QI Initiatives

Hospitalist-led teams in the ED help reduce diversions, improve patient flow, and provide more timely care to boarded patients, according to a study in the Journal of Hospital Medicine (JHM).

The single-center study, "Hospitalist-Led Medicine Emergency Department Team: Associations with Throughput, Timeliness of Patient Care, and Satisfaction," found a reduction in diversions due to medicine bed capacity of 27% (4.5% to 3%, P=<0.01). Boarded patients were rounded a mean of 2 hours and 9 minutes earlier with hospitalist-led teams; length of stay (LOS) in the ED, LOS in the hospital, and 48-hour returns were unchanged. The study, which took place at 477-bed Denver Health Medical Center (DHMC), assigned a hospitalist and an allied health provider to the ED during dayshifts. At night, ED coverage was rolled into the existing hospitalist duties.

Lead author Smitha R. Chadaga, MD, who works in DHMC's Department of Medicine, believes the study could spur more HM groups to consider dedicating a staffer to the ED. The team in Denver was created to care for medicine patients in the ED awaiting inpatient beds, and to work with nursing supervisors to improve bed management.

"There are numerous places that hospitalists can impact hospital flow, whether it's helping with bed management, providing consultative services to the ED, or caring for boarded patients," Dr. Chadaga says. "Knowing the ins and outs of inpatient medicine really lends itself well to some areas that hospitalists might not have thought about before."

Dr. Chadaga says the research is broadly applicable because HM groups can implement its different features. For example, adding a consultative phone service can help ED physicians determine whether a patient needs to be admitted and could improve patient flow.

Hospitalist-led teams in the ED help reduce diversions, improve patient flow, and provide more timely care to boarded patients, according to a study in the Journal of Hospital Medicine (JHM).

The single-center study, "Hospitalist-Led Medicine Emergency Department Team: Associations with Throughput, Timeliness of Patient Care, and Satisfaction," found a reduction in diversions due to medicine bed capacity of 27% (4.5% to 3%, P=<0.01). Boarded patients were rounded a mean of 2 hours and 9 minutes earlier with hospitalist-led teams; length of stay (LOS) in the ED, LOS in the hospital, and 48-hour returns were unchanged. The study, which took place at 477-bed Denver Health Medical Center (DHMC), assigned a hospitalist and an allied health provider to the ED during dayshifts. At night, ED coverage was rolled into the existing hospitalist duties.

Lead author Smitha R. Chadaga, MD, who works in DHMC's Department of Medicine, believes the study could spur more HM groups to consider dedicating a staffer to the ED. The team in Denver was created to care for medicine patients in the ED awaiting inpatient beds, and to work with nursing supervisors to improve bed management.

"There are numerous places that hospitalists can impact hospital flow, whether it's helping with bed management, providing consultative services to the ED, or caring for boarded patients," Dr. Chadaga says. "Knowing the ins and outs of inpatient medicine really lends itself well to some areas that hospitalists might not have thought about before."

Dr. Chadaga says the research is broadly applicable because HM groups can implement its different features. For example, adding a consultative phone service can help ED physicians determine whether a patient needs to be admitted and could improve patient flow.

Hospitalist-led teams in the ED help reduce diversions, improve patient flow, and provide more timely care to boarded patients, according to a study in the Journal of Hospital Medicine (JHM).

The single-center study, "Hospitalist-Led Medicine Emergency Department Team: Associations with Throughput, Timeliness of Patient Care, and Satisfaction," found a reduction in diversions due to medicine bed capacity of 27% (4.5% to 3%, P=<0.01). Boarded patients were rounded a mean of 2 hours and 9 minutes earlier with hospitalist-led teams; length of stay (LOS) in the ED, LOS in the hospital, and 48-hour returns were unchanged. The study, which took place at 477-bed Denver Health Medical Center (DHMC), assigned a hospitalist and an allied health provider to the ED during dayshifts. At night, ED coverage was rolled into the existing hospitalist duties.

Lead author Smitha R. Chadaga, MD, who works in DHMC's Department of Medicine, believes the study could spur more HM groups to consider dedicating a staffer to the ED. The team in Denver was created to care for medicine patients in the ED awaiting inpatient beds, and to work with nursing supervisors to improve bed management.

"There are numerous places that hospitalists can impact hospital flow, whether it's helping with bed management, providing consultative services to the ED, or caring for boarded patients," Dr. Chadaga says. "Knowing the ins and outs of inpatient medicine really lends itself well to some areas that hospitalists might not have thought about before."

Dr. Chadaga says the research is broadly applicable because HM groups can implement its different features. For example, adding a consultative phone service can help ED physicians determine whether a patient needs to be admitted and could improve patient flow.

Sometimes a hospitalist is put in the difficult position of communicating information that involves bad news—for instance, a poor prognosis to a patient or clarifying treatment options and goals for care to a family member of a patient with an advanced illness. A workshop at HM12 offered a technique that hospitalists can use to convey such difficult messages.

“Ask-Tell-Ask” is a back-and-forth cycle between the patient and health professional that addresses four essential components: the patient’s perspective, information that needs to be delivered, response to the patient’s emotions, and recommendations by the professional.

“In the setting of an advanced illness, the patient’s perspective needs to be more fully explored so that we can figure out what information they need and want,” says Kristen Schaefer, MD, a palliative-care physician and director of residency education at Brigham and Women’s Hospital in Boston who spoke at an HM12 workshop. “That communication needs to be multidirectional to promote shared decision-making. All of these communication techniques are based on a better understanding of the patient’s perspective, but with Ask-Tell-Ask, you are clarifying their emotional response to illness, their values and personal goals in life, and how they cope with setbacks.”

Physicians should always start in an open-ended way, asking questions and listening to the response, Dr. Schaefer explains. “Then you can tailor the information you provide to what they have told you. There’s always emotional content around these issues, and you need to clarify that emotion,” she says. “If there is a big emotion in the room, and it hasn’t been addressed, it doesn’t matter what you teach the patient. You’ll never get to the underlying problems.”

Another effective technique, Dr. Schaefer says, is the judicious use of silence. She says healthcare providers can learn to listen more, talk less, and always start with the patient’s perspective as the basis for communication.

“It makes for more satisfying work—and it’s also more effective,” she says.

Larry Beresford is a freelance writer in Oakland, Calif.

Sometimes a hospitalist is put in the difficult position of communicating information that involves bad news—for instance, a poor prognosis to a patient or clarifying treatment options and goals for care to a family member of a patient with an advanced illness. A workshop at HM12 offered a technique that hospitalists can use to convey such difficult messages.

“Ask-Tell-Ask” is a back-and-forth cycle between the patient and health professional that addresses four essential components: the patient’s perspective, information that needs to be delivered, response to the patient’s emotions, and recommendations by the professional.

“In the setting of an advanced illness, the patient’s perspective needs to be more fully explored so that we can figure out what information they need and want,” says Kristen Schaefer, MD, a palliative-care physician and director of residency education at Brigham and Women’s Hospital in Boston who spoke at an HM12 workshop. “That communication needs to be multidirectional to promote shared decision-making. All of these communication techniques are based on a better understanding of the patient’s perspective, but with Ask-Tell-Ask, you are clarifying their emotional response to illness, their values and personal goals in life, and how they cope with setbacks.”

Physicians should always start in an open-ended way, asking questions and listening to the response, Dr. Schaefer explains. “Then you can tailor the information you provide to what they have told you. There’s always emotional content around these issues, and you need to clarify that emotion,” she says. “If there is a big emotion in the room, and it hasn’t been addressed, it doesn’t matter what you teach the patient. You’ll never get to the underlying problems.”

Another effective technique, Dr. Schaefer says, is the judicious use of silence. She says healthcare providers can learn to listen more, talk less, and always start with the patient’s perspective as the basis for communication.

“It makes for more satisfying work—and it’s also more effective,” she says.

Larry Beresford is a freelance writer in Oakland, Calif.

Sometimes a hospitalist is put in the difficult position of communicating information that involves bad news—for instance, a poor prognosis to a patient or clarifying treatment options and goals for care to a family member of a patient with an advanced illness. A workshop at HM12 offered a technique that hospitalists can use to convey such difficult messages.

“Ask-Tell-Ask” is a back-and-forth cycle between the patient and health professional that addresses four essential components: the patient’s perspective, information that needs to be delivered, response to the patient’s emotions, and recommendations by the professional.

“In the setting of an advanced illness, the patient’s perspective needs to be more fully explored so that we can figure out what information they need and want,” says Kristen Schaefer, MD, a palliative-care physician and director of residency education at Brigham and Women’s Hospital in Boston who spoke at an HM12 workshop. “That communication needs to be multidirectional to promote shared decision-making. All of these communication techniques are based on a better understanding of the patient’s perspective, but with Ask-Tell-Ask, you are clarifying their emotional response to illness, their values and personal goals in life, and how they cope with setbacks.”

Physicians should always start in an open-ended way, asking questions and listening to the response, Dr. Schaefer explains. “Then you can tailor the information you provide to what they have told you. There’s always emotional content around these issues, and you need to clarify that emotion,” she says. “If there is a big emotion in the room, and it hasn’t been addressed, it doesn’t matter what you teach the patient. You’ll never get to the underlying problems.”

Another effective technique, Dr. Schaefer says, is the judicious use of silence. She says healthcare providers can learn to listen more, talk less, and always start with the patient’s perspective as the basis for communication.

“It makes for more satisfying work—and it’s also more effective,” she says.

Larry Beresford is a freelance writer in Oakland, Calif.

In May and June, U.S. Department of Health and Human Services (HHS) Secretary Kathleen Sebelius in May and June announced 107 healthcare innovations grants to improve coordination of care and reduce costs. The grants, a provision of the Affordable Care Act (ACA), range from $1 million to $30 million. HHS anticipates that the projects will reduce healthcare spending by $254 million over the next three years and provide "new ideas on how to deliver better health, improved care, and lower costs to people enrolled in Medicare, Medicaid and [the] Children's Health Insurance Program (CHIP)."

Hospitalists played key roles in planning and developing several of the projects. Common themes include coordination and integration of services, promotion of community collaborations, integrating behavioral and physical care, and the use of telemedicine—many of the same approaches utilized by SHM's Project BOOST and other national initiatives for preventing unnecessary readmissions.

In Atlanta, Emory University's Center for Critical Care received a $10.7 million grant to deploy 40 nurse practitioners (NPs) and physician assistants (PAs) trained in critical care to underserved and rural ICUs in Georgia. In many of the targeted hospitals, hospitalists manage patients in the ICU, but this program brings an additional layer of staffing and expertise to the care, allowing patients to stay in their beds rather than having to be transferred, says Daniel Owens, MBA, the center’s director of operations and senior administrator of the division of hospital medicine at Emory.

The project will bring NPs and PAs from participating hospitals to Emory for an intensive, six-month, critical-care residency. "If they don't have these folks, we'll help to identify staff for the jobs," he adds.

At Vanderbilt University Medical Center in Nashville, Tenn., a $2.4 million project to reduce rehospitalizations for a high-risk geriatric patients aims to close the gaps in care transitions between hospital, outpatient, post-acute, and extended-care settings, says Vanderbilt hospitalist Eduard Vasilevskis, MD. The project will employ transition advocates or coordinators in the hospital to improve communication at both ends, with evidence-based protocols to improve discharge planning. Long-term care providers will be offered Web-based training and video conferencing.

"The goal is to break the cycle of rehospitalization," says Dr. Vasilevskis, "but if patients need to come back to the hospital, there will be someone involved in their care who is familiar with the settings where they’ve come from."

Beth Israel Deaconess Medical Center (BIDMC) in Boston received $4.9 million for its Post-Acute Care Transitions program (PACT), which links the hospital to six affiliated primary care practices using a bundle of post-acute care interventions, care-transition specialists, and dedicated clinical pharmacists. Nurses remain in contact with patients by telephone for 30 days post-hospital discharge and coordinate the services of extended-care facilities and visiting nurses. Pharmacists perform in-hospital medication reconciliation and patient education, says hospitalist Lauren Doctoroff, MD, FHM. She and Julius Yang, MD, BIDMC medical director of inpatient quality, helped develop the pilot program, which began in August 2011.

"These care-transitions specialists offer us an added level of patient support and a different level of integration focused on risk assessment of such issues as social supports and problems with medical compliance, which can be used by the inpatient team to come up with the most rational and ideal discharge plan," Dr. Doctoroff says. "One of my colleagues said to me, ‘I feel so much better knowing there is this added level of support for patients after discharge.'"

The HHS grants reflect an important recognition that what happens to patients following discharge partly reflects what happens in the hospital but also depends on collaborations with post-acute providers, Dr. Doctoroff says.

"Hospitalists can't do everything, but they need their eye out of the hospital on post-acute providers in order to deliver the best care," she adds.

In May and June, U.S. Department of Health and Human Services (HHS) Secretary Kathleen Sebelius in May and June announced 107 healthcare innovations grants to improve coordination of care and reduce costs. The grants, a provision of the Affordable Care Act (ACA), range from $1 million to $30 million. HHS anticipates that the projects will reduce healthcare spending by $254 million over the next three years and provide "new ideas on how to deliver better health, improved care, and lower costs to people enrolled in Medicare, Medicaid and [the] Children's Health Insurance Program (CHIP)."

Hospitalists played key roles in planning and developing several of the projects. Common themes include coordination and integration of services, promotion of community collaborations, integrating behavioral and physical care, and the use of telemedicine—many of the same approaches utilized by SHM's Project BOOST and other national initiatives for preventing unnecessary readmissions.

In Atlanta, Emory University's Center for Critical Care received a $10.7 million grant to deploy 40 nurse practitioners (NPs) and physician assistants (PAs) trained in critical care to underserved and rural ICUs in Georgia. In many of the targeted hospitals, hospitalists manage patients in the ICU, but this program brings an additional layer of staffing and expertise to the care, allowing patients to stay in their beds rather than having to be transferred, says Daniel Owens, MBA, the center’s director of operations and senior administrator of the division of hospital medicine at Emory.

The project will bring NPs and PAs from participating hospitals to Emory for an intensive, six-month, critical-care residency. "If they don't have these folks, we'll help to identify staff for the jobs," he adds.

At Vanderbilt University Medical Center in Nashville, Tenn., a $2.4 million project to reduce rehospitalizations for a high-risk geriatric patients aims to close the gaps in care transitions between hospital, outpatient, post-acute, and extended-care settings, says Vanderbilt hospitalist Eduard Vasilevskis, MD. The project will employ transition advocates or coordinators in the hospital to improve communication at both ends, with evidence-based protocols to improve discharge planning. Long-term care providers will be offered Web-based training and video conferencing.

"The goal is to break the cycle of rehospitalization," says Dr. Vasilevskis, "but if patients need to come back to the hospital, there will be someone involved in their care who is familiar with the settings where they’ve come from."

Beth Israel Deaconess Medical Center (BIDMC) in Boston received $4.9 million for its Post-Acute Care Transitions program (PACT), which links the hospital to six affiliated primary care practices using a bundle of post-acute care interventions, care-transition specialists, and dedicated clinical pharmacists. Nurses remain in contact with patients by telephone for 30 days post-hospital discharge and coordinate the services of extended-care facilities and visiting nurses. Pharmacists perform in-hospital medication reconciliation and patient education, says hospitalist Lauren Doctoroff, MD, FHM. She and Julius Yang, MD, BIDMC medical director of inpatient quality, helped develop the pilot program, which began in August 2011.

"These care-transitions specialists offer us an added level of patient support and a different level of integration focused on risk assessment of such issues as social supports and problems with medical compliance, which can be used by the inpatient team to come up with the most rational and ideal discharge plan," Dr. Doctoroff says. "One of my colleagues said to me, ‘I feel so much better knowing there is this added level of support for patients after discharge.'"

The HHS grants reflect an important recognition that what happens to patients following discharge partly reflects what happens in the hospital but also depends on collaborations with post-acute providers, Dr. Doctoroff says.

"Hospitalists can't do everything, but they need their eye out of the hospital on post-acute providers in order to deliver the best care," she adds.

In May and June, U.S. Department of Health and Human Services (HHS) Secretary Kathleen Sebelius in May and June announced 107 healthcare innovations grants to improve coordination of care and reduce costs. The grants, a provision of the Affordable Care Act (ACA), range from $1 million to $30 million. HHS anticipates that the projects will reduce healthcare spending by $254 million over the next three years and provide "new ideas on how to deliver better health, improved care, and lower costs to people enrolled in Medicare, Medicaid and [the] Children's Health Insurance Program (CHIP)."

Hospitalists played key roles in planning and developing several of the projects. Common themes include coordination and integration of services, promotion of community collaborations, integrating behavioral and physical care, and the use of telemedicine—many of the same approaches utilized by SHM's Project BOOST and other national initiatives for preventing unnecessary readmissions.

In Atlanta, Emory University's Center for Critical Care received a $10.7 million grant to deploy 40 nurse practitioners (NPs) and physician assistants (PAs) trained in critical care to underserved and rural ICUs in Georgia. In many of the targeted hospitals, hospitalists manage patients in the ICU, but this program brings an additional layer of staffing and expertise to the care, allowing patients to stay in their beds rather than having to be transferred, says Daniel Owens, MBA, the center’s director of operations and senior administrator of the division of hospital medicine at Emory.

The project will bring NPs and PAs from participating hospitals to Emory for an intensive, six-month, critical-care residency. "If they don't have these folks, we'll help to identify staff for the jobs," he adds.

At Vanderbilt University Medical Center in Nashville, Tenn., a $2.4 million project to reduce rehospitalizations for a high-risk geriatric patients aims to close the gaps in care transitions between hospital, outpatient, post-acute, and extended-care settings, says Vanderbilt hospitalist Eduard Vasilevskis, MD. The project will employ transition advocates or coordinators in the hospital to improve communication at both ends, with evidence-based protocols to improve discharge planning. Long-term care providers will be offered Web-based training and video conferencing.

"The goal is to break the cycle of rehospitalization," says Dr. Vasilevskis, "but if patients need to come back to the hospital, there will be someone involved in their care who is familiar with the settings where they’ve come from."

Beth Israel Deaconess Medical Center (BIDMC) in Boston received $4.9 million for its Post-Acute Care Transitions program (PACT), which links the hospital to six affiliated primary care practices using a bundle of post-acute care interventions, care-transition specialists, and dedicated clinical pharmacists. Nurses remain in contact with patients by telephone for 30 days post-hospital discharge and coordinate the services of extended-care facilities and visiting nurses. Pharmacists perform in-hospital medication reconciliation and patient education, says hospitalist Lauren Doctoroff, MD, FHM. She and Julius Yang, MD, BIDMC medical director of inpatient quality, helped develop the pilot program, which began in August 2011.

"These care-transitions specialists offer us an added level of patient support and a different level of integration focused on risk assessment of such issues as social supports and problems with medical compliance, which can be used by the inpatient team to come up with the most rational and ideal discharge plan," Dr. Doctoroff says. "One of my colleagues said to me, ‘I feel so much better knowing there is this added level of support for patients after discharge.'"

The HHS grants reflect an important recognition that what happens to patients following discharge partly reflects what happens in the hospital but also depends on collaborations with post-acute providers, Dr. Doctoroff says.

"Hospitalists can't do everything, but they need their eye out of the hospital on post-acute providers in order to deliver the best care," she adds.

Earlier this month CMS announced 17 additional awards under its Community-Based Care Transitions Program (CCTP), which now encompasses 200 acute-care hospitals and their hospitalists partnering with community agencies and coalitions to improve transitions of care in advance of the Oct. 1 start for excessive readmissions penalties. Innovative solutions to the readmissions dilemma are being tested at the local level by a variety of partnerships with hospitals and hospitalists.

For example, William C. Cook, DO, chief of hospital medicine for the Ohio Permanente Medical Group in Cleveland, is part of a community-wide quality coalition called Better Health Greater Cleveland, one of 17 such groups in the Robert Wood Johnson Foundation's Aligning Forces for Quality collaborative. The program includes 150 quality teams in 100 hospitals posting readmissions reductions and other quality metrics. Dr. Cook, who co-chairs Better Health's Steering Committee for Transitions of Care, is spearheading a transitions pilot with two local nursing homes.

"From the hospitalist perspective, our role is to make care transitions safe and predictable," Dr. Cook says. "The way I can contribute most to these transitions is by thinking ahead about what's going to happen next—and how do I prepare the patient and the next provider." One key step is taking time to complete the real-time discharge summary for each patient, he adds.

The idea, Dr. Cook explains, is to identify and communicate with collaborators across care settings so that the "coaching baton" can be passed in a manner that appears seamless to the patient.

Nearly a third of the 17 new CCTP sites participate in SHM's Project BOOST, including three hospitals in California and one each in Illinois and Pennsylvania. Project BOOST is accepting applications for its next round of sites through September.

Earlier this month CMS announced 17 additional awards under its Community-Based Care Transitions Program (CCTP), which now encompasses 200 acute-care hospitals and their hospitalists partnering with community agencies and coalitions to improve transitions of care in advance of the Oct. 1 start for excessive readmissions penalties. Innovative solutions to the readmissions dilemma are being tested at the local level by a variety of partnerships with hospitals and hospitalists.

For example, William C. Cook, DO, chief of hospital medicine for the Ohio Permanente Medical Group in Cleveland, is part of a community-wide quality coalition called Better Health Greater Cleveland, one of 17 such groups in the Robert Wood Johnson Foundation's Aligning Forces for Quality collaborative. The program includes 150 quality teams in 100 hospitals posting readmissions reductions and other quality metrics. Dr. Cook, who co-chairs Better Health's Steering Committee for Transitions of Care, is spearheading a transitions pilot with two local nursing homes.

"From the hospitalist perspective, our role is to make care transitions safe and predictable," Dr. Cook says. "The way I can contribute most to these transitions is by thinking ahead about what's going to happen next—and how do I prepare the patient and the next provider." One key step is taking time to complete the real-time discharge summary for each patient, he adds.

The idea, Dr. Cook explains, is to identify and communicate with collaborators across care settings so that the "coaching baton" can be passed in a manner that appears seamless to the patient.

Nearly a third of the 17 new CCTP sites participate in SHM's Project BOOST, including three hospitals in California and one each in Illinois and Pennsylvania. Project BOOST is accepting applications for its next round of sites through September.

Earlier this month CMS announced 17 additional awards under its Community-Based Care Transitions Program (CCTP), which now encompasses 200 acute-care hospitals and their hospitalists partnering with community agencies and coalitions to improve transitions of care in advance of the Oct. 1 start for excessive readmissions penalties. Innovative solutions to the readmissions dilemma are being tested at the local level by a variety of partnerships with hospitals and hospitalists.

For example, William C. Cook, DO, chief of hospital medicine for the Ohio Permanente Medical Group in Cleveland, is part of a community-wide quality coalition called Better Health Greater Cleveland, one of 17 such groups in the Robert Wood Johnson Foundation's Aligning Forces for Quality collaborative. The program includes 150 quality teams in 100 hospitals posting readmissions reductions and other quality metrics. Dr. Cook, who co-chairs Better Health's Steering Committee for Transitions of Care, is spearheading a transitions pilot with two local nursing homes.

"From the hospitalist perspective, our role is to make care transitions safe and predictable," Dr. Cook says. "The way I can contribute most to these transitions is by thinking ahead about what's going to happen next—and how do I prepare the patient and the next provider." One key step is taking time to complete the real-time discharge summary for each patient, he adds.

The idea, Dr. Cook explains, is to identify and communicate with collaborators across care settings so that the "coaching baton" can be passed in a manner that appears seamless to the patient.

Nearly a third of the 17 new CCTP sites participate in SHM's Project BOOST, including three hospitals in California and one each in Illinois and Pennsylvania. Project BOOST is accepting applications for its next round of sites through September.

The Institute of Medicine (IOM) issued the report Health IT and Patient Safety: Building Safer Systems for Better Care in November 2011. SHM considers this a landmark report that serves as a call to action to improve the health information technology (HIT) systems used daily to deliver on the promise of safer, more efficient care. SHM’s IT Committee and IT Policy Committee carefully reviewed this report and have released a letter in support of its findings. SHM encourages its members to read the IOM report (www.iom.edu) or the summary of the report.

In support of the report, SHM highlighted the following:

• SHM specifically supports a call for safety transparency; a mandatory reporting mechanism for vendors; a voluntary reporting mechanism for providers to report unsafe conditions in electronic health records (EHRs) and adverse events; and the elimination of nondisclosure clauses.
• SHM supports the need for additional research to guide the design and implementation of EHR, computerized physician order entry (CPOE) systems, and clinical-decision-support (CDS) systems, including usability and expanded functionality.
• SHM supports the need for HIT education at all levels of the healthcare system from providers to vendors to include quality/safety science and process improvement.
• SHM echoes the need for interoperability, not only for data exchange, but also for CDS tools and for liquidity of data to allow new product incomers into the market and the ability to move between vendors.
• SHM believes in dual accountability between vendors and providers in HIT products to help motivate the industry to more quickly improve the safety and usability of products.
• SHM is moving ahead on these areas independently and believes that hospitalists are well positioned to be involved in achieving these goals. To assist members in their efforts, the IT Education Committee is working on in-person and online HIT educational venues for SHM members. SHM’s Health IT Quality Committee is organizing collaboratives around CDS and quality innovation sharing. The Health Quality and Patient Safety Committee continues to discuss the safety of IT systems and methods to improve them. SHM’s mentored implementation programs are engaging directly with vendors to try to build products and the functionality needed around glycemic control, care transitions, and VTE prophylaxis.
• SHM believes that its members can be involved in the research to answer many of the important questions that are unresolved in HIT. Please contact SHM to ensure that the organization is representing your needs in this important area. The current situation is a long way from the full potential HIT can provide, and SHM is committed to helping its members and the industry in moving to the next level.

The Institute of Medicine (IOM) issued the report Health IT and Patient Safety: Building Safer Systems for Better Care in November 2011. SHM considers this a landmark report that serves as a call to action to improve the health information technology (HIT) systems used daily to deliver on the promise of safer, more efficient care. SHM’s IT Committee and IT Policy Committee carefully reviewed this report and have released a letter in support of its findings. SHM encourages its members to read the IOM report (www.iom.edu) or the summary of the report.

In support of the report, SHM highlighted the following:

• SHM specifically supports a call for safety transparency; a mandatory reporting mechanism for vendors; a voluntary reporting mechanism for providers to report unsafe conditions in electronic health records (EHRs) and adverse events; and the elimination of nondisclosure clauses.
• SHM supports the need for additional research to guide the design and implementation of EHR, computerized physician order entry (CPOE) systems, and clinical-decision-support (CDS) systems, including usability and expanded functionality.
• SHM supports the need for HIT education at all levels of the healthcare system from providers to vendors to include quality/safety science and process improvement.
• SHM echoes the need for interoperability, not only for data exchange, but also for CDS tools and for liquidity of data to allow new product incomers into the market and the ability to move between vendors.
• SHM believes in dual accountability between vendors and providers in HIT products to help motivate the industry to more quickly improve the safety and usability of products.
• SHM is moving ahead on these areas independently and believes that hospitalists are well positioned to be involved in achieving these goals. To assist members in their efforts, the IT Education Committee is working on in-person and online HIT educational venues for SHM members. SHM’s Health IT Quality Committee is organizing collaboratives around CDS and quality innovation sharing. The Health Quality and Patient Safety Committee continues to discuss the safety of IT systems and methods to improve them. SHM’s mentored implementation programs are engaging directly with vendors to try to build products and the functionality needed around glycemic control, care transitions, and VTE prophylaxis.
• SHM believes that its members can be involved in the research to answer many of the important questions that are unresolved in HIT. Please contact SHM to ensure that the organization is representing your needs in this important area. The current situation is a long way from the full potential HIT can provide, and SHM is committed to helping its members and the industry in moving to the next level.

The Institute of Medicine (IOM) issued the report Health IT and Patient Safety: Building Safer Systems for Better Care in November 2011. SHM considers this a landmark report that serves as a call to action to improve the health information technology (HIT) systems used daily to deliver on the promise of safer, more efficient care. SHM’s IT Committee and IT Policy Committee carefully reviewed this report and have released a letter in support of its findings. SHM encourages its members to read the IOM report (www.iom.edu) or the summary of the report.

In support of the report, SHM highlighted the following:

• SHM specifically supports a call for safety transparency; a mandatory reporting mechanism for vendors; a voluntary reporting mechanism for providers to report unsafe conditions in electronic health records (EHRs) and adverse events; and the elimination of nondisclosure clauses.
• SHM supports the need for additional research to guide the design and implementation of EHR, computerized physician order entry (CPOE) systems, and clinical-decision-support (CDS) systems, including usability and expanded functionality.
• SHM supports the need for HIT education at all levels of the healthcare system from providers to vendors to include quality/safety science and process improvement.
• SHM echoes the need for interoperability, not only for data exchange, but also for CDS tools and for liquidity of data to allow new product incomers into the market and the ability to move between vendors.
• SHM believes in dual accountability between vendors and providers in HIT products to help motivate the industry to more quickly improve the safety and usability of products.
• SHM is moving ahead on these areas independently and believes that hospitalists are well positioned to be involved in achieving these goals. To assist members in their efforts, the IT Education Committee is working on in-person and online HIT educational venues for SHM members. SHM’s Health IT Quality Committee is organizing collaboratives around CDS and quality innovation sharing. The Health Quality and Patient Safety Committee continues to discuss the safety of IT systems and methods to improve them. SHM’s mentored implementation programs are engaging directly with vendors to try to build products and the functionality needed around glycemic control, care transitions, and VTE prophylaxis.
• SHM believes that its members can be involved in the research to answer many of the important questions that are unresolved in HIT. Please contact SHM to ensure that the organization is representing your needs in this important area. The current situation is a long way from the full potential HIT can provide, and SHM is committed to helping its members and the industry in moving to the next level.

Hospitalists coordinate the care of large numbers of very sick, very complicated patients, making patient-hospitalist communication very important. When done effectively, communication can help hospitalists improve their patients’ sense of well-being and reinforce their adherence to medical treatments post-discharge. It also can build trust and help patients better understand their illnesses.

Nonetheless, communication gaps do occur. The main culprits include time pressures, the lack of a pre-existing patient relationship, patient emotions, medical jargon, and physicians’ tendencies to lecture.

The following five examples outline common communication pitfalls, followed by fundamental skills that can be used to solve communication problems.

Tick, Tock Goes the Clock

Scenario: A hospitalist mentions a medication change during a brief patient visit in the midst of a hectic day. The hospitalist pauses for a moment, glances at his watch, and reaches for the room’s door handle. When no question is forthcoming, he excuses himself to visit the next patient.

The patient has questions about the new medication but feels guilty about taking up the hospitalist’s time. The patient decides she can ask about the medication and the reason for the change when the hospitalist isn’t in such a hurry.

Skill: Creating an environment in which patients are encouraged to ask questions need not result in lengthy conversations. The key is having a clear framework for directing conversations, says Cindy Lien, MD, an academic hospitalist at Beth Israel Deaconess Medical Center in Boston. Dr. Lien uses “Ask-Tell-Ask” as a mnemonic when teaching communication skills to internal-medicine trainees.

“We have a tendency to just tell, tell, tell information,” she says. “Ask-Tell-Ask reminds you that one of the most important things to do is to ask the patient to describe what their understanding is of the situation so you have a sense of where they’re coming from.”

Opening questions can include “What is the most important issue on your mind today?” and “What do you understand about your medications?”

After listening to the patient’s response, tell the patient in a few straightforward sentences the information you need to communicate, Dr. Lien says. Then ask the patient if they understand the information conveyed to them, which will give them a chance to ask questions. Additional questions for the patient can include “Do you need further information at this point?” and “How do you feel about what we’ve discussed?”

The way our brains are built, emotion will trump cognition every time. If you as the doctor keep talking when someone is having an emotional moment, they will generally miss all the information you provided.

—Anthony Back, MD, professor of medicine, University of Washington, Seattle

What’s Your Name Again?

Scenario: A hospitalist wearing professional dress with no nametag enters a patient room and introduces herself before informing the patient that she’s ordered additional tests. The hospitalist visits the patient several times during his hospital stay to discuss test results and self-care instructions upon discharge but never reintroduces herself.

The patient was exhausted and in discomfort when the clinician first introduced herself as a hospitalist. She said her name so quickly that the patient didn’t catch it. The patient sees the hospitalist more often than other providers during his admission, but he’s not sure what her role is and he finds it too awkward to ask.

Skill: First impressions are lasting, so make a solid introduction, says David Meltzer, MD, PhD, FHM, associate professor in the department of medicine at the University of Chicago. Because patients are more likely to identify a hospitalist if they understand the hospitalist has a relationship with their primary-care physician (PCP), the initial greeting should be stated clearly, slowly, and include a reference to the PCP.

“After providing your name, you can say something like, ‘I see you’re Dr. Smith’s patient. I’ve worked with Dr. Smith for many years. We’ll make sure we communicate what happens during your hospitalization. I hope to develop a good relationship with you while you’re in the hospital,’” Dr. Meltzer says.

The hospitalist team should also consider providing brochures with photos of the hospitalists and an explanation of what hospitalists do, says Michael Pistoria, DO, FACP, SFHM, associate chief of the division of general internal medicine at Lehigh Valley Health Network in Allentown, Pa.

“Brochures can be handed to patients at the time of admission with the hospitalist explaining, ‘I’m going to be the doctor in charge of coordinating your care,’” he explains.

Mind Over Matter

Scenario: A hospitalist explains to the patient that her illness is getting worse and more aggressive treatment is advised. While reviewing treatment options, the hospitalist notices the patient is staring out the window, her chin quivering. The hospitalist presses on with what she has to say.

The patient can hear the hospitalist talking, but she’s thinking about how this setback will affect her family. She’s doing all she can to keep from crying and nods her head out of politeness to feign understanding of the information being provided.

Skill: Acknowledging patient emotion is imperative, because doctors who ignore these signals do so at their own professional peril, says Anthony Back, MD, professor of medicine at the University of Washington in Seattle.

“The way our brains are built, emotion will trump cognition every time,” he says. “If you as the doctor keep talking when someone is having an emotional moment, they will generally miss all the information you provided.

“If you see the patient has a lot of emotion, you can say, ‘I notice you are really concerned about this. Can you tell me more?’” Dr. Back says. “Just the act of getting it out in the open will often enable a patient to process the emotion enough so that you can go on to medical issues that are important for the patient to know.”

In most cases, respectfully acknowledging the emotion won’t take long. He says most patients recognize they have limited time with the doctor, and they want to get to the important medical information, too.

It’s Gibberish to Me

Dr. Meltzer

Scenario: A hospitalist believes a patient has a solid understanding of his diagnosis. The hospitalist sends the patient for several tests and discusses with him the risks and benefits of various medications and interventions, sometimes using complex terminology.

The patient doesn’t know why he’s had to undergo so many tests. He’s tried to follow along as the hospitalist talks about treatment options and has even asked his daughter to look up medical terminology on her smartphone so he can better understand what is going on. He wishes the hospitalist would explain his condition in basic terms.

Skill: Simplify the language used to communicate with patients by speaking in plain English, says Jeff Greenwald, MD, SFHM, associate professor of medicine at Harvard Medical School and a teaching hospitalist at Massachusetts General Hospital in Boston. Hospitalists should be aware that words and terminology they think are commonplace many times are medical jargon and confusing to patients, he adds.

“For example, when I say ‘take this medication orally,’ that doesn’t strike me as technical language. But ‘orally’ is a word that is not understood by a significant percentage of the population,” Dr. Greenwald says.

Dr. Greenwald

A good rule of thumb is to continually check in with patients about the words and terms being used, Dr. Meltzer adds.

“Ask patients if they would like you to explain a term,” he says. “You can say something like, ‘I know this is a term many people aren’t familiar with. Would you like me to tell you more about what it means?’”

Data-Dumping

Scenario: A hospitalist checks in on a patient with atrial fibrillation and uses the visit to talk about Coumadin. She instructs the patient on how the drug works in the body, how it increases the chance of bleeding, and how the medication should be taken and monitored.

Later that day, the patient tells her daughter about the hospitalist’s instructions regarding her new medication. The patient remembers that she should avoid certain foods and beverages while on Coumadin but can’t immediately recall what they are. The patient also has trouble recounting what danger signs she should look out for when taking Coumadin.

Skill: Teach-back is an effective tool that can—and should—be used anytime a hospitalist is providing important information to a patient, Dr. Greenwald says. The hospitalist asks the patient to explain back the information in his or her own words in order to determine the patient’s understanding. If errors are identified, the hospitalist can explain the information again to ensure the patient’s comprehension.

“You might say, ‘How are you going to explain to your primary-care doctor about why you’re on an antibiotic?’ or ‘What are you going to tell your son about how your diet has to change?’” Dr. Greenwald says.

He outlines three important elements of teach-back:

• Concentrate on the critical information that patients need to know in order to function;
• Provide information in small bites that the patient can digest; and
• Repeat and reinforce the information with the help of all the members of the care team.

Teach-back should be used consistently, he says, so hospitalists can build on the information taught previously by adding layers to the patient’s knowledge.

Lisa Ryan is a freelance writer in New Jersey.

Hospitalists coordinate the care of large numbers of very sick, very complicated patients, making patient-hospitalist communication very important. When done effectively, communication can help hospitalists improve their patients’ sense of well-being and reinforce their adherence to medical treatments post-discharge. It also can build trust and help patients better understand their illnesses.

Nonetheless, communication gaps do occur. The main culprits include time pressures, the lack of a pre-existing patient relationship, patient emotions, medical jargon, and physicians’ tendencies to lecture.

The following five examples outline common communication pitfalls, followed by fundamental skills that can be used to solve communication problems.

Tick, Tock Goes the Clock

Scenario: A hospitalist mentions a medication change during a brief patient visit in the midst of a hectic day. The hospitalist pauses for a moment, glances at his watch, and reaches for the room’s door handle. When no question is forthcoming, he excuses himself to visit the next patient.

The patient has questions about the new medication but feels guilty about taking up the hospitalist’s time. The patient decides she can ask about the medication and the reason for the change when the hospitalist isn’t in such a hurry.

Skill: Creating an environment in which patients are encouraged to ask questions need not result in lengthy conversations. The key is having a clear framework for directing conversations, says Cindy Lien, MD, an academic hospitalist at Beth Israel Deaconess Medical Center in Boston. Dr. Lien uses “Ask-Tell-Ask” as a mnemonic when teaching communication skills to internal-medicine trainees.

“We have a tendency to just tell, tell, tell information,” she says. “Ask-Tell-Ask reminds you that one of the most important things to do is to ask the patient to describe what their understanding is of the situation so you have a sense of where they’re coming from.”

Opening questions can include “What is the most important issue on your mind today?” and “What do you understand about your medications?”

After listening to the patient’s response, tell the patient in a few straightforward sentences the information you need to communicate, Dr. Lien says. Then ask the patient if they understand the information conveyed to them, which will give them a chance to ask questions. Additional questions for the patient can include “Do you need further information at this point?” and “How do you feel about what we’ve discussed?”

The way our brains are built, emotion will trump cognition every time. If you as the doctor keep talking when someone is having an emotional moment, they will generally miss all the information you provided.

—Anthony Back, MD, professor of medicine, University of Washington, Seattle

What’s Your Name Again?

Scenario: A hospitalist wearing professional dress with no nametag enters a patient room and introduces herself before informing the patient that she’s ordered additional tests. The hospitalist visits the patient several times during his hospital stay to discuss test results and self-care instructions upon discharge but never reintroduces herself.

The patient was exhausted and in discomfort when the clinician first introduced herself as a hospitalist. She said her name so quickly that the patient didn’t catch it. The patient sees the hospitalist more often than other providers during his admission, but he’s not sure what her role is and he finds it too awkward to ask.

Skill: First impressions are lasting, so make a solid introduction, says David Meltzer, MD, PhD, FHM, associate professor in the department of medicine at the University of Chicago. Because patients are more likely to identify a hospitalist if they understand the hospitalist has a relationship with their primary-care physician (PCP), the initial greeting should be stated clearly, slowly, and include a reference to the PCP.

“After providing your name, you can say something like, ‘I see you’re Dr. Smith’s patient. I’ve worked with Dr. Smith for many years. We’ll make sure we communicate what happens during your hospitalization. I hope to develop a good relationship with you while you’re in the hospital,’” Dr. Meltzer says.

The hospitalist team should also consider providing brochures with photos of the hospitalists and an explanation of what hospitalists do, says Michael Pistoria, DO, FACP, SFHM, associate chief of the division of general internal medicine at Lehigh Valley Health Network in Allentown, Pa.

“Brochures can be handed to patients at the time of admission with the hospitalist explaining, ‘I’m going to be the doctor in charge of coordinating your care,’” he explains.

Mind Over Matter

Scenario: A hospitalist explains to the patient that her illness is getting worse and more aggressive treatment is advised. While reviewing treatment options, the hospitalist notices the patient is staring out the window, her chin quivering. The hospitalist presses on with what she has to say.

The patient can hear the hospitalist talking, but she’s thinking about how this setback will affect her family. She’s doing all she can to keep from crying and nods her head out of politeness to feign understanding of the information being provided.

Skill: Acknowledging patient emotion is imperative, because doctors who ignore these signals do so at their own professional peril, says Anthony Back, MD, professor of medicine at the University of Washington in Seattle.

“The way our brains are built, emotion will trump cognition every time,” he says. “If you as the doctor keep talking when someone is having an emotional moment, they will generally miss all the information you provided.

“If you see the patient has a lot of emotion, you can say, ‘I notice you are really concerned about this. Can you tell me more?’” Dr. Back says. “Just the act of getting it out in the open will often enable a patient to process the emotion enough so that you can go on to medical issues that are important for the patient to know.”

In most cases, respectfully acknowledging the emotion won’t take long. He says most patients recognize they have limited time with the doctor, and they want to get to the important medical information, too.

It’s Gibberish to Me

Dr. Meltzer

Scenario: A hospitalist believes a patient has a solid understanding of his diagnosis. The hospitalist sends the patient for several tests and discusses with him the risks and benefits of various medications and interventions, sometimes using complex terminology.

The patient doesn’t know why he’s had to undergo so many tests. He’s tried to follow along as the hospitalist talks about treatment options and has even asked his daughter to look up medical terminology on her smartphone so he can better understand what is going on. He wishes the hospitalist would explain his condition in basic terms.

Skill: Simplify the language used to communicate with patients by speaking in plain English, says Jeff Greenwald, MD, SFHM, associate professor of medicine at Harvard Medical School and a teaching hospitalist at Massachusetts General Hospital in Boston. Hospitalists should be aware that words and terminology they think are commonplace many times are medical jargon and confusing to patients, he adds.

“For example, when I say ‘take this medication orally,’ that doesn’t strike me as technical language. But ‘orally’ is a word that is not understood by a significant percentage of the population,” Dr. Greenwald says.

Dr. Greenwald

A good rule of thumb is to continually check in with patients about the words and terms being used, Dr. Meltzer adds.

“Ask patients if they would like you to explain a term,” he says. “You can say something like, ‘I know this is a term many people aren’t familiar with. Would you like me to tell you more about what it means?’”

Data-Dumping

Scenario: A hospitalist checks in on a patient with atrial fibrillation and uses the visit to talk about Coumadin. She instructs the patient on how the drug works in the body, how it increases the chance of bleeding, and how the medication should be taken and monitored.

Later that day, the patient tells her daughter about the hospitalist’s instructions regarding her new medication. The patient remembers that she should avoid certain foods and beverages while on Coumadin but can’t immediately recall what they are. The patient also has trouble recounting what danger signs she should look out for when taking Coumadin.

Skill: Teach-back is an effective tool that can—and should—be used anytime a hospitalist is providing important information to a patient, Dr. Greenwald says. The hospitalist asks the patient to explain back the information in his or her own words in order to determine the patient’s understanding. If errors are identified, the hospitalist can explain the information again to ensure the patient’s comprehension.

“You might say, ‘How are you going to explain to your primary-care doctor about why you’re on an antibiotic?’ or ‘What are you going to tell your son about how your diet has to change?’” Dr. Greenwald says.

He outlines three important elements of teach-back:

• Concentrate on the critical information that patients need to know in order to function;
• Provide information in small bites that the patient can digest; and
• Repeat and reinforce the information with the help of all the members of the care team.

Teach-back should be used consistently, he says, so hospitalists can build on the information taught previously by adding layers to the patient’s knowledge.

Lisa Ryan is a freelance writer in New Jersey.

Hospitalists coordinate the care of large numbers of very sick, very complicated patients, making patient-hospitalist communication very important. When done effectively, communication can help hospitalists improve their patients’ sense of well-being and reinforce their adherence to medical treatments post-discharge. It also can build trust and help patients better understand their illnesses.

Nonetheless, communication gaps do occur. The main culprits include time pressures, the lack of a pre-existing patient relationship, patient emotions, medical jargon, and physicians’ tendencies to lecture.

The following five examples outline common communication pitfalls, followed by fundamental skills that can be used to solve communication problems.

Tick, Tock Goes the Clock

Scenario: A hospitalist mentions a medication change during a brief patient visit in the midst of a hectic day. The hospitalist pauses for a moment, glances at his watch, and reaches for the room’s door handle. When no question is forthcoming, he excuses himself to visit the next patient.

The patient has questions about the new medication but feels guilty about taking up the hospitalist’s time. The patient decides she can ask about the medication and the reason for the change when the hospitalist isn’t in such a hurry.

Skill: Creating an environment in which patients are encouraged to ask questions need not result in lengthy conversations. The key is having a clear framework for directing conversations, says Cindy Lien, MD, an academic hospitalist at Beth Israel Deaconess Medical Center in Boston. Dr. Lien uses “Ask-Tell-Ask” as a mnemonic when teaching communication skills to internal-medicine trainees.

“We have a tendency to just tell, tell, tell information,” she says. “Ask-Tell-Ask reminds you that one of the most important things to do is to ask the patient to describe what their understanding is of the situation so you have a sense of where they’re coming from.”

Opening questions can include “What is the most important issue on your mind today?” and “What do you understand about your medications?”

After listening to the patient’s response, tell the patient in a few straightforward sentences the information you need to communicate, Dr. Lien says. Then ask the patient if they understand the information conveyed to them, which will give them a chance to ask questions. Additional questions for the patient can include “Do you need further information at this point?” and “How do you feel about what we’ve discussed?”

The way our brains are built, emotion will trump cognition every time. If you as the doctor keep talking when someone is having an emotional moment, they will generally miss all the information you provided.

—Anthony Back, MD, professor of medicine, University of Washington, Seattle

What’s Your Name Again?

Scenario: A hospitalist wearing professional dress with no nametag enters a patient room and introduces herself before informing the patient that she’s ordered additional tests. The hospitalist visits the patient several times during his hospital stay to discuss test results and self-care instructions upon discharge but never reintroduces herself.

The patient was exhausted and in discomfort when the clinician first introduced herself as a hospitalist. She said her name so quickly that the patient didn’t catch it. The patient sees the hospitalist more often than other providers during his admission, but he’s not sure what her role is and he finds it too awkward to ask.

Skill: First impressions are lasting, so make a solid introduction, says David Meltzer, MD, PhD, FHM, associate professor in the department of medicine at the University of Chicago. Because patients are more likely to identify a hospitalist if they understand the hospitalist has a relationship with their primary-care physician (PCP), the initial greeting should be stated clearly, slowly, and include a reference to the PCP.

“After providing your name, you can say something like, ‘I see you’re Dr. Smith’s patient. I’ve worked with Dr. Smith for many years. We’ll make sure we communicate what happens during your hospitalization. I hope to develop a good relationship with you while you’re in the hospital,’” Dr. Meltzer says.

The hospitalist team should also consider providing brochures with photos of the hospitalists and an explanation of what hospitalists do, says Michael Pistoria, DO, FACP, SFHM, associate chief of the division of general internal medicine at Lehigh Valley Health Network in Allentown, Pa.

“Brochures can be handed to patients at the time of admission with the hospitalist explaining, ‘I’m going to be the doctor in charge of coordinating your care,’” he explains.

Mind Over Matter

Scenario: A hospitalist explains to the patient that her illness is getting worse and more aggressive treatment is advised. While reviewing treatment options, the hospitalist notices the patient is staring out the window, her chin quivering. The hospitalist presses on with what she has to say.

The patient can hear the hospitalist talking, but she’s thinking about how this setback will affect her family. She’s doing all she can to keep from crying and nods her head out of politeness to feign understanding of the information being provided.

Skill: Acknowledging patient emotion is imperative, because doctors who ignore these signals do so at their own professional peril, says Anthony Back, MD, professor of medicine at the University of Washington in Seattle.

“The way our brains are built, emotion will trump cognition every time,” he says. “If you as the doctor keep talking when someone is having an emotional moment, they will generally miss all the information you provided.

“If you see the patient has a lot of emotion, you can say, ‘I notice you are really concerned about this. Can you tell me more?’” Dr. Back says. “Just the act of getting it out in the open will often enable a patient to process the emotion enough so that you can go on to medical issues that are important for the patient to know.”

In most cases, respectfully acknowledging the emotion won’t take long. He says most patients recognize they have limited time with the doctor, and they want to get to the important medical information, too.

It’s Gibberish to Me

Dr. Meltzer

Scenario: A hospitalist believes a patient has a solid understanding of his diagnosis. The hospitalist sends the patient for several tests and discusses with him the risks and benefits of various medications and interventions, sometimes using complex terminology.

The patient doesn’t know why he’s had to undergo so many tests. He’s tried to follow along as the hospitalist talks about treatment options and has even asked his daughter to look up medical terminology on her smartphone so he can better understand what is going on. He wishes the hospitalist would explain his condition in basic terms.

Skill: Simplify the language used to communicate with patients by speaking in plain English, says Jeff Greenwald, MD, SFHM, associate professor of medicine at Harvard Medical School and a teaching hospitalist at Massachusetts General Hospital in Boston. Hospitalists should be aware that words and terminology they think are commonplace many times are medical jargon and confusing to patients, he adds.

“For example, when I say ‘take this medication orally,’ that doesn’t strike me as technical language. But ‘orally’ is a word that is not understood by a significant percentage of the population,” Dr. Greenwald says.

Dr. Greenwald

A good rule of thumb is to continually check in with patients about the words and terms being used, Dr. Meltzer adds.

“Ask patients if they would like you to explain a term,” he says. “You can say something like, ‘I know this is a term many people aren’t familiar with. Would you like me to tell you more about what it means?’”

Data-Dumping

Scenario: A hospitalist checks in on a patient with atrial fibrillation and uses the visit to talk about Coumadin. She instructs the patient on how the drug works in the body, how it increases the chance of bleeding, and how the medication should be taken and monitored.

Later that day, the patient tells her daughter about the hospitalist’s instructions regarding her new medication. The patient remembers that she should avoid certain foods and beverages while on Coumadin but can’t immediately recall what they are. The patient also has trouble recounting what danger signs she should look out for when taking Coumadin.

Skill: Teach-back is an effective tool that can—and should—be used anytime a hospitalist is providing important information to a patient, Dr. Greenwald says. The hospitalist asks the patient to explain back the information in his or her own words in order to determine the patient’s understanding. If errors are identified, the hospitalist can explain the information again to ensure the patient’s comprehension.

“You might say, ‘How are you going to explain to your primary-care doctor about why you’re on an antibiotic?’ or ‘What are you going to tell your son about how your diet has to change?’” Dr. Greenwald says.

He outlines three important elements of teach-back:

• Concentrate on the critical information that patients need to know in order to function;
• Provide information in small bites that the patient can digest; and
• Repeat and reinforce the information with the help of all the members of the care team.

Teach-back should be used consistently, he says, so hospitalists can build on the information taught previously by adding layers to the patient’s knowledge.

Lisa Ryan is a freelance writer in New Jersey.

An interactive program to teach quality and leadership skills to internal-medicine residents at Mount Sinai School of Medicine in New York City—described in an Research, Innovations and Clinical Vignettes (RIV) poster presented at HM12 in San Diego—found that medical trainees are eager and willing to learn the skills that will be required from hospitalists in a reformed healthcare system.¹ Lead author Brian Markoff, MD, SFHM, associate chief of hospital medicine at Mount Sinai, says the Healthcare Leadership Track’s elective, one-month block in quality improvement (QI) and patient safety was established with four second-year residents in 2011-2012.

Along with didactic presentations, participants were offered novel structured learning exercises that included:

• Teaching a care-transitions module to interns;
• Proposing a new clinical pathway;
• Leading a conference on QI;
• Examining a hospital readmission for what went wrong;
• Pairing with a ward medical director;
• Conducting a mentored QI research project; and
• Participating in a book club.

All four participants from the first year “strongly agree that the block was highly relevant to their current and future careers,” Dr. Markoff says.

In their third year, the residents will have the opportunity to participate in one-month electives for leadership, teaching, and the business of medicine.

Six new second-year residents are joining the program, and longitudinal components span the program’s two years. “Most institutions that train residents have a lot of this activity going on,” he says. “Why not get house staff involved in experiential learning in these areas?”

Reference

1. Markoff B, Dunn A. Healthcare leadership track: a novel track to train leaders in inpatient medicine. Paper presented at: HM12, Society of Hospital Medicine annual meeting; April 1-4, 2012; San Diego.

An interactive program to teach quality and leadership skills to internal-medicine residents at Mount Sinai School of Medicine in New York City—described in an Research, Innovations and Clinical Vignettes (RIV) poster presented at HM12 in San Diego—found that medical trainees are eager and willing to learn the skills that will be required from hospitalists in a reformed healthcare system.¹ Lead author Brian Markoff, MD, SFHM, associate chief of hospital medicine at Mount Sinai, says the Healthcare Leadership Track’s elective, one-month block in quality improvement (QI) and patient safety was established with four second-year residents in 2011-2012.

Along with didactic presentations, participants were offered novel structured learning exercises that included:

• Teaching a care-transitions module to interns;
• Proposing a new clinical pathway;
• Leading a conference on QI;
• Examining a hospital readmission for what went wrong;
• Pairing with a ward medical director;
• Conducting a mentored QI research project; and
• Participating in a book club.

All four participants from the first year “strongly agree that the block was highly relevant to their current and future careers,” Dr. Markoff says.

In their third year, the residents will have the opportunity to participate in one-month electives for leadership, teaching, and the business of medicine.

Six new second-year residents are joining the program, and longitudinal components span the program’s two years. “Most institutions that train residents have a lot of this activity going on,” he says. “Why not get house staff involved in experiential learning in these areas?”

Reference

1. Markoff B, Dunn A. Healthcare leadership track: a novel track to train leaders in inpatient medicine. Paper presented at: HM12, Society of Hospital Medicine annual meeting; April 1-4, 2012; San Diego.

An interactive program to teach quality and leadership skills to internal-medicine residents at Mount Sinai School of Medicine in New York City—described in an Research, Innovations and Clinical Vignettes (RIV) poster presented at HM12 in San Diego—found that medical trainees are eager and willing to learn the skills that will be required from hospitalists in a reformed healthcare system.¹ Lead author Brian Markoff, MD, SFHM, associate chief of hospital medicine at Mount Sinai, says the Healthcare Leadership Track’s elective, one-month block in quality improvement (QI) and patient safety was established with four second-year residents in 2011-2012.

Along with didactic presentations, participants were offered novel structured learning exercises that included:

• Teaching a care-transitions module to interns;
• Proposing a new clinical pathway;
• Leading a conference on QI;
• Examining a hospital readmission for what went wrong;
• Pairing with a ward medical director;
• Conducting a mentored QI research project; and
• Participating in a book club.

All four participants from the first year “strongly agree that the block was highly relevant to their current and future careers,” Dr. Markoff says.

In their third year, the residents will have the opportunity to participate in one-month electives for leadership, teaching, and the business of medicine.

Six new second-year residents are joining the program, and longitudinal components span the program’s two years. “Most institutions that train residents have a lot of this activity going on,” he says. “Why not get house staff involved in experiential learning in these areas?”

Reference

1. Markoff B, Dunn A. Healthcare leadership track: a novel track to train leaders in inpatient medicine. Paper presented at: HM12, Society of Hospital Medicine annual meeting; April 1-4, 2012; San Diego.

In “The Lean Startup,” author Eric Ries notes that in its early stages, his gaming company would routinely issue new versions of their software application several times each day. Continuous deployment—the process Ries’ company used—leveraged such Lean principles as reduced batch size and continuous learning based on end-user feedback to achieve rapid improvements in their product.

Ries says companies that learn the quickest about what the customer wants, and can incorporate that information into products more efficiently, stand the greatest chance of succeeding. A software engineer by trade, Ries uses many examples of companies that have succeeded with this approach, none of which are from healthcare.

In stark relief, the chief technology hospitalists interface with daily is the electronic health record (EHR), widely recognized as a system that fails to consider the end-user experience, that is unable to interoperate with other software, and is incapable of using data for quality improvement (QI). The PDSA (“plan, do, study, act”) cycle is the foundation of QI activities and relies on rapidly incorporating observations made by those performing the work to create novel workflows and processes based on learning. EHRs, by digitizing health information, theoretically provide the ideal tool for supporting QI.

The reality is that EHRs have been a colossal disappointment with regard to QI efforts. The space in and around EHR effectively represents “dead zones” for innovation and improvement. Mandl and Kohane note:

EHR companies have followed a business model whereby they control all data, rather than liberating the data for use in innovative applications in clinical care.

Conducting a Google-style search of an EHR database usually requires involvement of a clinician’s information services department and often the specialized knowledge and cooperation of the vendor’s technical teams.

Greg Maynard, MD, MSc, SFHM, senior vice president of SHM’s Center for Hospital Innovation and Improvement, recently provided testimony to the Office of the National Coordinator for Health Information Technology about the challenges current EHRs present to QI efforts and what features EHRs need to incorporate to better serve the needs of patients and clinicians. Dr. Maynard answered a few questions for The Hospitalist:

Q: What is it about current EHRs that make continuous improvement so difficult?

A: EHRs were built for fiscal and administrative purposes, not for quality improvement and safety. The administrative/fiscal roots of today’s IT systems lead to poor availability of clinical, quality, and safety data. In many medical centers and practices, the great majority of information available is months-old administrative data, which does not lend itself to rapid cycle improvement.

Q: Why is the PDSA cycle endangered in most systems?

A: EHRs often do not facilitate rapid-cycle, PDSA-style improvements on a small pilot scale. Most improvement teams get one shot to get the clinical decision support and data-capture tools correct after months of waiting in queue and development time. Any request for revisions and refinements is treated as a failure of the improvement team, and it is often difficult or impossible to pilot new tools in a limited setting.

Q: What features would you like to see in EHRs that would facilitate QI?

A: We need a user-friendly interface for clinicians and for data analysts/reporters. Other industries have common data formats to allow for sharing of information across disparate systems. We need the same capability for clinical information in healthcare. Also, a change in architecture of EHRs and other health IT tools that allows for not just interoperability but substitutable options is required. In the more “app”-like environment, innovation and flexibility would be the rule. An underlying architecture could have different plug-and-play modules for different functions. Some companies are overcoming the current barriers to provide wonderful, easy-to-generate and useful reports, but most are stymied by proprietary systems.

Reference

1. Mandl KD, Kohane IS. Escaping the EHR trap: the future of health IT. N Engl J Med. 2012;366(24):2240-2242.

Dr. Whitcomb is medical director of healthcare quality at Baystate Medical Center in Springfield, Mass. He is a co-founder and past president of SHM. Email him at wfwhit@comcast.net.

In “The Lean Startup,” author Eric Ries notes that in its early stages, his gaming company would routinely issue new versions of their software application several times each day. Continuous deployment—the process Ries’ company used—leveraged such Lean principles as reduced batch size and continuous learning based on end-user feedback to achieve rapid improvements in their product.

Ries says companies that learn the quickest about what the customer wants, and can incorporate that information into products more efficiently, stand the greatest chance of succeeding. A software engineer by trade, Ries uses many examples of companies that have succeeded with this approach, none of which are from healthcare.

In stark relief, the chief technology hospitalists interface with daily is the electronic health record (EHR), widely recognized as a system that fails to consider the end-user experience, that is unable to interoperate with other software, and is incapable of using data for quality improvement (QI). The PDSA (“plan, do, study, act”) cycle is the foundation of QI activities and relies on rapidly incorporating observations made by those performing the work to create novel workflows and processes based on learning. EHRs, by digitizing health information, theoretically provide the ideal tool for supporting QI.

The reality is that EHRs have been a colossal disappointment with regard to QI efforts. The space in and around EHR effectively represents “dead zones” for innovation and improvement. Mandl and Kohane note:

EHR companies have followed a business model whereby they control all data, rather than liberating the data for use in innovative applications in clinical care.

Conducting a Google-style search of an EHR database usually requires involvement of a clinician’s information services department and often the specialized knowledge and cooperation of the vendor’s technical teams.

Greg Maynard, MD, MSc, SFHM, senior vice president of SHM’s Center for Hospital Innovation and Improvement, recently provided testimony to the Office of the National Coordinator for Health Information Technology about the challenges current EHRs present to QI efforts and what features EHRs need to incorporate to better serve the needs of patients and clinicians. Dr. Maynard answered a few questions for The Hospitalist:

Q: What is it about current EHRs that make continuous improvement so difficult?

A: EHRs were built for fiscal and administrative purposes, not for quality improvement and safety. The administrative/fiscal roots of today’s IT systems lead to poor availability of clinical, quality, and safety data. In many medical centers and practices, the great majority of information available is months-old administrative data, which does not lend itself to rapid cycle improvement.

Q: Why is the PDSA cycle endangered in most systems?

A: EHRs often do not facilitate rapid-cycle, PDSA-style improvements on a small pilot scale. Most improvement teams get one shot to get the clinical decision support and data-capture tools correct after months of waiting in queue and development time. Any request for revisions and refinements is treated as a failure of the improvement team, and it is often difficult or impossible to pilot new tools in a limited setting.

Q: What features would you like to see in EHRs that would facilitate QI?

A: We need a user-friendly interface for clinicians and for data analysts/reporters. Other industries have common data formats to allow for sharing of information across disparate systems. We need the same capability for clinical information in healthcare. Also, a change in architecture of EHRs and other health IT tools that allows for not just interoperability but substitutable options is required. In the more “app”-like environment, innovation and flexibility would be the rule. An underlying architecture could have different plug-and-play modules for different functions. Some companies are overcoming the current barriers to provide wonderful, easy-to-generate and useful reports, but most are stymied by proprietary systems.

Reference

1. Mandl KD, Kohane IS. Escaping the EHR trap: the future of health IT. N Engl J Med. 2012;366(24):2240-2242.

Dr. Whitcomb is medical director of healthcare quality at Baystate Medical Center in Springfield, Mass. He is a co-founder and past president of SHM. Email him at wfwhit@comcast.net.

In “The Lean Startup,” author Eric Ries notes that in its early stages, his gaming company would routinely issue new versions of their software application several times each day. Continuous deployment—the process Ries’ company used—leveraged such Lean principles as reduced batch size and continuous learning based on end-user feedback to achieve rapid improvements in their product.

Ries says companies that learn the quickest about what the customer wants, and can incorporate that information into products more efficiently, stand the greatest chance of succeeding. A software engineer by trade, Ries uses many examples of companies that have succeeded with this approach, none of which are from healthcare.

In stark relief, the chief technology hospitalists interface with daily is the electronic health record (EHR), widely recognized as a system that fails to consider the end-user experience, that is unable to interoperate with other software, and is incapable of using data for quality improvement (QI). The PDSA (“plan, do, study, act”) cycle is the foundation of QI activities and relies on rapidly incorporating observations made by those performing the work to create novel workflows and processes based on learning. EHRs, by digitizing health information, theoretically provide the ideal tool for supporting QI.

The reality is that EHRs have been a colossal disappointment with regard to QI efforts. The space in and around EHR effectively represents “dead zones” for innovation and improvement. Mandl and Kohane note:

EHR companies have followed a business model whereby they control all data, rather than liberating the data for use in innovative applications in clinical care.

Conducting a Google-style search of an EHR database usually requires involvement of a clinician’s information services department and often the specialized knowledge and cooperation of the vendor’s technical teams.

Greg Maynard, MD, MSc, SFHM, senior vice president of SHM’s Center for Hospital Innovation and Improvement, recently provided testimony to the Office of the National Coordinator for Health Information Technology about the challenges current EHRs present to QI efforts and what features EHRs need to incorporate to better serve the needs of patients and clinicians. Dr. Maynard answered a few questions for The Hospitalist:

Q: What is it about current EHRs that make continuous improvement so difficult?

A: EHRs were built for fiscal and administrative purposes, not for quality improvement and safety. The administrative/fiscal roots of today’s IT systems lead to poor availability of clinical, quality, and safety data. In many medical centers and practices, the great majority of information available is months-old administrative data, which does not lend itself to rapid cycle improvement.

Q: Why is the PDSA cycle endangered in most systems?

A: EHRs often do not facilitate rapid-cycle, PDSA-style improvements on a small pilot scale. Most improvement teams get one shot to get the clinical decision support and data-capture tools correct after months of waiting in queue and development time. Any request for revisions and refinements is treated as a failure of the improvement team, and it is often difficult or impossible to pilot new tools in a limited setting.

Q: What features would you like to see in EHRs that would facilitate QI?

A: We need a user-friendly interface for clinicians and for data analysts/reporters. Other industries have common data formats to allow for sharing of information across disparate systems. We need the same capability for clinical information in healthcare. Also, a change in architecture of EHRs and other health IT tools that allows for not just interoperability but substitutable options is required. In the more “app”-like environment, innovation and flexibility would be the rule. An underlying architecture could have different plug-and-play modules for different functions. Some companies are overcoming the current barriers to provide wonderful, easy-to-generate and useful reports, but most are stymied by proprietary systems.

Reference

1. Mandl KD, Kohane IS. Escaping the EHR trap: the future of health IT. N Engl J Med. 2012;366(24):2240-2242.

Dr. Whitcomb is medical director of healthcare quality at Baystate Medical Center in Springfield, Mass. He is a co-founder and past president of SHM. Email him at wfwhit@comcast.net.

Dr. Frost

In my previous column, we considered a comprehensive and practical definition of accountability advanced by Connors, Smith, and Hickman in their well-written book “The Oz Principle.”¹ In order to apply these concepts successfully to HM practice, it is useful to conceive of accountability as a process that should be approached in a step-wise manner. In this month’s column, we will explore the “process of accountability” by considering how “The Oz Principle” can further assist hospitalists in accomplishing what is expected of them as agents of high-quality, cost-effective healthcare delivery.

The Process

Recall that Connors and colleagues define accountability as “a personal choice to rise above one’s circumstances, and demonstrate ownership necessary for achieving results.” Such a definition empowers us to anticipate the future by proactively avoiding problems versus retrospectively explaining why problems occurred. To apply this definition in our daily lives, we must contemplate how to proactively avoid problems. This can be accomplished by following a process described as the four-step approach: “see it, own it, solve it, and do it.”

Step No. 1 on the road to accountability requires that hospitalists be aware of issues in their external environments that affect their practice, and is referred to by Connors et al as “seeing it.” As it concerns healthcare reform, Step 1 requires that hospitalists educate themselves about such keystone reform initiatives as value-based purchasing and the public reporting of performance. Initiatives such as these are centerpieces of care delivery reform, and will occur irrespective of the fate of such legislation as the Affordable Care Act. Clinicians thus must understand the features of these initiatives, and appreciate how policies and programs emanating from them will necessitate changes in medical practice.

There are innumerable resources available to assist with understanding these concepts. If you have yet to do so, I encourage you to explore the hospital value-based purchasing (HVBP) toolkit on SHM’s website (www.hospitalmedicine.org/hvbp). Additionally, in order to appreciate the power of public performance reporting, please review the Hospital Compare and Physician Compare pages on the Centers for Medicare & Medicaid Services (CMS) website. Knowledge is power, and in this situation it is essential to ensure your continued professional success. “The Oz Principle” admonishes that “if changes are inevitable, then those who resist them will inevitably fail.” Please ensure that failure is not an option by seeking first to understand how healthcare reform will impact your practice.

Step No. 2 on the road to accountability requires that hospitalists sincerely accept healthcare challenges as theirs to personally embrace. Connors et al define this step as “owning it.” In order to truly own our country’s problem of substandard healthcare delivery, “The Oz Principle” suggests that the profession of medicine must “accept ownership of past and present behaviors that keep it mired in current circumstances, (as this is the only way it can) hope to improve its future situation.”

This is challenging for hospitalists, as most HM practitioners are only a few years removed from completion of clinical training. It is thus tempting for young hospitalists to refuse ownership of healthcare system problems as ones that they personally created. Although this position is understandable, we should not accept it. It might be true that a single physician’s practice contributed little to our current overall healthcare challenges; however, we are all members of the same profession, and a collective identity when it comes to ownership of healthcare system problems is essential to our ability to eventually solve these problems. Complaining that our predecessors are responsible for our present maladies will stifle improvement efforts by creating a culture of victimization. According to “The Oz Principle,” “owning our circumstances gives us the strength to overcome the powerlessness that comes from being a victim, and allows us to move forward and achieve more satisfying results.”

Step No. 3 mandates that hospitalists capitalize on reform opportunities by designing process-improvement strategies through critical analysis and innovative thinking. Connors and colleagues define this step as “solving it.” Contributing to “solving it” is a fundamental job responsibility of every hospitalist, and not the exclusive province of hospitalist leaders. HM clinicians focusing primarily on bedside care must actively participate in the process of solving the problems that currently plague our healthcare system.

To do so should not necessitate an overly burdensome time commitment. It is often sufficient to simply attend and actively participate in your team and hospital staff meetings. At other times, it might be necessary for you to volunteer an hour or so once a month in service to a hospital committee or a team activity. Contributing your observations and thoughts in these forums is essential to creating effective solutions. Although you might not be the ultimate decision-maker, you have an obligation to build a broad collective understanding of the issues through the voicing of your opinions.

According to “The Oz Principle,” “solving it is not an extra activity, but part of the job.” Each of us has a professional obligation to identify better methods to deliver high-value healthcare. Doing so necessitates that we each identify improvement opportunities by critically evaluating the success of our current situations. We must then, at a minimum, share our thoughts with the decision-makers responsible for enacting improvement strategies.

The fourth and final step on the road to accountability requires that hospitalists successfully implement solutions and ensure that the desired results are achieved. Connors and colleagues define this step as “doing it.” Successfully “doing it” to enhance healthcare quality and efficiency necessitates hard work, because rarely is it sufficient to simply implement a healthcare improvement project. In order to achieve true results, projects must be actively managed after initial deployment, tweaked to become better, then redeployed and reanalyzed to ensure effectiveness.

In healthcare, it is tempting to become satisfied with simply deploying processes, as much of the healthcare reform work done to date has focused on payment for process improvements. This, however, will change in the near future. For example, Medicare’s hospital value-based purchasing program (see “Value-Based Purchasing Raises the Stakes,” January 2012, p. 1) will incorporate outcome measures as soon as 2014. We must, therefore, get into the habit of aggressively managing the processes that we operate through diligent data collection and subsequent decision-making that is informed by actionable information.

Conclusion

Holding ourselves accountable for enacting healthcare reform initiatives to improve the care of our patients will be difficult. The task is made easier by employing a process to guide our efforts. “The Oz Principle” teaches us a succinct, four-step approach. Applying this approach to changes mandated by healthcare reform will make it easier for hospitalists to transcend their current dysfunctional situations and achieve demonstrable healthcare system improvements for the betterment of patient care.

Dr. Frost is president of SHM.

Reference

1. Connors R, Smith T, Hickman C. The Oz Principle: Getting Results Through Individual and Organizational Accountability. New York: Portfolio; 2004.

Dr. Frost

In my previous column, we considered a comprehensive and practical definition of accountability advanced by Connors, Smith, and Hickman in their well-written book “The Oz Principle.”¹ In order to apply these concepts successfully to HM practice, it is useful to conceive of accountability as a process that should be approached in a step-wise manner. In this month’s column, we will explore the “process of accountability” by considering how “The Oz Principle” can further assist hospitalists in accomplishing what is expected of them as agents of high-quality, cost-effective healthcare delivery.

The Process

Recall that Connors and colleagues define accountability as “a personal choice to rise above one’s circumstances, and demonstrate ownership necessary for achieving results.” Such a definition empowers us to anticipate the future by proactively avoiding problems versus retrospectively explaining why problems occurred. To apply this definition in our daily lives, we must contemplate how to proactively avoid problems. This can be accomplished by following a process described as the four-step approach: “see it, own it, solve it, and do it.”

Step No. 1 on the road to accountability requires that hospitalists be aware of issues in their external environments that affect their practice, and is referred to by Connors et al as “seeing it.” As it concerns healthcare reform, Step 1 requires that hospitalists educate themselves about such keystone reform initiatives as value-based purchasing and the public reporting of performance. Initiatives such as these are centerpieces of care delivery reform, and will occur irrespective of the fate of such legislation as the Affordable Care Act. Clinicians thus must understand the features of these initiatives, and appreciate how policies and programs emanating from them will necessitate changes in medical practice.

There are innumerable resources available to assist with understanding these concepts. If you have yet to do so, I encourage you to explore the hospital value-based purchasing (HVBP) toolkit on SHM’s website (www.hospitalmedicine.org/hvbp). Additionally, in order to appreciate the power of public performance reporting, please review the Hospital Compare and Physician Compare pages on the Centers for Medicare & Medicaid Services (CMS) website. Knowledge is power, and in this situation it is essential to ensure your continued professional success. “The Oz Principle” admonishes that “if changes are inevitable, then those who resist them will inevitably fail.” Please ensure that failure is not an option by seeking first to understand how healthcare reform will impact your practice.

Step No. 2 on the road to accountability requires that hospitalists sincerely accept healthcare challenges as theirs to personally embrace. Connors et al define this step as “owning it.” In order to truly own our country’s problem of substandard healthcare delivery, “The Oz Principle” suggests that the profession of medicine must “accept ownership of past and present behaviors that keep it mired in current circumstances, (as this is the only way it can) hope to improve its future situation.”

This is challenging for hospitalists, as most HM practitioners are only a few years removed from completion of clinical training. It is thus tempting for young hospitalists to refuse ownership of healthcare system problems as ones that they personally created. Although this position is understandable, we should not accept it. It might be true that a single physician’s practice contributed little to our current overall healthcare challenges; however, we are all members of the same profession, and a collective identity when it comes to ownership of healthcare system problems is essential to our ability to eventually solve these problems. Complaining that our predecessors are responsible for our present maladies will stifle improvement efforts by creating a culture of victimization. According to “The Oz Principle,” “owning our circumstances gives us the strength to overcome the powerlessness that comes from being a victim, and allows us to move forward and achieve more satisfying results.”

Step No. 3 mandates that hospitalists capitalize on reform opportunities by designing process-improvement strategies through critical analysis and innovative thinking. Connors and colleagues define this step as “solving it.” Contributing to “solving it” is a fundamental job responsibility of every hospitalist, and not the exclusive province of hospitalist leaders. HM clinicians focusing primarily on bedside care must actively participate in the process of solving the problems that currently plague our healthcare system.

To do so should not necessitate an overly burdensome time commitment. It is often sufficient to simply attend and actively participate in your team and hospital staff meetings. At other times, it might be necessary for you to volunteer an hour or so once a month in service to a hospital committee or a team activity. Contributing your observations and thoughts in these forums is essential to creating effective solutions. Although you might not be the ultimate decision-maker, you have an obligation to build a broad collective understanding of the issues through the voicing of your opinions.

According to “The Oz Principle,” “solving it is not an extra activity, but part of the job.” Each of us has a professional obligation to identify better methods to deliver high-value healthcare. Doing so necessitates that we each identify improvement opportunities by critically evaluating the success of our current situations. We must then, at a minimum, share our thoughts with the decision-makers responsible for enacting improvement strategies.

The fourth and final step on the road to accountability requires that hospitalists successfully implement solutions and ensure that the desired results are achieved. Connors and colleagues define this step as “doing it.” Successfully “doing it” to enhance healthcare quality and efficiency necessitates hard work, because rarely is it sufficient to simply implement a healthcare improvement project. In order to achieve true results, projects must be actively managed after initial deployment, tweaked to become better, then redeployed and reanalyzed to ensure effectiveness.

In healthcare, it is tempting to become satisfied with simply deploying processes, as much of the healthcare reform work done to date has focused on payment for process improvements. This, however, will change in the near future. For example, Medicare’s hospital value-based purchasing program (see “Value-Based Purchasing Raises the Stakes,” January 2012, p. 1) will incorporate outcome measures as soon as 2014. We must, therefore, get into the habit of aggressively managing the processes that we operate through diligent data collection and subsequent decision-making that is informed by actionable information.

Conclusion

Holding ourselves accountable for enacting healthcare reform initiatives to improve the care of our patients will be difficult. The task is made easier by employing a process to guide our efforts. “The Oz Principle” teaches us a succinct, four-step approach. Applying this approach to changes mandated by healthcare reform will make it easier for hospitalists to transcend their current dysfunctional situations and achieve demonstrable healthcare system improvements for the betterment of patient care.

Dr. Frost is president of SHM.

Reference

1. Connors R, Smith T, Hickman C. The Oz Principle: Getting Results Through Individual and Organizational Accountability. New York: Portfolio; 2004.

Dr. Frost

In my previous column, we considered a comprehensive and practical definition of accountability advanced by Connors, Smith, and Hickman in their well-written book “The Oz Principle.”¹ In order to apply these concepts successfully to HM practice, it is useful to conceive of accountability as a process that should be approached in a step-wise manner. In this month’s column, we will explore the “process of accountability” by considering how “The Oz Principle” can further assist hospitalists in accomplishing what is expected of them as agents of high-quality, cost-effective healthcare delivery.

The Process

Recall that Connors and colleagues define accountability as “a personal choice to rise above one’s circumstances, and demonstrate ownership necessary for achieving results.” Such a definition empowers us to anticipate the future by proactively avoiding problems versus retrospectively explaining why problems occurred. To apply this definition in our daily lives, we must contemplate how to proactively avoid problems. This can be accomplished by following a process described as the four-step approach: “see it, own it, solve it, and do it.”

Step No. 1 on the road to accountability requires that hospitalists be aware of issues in their external environments that affect their practice, and is referred to by Connors et al as “seeing it.” As it concerns healthcare reform, Step 1 requires that hospitalists educate themselves about such keystone reform initiatives as value-based purchasing and the public reporting of performance. Initiatives such as these are centerpieces of care delivery reform, and will occur irrespective of the fate of such legislation as the Affordable Care Act. Clinicians thus must understand the features of these initiatives, and appreciate how policies and programs emanating from them will necessitate changes in medical practice.

There are innumerable resources available to assist with understanding these concepts. If you have yet to do so, I encourage you to explore the hospital value-based purchasing (HVBP) toolkit on SHM’s website (www.hospitalmedicine.org/hvbp). Additionally, in order to appreciate the power of public performance reporting, please review the Hospital Compare and Physician Compare pages on the Centers for Medicare & Medicaid Services (CMS) website. Knowledge is power, and in this situation it is essential to ensure your continued professional success. “The Oz Principle” admonishes that “if changes are inevitable, then those who resist them will inevitably fail.” Please ensure that failure is not an option by seeking first to understand how healthcare reform will impact your practice.

Step No. 2 on the road to accountability requires that hospitalists sincerely accept healthcare challenges as theirs to personally embrace. Connors et al define this step as “owning it.” In order to truly own our country’s problem of substandard healthcare delivery, “The Oz Principle” suggests that the profession of medicine must “accept ownership of past and present behaviors that keep it mired in current circumstances, (as this is the only way it can) hope to improve its future situation.”

This is challenging for hospitalists, as most HM practitioners are only a few years removed from completion of clinical training. It is thus tempting for young hospitalists to refuse ownership of healthcare system problems as ones that they personally created. Although this position is understandable, we should not accept it. It might be true that a single physician’s practice contributed little to our current overall healthcare challenges; however, we are all members of the same profession, and a collective identity when it comes to ownership of healthcare system problems is essential to our ability to eventually solve these problems. Complaining that our predecessors are responsible for our present maladies will stifle improvement efforts by creating a culture of victimization. According to “The Oz Principle,” “owning our circumstances gives us the strength to overcome the powerlessness that comes from being a victim, and allows us to move forward and achieve more satisfying results.”

Step No. 3 mandates that hospitalists capitalize on reform opportunities by designing process-improvement strategies through critical analysis and innovative thinking. Connors and colleagues define this step as “solving it.” Contributing to “solving it” is a fundamental job responsibility of every hospitalist, and not the exclusive province of hospitalist leaders. HM clinicians focusing primarily on bedside care must actively participate in the process of solving the problems that currently plague our healthcare system.

To do so should not necessitate an overly burdensome time commitment. It is often sufficient to simply attend and actively participate in your team and hospital staff meetings. At other times, it might be necessary for you to volunteer an hour or so once a month in service to a hospital committee or a team activity. Contributing your observations and thoughts in these forums is essential to creating effective solutions. Although you might not be the ultimate decision-maker, you have an obligation to build a broad collective understanding of the issues through the voicing of your opinions.

According to “The Oz Principle,” “solving it is not an extra activity, but part of the job.” Each of us has a professional obligation to identify better methods to deliver high-value healthcare. Doing so necessitates that we each identify improvement opportunities by critically evaluating the success of our current situations. We must then, at a minimum, share our thoughts with the decision-makers responsible for enacting improvement strategies.

The fourth and final step on the road to accountability requires that hospitalists successfully implement solutions and ensure that the desired results are achieved. Connors and colleagues define this step as “doing it.” Successfully “doing it” to enhance healthcare quality and efficiency necessitates hard work, because rarely is it sufficient to simply implement a healthcare improvement project. In order to achieve true results, projects must be actively managed after initial deployment, tweaked to become better, then redeployed and reanalyzed to ensure effectiveness.

In healthcare, it is tempting to become satisfied with simply deploying processes, as much of the healthcare reform work done to date has focused on payment for process improvements. This, however, will change in the near future. For example, Medicare’s hospital value-based purchasing program (see “Value-Based Purchasing Raises the Stakes,” January 2012, p. 1) will incorporate outcome measures as soon as 2014. We must, therefore, get into the habit of aggressively managing the processes that we operate through diligent data collection and subsequent decision-making that is informed by actionable information.

Conclusion

Holding ourselves accountable for enacting healthcare reform initiatives to improve the care of our patients will be difficult. The task is made easier by employing a process to guide our efforts. “The Oz Principle” teaches us a succinct, four-step approach. Applying this approach to changes mandated by healthcare reform will make it easier for hospitalists to transcend their current dysfunctional situations and achieve demonstrable healthcare system improvements for the betterment of patient care.

Dr. Frost is president of SHM.

Reference

1. Connors R, Smith T, Hickman C. The Oz Principle: Getting Results Through Individual and Organizational Accountability. New York: Portfolio; 2004.

Dr. Hospitalist

One of our providers wants to use adult hospitalists for coverage of inpatient orthopedic surgery patients. Is this acceptable practice? Are there qualifiers?

—Libby Gardner

Dr. Hospitalist responds:

Let’s see how far we can tackle this open-ended question. There has been lots of discussion on the topic of comanagement in the past by people eminently more qualified than I am. Still, it never hurts to take a fresh look at things.

For one, on the subject of admissions, I am a firm believer that hospitalists should admit all adult hip fractures. The overwhelming majority of the time, these patients are elderly with comorbid conditions. Sure, they are going to get their hip fixed, because the alternative usually is unacceptable, but some thought needs to go into the process.

The orthopedic surgeon sees a hip that needs fixing and not much else. When such issues as renal failure, afib, congestive heart failure, prior DVT, dementia, and all the other common conditions are present, we as adult hospitalists should take charge of the case. That is the best way to ensure that the patient receives optimal medical care and the documentation that goes along with it. I love our orthopedic surgeons, but I don’t want them primarily admitting, managing, and discharging my elderly patients. Let the surgeon do what they do best—operate—and leave the rest to us as hospitalists.

On the subject of orthopedic trauma, I take the exact opposite approach—this is not something where we have daily expertise. A young, healthy patient with trauma should be admitted by the orthopedic service; that patient population’s complications are much more likely to be directly related to their trauma.

When it comes to elective surgery when the admitting surgeon (orthopedic or otherwise) wants the help of a hospitalist, then I think it is of paramount importance to establish clear “rules of engagement” (see “The Comanagement Conundrum,” April 2011, p. 1). I think with good expectations, you can have a fantastic relationship with your surgeons. Without them, it becomes a nightmare. As a real-life example, here are my HM group’s rules for elective orthopedic surgery:

• Orthopedics handles all pain medications and VTE prophylaxis, including discharge prescriptions;
• Medicine does the admission and medication reconciliation (“med rec”) at discharge;
• There is shared discussion on the need for transfusion; and
• There is shared discussion on the need for VTE prophylaxis when a patient already is on chronic anticoagulation.

We do not vary from this protocol. I never adjust a patient’s pain medications—even the floor nurses know this. Because I’m doing the admit and med rec, it also means that the patient doesn’t have their HCTZ continued after 600cc of EBL and spinal anesthesia. It works because the rules are clear and the communication is consistent.

This does not mean that we cover the orthopedic service at night; they are equally responsible for their patients under the items outlined above. In my view—and this might sound simplistic—the surgeon caused the post-op pain, so they should be responsible for managing it. With regard to VTE prophylaxis, I might take a more nuanced view, but for our surgeons, they own the wound and the post-op follow-up, so they get the choice on what agent to use.

Would I accept an arrangement in which I covered all the orthopedic issues out of regular hours? Nope—not when they have primary responsibility for the case; they should always be directly available to the nurse. I think that anything else would be a system ripe for abuse.

Our exact rules will not work for every situation, but I would strongly encourage the two basic tenets from above: No. 1, the hospitalist should primarily admit and manage elderly hip fractures, and No. 2, there should be clear rules of engagement with your orthopedic or surgery group. It’s a discussion worth having during daylight hours, because trying to figure out the rules at 3 in the morning rarely ends well.

Dr. Hospitalist

One of our providers wants to use adult hospitalists for coverage of inpatient orthopedic surgery patients. Is this acceptable practice? Are there qualifiers?

—Libby Gardner

Dr. Hospitalist responds:

Let’s see how far we can tackle this open-ended question. There has been lots of discussion on the topic of comanagement in the past by people eminently more qualified than I am. Still, it never hurts to take a fresh look at things.

For one, on the subject of admissions, I am a firm believer that hospitalists should admit all adult hip fractures. The overwhelming majority of the time, these patients are elderly with comorbid conditions. Sure, they are going to get their hip fixed, because the alternative usually is unacceptable, but some thought needs to go into the process.

The orthopedic surgeon sees a hip that needs fixing and not much else. When such issues as renal failure, afib, congestive heart failure, prior DVT, dementia, and all the other common conditions are present, we as adult hospitalists should take charge of the case. That is the best way to ensure that the patient receives optimal medical care and the documentation that goes along with it. I love our orthopedic surgeons, but I don’t want them primarily admitting, managing, and discharging my elderly patients. Let the surgeon do what they do best—operate—and leave the rest to us as hospitalists.

On the subject of orthopedic trauma, I take the exact opposite approach—this is not something where we have daily expertise. A young, healthy patient with trauma should be admitted by the orthopedic service; that patient population’s complications are much more likely to be directly related to their trauma.

When it comes to elective surgery when the admitting surgeon (orthopedic or otherwise) wants the help of a hospitalist, then I think it is of paramount importance to establish clear “rules of engagement” (see “The Comanagement Conundrum,” April 2011, p. 1). I think with good expectations, you can have a fantastic relationship with your surgeons. Without them, it becomes a nightmare. As a real-life example, here are my HM group’s rules for elective orthopedic surgery:

• Orthopedics handles all pain medications and VTE prophylaxis, including discharge prescriptions;
• Medicine does the admission and medication reconciliation (“med rec”) at discharge;
• There is shared discussion on the need for transfusion; and
• There is shared discussion on the need for VTE prophylaxis when a patient already is on chronic anticoagulation.

We do not vary from this protocol. I never adjust a patient’s pain medications—even the floor nurses know this. Because I’m doing the admit and med rec, it also means that the patient doesn’t have their HCTZ continued after 600cc of EBL and spinal anesthesia. It works because the rules are clear and the communication is consistent.

This does not mean that we cover the orthopedic service at night; they are equally responsible for their patients under the items outlined above. In my view—and this might sound simplistic—the surgeon caused the post-op pain, so they should be responsible for managing it. With regard to VTE prophylaxis, I might take a more nuanced view, but for our surgeons, they own the wound and the post-op follow-up, so they get the choice on what agent to use.

Would I accept an arrangement in which I covered all the orthopedic issues out of regular hours? Nope—not when they have primary responsibility for the case; they should always be directly available to the nurse. I think that anything else would be a system ripe for abuse.

Our exact rules will not work for every situation, but I would strongly encourage the two basic tenets from above: No. 1, the hospitalist should primarily admit and manage elderly hip fractures, and No. 2, there should be clear rules of engagement with your orthopedic or surgery group. It’s a discussion worth having during daylight hours, because trying to figure out the rules at 3 in the morning rarely ends well.

Dr. Hospitalist

One of our providers wants to use adult hospitalists for coverage of inpatient orthopedic surgery patients. Is this acceptable practice? Are there qualifiers?

—Libby Gardner

Dr. Hospitalist responds:

Let’s see how far we can tackle this open-ended question. There has been lots of discussion on the topic of comanagement in the past by people eminently more qualified than I am. Still, it never hurts to take a fresh look at things.

For one, on the subject of admissions, I am a firm believer that hospitalists should admit all adult hip fractures. The overwhelming majority of the time, these patients are elderly with comorbid conditions. Sure, they are going to get their hip fixed, because the alternative usually is unacceptable, but some thought needs to go into the process.

The orthopedic surgeon sees a hip that needs fixing and not much else. When such issues as renal failure, afib, congestive heart failure, prior DVT, dementia, and all the other common conditions are present, we as adult hospitalists should take charge of the case. That is the best way to ensure that the patient receives optimal medical care and the documentation that goes along with it. I love our orthopedic surgeons, but I don’t want them primarily admitting, managing, and discharging my elderly patients. Let the surgeon do what they do best—operate—and leave the rest to us as hospitalists.

On the subject of orthopedic trauma, I take the exact opposite approach—this is not something where we have daily expertise. A young, healthy patient with trauma should be admitted by the orthopedic service; that patient population’s complications are much more likely to be directly related to their trauma.

When it comes to elective surgery when the admitting surgeon (orthopedic or otherwise) wants the help of a hospitalist, then I think it is of paramount importance to establish clear “rules of engagement” (see “The Comanagement Conundrum,” April 2011, p. 1). I think with good expectations, you can have a fantastic relationship with your surgeons. Without them, it becomes a nightmare. As a real-life example, here are my HM group’s rules for elective orthopedic surgery:

• Orthopedics handles all pain medications and VTE prophylaxis, including discharge prescriptions;
• Medicine does the admission and medication reconciliation (“med rec”) at discharge;
• There is shared discussion on the need for transfusion; and
• There is shared discussion on the need for VTE prophylaxis when a patient already is on chronic anticoagulation.

We do not vary from this protocol. I never adjust a patient’s pain medications—even the floor nurses know this. Because I’m doing the admit and med rec, it also means that the patient doesn’t have their HCTZ continued after 600cc of EBL and spinal anesthesia. It works because the rules are clear and the communication is consistent.

This does not mean that we cover the orthopedic service at night; they are equally responsible for their patients under the items outlined above. In my view—and this might sound simplistic—the surgeon caused the post-op pain, so they should be responsible for managing it. With regard to VTE prophylaxis, I might take a more nuanced view, but for our surgeons, they own the wound and the post-op follow-up, so they get the choice on what agent to use.

Would I accept an arrangement in which I covered all the orthopedic issues out of regular hours? Nope—not when they have primary responsibility for the case; they should always be directly available to the nurse. I think that anything else would be a system ripe for abuse.

Our exact rules will not work for every situation, but I would strongly encourage the two basic tenets from above: No. 1, the hospitalist should primarily admit and manage elderly hip fractures, and No. 2, there should be clear rules of engagement with your orthopedic or surgery group. It’s a discussion worth having during daylight hours, because trying to figure out the rules at 3 in the morning rarely ends well.