. And what was the inspiration? A 90-year-old male patient with metastatic melanoma who, in the fall of 2011, refused to take medication for VTE prophylaxis, as lesions on his skin made the process rather painful. After refusing the doses for a bit, though, the high-risk patient unsurprisingly developed a pulmonary embolism (PE).

The man survived the PE, but Dr. Hecht and his colleagues began to wonder how many patients refuse VTE prophylaxis. So they investigated, and it turned out that from December 2010 to February 2011, 26.4% of the prescribed doses of prophylaxis on the medicine floors they studied were missed. Moreover, nearly 80% of all missed doses on the medicine floors were due to patient refusal.

“It was astonishing to me that it was that high,” Dr. Hecht says. “If there were 1,000 doses in a month, 260 of them were not being given—and 205 of them were not given because they were refused.”

Checklist Integration

So Dr. Hecht and colleagues set out to create a checklist that could be used daily on multidisciplinary rounds to help reduce the risk of VTE. First question on the list: Has prophylaxis been ordered, and if so, is the patient refusing it? Knowing that patients are “refusing” medication can lead to discussions about why that is happening, which in turn can lead to ways to convince the patient that the preventative measure is a good idea.

Dr. Hecht says the team also realized a checklist creates the opportunity to improve other quality metrics, such as hospital-associated infections (HAIs). Two questions on the checklist ask whether indwelling urinary catheters (IUCs) and central venous catheters (CVCs) can be removed. Two questions ask if telemetry can be stopped and whether there are any pain-management concerns. A final query asks whether there are any nursing, social work, or discharge-related questions—a step that, according to Dr. Hecht, loops the entire multidisciplinary team into the care-plan discussion.

“An ongoing challenge is making sure it’s not just questions being asked and being answered by rote,” Dr. Hecht says. “Just pause and think for just a second for each question. You can get through the checklist in 10 seconds, but you can’t go through the checklist in two seconds.”

The project’s results are what made it a finalist. After the checklist intervention, the number of missed doses of VTE prophylaxis plummeted 59% to just 10.9% (P<0.001) from September to November 2012; the number of “patient refused” doses dropped to 6.3% (P<0.001).

Not only was Dr. Hecht caught off guard by his findings, but so were the judges who visited his poster—Mangla Gulati, MD, FHM, of the University of Maryland School of Medicine and Rachel George, MD, MBA, FHM, of Cogent HMG.

“I wonder if it’s like that in every hospital,” Dr. George says. “I’d like to know.”

The positive reaction and feedback to Dr. Hecht’s poster, however, was not enough to win the Innovations category. That honor went to “SEPTRIS: Improving Sepsis Recognition and Management Through a Mobile Educational Game,” which was developed by a team of researchers at Stanford University in Palo Alto, Calif. The video game

(http://med.stanford.edu/septris/)—a mashup of sepsis and the once-popular Tetris puzzle game—already has been played 17,000 times and is on its way to being shared in other languages.

“Win or lose, it doesn’t matter,” Dr. Hecht says. “The goal is to share your information with other people and learn from them.”

Peter Watson, MD, FACP, FHM, sees it the same way. That’s why this year he was both judge and judged. The division head of hospital medicine for Henry Ford Medical Group in Detroit was part of a group presenting “Feasibility and Efficacy of a Specialized Pilot Training Program to Enhance Inpatient Communication Skills of Hospitalists.” He was a judge for the Research portion of the contest. He says he’s hard-pressed to say which process he enjoyed more, but one trick of the poster trade he passes along is that “judging actually makes you a better presenter on the back end,” especially when it comes to describing in less than five minutes a poster whose work may date back 12 to 18 months.

“In your brain,” he says, “you have a Tolstoy novel of information, but you have to break that down into a paragraph of CliffsNotes, and actually convince the people that are judging you that you have a really cool project that either is going to have a big impact in the field or may lead to other big studies or is going to impress somebody so much that they’re going to go back to their institution and say, ‘Hey, I’m going to do that.’”

Dr. Watson also urges people not to be discouraged by not winning the poster contest. First, all of the accepted abstracts get published online (www.shmabstracts.com) by the Journal of Hospital Medicine, a high point for medical students, residents, and early-career physicians looking to make a mark. Second, presenting information of value to one’s peers is the definition of a specialty that prides itself on collaboration.

“To see a second-year medical student presenting all the way up to a very senior division chief and everything in between is a really good example for our profession,” he says. “That’s really the magic of this meeting.”

Richard Quinn is a freelance writer in New Jersey.

Like a grinning child at a carnival, Iqbal M. Binoj, MD, steps right up and gives it a try—except instead of tossing rings, he’s gripping an intraosseous infusion drill.

A tutor shows him how the device, which looks remarkably like a glue gun, inserts into the bones of the shoulder or knee and drills down until it hits the marrow. He is guided on using a steady speed to maintain the integrity of the cavity. He’s also taught about the maneuver’s low complication rates and ability to expedite workups.

“I’ve seen it used before, but I never did it,” says Dr. Binoj, a hospitalist with Cogent HMG at Genesis Medical Center in Davenport, Iowa.

Well, he never did it before a hands-on pre-course at HM13 that focused on improving hospitalists’ proficiency at such procedures as lumbar punctures and ultrasound-guided vascular access. Quality improvement (QI) is always a focus of SHM’s annual meeting, but sometimes the science of improving care is viewed from up on high.

Not everything needs to be a national imitative, an institution-wide project, or even a unit-based intervention. Sometimes, it’s as simple as teaching a room full of hospitalists how to use an intraosseous infusion drill, says Michelle Fox, RN, BSN, senior director of clinical affairs with Vidacare, which manufactures the drill used in the demonstration.

“Hospitalists have an increasing role in doing these procedures, not only in the environment they predominantly support but in other areas of the hospital,” Fox says, adding that “the primary goal of this course is to give them the opportunity to perfect those skills.”

Hospitalist Bradley Rosen, MD, MBA, FHM, medical of the inpatient specialty program at Cedars-Sinai in Los Angeles, says the point of hands-on demonstrations is to translate QI to the bedside. Take ultrasound devices, he says. In the past few years, the technology has become less expensive, better in resolution, more common, and more portable. Hospitalists must ensure hands-on training that keeps pace with that technology.

“We actually want people to get gloves on, hands on, learn where they may have challenges in terms of their own dexterity or workflow, which hand is dominant, and how to visualize on the ultrasound machine a three-dimensional structure in 2D,” he says. “We don’t want people watching from the sidelines. ... We try to get people in it and engaged.”

And once hospitalists master procedures or diagnostic maneuvers, they invariably are sought out by other physicians to pass that knowledge on to others, Dr. Rosen says.

“In so doing, we get involved in larger quality initiatives and systemwide changes that can go top-down,” he adds, “but from our perspective, it starts with the individual practitioner. And I think SHM has always advocated and preached the importance of the individual hospitalist doing the best possible job for your patient, and the group, and the institution.”

Shared Excellence

What’s best for individual institutions moving forward is what worries SHM immediate past president Shaun Frost, MD, SFHM. He fears CMS’ Value-Based Payment Modifier (VBPM) program could have the unintended consequence of spurring some hospitals to hang on to innovative ideas in order to keep a competitive business advantage.

In health care, where quality and affordability have long been viewed as valuable for nonmonetary reasons, “the medical profession willingly shares new information” to improve patient care, Dr. Frost said in his farewell speech. But he is concerned that commodification—imbuing monetary value into something that previously had none—could change that dynamic, a situation he says is “ethically not acceptable.”

“When somebody builds a better mousetrap, it should be freely shared so that all patients have the opportunity to benefit,” Dr. Frost said. “The pursuit of economic competitive advantage should not prevent us from collaborating and sharing new ideas that hopefully make the health system better.”

Kendall Rogers, MD, FACP, SFHM, chief of the division of hospital medicine at the University of New Mexico Health Sciences Center in Albuquerque, N.M., says part of that improvement in quality and patient safety will come via hospitalists pushing for improvements to health information technology (HIT), particularly to maximize computerized physician order entry (CPOE) and order sets. He empathizes with those who complain about the operability of existing systems but urges physicians to stop complaining and take action.

“We need to stop accepting what our existing limitations are, and we need to be the innovators,” he says. “Many of us aren’t even thinking about, ‘What are the products we need?’ We’re just reacting to the products we currently have and stating how they don’t meet our needs.”

He suggests people communally report safety or troubleshooting issues, in part via Hospital Medicine Exchange (HMX), an online community SHM launched last year to discuss HM issues (www.hmxchange.org). He also wants hospitalists to push HIT vendors to provide improved functionality, and for institutions to provide necessary training.

“We just need to be vocal,” says Dr. Rogers, chair of SHM’s IT Executive Committee. “I do believe this is all leading us to a good place, but there’s a dip down before we have a swing up.”

Frustration Surge

In the long run, hospitalist Anuj Mehta, MD, medical director of the adult hospitalist program at Nyack Hospital in New York, agrees with Dr. Rogers. But as a provider seeing patients day after day, he says it’s often easier to not engage HIT than it is to slog through it.

“We try to work around the system, and sometimes it’s a much longer workaround,” he says. “So what happens is loss of productivity, greater length of stay, poor patient satisfaction, more screen time, and less bedside time.”

Dr. Mehta says frustration is building as society—outside of medicine—moves rapidly through such technology as smartphones, tablets, and other intuitive devices that make actions easier. He notes that his toddler daughter could learn how to navigate an iPad in a fraction of the time it takes him to complete an HIT training course.

“You cannot have physicians going through learning for four hours, learning a system to do step one before step two before step three,” he laments. “It should flow naturally. I don’t think the IT people have realized that as of yet.”

Richard Quinn is a freelance writer in New Jersey.

Like a grinning child at a carnival, Iqbal M. Binoj, MD, steps right up and gives it a try—except instead of tossing rings, he’s gripping an intraosseous infusion drill.

A tutor shows him how the device, which looks remarkably like a glue gun, inserts into the bones of the shoulder or knee and drills down until it hits the marrow. He is guided on using a steady speed to maintain the integrity of the cavity. He’s also taught about the maneuver’s low complication rates and ability to expedite workups.

“I’ve seen it used before, but I never did it,” says Dr. Binoj, a hospitalist with Cogent HMG at Genesis Medical Center in Davenport, Iowa.

Well, he never did it before a hands-on pre-course at HM13 that focused on improving hospitalists’ proficiency at such procedures as lumbar punctures and ultrasound-guided vascular access. Quality improvement (QI) is always a focus of SHM’s annual meeting, but sometimes the science of improving care is viewed from up on high.

Not everything needs to be a national imitative, an institution-wide project, or even a unit-based intervention. Sometimes, it’s as simple as teaching a room full of hospitalists how to use an intraosseous infusion drill, says Michelle Fox, RN, BSN, senior director of clinical affairs with Vidacare, which manufactures the drill used in the demonstration.

“Hospitalists have an increasing role in doing these procedures, not only in the environment they predominantly support but in other areas of the hospital,” Fox says, adding that “the primary goal of this course is to give them the opportunity to perfect those skills.”

Hospitalist Bradley Rosen, MD, MBA, FHM, medical of the inpatient specialty program at Cedars-Sinai in Los Angeles, says the point of hands-on demonstrations is to translate QI to the bedside. Take ultrasound devices, he says. In the past few years, the technology has become less expensive, better in resolution, more common, and more portable. Hospitalists must ensure hands-on training that keeps pace with that technology.

“We actually want people to get gloves on, hands on, learn where they may have challenges in terms of their own dexterity or workflow, which hand is dominant, and how to visualize on the ultrasound machine a three-dimensional structure in 2D,” he says. “We don’t want people watching from the sidelines. ... We try to get people in it and engaged.”

And once hospitalists master procedures or diagnostic maneuvers, they invariably are sought out by other physicians to pass that knowledge on to others, Dr. Rosen says.

“In so doing, we get involved in larger quality initiatives and systemwide changes that can go top-down,” he adds, “but from our perspective, it starts with the individual practitioner. And I think SHM has always advocated and preached the importance of the individual hospitalist doing the best possible job for your patient, and the group, and the institution.”

Shared Excellence

What’s best for individual institutions moving forward is what worries SHM immediate past president Shaun Frost, MD, SFHM. He fears CMS’ Value-Based Payment Modifier (VBPM) program could have the unintended consequence of spurring some hospitals to hang on to innovative ideas in order to keep a competitive business advantage.

In health care, where quality and affordability have long been viewed as valuable for nonmonetary reasons, “the medical profession willingly shares new information” to improve patient care, Dr. Frost said in his farewell speech. But he is concerned that commodification—imbuing monetary value into something that previously had none—could change that dynamic, a situation he says is “ethically not acceptable.”

“When somebody builds a better mousetrap, it should be freely shared so that all patients have the opportunity to benefit,” Dr. Frost said. “The pursuit of economic competitive advantage should not prevent us from collaborating and sharing new ideas that hopefully make the health system better.”

Kendall Rogers, MD, FACP, SFHM, chief of the division of hospital medicine at the University of New Mexico Health Sciences Center in Albuquerque, N.M., says part of that improvement in quality and patient safety will come via hospitalists pushing for improvements to health information technology (HIT), particularly to maximize computerized physician order entry (CPOE) and order sets. He empathizes with those who complain about the operability of existing systems but urges physicians to stop complaining and take action.

“We need to stop accepting what our existing limitations are, and we need to be the innovators,” he says. “Many of us aren’t even thinking about, ‘What are the products we need?’ We’re just reacting to the products we currently have and stating how they don’t meet our needs.”

He suggests people communally report safety or troubleshooting issues, in part via Hospital Medicine Exchange (HMX), an online community SHM launched last year to discuss HM issues (www.hmxchange.org). He also wants hospitalists to push HIT vendors to provide improved functionality, and for institutions to provide necessary training.

“We just need to be vocal,” says Dr. Rogers, chair of SHM’s IT Executive Committee. “I do believe this is all leading us to a good place, but there’s a dip down before we have a swing up.”

Frustration Surge

In the long run, hospitalist Anuj Mehta, MD, medical director of the adult hospitalist program at Nyack Hospital in New York, agrees with Dr. Rogers. But as a provider seeing patients day after day, he says it’s often easier to not engage HIT than it is to slog through it.

“We try to work around the system, and sometimes it’s a much longer workaround,” he says. “So what happens is loss of productivity, greater length of stay, poor patient satisfaction, more screen time, and less bedside time.”

Dr. Mehta says frustration is building as society—outside of medicine—moves rapidly through such technology as smartphones, tablets, and other intuitive devices that make actions easier. He notes that his toddler daughter could learn how to navigate an iPad in a fraction of the time it takes him to complete an HIT training course.

“You cannot have physicians going through learning for four hours, learning a system to do step one before step two before step three,” he laments. “It should flow naturally. I don’t think the IT people have realized that as of yet.”

Richard Quinn is a freelance writer in New Jersey.

Like a grinning child at a carnival, Iqbal M. Binoj, MD, steps right up and gives it a try—except instead of tossing rings, he’s gripping an intraosseous infusion drill.

A tutor shows him how the device, which looks remarkably like a glue gun, inserts into the bones of the shoulder or knee and drills down until it hits the marrow. He is guided on using a steady speed to maintain the integrity of the cavity. He’s also taught about the maneuver’s low complication rates and ability to expedite workups.

“I’ve seen it used before, but I never did it,” says Dr. Binoj, a hospitalist with Cogent HMG at Genesis Medical Center in Davenport, Iowa.

Well, he never did it before a hands-on pre-course at HM13 that focused on improving hospitalists’ proficiency at such procedures as lumbar punctures and ultrasound-guided vascular access. Quality improvement (QI) is always a focus of SHM’s annual meeting, but sometimes the science of improving care is viewed from up on high.

Not everything needs to be a national imitative, an institution-wide project, or even a unit-based intervention. Sometimes, it’s as simple as teaching a room full of hospitalists how to use an intraosseous infusion drill, says Michelle Fox, RN, BSN, senior director of clinical affairs with Vidacare, which manufactures the drill used in the demonstration.

“Hospitalists have an increasing role in doing these procedures, not only in the environment they predominantly support but in other areas of the hospital,” Fox says, adding that “the primary goal of this course is to give them the opportunity to perfect those skills.”

Hospitalist Bradley Rosen, MD, MBA, FHM, medical of the inpatient specialty program at Cedars-Sinai in Los Angeles, says the point of hands-on demonstrations is to translate QI to the bedside. Take ultrasound devices, he says. In the past few years, the technology has become less expensive, better in resolution, more common, and more portable. Hospitalists must ensure hands-on training that keeps pace with that technology.

“We actually want people to get gloves on, hands on, learn where they may have challenges in terms of their own dexterity or workflow, which hand is dominant, and how to visualize on the ultrasound machine a three-dimensional structure in 2D,” he says. “We don’t want people watching from the sidelines. ... We try to get people in it and engaged.”

And once hospitalists master procedures or diagnostic maneuvers, they invariably are sought out by other physicians to pass that knowledge on to others, Dr. Rosen says.

“In so doing, we get involved in larger quality initiatives and systemwide changes that can go top-down,” he adds, “but from our perspective, it starts with the individual practitioner. And I think SHM has always advocated and preached the importance of the individual hospitalist doing the best possible job for your patient, and the group, and the institution.”

Shared Excellence

What’s best for individual institutions moving forward is what worries SHM immediate past president Shaun Frost, MD, SFHM. He fears CMS’ Value-Based Payment Modifier (VBPM) program could have the unintended consequence of spurring some hospitals to hang on to innovative ideas in order to keep a competitive business advantage.

In health care, where quality and affordability have long been viewed as valuable for nonmonetary reasons, “the medical profession willingly shares new information” to improve patient care, Dr. Frost said in his farewell speech. But he is concerned that commodification—imbuing monetary value into something that previously had none—could change that dynamic, a situation he says is “ethically not acceptable.”

“When somebody builds a better mousetrap, it should be freely shared so that all patients have the opportunity to benefit,” Dr. Frost said. “The pursuit of economic competitive advantage should not prevent us from collaborating and sharing new ideas that hopefully make the health system better.”

Kendall Rogers, MD, FACP, SFHM, chief of the division of hospital medicine at the University of New Mexico Health Sciences Center in Albuquerque, N.M., says part of that improvement in quality and patient safety will come via hospitalists pushing for improvements to health information technology (HIT), particularly to maximize computerized physician order entry (CPOE) and order sets. He empathizes with those who complain about the operability of existing systems but urges physicians to stop complaining and take action.

“We need to stop accepting what our existing limitations are, and we need to be the innovators,” he says. “Many of us aren’t even thinking about, ‘What are the products we need?’ We’re just reacting to the products we currently have and stating how they don’t meet our needs.”

He suggests people communally report safety or troubleshooting issues, in part via Hospital Medicine Exchange (HMX), an online community SHM launched last year to discuss HM issues (www.hmxchange.org). He also wants hospitalists to push HIT vendors to provide improved functionality, and for institutions to provide necessary training.

“We just need to be vocal,” says Dr. Rogers, chair of SHM’s IT Executive Committee. “I do believe this is all leading us to a good place, but there’s a dip down before we have a swing up.”

Frustration Surge

In the long run, hospitalist Anuj Mehta, MD, medical director of the adult hospitalist program at Nyack Hospital in New York, agrees with Dr. Rogers. But as a provider seeing patients day after day, he says it’s often easier to not engage HIT than it is to slog through it.

“We try to work around the system, and sometimes it’s a much longer workaround,” he says. “So what happens is loss of productivity, greater length of stay, poor patient satisfaction, more screen time, and less bedside time.”

Dr. Mehta says frustration is building as society—outside of medicine—moves rapidly through such technology as smartphones, tablets, and other intuitive devices that make actions easier. He notes that his toddler daughter could learn how to navigate an iPad in a fraction of the time it takes him to complete an HIT training course.

“You cannot have physicians going through learning for four hours, learning a system to do step one before step two before step three,” he laments. “It should flow naturally. I don’t think the IT people have realized that as of yet.”

Richard Quinn is a freelance writer in New Jersey.

You have to make a difficult decision, to try to help the family. You’re trying to provide good care, but on the other hand, there are rules and regulations and bylaws you work under. They don’t align that well, in this case.

—Karim Godamunne, MD, MBA, SFHM

Hospitalists are pushing hard for a change to a Medicare rule requiring beneficiaries to accumulate at least three consecutive days of inpatient treatment at a hospital (not counting day of discharge) before it will cover care in a skilled nursing facility (SNF).

The issue was one of the talking points during last month’s Hospitalists on the Hill, SHM’s annual daylong advocacy campaign that this year coincided with the annual meeting in the nation’s capital. The issue gained attention from hospitalists and others in recent years, in part because of penalties hospitals face for readmissions—and also in part because hospitalists increasingly are providing care at SNFs and other post-acute-care facilities.

The spotlight is brighter now because a group of legislators is trying to identify Medicare beneficiaries previously given “observation status” as inpatients. The Improving Access to Medicare Coverage Act (H.R. 1179 and S. 569) also would establish a 90-day appeal period for those who have been denied the benefit.

SHM senior vice president Joe Miller says hospitalists used HM13 and the Hospitalists on the Hill advocacy day to discuss the issues and the proposed legislation with members of Congress, their staffs, and federal officials. He urges members to continue lobbying for changes. Although the topic might not have the resonance and impact of a fix to the sustainable growth rate (SGR), Miller says, “anybody that deals with admitting or discharging a patient will recognize the importance of this issue.”

The issue, according to Toby Edelman, a senior policy attorney for the Center for Medicare Advocacy in Washington, D.C, is that Medicare mandates that its program enrollees have at least three days of inpatient treatment before it will pay for SNF care. Medicare also covers the costs of post-acute care in other settings but does not require three days of inpatient treatment before doing so. The construct can be confusing to patients who spend time in a hospital but don’t realize that some or all of their stay is spent in “observation status,” meaning none of that time counts toward Medicare’s three-day threshold for reimbursement.

“Most people can’t believe you could be in a hospital bed for a week and then be told as you leave, ‘By the way, bring your checkbook to the nursing home because you weren’t an inpatient here and so now Medicare won’t pay for your stay in the nursing home,’” Edelman says. “This has been an issue for us for quite a while because the consequence for beneficiaries of being in observation is that people have to pay out of pocket for their nursing home care, and that cost is typically hundreds of dollars a day.”

The particular dilemma for hospitalists is managing transitions of care. Hospitalist Karim Godamunne, MD, MBA, SFHM, chief medical officer of North Fulton Hospital in Roswell, Ga., says hospitalists don’t want financial burdens to dictate care decisions, but they are caught in the middle of decisions that could saddle patients with uncovered costs.

He also worries that the issue will only grow in coming years as baby boomers put more pressure on the health-care system. “We have an aging population,” he adds. “This is not going to go away.”

That is one reason SHM is supporting the Improving Access to Medicare Coverage Act. SHM supported the bill when it was first introduced in March and it has been rapidly gaining cosponsors in recent weeks. This uptick in Congressional interest may be partly a response to the efforts of hospitalists during their time on the Hill. SHM staff and hospitalists are continuing their push now as society officials say hospitalists, who often handle both discharges from the hospital and care provided at SNFs, are in a position to lead discussions on how to sensibly fix the problem.

To that end, a recent SHM letter to the bill’s sponsors casts the issue as one of fiscal responsibility.¹ Medicare not covering beneficiaries’ observation days cost patients out-of-pocket money and could cost hospitals in the long run.

“Patients who are admitted with observation status often choose to return home rather than paying out of pocket for a SNF stay,” SHM’s letter reads. “The resultant lack of appropriate post-acute SNF care can result in additional problems such as dehydration, falls, and many other avoidable complications. These complications can not only lead to otherwise preventable readmissions but also increase costs to Medicare for the treatment of conditions that were not present at the time of the original hospital stay.”

Given the debate on observation, Miller says, adopting the bill into law should be a no-brainer. The biggest sticking point likely is the perceived added cost to Medicare. Still, to streamline care and remove an added hurdle to coordinated care, Dr. Godamunne believes the bill should be embraced. He also says that many private insurers look to Medicare decisions to determine their own coverage approaches.

Basically, if Medicare changes its rules, that will carry a lot of weight in the private insurance world.

“This creates a lot of situations for the provider and the family,” Dr. Godamunne says. “You have to make a difficult decision, to try to help the family. You’re trying to provide good care, but on the other hand, there are rules and regulations and bylaws you work under. They don’t align that well, in this case.”

Richard Quinn is a freelance writer in New Jersey.

References

1. SHM. Letter to Congress members. SHM website. Available at: http://www.hospitalmedicine.org/AM/Template.cfm?Section=Letters_to_Congress_and_Regulatory_Agencies&Template=/CM/ContentDisplay.cfm&ContentID=33169. Accessed May 3, 2013.

You have to make a difficult decision, to try to help the family. You’re trying to provide good care, but on the other hand, there are rules and regulations and bylaws you work under. They don’t align that well, in this case.

—Karim Godamunne, MD, MBA, SFHM

Hospitalists are pushing hard for a change to a Medicare rule requiring beneficiaries to accumulate at least three consecutive days of inpatient treatment at a hospital (not counting day of discharge) before it will cover care in a skilled nursing facility (SNF).

The issue was one of the talking points during last month’s Hospitalists on the Hill, SHM’s annual daylong advocacy campaign that this year coincided with the annual meeting in the nation’s capital. The issue gained attention from hospitalists and others in recent years, in part because of penalties hospitals face for readmissions—and also in part because hospitalists increasingly are providing care at SNFs and other post-acute-care facilities.

The spotlight is brighter now because a group of legislators is trying to identify Medicare beneficiaries previously given “observation status” as inpatients. The Improving Access to Medicare Coverage Act (H.R. 1179 and S. 569) also would establish a 90-day appeal period for those who have been denied the benefit.

SHM senior vice president Joe Miller says hospitalists used HM13 and the Hospitalists on the Hill advocacy day to discuss the issues and the proposed legislation with members of Congress, their staffs, and federal officials. He urges members to continue lobbying for changes. Although the topic might not have the resonance and impact of a fix to the sustainable growth rate (SGR), Miller says, “anybody that deals with admitting or discharging a patient will recognize the importance of this issue.”

The issue, according to Toby Edelman, a senior policy attorney for the Center for Medicare Advocacy in Washington, D.C, is that Medicare mandates that its program enrollees have at least three days of inpatient treatment before it will pay for SNF care. Medicare also covers the costs of post-acute care in other settings but does not require three days of inpatient treatment before doing so. The construct can be confusing to patients who spend time in a hospital but don’t realize that some or all of their stay is spent in “observation status,” meaning none of that time counts toward Medicare’s three-day threshold for reimbursement.

“Most people can’t believe you could be in a hospital bed for a week and then be told as you leave, ‘By the way, bring your checkbook to the nursing home because you weren’t an inpatient here and so now Medicare won’t pay for your stay in the nursing home,’” Edelman says. “This has been an issue for us for quite a while because the consequence for beneficiaries of being in observation is that people have to pay out of pocket for their nursing home care, and that cost is typically hundreds of dollars a day.”

The particular dilemma for hospitalists is managing transitions of care. Hospitalist Karim Godamunne, MD, MBA, SFHM, chief medical officer of North Fulton Hospital in Roswell, Ga., says hospitalists don’t want financial burdens to dictate care decisions, but they are caught in the middle of decisions that could saddle patients with uncovered costs.

He also worries that the issue will only grow in coming years as baby boomers put more pressure on the health-care system. “We have an aging population,” he adds. “This is not going to go away.”

That is one reason SHM is supporting the Improving Access to Medicare Coverage Act. SHM supported the bill when it was first introduced in March and it has been rapidly gaining cosponsors in recent weeks. This uptick in Congressional interest may be partly a response to the efforts of hospitalists during their time on the Hill. SHM staff and hospitalists are continuing their push now as society officials say hospitalists, who often handle both discharges from the hospital and care provided at SNFs, are in a position to lead discussions on how to sensibly fix the problem.

To that end, a recent SHM letter to the bill’s sponsors casts the issue as one of fiscal responsibility.¹ Medicare not covering beneficiaries’ observation days cost patients out-of-pocket money and could cost hospitals in the long run.

“Patients who are admitted with observation status often choose to return home rather than paying out of pocket for a SNF stay,” SHM’s letter reads. “The resultant lack of appropriate post-acute SNF care can result in additional problems such as dehydration, falls, and many other avoidable complications. These complications can not only lead to otherwise preventable readmissions but also increase costs to Medicare for the treatment of conditions that were not present at the time of the original hospital stay.”

Given the debate on observation, Miller says, adopting the bill into law should be a no-brainer. The biggest sticking point likely is the perceived added cost to Medicare. Still, to streamline care and remove an added hurdle to coordinated care, Dr. Godamunne believes the bill should be embraced. He also says that many private insurers look to Medicare decisions to determine their own coverage approaches.

Basically, if Medicare changes its rules, that will carry a lot of weight in the private insurance world.

“This creates a lot of situations for the provider and the family,” Dr. Godamunne says. “You have to make a difficult decision, to try to help the family. You’re trying to provide good care, but on the other hand, there are rules and regulations and bylaws you work under. They don’t align that well, in this case.”

Richard Quinn is a freelance writer in New Jersey.

References

1. SHM. Letter to Congress members. SHM website. Available at: http://www.hospitalmedicine.org/AM/Template.cfm?Section=Letters_to_Congress_and_Regulatory_Agencies&Template=/CM/ContentDisplay.cfm&ContentID=33169. Accessed May 3, 2013.

You have to make a difficult decision, to try to help the family. You’re trying to provide good care, but on the other hand, there are rules and regulations and bylaws you work under. They don’t align that well, in this case.

—Karim Godamunne, MD, MBA, SFHM

Hospitalists are pushing hard for a change to a Medicare rule requiring beneficiaries to accumulate at least three consecutive days of inpatient treatment at a hospital (not counting day of discharge) before it will cover care in a skilled nursing facility (SNF).

The issue was one of the talking points during last month’s Hospitalists on the Hill, SHM’s annual daylong advocacy campaign that this year coincided with the annual meeting in the nation’s capital. The issue gained attention from hospitalists and others in recent years, in part because of penalties hospitals face for readmissions—and also in part because hospitalists increasingly are providing care at SNFs and other post-acute-care facilities.

The spotlight is brighter now because a group of legislators is trying to identify Medicare beneficiaries previously given “observation status” as inpatients. The Improving Access to Medicare Coverage Act (H.R. 1179 and S. 569) also would establish a 90-day appeal period for those who have been denied the benefit.

SHM senior vice president Joe Miller says hospitalists used HM13 and the Hospitalists on the Hill advocacy day to discuss the issues and the proposed legislation with members of Congress, their staffs, and federal officials. He urges members to continue lobbying for changes. Although the topic might not have the resonance and impact of a fix to the sustainable growth rate (SGR), Miller says, “anybody that deals with admitting or discharging a patient will recognize the importance of this issue.”

The issue, according to Toby Edelman, a senior policy attorney for the Center for Medicare Advocacy in Washington, D.C, is that Medicare mandates that its program enrollees have at least three days of inpatient treatment before it will pay for SNF care. Medicare also covers the costs of post-acute care in other settings but does not require three days of inpatient treatment before doing so. The construct can be confusing to patients who spend time in a hospital but don’t realize that some or all of their stay is spent in “observation status,” meaning none of that time counts toward Medicare’s three-day threshold for reimbursement.

“Most people can’t believe you could be in a hospital bed for a week and then be told as you leave, ‘By the way, bring your checkbook to the nursing home because you weren’t an inpatient here and so now Medicare won’t pay for your stay in the nursing home,’” Edelman says. “This has been an issue for us for quite a while because the consequence for beneficiaries of being in observation is that people have to pay out of pocket for their nursing home care, and that cost is typically hundreds of dollars a day.”

The particular dilemma for hospitalists is managing transitions of care. Hospitalist Karim Godamunne, MD, MBA, SFHM, chief medical officer of North Fulton Hospital in Roswell, Ga., says hospitalists don’t want financial burdens to dictate care decisions, but they are caught in the middle of decisions that could saddle patients with uncovered costs.

He also worries that the issue will only grow in coming years as baby boomers put more pressure on the health-care system. “We have an aging population,” he adds. “This is not going to go away.”

That is one reason SHM is supporting the Improving Access to Medicare Coverage Act. SHM supported the bill when it was first introduced in March and it has been rapidly gaining cosponsors in recent weeks. This uptick in Congressional interest may be partly a response to the efforts of hospitalists during their time on the Hill. SHM staff and hospitalists are continuing their push now as society officials say hospitalists, who often handle both discharges from the hospital and care provided at SNFs, are in a position to lead discussions on how to sensibly fix the problem.

To that end, a recent SHM letter to the bill’s sponsors casts the issue as one of fiscal responsibility.¹ Medicare not covering beneficiaries’ observation days cost patients out-of-pocket money and could cost hospitals in the long run.

“Patients who are admitted with observation status often choose to return home rather than paying out of pocket for a SNF stay,” SHM’s letter reads. “The resultant lack of appropriate post-acute SNF care can result in additional problems such as dehydration, falls, and many other avoidable complications. These complications can not only lead to otherwise preventable readmissions but also increase costs to Medicare for the treatment of conditions that were not present at the time of the original hospital stay.”

Given the debate on observation, Miller says, adopting the bill into law should be a no-brainer. The biggest sticking point likely is the perceived added cost to Medicare. Still, to streamline care and remove an added hurdle to coordinated care, Dr. Godamunne believes the bill should be embraced. He also says that many private insurers look to Medicare decisions to determine their own coverage approaches.

Basically, if Medicare changes its rules, that will carry a lot of weight in the private insurance world.

“This creates a lot of situations for the provider and the family,” Dr. Godamunne says. “You have to make a difficult decision, to try to help the family. You’re trying to provide good care, but on the other hand, there are rules and regulations and bylaws you work under. They don’t align that well, in this case.”

Richard Quinn is a freelance writer in New Jersey.

References

1. SHM. Letter to Congress members. SHM website. Available at: http://www.hospitalmedicine.org/AM/Template.cfm?Section=Letters_to_Congress_and_Regulatory_Agencies&Template=/CM/ContentDisplay.cfm&ContentID=33169. Accessed May 3, 2013.

Dear Mark,

I am pleased and excited that you are willing to abandon your plan for being a vagabond and will give serious consideration to joining the faculty of the Department of Pediatrics to become a core member of a new [general pediatric inpatient] program that I believe has exciting potential.

So reads the first line of my very first job offer letter. Obviously, my chairman had a sense of humor. But he also was not off target, as before May 21 of my third year of residency, I had no meaningful work lined up. Dreams of locum tenens work in Hawaii or a California coastal town quickly disappeared as I received only offers for work in small-town Mississippi and Oklahoma. Eleven years later, I don’t think I could have planned a more fulfilling early career, particularly when the alternative might have been surfing on the Mississippi River.

I would like this opportunity, in my final column as The Hospitalist’s pediatric editor, to reflect on this odyssey from vagabond to hospitalist.

The Early Years

As a new attending, I was appropriately terrified of how much I didn’t know. I also had ambitious goals at first, wanting to emulate my two favorite role models from residency, Charles Ginsburg and Heinz Eichenwald. We might call them hospitalists now, but back then they were old-fashioned, generalist inpatient clinician-educators, even while chairing the department of pediatrics over their separate tenures. They were the smartest and wisest teachers that I have ever met. These early years were a pseudo-fellowship of sorts; under their tutelage, I soaked up more than I ever had during residency.

Despite all of this learning, I remained sheltered in my clinician-educator bubble. The path to excellence for me was defined through frequent trips to the library (where journals used to be stored) and trying to teach as well as my mentors did. I largely was ignorant of the national hospitalist movement, until the 2007 SHM annual meeting was held in my backyard in Dallas. Listening to Bob Wachter that year, and then Don Berwick the following year, I suddenly realized the tremendous and intertwined importance of the quality movement and hospitalists. We were going to fix medicine. OK, maybe not all of medicine, but it happened to be the perfect time for me to learn about our health-care crisis, quality, and the role of hospital medicine.

If my first five years were about clinical medicine, the next five years were all about lessons in leadership. I had a new role, directing 8 15 20 25 hospitalists—and now was accountable for the group’s results. I’ve often said that an explicit leadership role is like stepping behind a curtain, where your own previous n=1 perspective is now the challenge of herding a group of n=25. And let’s be clear that it’s one thing to manage the group and keep the ship afloat, but it’s entirely another thing to lead the group toward success.

A Path for Me

Although the cacophony of managing that many voices was deafening early on, I found solace in the lessons of quality improvement (QI), where no project lives without a team that is all going the same direction. Between the national opportunities for collaborative improvement and the day-to-day experiences within my group, I found two simple principles worked well: 1) engage the team and 2) deliver objective results.

And just as I had craved a clinical learning environment early on, I now found myself learning from local and national peers putting their leadership skills in action to produce quality outcomes. The beauty of collaborative teamwork is that it creates self-sustaining capacity for more positive results.

Looking forward, the opportunities seem limitless for pediatric hospital medicine. From the inherent fulfillment of our day-to-day bedside work to the explicit leadership that we offer the complex hospital system, our family of pediatric hospitalists has blazed career paths in all directions. We are program directors. We are directors of quality and safety. We are division directors and section chiefs. We are professors. We are fellowship-trained. We are CEOs, of entire hospitals and the CMO of CMS. There has never been a better time to be a pediatric hospitalist.

This rapid ascent has to be the fastest in the history of medicine and might surprise the unsuspecting, but these career paths really should have been expected. Residents and students still identify the most with their ward months—we always will be leaders in education. Hospitals and health-care systems recognize the value of hospitalists as systems improvers and will forever need enlightened physicians to guide safer, better care. But we also remain generalists, perched over the exact intersection of acute illness and health. From this vantage point, we have the perfect perspective from which to lead the transformation of our health-care system. I’m not sure there is a leadership position in health care that a hospitalist will not fill in the near future.

A New Frontier

With all of this opportunity before us, there exists an imperative for true leadership. And unlike all of our past requirements for achievement, relying on our quantitative abilities will no longer be enough. Rather, we will need to focus on the qualitative “soft” skills, whether you call this emotional intelligence, interpersonal communication, or behavioral economics. The creation of value-based, care-delivery systems requires high-functioning units. We will need to design and lead teams from the bedside to the boardroom.

In the coming years, this leadership imperative will only intensify, as we all will be pressured to do more with less. We will be asked to improve quality and decrease costs. We will need to broaden our focus to health in addition to acute illness. Doing more with less will require courage and leadership. If you look at our growth curve to date, we have an abundance of both.

Dr. Shen is medical director of hospital medicine at Dell Children's Medical Center in Austin, Texas. He served as The Hospitalist's pediatric editor since 2010 and this marks his last column in his role as editor. In his newfound spare time, he looks forward to defining value in health care.

Dear Mark,

I am pleased and excited that you are willing to abandon your plan for being a vagabond and will give serious consideration to joining the faculty of the Department of Pediatrics to become a core member of a new [general pediatric inpatient] program that I believe has exciting potential.

So reads the first line of my very first job offer letter. Obviously, my chairman had a sense of humor. But he also was not off target, as before May 21 of my third year of residency, I had no meaningful work lined up. Dreams of locum tenens work in Hawaii or a California coastal town quickly disappeared as I received only offers for work in small-town Mississippi and Oklahoma. Eleven years later, I don’t think I could have planned a more fulfilling early career, particularly when the alternative might have been surfing on the Mississippi River.

I would like this opportunity, in my final column as The Hospitalist’s pediatric editor, to reflect on this odyssey from vagabond to hospitalist.

The Early Years

As a new attending, I was appropriately terrified of how much I didn’t know. I also had ambitious goals at first, wanting to emulate my two favorite role models from residency, Charles Ginsburg and Heinz Eichenwald. We might call them hospitalists now, but back then they were old-fashioned, generalist inpatient clinician-educators, even while chairing the department of pediatrics over their separate tenures. They were the smartest and wisest teachers that I have ever met. These early years were a pseudo-fellowship of sorts; under their tutelage, I soaked up more than I ever had during residency.

Despite all of this learning, I remained sheltered in my clinician-educator bubble. The path to excellence for me was defined through frequent trips to the library (where journals used to be stored) and trying to teach as well as my mentors did. I largely was ignorant of the national hospitalist movement, until the 2007 SHM annual meeting was held in my backyard in Dallas. Listening to Bob Wachter that year, and then Don Berwick the following year, I suddenly realized the tremendous and intertwined importance of the quality movement and hospitalists. We were going to fix medicine. OK, maybe not all of medicine, but it happened to be the perfect time for me to learn about our health-care crisis, quality, and the role of hospital medicine.

If my first five years were about clinical medicine, the next five years were all about lessons in leadership. I had a new role, directing 8 15 20 25 hospitalists—and now was accountable for the group’s results. I’ve often said that an explicit leadership role is like stepping behind a curtain, where your own previous n=1 perspective is now the challenge of herding a group of n=25. And let’s be clear that it’s one thing to manage the group and keep the ship afloat, but it’s entirely another thing to lead the group toward success.

A Path for Me

Although the cacophony of managing that many voices was deafening early on, I found solace in the lessons of quality improvement (QI), where no project lives without a team that is all going the same direction. Between the national opportunities for collaborative improvement and the day-to-day experiences within my group, I found two simple principles worked well: 1) engage the team and 2) deliver objective results.

And just as I had craved a clinical learning environment early on, I now found myself learning from local and national peers putting their leadership skills in action to produce quality outcomes. The beauty of collaborative teamwork is that it creates self-sustaining capacity for more positive results.

Looking forward, the opportunities seem limitless for pediatric hospital medicine. From the inherent fulfillment of our day-to-day bedside work to the explicit leadership that we offer the complex hospital system, our family of pediatric hospitalists has blazed career paths in all directions. We are program directors. We are directors of quality and safety. We are division directors and section chiefs. We are professors. We are fellowship-trained. We are CEOs, of entire hospitals and the CMO of CMS. There has never been a better time to be a pediatric hospitalist.

This rapid ascent has to be the fastest in the history of medicine and might surprise the unsuspecting, but these career paths really should have been expected. Residents and students still identify the most with their ward months—we always will be leaders in education. Hospitals and health-care systems recognize the value of hospitalists as systems improvers and will forever need enlightened physicians to guide safer, better care. But we also remain generalists, perched over the exact intersection of acute illness and health. From this vantage point, we have the perfect perspective from which to lead the transformation of our health-care system. I’m not sure there is a leadership position in health care that a hospitalist will not fill in the near future.

A New Frontier

With all of this opportunity before us, there exists an imperative for true leadership. And unlike all of our past requirements for achievement, relying on our quantitative abilities will no longer be enough. Rather, we will need to focus on the qualitative “soft” skills, whether you call this emotional intelligence, interpersonal communication, or behavioral economics. The creation of value-based, care-delivery systems requires high-functioning units. We will need to design and lead teams from the bedside to the boardroom.

In the coming years, this leadership imperative will only intensify, as we all will be pressured to do more with less. We will be asked to improve quality and decrease costs. We will need to broaden our focus to health in addition to acute illness. Doing more with less will require courage and leadership. If you look at our growth curve to date, we have an abundance of both.

Dr. Shen is medical director of hospital medicine at Dell Children's Medical Center in Austin, Texas. He served as The Hospitalist's pediatric editor since 2010 and this marks his last column in his role as editor. In his newfound spare time, he looks forward to defining value in health care.

Dear Mark,

I am pleased and excited that you are willing to abandon your plan for being a vagabond and will give serious consideration to joining the faculty of the Department of Pediatrics to become a core member of a new [general pediatric inpatient] program that I believe has exciting potential.

So reads the first line of my very first job offer letter. Obviously, my chairman had a sense of humor. But he also was not off target, as before May 21 of my third year of residency, I had no meaningful work lined up. Dreams of locum tenens work in Hawaii or a California coastal town quickly disappeared as I received only offers for work in small-town Mississippi and Oklahoma. Eleven years later, I don’t think I could have planned a more fulfilling early career, particularly when the alternative might have been surfing on the Mississippi River.

I would like this opportunity, in my final column as The Hospitalist’s pediatric editor, to reflect on this odyssey from vagabond to hospitalist.

The Early Years

As a new attending, I was appropriately terrified of how much I didn’t know. I also had ambitious goals at first, wanting to emulate my two favorite role models from residency, Charles Ginsburg and Heinz Eichenwald. We might call them hospitalists now, but back then they were old-fashioned, generalist inpatient clinician-educators, even while chairing the department of pediatrics over their separate tenures. They were the smartest and wisest teachers that I have ever met. These early years were a pseudo-fellowship of sorts; under their tutelage, I soaked up more than I ever had during residency.

Despite all of this learning, I remained sheltered in my clinician-educator bubble. The path to excellence for me was defined through frequent trips to the library (where journals used to be stored) and trying to teach as well as my mentors did. I largely was ignorant of the national hospitalist movement, until the 2007 SHM annual meeting was held in my backyard in Dallas. Listening to Bob Wachter that year, and then Don Berwick the following year, I suddenly realized the tremendous and intertwined importance of the quality movement and hospitalists. We were going to fix medicine. OK, maybe not all of medicine, but it happened to be the perfect time for me to learn about our health-care crisis, quality, and the role of hospital medicine.

If my first five years were about clinical medicine, the next five years were all about lessons in leadership. I had a new role, directing 8 15 20 25 hospitalists—and now was accountable for the group’s results. I’ve often said that an explicit leadership role is like stepping behind a curtain, where your own previous n=1 perspective is now the challenge of herding a group of n=25. And let’s be clear that it’s one thing to manage the group and keep the ship afloat, but it’s entirely another thing to lead the group toward success.

A Path for Me

Although the cacophony of managing that many voices was deafening early on, I found solace in the lessons of quality improvement (QI), where no project lives without a team that is all going the same direction. Between the national opportunities for collaborative improvement and the day-to-day experiences within my group, I found two simple principles worked well: 1) engage the team and 2) deliver objective results.

And just as I had craved a clinical learning environment early on, I now found myself learning from local and national peers putting their leadership skills in action to produce quality outcomes. The beauty of collaborative teamwork is that it creates self-sustaining capacity for more positive results.

Looking forward, the opportunities seem limitless for pediatric hospital medicine. From the inherent fulfillment of our day-to-day bedside work to the explicit leadership that we offer the complex hospital system, our family of pediatric hospitalists has blazed career paths in all directions. We are program directors. We are directors of quality and safety. We are division directors and section chiefs. We are professors. We are fellowship-trained. We are CEOs, of entire hospitals and the CMO of CMS. There has never been a better time to be a pediatric hospitalist.

This rapid ascent has to be the fastest in the history of medicine and might surprise the unsuspecting, but these career paths really should have been expected. Residents and students still identify the most with their ward months—we always will be leaders in education. Hospitals and health-care systems recognize the value of hospitalists as systems improvers and will forever need enlightened physicians to guide safer, better care. But we also remain generalists, perched over the exact intersection of acute illness and health. From this vantage point, we have the perfect perspective from which to lead the transformation of our health-care system. I’m not sure there is a leadership position in health care that a hospitalist will not fill in the near future.

A New Frontier

With all of this opportunity before us, there exists an imperative for true leadership. And unlike all of our past requirements for achievement, relying on our quantitative abilities will no longer be enough. Rather, we will need to focus on the qualitative “soft” skills, whether you call this emotional intelligence, interpersonal communication, or behavioral economics. The creation of value-based, care-delivery systems requires high-functioning units. We will need to design and lead teams from the bedside to the boardroom.

In the coming years, this leadership imperative will only intensify, as we all will be pressured to do more with less. We will be asked to improve quality and decrease costs. We will need to broaden our focus to health in addition to acute illness. Doing more with less will require courage and leadership. If you look at our growth curve to date, we have an abundance of both.

Dr. Shen is medical director of hospital medicine at Dell Children's Medical Center in Austin, Texas. He served as The Hospitalist's pediatric editor since 2010 and this marks his last column in his role as editor. In his newfound spare time, he looks forward to defining value in health care.

To some HM13 attendees, the keynote speakers might have seemed to be talking about different things.

Patrick Conway, MD, MSc, FAAP, SFHM, chief medical officer and director of the Center for Clinical Standards and Quality at the Centers for Medicare & Medicaid Services (CMS), hinted at promising results from the first accountable-care organizations (ACOs) and noted a meaningful reduction in 30-day readmission rates for the first time in years.

David Feinberg, MD, MBA, president of UCLA Health System in Los Angeles, told hospitalists that unless they’re getting patient care right every time, they’re not getting it right enough. And nothing would make him happier than seeing fewer hospitalists at SHM’s annual meeting—because that would mean fewer hospitalized patients.

HM pioneer Bob Wachter, MD, MHM, said it’s time for hospitalists to link their quality-improvement (QI) efforts and safety acumen to projects focused on cutting costs and reducing waste in the health-care system.

So while each made their points in a different way, each plenary speaker left many meeting-goers with a similar thought: Hospitalists are positioned at the nexus of big-picture reform and day-to-day implementation. So if hospitalists as a specialty continue to embrace teamwork, evidence-based practice, quality, safety, and a sense that the patient comes first, they will cement themselves as leaders in the next iteration of health-care delivery.

“There is enormous change going on in the healthcare system,” says SHM CEO Larry Wellikson. “And we are right in the middle of this. We are essential. If we are bad, we are going to sink it. And if we’re great, we are going to take it to another level.”

Needle Movement

Dr. Conway said some of that progress already is evident. He disclosed that initial findings from the first data sets coming from the first ACOs are showing promising results, though he can’t go into detail until the information is publicly released. However, he did boast that after decades of Medicare readmission rates hovering around 19%, data from late 2012 and early 2013 show that figure has dropped to below 18%.

“That is a 1.5% to 2% shift in readmissions nationally,” he said. “It is a credit to the work you and others are doing in the field. That’s hundreds of thousands of Medicare beneficiaries that are not readmitted every year, that stay home healthy. … It’s a tremendous example of moving a national needle.”

He dismissed those who attribute the initial readmission progress solely to penalties instituted on readmissions, though he acknowledged that CMS is using both carrots and sticks to push change.

“It’s a combination of interventions,” he said.

And all of those initiatives must be aimed jointly at improving the patient experience, said Dr. Feinberg, a child psychiatrist by training whose mantra is “patient-centeredness.” Dr. Feinberg’s reputation is that of a physician-administrator who puts patients first. For example, even though his health system (www.uclahealth.org) is in the 99th percentile for patient satisfaction, he is unhappy. That’s because the top ranking means roughly 85 out of every 100 patients served are pretty happy with their experience.

“It means that we’re the cream of the crap,” he said. “Of the last 100 people we took care of, 15 of them—and, by definition, those 15 people are someone’s mom, someone’s brother, someone’s coworker—would not refer us to a friend, or rate us a 9 or 10. So, I think, while we’ve really moved the needle, we’re really not done until we get it right with every patient, every time.”

He added that those who argue against difficult or time-consuming innovations and improvements that better patient care are arguing against the moral high ground of how they would want a family member to be treated in the hospital.

“The pushback I hear is, ‘Some of this stuff is unpreventable,’” Dr. Feinberg said. “Well, maybe it’s unpreventable the way we’re doing it now. But maybe we need to think differently. Maybe it is unpreventable, but if this decreases the prevalence, or makes it better, then to me, it’s important to do.”

Dr. Feinberg, who took over as UCLA Health System’s president in 2011, says he still spends several hours every day talking to patients. For those who say there’s not enough time to stay connected to patients and that all the time spent making sure patients are happy takes away from other activities, he says they’re forgetting what brought them into medicine in the first place: healing. He blames the delivery system for stifling what he believes is a provider’s desire to help people.

“We haven’t allowed the culture to come out,” he said. “I think it’s there.”

Dr. Wachter has a similar faith in the hospitalist culture—although his is based in the pluripotent nature of the specialty. Hospitalists have worked hard to be viewed as “generalists, able to solve all kinds of problems,” and that means the specialty is poised to adapt and thrive.

“We will morph into what is needed,” said Dr. Wachter, a past president of SHM whose titles include chief of the division of hospital medicine at the University of California at San Francisco and chair of the American Board of Internal Medicine. “That will be all sorts of things: comanagement, dealing with the residency limits in teaching hospitals, systems improvement, cost reductions, transitions, working in skilled nursing facilities, all the specialty hospitalists.

“We will fill new niches,” he said.

What Dr. Wachter does not want to see is that the field grows “fat and happy,” as it is now firmly entrenched in the U.S. health-care delivery system. In fact, he urged hospitalists to welcome change, particularly initiatives that improve quality and safety, reduce costs and waste, and, ultimately, improve the patient experience.

But he cautioned against conceptually separating QI and cost reduction. Instead, they should be viewed as equally meaningful parts of his oft-quoted value equation, which, viewed from the health-care consumer’s point of view, is quality divided by cost.

“You can’t survive and thrive in a world with the kinds of pressures that we have to improve performance if you do business the same old way,” he added. “It’s no longer possible to achieve the things you need to achieve handling these as single projects. You need to transform the way you think about care.”

Richard Quinn is a freelance writer in New Jersey.

To some HM13 attendees, the keynote speakers might have seemed to be talking about different things.

Patrick Conway, MD, MSc, FAAP, SFHM, chief medical officer and director of the Center for Clinical Standards and Quality at the Centers for Medicare & Medicaid Services (CMS), hinted at promising results from the first accountable-care organizations (ACOs) and noted a meaningful reduction in 30-day readmission rates for the first time in years.

David Feinberg, MD, MBA, president of UCLA Health System in Los Angeles, told hospitalists that unless they’re getting patient care right every time, they’re not getting it right enough. And nothing would make him happier than seeing fewer hospitalists at SHM’s annual meeting—because that would mean fewer hospitalized patients.

HM pioneer Bob Wachter, MD, MHM, said it’s time for hospitalists to link their quality-improvement (QI) efforts and safety acumen to projects focused on cutting costs and reducing waste in the health-care system.

So while each made their points in a different way, each plenary speaker left many meeting-goers with a similar thought: Hospitalists are positioned at the nexus of big-picture reform and day-to-day implementation. So if hospitalists as a specialty continue to embrace teamwork, evidence-based practice, quality, safety, and a sense that the patient comes first, they will cement themselves as leaders in the next iteration of health-care delivery.

“There is enormous change going on in the healthcare system,” says SHM CEO Larry Wellikson. “And we are right in the middle of this. We are essential. If we are bad, we are going to sink it. And if we’re great, we are going to take it to another level.”

Needle Movement

Dr. Conway said some of that progress already is evident. He disclosed that initial findings from the first data sets coming from the first ACOs are showing promising results, though he can’t go into detail until the information is publicly released. However, he did boast that after decades of Medicare readmission rates hovering around 19%, data from late 2012 and early 2013 show that figure has dropped to below 18%.

“That is a 1.5% to 2% shift in readmissions nationally,” he said. “It is a credit to the work you and others are doing in the field. That’s hundreds of thousands of Medicare beneficiaries that are not readmitted every year, that stay home healthy. … It’s a tremendous example of moving a national needle.”

He dismissed those who attribute the initial readmission progress solely to penalties instituted on readmissions, though he acknowledged that CMS is using both carrots and sticks to push change.

“It’s a combination of interventions,” he said.

And all of those initiatives must be aimed jointly at improving the patient experience, said Dr. Feinberg, a child psychiatrist by training whose mantra is “patient-centeredness.” Dr. Feinberg’s reputation is that of a physician-administrator who puts patients first. For example, even though his health system (www.uclahealth.org) is in the 99th percentile for patient satisfaction, he is unhappy. That’s because the top ranking means roughly 85 out of every 100 patients served are pretty happy with their experience.

“It means that we’re the cream of the crap,” he said. “Of the last 100 people we took care of, 15 of them—and, by definition, those 15 people are someone’s mom, someone’s brother, someone’s coworker—would not refer us to a friend, or rate us a 9 or 10. So, I think, while we’ve really moved the needle, we’re really not done until we get it right with every patient, every time.”

He added that those who argue against difficult or time-consuming innovations and improvements that better patient care are arguing against the moral high ground of how they would want a family member to be treated in the hospital.

“The pushback I hear is, ‘Some of this stuff is unpreventable,’” Dr. Feinberg said. “Well, maybe it’s unpreventable the way we’re doing it now. But maybe we need to think differently. Maybe it is unpreventable, but if this decreases the prevalence, or makes it better, then to me, it’s important to do.”

Dr. Feinberg, who took over as UCLA Health System’s president in 2011, says he still spends several hours every day talking to patients. For those who say there’s not enough time to stay connected to patients and that all the time spent making sure patients are happy takes away from other activities, he says they’re forgetting what brought them into medicine in the first place: healing. He blames the delivery system for stifling what he believes is a provider’s desire to help people.

“We haven’t allowed the culture to come out,” he said. “I think it’s there.”

Dr. Wachter has a similar faith in the hospitalist culture—although his is based in the pluripotent nature of the specialty. Hospitalists have worked hard to be viewed as “generalists, able to solve all kinds of problems,” and that means the specialty is poised to adapt and thrive.

“We will morph into what is needed,” said Dr. Wachter, a past president of SHM whose titles include chief of the division of hospital medicine at the University of California at San Francisco and chair of the American Board of Internal Medicine. “That will be all sorts of things: comanagement, dealing with the residency limits in teaching hospitals, systems improvement, cost reductions, transitions, working in skilled nursing facilities, all the specialty hospitalists.

“We will fill new niches,” he said.

What Dr. Wachter does not want to see is that the field grows “fat and happy,” as it is now firmly entrenched in the U.S. health-care delivery system. In fact, he urged hospitalists to welcome change, particularly initiatives that improve quality and safety, reduce costs and waste, and, ultimately, improve the patient experience.

But he cautioned against conceptually separating QI and cost reduction. Instead, they should be viewed as equally meaningful parts of his oft-quoted value equation, which, viewed from the health-care consumer’s point of view, is quality divided by cost.

“You can’t survive and thrive in a world with the kinds of pressures that we have to improve performance if you do business the same old way,” he added. “It’s no longer possible to achieve the things you need to achieve handling these as single projects. You need to transform the way you think about care.”

Richard Quinn is a freelance writer in New Jersey.

To some HM13 attendees, the keynote speakers might have seemed to be talking about different things.

Patrick Conway, MD, MSc, FAAP, SFHM, chief medical officer and director of the Center for Clinical Standards and Quality at the Centers for Medicare & Medicaid Services (CMS), hinted at promising results from the first accountable-care organizations (ACOs) and noted a meaningful reduction in 30-day readmission rates for the first time in years.

David Feinberg, MD, MBA, president of UCLA Health System in Los Angeles, told hospitalists that unless they’re getting patient care right every time, they’re not getting it right enough. And nothing would make him happier than seeing fewer hospitalists at SHM’s annual meeting—because that would mean fewer hospitalized patients.

HM pioneer Bob Wachter, MD, MHM, said it’s time for hospitalists to link their quality-improvement (QI) efforts and safety acumen to projects focused on cutting costs and reducing waste in the health-care system.

So while each made their points in a different way, each plenary speaker left many meeting-goers with a similar thought: Hospitalists are positioned at the nexus of big-picture reform and day-to-day implementation. So if hospitalists as a specialty continue to embrace teamwork, evidence-based practice, quality, safety, and a sense that the patient comes first, they will cement themselves as leaders in the next iteration of health-care delivery.

“There is enormous change going on in the healthcare system,” says SHM CEO Larry Wellikson. “And we are right in the middle of this. We are essential. If we are bad, we are going to sink it. And if we’re great, we are going to take it to another level.”

Needle Movement

Dr. Conway said some of that progress already is evident. He disclosed that initial findings from the first data sets coming from the first ACOs are showing promising results, though he can’t go into detail until the information is publicly released. However, he did boast that after decades of Medicare readmission rates hovering around 19%, data from late 2012 and early 2013 show that figure has dropped to below 18%.

“That is a 1.5% to 2% shift in readmissions nationally,” he said. “It is a credit to the work you and others are doing in the field. That’s hundreds of thousands of Medicare beneficiaries that are not readmitted every year, that stay home healthy. … It’s a tremendous example of moving a national needle.”

He dismissed those who attribute the initial readmission progress solely to penalties instituted on readmissions, though he acknowledged that CMS is using both carrots and sticks to push change.

“It’s a combination of interventions,” he said.

And all of those initiatives must be aimed jointly at improving the patient experience, said Dr. Feinberg, a child psychiatrist by training whose mantra is “patient-centeredness.” Dr. Feinberg’s reputation is that of a physician-administrator who puts patients first. For example, even though his health system (www.uclahealth.org) is in the 99th percentile for patient satisfaction, he is unhappy. That’s because the top ranking means roughly 85 out of every 100 patients served are pretty happy with their experience.

“It means that we’re the cream of the crap,” he said. “Of the last 100 people we took care of, 15 of them—and, by definition, those 15 people are someone’s mom, someone’s brother, someone’s coworker—would not refer us to a friend, or rate us a 9 or 10. So, I think, while we’ve really moved the needle, we’re really not done until we get it right with every patient, every time.”

He added that those who argue against difficult or time-consuming innovations and improvements that better patient care are arguing against the moral high ground of how they would want a family member to be treated in the hospital.

“The pushback I hear is, ‘Some of this stuff is unpreventable,’” Dr. Feinberg said. “Well, maybe it’s unpreventable the way we’re doing it now. But maybe we need to think differently. Maybe it is unpreventable, but if this decreases the prevalence, or makes it better, then to me, it’s important to do.”

Dr. Feinberg, who took over as UCLA Health System’s president in 2011, says he still spends several hours every day talking to patients. For those who say there’s not enough time to stay connected to patients and that all the time spent making sure patients are happy takes away from other activities, he says they’re forgetting what brought them into medicine in the first place: healing. He blames the delivery system for stifling what he believes is a provider’s desire to help people.

“We haven’t allowed the culture to come out,” he said. “I think it’s there.”

Dr. Wachter has a similar faith in the hospitalist culture—although his is based in the pluripotent nature of the specialty. Hospitalists have worked hard to be viewed as “generalists, able to solve all kinds of problems,” and that means the specialty is poised to adapt and thrive.

“We will morph into what is needed,” said Dr. Wachter, a past president of SHM whose titles include chief of the division of hospital medicine at the University of California at San Francisco and chair of the American Board of Internal Medicine. “That will be all sorts of things: comanagement, dealing with the residency limits in teaching hospitals, systems improvement, cost reductions, transitions, working in skilled nursing facilities, all the specialty hospitalists.

“We will fill new niches,” he said.

What Dr. Wachter does not want to see is that the field grows “fat and happy,” as it is now firmly entrenched in the U.S. health-care delivery system. In fact, he urged hospitalists to welcome change, particularly initiatives that improve quality and safety, reduce costs and waste, and, ultimately, improve the patient experience.

But he cautioned against conceptually separating QI and cost reduction. Instead, they should be viewed as equally meaningful parts of his oft-quoted value equation, which, viewed from the health-care consumer’s point of view, is quality divided by cost.

“You can’t survive and thrive in a world with the kinds of pressures that we have to improve performance if you do business the same old way,” he added. “It’s no longer possible to achieve the things you need to achieve handling these as single projects. You need to transform the way you think about care.”

Richard Quinn is a freelance writer in New Jersey.

A study published online in JAMA Internal Medicine finds a clear association between elder abuse and hospitalization rates.⁴

Unadjusted mean annual rate of hospitalization was 1.97% for those with reported elder abuse to social service agencies among 6,674 participants in the Chicago Health and Aging Project between 1993 and 2010.⁴ That rate was more than three times the rate for those without reported abuse.

The authors define elder abuse to include physical, sexual, or psychological abuse, caregiver neglect, and financial exploitation. Its identification as a risk factor for increased hospitalizations poses important policy implications for the need to identify elder abuse and caregiver neglect, says lead author XinQi Dong, MD, a researcher and geriatrician at Rush University in Chicago. Hospitalists, according to Dr. Dong, should consider screening patients who present with dehydration, malnutrition, delirium, and skin ulcers.

Larry Beresford is a freelance writer in San Francisco

References

1. Weigel C, Suen W, Gupta G. Using Lean methodology to teach quality improvement to internal medicine residents at a safety net hospital. Am J Med Qual. 2013 Feb 4 [Epub ahead of print].
2. Morganti KG, Lovejoy S, Beckjord EB, Haviland AM, Haas AC, Farley DO. A retrospective evaluation of the Perfecting Patient Care University training program for health care organizations. Am J Med Qual. 2013 Apr 9 [Epub ahead of print].
3. Myers JS, Tess A, Glasheen JJ, et al. The Quality and Safety Educators’ Academy: fulfilling an unmet need for faculty development. Am J Med Qual.  2013 Apr 11 [Epub ahead of print].
4. Dong XQ, Simon MA. Elder abuse as a risk factor for hospitalization in older persons. JAMA Intern Med. 2013 Apr 8:1-7. doi: 10.1001/jamainternmed.2013.238 [Epub ahead of print].
5. Cisco mConcierge. 90% American workers use their own smartphones for work. Cisco mConcierge website. Available at: http://www.ciscomcon.com/sw/swchannel/registration/internet/registrationcfm?SWAPPID=91&RegPageID=350200&SWTHEMEID=12949. Accessed

A study published online in JAMA Internal Medicine finds a clear association between elder abuse and hospitalization rates.⁴

Unadjusted mean annual rate of hospitalization was 1.97% for those with reported elder abuse to social service agencies among 6,674 participants in the Chicago Health and Aging Project between 1993 and 2010.⁴ That rate was more than three times the rate for those without reported abuse.

The authors define elder abuse to include physical, sexual, or psychological abuse, caregiver neglect, and financial exploitation. Its identification as a risk factor for increased hospitalizations poses important policy implications for the need to identify elder abuse and caregiver neglect, says lead author XinQi Dong, MD, a researcher and geriatrician at Rush University in Chicago. Hospitalists, according to Dr. Dong, should consider screening patients who present with dehydration, malnutrition, delirium, and skin ulcers.

Larry Beresford is a freelance writer in San Francisco

References

1. Weigel C, Suen W, Gupta G. Using Lean methodology to teach quality improvement to internal medicine residents at a safety net hospital. Am J Med Qual. 2013 Feb 4 [Epub ahead of print].
2. Morganti KG, Lovejoy S, Beckjord EB, Haviland AM, Haas AC, Farley DO. A retrospective evaluation of the Perfecting Patient Care University training program for health care organizations. Am J Med Qual. 2013 Apr 9 [Epub ahead of print].
3. Myers JS, Tess A, Glasheen JJ, et al. The Quality and Safety Educators’ Academy: fulfilling an unmet need for faculty development. Am J Med Qual.  2013 Apr 11 [Epub ahead of print].
4. Dong XQ, Simon MA. Elder abuse as a risk factor for hospitalization in older persons. JAMA Intern Med. 2013 Apr 8:1-7. doi: 10.1001/jamainternmed.2013.238 [Epub ahead of print].
5. Cisco mConcierge. 90% American workers use their own smartphones for work. Cisco mConcierge website. Available at: http://www.ciscomcon.com/sw/swchannel/registration/internet/registrationcfm?SWAPPID=91&RegPageID=350200&SWTHEMEID=12949. Accessed

A study published online in JAMA Internal Medicine finds a clear association between elder abuse and hospitalization rates.⁴

Unadjusted mean annual rate of hospitalization was 1.97% for those with reported elder abuse to social service agencies among 6,674 participants in the Chicago Health and Aging Project between 1993 and 2010.⁴ That rate was more than three times the rate for those without reported abuse.

The authors define elder abuse to include physical, sexual, or psychological abuse, caregiver neglect, and financial exploitation. Its identification as a risk factor for increased hospitalizations poses important policy implications for the need to identify elder abuse and caregiver neglect, says lead author XinQi Dong, MD, a researcher and geriatrician at Rush University in Chicago. Hospitalists, according to Dr. Dong, should consider screening patients who present with dehydration, malnutrition, delirium, and skin ulcers.

Larry Beresford is a freelance writer in San Francisco

References

1. Weigel C, Suen W, Gupta G. Using Lean methodology to teach quality improvement to internal medicine residents at a safety net hospital. Am J Med Qual. 2013 Feb 4 [Epub ahead of print].
2. Morganti KG, Lovejoy S, Beckjord EB, Haviland AM, Haas AC, Farley DO. A retrospective evaluation of the Perfecting Patient Care University training program for health care organizations. Am J Med Qual. 2013 Apr 9 [Epub ahead of print].
3. Myers JS, Tess A, Glasheen JJ, et al. The Quality and Safety Educators’ Academy: fulfilling an unmet need for faculty development. Am J Med Qual.  2013 Apr 11 [Epub ahead of print].
4. Dong XQ, Simon MA. Elder abuse as a risk factor for hospitalization in older persons. JAMA Intern Med. 2013 Apr 8:1-7. doi: 10.1001/jamainternmed.2013.238 [Epub ahead of print].
5. Cisco mConcierge. 90% American workers use their own smartphones for work. Cisco mConcierge website. Available at: http://www.ciscomcon.com/sw/swchannel/registration/internet/registrationcfm?SWAPPID=91&RegPageID=350200&SWTHEMEID=12949. Accessed

The Association of Health Care Journalists, a professional association that includes 1,400 journalists, is tackling some of the barriers consumers and advocates face when trying to access such information as hospital safety records. AHCJ’s www.HospitalInfections.org is a free, searchable news application that went live in March with detailed reports of deficiencies cited in federal inspection visits for acute- and critical-access hospitals nationwide.

Through years of advocacy, AHCJ has filed Freedom of Information Act requests and negotiated with the Centers for Medicare & Medicaid Services (CMS) to get access to hospital safety information in electronic form.

CMS’ Hospital Compare website (www.medicare.gov/hospitalcompare) and the Joint Commission’s Quality Check (www.qualitycheck.org) program both publicly report hospital quality data, but they have significant time lags and data that are difficult for the average consumer to understand, according to AHCJ. The association touts its new site as an “early attempt by an advocacy group to make hospital safety information easier to access and more consumer-driven.”

“Being able to easily review the performance of your local hospital is vital for health-care journalists and for the public,” AHCJ president Charles Ornstein, a senior reporter at ProPublica in New York, said in a statement.

Larry Beresford is a freelance writer in San Francisco

References

1. Weigel C, Suen W, Gupta G. Using Lean methodology to teach quality improvement to internal medicine residents at a safety net hospital. Am J Med Qual. 2013 Feb 4 [Epub ahead of print].
2. Morganti KG, Lovejoy S, Beckjord EB, Haviland AM, Haas AC, Farley DO. A retrospective evaluation of the Perfecting Patient Care University training program for health care organizations. Am J Med Qual. 2013 Apr 9 [Epub ahead of print].
3. Myers JS, Tess A, Glasheen JJ, et al. The Quality and Safety Educators’ Academy: fulfilling an unmet need for faculty development. Am J Med Qual.  2013 Apr 11 [Epub ahead of print].
4. Dong XQ, Simon MA. Elder abuse as a risk factor for hospitalization in older persons. JAMA Intern Med. 2013 Apr 8:1-7. doi: 10.1001/jamainternmed.2013.238 [Epub ahead of print].
5. Cisco mConcierge. 90% American workers use their own smartphones for work. Cisco mConcierge website. Available at: http://www.ciscomcon.com/sw/swchannel/registration/internet/registrationcfm?SWAPPID=91&RegPageID=350200&SWTHEMEID=12949. Accessed

The Association of Health Care Journalists, a professional association that includes 1,400 journalists, is tackling some of the barriers consumers and advocates face when trying to access such information as hospital safety records. AHCJ’s www.HospitalInfections.org is a free, searchable news application that went live in March with detailed reports of deficiencies cited in federal inspection visits for acute- and critical-access hospitals nationwide.

Through years of advocacy, AHCJ has filed Freedom of Information Act requests and negotiated with the Centers for Medicare & Medicaid Services (CMS) to get access to hospital safety information in electronic form.

CMS’ Hospital Compare website (www.medicare.gov/hospitalcompare) and the Joint Commission’s Quality Check (www.qualitycheck.org) program both publicly report hospital quality data, but they have significant time lags and data that are difficult for the average consumer to understand, according to AHCJ. The association touts its new site as an “early attempt by an advocacy group to make hospital safety information easier to access and more consumer-driven.”

“Being able to easily review the performance of your local hospital is vital for health-care journalists and for the public,” AHCJ president Charles Ornstein, a senior reporter at ProPublica in New York, said in a statement.

Larry Beresford is a freelance writer in San Francisco

References

1. Weigel C, Suen W, Gupta G. Using Lean methodology to teach quality improvement to internal medicine residents at a safety net hospital. Am J Med Qual. 2013 Feb 4 [Epub ahead of print].
2. Morganti KG, Lovejoy S, Beckjord EB, Haviland AM, Haas AC, Farley DO. A retrospective evaluation of the Perfecting Patient Care University training program for health care organizations. Am J Med Qual. 2013 Apr 9 [Epub ahead of print].
3. Myers JS, Tess A, Glasheen JJ, et al. The Quality and Safety Educators’ Academy: fulfilling an unmet need for faculty development. Am J Med Qual.  2013 Apr 11 [Epub ahead of print].
4. Dong XQ, Simon MA. Elder abuse as a risk factor for hospitalization in older persons. JAMA Intern Med. 2013 Apr 8:1-7. doi: 10.1001/jamainternmed.2013.238 [Epub ahead of print].
5. Cisco mConcierge. 90% American workers use their own smartphones for work. Cisco mConcierge website. Available at: http://www.ciscomcon.com/sw/swchannel/registration/internet/registrationcfm?SWAPPID=91&RegPageID=350200&SWTHEMEID=12949. Accessed

The Association of Health Care Journalists, a professional association that includes 1,400 journalists, is tackling some of the barriers consumers and advocates face when trying to access such information as hospital safety records. AHCJ’s www.HospitalInfections.org is a free, searchable news application that went live in March with detailed reports of deficiencies cited in federal inspection visits for acute- and critical-access hospitals nationwide.

Through years of advocacy, AHCJ has filed Freedom of Information Act requests and negotiated with the Centers for Medicare & Medicaid Services (CMS) to get access to hospital safety information in electronic form.

CMS’ Hospital Compare website (www.medicare.gov/hospitalcompare) and the Joint Commission’s Quality Check (www.qualitycheck.org) program both publicly report hospital quality data, but they have significant time lags and data that are difficult for the average consumer to understand, according to AHCJ. The association touts its new site as an “early attempt by an advocacy group to make hospital safety information easier to access and more consumer-driven.”

“Being able to easily review the performance of your local hospital is vital for health-care journalists and for the public,” AHCJ president Charles Ornstein, a senior reporter at ProPublica in New York, said in a statement.

Larry Beresford is a freelance writer in San Francisco

References

1. Weigel C, Suen W, Gupta G. Using Lean methodology to teach quality improvement to internal medicine residents at a safety net hospital. Am J Med Qual. 2013 Feb 4 [Epub ahead of print].
2. Morganti KG, Lovejoy S, Beckjord EB, Haviland AM, Haas AC, Farley DO. A retrospective evaluation of the Perfecting Patient Care University training program for health care organizations. Am J Med Qual. 2013 Apr 9 [Epub ahead of print].
3. Myers JS, Tess A, Glasheen JJ, et al. The Quality and Safety Educators’ Academy: fulfilling an unmet need for faculty development. Am J Med Qual.  2013 Apr 11 [Epub ahead of print].
4. Dong XQ, Simon MA. Elder abuse as a risk factor for hospitalization in older persons. JAMA Intern Med. 2013 Apr 8:1-7. doi: 10.1001/jamainternmed.2013.238 [Epub ahead of print].
5. Cisco mConcierge. 90% American workers use their own smartphones for work. Cisco mConcierge website. Available at: http://www.ciscomcon.com/sw/swchannel/registration/internet/registrationcfm?SWAPPID=91&RegPageID=350200&SWTHEMEID=12949. Accessed

Curriculums using Lean quality-improvement (QI) principles and techniques are becoming entrenched in medical teaching programs across the country.

A curriculum based on Lean QI is teaching medical residents at Boston Medical Center techniques based on successes in manufacturing and service industries, according to Charlene Weigel, MD, who now works as a hospitalist at Mount Auburn Hospital in Cambridge, Mass. Residents also are learning about implementation of Lean principles at the medical center, Dr. Weigel and co-authors report in a study published in the American Journal of Medical Quality.¹

“In Week One, we gave an introduction to QI and explained what Lean means,” Dr. Weigel says. Three other interactive sessions explored such techniques as how to create process maps and root-cause analysis, and identifying steps that aren’t helpful. The 90 residents and eight Boston University School of Public Health students also created 17 group QI project plans. “The goal was for the QI classwork and ideas to become implemented in hospital QI projects, but logistically, we had to scale back expectations for that initial go-round,” Dr. Weigel says.

The medical center recently started a second cycle of the QI course, with students from the first cycle encouraged to continue their QI projects on their own. One group submitted its project as an Institute for Healthcare Improvement storyboard at a national meeting.

“The experience also exposed the residents to our interprofessional team structure, which reflects their future working relationships and professional roles in QI,” Dr. Weigel says.

Lean concepts also are the basis for the Perfecting Patient Care University (PPCU, www.prhi.org/perfecting-patient-care/what-is-ppc), a QI training program for health-care leaders and clinicians offered in a variety of formats by the Pittsburgh Regional Health Initiative, a regional health collaborative. An evaluation of outcomes at PPCU was published online in the American Journal of Medical Quality in April.² The same journal also describes the curriculum, program evaluation, and lessons learned by SHM’s Quality and Safety Educators Academy (http://sites.hospitalmedicine.org/qsea), which provides training in QI and patient safety for teaching faculty.³ The academy, a 2.5-day course, is co-sponsored by the Alliance for Academic Internal Medicine.

Larry Beresford is a freelance writer in San Francisco

References

1. Weigel C, Suen W, Gupta G. Using Lean methodology to teach quality improvement to internal medicine residents at a safety net hospital. Am J Med Qual. 2013 Feb 4 [Epub ahead of print].
2. Morganti KG, Lovejoy S, Beckjord EB, Haviland AM, Haas AC, Farley DO. A retrospective evaluation of the Perfecting Patient Care University training program for health care organizations. Am J Med Qual. 2013 Apr 9 [Epub ahead of print].
3. Myers JS, Tess A, Glasheen JJ, et al. The Quality and Safety Educators’ Academy: fulfilling an unmet need for faculty development. Am J Med Qual.  2013 Apr 11 [Epub ahead of print].
4. Dong XQ, Simon MA. Elder abuse as a risk factor for hospitalization in older persons. JAMA Intern Med. 2013 Apr 8:1-7. doi: 10.1001/jamainternmed.2013.238 [Epub ahead of print].
5. Cisco mConcierge. 90% American workers use their own smartphones for work. Cisco mConcierge website. Available at: http://www.ciscomcon.com/sw/swchannel/registration/internet/registrationcfm?SWAPPID=91&RegPageID=350200&SWTHEMEID=12949. Accessed

Curriculums using Lean quality-improvement (QI) principles and techniques are becoming entrenched in medical teaching programs across the country.

A curriculum based on Lean QI is teaching medical residents at Boston Medical Center techniques based on successes in manufacturing and service industries, according to Charlene Weigel, MD, who now works as a hospitalist at Mount Auburn Hospital in Cambridge, Mass. Residents also are learning about implementation of Lean principles at the medical center, Dr. Weigel and co-authors report in a study published in the American Journal of Medical Quality.¹

“In Week One, we gave an introduction to QI and explained what Lean means,” Dr. Weigel says. Three other interactive sessions explored such techniques as how to create process maps and root-cause analysis, and identifying steps that aren’t helpful. The 90 residents and eight Boston University School of Public Health students also created 17 group QI project plans. “The goal was for the QI classwork and ideas to become implemented in hospital QI projects, but logistically, we had to scale back expectations for that initial go-round,” Dr. Weigel says.

The medical center recently started a second cycle of the QI course, with students from the first cycle encouraged to continue their QI projects on their own. One group submitted its project as an Institute for Healthcare Improvement storyboard at a national meeting.

“The experience also exposed the residents to our interprofessional team structure, which reflects their future working relationships and professional roles in QI,” Dr. Weigel says.

Lean concepts also are the basis for the Perfecting Patient Care University (PPCU, www.prhi.org/perfecting-patient-care/what-is-ppc), a QI training program for health-care leaders and clinicians offered in a variety of formats by the Pittsburgh Regional Health Initiative, a regional health collaborative. An evaluation of outcomes at PPCU was published online in the American Journal of Medical Quality in April.² The same journal also describes the curriculum, program evaluation, and lessons learned by SHM’s Quality and Safety Educators Academy (http://sites.hospitalmedicine.org/qsea), which provides training in QI and patient safety for teaching faculty.³ The academy, a 2.5-day course, is co-sponsored by the Alliance for Academic Internal Medicine.

Larry Beresford is a freelance writer in San Francisco

References

1. Weigel C, Suen W, Gupta G. Using Lean methodology to teach quality improvement to internal medicine residents at a safety net hospital. Am J Med Qual. 2013 Feb 4 [Epub ahead of print].
2. Morganti KG, Lovejoy S, Beckjord EB, Haviland AM, Haas AC, Farley DO. A retrospective evaluation of the Perfecting Patient Care University training program for health care organizations. Am J Med Qual. 2013 Apr 9 [Epub ahead of print].
3. Myers JS, Tess A, Glasheen JJ, et al. The Quality and Safety Educators’ Academy: fulfilling an unmet need for faculty development. Am J Med Qual.  2013 Apr 11 [Epub ahead of print].
4. Dong XQ, Simon MA. Elder abuse as a risk factor for hospitalization in older persons. JAMA Intern Med. 2013 Apr 8:1-7. doi: 10.1001/jamainternmed.2013.238 [Epub ahead of print].
5. Cisco mConcierge. 90% American workers use their own smartphones for work. Cisco mConcierge website. Available at: http://www.ciscomcon.com/sw/swchannel/registration/internet/registrationcfm?SWAPPID=91&RegPageID=350200&SWTHEMEID=12949. Accessed

Curriculums using Lean quality-improvement (QI) principles and techniques are becoming entrenched in medical teaching programs across the country.

A curriculum based on Lean QI is teaching medical residents at Boston Medical Center techniques based on successes in manufacturing and service industries, according to Charlene Weigel, MD, who now works as a hospitalist at Mount Auburn Hospital in Cambridge, Mass. Residents also are learning about implementation of Lean principles at the medical center, Dr. Weigel and co-authors report in a study published in the American Journal of Medical Quality.¹

“In Week One, we gave an introduction to QI and explained what Lean means,” Dr. Weigel says. Three other interactive sessions explored such techniques as how to create process maps and root-cause analysis, and identifying steps that aren’t helpful. The 90 residents and eight Boston University School of Public Health students also created 17 group QI project plans. “The goal was for the QI classwork and ideas to become implemented in hospital QI projects, but logistically, we had to scale back expectations for that initial go-round,” Dr. Weigel says.

The medical center recently started a second cycle of the QI course, with students from the first cycle encouraged to continue their QI projects on their own. One group submitted its project as an Institute for Healthcare Improvement storyboard at a national meeting.

“The experience also exposed the residents to our interprofessional team structure, which reflects their future working relationships and professional roles in QI,” Dr. Weigel says.

Lean concepts also are the basis for the Perfecting Patient Care University (PPCU, www.prhi.org/perfecting-patient-care/what-is-ppc), a QI training program for health-care leaders and clinicians offered in a variety of formats by the Pittsburgh Regional Health Initiative, a regional health collaborative. An evaluation of outcomes at PPCU was published online in the American Journal of Medical Quality in April.² The same journal also describes the curriculum, program evaluation, and lessons learned by SHM’s Quality and Safety Educators Academy (http://sites.hospitalmedicine.org/qsea), which provides training in QI and patient safety for teaching faculty.³ The academy, a 2.5-day course, is co-sponsored by the Alliance for Academic Internal Medicine.

Larry Beresford is a freelance writer in San Francisco

References

1. Weigel C, Suen W, Gupta G. Using Lean methodology to teach quality improvement to internal medicine residents at a safety net hospital. Am J Med Qual. 2013 Feb 4 [Epub ahead of print].
2. Morganti KG, Lovejoy S, Beckjord EB, Haviland AM, Haas AC, Farley DO. A retrospective evaluation of the Perfecting Patient Care University training program for health care organizations. Am J Med Qual. 2013 Apr 9 [Epub ahead of print].
3. Myers JS, Tess A, Glasheen JJ, et al. The Quality and Safety Educators’ Academy: fulfilling an unmet need for faculty development. Am J Med Qual.  2013 Apr 11 [Epub ahead of print].
4. Dong XQ, Simon MA. Elder abuse as a risk factor for hospitalization in older persons. JAMA Intern Med. 2013 Apr 8:1-7. doi: 10.1001/jamainternmed.2013.238 [Epub ahead of print].
5. Cisco mConcierge. 90% American workers use their own smartphones for work. Cisco mConcierge website. Available at: http://www.ciscomcon.com/sw/swchannel/registration/internet/registrationcfm?SWAPPID=91&RegPageID=350200&SWTHEMEID=12949. Accessed