QI Initiatives

Getting involved—and getting ahead—in hospital medicine has never been easier, with just some planning and preparation. Here are three ways to move your hospital—and your career—forward this month.

1. Add “award-winning” to your CV: SHM’s Awards of Excellence deadline is Sept. 16.

Although 2013’s award-winners are still fresh in hospitalists’ minds, now is the time to put together award applications for the 2014 Awards of Excellence.

Each year, SHM presents six different awards that recognize individuals and one award to a team that is transforming health care and revolutionizing patient care for hospitalized patients:

• Excellence in Research Award;
• Excellence in Hospital Medicine for Non-Physicians;
• Award for Excellence in Teaching;
• Award for Outstanding Service in Hospital Medicine;
• Award for Clinical Excellence; and
• Excellence in Teamwork in Quality Improvement.

Last year, SHM received award nominations from a diverse group of hospitalists and looks forward to receiving even more this year. Each winner receives an all-expenses-paid trip to HM14 in Las Vegas, including complimentary meeting registration.

The deadline for applications for SHM’s five individual awards is Sept. 16. The deadline for the Excellence in Teamwork in Quality Improvement is Oct. 15. All SHM members are eligible, and nominees can be self-nominated.

For more information, visit www.hospital medicine.org/awards.

2. Bring the experts in reducing readmissions to your hospital: Apply now for Project BOOST.

There is still time to apply for SHM’s Project BOOST, which helps hospitals design discharge programs to reduce readmissions. SHM will accept applications for Project BOOST until the end of August.

Project BOOST is based on SHM’s award-winning mentored implementation model that brings individualized attention from national experts in reducing readmissions to hospitals across the country. Each Project BOOST site receives:

• A comprehensive intervention developed by a panel of nationally recognized experts based on the best available evidence.
• A comprehensive implementation guide that provides step-by-step instructions and project-management tools, such as the teachback training curriculum, to help interdisciplinary teams redesign workflow and plan, implement, and evaluate the intervention.
• Longitudinal technical assistance providing face-to-face training and a year of expert mentoring and coaching to implement BOOST interventions that build a culture that supports safe and complete transitions. The mentoring program provides a training DVD and curriculum for nurses and case managers on using the teachback process, as well as webinars that target the educational needs of other team members, including administrators, data analysts, physicians, nurses, and others.
• Collaboration that allows sites to communicate with and learn from each other via the BOOST community site and quarterly all-site teleconferences and webinars.
• The BOOST data center, an online resource that allows sites to store and benchmark data against control units and other sites and generates reports.

For more information, visit www.hospital medicine.org/boost.

3. Start Choosing Wisely today.

In 2014, as part of a grant from the ABIM Foundation, SHM will begin its first Choosing Wisely case-study competition to highlight hospitalists’ best practices within the popular campaign.

But in order to have a successful case study next year, some preparation is in order now. Developing goals, gathering a team, and, perhaps most important, developing benchmarking data on a project motivated by Choosing Wisely will all be important parts of a compelling case study.

To start brainstorming your project to implement Choosing Wisely recommendations at your hospital, visit www.hospitalmedicine.org/choosingwisely.

Brendon Shank is SHM’s associate vice president of communications.

Getting involved—and getting ahead—in hospital medicine has never been easier, with just some planning and preparation. Here are three ways to move your hospital—and your career—forward this month.

1. Add “award-winning” to your CV: SHM’s Awards of Excellence deadline is Sept. 16.

Although 2013’s award-winners are still fresh in hospitalists’ minds, now is the time to put together award applications for the 2014 Awards of Excellence.

Each year, SHM presents six different awards that recognize individuals and one award to a team that is transforming health care and revolutionizing patient care for hospitalized patients:

• Excellence in Research Award;
• Excellence in Hospital Medicine for Non-Physicians;
• Award for Excellence in Teaching;
• Award for Outstanding Service in Hospital Medicine;
• Award for Clinical Excellence; and
• Excellence in Teamwork in Quality Improvement.

Last year, SHM received award nominations from a diverse group of hospitalists and looks forward to receiving even more this year. Each winner receives an all-expenses-paid trip to HM14 in Las Vegas, including complimentary meeting registration.

The deadline for applications for SHM’s five individual awards is Sept. 16. The deadline for the Excellence in Teamwork in Quality Improvement is Oct. 15. All SHM members are eligible, and nominees can be self-nominated.

For more information, visit www.hospital medicine.org/awards.

2. Bring the experts in reducing readmissions to your hospital: Apply now for Project BOOST.

There is still time to apply for SHM’s Project BOOST, which helps hospitals design discharge programs to reduce readmissions. SHM will accept applications for Project BOOST until the end of August.

Project BOOST is based on SHM’s award-winning mentored implementation model that brings individualized attention from national experts in reducing readmissions to hospitals across the country. Each Project BOOST site receives:

• A comprehensive intervention developed by a panel of nationally recognized experts based on the best available evidence.
• A comprehensive implementation guide that provides step-by-step instructions and project-management tools, such as the teachback training curriculum, to help interdisciplinary teams redesign workflow and plan, implement, and evaluate the intervention.
• Longitudinal technical assistance providing face-to-face training and a year of expert mentoring and coaching to implement BOOST interventions that build a culture that supports safe and complete transitions. The mentoring program provides a training DVD and curriculum for nurses and case managers on using the teachback process, as well as webinars that target the educational needs of other team members, including administrators, data analysts, physicians, nurses, and others.
• Collaboration that allows sites to communicate with and learn from each other via the BOOST community site and quarterly all-site teleconferences and webinars.
• The BOOST data center, an online resource that allows sites to store and benchmark data against control units and other sites and generates reports.

For more information, visit www.hospital medicine.org/boost.

3. Start Choosing Wisely today.

In 2014, as part of a grant from the ABIM Foundation, SHM will begin its first Choosing Wisely case-study competition to highlight hospitalists’ best practices within the popular campaign.

But in order to have a successful case study next year, some preparation is in order now. Developing goals, gathering a team, and, perhaps most important, developing benchmarking data on a project motivated by Choosing Wisely will all be important parts of a compelling case study.

To start brainstorming your project to implement Choosing Wisely recommendations at your hospital, visit www.hospitalmedicine.org/choosingwisely.

Brendon Shank is SHM’s associate vice president of communications.

Getting involved—and getting ahead—in hospital medicine has never been easier, with just some planning and preparation. Here are three ways to move your hospital—and your career—forward this month.

1. Add “award-winning” to your CV: SHM’s Awards of Excellence deadline is Sept. 16.

Although 2013’s award-winners are still fresh in hospitalists’ minds, now is the time to put together award applications for the 2014 Awards of Excellence.

Each year, SHM presents six different awards that recognize individuals and one award to a team that is transforming health care and revolutionizing patient care for hospitalized patients:

• Excellence in Research Award;
• Excellence in Hospital Medicine for Non-Physicians;
• Award for Excellence in Teaching;
• Award for Outstanding Service in Hospital Medicine;
• Award for Clinical Excellence; and
• Excellence in Teamwork in Quality Improvement.

Last year, SHM received award nominations from a diverse group of hospitalists and looks forward to receiving even more this year. Each winner receives an all-expenses-paid trip to HM14 in Las Vegas, including complimentary meeting registration.

The deadline for applications for SHM’s five individual awards is Sept. 16. The deadline for the Excellence in Teamwork in Quality Improvement is Oct. 15. All SHM members are eligible, and nominees can be self-nominated.

For more information, visit www.hospital medicine.org/awards.

2. Bring the experts in reducing readmissions to your hospital: Apply now for Project BOOST.

There is still time to apply for SHM’s Project BOOST, which helps hospitals design discharge programs to reduce readmissions. SHM will accept applications for Project BOOST until the end of August.

Project BOOST is based on SHM’s award-winning mentored implementation model that brings individualized attention from national experts in reducing readmissions to hospitals across the country. Each Project BOOST site receives:

• A comprehensive intervention developed by a panel of nationally recognized experts based on the best available evidence.
• A comprehensive implementation guide that provides step-by-step instructions and project-management tools, such as the teachback training curriculum, to help interdisciplinary teams redesign workflow and plan, implement, and evaluate the intervention.
• Longitudinal technical assistance providing face-to-face training and a year of expert mentoring and coaching to implement BOOST interventions that build a culture that supports safe and complete transitions. The mentoring program provides a training DVD and curriculum for nurses and case managers on using the teachback process, as well as webinars that target the educational needs of other team members, including administrators, data analysts, physicians, nurses, and others.
• Collaboration that allows sites to communicate with and learn from each other via the BOOST community site and quarterly all-site teleconferences and webinars.
• The BOOST data center, an online resource that allows sites to store and benchmark data against control units and other sites and generates reports.

For more information, visit www.hospital medicine.org/boost.

3. Start Choosing Wisely today.

In 2014, as part of a grant from the ABIM Foundation, SHM will begin its first Choosing Wisely case-study competition to highlight hospitalists’ best practices within the popular campaign.

But in order to have a successful case study next year, some preparation is in order now. Developing goals, gathering a team, and, perhaps most important, developing benchmarking data on a project motivated by Choosing Wisely will all be important parts of a compelling case study.

To start brainstorming your project to implement Choosing Wisely recommendations at your hospital, visit www.hospitalmedicine.org/choosingwisely.

Brendon Shank is SHM’s associate vice president of communications.

An electronic health record (EHR)—sometimes called an electronic medical record (EMR)—allows health-care providers to record patient information electronically instead of using paper records.¹ It also has the capability to perform various tasks that can assist in health-care delivery while maintaining standards of practice. The Health Information Technology for Economic and Clinical Health (HITECH) Act, enacted under the American Recovery and Reinvestment Act of 2009 (Recovery Act), established a provision for incentive payments for eligible professionals (EPs), critical-access hospitals (CAHs), and eligible hospitals if they can demonstrate meaningful use of certified EHR technology:²

• The use of a certified EHR in a meaningful manner (e.g. e-prescribing);
• The use of certified EHR technology for electronic exchange of health information to improve quality of health care; and
• The use of certified EHR technology to submit clinical quality and other measures.

Eligible professionals must satisfy 20 of 25 meaningful-use objectives (15 required core objectives and five objectives chosen from a list of 10 menu-set objectives).³ Eligible hospitals and CAHs must achieve 19 of 24 objectives (14 required core objectives and five objectives chosen from a list of 10 menu-set objectives).³

It seems that any program implementation with the potential to generate new or additional payment also has the potential to generate new or additional scrutiny of its application to ensure the generated payment is appropriate.⁵ Issues with EHR that recently have been highlighted include copy-and-paste, pulling notes forward, and upcoding based on volume instead of necessity.

Consider the Case

A patient is admitted to the hospital for pain, warmth, and swelling in the left lower extremity; r/o deep vein thrombosis (DVT) versus cellulitis. The patient’s history includes peripheral vascular disease (PVD), chronic renal insufficiency (CRI), and allergic rhinitis (AR). Testing confirms DVT, and the patient begins anticoagulation therapy. To achieve a therapeutic balance and prevent adverse reactions, the hospitalist orders INR monitoring.

On admission, the complexity of the patient’s condition may be considered high given the nature of the presenting problem.⁴ The hospitalist receives extensive credit for developing a care plan involving differential diagnoses with additional testing in anticipation of confirming a diagnosis. The patient’s presenting problem elevates the risk of morbidity/mortality, while the determined course of anticoagulation therapy places the patient at increased (i.e. “high”) risk for bleeding and requires intensive monitoring for toxicity. In this instance, 99223 may be warranted if the documentation requirements corresponding to this visit level have been satisfied.

As subsequent hospital days ensue, the complexity of the patient’s condition may not be as high. Even though the risk of anticoagulation remains high, the number of diagnoses and/or data ordered/reviewed may be less extensive than the initial encounter. Therefore, without any new or additional factors, the overall complexity of decision-making may be more appropriately categorized as moderate or low (e.g. 99232 or 99231, respectively).⁴

Do not fall victim to shortcuts that may falsely ease the workload of the overburdened physician. For example, the patient’s co-existing conditions of PVD, CRI, and AR likely were addressed during the initial encounter for DVT with inclusion in the plan of care. When using an electronic documentation system, it might be possible to copy the previously entered information from the initial encounter into the current encounter to save time. However, the previously entered information could include elements that do not need to be re-addressed during a subsequent encounter (e.g., AR) or yield information involving care for conditions that are being managed concurrently by another specialist (e.g. CRI being managed by the nephrologist).

Leaving the pasted information unaltered, without modification, can misrepresent the patient’s condition or the care provided by the hospitalist during the subsequent encounter.

Preventative Measures

Documentation should support the service provided on a given date, and the information included in the entry should reflect the content that was rendered and/or considered for assessment and management. Information that is pulled forward or copied and pasted from a previous entry should be modified to demonstrate updated content and nonoverlapping care with relevance for that date.

Do not use coding tools, or EHR “service calculators,” that override medical decision-making to determine the service level. Determining the service level for a particular CPT code category depends upon the key components of history, exam, and medical decision-making (MDM).⁴ For some code categories, each of the three key components must meet the documentation guidelines for the corresponding visit level (i.e. initial hospital care, initial observation care, and consultations). If all three components do not satisfy the requirements for a particular visit level, code selection is determined by the lowest component. For example, the physician must select 99221 when documenting a detailed history despite having also documented a comprehensive exam and high complexity decision-making. In other code categories, coding principles require that only two key components need to meet the documentation guidelines (i.e. subsequent hospital care and subsequent observation care) for code selection.

More specifically, code selection is determined by the second-lowest component. For example, the physician may appropriately select 99233 when only documenting a brief history after having also documented a detailed exam and high complexity decision-making. Based on this “two of three” stipulation, 99233 is acceptable. Service calculators that override MDM as one of the two supporting components in subsequent care services could generate 99233 for a service involving a detailed history and a detailed exam but only low complexity decision-making. Such coding practice can leave the hospitalist vulnerable to external inquiries involving medical necessity and upcoding. Despite this “two component” technicality with subsequent services (99231-99233 and 99224-99226), MDM always should be one of the two key components considered during subsequent visit level selection as it most clearly conveys the medical necessity of the encounter.

References

1. Centers for Medicare & Medicaid Services. The official web site for the Medicare and Medicaid electronic health records (EHR) incentive programs. Centers for Medicare & Medicaid Services website. Available at: http://www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/index.html?redirect=/ehrincentiveprograms/. Accessed March 10, 2013.
2. Centers for Medicare & Medicaid Services. Frequently asked questions (FAQs). Centers for Medicare & Medicaid Services website. Available at: http://www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/FAQ.html. Accessed March 10, 2013.
3. Centers for Medicare & Medicaid Services. Meaningful use. Centers for Medicare & Medicaid Services website. Available at: http://www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/Meaningful_Use.html. Accessed March 10, 2013.
4. Abraham M, Ahlman J, Anderson C, Boudreau A, Connelly J. Current Procedural Terminology 2012 Professional Edition. Chicago: American Medical Association Press; 2011:13-17.
5. U.S. Department of Health and Human Services. Office of Inspector General work plan fiscal year 2013. U.S. Department of Health and Human Services website. Available at: http://oig.hhs.gov/reports-and-publications/archives/workplan/2013/Work-Plan-2013.pdf. Accessed March 11, 2013.

An electronic health record (EHR)—sometimes called an electronic medical record (EMR)—allows health-care providers to record patient information electronically instead of using paper records.¹ It also has the capability to perform various tasks that can assist in health-care delivery while maintaining standards of practice. The Health Information Technology for Economic and Clinical Health (HITECH) Act, enacted under the American Recovery and Reinvestment Act of 2009 (Recovery Act), established a provision for incentive payments for eligible professionals (EPs), critical-access hospitals (CAHs), and eligible hospitals if they can demonstrate meaningful use of certified EHR technology:²

• The use of a certified EHR in a meaningful manner (e.g. e-prescribing);
• The use of certified EHR technology for electronic exchange of health information to improve quality of health care; and
• The use of certified EHR technology to submit clinical quality and other measures.

Eligible professionals must satisfy 20 of 25 meaningful-use objectives (15 required core objectives and five objectives chosen from a list of 10 menu-set objectives).³ Eligible hospitals and CAHs must achieve 19 of 24 objectives (14 required core objectives and five objectives chosen from a list of 10 menu-set objectives).³

It seems that any program implementation with the potential to generate new or additional payment also has the potential to generate new or additional scrutiny of its application to ensure the generated payment is appropriate.⁵ Issues with EHR that recently have been highlighted include copy-and-paste, pulling notes forward, and upcoding based on volume instead of necessity.

Consider the Case

A patient is admitted to the hospital for pain, warmth, and swelling in the left lower extremity; r/o deep vein thrombosis (DVT) versus cellulitis. The patient’s history includes peripheral vascular disease (PVD), chronic renal insufficiency (CRI), and allergic rhinitis (AR). Testing confirms DVT, and the patient begins anticoagulation therapy. To achieve a therapeutic balance and prevent adverse reactions, the hospitalist orders INR monitoring.

On admission, the complexity of the patient’s condition may be considered high given the nature of the presenting problem.⁴ The hospitalist receives extensive credit for developing a care plan involving differential diagnoses with additional testing in anticipation of confirming a diagnosis. The patient’s presenting problem elevates the risk of morbidity/mortality, while the determined course of anticoagulation therapy places the patient at increased (i.e. “high”) risk for bleeding and requires intensive monitoring for toxicity. In this instance, 99223 may be warranted if the documentation requirements corresponding to this visit level have been satisfied.

As subsequent hospital days ensue, the complexity of the patient’s condition may not be as high. Even though the risk of anticoagulation remains high, the number of diagnoses and/or data ordered/reviewed may be less extensive than the initial encounter. Therefore, without any new or additional factors, the overall complexity of decision-making may be more appropriately categorized as moderate or low (e.g. 99232 or 99231, respectively).⁴

Do not fall victim to shortcuts that may falsely ease the workload of the overburdened physician. For example, the patient’s co-existing conditions of PVD, CRI, and AR likely were addressed during the initial encounter for DVT with inclusion in the plan of care. When using an electronic documentation system, it might be possible to copy the previously entered information from the initial encounter into the current encounter to save time. However, the previously entered information could include elements that do not need to be re-addressed during a subsequent encounter (e.g., AR) or yield information involving care for conditions that are being managed concurrently by another specialist (e.g. CRI being managed by the nephrologist).

Leaving the pasted information unaltered, without modification, can misrepresent the patient’s condition or the care provided by the hospitalist during the subsequent encounter.

Preventative Measures

Documentation should support the service provided on a given date, and the information included in the entry should reflect the content that was rendered and/or considered for assessment and management. Information that is pulled forward or copied and pasted from a previous entry should be modified to demonstrate updated content and nonoverlapping care with relevance for that date.

Do not use coding tools, or EHR “service calculators,” that override medical decision-making to determine the service level. Determining the service level for a particular CPT code category depends upon the key components of history, exam, and medical decision-making (MDM).⁴ For some code categories, each of the three key components must meet the documentation guidelines for the corresponding visit level (i.e. initial hospital care, initial observation care, and consultations). If all three components do not satisfy the requirements for a particular visit level, code selection is determined by the lowest component. For example, the physician must select 99221 when documenting a detailed history despite having also documented a comprehensive exam and high complexity decision-making. In other code categories, coding principles require that only two key components need to meet the documentation guidelines (i.e. subsequent hospital care and subsequent observation care) for code selection.

More specifically, code selection is determined by the second-lowest component. For example, the physician may appropriately select 99233 when only documenting a brief history after having also documented a detailed exam and high complexity decision-making. Based on this “two of three” stipulation, 99233 is acceptable. Service calculators that override MDM as one of the two supporting components in subsequent care services could generate 99233 for a service involving a detailed history and a detailed exam but only low complexity decision-making. Such coding practice can leave the hospitalist vulnerable to external inquiries involving medical necessity and upcoding. Despite this “two component” technicality with subsequent services (99231-99233 and 99224-99226), MDM always should be one of the two key components considered during subsequent visit level selection as it most clearly conveys the medical necessity of the encounter.

References

1. Centers for Medicare & Medicaid Services. The official web site for the Medicare and Medicaid electronic health records (EHR) incentive programs. Centers for Medicare & Medicaid Services website. Available at: http://www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/index.html?redirect=/ehrincentiveprograms/. Accessed March 10, 2013.
2. Centers for Medicare & Medicaid Services. Frequently asked questions (FAQs). Centers for Medicare & Medicaid Services website. Available at: http://www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/FAQ.html. Accessed March 10, 2013.
3. Centers for Medicare & Medicaid Services. Meaningful use. Centers for Medicare & Medicaid Services website. Available at: http://www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/Meaningful_Use.html. Accessed March 10, 2013.
4. Abraham M, Ahlman J, Anderson C, Boudreau A, Connelly J. Current Procedural Terminology 2012 Professional Edition. Chicago: American Medical Association Press; 2011:13-17.
5. U.S. Department of Health and Human Services. Office of Inspector General work plan fiscal year 2013. U.S. Department of Health and Human Services website. Available at: http://oig.hhs.gov/reports-and-publications/archives/workplan/2013/Work-Plan-2013.pdf. Accessed March 11, 2013.

An electronic health record (EHR)—sometimes called an electronic medical record (EMR)—allows health-care providers to record patient information electronically instead of using paper records.¹ It also has the capability to perform various tasks that can assist in health-care delivery while maintaining standards of practice. The Health Information Technology for Economic and Clinical Health (HITECH) Act, enacted under the American Recovery and Reinvestment Act of 2009 (Recovery Act), established a provision for incentive payments for eligible professionals (EPs), critical-access hospitals (CAHs), and eligible hospitals if they can demonstrate meaningful use of certified EHR technology:²

• The use of a certified EHR in a meaningful manner (e.g. e-prescribing);
• The use of certified EHR technology for electronic exchange of health information to improve quality of health care; and
• The use of certified EHR technology to submit clinical quality and other measures.

Eligible professionals must satisfy 20 of 25 meaningful-use objectives (15 required core objectives and five objectives chosen from a list of 10 menu-set objectives).³ Eligible hospitals and CAHs must achieve 19 of 24 objectives (14 required core objectives and five objectives chosen from a list of 10 menu-set objectives).³

It seems that any program implementation with the potential to generate new or additional payment also has the potential to generate new or additional scrutiny of its application to ensure the generated payment is appropriate.⁵ Issues with EHR that recently have been highlighted include copy-and-paste, pulling notes forward, and upcoding based on volume instead of necessity.

Consider the Case

A patient is admitted to the hospital for pain, warmth, and swelling in the left lower extremity; r/o deep vein thrombosis (DVT) versus cellulitis. The patient’s history includes peripheral vascular disease (PVD), chronic renal insufficiency (CRI), and allergic rhinitis (AR). Testing confirms DVT, and the patient begins anticoagulation therapy. To achieve a therapeutic balance and prevent adverse reactions, the hospitalist orders INR monitoring.

On admission, the complexity of the patient’s condition may be considered high given the nature of the presenting problem.⁴ The hospitalist receives extensive credit for developing a care plan involving differential diagnoses with additional testing in anticipation of confirming a diagnosis. The patient’s presenting problem elevates the risk of morbidity/mortality, while the determined course of anticoagulation therapy places the patient at increased (i.e. “high”) risk for bleeding and requires intensive monitoring for toxicity. In this instance, 99223 may be warranted if the documentation requirements corresponding to this visit level have been satisfied.

As subsequent hospital days ensue, the complexity of the patient’s condition may not be as high. Even though the risk of anticoagulation remains high, the number of diagnoses and/or data ordered/reviewed may be less extensive than the initial encounter. Therefore, without any new or additional factors, the overall complexity of decision-making may be more appropriately categorized as moderate or low (e.g. 99232 or 99231, respectively).⁴

Do not fall victim to shortcuts that may falsely ease the workload of the overburdened physician. For example, the patient’s co-existing conditions of PVD, CRI, and AR likely were addressed during the initial encounter for DVT with inclusion in the plan of care. When using an electronic documentation system, it might be possible to copy the previously entered information from the initial encounter into the current encounter to save time. However, the previously entered information could include elements that do not need to be re-addressed during a subsequent encounter (e.g., AR) or yield information involving care for conditions that are being managed concurrently by another specialist (e.g. CRI being managed by the nephrologist).

Leaving the pasted information unaltered, without modification, can misrepresent the patient’s condition or the care provided by the hospitalist during the subsequent encounter.

Preventative Measures

Documentation should support the service provided on a given date, and the information included in the entry should reflect the content that was rendered and/or considered for assessment and management. Information that is pulled forward or copied and pasted from a previous entry should be modified to demonstrate updated content and nonoverlapping care with relevance for that date.

Do not use coding tools, or EHR “service calculators,” that override medical decision-making to determine the service level. Determining the service level for a particular CPT code category depends upon the key components of history, exam, and medical decision-making (MDM).⁴ For some code categories, each of the three key components must meet the documentation guidelines for the corresponding visit level (i.e. initial hospital care, initial observation care, and consultations). If all three components do not satisfy the requirements for a particular visit level, code selection is determined by the lowest component. For example, the physician must select 99221 when documenting a detailed history despite having also documented a comprehensive exam and high complexity decision-making. In other code categories, coding principles require that only two key components need to meet the documentation guidelines (i.e. subsequent hospital care and subsequent observation care) for code selection.

More specifically, code selection is determined by the second-lowest component. For example, the physician may appropriately select 99233 when only documenting a brief history after having also documented a detailed exam and high complexity decision-making. Based on this “two of three” stipulation, 99233 is acceptable. Service calculators that override MDM as one of the two supporting components in subsequent care services could generate 99233 for a service involving a detailed history and a detailed exam but only low complexity decision-making. Such coding practice can leave the hospitalist vulnerable to external inquiries involving medical necessity and upcoding. Despite this “two component” technicality with subsequent services (99231-99233 and 99224-99226), MDM always should be one of the two key components considered during subsequent visit level selection as it most clearly conveys the medical necessity of the encounter.

References

1. Centers for Medicare & Medicaid Services. The official web site for the Medicare and Medicaid electronic health records (EHR) incentive programs. Centers for Medicare & Medicaid Services website. Available at: http://www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/index.html?redirect=/ehrincentiveprograms/. Accessed March 10, 2013.
2. Centers for Medicare & Medicaid Services. Frequently asked questions (FAQs). Centers for Medicare & Medicaid Services website. Available at: http://www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/FAQ.html. Accessed March 10, 2013.
3. Centers for Medicare & Medicaid Services. Meaningful use. Centers for Medicare & Medicaid Services website. Available at: http://www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/Meaningful_Use.html. Accessed March 10, 2013.
4. Abraham M, Ahlman J, Anderson C, Boudreau A, Connelly J. Current Procedural Terminology 2012 Professional Edition. Chicago: American Medical Association Press; 2011:13-17.
5. U.S. Department of Health and Human Services. Office of Inspector General work plan fiscal year 2013. U.S. Department of Health and Human Services website. Available at: http://oig.hhs.gov/reports-and-publications/archives/workplan/2013/Work-Plan-2013.pdf. Accessed March 11, 2013.

With general agreement that health-care costs in the U.S. are unsustainable, the Centers for Medicare & Medicaid Services (CMS), through the Center for Medicare and Medicaid Innovation (CMMI), and the private sector are embarking on new approaches to cost containment. On the one hand, we have value-based purchasing (VBP), which rests on the existing fee-for-service system and aims for incremental change. On the other hand, we have accountable-care organizations (ACOs), which provide a global payment for a population of patients, and bundled-payment programs, which provide a single payment for an episode of care. These reimbursement models represent a fundamental change in how we pay for health care.

On a broad scale, ACOs may be further along in development than bundled-payment programs, even though pockets of bundling prototypes have existed for years. Examples include the Prometheus payment system, Geisinger’s ProvenCare, and CMS’ Acute Care Episode demonstration project, which bundled Part A (hospital) and Part B (doctors, others) payments for cardiac and orthopedic surgery procedures. Over the past two years, we have seen a dramatic uptick in bundling activity, including programs in a number of states (including Arkansas, California, and Massachusetts). Here at Baystate Health in Massachusetts, we kicked off a total-hip-replacement bundle with our subsidiary health plan in January 2011.

Perhaps most notably, bundled payments are part of the Affordable Care Act. The Bundled Payments for Care Improvement initiative, launched earlier this year by CMMI, is enrolling traditional Medicare patients in bundled-payment programs across the country at more than 400 health systems.

How Bundled Payments Work

Bundled-payment programs provide a single payment to hospitals, doctors, post-acute providers, and other providers (for home care, lab, medical equipment, etc.) for a defined episode of care. Most bundles encompass at least an acute hospital episode and physician payments for the episode; many include some period after hospitalization, covering rehabilitation at a facility or at home and doctors’ visits during recovery. Bundling goes beyond Medicare’s diagnosis-related group (DRG) payments, which reimburse hospitals for all elements of an inpatient hospital stay for a given diagnosis but do not include services performed by nonhospital providers.

How do the finances work in a bundled-payment program? A single price for an episode of care is determined based on historical performance, factoring in all the services one wishes to include in a bundle (e.g. hospital, doctor visits in hospital, home physical therapy, follow-up doctor visits, follow up X-ray and labs for a defined time period). If the hospital, doctors, and others in the bundle generate new efficiencies in care (e.g. due to better care coordination, less wasteful test ordering, or lower implant/device costs), the savings are then distributed to these providers. What if spending exceeds the predetermined price? In some instances, the health plan bears the financial risk; in other instances, the hospital, physicians, and other bundle providers must pay back the shortfall. Important to note is that all sharing of savings is contingent on attainment of or improvement in demonstrated quality-of-care measures relevant to the bundle. In the future, bundling will evolve from shared savings to a single prospective payment for a care episode.

For now, most bundles encompass surgical procedures, although CMMI is working with health systems on several medical bundles, including acute MI, COPD, and stroke. All of these bundles are initiated by an acute hospitalization. Other types of bundles exist, such as with chronic conditions or with post-acute care only. In Massachusetts, a pediatric asthma bundle is being implemented through Medicaid, covering that population for a year or longer. The aim is to redirect dollars that normally would pay for ED visits and inpatient care to pay for interventions that promote better control of the disease and prevent acute flare-ups that lead to hospital visits.

How Hospitalists Fit In

To date, there has been little discussion of how physicians other than the surgeons doing the procedure (most bundles are for surgeries) fit into the clinical or financial model underpinning the program. However, with most patients in surgical or medical bundles being discharged to home, we now recognize that primary-care physicians (PCPs) will be essential to the success of a bundle.

Similarly, with medically complex patients enrolling in surgical bundles, hospitalists will be essential to the pre- and perioperative care of these patients. Also, transitioning bundle patients to home or to a rehabilitation will benefit from the involvement of a hospitalist.

What You Can Do Today

Although this might seem abstract for hospitalists practicing in the here and now, there are compelling opportunities for hospitalists who get involved in bundled-payment programs. Here’s what I suggest:

Find out if your hospital or post-acute facility is participating in bundling by looking at a map of CMMI bundle programs here: http://innovation.cms.gov/initiatives/bundled-payments;

• Get a seat at the table working on the bundle; and
• Negotiate a portion of the bundle’s shared savings on the basis of 1) increased efficiency and quality resulting from hospitalist involvement and 2) hospitalist direct oversight of bundled patients in post-acute facilities (if you choose).

Post-acute care may be new for your hospitalist program. Bundling programs are an important new business case for hospitalists in this setting.

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

With general agreement that health-care costs in the U.S. are unsustainable, the Centers for Medicare & Medicaid Services (CMS), through the Center for Medicare and Medicaid Innovation (CMMI), and the private sector are embarking on new approaches to cost containment. On the one hand, we have value-based purchasing (VBP), which rests on the existing fee-for-service system and aims for incremental change. On the other hand, we have accountable-care organizations (ACOs), which provide a global payment for a population of patients, and bundled-payment programs, which provide a single payment for an episode of care. These reimbursement models represent a fundamental change in how we pay for health care.

On a broad scale, ACOs may be further along in development than bundled-payment programs, even though pockets of bundling prototypes have existed for years. Examples include the Prometheus payment system, Geisinger’s ProvenCare, and CMS’ Acute Care Episode demonstration project, which bundled Part A (hospital) and Part B (doctors, others) payments for cardiac and orthopedic surgery procedures. Over the past two years, we have seen a dramatic uptick in bundling activity, including programs in a number of states (including Arkansas, California, and Massachusetts). Here at Baystate Health in Massachusetts, we kicked off a total-hip-replacement bundle with our subsidiary health plan in January 2011.

Perhaps most notably, bundled payments are part of the Affordable Care Act. The Bundled Payments for Care Improvement initiative, launched earlier this year by CMMI, is enrolling traditional Medicare patients in bundled-payment programs across the country at more than 400 health systems.

How Bundled Payments Work

Bundled-payment programs provide a single payment to hospitals, doctors, post-acute providers, and other providers (for home care, lab, medical equipment, etc.) for a defined episode of care. Most bundles encompass at least an acute hospital episode and physician payments for the episode; many include some period after hospitalization, covering rehabilitation at a facility or at home and doctors’ visits during recovery. Bundling goes beyond Medicare’s diagnosis-related group (DRG) payments, which reimburse hospitals for all elements of an inpatient hospital stay for a given diagnosis but do not include services performed by nonhospital providers.

How do the finances work in a bundled-payment program? A single price for an episode of care is determined based on historical performance, factoring in all the services one wishes to include in a bundle (e.g. hospital, doctor visits in hospital, home physical therapy, follow-up doctor visits, follow up X-ray and labs for a defined time period). If the hospital, doctors, and others in the bundle generate new efficiencies in care (e.g. due to better care coordination, less wasteful test ordering, or lower implant/device costs), the savings are then distributed to these providers. What if spending exceeds the predetermined price? In some instances, the health plan bears the financial risk; in other instances, the hospital, physicians, and other bundle providers must pay back the shortfall. Important to note is that all sharing of savings is contingent on attainment of or improvement in demonstrated quality-of-care measures relevant to the bundle. In the future, bundling will evolve from shared savings to a single prospective payment for a care episode.

For now, most bundles encompass surgical procedures, although CMMI is working with health systems on several medical bundles, including acute MI, COPD, and stroke. All of these bundles are initiated by an acute hospitalization. Other types of bundles exist, such as with chronic conditions or with post-acute care only. In Massachusetts, a pediatric asthma bundle is being implemented through Medicaid, covering that population for a year or longer. The aim is to redirect dollars that normally would pay for ED visits and inpatient care to pay for interventions that promote better control of the disease and prevent acute flare-ups that lead to hospital visits.

How Hospitalists Fit In

To date, there has been little discussion of how physicians other than the surgeons doing the procedure (most bundles are for surgeries) fit into the clinical or financial model underpinning the program. However, with most patients in surgical or medical bundles being discharged to home, we now recognize that primary-care physicians (PCPs) will be essential to the success of a bundle.

Similarly, with medically complex patients enrolling in surgical bundles, hospitalists will be essential to the pre- and perioperative care of these patients. Also, transitioning bundle patients to home or to a rehabilitation will benefit from the involvement of a hospitalist.

What You Can Do Today

Although this might seem abstract for hospitalists practicing in the here and now, there are compelling opportunities for hospitalists who get involved in bundled-payment programs. Here’s what I suggest:

Find out if your hospital or post-acute facility is participating in bundling by looking at a map of CMMI bundle programs here: http://innovation.cms.gov/initiatives/bundled-payments;

• Get a seat at the table working on the bundle; and
• Negotiate a portion of the bundle’s shared savings on the basis of 1) increased efficiency and quality resulting from hospitalist involvement and 2) hospitalist direct oversight of bundled patients in post-acute facilities (if you choose).

Post-acute care may be new for your hospitalist program. Bundling programs are an important new business case for hospitalists in this setting.

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

With general agreement that health-care costs in the U.S. are unsustainable, the Centers for Medicare & Medicaid Services (CMS), through the Center for Medicare and Medicaid Innovation (CMMI), and the private sector are embarking on new approaches to cost containment. On the one hand, we have value-based purchasing (VBP), which rests on the existing fee-for-service system and aims for incremental change. On the other hand, we have accountable-care organizations (ACOs), which provide a global payment for a population of patients, and bundled-payment programs, which provide a single payment for an episode of care. These reimbursement models represent a fundamental change in how we pay for health care.

On a broad scale, ACOs may be further along in development than bundled-payment programs, even though pockets of bundling prototypes have existed for years. Examples include the Prometheus payment system, Geisinger’s ProvenCare, and CMS’ Acute Care Episode demonstration project, which bundled Part A (hospital) and Part B (doctors, others) payments for cardiac and orthopedic surgery procedures. Over the past two years, we have seen a dramatic uptick in bundling activity, including programs in a number of states (including Arkansas, California, and Massachusetts). Here at Baystate Health in Massachusetts, we kicked off a total-hip-replacement bundle with our subsidiary health plan in January 2011.

Perhaps most notably, bundled payments are part of the Affordable Care Act. The Bundled Payments for Care Improvement initiative, launched earlier this year by CMMI, is enrolling traditional Medicare patients in bundled-payment programs across the country at more than 400 health systems.

How Bundled Payments Work

Bundled-payment programs provide a single payment to hospitals, doctors, post-acute providers, and other providers (for home care, lab, medical equipment, etc.) for a defined episode of care. Most bundles encompass at least an acute hospital episode and physician payments for the episode; many include some period after hospitalization, covering rehabilitation at a facility or at home and doctors’ visits during recovery. Bundling goes beyond Medicare’s diagnosis-related group (DRG) payments, which reimburse hospitals for all elements of an inpatient hospital stay for a given diagnosis but do not include services performed by nonhospital providers.

How do the finances work in a bundled-payment program? A single price for an episode of care is determined based on historical performance, factoring in all the services one wishes to include in a bundle (e.g. hospital, doctor visits in hospital, home physical therapy, follow-up doctor visits, follow up X-ray and labs for a defined time period). If the hospital, doctors, and others in the bundle generate new efficiencies in care (e.g. due to better care coordination, less wasteful test ordering, or lower implant/device costs), the savings are then distributed to these providers. What if spending exceeds the predetermined price? In some instances, the health plan bears the financial risk; in other instances, the hospital, physicians, and other bundle providers must pay back the shortfall. Important to note is that all sharing of savings is contingent on attainment of or improvement in demonstrated quality-of-care measures relevant to the bundle. In the future, bundling will evolve from shared savings to a single prospective payment for a care episode.

For now, most bundles encompass surgical procedures, although CMMI is working with health systems on several medical bundles, including acute MI, COPD, and stroke. All of these bundles are initiated by an acute hospitalization. Other types of bundles exist, such as with chronic conditions or with post-acute care only. In Massachusetts, a pediatric asthma bundle is being implemented through Medicaid, covering that population for a year or longer. The aim is to redirect dollars that normally would pay for ED visits and inpatient care to pay for interventions that promote better control of the disease and prevent acute flare-ups that lead to hospital visits.

How Hospitalists Fit In

To date, there has been little discussion of how physicians other than the surgeons doing the procedure (most bundles are for surgeries) fit into the clinical or financial model underpinning the program. However, with most patients in surgical or medical bundles being discharged to home, we now recognize that primary-care physicians (PCPs) will be essential to the success of a bundle.

Similarly, with medically complex patients enrolling in surgical bundles, hospitalists will be essential to the pre- and perioperative care of these patients. Also, transitioning bundle patients to home or to a rehabilitation will benefit from the involvement of a hospitalist.

What You Can Do Today

Although this might seem abstract for hospitalists practicing in the here and now, there are compelling opportunities for hospitalists who get involved in bundled-payment programs. Here’s what I suggest:

Find out if your hospital or post-acute facility is participating in bundling by looking at a map of CMMI bundle programs here: http://innovation.cms.gov/initiatives/bundled-payments;

• Get a seat at the table working on the bundle; and
• Negotiate a portion of the bundle’s shared savings on the basis of 1) increased efficiency and quality resulting from hospitalist involvement and 2) hospitalist direct oversight of bundled patients in post-acute facilities (if you choose).

Post-acute care may be new for your hospitalist program. Bundling programs are an important new business case for hospitalists in this setting.

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

Although it was more than a decade ago (the last century, in fact), I remember it like it was yesterday. It was my first month as chief resident at Johns Hopkins Bayview Medical Center in Baltimore, our 335-bed hospital, with the ED chair and my chair of medicine in a heated argument. Very heated. There was no yelling; it was the kind of discussion where, even as a kid, you knew the severely stern voices meant that this was beyond the yelling stage.

“Medicine patients clog up my ED. Your docs take hours to arrive and then hours more on the workup,” the ED chair said. “They block and delay. Patients are suffering.”

“If your ED knew who to admit to which service, we wouldn’t have to spend hours figuring out where to admit them. We have a lot of work upstairs; we’re not sitting around waiting for the ED to call,” my chair replied.

They both were right, of course.

The ED chair had internal data that showed medicine did, in fact, cause delays, hours and hours of delays, every day. The department of medicine had concrete examples of less-than-ideal disposition decisions that, in hindsight, could have been done better (and sometimes a lot better).

This was the late 1990s, and all of us were just beginning to understand the adverse impact that ED boarding (admissions stuck in the ED) has on patients and our institution. Over the last decade, a number of studies have proved the fears we had in the 1990s right: From increased pain to higher mortality, admitted patients suffer when they need to be “upstairs” but are stuck in the ED.^1-4

Prior to this meeting of chairmen, we tried multiple “ED fixes” over the years. Like so many other institutions, we mandated medicine physician response times to the ED, drew policies, sent memos, and even gave the ED admitting privileges to medicine. None of them worked. Culture and cultural divide trumped policy every time, and the more than 100 house staff and attendings, both in the ED and in medicine, never made a change that positively impacted ED boarding during my entire three-year residency.

In hindsight, that’s not surprising. There has been a lot of study on ED flow and quality improvement (QI) more broadly.^5-8 To expect individuals to “do better” in a broken system is asking for failure. Asking hundreds of physicians to change behavior is an exercise in futility, especially when resources are limited and systems force “silo” behavior. Even drastic measures, such as expanding total ED capacity, don’t impact ED flow favorably. Institutions must find ways to open the “admission door.”

To the Rescue

Mirroring the rest of the country, in the late 1990s, a new group of doctors were being hired at my hospital. Ex-chief residents were staying on a year or two to run a new inpatient service. Although hospitalists were still new at the time, the idea to give them the “admission problem” took about a nanosecond.

Hospitalists across the country have become adept at tackling many institutional challenges, from readmissions (think Project BOOST) to teaching attendings from comanagement to neuromanagement. If it happens inside the walls of the hospital (and sometimes outside), hospitalists likely have played an important role in making it better somewhere.

Our hospitalists became a vital partner with the ED and within our own department of medicine, of course. We did the usual: seeing inpatients. But we also began experimenting with new and radical ways to get admitted patients out of the ED and upstairs as quickly as possible. We tried a number of admission systems, and many failed initially. We learned important lessons from the failures and continued to innovate.

Soon, hospitalists were successfully triaging admitted patients to all of general medicine using a combination of telephone and in-person triage based on the needs of the patient. This process had the triage hospitalist doing a limited ED assessment and then assigning the admission duties, often done after transfer upstairs to the best available medicine team, including the four house staff inpatient teams and hospitalist group. Later, this hospitalist admission process was expanded to all of medicine, using hospitalists to triage to the ICUs as well as specialty units in addition to general medicine. The hospital dedicated large amounts of money to allow a dedicated triage shift 24-7, staffed exclusively by hospitalists. A few years later, the hospitalists developed an in-house Web-based triage program, allowing accurate tracking of the more than 14,000 admissions annually.

The results have been better than anyone could have imagined 15 years ago. ED length of stay for admitted patients has continued to decrease dramatically—by hours, not minutes. Certain types of ambulance diversion (red alert in the state of Maryland) that were commonplace a decade ago, to the tune of 2,000-plus hours a year, virtually have been eliminated. Since ambulance diversion is known to harm patients and drive away business, this was a true win for patients as well as our hospital.⁹ Our ED volumes continued to grow, and patient-care indicators show the care provided by the current admissions process is at least as safe as before.

Hospitalists partnering with EDs to improve the admissions process are not isolated to Johns Hopkins Bayview. Many hospitalist leaders recognize that there are a variety of options for improving the care our patients get during the admissions process:

• Virginia Commonwealth University’s hospitalist group, led by Dr. Heather Masters, has worked tirelessly for years on a triage program.
• Dr. Melinda Kantsiper has done something similar at Howard County General Hospital in Maryland.
• Dr. MaryEllen Pfeiffer of Wellspan in York, Pa., is launching a triage program for admissions in the fall, and Dr. Christine Soong has focused on educating her house staff on the triage process at Mount Sinai in Toronto.

The Institute of Medicine reports that 91% of EDs are crowded routinely, an issue unlikely to go away on its own. I believe that hospitalists hold the key to unlocking the “admission door.” Hospitalists are critical partners in quality improvement, including ED flow, and can positively impact our patients, our institutions, and our specialty.

If that’s not enough to convince you, then let me tell you the true story of how the Hopkins Bayview ED physicians and hospitalists became close colleagues and the time I had Thanksgiving dinner at the ED chairman’s house. It was a lovely dinner, really.

Dr. Howell is president of SHM, chief of the division of hospital medicine at Johns Hopkins Bayview in Baltimore, and spends a significant part of his time and research on hospital operations. Email questions or comments to ehowell@jhmi.edu.

References

1. Chaflin DB, Trzeciak S, Likourezos A, Baumann BM, Dellinger RP. Impact of delayed transfer of critically ill patients from the ED to the ICU. Crit Care Med. 2007;35(6):1477-1483.
2. Duke G, Green J, Briedis J. Survival of critically ill patients is time-critical. Crit Care Resusc. 2004;6(4):261-267.
3. Scheulen JJ, Li G, Kelen GD. Impact of ambulance diversion policies in urban, suburban and rural areas of central Maryland. Acad Emerg Med. 2001;8(1):36-40.
4. Sikka R, Metha S, Kaucky C, Kulstad EB. ED crowding is associated with increased time to pneumonia treatment. Am J of Emerg Med. 2010; 28(7):809-812.
5. Holroyd BR, Bullard MJ, Latoszek K. Impact of a triage physician on emergency department overcrowding and throughput: a randomized trial. Acad Emerg Med. 2007;14(8)702-708.
6. Han JH, Zhou C, France DJ. The effect of emergency department expansion on emergency department overcrowding. Acad Emerg Med. 2007;14(4)338-343.
7. Howell E, Bessman E, Kravet S, Kolodner K, Marshall R, Wright S. Active bed management by hospitalists and emergency department throughput. Ann Intern Med. 2008;149(11):804-811.
8. Briones A, Markoff B, Kathuria N. A model of a hospitalist role in the care of admitted patients in the emergency department. J Hosp Med. 2010;5(6):360-364.
9. Nicholl J, West J, Goodacre S, Turner J. The relationship between distance to hospital and patient mortality in emergencies: an observational study. Emerg Med J. 2007; 24(9):665-668.

Although it was more than a decade ago (the last century, in fact), I remember it like it was yesterday. It was my first month as chief resident at Johns Hopkins Bayview Medical Center in Baltimore, our 335-bed hospital, with the ED chair and my chair of medicine in a heated argument. Very heated. There was no yelling; it was the kind of discussion where, even as a kid, you knew the severely stern voices meant that this was beyond the yelling stage.

“Medicine patients clog up my ED. Your docs take hours to arrive and then hours more on the workup,” the ED chair said. “They block and delay. Patients are suffering.”

“If your ED knew who to admit to which service, we wouldn’t have to spend hours figuring out where to admit them. We have a lot of work upstairs; we’re not sitting around waiting for the ED to call,” my chair replied.

They both were right, of course.

The ED chair had internal data that showed medicine did, in fact, cause delays, hours and hours of delays, every day. The department of medicine had concrete examples of less-than-ideal disposition decisions that, in hindsight, could have been done better (and sometimes a lot better).

This was the late 1990s, and all of us were just beginning to understand the adverse impact that ED boarding (admissions stuck in the ED) has on patients and our institution. Over the last decade, a number of studies have proved the fears we had in the 1990s right: From increased pain to higher mortality, admitted patients suffer when they need to be “upstairs” but are stuck in the ED.^1-4

Prior to this meeting of chairmen, we tried multiple “ED fixes” over the years. Like so many other institutions, we mandated medicine physician response times to the ED, drew policies, sent memos, and even gave the ED admitting privileges to medicine. None of them worked. Culture and cultural divide trumped policy every time, and the more than 100 house staff and attendings, both in the ED and in medicine, never made a change that positively impacted ED boarding during my entire three-year residency.

In hindsight, that’s not surprising. There has been a lot of study on ED flow and quality improvement (QI) more broadly.^5-8 To expect individuals to “do better” in a broken system is asking for failure. Asking hundreds of physicians to change behavior is an exercise in futility, especially when resources are limited and systems force “silo” behavior. Even drastic measures, such as expanding total ED capacity, don’t impact ED flow favorably. Institutions must find ways to open the “admission door.”

To the Rescue

Mirroring the rest of the country, in the late 1990s, a new group of doctors were being hired at my hospital. Ex-chief residents were staying on a year or two to run a new inpatient service. Although hospitalists were still new at the time, the idea to give them the “admission problem” took about a nanosecond.

Hospitalists across the country have become adept at tackling many institutional challenges, from readmissions (think Project BOOST) to teaching attendings from comanagement to neuromanagement. If it happens inside the walls of the hospital (and sometimes outside), hospitalists likely have played an important role in making it better somewhere.

Our hospitalists became a vital partner with the ED and within our own department of medicine, of course. We did the usual: seeing inpatients. But we also began experimenting with new and radical ways to get admitted patients out of the ED and upstairs as quickly as possible. We tried a number of admission systems, and many failed initially. We learned important lessons from the failures and continued to innovate.

Soon, hospitalists were successfully triaging admitted patients to all of general medicine using a combination of telephone and in-person triage based on the needs of the patient. This process had the triage hospitalist doing a limited ED assessment and then assigning the admission duties, often done after transfer upstairs to the best available medicine team, including the four house staff inpatient teams and hospitalist group. Later, this hospitalist admission process was expanded to all of medicine, using hospitalists to triage to the ICUs as well as specialty units in addition to general medicine. The hospital dedicated large amounts of money to allow a dedicated triage shift 24-7, staffed exclusively by hospitalists. A few years later, the hospitalists developed an in-house Web-based triage program, allowing accurate tracking of the more than 14,000 admissions annually.

The results have been better than anyone could have imagined 15 years ago. ED length of stay for admitted patients has continued to decrease dramatically—by hours, not minutes. Certain types of ambulance diversion (red alert in the state of Maryland) that were commonplace a decade ago, to the tune of 2,000-plus hours a year, virtually have been eliminated. Since ambulance diversion is known to harm patients and drive away business, this was a true win for patients as well as our hospital.⁹ Our ED volumes continued to grow, and patient-care indicators show the care provided by the current admissions process is at least as safe as before.

Hospitalists partnering with EDs to improve the admissions process are not isolated to Johns Hopkins Bayview. Many hospitalist leaders recognize that there are a variety of options for improving the care our patients get during the admissions process:

• Virginia Commonwealth University’s hospitalist group, led by Dr. Heather Masters, has worked tirelessly for years on a triage program.
• Dr. Melinda Kantsiper has done something similar at Howard County General Hospital in Maryland.
• Dr. MaryEllen Pfeiffer of Wellspan in York, Pa., is launching a triage program for admissions in the fall, and Dr. Christine Soong has focused on educating her house staff on the triage process at Mount Sinai in Toronto.

The Institute of Medicine reports that 91% of EDs are crowded routinely, an issue unlikely to go away on its own. I believe that hospitalists hold the key to unlocking the “admission door.” Hospitalists are critical partners in quality improvement, including ED flow, and can positively impact our patients, our institutions, and our specialty.

If that’s not enough to convince you, then let me tell you the true story of how the Hopkins Bayview ED physicians and hospitalists became close colleagues and the time I had Thanksgiving dinner at the ED chairman’s house. It was a lovely dinner, really.

Dr. Howell is president of SHM, chief of the division of hospital medicine at Johns Hopkins Bayview in Baltimore, and spends a significant part of his time and research on hospital operations. Email questions or comments to ehowell@jhmi.edu.

References

1. Chaflin DB, Trzeciak S, Likourezos A, Baumann BM, Dellinger RP. Impact of delayed transfer of critically ill patients from the ED to the ICU. Crit Care Med. 2007;35(6):1477-1483.
2. Duke G, Green J, Briedis J. Survival of critically ill patients is time-critical. Crit Care Resusc. 2004;6(4):261-267.
3. Scheulen JJ, Li G, Kelen GD. Impact of ambulance diversion policies in urban, suburban and rural areas of central Maryland. Acad Emerg Med. 2001;8(1):36-40.
4. Sikka R, Metha S, Kaucky C, Kulstad EB. ED crowding is associated with increased time to pneumonia treatment. Am J of Emerg Med. 2010; 28(7):809-812.
5. Holroyd BR, Bullard MJ, Latoszek K. Impact of a triage physician on emergency department overcrowding and throughput: a randomized trial. Acad Emerg Med. 2007;14(8)702-708.
6. Han JH, Zhou C, France DJ. The effect of emergency department expansion on emergency department overcrowding. Acad Emerg Med. 2007;14(4)338-343.
7. Howell E, Bessman E, Kravet S, Kolodner K, Marshall R, Wright S. Active bed management by hospitalists and emergency department throughput. Ann Intern Med. 2008;149(11):804-811.
8. Briones A, Markoff B, Kathuria N. A model of a hospitalist role in the care of admitted patients in the emergency department. J Hosp Med. 2010;5(6):360-364.
9. Nicholl J, West J, Goodacre S, Turner J. The relationship between distance to hospital and patient mortality in emergencies: an observational study. Emerg Med J. 2007; 24(9):665-668.

Although it was more than a decade ago (the last century, in fact), I remember it like it was yesterday. It was my first month as chief resident at Johns Hopkins Bayview Medical Center in Baltimore, our 335-bed hospital, with the ED chair and my chair of medicine in a heated argument. Very heated. There was no yelling; it was the kind of discussion where, even as a kid, you knew the severely stern voices meant that this was beyond the yelling stage.

“Medicine patients clog up my ED. Your docs take hours to arrive and then hours more on the workup,” the ED chair said. “They block and delay. Patients are suffering.”

“If your ED knew who to admit to which service, we wouldn’t have to spend hours figuring out where to admit them. We have a lot of work upstairs; we’re not sitting around waiting for the ED to call,” my chair replied.

They both were right, of course.

The ED chair had internal data that showed medicine did, in fact, cause delays, hours and hours of delays, every day. The department of medicine had concrete examples of less-than-ideal disposition decisions that, in hindsight, could have been done better (and sometimes a lot better).

This was the late 1990s, and all of us were just beginning to understand the adverse impact that ED boarding (admissions stuck in the ED) has on patients and our institution. Over the last decade, a number of studies have proved the fears we had in the 1990s right: From increased pain to higher mortality, admitted patients suffer when they need to be “upstairs” but are stuck in the ED.^1-4

Prior to this meeting of chairmen, we tried multiple “ED fixes” over the years. Like so many other institutions, we mandated medicine physician response times to the ED, drew policies, sent memos, and even gave the ED admitting privileges to medicine. None of them worked. Culture and cultural divide trumped policy every time, and the more than 100 house staff and attendings, both in the ED and in medicine, never made a change that positively impacted ED boarding during my entire three-year residency.

In hindsight, that’s not surprising. There has been a lot of study on ED flow and quality improvement (QI) more broadly.^5-8 To expect individuals to “do better” in a broken system is asking for failure. Asking hundreds of physicians to change behavior is an exercise in futility, especially when resources are limited and systems force “silo” behavior. Even drastic measures, such as expanding total ED capacity, don’t impact ED flow favorably. Institutions must find ways to open the “admission door.”

To the Rescue

Mirroring the rest of the country, in the late 1990s, a new group of doctors were being hired at my hospital. Ex-chief residents were staying on a year or two to run a new inpatient service. Although hospitalists were still new at the time, the idea to give them the “admission problem” took about a nanosecond.

Hospitalists across the country have become adept at tackling many institutional challenges, from readmissions (think Project BOOST) to teaching attendings from comanagement to neuromanagement. If it happens inside the walls of the hospital (and sometimes outside), hospitalists likely have played an important role in making it better somewhere.

Our hospitalists became a vital partner with the ED and within our own department of medicine, of course. We did the usual: seeing inpatients. But we also began experimenting with new and radical ways to get admitted patients out of the ED and upstairs as quickly as possible. We tried a number of admission systems, and many failed initially. We learned important lessons from the failures and continued to innovate.

Soon, hospitalists were successfully triaging admitted patients to all of general medicine using a combination of telephone and in-person triage based on the needs of the patient. This process had the triage hospitalist doing a limited ED assessment and then assigning the admission duties, often done after transfer upstairs to the best available medicine team, including the four house staff inpatient teams and hospitalist group. Later, this hospitalist admission process was expanded to all of medicine, using hospitalists to triage to the ICUs as well as specialty units in addition to general medicine. The hospital dedicated large amounts of money to allow a dedicated triage shift 24-7, staffed exclusively by hospitalists. A few years later, the hospitalists developed an in-house Web-based triage program, allowing accurate tracking of the more than 14,000 admissions annually.

The results have been better than anyone could have imagined 15 years ago. ED length of stay for admitted patients has continued to decrease dramatically—by hours, not minutes. Certain types of ambulance diversion (red alert in the state of Maryland) that were commonplace a decade ago, to the tune of 2,000-plus hours a year, virtually have been eliminated. Since ambulance diversion is known to harm patients and drive away business, this was a true win for patients as well as our hospital.⁹ Our ED volumes continued to grow, and patient-care indicators show the care provided by the current admissions process is at least as safe as before.

Hospitalists partnering with EDs to improve the admissions process are not isolated to Johns Hopkins Bayview. Many hospitalist leaders recognize that there are a variety of options for improving the care our patients get during the admissions process:

• Virginia Commonwealth University’s hospitalist group, led by Dr. Heather Masters, has worked tirelessly for years on a triage program.
• Dr. Melinda Kantsiper has done something similar at Howard County General Hospital in Maryland.
• Dr. MaryEllen Pfeiffer of Wellspan in York, Pa., is launching a triage program for admissions in the fall, and Dr. Christine Soong has focused on educating her house staff on the triage process at Mount Sinai in Toronto.

The Institute of Medicine reports that 91% of EDs are crowded routinely, an issue unlikely to go away on its own. I believe that hospitalists hold the key to unlocking the “admission door.” Hospitalists are critical partners in quality improvement, including ED flow, and can positively impact our patients, our institutions, and our specialty.

If that’s not enough to convince you, then let me tell you the true story of how the Hopkins Bayview ED physicians and hospitalists became close colleagues and the time I had Thanksgiving dinner at the ED chairman’s house. It was a lovely dinner, really.

Dr. Howell is president of SHM, chief of the division of hospital medicine at Johns Hopkins Bayview in Baltimore, and spends a significant part of his time and research on hospital operations. Email questions or comments to ehowell@jhmi.edu.

References

1. Chaflin DB, Trzeciak S, Likourezos A, Baumann BM, Dellinger RP. Impact of delayed transfer of critically ill patients from the ED to the ICU. Crit Care Med. 2007;35(6):1477-1483.
2. Duke G, Green J, Briedis J. Survival of critically ill patients is time-critical. Crit Care Resusc. 2004;6(4):261-267.
3. Scheulen JJ, Li G, Kelen GD. Impact of ambulance diversion policies in urban, suburban and rural areas of central Maryland. Acad Emerg Med. 2001;8(1):36-40.
4. Sikka R, Metha S, Kaucky C, Kulstad EB. ED crowding is associated with increased time to pneumonia treatment. Am J of Emerg Med. 2010; 28(7):809-812.
5. Holroyd BR, Bullard MJ, Latoszek K. Impact of a triage physician on emergency department overcrowding and throughput: a randomized trial. Acad Emerg Med. 2007;14(8)702-708.
6. Han JH, Zhou C, France DJ. The effect of emergency department expansion on emergency department overcrowding. Acad Emerg Med. 2007;14(4)338-343.
7. Howell E, Bessman E, Kravet S, Kolodner K, Marshall R, Wright S. Active bed management by hospitalists and emergency department throughput. Ann Intern Med. 2008;149(11):804-811.
8. Briones A, Markoff B, Kathuria N. A model of a hospitalist role in the care of admitted patients in the emergency department. J Hosp Med. 2010;5(6):360-364.
9. Nicholl J, West J, Goodacre S, Turner J. The relationship between distance to hospital and patient mortality in emergencies: an observational study. Emerg Med J. 2007; 24(9):665-668.

Many health-care-reform initiatives are so new that few data are available to assess whether they are working as intended. The Centers for Medicare & Medicaid Services (CMS), however, has touted the early numbers from its Hospital Readmission Reduction Program to suggest that the policy is making a difference in curbing bounce-backs. The overall impact, however, might be decidedly more nuanced and provides a telling example of the challenges that such programs can present to hospitalists and other health-care providers.

At a Senate Finance Committee Hearing in February, Jonathan Blum, deputy administrator and director for the Center of Medicare at CMS, released data suggesting that 30-day readmission rates for all causes dropped to 17.8% of hospitalizations near the end of 2012 after remaining at roughly 19% in each of the five previous years. The difference translates into 70,000 fewer readmissions annually.

During the first round of penalties, CMS dinged 2,213 hospitals for an estimated $280 million, or an average of about $126,500 per hospital, for excessive readmissions linked to heart attack, heart failure, and pneumonia care. Blum made the case that the penalties—or the threat thereof—are helping to improve rates.

Those arguing that the policy could disproportionately impact institutions caring for more vulnerable, high-risk patients also found new support in a recent New England Journal of Medicine perspective suggesting that academic medical centers and safety-net hospitals were more likely to be penalized.¹ Among their suggestions, the perspective’s co-authors, from Harvard’s School of Public Health, suggested that the policy take patient socioeconomic status into account to provide a fairer basis of comparison.

A second recent study suggested that even the reduced readmission rates might not be telling the whole story. An analysis of patients released in 2010 from safety-net hospital Boston Medical Center showed that nearly 1 in 4 returned to the ED within a month of discharge.2 But more than half of those patients weren’t readmitted as inpatients, meaning that they wouldn’t show up under Medicare’s readmissions statistics.

Along with the mixed early reviews of EHR rollouts and the HCAHPS portion of the Hospital Value-Based Purchasing program, it’s another reminder that CMS metrics and incentives might not always add up as envisioned. In the near future, it seems, hospitals and health-care providers might have to contend with some imperfect numbers. TH

Bryn Nelson is a freelance medical writer in Seattle.

References

1. Joynt KE, Jha AK. Thirty-day readmissions–truth and consequences. N Engl J Med. 2012;366:1366-1369.

2. Rising KL, White LF, Fernandez WG, Boutwell, AE. Emergency department visits after hospital discharge: a missing part of the equation. Ann Emerg Med. 2013; in press.

Many health-care-reform initiatives are so new that few data are available to assess whether they are working as intended. The Centers for Medicare & Medicaid Services (CMS), however, has touted the early numbers from its Hospital Readmission Reduction Program to suggest that the policy is making a difference in curbing bounce-backs. The overall impact, however, might be decidedly more nuanced and provides a telling example of the challenges that such programs can present to hospitalists and other health-care providers.

At a Senate Finance Committee Hearing in February, Jonathan Blum, deputy administrator and director for the Center of Medicare at CMS, released data suggesting that 30-day readmission rates for all causes dropped to 17.8% of hospitalizations near the end of 2012 after remaining at roughly 19% in each of the five previous years. The difference translates into 70,000 fewer readmissions annually.

During the first round of penalties, CMS dinged 2,213 hospitals for an estimated $280 million, or an average of about $126,500 per hospital, for excessive readmissions linked to heart attack, heart failure, and pneumonia care. Blum made the case that the penalties—or the threat thereof—are helping to improve rates.

Those arguing that the policy could disproportionately impact institutions caring for more vulnerable, high-risk patients also found new support in a recent New England Journal of Medicine perspective suggesting that academic medical centers and safety-net hospitals were more likely to be penalized.¹ Among their suggestions, the perspective’s co-authors, from Harvard’s School of Public Health, suggested that the policy take patient socioeconomic status into account to provide a fairer basis of comparison.

A second recent study suggested that even the reduced readmission rates might not be telling the whole story. An analysis of patients released in 2010 from safety-net hospital Boston Medical Center showed that nearly 1 in 4 returned to the ED within a month of discharge.2 But more than half of those patients weren’t readmitted as inpatients, meaning that they wouldn’t show up under Medicare’s readmissions statistics.

Along with the mixed early reviews of EHR rollouts and the HCAHPS portion of the Hospital Value-Based Purchasing program, it’s another reminder that CMS metrics and incentives might not always add up as envisioned. In the near future, it seems, hospitals and health-care providers might have to contend with some imperfect numbers. TH

Bryn Nelson is a freelance medical writer in Seattle.

References

1. Joynt KE, Jha AK. Thirty-day readmissions–truth and consequences. N Engl J Med. 2012;366:1366-1369.

2. Rising KL, White LF, Fernandez WG, Boutwell, AE. Emergency department visits after hospital discharge: a missing part of the equation. Ann Emerg Med. 2013; in press.

Many health-care-reform initiatives are so new that few data are available to assess whether they are working as intended. The Centers for Medicare & Medicaid Services (CMS), however, has touted the early numbers from its Hospital Readmission Reduction Program to suggest that the policy is making a difference in curbing bounce-backs. The overall impact, however, might be decidedly more nuanced and provides a telling example of the challenges that such programs can present to hospitalists and other health-care providers.

At a Senate Finance Committee Hearing in February, Jonathan Blum, deputy administrator and director for the Center of Medicare at CMS, released data suggesting that 30-day readmission rates for all causes dropped to 17.8% of hospitalizations near the end of 2012 after remaining at roughly 19% in each of the five previous years. The difference translates into 70,000 fewer readmissions annually.

During the first round of penalties, CMS dinged 2,213 hospitals for an estimated $280 million, or an average of about $126,500 per hospital, for excessive readmissions linked to heart attack, heart failure, and pneumonia care. Blum made the case that the penalties—or the threat thereof—are helping to improve rates.

Those arguing that the policy could disproportionately impact institutions caring for more vulnerable, high-risk patients also found new support in a recent New England Journal of Medicine perspective suggesting that academic medical centers and safety-net hospitals were more likely to be penalized.¹ Among their suggestions, the perspective’s co-authors, from Harvard’s School of Public Health, suggested that the policy take patient socioeconomic status into account to provide a fairer basis of comparison.

A second recent study suggested that even the reduced readmission rates might not be telling the whole story. An analysis of patients released in 2010 from safety-net hospital Boston Medical Center showed that nearly 1 in 4 returned to the ED within a month of discharge.2 But more than half of those patients weren’t readmitted as inpatients, meaning that they wouldn’t show up under Medicare’s readmissions statistics.

Along with the mixed early reviews of EHR rollouts and the HCAHPS portion of the Hospital Value-Based Purchasing program, it’s another reminder that CMS metrics and incentives might not always add up as envisioned. In the near future, it seems, hospitals and health-care providers might have to contend with some imperfect numbers. TH

Bryn Nelson is a freelance medical writer in Seattle.

References

1. Joynt KE, Jha AK. Thirty-day readmissions–truth and consequences. N Engl J Med. 2012;366:1366-1369.

2. Rising KL, White LF, Fernandez WG, Boutwell, AE. Emergency department visits after hospital discharge: a missing part of the equation. Ann Emerg Med. 2013; in press.

Dr. Tierza

VBP. ACO. HAC. EHR. Suddenly, Medicare-derived acronyms are everywhere, and many of them are attached to a growing set of programs aimed at boosting efficiency and quality. Some are optional; others are mandatory. Some have carrots as incentives; others have sticks. Some seem well-designed; others seemingly work at cross-purposes.

Love or hate these initiatives, the combined time, money, and resources needed to address all of them could put hospitals and hospitalists under considerable duress.

“It can either prove or dismantle the whole hospitalist movement,” says Brian Hazen, MD, medical director of the hospitalist division at Inova Fairfax Hospital in Falls Church, Va. “Hospitals expect us to be agile and adapt to the pressures to keep them alive. If we cannot adapt and provide that, then why give us a job?”

Whether or not the focus is on lowering readmission rates, decreasing the incidence of hospital-acquired conditions, or improving efficiencies, Dr. Hazen tends to lump most of the sticks and carrots together. “I throw them all into one basket because for the most part, they’re all reflective of good care,” he says.

The basket is growing, however, and the bundle of sticks could deliver a financial beating to the unwary.

It’s possible that some low-margin hospitals that are facing big penalties could actually have their solvency threatened. If hospitals that are a vital part of the community are threatened with insolvency because of these programs, we may need to take a second look at how we structure the penalties.

—Win Whitcomb, MD, MHM, medical director of healthcare quality, Baystate Medical Center, Springfield, Mass.; SHM Performance and Measurement Reporting Committee member; co-founder and past president of SHM; author of The Hospitalist’s “On the Horizon” column

At What Cost?

For the lowest-performing hospitals, the top readmission penalties will grow to 2% of Medicare reimbursements in fiscal year 2014 and 3% in 2015. Meanwhile, CMS’ Hospital-Acquired Conditions (HAC) program will begin assessing a 1% penalty on the worst performing hospitals in 2015, and the amount withheld under the Hospital Value-Based Purchasing (VBP) program will reach 2% in 2017 (top-performing hospitals can recoup the withhold and more, depending on performance). By that year, the three programs alone could result in a 6% loss of reimbursements.

Win Whitcomb, MD, MHM, medical director of healthcare quality at Baystate Medical Center in Springfield, Mass., and a member of SHM’s Performance and Measurement Reporting Committee, estimates that by 2017, the total at-risk payments could reach about $10 million for a 650-bed academic medical center. The tally for a 90-bed community hospital, he estimates, might run a bit less than $1 million. Although the combined penalty is probably enough to get the attention of most hospitals, very few institutions are likely to be dinged for the entire amount.

Nevertheless, the cumulative loss of reimbursements could be a tipping point for hospitals already in dire straits. “It’s possible that some low-margin hospitals that are facing big penalties could actually have their solvency threatened,” Dr. Whitcomb says. “If hospitals that are a vital part of the community are threatened with insolvency because of these programs, we may need to take a second look at how we structure the penalties.”

The necessary investment in infrastructure, he says, could prove to be a far bigger concern—at least initially.

“What is more expensive is just putting out the effort to do the work to improve and perform well under these programs,” says Dr. Whitcomb, co-founder and past president of SHM and author of The Hospitalist’s “On the Horizon” column. “That’s a big unreported hidden expense of all of these programs.”

With the fairly rapid implementation of multiple measures mandated by the Accountable Care Act, Medicare may be disinclined to dramatically ramp up the programs in play until it has a better sense of what’s working well. Then again, analysts like Laurence Baker, PhD, professor of health research and policy at Stanford University, say it’s doubtful that the agency will scale back its efforts given the widely held perception that plenty of waste can yet be wrung from the system.

“If I was a hospitalist, I would expect more of this coming,” Dr. Baker says.

Of course, rolling out new incentive programs is always a difficult balancing act in which the creators must be careful not to focus too much attention on the wrong measure or create unintended disincentives.

“That’s one of the great challenges: making a program that’s going to be successful when we know that people will do what’s measured and maybe even, without thinking about it, do less of what’s not measured. So we have to be careful about that,” Dr. Baker says.

We’re getting a lot of traction to get physicians to work together to improve care, where before there wasn’t an incentive to do this. So we see this as a good thing, and I think it has potential to reduce expenses in high-cost areas.

—Monty Duke, MD, chief physician executive, Lancaster General Hospital, Lancaster, Pa.

Out of Alignment

Beyond cost and infrastructure, the proliferation of new measures also presents challenges for alignment. Monty Duke, MD, chief physician executive at Lancaster General Hospital in Lancaster, Pa., says the targets are changing so rapidly that tension can arise between hospitals and hospitalists in aligning expectations about priorities and considering how much time, resources, and staffing will be required to address them.

Likewise, the impetus to install new infrastructure can sometimes have unintended consequences, as Dr. Duke has seen firsthand with his hospital’s recent implementation of electronic health records (EHRs).

“In many ways, the electronic health record has changed the dynamic of rounding between physicians and nurses, and it’s really challenging communication,” he says. How so? “Because people spend more time communicating with the computer than they do talking to one another,” he says. The discordant communication, in turn, can conspire against a clear plan of care and overall goals as well as challenge efforts that emphasize a team-based approach.

Despite federal meaningful-use incentives, a recent survey also suggested that a majority of healthcare practices still may not achieve a positive return on investment for EHRs unless they can figure out how to use the systems to increase revenue.¹ A minority of providers have succeeded by seeing more patients every day or by improving their billing process so the codes are more accurate and fewer claims are rejected.

Similarly, hospitalists like Dr. Hazen contend that some patient-satisfaction measures in the HCAHPS section of the VBP program can work against good clinical care. “That one drives me crazy because we’re not waiters or waitresses in a five-star restaurant,” he says. “Health care is complicated; it’s not like sending back a bowl of cold soup the way you can in a restaurant.”

Increasing satisfaction by keeping patients in the hospital longer than warranted or leaving in a Foley catheter for patient convenience, for example, can negatively impact actual outcomes.

“Physicians and nurses get put in this catch-22 where we have to choose between patient satisfaction and by-the-book clinical care,” Dr. Hazen says. “And our job is to try to mitigate that, but you’re kind of damned if you do and damned if you don’t.”

A new study, on the other hand, suggests that HCAHPS scores reflecting lower staff responsiveness are associated with an increased risk of HACs like central line–associated bloodstream infections and that lower scores may be a symptom of hospitals “with a multitude of problems.”²

A 10-Step Program

As existing rules and metrics are revised, new ones added, and others merged or discontinued, hospitalists are likely to encounter more hiccups and headaches. So what’s the solution? Beyond establishing good personal habits like hand-washing when entering and leaving a patient’s room, hospitalist leaders and healthcare analysts point to 10 strategies that may help keep HM providers from getting squeezed by all the demands:

1) Keep everyone on the same page. Because hospitals and health systems often take a subset of CMS core measures and make them strategic priorities, Dr. Whitcomb says hospitalists must thoroughly understand their own institutions’ internal system-level quality and safety goals. He stresses the need for hospitalists to develop and maintain close working connections with their organization’s safety- and quality-improvement (QI) teams “to understand exactly what the rules of the road are.”

Dr. Whitcomb says hospitals should compensate hospitalists for time spent working with these teams on feasible solutions. Hospitalist representatives can then champion specific safety or quality issues and keep them foremost in the minds of their colleagues. “I’m a big believer in paying people to do that work,” he says.

2) Take a wider view. It’s clear that most providers wouldn’t have chosen some of the performance indicators that Medicare and other third-party payors are asking them to meet, and many physicians have been more focused on outcomes than on clinical measures. Like it or not, however, thriving in the new era of health care means accepting more benchmarks. “We’ve had to broaden our scope to say, ‘OK, these other things matter, too,’” Dr. Duke says.

3) Use visual cues. Hospitalists can’t rely on memory to keep track of the dozens of measures for which they are being held accountable. “Every hospitalist program should have a dashboard of priority measures that they’re paying attention to and that’s out in front of them on a regular basis,” Dr. Whitcomb says. “It could be presented to them at monthly meetings, or it could be in a prominent place in their office, but there needs to be a set of cues.”

4) Use bonuses for alignment. Dr. Hazen says hospitals also may find success in using bonuses as a positive reinforcement for well-aligned care. Inova Fairfax’s bonuses include a clinical component that aligns with many of CMS’s core measures, and the financial incentives ensure that discharge summaries are completed and distributed in a timely manner.

5) Emphasize a team approach. Espousing a multidisciplinary approach to care can give patients the confidence that all providers are on the same page, thereby aiding patient-satisfaction scores and easing throughput. And as Dr. Hazen points out, avoiding a silo mentality can pay dividends for improving patient safety.

Dr. Tierza

6) Offer the right information. Tierza Stephan, MD, regional hospitalist medical director for Allina Health in Minneapolis and the incoming chair of SHM’s Practice Analysis Committee, says Allina has worked hard to ensure that hospitalists complete their discharge summaries within 24 hours of a patient’s release from the hospital. Beyond timeliness, the health system is emphasizing content that informs without overwhelming the patient, caregiver, or follow-up provider with unnecessary details.

The discharge summary, for example, includes a section called “Recommendations for the Outpatient Provider,” which provides a checklist of sorts so those providers don’t miss the forest for the trees. The same is true for patients. “The hospital is probably not the best place to be educating patients, so we really focus more on patient instruction at discharge and then timely follow-up,” Dr. Stephan says.

In addition to allowing better care coordination between inpatient and outpatient providers, she says, “it cuts across patient experience and readmissions, and it helps patients to be engaged because they have very clear, easy-to-read information.” Paying attention to such details may have outsized impacts: In a recent study, researchers found that patients who are actively engaged in their own health care are significantly less costly to treat, on average.³

7) Follow through after discharge. Inova Fairfax is setting up an outpatient follow-up clinic as a safety net for patients at the highest risk of being readmitted. Many of these target patients are uninsured or underinsured and battling complex medical problems like heart failure or pneumonia. Establishing a physical location for follow-ups and direct communication with primary-care providers, the hospital hopes, might reduce noncompliance among these outpatients and thereby curtail subsequent readmissions.

8) Optimize EHR. When optimized, experts say, electronic medical records can help hospitals ensure that their providers are following core measures and preventing hospital-acquired conditions while leaving channels of communication open and keeping revenue streams flowing.

“Luckily, we just switched to electronic medical records so we can monitor who has a Foley catheter in, who does or doesn’t have DVT prophylaxis, because even really good docs sometimes make these knucklehead mistakes every once in a while,” Dr. Hazen says. “So we try to use systems to back ourselves up. But for the most part, there’s just no substitute for having good docs do the right thing and documenting that.”

9) Bundle up. Although bundled payments represent yet another CMS initiative, Dr. Duke says the model has the potential to reduce waste, standardize care, and monitor outcomes. Lancaster General has been working on the approach for the past few years, with an initial focus on cardiovascular medicine, orthopedics, and neurosurgery. “We’re getting a lot of traction to get physicians to work together to improve care, where before there wasn’t an incentive to do this,” Dr. Duke says. “So we see this as a good thing, and I think it has potential to reduce expenses in high-cost areas.”

10) Connect the dots. Joane Goodroe, an independent healthcare consultant based in Atlanta, says CMS expects providers to connect the dots and combine their efforts in the separate incentive programs to maximize their resources. By providing consistent care coordination and setting patients on the right track, then, she says hospitalists might help boost savings across the board—a benefit that wouldn’t necessarily be apparent based solely on improved quality metrics in specific programs.

Even here, though, the current fee-for-service model can create awkward side effects. For example, Goodroe recommends following the path that many care groups delving into accountable care and bundled payment systems are already taking: connecting those models to efforts aimed at reducing hospital readmissions. Without the proper financial incentives, however, those efforts may be constrained due to a significant increase in expended resources and a potential decrease in overall revenues.

Some of the kinks may work themselves out of the system over time, but experts say the era of multiple metrics—and additional pressure—is just beginning. Combined, they will require providers to be much better at working as a system and coordinating care across multiple environments beyond the hospital, Dr. Stephan says.

One main question boils down to this, she says: “How do we get more efficient as a system and eliminate waste? I think the hospitalists really play a vital role, and it’s mainly through communication and transfer of information. Hospitalists have to be really well-connected with the different physicians and venues that send the patients into the hospital so that we’re not duplicating services and so that we can get right to the crux of the problem.”

Doing so, regardless of which CMS program is on tap, may be the very best way to avoid getting squeezed.

Bryn Nelson is a freelance medical writer in Seattle.

References

1. Adler-Milstein J, Green CE, Bates DW. A survey analysis suggests that electronic health records will yield revenue gains for some practices and losses for many. Health Affairs. 2013;32(3):562-570.
2. Saman DM, Kavanagh KT, Johnson B, Lutfiyya MN. Can inpatient hospital experiences predict central line-associated bloodstream infections? PLoS ONE. 2013;8(4):e61097.
3. Hibbard JH, Greene J, Overton V. Patients with lower activation associated with higher costs; delivery systems should know their patients’ ‘scores.’ Health Affairs. 2013; 32(2):216-222.

Dr. Tierza

VBP. ACO. HAC. EHR. Suddenly, Medicare-derived acronyms are everywhere, and many of them are attached to a growing set of programs aimed at boosting efficiency and quality. Some are optional; others are mandatory. Some have carrots as incentives; others have sticks. Some seem well-designed; others seemingly work at cross-purposes.

Love or hate these initiatives, the combined time, money, and resources needed to address all of them could put hospitals and hospitalists under considerable duress.

“It can either prove or dismantle the whole hospitalist movement,” says Brian Hazen, MD, medical director of the hospitalist division at Inova Fairfax Hospital in Falls Church, Va. “Hospitals expect us to be agile and adapt to the pressures to keep them alive. If we cannot adapt and provide that, then why give us a job?”

Whether or not the focus is on lowering readmission rates, decreasing the incidence of hospital-acquired conditions, or improving efficiencies, Dr. Hazen tends to lump most of the sticks and carrots together. “I throw them all into one basket because for the most part, they’re all reflective of good care,” he says.

The basket is growing, however, and the bundle of sticks could deliver a financial beating to the unwary.

It’s possible that some low-margin hospitals that are facing big penalties could actually have their solvency threatened. If hospitals that are a vital part of the community are threatened with insolvency because of these programs, we may need to take a second look at how we structure the penalties.

—Win Whitcomb, MD, MHM, medical director of healthcare quality, Baystate Medical Center, Springfield, Mass.; SHM Performance and Measurement Reporting Committee member; co-founder and past president of SHM; author of The Hospitalist’s “On the Horizon” column

At What Cost?

For the lowest-performing hospitals, the top readmission penalties will grow to 2% of Medicare reimbursements in fiscal year 2014 and 3% in 2015. Meanwhile, CMS’ Hospital-Acquired Conditions (HAC) program will begin assessing a 1% penalty on the worst performing hospitals in 2015, and the amount withheld under the Hospital Value-Based Purchasing (VBP) program will reach 2% in 2017 (top-performing hospitals can recoup the withhold and more, depending on performance). By that year, the three programs alone could result in a 6% loss of reimbursements.

Win Whitcomb, MD, MHM, medical director of healthcare quality at Baystate Medical Center in Springfield, Mass., and a member of SHM’s Performance and Measurement Reporting Committee, estimates that by 2017, the total at-risk payments could reach about $10 million for a 650-bed academic medical center. The tally for a 90-bed community hospital, he estimates, might run a bit less than $1 million. Although the combined penalty is probably enough to get the attention of most hospitals, very few institutions are likely to be dinged for the entire amount.

Nevertheless, the cumulative loss of reimbursements could be a tipping point for hospitals already in dire straits. “It’s possible that some low-margin hospitals that are facing big penalties could actually have their solvency threatened,” Dr. Whitcomb says. “If hospitals that are a vital part of the community are threatened with insolvency because of these programs, we may need to take a second look at how we structure the penalties.”

The necessary investment in infrastructure, he says, could prove to be a far bigger concern—at least initially.

“What is more expensive is just putting out the effort to do the work to improve and perform well under these programs,” says Dr. Whitcomb, co-founder and past president of SHM and author of The Hospitalist’s “On the Horizon” column. “That’s a big unreported hidden expense of all of these programs.”

With the fairly rapid implementation of multiple measures mandated by the Accountable Care Act, Medicare may be disinclined to dramatically ramp up the programs in play until it has a better sense of what’s working well. Then again, analysts like Laurence Baker, PhD, professor of health research and policy at Stanford University, say it’s doubtful that the agency will scale back its efforts given the widely held perception that plenty of waste can yet be wrung from the system.

“If I was a hospitalist, I would expect more of this coming,” Dr. Baker says.

Of course, rolling out new incentive programs is always a difficult balancing act in which the creators must be careful not to focus too much attention on the wrong measure or create unintended disincentives.

“That’s one of the great challenges: making a program that’s going to be successful when we know that people will do what’s measured and maybe even, without thinking about it, do less of what’s not measured. So we have to be careful about that,” Dr. Baker says.

We’re getting a lot of traction to get physicians to work together to improve care, where before there wasn’t an incentive to do this. So we see this as a good thing, and I think it has potential to reduce expenses in high-cost areas.

—Monty Duke, MD, chief physician executive, Lancaster General Hospital, Lancaster, Pa.

Out of Alignment

Beyond cost and infrastructure, the proliferation of new measures also presents challenges for alignment. Monty Duke, MD, chief physician executive at Lancaster General Hospital in Lancaster, Pa., says the targets are changing so rapidly that tension can arise between hospitals and hospitalists in aligning expectations about priorities and considering how much time, resources, and staffing will be required to address them.

Likewise, the impetus to install new infrastructure can sometimes have unintended consequences, as Dr. Duke has seen firsthand with his hospital’s recent implementation of electronic health records (EHRs).

“In many ways, the electronic health record has changed the dynamic of rounding between physicians and nurses, and it’s really challenging communication,” he says. How so? “Because people spend more time communicating with the computer than they do talking to one another,” he says. The discordant communication, in turn, can conspire against a clear plan of care and overall goals as well as challenge efforts that emphasize a team-based approach.

Despite federal meaningful-use incentives, a recent survey also suggested that a majority of healthcare practices still may not achieve a positive return on investment for EHRs unless they can figure out how to use the systems to increase revenue.¹ A minority of providers have succeeded by seeing more patients every day or by improving their billing process so the codes are more accurate and fewer claims are rejected.

Similarly, hospitalists like Dr. Hazen contend that some patient-satisfaction measures in the HCAHPS section of the VBP program can work against good clinical care. “That one drives me crazy because we’re not waiters or waitresses in a five-star restaurant,” he says. “Health care is complicated; it’s not like sending back a bowl of cold soup the way you can in a restaurant.”

Increasing satisfaction by keeping patients in the hospital longer than warranted or leaving in a Foley catheter for patient convenience, for example, can negatively impact actual outcomes.

“Physicians and nurses get put in this catch-22 where we have to choose between patient satisfaction and by-the-book clinical care,” Dr. Hazen says. “And our job is to try to mitigate that, but you’re kind of damned if you do and damned if you don’t.”

A new study, on the other hand, suggests that HCAHPS scores reflecting lower staff responsiveness are associated with an increased risk of HACs like central line–associated bloodstream infections and that lower scores may be a symptom of hospitals “with a multitude of problems.”²

A 10-Step Program

As existing rules and metrics are revised, new ones added, and others merged or discontinued, hospitalists are likely to encounter more hiccups and headaches. So what’s the solution? Beyond establishing good personal habits like hand-washing when entering and leaving a patient’s room, hospitalist leaders and healthcare analysts point to 10 strategies that may help keep HM providers from getting squeezed by all the demands:

1) Keep everyone on the same page. Because hospitals and health systems often take a subset of CMS core measures and make them strategic priorities, Dr. Whitcomb says hospitalists must thoroughly understand their own institutions’ internal system-level quality and safety goals. He stresses the need for hospitalists to develop and maintain close working connections with their organization’s safety- and quality-improvement (QI) teams “to understand exactly what the rules of the road are.”

Dr. Whitcomb says hospitals should compensate hospitalists for time spent working with these teams on feasible solutions. Hospitalist representatives can then champion specific safety or quality issues and keep them foremost in the minds of their colleagues. “I’m a big believer in paying people to do that work,” he says.

2) Take a wider view. It’s clear that most providers wouldn’t have chosen some of the performance indicators that Medicare and other third-party payors are asking them to meet, and many physicians have been more focused on outcomes than on clinical measures. Like it or not, however, thriving in the new era of health care means accepting more benchmarks. “We’ve had to broaden our scope to say, ‘OK, these other things matter, too,’” Dr. Duke says.

3) Use visual cues. Hospitalists can’t rely on memory to keep track of the dozens of measures for which they are being held accountable. “Every hospitalist program should have a dashboard of priority measures that they’re paying attention to and that’s out in front of them on a regular basis,” Dr. Whitcomb says. “It could be presented to them at monthly meetings, or it could be in a prominent place in their office, but there needs to be a set of cues.”

4) Use bonuses for alignment. Dr. Hazen says hospitals also may find success in using bonuses as a positive reinforcement for well-aligned care. Inova Fairfax’s bonuses include a clinical component that aligns with many of CMS’s core measures, and the financial incentives ensure that discharge summaries are completed and distributed in a timely manner.

5) Emphasize a team approach. Espousing a multidisciplinary approach to care can give patients the confidence that all providers are on the same page, thereby aiding patient-satisfaction scores and easing throughput. And as Dr. Hazen points out, avoiding a silo mentality can pay dividends for improving patient safety.

Dr. Tierza

6) Offer the right information. Tierza Stephan, MD, regional hospitalist medical director for Allina Health in Minneapolis and the incoming chair of SHM’s Practice Analysis Committee, says Allina has worked hard to ensure that hospitalists complete their discharge summaries within 24 hours of a patient’s release from the hospital. Beyond timeliness, the health system is emphasizing content that informs without overwhelming the patient, caregiver, or follow-up provider with unnecessary details.

The discharge summary, for example, includes a section called “Recommendations for the Outpatient Provider,” which provides a checklist of sorts so those providers don’t miss the forest for the trees. The same is true for patients. “The hospital is probably not the best place to be educating patients, so we really focus more on patient instruction at discharge and then timely follow-up,” Dr. Stephan says.

In addition to allowing better care coordination between inpatient and outpatient providers, she says, “it cuts across patient experience and readmissions, and it helps patients to be engaged because they have very clear, easy-to-read information.” Paying attention to such details may have outsized impacts: In a recent study, researchers found that patients who are actively engaged in their own health care are significantly less costly to treat, on average.³

7) Follow through after discharge. Inova Fairfax is setting up an outpatient follow-up clinic as a safety net for patients at the highest risk of being readmitted. Many of these target patients are uninsured or underinsured and battling complex medical problems like heart failure or pneumonia. Establishing a physical location for follow-ups and direct communication with primary-care providers, the hospital hopes, might reduce noncompliance among these outpatients and thereby curtail subsequent readmissions.

8) Optimize EHR. When optimized, experts say, electronic medical records can help hospitals ensure that their providers are following core measures and preventing hospital-acquired conditions while leaving channels of communication open and keeping revenue streams flowing.

“Luckily, we just switched to electronic medical records so we can monitor who has a Foley catheter in, who does or doesn’t have DVT prophylaxis, because even really good docs sometimes make these knucklehead mistakes every once in a while,” Dr. Hazen says. “So we try to use systems to back ourselves up. But for the most part, there’s just no substitute for having good docs do the right thing and documenting that.”

9) Bundle up. Although bundled payments represent yet another CMS initiative, Dr. Duke says the model has the potential to reduce waste, standardize care, and monitor outcomes. Lancaster General has been working on the approach for the past few years, with an initial focus on cardiovascular medicine, orthopedics, and neurosurgery. “We’re getting a lot of traction to get physicians to work together to improve care, where before there wasn’t an incentive to do this,” Dr. Duke says. “So we see this as a good thing, and I think it has potential to reduce expenses in high-cost areas.”

10) Connect the dots. Joane Goodroe, an independent healthcare consultant based in Atlanta, says CMS expects providers to connect the dots and combine their efforts in the separate incentive programs to maximize their resources. By providing consistent care coordination and setting patients on the right track, then, she says hospitalists might help boost savings across the board—a benefit that wouldn’t necessarily be apparent based solely on improved quality metrics in specific programs.

Even here, though, the current fee-for-service model can create awkward side effects. For example, Goodroe recommends following the path that many care groups delving into accountable care and bundled payment systems are already taking: connecting those models to efforts aimed at reducing hospital readmissions. Without the proper financial incentives, however, those efforts may be constrained due to a significant increase in expended resources and a potential decrease in overall revenues.

Some of the kinks may work themselves out of the system over time, but experts say the era of multiple metrics—and additional pressure—is just beginning. Combined, they will require providers to be much better at working as a system and coordinating care across multiple environments beyond the hospital, Dr. Stephan says.

One main question boils down to this, she says: “How do we get more efficient as a system and eliminate waste? I think the hospitalists really play a vital role, and it’s mainly through communication and transfer of information. Hospitalists have to be really well-connected with the different physicians and venues that send the patients into the hospital so that we’re not duplicating services and so that we can get right to the crux of the problem.”

Doing so, regardless of which CMS program is on tap, may be the very best way to avoid getting squeezed.

Bryn Nelson is a freelance medical writer in Seattle.

References

1. Adler-Milstein J, Green CE, Bates DW. A survey analysis suggests that electronic health records will yield revenue gains for some practices and losses for many. Health Affairs. 2013;32(3):562-570.
2. Saman DM, Kavanagh KT, Johnson B, Lutfiyya MN. Can inpatient hospital experiences predict central line-associated bloodstream infections? PLoS ONE. 2013;8(4):e61097.
3. Hibbard JH, Greene J, Overton V. Patients with lower activation associated with higher costs; delivery systems should know their patients’ ‘scores.’ Health Affairs. 2013; 32(2):216-222.

Dr. Tierza

VBP. ACO. HAC. EHR. Suddenly, Medicare-derived acronyms are everywhere, and many of them are attached to a growing set of programs aimed at boosting efficiency and quality. Some are optional; others are mandatory. Some have carrots as incentives; others have sticks. Some seem well-designed; others seemingly work at cross-purposes.

Love or hate these initiatives, the combined time, money, and resources needed to address all of them could put hospitals and hospitalists under considerable duress.

“It can either prove or dismantle the whole hospitalist movement,” says Brian Hazen, MD, medical director of the hospitalist division at Inova Fairfax Hospital in Falls Church, Va. “Hospitals expect us to be agile and adapt to the pressures to keep them alive. If we cannot adapt and provide that, then why give us a job?”

Whether or not the focus is on lowering readmission rates, decreasing the incidence of hospital-acquired conditions, or improving efficiencies, Dr. Hazen tends to lump most of the sticks and carrots together. “I throw them all into one basket because for the most part, they’re all reflective of good care,” he says.

The basket is growing, however, and the bundle of sticks could deliver a financial beating to the unwary.

It’s possible that some low-margin hospitals that are facing big penalties could actually have their solvency threatened. If hospitals that are a vital part of the community are threatened with insolvency because of these programs, we may need to take a second look at how we structure the penalties.

—Win Whitcomb, MD, MHM, medical director of healthcare quality, Baystate Medical Center, Springfield, Mass.; SHM Performance and Measurement Reporting Committee member; co-founder and past president of SHM; author of The Hospitalist’s “On the Horizon” column

At What Cost?

For the lowest-performing hospitals, the top readmission penalties will grow to 2% of Medicare reimbursements in fiscal year 2014 and 3% in 2015. Meanwhile, CMS’ Hospital-Acquired Conditions (HAC) program will begin assessing a 1% penalty on the worst performing hospitals in 2015, and the amount withheld under the Hospital Value-Based Purchasing (VBP) program will reach 2% in 2017 (top-performing hospitals can recoup the withhold and more, depending on performance). By that year, the three programs alone could result in a 6% loss of reimbursements.

Win Whitcomb, MD, MHM, medical director of healthcare quality at Baystate Medical Center in Springfield, Mass., and a member of SHM’s Performance and Measurement Reporting Committee, estimates that by 2017, the total at-risk payments could reach about $10 million for a 650-bed academic medical center. The tally for a 90-bed community hospital, he estimates, might run a bit less than $1 million. Although the combined penalty is probably enough to get the attention of most hospitals, very few institutions are likely to be dinged for the entire amount.

Nevertheless, the cumulative loss of reimbursements could be a tipping point for hospitals already in dire straits. “It’s possible that some low-margin hospitals that are facing big penalties could actually have their solvency threatened,” Dr. Whitcomb says. “If hospitals that are a vital part of the community are threatened with insolvency because of these programs, we may need to take a second look at how we structure the penalties.”

The necessary investment in infrastructure, he says, could prove to be a far bigger concern—at least initially.

“What is more expensive is just putting out the effort to do the work to improve and perform well under these programs,” says Dr. Whitcomb, co-founder and past president of SHM and author of The Hospitalist’s “On the Horizon” column. “That’s a big unreported hidden expense of all of these programs.”

With the fairly rapid implementation of multiple measures mandated by the Accountable Care Act, Medicare may be disinclined to dramatically ramp up the programs in play until it has a better sense of what’s working well. Then again, analysts like Laurence Baker, PhD, professor of health research and policy at Stanford University, say it’s doubtful that the agency will scale back its efforts given the widely held perception that plenty of waste can yet be wrung from the system.

“If I was a hospitalist, I would expect more of this coming,” Dr. Baker says.

Of course, rolling out new incentive programs is always a difficult balancing act in which the creators must be careful not to focus too much attention on the wrong measure or create unintended disincentives.

“That’s one of the great challenges: making a program that’s going to be successful when we know that people will do what’s measured and maybe even, without thinking about it, do less of what’s not measured. So we have to be careful about that,” Dr. Baker says.

We’re getting a lot of traction to get physicians to work together to improve care, where before there wasn’t an incentive to do this. So we see this as a good thing, and I think it has potential to reduce expenses in high-cost areas.

—Monty Duke, MD, chief physician executive, Lancaster General Hospital, Lancaster, Pa.

Out of Alignment

Beyond cost and infrastructure, the proliferation of new measures also presents challenges for alignment. Monty Duke, MD, chief physician executive at Lancaster General Hospital in Lancaster, Pa., says the targets are changing so rapidly that tension can arise between hospitals and hospitalists in aligning expectations about priorities and considering how much time, resources, and staffing will be required to address them.

Likewise, the impetus to install new infrastructure can sometimes have unintended consequences, as Dr. Duke has seen firsthand with his hospital’s recent implementation of electronic health records (EHRs).

“In many ways, the electronic health record has changed the dynamic of rounding between physicians and nurses, and it’s really challenging communication,” he says. How so? “Because people spend more time communicating with the computer than they do talking to one another,” he says. The discordant communication, in turn, can conspire against a clear plan of care and overall goals as well as challenge efforts that emphasize a team-based approach.

Despite federal meaningful-use incentives, a recent survey also suggested that a majority of healthcare practices still may not achieve a positive return on investment for EHRs unless they can figure out how to use the systems to increase revenue.¹ A minority of providers have succeeded by seeing more patients every day or by improving their billing process so the codes are more accurate and fewer claims are rejected.

Similarly, hospitalists like Dr. Hazen contend that some patient-satisfaction measures in the HCAHPS section of the VBP program can work against good clinical care. “That one drives me crazy because we’re not waiters or waitresses in a five-star restaurant,” he says. “Health care is complicated; it’s not like sending back a bowl of cold soup the way you can in a restaurant.”

Increasing satisfaction by keeping patients in the hospital longer than warranted or leaving in a Foley catheter for patient convenience, for example, can negatively impact actual outcomes.

“Physicians and nurses get put in this catch-22 where we have to choose between patient satisfaction and by-the-book clinical care,” Dr. Hazen says. “And our job is to try to mitigate that, but you’re kind of damned if you do and damned if you don’t.”

A new study, on the other hand, suggests that HCAHPS scores reflecting lower staff responsiveness are associated with an increased risk of HACs like central line–associated bloodstream infections and that lower scores may be a symptom of hospitals “with a multitude of problems.”²

A 10-Step Program

As existing rules and metrics are revised, new ones added, and others merged or discontinued, hospitalists are likely to encounter more hiccups and headaches. So what’s the solution? Beyond establishing good personal habits like hand-washing when entering and leaving a patient’s room, hospitalist leaders and healthcare analysts point to 10 strategies that may help keep HM providers from getting squeezed by all the demands:

1) Keep everyone on the same page. Because hospitals and health systems often take a subset of CMS core measures and make them strategic priorities, Dr. Whitcomb says hospitalists must thoroughly understand their own institutions’ internal system-level quality and safety goals. He stresses the need for hospitalists to develop and maintain close working connections with their organization’s safety- and quality-improvement (QI) teams “to understand exactly what the rules of the road are.”

Dr. Whitcomb says hospitals should compensate hospitalists for time spent working with these teams on feasible solutions. Hospitalist representatives can then champion specific safety or quality issues and keep them foremost in the minds of their colleagues. “I’m a big believer in paying people to do that work,” he says.

2) Take a wider view. It’s clear that most providers wouldn’t have chosen some of the performance indicators that Medicare and other third-party payors are asking them to meet, and many physicians have been more focused on outcomes than on clinical measures. Like it or not, however, thriving in the new era of health care means accepting more benchmarks. “We’ve had to broaden our scope to say, ‘OK, these other things matter, too,’” Dr. Duke says.

3) Use visual cues. Hospitalists can’t rely on memory to keep track of the dozens of measures for which they are being held accountable. “Every hospitalist program should have a dashboard of priority measures that they’re paying attention to and that’s out in front of them on a regular basis,” Dr. Whitcomb says. “It could be presented to them at monthly meetings, or it could be in a prominent place in their office, but there needs to be a set of cues.”

4) Use bonuses for alignment. Dr. Hazen says hospitals also may find success in using bonuses as a positive reinforcement for well-aligned care. Inova Fairfax’s bonuses include a clinical component that aligns with many of CMS’s core measures, and the financial incentives ensure that discharge summaries are completed and distributed in a timely manner.

5) Emphasize a team approach. Espousing a multidisciplinary approach to care can give patients the confidence that all providers are on the same page, thereby aiding patient-satisfaction scores and easing throughput. And as Dr. Hazen points out, avoiding a silo mentality can pay dividends for improving patient safety.

Dr. Tierza

6) Offer the right information. Tierza Stephan, MD, regional hospitalist medical director for Allina Health in Minneapolis and the incoming chair of SHM’s Practice Analysis Committee, says Allina has worked hard to ensure that hospitalists complete their discharge summaries within 24 hours of a patient’s release from the hospital. Beyond timeliness, the health system is emphasizing content that informs without overwhelming the patient, caregiver, or follow-up provider with unnecessary details.

The discharge summary, for example, includes a section called “Recommendations for the Outpatient Provider,” which provides a checklist of sorts so those providers don’t miss the forest for the trees. The same is true for patients. “The hospital is probably not the best place to be educating patients, so we really focus more on patient instruction at discharge and then timely follow-up,” Dr. Stephan says.

In addition to allowing better care coordination between inpatient and outpatient providers, she says, “it cuts across patient experience and readmissions, and it helps patients to be engaged because they have very clear, easy-to-read information.” Paying attention to such details may have outsized impacts: In a recent study, researchers found that patients who are actively engaged in their own health care are significantly less costly to treat, on average.³

7) Follow through after discharge. Inova Fairfax is setting up an outpatient follow-up clinic as a safety net for patients at the highest risk of being readmitted. Many of these target patients are uninsured or underinsured and battling complex medical problems like heart failure or pneumonia. Establishing a physical location for follow-ups and direct communication with primary-care providers, the hospital hopes, might reduce noncompliance among these outpatients and thereby curtail subsequent readmissions.

8) Optimize EHR. When optimized, experts say, electronic medical records can help hospitals ensure that their providers are following core measures and preventing hospital-acquired conditions while leaving channels of communication open and keeping revenue streams flowing.

“Luckily, we just switched to electronic medical records so we can monitor who has a Foley catheter in, who does or doesn’t have DVT prophylaxis, because even really good docs sometimes make these knucklehead mistakes every once in a while,” Dr. Hazen says. “So we try to use systems to back ourselves up. But for the most part, there’s just no substitute for having good docs do the right thing and documenting that.”

9) Bundle up. Although bundled payments represent yet another CMS initiative, Dr. Duke says the model has the potential to reduce waste, standardize care, and monitor outcomes. Lancaster General has been working on the approach for the past few years, with an initial focus on cardiovascular medicine, orthopedics, and neurosurgery. “We’re getting a lot of traction to get physicians to work together to improve care, where before there wasn’t an incentive to do this,” Dr. Duke says. “So we see this as a good thing, and I think it has potential to reduce expenses in high-cost areas.”

10) Connect the dots. Joane Goodroe, an independent healthcare consultant based in Atlanta, says CMS expects providers to connect the dots and combine their efforts in the separate incentive programs to maximize their resources. By providing consistent care coordination and setting patients on the right track, then, she says hospitalists might help boost savings across the board—a benefit that wouldn’t necessarily be apparent based solely on improved quality metrics in specific programs.

Even here, though, the current fee-for-service model can create awkward side effects. For example, Goodroe recommends following the path that many care groups delving into accountable care and bundled payment systems are already taking: connecting those models to efforts aimed at reducing hospital readmissions. Without the proper financial incentives, however, those efforts may be constrained due to a significant increase in expended resources and a potential decrease in overall revenues.

Some of the kinks may work themselves out of the system over time, but experts say the era of multiple metrics—and additional pressure—is just beginning. Combined, they will require providers to be much better at working as a system and coordinating care across multiple environments beyond the hospital, Dr. Stephan says.

One main question boils down to this, she says: “How do we get more efficient as a system and eliminate waste? I think the hospitalists really play a vital role, and it’s mainly through communication and transfer of information. Hospitalists have to be really well-connected with the different physicians and venues that send the patients into the hospital so that we’re not duplicating services and so that we can get right to the crux of the problem.”

Doing so, regardless of which CMS program is on tap, may be the very best way to avoid getting squeezed.

Bryn Nelson is a freelance medical writer in Seattle.

References

1. Adler-Milstein J, Green CE, Bates DW. A survey analysis suggests that electronic health records will yield revenue gains for some practices and losses for many. Health Affairs. 2013;32(3):562-570.
2. Saman DM, Kavanagh KT, Johnson B, Lutfiyya MN. Can inpatient hospital experiences predict central line-associated bloodstream infections? PLoS ONE. 2013;8(4):e61097.
3. Hibbard JH, Greene J, Overton V. Patients with lower activation associated with higher costs; delivery systems should know their patients’ ‘scores.’ Health Affairs. 2013; 32(2):216-222.

SHM announced in May the launch of a new interdisciplinary partnership, the Alliance to Advance Patient Nutrition, in conjunction with four other organizations. The alliance’s mission is to improve patient outcomes through nutrition intervention in the hospital.

Representing more than 100,000 dietitians, nurses, hospitalists, and other physicians and clinicians from across the nation, the following organizations have come together with SHM to champion for early nutrition screening, assessment, and intervention in hospitals:

• Academy of Medical-Surgical Nurses (AMSN);
• Academy of Nutrition and Dietetics (AND);
• American Society for Parenteral and Enteral Nutrition (ASPEN); and
• Abbott Nutrition.

Malnutrition increases costs, length of stay, and unfavorable outcomes. Properly addressing hospital malnutrition creates an opportunity to improve quality of care while also reducing healthcare costs. Additional clinical research finds that malnourished patients are two times more likely to develop a pressure ulcer, while patients with malnutrition have three times the rate of infection.

Yet when hospitalized patients are provided intervention via oral nutrition supplements, health economic research finds associated benefits:

Nutrition intervention can reduce hospital length of stay by an average of two days, and nutrition intervention has been shown to reduce patient hospitalization costs by 21.6%, or $4,734 per episode.

Additionally, there was a 6.7% reduction in the probability of 30-day readmission with patients who had at least one known subsequent readmission and were offered oral nutrition supplements during hospitalization.

“There is a growing body of evidence supporting the positive impact nutrition has on improving patient outcomes,” says hospitalist Melissa Parkhurst, MD, FHM, who serves as medical director for the University of Kansas Hospital’s hospitalist section and its nutrition support service. “We are seeing that early intervention can make a significant difference. As physicians, we need to work with the entire clinician team to ensure that nutrition is an integral part of our patients’ treatment plans.”

The alliance launched a website at www.malnutrition.org to provide hospital-based clinicians with the following resources:

• Research and fact sheets about malnutrition and the positive impact nutrition intervention has on patient care and outcomes;
• The Alliance Nutrition Toolkit, which facilitates clinician collaboration and nutrition integration; and
• Information about educational events, such as quick learning modules, continuing medical education (CME) programs.

The Alliance to Advance Patient Nutrition is made possible with support from Abbott’s nutrition business.

SHM announced in May the launch of a new interdisciplinary partnership, the Alliance to Advance Patient Nutrition, in conjunction with four other organizations. The alliance’s mission is to improve patient outcomes through nutrition intervention in the hospital.

Representing more than 100,000 dietitians, nurses, hospitalists, and other physicians and clinicians from across the nation, the following organizations have come together with SHM to champion for early nutrition screening, assessment, and intervention in hospitals:

• Academy of Medical-Surgical Nurses (AMSN);
• Academy of Nutrition and Dietetics (AND);
• American Society for Parenteral and Enteral Nutrition (ASPEN); and
• Abbott Nutrition.

Malnutrition increases costs, length of stay, and unfavorable outcomes. Properly addressing hospital malnutrition creates an opportunity to improve quality of care while also reducing healthcare costs. Additional clinical research finds that malnourished patients are two times more likely to develop a pressure ulcer, while patients with malnutrition have three times the rate of infection.

Yet when hospitalized patients are provided intervention via oral nutrition supplements, health economic research finds associated benefits:

Nutrition intervention can reduce hospital length of stay by an average of two days, and nutrition intervention has been shown to reduce patient hospitalization costs by 21.6%, or $4,734 per episode.

Additionally, there was a 6.7% reduction in the probability of 30-day readmission with patients who had at least one known subsequent readmission and were offered oral nutrition supplements during hospitalization.

“There is a growing body of evidence supporting the positive impact nutrition has on improving patient outcomes,” says hospitalist Melissa Parkhurst, MD, FHM, who serves as medical director for the University of Kansas Hospital’s hospitalist section and its nutrition support service. “We are seeing that early intervention can make a significant difference. As physicians, we need to work with the entire clinician team to ensure that nutrition is an integral part of our patients’ treatment plans.”

The alliance launched a website at www.malnutrition.org to provide hospital-based clinicians with the following resources:

• Research and fact sheets about malnutrition and the positive impact nutrition intervention has on patient care and outcomes;
• The Alliance Nutrition Toolkit, which facilitates clinician collaboration and nutrition integration; and
• Information about educational events, such as quick learning modules, continuing medical education (CME) programs.

The Alliance to Advance Patient Nutrition is made possible with support from Abbott’s nutrition business.

SHM announced in May the launch of a new interdisciplinary partnership, the Alliance to Advance Patient Nutrition, in conjunction with four other organizations. The alliance’s mission is to improve patient outcomes through nutrition intervention in the hospital.

Representing more than 100,000 dietitians, nurses, hospitalists, and other physicians and clinicians from across the nation, the following organizations have come together with SHM to champion for early nutrition screening, assessment, and intervention in hospitals:

• Academy of Medical-Surgical Nurses (AMSN);
• Academy of Nutrition and Dietetics (AND);
• American Society for Parenteral and Enteral Nutrition (ASPEN); and
• Abbott Nutrition.

Malnutrition increases costs, length of stay, and unfavorable outcomes. Properly addressing hospital malnutrition creates an opportunity to improve quality of care while also reducing healthcare costs. Additional clinical research finds that malnourished patients are two times more likely to develop a pressure ulcer, while patients with malnutrition have three times the rate of infection.

Yet when hospitalized patients are provided intervention via oral nutrition supplements, health economic research finds associated benefits:

Nutrition intervention can reduce hospital length of stay by an average of two days, and nutrition intervention has been shown to reduce patient hospitalization costs by 21.6%, or $4,734 per episode.

Additionally, there was a 6.7% reduction in the probability of 30-day readmission with patients who had at least one known subsequent readmission and were offered oral nutrition supplements during hospitalization.

“There is a growing body of evidence supporting the positive impact nutrition has on improving patient outcomes,” says hospitalist Melissa Parkhurst, MD, FHM, who serves as medical director for the University of Kansas Hospital’s hospitalist section and its nutrition support service. “We are seeing that early intervention can make a significant difference. As physicians, we need to work with the entire clinician team to ensure that nutrition is an integral part of our patients’ treatment plans.”

The alliance launched a website at www.malnutrition.org to provide hospital-based clinicians with the following resources:

• Research and fact sheets about malnutrition and the positive impact nutrition intervention has on patient care and outcomes;
• The Alliance Nutrition Toolkit, which facilitates clinician collaboration and nutrition integration; and
• Information about educational events, such as quick learning modules, continuing medical education (CME) programs.

The Alliance to Advance Patient Nutrition is made possible with support from Abbott’s nutrition business.

Clinical question: What is the impact of a peer benchmarking network on resource utilization in acute bronchiolitis?

Background: Acute bronchiolitis is the most common illness requiring hospitalization in children. Despite the publication of national evidence-based guidelines, variation and overuse of common therapies remains. Despite one report of successful implementation of evidence-based guidelines in a collaborative of freestanding children’s hospitals, most children are hospitalized outside of such institutions, and large-scale, lower-resource efforts have not been described.

Study design: Voluntary, quality-improvement (QI), and benchmarking collaborative.

Setting: Seventeen hospitals, including both community and freestanding children’s facilities.

Synopsis: Over a four-year period, data on 11,568 bronchiolitis hospitalizations were collected. The collaborative facilitated sharing of resources (e.g. scoring tools, guidelines), celebrated high performers on an annual basis, and encouraged regular data collection, primarily via conference calls and email. Notably, a common bundle of interventions were not used; groups worked on local improvement cycles, with only a few groups forming a small subcollaborative utilizing a shared pathway. A significant decrease in bronchodilator utilization and chest physiotherapy was seen over the course of the collaborative, although no change in chest radiography, steroid utilization, and RSV testing was noted.

This voluntary and low-resource effort by similarly motivated peers across a variety of inpatient settings demonstrated improvement over time. It is particularly notable as inpatient collaboratives with face-to-face meeting requirements, and annual fees, become more commonplace.

Study limitations include the lack of a conceptual model for studying contextual factors that might have led to improvement in the varied settings and secular changes over this time period. Additionally, EDs were not included in this initiative, which likely accounted for the lack of improvement in chest radiography and RSV testing. Nonetheless, scalable innovations such as this will become increasingly important as hospitalists search for value in health care.

Bottom line: Creating a national community of practice may reduce overutilization in bronchiolitis.

Citation: Ralston S, Garber M, Narang S, et al. Decreasing unnecessary utilization in acute bronchiolitis care: results from the Value in Inpatient Pediatrics Network. J Hosp Med. 2013;8(1):25-30.

Reviewed by Pediatric Editor Mark Shen, MD, SFHM, medical director of hospital medicine at Dell Children's Medical Center, Austin, Texas.

Clinical question: What is the impact of a peer benchmarking network on resource utilization in acute bronchiolitis?

Background: Acute bronchiolitis is the most common illness requiring hospitalization in children. Despite the publication of national evidence-based guidelines, variation and overuse of common therapies remains. Despite one report of successful implementation of evidence-based guidelines in a collaborative of freestanding children’s hospitals, most children are hospitalized outside of such institutions, and large-scale, lower-resource efforts have not been described.

Study design: Voluntary, quality-improvement (QI), and benchmarking collaborative.

Setting: Seventeen hospitals, including both community and freestanding children’s facilities.

Synopsis: Over a four-year period, data on 11,568 bronchiolitis hospitalizations were collected. The collaborative facilitated sharing of resources (e.g. scoring tools, guidelines), celebrated high performers on an annual basis, and encouraged regular data collection, primarily via conference calls and email. Notably, a common bundle of interventions were not used; groups worked on local improvement cycles, with only a few groups forming a small subcollaborative utilizing a shared pathway. A significant decrease in bronchodilator utilization and chest physiotherapy was seen over the course of the collaborative, although no change in chest radiography, steroid utilization, and RSV testing was noted.

This voluntary and low-resource effort by similarly motivated peers across a variety of inpatient settings demonstrated improvement over time. It is particularly notable as inpatient collaboratives with face-to-face meeting requirements, and annual fees, become more commonplace.

Study limitations include the lack of a conceptual model for studying contextual factors that might have led to improvement in the varied settings and secular changes over this time period. Additionally, EDs were not included in this initiative, which likely accounted for the lack of improvement in chest radiography and RSV testing. Nonetheless, scalable innovations such as this will become increasingly important as hospitalists search for value in health care.

Bottom line: Creating a national community of practice may reduce overutilization in bronchiolitis.

Citation: Ralston S, Garber M, Narang S, et al. Decreasing unnecessary utilization in acute bronchiolitis care: results from the Value in Inpatient Pediatrics Network. J Hosp Med. 2013;8(1):25-30.

Reviewed by Pediatric Editor Mark Shen, MD, SFHM, medical director of hospital medicine at Dell Children's Medical Center, Austin, Texas.

Clinical question: What is the impact of a peer benchmarking network on resource utilization in acute bronchiolitis?

Background: Acute bronchiolitis is the most common illness requiring hospitalization in children. Despite the publication of national evidence-based guidelines, variation and overuse of common therapies remains. Despite one report of successful implementation of evidence-based guidelines in a collaborative of freestanding children’s hospitals, most children are hospitalized outside of such institutions, and large-scale, lower-resource efforts have not been described.

Study design: Voluntary, quality-improvement (QI), and benchmarking collaborative.

Setting: Seventeen hospitals, including both community and freestanding children’s facilities.

Synopsis: Over a four-year period, data on 11,568 bronchiolitis hospitalizations were collected. The collaborative facilitated sharing of resources (e.g. scoring tools, guidelines), celebrated high performers on an annual basis, and encouraged regular data collection, primarily via conference calls and email. Notably, a common bundle of interventions were not used; groups worked on local improvement cycles, with only a few groups forming a small subcollaborative utilizing a shared pathway. A significant decrease in bronchodilator utilization and chest physiotherapy was seen over the course of the collaborative, although no change in chest radiography, steroid utilization, and RSV testing was noted.

This voluntary and low-resource effort by similarly motivated peers across a variety of inpatient settings demonstrated improvement over time. It is particularly notable as inpatient collaboratives with face-to-face meeting requirements, and annual fees, become more commonplace.

Study limitations include the lack of a conceptual model for studying contextual factors that might have led to improvement in the varied settings and secular changes over this time period. Additionally, EDs were not included in this initiative, which likely accounted for the lack of improvement in chest radiography and RSV testing. Nonetheless, scalable innovations such as this will become increasingly important as hospitalists search for value in health care.

Bottom line: Creating a national community of practice may reduce overutilization in bronchiolitis.

Citation: Ralston S, Garber M, Narang S, et al. Decreasing unnecessary utilization in acute bronchiolitis care: results from the Value in Inpatient Pediatrics Network. J Hosp Med. 2013;8(1):25-30.

Reviewed by Pediatric Editor Mark Shen, MD, SFHM, medical director of hospital medicine at Dell Children's Medical Center, Austin, Texas.

The yearlong IPC-UCSF Fellowship for Hospitalist Leaders brings about 40 IPC: The Hospitalist Company group leaders together for a series of three-day training sessions and ongoing distance learning, executive coaching, and project mentoring.

The program emphasizes role plays and simulations, and even involves an acting coach to help participants learn to make more effective presentations, such as harnessing the power of storytelling, says Niraj L. Sehgal, MD, MPH, a hospitalist at the University of California at San Francisco (UCSF) who directs the fellowship through UCSF’s Center for Health Professions.

The first class graduated in November 2011, and the third is in session. Participants implement a mentored project in their home facility, with measurable results, as a vehicle for leadership development in such areas as quality improvement (QI), patient safety, or readmissions prevention. But the specific project is not as important as whether or not that project is well-designed to stretch the individual in areas where they weren’t comfortable before, Dr. Sehgal says.

Through her QI project, Jasmin Baleva, MD, of Memorial Hermann Memorial City Medical Center in Houston, a 2012 participant, found an alternate to the costly nocturnist model while maintaining the time it takes for the first hospitalist encounter with newly admitted patients. “I think the IPC-UCSF project gave my proposal a little more legitimacy,” she tells TH. “They also taught me how to present it in an effective package and to approach the C-suite feeling less intimidated.”

Larry Beresford is a freelance writer in Oakland, Calif.

References

1. Stobbe, M. Germ-zapping “robots”: Hospitals combat superbugs. Associated Press website. Available at: http://bigstory.ap.org/article/hospitals-see-surge-superbug-fighting-products. Accessed June 7, 2013.
2. Centers for Disease Control and Prevention. Vital Signs: Carbapenem-Resistant Enterobacteriaceae. Centers for Disease Control and Prevention website. Available at: http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6209a3.htm?s_cid=mm6209a3_w. Accessed June 7, 2013.
3. Wise ME, Scott RD, Baggs JM, et al. National estimates of central line-associated bloodstream infections in critical care patients. Infect Control Hosp Epidemiol, 2013;34(6):547-554.
4. Hsu E, Lin D, Evans SJ, et al. Doing well by doing good: assessing the cost savings of an intervention to reduce central line-associated bloodstream infections in a Hawaii hospital. Am J Med Qual, 2013 May 7 [Epub ahead of print].
5. Association of American Medical Colleges. Medical school enrollment on pace to reach 30 percent increase by 2017. Association of American Medical Colleges website. Available at: https://www.aamc.org/newsroom/newsreleases/ 335244/050213.html. Accessed June 7, 2013.

The yearlong IPC-UCSF Fellowship for Hospitalist Leaders brings about 40 IPC: The Hospitalist Company group leaders together for a series of three-day training sessions and ongoing distance learning, executive coaching, and project mentoring.

The program emphasizes role plays and simulations, and even involves an acting coach to help participants learn to make more effective presentations, such as harnessing the power of storytelling, says Niraj L. Sehgal, MD, MPH, a hospitalist at the University of California at San Francisco (UCSF) who directs the fellowship through UCSF’s Center for Health Professions.

The first class graduated in November 2011, and the third is in session. Participants implement a mentored project in their home facility, with measurable results, as a vehicle for leadership development in such areas as quality improvement (QI), patient safety, or readmissions prevention. But the specific project is not as important as whether or not that project is well-designed to stretch the individual in areas where they weren’t comfortable before, Dr. Sehgal says.

Through her QI project, Jasmin Baleva, MD, of Memorial Hermann Memorial City Medical Center in Houston, a 2012 participant, found an alternate to the costly nocturnist model while maintaining the time it takes for the first hospitalist encounter with newly admitted patients. “I think the IPC-UCSF project gave my proposal a little more legitimacy,” she tells TH. “They also taught me how to present it in an effective package and to approach the C-suite feeling less intimidated.”

Larry Beresford is a freelance writer in Oakland, Calif.

References

1. Stobbe, M. Germ-zapping “robots”: Hospitals combat superbugs. Associated Press website. Available at: http://bigstory.ap.org/article/hospitals-see-surge-superbug-fighting-products. Accessed June 7, 2013.
2. Centers for Disease Control and Prevention. Vital Signs: Carbapenem-Resistant Enterobacteriaceae. Centers for Disease Control and Prevention website. Available at: http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6209a3.htm?s_cid=mm6209a3_w. Accessed June 7, 2013.
3. Wise ME, Scott RD, Baggs JM, et al. National estimates of central line-associated bloodstream infections in critical care patients. Infect Control Hosp Epidemiol, 2013;34(6):547-554.
4. Hsu E, Lin D, Evans SJ, et al. Doing well by doing good: assessing the cost savings of an intervention to reduce central line-associated bloodstream infections in a Hawaii hospital. Am J Med Qual, 2013 May 7 [Epub ahead of print].
5. Association of American Medical Colleges. Medical school enrollment on pace to reach 30 percent increase by 2017. Association of American Medical Colleges website. Available at: https://www.aamc.org/newsroom/newsreleases/ 335244/050213.html. Accessed June 7, 2013.

The yearlong IPC-UCSF Fellowship for Hospitalist Leaders brings about 40 IPC: The Hospitalist Company group leaders together for a series of three-day training sessions and ongoing distance learning, executive coaching, and project mentoring.

The program emphasizes role plays and simulations, and even involves an acting coach to help participants learn to make more effective presentations, such as harnessing the power of storytelling, says Niraj L. Sehgal, MD, MPH, a hospitalist at the University of California at San Francisco (UCSF) who directs the fellowship through UCSF’s Center for Health Professions.

The first class graduated in November 2011, and the third is in session. Participants implement a mentored project in their home facility, with measurable results, as a vehicle for leadership development in such areas as quality improvement (QI), patient safety, or readmissions prevention. But the specific project is not as important as whether or not that project is well-designed to stretch the individual in areas where they weren’t comfortable before, Dr. Sehgal says.

Through her QI project, Jasmin Baleva, MD, of Memorial Hermann Memorial City Medical Center in Houston, a 2012 participant, found an alternate to the costly nocturnist model while maintaining the time it takes for the first hospitalist encounter with newly admitted patients. “I think the IPC-UCSF project gave my proposal a little more legitimacy,” she tells TH. “They also taught me how to present it in an effective package and to approach the C-suite feeling less intimidated.”

Larry Beresford is a freelance writer in Oakland, Calif.

References

1. Stobbe, M. Germ-zapping “robots”: Hospitals combat superbugs. Associated Press website. Available at: http://bigstory.ap.org/article/hospitals-see-surge-superbug-fighting-products. Accessed June 7, 2013.
2. Centers for Disease Control and Prevention. Vital Signs: Carbapenem-Resistant Enterobacteriaceae. Centers for Disease Control and Prevention website. Available at: http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6209a3.htm?s_cid=mm6209a3_w. Accessed June 7, 2013.
3. Wise ME, Scott RD, Baggs JM, et al. National estimates of central line-associated bloodstream infections in critical care patients. Infect Control Hosp Epidemiol, 2013;34(6):547-554.
4. Hsu E, Lin D, Evans SJ, et al. Doing well by doing good: assessing the cost savings of an intervention to reduce central line-associated bloodstream infections in a Hawaii hospital. Am J Med Qual, 2013 May 7 [Epub ahead of print].
5. Association of American Medical Colleges. Medical school enrollment on pace to reach 30 percent increase by 2017. Association of American Medical Colleges website. Available at: https://www.aamc.org/newsroom/newsreleases/ 335244/050213.html. Accessed June 7, 2013.