Quality

“You must define yourself as a hospitalist.” I smiled uncomfortably at my colleagues across the table as I pondered how best to respond to this statement. This seemingly innocuous comment had me perplexed, despite the fact that I aced the “What I want to be when I grow up” question as a fifth-grader. What had changed in all these years?

It was my first job as a hospitalist. I was two months out of residency and had accepted a position at the large academic hospital where I’d spent the previous three years of my life. The comfort was alluring and the transition appeared mundane. However, I naively did not realize that the difference between residency and the launch of a professional career was far greater than a miraculous transformation of paychecks.

Don’t get me wrong—throughout residency, I knew that I had a wealth of untapped energy and ideas; I was just too exhausted from patient-care duties to put action and plans into place. But as I vaulted into my career, I realized I now had the opportunity to act on these ideas and transcend the physician-in-training stereotype.

And so here I was, sitting with colleagues, attempting to define what would occupy the nonclinical portion of my upcoming career.

You might be wondering, “Isn’t great patient care enough for me as a hospitalist?” Indeed, in residency, we are praised, ranked, and valued almost solely on clinical acuity. As a hospitalist, however, we have the unique opportunity of defining ourselves in ways beyond bedside skills. While we are all astute clinicians, an important secret was kept from you during residency: You can choose another hat to wear and—unlike during your training years—you will have the time to do so.

Not buying it? It’s true. Simply pause and reflect on the hospitalists or general internal-medicine physicians you once admired; odds are they weren’t just clinicians, but they were also clinician-educators, clinician-researchers, clinician-administrators, clinician-fill-in-the-blank. In essence, they found a niche, a path that defined their careers.

And now, it’s time you did the same. But how, you ask? Here are a few pointers to get you started:

No. 1: Take Your Time

Before you go off trying to find your claim to fame, keep in mind that the first few years out of residency are a time of transition. Simply put, taking on too much, too early, could capsize your vessel. Learning to become an attending comes with a myriad of diverse responsibilities and a slow march to confidence in your clinical skills. This is a full-time position and one that requires diligence, both to ensure that you gain a strong clinical footing and fully understand the dimensions and nuances of potential “niches.” Get secure in your new role before beginning the search for your new calling. Once you feel comfortable with the resident-to-attending transition, you might find yourself itching to take on that new role in the hospital.

No. 2: Identify Your Passion

My mentor in residency was Dr. M, an all-star attending who had the energy to inspire by building an effortless bridge over the intern-resident-attending communication gap. As I studied her actions during my intern year, I found myself asking, “Could I ever be that successful in my career?”

As we shared experiences, I realized Dr. M genuinely was happy and passionate about her job every day. Her ability to effectively communicate to residents, nurses, and patients was a simple segue to her niche. So what is her niche? Dr. M is a clinician-communicator. Whether it is blogging about a recent patient experience on the wards or appearing as a physician correspondent for an Atlanta news affiliate, Dr. M’s strength is effective communication. Despite being a great clinician, it was her drive outside the wards that helped me understand she had found, and was living, her passion.

During residency, every physician had that one thing that continued to drive us when the going got tough. For some, it was the eager medical student who deserved to learn about that critical aortic stenosis murmur, even if you were 28 hours into your shift. For others, it was quality-improvement (QI) projects that arose from experiencing firsthand the effects of haphazard care transitions. Still others became passionate about patient advocacy after watching patients struggle to understand complex diseases.

Why are these examples relevant? Because each example represents a pathway to your niche. The first person might find a niche as a clinician-educator, exploring opportunities with the medical school during their first year. The second might align themselves with like-minded colleagues in QI and begin projects that will solve frustrations or improve physician efficiency. The third might get involved with local health fairs or local news stations to promote health awareness. The common link between all of these examples is that a clinician’s niche is based on their passion.

No. 3: Stay in Your Own Orbit

We’ve all been go-getters. We’re used to stretching ourselves thin to show what efficient, all-around superdocs we are. And this drive to say yes to your boss, that clinical nurse specialist, and to your colleague who schedules medical student clinical exams will lead to fruitful clinical ventures. Ultimately, however, this approach will leave you exhausted and will leave your colleagues wondering what it is that you actually do with your nonclinical time.

The solution? Learn to invest yourself, and your time, wisely.

During the first week of my new career (when I was asked that fateful question to define myself), I received the best advice. Dr. S (yes, another mentor—it’s OK to have multiple mentors) drew a series of random dots on a sheet of paper. Each of these dots represented opportunities that would arise during my first year. Circling a dot in the middle of the page, Dr. S looked at me and said, “One of these dots represents your passion. The remaining dots are where others’ interests lie. Pick one of these and work in its orbit only. Sure, you may jump up to another dot for a project, but the more you stay within the orbit of your passion, the happier and more productive you’ll be.”

In your first few years on the job, do say yes to joining committees, taking on projects, and collaborating with colleagues. But as you do, ensure that each of these decisions is within your orbit. Saying yes is easy, but saying yes and making it count twice is a skill that you will develop as your career progresses.

Not sure what your orbit is? I encourage you to refer back to tip No. 2 and start seeking out opportunities that center around your passion, not someone else’s.

No. 4: Master the Network

Networking is an art in which our business-minded friends from college excel. Unfortunately, studying for exams and resting after a 30-hour MICU call is a solo venture that leaves little room to hone networking skills. But now, the onlooker must become the master … of networking.

Networking is an important skill to develop, and you start the very first day of your career. The relationships you forge with successful colleagues and superiors will provide you with opportunities beyond the clinical arena (see “Simple Strategies to Expand Your HM Network,” below).

Not sure where to start? A mentor can help. Look at the well-respected leaders in your department and institution, and take note of how each of these people always talk about their mentors and the role they played in crystallizing their career paths. Good mentors steer you toward other like-minded professionals. They help you navigate the complex relationships that are at the base of a successful networking strategy. A wise strategy is to find multiple mentors who serve different purposes in your career; this usually leads to untold opportunities.

Can’t find a suitable mentor at the workplace? Fear not. Consider networking at local, regional, and national society meetings (www.hospitalmedicine.org/events). When the opportunity arises, do more than just attend the clinical sessions during these meetings. Learn which committees are available through the various societies and contact their leaders to express interest in joining next year’s group. Your fellow committee members will be a natural place to practice your networking skills. High-quality relationships made during this time have the potential to grow, and they could lead to more opportunities as your career progresses.

No. 5: Take Calculated Risks

This might sound simple enough, but it is not easy. It is uncomfortable to make mistakes in front of a public audience (and believe me, we all make mistakes). But you will be successful, too, and you must learn how to promote yourself during these times.

Challenge yourself by attending SHM’s Academic Hospitalist Academy (www.academichospitalist.org), or by taking on that project discussed at the last committee meeting. Say yes to your mentor when they learn your passion is QI and appropriately volunteer you to lead a resident research project. Submit your most recent project to an abstract competition, such as SHM’s Research, Innovation, and Clinical Vignettes (RIV) competition. Before you go, research others in your field with similar interests and seek them out during the meeting to share your experiences. Be ready to explain your pitfalls as well, and use this as an opportunity to learn from experienced colleagues.

Whether it is speaking in front of a group of strangers at the academy, giving a presentation to your colleagues, or meeting HM leaders at the national meeting, opportunities abound and often pay off in the long run.

No. 6: Ready For Change

Wait, change? Back up to tip No. 2. I know you’re saying, “But I’m following my passion.” Remember that, fresh out of residency, your interests likely are somewhat different than those of your future self. Thus, as the saying goes, the only thing that is certain is change.

Through networking and putting yourself in new positions, you will discover a world that was never revealed to you in residency. Case in point: my friend and colleague Dr. H. As a chief resident, Dr. H was exposed to a year of educational opportunities before she embarked on a hospitalist career. Education seemed like a natural fit in her first year as a hospitalist. In fact, she never imagined that it would be her experience with the inner workings of her hospital’s electronic medical record (EMR) during her chief year that would catapult her career as the physician director for information services. Yes, she is now a hospitalist-administrator. The bottom line: Remain resilient and ready to take up that next interesting opportunity.

Residency provides you with the skills to be a confident and effective clinician. But as residency comes to a close, think about what really drives you. Where do you see yourself in five years? How about 10 years?

Plot your course to live your passion at work every day; as you start your new job, find, refine, and define your niche.

Dr. Payne is a hospitalist in the Department of Internal Medicine at Emory University Hospital in Atlanta, and a clinical instructor of medicine at Emory University School of Medicine.

“You must define yourself as a hospitalist.” I smiled uncomfortably at my colleagues across the table as I pondered how best to respond to this statement. This seemingly innocuous comment had me perplexed, despite the fact that I aced the “What I want to be when I grow up” question as a fifth-grader. What had changed in all these years?

It was my first job as a hospitalist. I was two months out of residency and had accepted a position at the large academic hospital where I’d spent the previous three years of my life. The comfort was alluring and the transition appeared mundane. However, I naively did not realize that the difference between residency and the launch of a professional career was far greater than a miraculous transformation of paychecks.

Don’t get me wrong—throughout residency, I knew that I had a wealth of untapped energy and ideas; I was just too exhausted from patient-care duties to put action and plans into place. But as I vaulted into my career, I realized I now had the opportunity to act on these ideas and transcend the physician-in-training stereotype.

And so here I was, sitting with colleagues, attempting to define what would occupy the nonclinical portion of my upcoming career.

You might be wondering, “Isn’t great patient care enough for me as a hospitalist?” Indeed, in residency, we are praised, ranked, and valued almost solely on clinical acuity. As a hospitalist, however, we have the unique opportunity of defining ourselves in ways beyond bedside skills. While we are all astute clinicians, an important secret was kept from you during residency: You can choose another hat to wear and—unlike during your training years—you will have the time to do so.

Not buying it? It’s true. Simply pause and reflect on the hospitalists or general internal-medicine physicians you once admired; odds are they weren’t just clinicians, but they were also clinician-educators, clinician-researchers, clinician-administrators, clinician-fill-in-the-blank. In essence, they found a niche, a path that defined their careers.

And now, it’s time you did the same. But how, you ask? Here are a few pointers to get you started:

No. 1: Take Your Time

Before you go off trying to find your claim to fame, keep in mind that the first few years out of residency are a time of transition. Simply put, taking on too much, too early, could capsize your vessel. Learning to become an attending comes with a myriad of diverse responsibilities and a slow march to confidence in your clinical skills. This is a full-time position and one that requires diligence, both to ensure that you gain a strong clinical footing and fully understand the dimensions and nuances of potential “niches.” Get secure in your new role before beginning the search for your new calling. Once you feel comfortable with the resident-to-attending transition, you might find yourself itching to take on that new role in the hospital.

No. 2: Identify Your Passion

My mentor in residency was Dr. M, an all-star attending who had the energy to inspire by building an effortless bridge over the intern-resident-attending communication gap. As I studied her actions during my intern year, I found myself asking, “Could I ever be that successful in my career?”

As we shared experiences, I realized Dr. M genuinely was happy and passionate about her job every day. Her ability to effectively communicate to residents, nurses, and patients was a simple segue to her niche. So what is her niche? Dr. M is a clinician-communicator. Whether it is blogging about a recent patient experience on the wards or appearing as a physician correspondent for an Atlanta news affiliate, Dr. M’s strength is effective communication. Despite being a great clinician, it was her drive outside the wards that helped me understand she had found, and was living, her passion.

During residency, every physician had that one thing that continued to drive us when the going got tough. For some, it was the eager medical student who deserved to learn about that critical aortic stenosis murmur, even if you were 28 hours into your shift. For others, it was quality-improvement (QI) projects that arose from experiencing firsthand the effects of haphazard care transitions. Still others became passionate about patient advocacy after watching patients struggle to understand complex diseases.

Why are these examples relevant? Because each example represents a pathway to your niche. The first person might find a niche as a clinician-educator, exploring opportunities with the medical school during their first year. The second might align themselves with like-minded colleagues in QI and begin projects that will solve frustrations or improve physician efficiency. The third might get involved with local health fairs or local news stations to promote health awareness. The common link between all of these examples is that a clinician’s niche is based on their passion.

No. 3: Stay in Your Own Orbit

We’ve all been go-getters. We’re used to stretching ourselves thin to show what efficient, all-around superdocs we are. And this drive to say yes to your boss, that clinical nurse specialist, and to your colleague who schedules medical student clinical exams will lead to fruitful clinical ventures. Ultimately, however, this approach will leave you exhausted and will leave your colleagues wondering what it is that you actually do with your nonclinical time.

The solution? Learn to invest yourself, and your time, wisely.

During the first week of my new career (when I was asked that fateful question to define myself), I received the best advice. Dr. S (yes, another mentor—it’s OK to have multiple mentors) drew a series of random dots on a sheet of paper. Each of these dots represented opportunities that would arise during my first year. Circling a dot in the middle of the page, Dr. S looked at me and said, “One of these dots represents your passion. The remaining dots are where others’ interests lie. Pick one of these and work in its orbit only. Sure, you may jump up to another dot for a project, but the more you stay within the orbit of your passion, the happier and more productive you’ll be.”

In your first few years on the job, do say yes to joining committees, taking on projects, and collaborating with colleagues. But as you do, ensure that each of these decisions is within your orbit. Saying yes is easy, but saying yes and making it count twice is a skill that you will develop as your career progresses.

Not sure what your orbit is? I encourage you to refer back to tip No. 2 and start seeking out opportunities that center around your passion, not someone else’s.

No. 4: Master the Network

Networking is an art in which our business-minded friends from college excel. Unfortunately, studying for exams and resting after a 30-hour MICU call is a solo venture that leaves little room to hone networking skills. But now, the onlooker must become the master … of networking.

Networking is an important skill to develop, and you start the very first day of your career. The relationships you forge with successful colleagues and superiors will provide you with opportunities beyond the clinical arena (see “Simple Strategies to Expand Your HM Network,” below).

Not sure where to start? A mentor can help. Look at the well-respected leaders in your department and institution, and take note of how each of these people always talk about their mentors and the role they played in crystallizing their career paths. Good mentors steer you toward other like-minded professionals. They help you navigate the complex relationships that are at the base of a successful networking strategy. A wise strategy is to find multiple mentors who serve different purposes in your career; this usually leads to untold opportunities.

Can’t find a suitable mentor at the workplace? Fear not. Consider networking at local, regional, and national society meetings (www.hospitalmedicine.org/events). When the opportunity arises, do more than just attend the clinical sessions during these meetings. Learn which committees are available through the various societies and contact their leaders to express interest in joining next year’s group. Your fellow committee members will be a natural place to practice your networking skills. High-quality relationships made during this time have the potential to grow, and they could lead to more opportunities as your career progresses.

No. 5: Take Calculated Risks

This might sound simple enough, but it is not easy. It is uncomfortable to make mistakes in front of a public audience (and believe me, we all make mistakes). But you will be successful, too, and you must learn how to promote yourself during these times.

Challenge yourself by attending SHM’s Academic Hospitalist Academy (www.academichospitalist.org), or by taking on that project discussed at the last committee meeting. Say yes to your mentor when they learn your passion is QI and appropriately volunteer you to lead a resident research project. Submit your most recent project to an abstract competition, such as SHM’s Research, Innovation, and Clinical Vignettes (RIV) competition. Before you go, research others in your field with similar interests and seek them out during the meeting to share your experiences. Be ready to explain your pitfalls as well, and use this as an opportunity to learn from experienced colleagues.

Whether it is speaking in front of a group of strangers at the academy, giving a presentation to your colleagues, or meeting HM leaders at the national meeting, opportunities abound and often pay off in the long run.

No. 6: Ready For Change

Wait, change? Back up to tip No. 2. I know you’re saying, “But I’m following my passion.” Remember that, fresh out of residency, your interests likely are somewhat different than those of your future self. Thus, as the saying goes, the only thing that is certain is change.

Through networking and putting yourself in new positions, you will discover a world that was never revealed to you in residency. Case in point: my friend and colleague Dr. H. As a chief resident, Dr. H was exposed to a year of educational opportunities before she embarked on a hospitalist career. Education seemed like a natural fit in her first year as a hospitalist. In fact, she never imagined that it would be her experience with the inner workings of her hospital’s electronic medical record (EMR) during her chief year that would catapult her career as the physician director for information services. Yes, she is now a hospitalist-administrator. The bottom line: Remain resilient and ready to take up that next interesting opportunity.

Residency provides you with the skills to be a confident and effective clinician. But as residency comes to a close, think about what really drives you. Where do you see yourself in five years? How about 10 years?

Plot your course to live your passion at work every day; as you start your new job, find, refine, and define your niche.

Dr. Payne is a hospitalist in the Department of Internal Medicine at Emory University Hospital in Atlanta, and a clinical instructor of medicine at Emory University School of Medicine.

“You must define yourself as a hospitalist.” I smiled uncomfortably at my colleagues across the table as I pondered how best to respond to this statement. This seemingly innocuous comment had me perplexed, despite the fact that I aced the “What I want to be when I grow up” question as a fifth-grader. What had changed in all these years?

It was my first job as a hospitalist. I was two months out of residency and had accepted a position at the large academic hospital where I’d spent the previous three years of my life. The comfort was alluring and the transition appeared mundane. However, I naively did not realize that the difference between residency and the launch of a professional career was far greater than a miraculous transformation of paychecks.

Don’t get me wrong—throughout residency, I knew that I had a wealth of untapped energy and ideas; I was just too exhausted from patient-care duties to put action and plans into place. But as I vaulted into my career, I realized I now had the opportunity to act on these ideas and transcend the physician-in-training stereotype.

And so here I was, sitting with colleagues, attempting to define what would occupy the nonclinical portion of my upcoming career.

You might be wondering, “Isn’t great patient care enough for me as a hospitalist?” Indeed, in residency, we are praised, ranked, and valued almost solely on clinical acuity. As a hospitalist, however, we have the unique opportunity of defining ourselves in ways beyond bedside skills. While we are all astute clinicians, an important secret was kept from you during residency: You can choose another hat to wear and—unlike during your training years—you will have the time to do so.

Not buying it? It’s true. Simply pause and reflect on the hospitalists or general internal-medicine physicians you once admired; odds are they weren’t just clinicians, but they were also clinician-educators, clinician-researchers, clinician-administrators, clinician-fill-in-the-blank. In essence, they found a niche, a path that defined their careers.

And now, it’s time you did the same. But how, you ask? Here are a few pointers to get you started:

No. 1: Take Your Time

Before you go off trying to find your claim to fame, keep in mind that the first few years out of residency are a time of transition. Simply put, taking on too much, too early, could capsize your vessel. Learning to become an attending comes with a myriad of diverse responsibilities and a slow march to confidence in your clinical skills. This is a full-time position and one that requires diligence, both to ensure that you gain a strong clinical footing and fully understand the dimensions and nuances of potential “niches.” Get secure in your new role before beginning the search for your new calling. Once you feel comfortable with the resident-to-attending transition, you might find yourself itching to take on that new role in the hospital.

No. 2: Identify Your Passion

My mentor in residency was Dr. M, an all-star attending who had the energy to inspire by building an effortless bridge over the intern-resident-attending communication gap. As I studied her actions during my intern year, I found myself asking, “Could I ever be that successful in my career?”

As we shared experiences, I realized Dr. M genuinely was happy and passionate about her job every day. Her ability to effectively communicate to residents, nurses, and patients was a simple segue to her niche. So what is her niche? Dr. M is a clinician-communicator. Whether it is blogging about a recent patient experience on the wards or appearing as a physician correspondent for an Atlanta news affiliate, Dr. M’s strength is effective communication. Despite being a great clinician, it was her drive outside the wards that helped me understand she had found, and was living, her passion.

During residency, every physician had that one thing that continued to drive us when the going got tough. For some, it was the eager medical student who deserved to learn about that critical aortic stenosis murmur, even if you were 28 hours into your shift. For others, it was quality-improvement (QI) projects that arose from experiencing firsthand the effects of haphazard care transitions. Still others became passionate about patient advocacy after watching patients struggle to understand complex diseases.

Why are these examples relevant? Because each example represents a pathway to your niche. The first person might find a niche as a clinician-educator, exploring opportunities with the medical school during their first year. The second might align themselves with like-minded colleagues in QI and begin projects that will solve frustrations or improve physician efficiency. The third might get involved with local health fairs or local news stations to promote health awareness. The common link between all of these examples is that a clinician’s niche is based on their passion.

No. 3: Stay in Your Own Orbit

We’ve all been go-getters. We’re used to stretching ourselves thin to show what efficient, all-around superdocs we are. And this drive to say yes to your boss, that clinical nurse specialist, and to your colleague who schedules medical student clinical exams will lead to fruitful clinical ventures. Ultimately, however, this approach will leave you exhausted and will leave your colleagues wondering what it is that you actually do with your nonclinical time.

The solution? Learn to invest yourself, and your time, wisely.

During the first week of my new career (when I was asked that fateful question to define myself), I received the best advice. Dr. S (yes, another mentor—it’s OK to have multiple mentors) drew a series of random dots on a sheet of paper. Each of these dots represented opportunities that would arise during my first year. Circling a dot in the middle of the page, Dr. S looked at me and said, “One of these dots represents your passion. The remaining dots are where others’ interests lie. Pick one of these and work in its orbit only. Sure, you may jump up to another dot for a project, but the more you stay within the orbit of your passion, the happier and more productive you’ll be.”

In your first few years on the job, do say yes to joining committees, taking on projects, and collaborating with colleagues. But as you do, ensure that each of these decisions is within your orbit. Saying yes is easy, but saying yes and making it count twice is a skill that you will develop as your career progresses.

Not sure what your orbit is? I encourage you to refer back to tip No. 2 and start seeking out opportunities that center around your passion, not someone else’s.

No. 4: Master the Network

Networking is an art in which our business-minded friends from college excel. Unfortunately, studying for exams and resting after a 30-hour MICU call is a solo venture that leaves little room to hone networking skills. But now, the onlooker must become the master … of networking.

Networking is an important skill to develop, and you start the very first day of your career. The relationships you forge with successful colleagues and superiors will provide you with opportunities beyond the clinical arena (see “Simple Strategies to Expand Your HM Network,” below).

Not sure where to start? A mentor can help. Look at the well-respected leaders in your department and institution, and take note of how each of these people always talk about their mentors and the role they played in crystallizing their career paths. Good mentors steer you toward other like-minded professionals. They help you navigate the complex relationships that are at the base of a successful networking strategy. A wise strategy is to find multiple mentors who serve different purposes in your career; this usually leads to untold opportunities.

Can’t find a suitable mentor at the workplace? Fear not. Consider networking at local, regional, and national society meetings (www.hospitalmedicine.org/events). When the opportunity arises, do more than just attend the clinical sessions during these meetings. Learn which committees are available through the various societies and contact their leaders to express interest in joining next year’s group. Your fellow committee members will be a natural place to practice your networking skills. High-quality relationships made during this time have the potential to grow, and they could lead to more opportunities as your career progresses.

No. 5: Take Calculated Risks

This might sound simple enough, but it is not easy. It is uncomfortable to make mistakes in front of a public audience (and believe me, we all make mistakes). But you will be successful, too, and you must learn how to promote yourself during these times.

Challenge yourself by attending SHM’s Academic Hospitalist Academy (www.academichospitalist.org), or by taking on that project discussed at the last committee meeting. Say yes to your mentor when they learn your passion is QI and appropriately volunteer you to lead a resident research project. Submit your most recent project to an abstract competition, such as SHM’s Research, Innovation, and Clinical Vignettes (RIV) competition. Before you go, research others in your field with similar interests and seek them out during the meeting to share your experiences. Be ready to explain your pitfalls as well, and use this as an opportunity to learn from experienced colleagues.

Whether it is speaking in front of a group of strangers at the academy, giving a presentation to your colleagues, or meeting HM leaders at the national meeting, opportunities abound and often pay off in the long run.

No. 6: Ready For Change

Wait, change? Back up to tip No. 2. I know you’re saying, “But I’m following my passion.” Remember that, fresh out of residency, your interests likely are somewhat different than those of your future self. Thus, as the saying goes, the only thing that is certain is change.

Through networking and putting yourself in new positions, you will discover a world that was never revealed to you in residency. Case in point: my friend and colleague Dr. H. As a chief resident, Dr. H was exposed to a year of educational opportunities before she embarked on a hospitalist career. Education seemed like a natural fit in her first year as a hospitalist. In fact, she never imagined that it would be her experience with the inner workings of her hospital’s electronic medical record (EMR) during her chief year that would catapult her career as the physician director for information services. Yes, she is now a hospitalist-administrator. The bottom line: Remain resilient and ready to take up that next interesting opportunity.

Residency provides you with the skills to be a confident and effective clinician. But as residency comes to a close, think about what really drives you. Where do you see yourself in five years? How about 10 years?

Plot your course to live your passion at work every day; as you start your new job, find, refine, and define your niche.

Dr. Payne is a hospitalist in the Department of Internal Medicine at Emory University Hospital in Atlanta, and a clinical instructor of medicine at Emory University School of Medicine.

Like many physicians, Larry Holder, MD, FACP, FHM, entered the medical profession with the desire to make a difference. After completing a fellowship in hematology and oncology in 1988, he joined Cancer Care Specialists of Central Illinois, a community oncology practice based in Decatur, and anticipated a lengthy career in which he would contribute to significant breakthroughs in cancer treatment.

After 12 years, however, he changed direction.

“I had become a bit disillusioned and realized we weren’t making big impacts, especially on the more common cancers,” he says. “I also got very attached to my patients, and in oncology, that’s not always a good thing. It became very trying emotionally.”

Dr. Holder spent the next five years practicing internal medicine at Community Health Improvement Center in Decatur. In 2005, he joined the hospitalist program at Decatur Memorial Hospital. Last year, he became medical director of hospitalist services, chief medical informatics officer (CMIO), and medical director of information systems.

Although he has found a new niche, his philosophy remains the same.

“Everything I do comes down to the fact I still love taking care of patients,” says Dr. Holder, one of six new members of Team Hospitalist. “That’s why I became a doctor. It’s very rewarding, and I never want to give that up.”

As a physician, I still find [clinical work] extremely rewarding. As medical director, I need to be in the trenches to know what the hospitalists are going through and what problems they are having. As CMIO, it’s very important that I use the system I’m in charge of trying to optimize.

Question: You left oncology partly because you became attached to your patients. Does that approach help you as a hospitalist?

Answer: Definitely. I try to teach younger hospitalists the value of developing a rapport with patients. I enjoy building that emotional or intellectual attachment. I’m a big believer in the human aspect of what we do, and it’s one of the aspects of my job I love the most.

Q: Did you join Decatur Memorial with aspirations of leading its hospitalist program?

A: No. My plan was to focus on giving good patient care, get involved on the quality side, and become the CMIO for the hospital. When the medical director role opened up, it seemed to be sitting there waiting to be filled. I structured it so I could continue to see patients and split my administrative time between being the medical director of the hospitalists and being the CMIO.

Q: Why is it so important for you to still see patients?

A: As a physician, I still find it extremely rewarding. As medical director, I need to be in the trenches to know what the hospitalists are going through and what problems they are having. As CMIO, it’s very important that I use the system I’m in charge of trying to optimize.

Q: What advice would you give to a physician who is about to become leader of a program?

A: You need to anticipate growth. I was caught off guard by how fast our program continued to grow, and how quickly we reached the point where we needed more hospitalists. In retrospect, I should have immediately started looking to recruit. I also was not prepared for the financial aspect. If you don’t have a financial background, I would very quickly get training in that area.

Q: What is your biggest challenge as medical director?

A: Getting others in the hospital to accept change, even when all indications are it’s for the better.

Q: Have you identified a strategy that helps make that process easier?

A: The first step is to establish a sense of urgency. Then I try to get people who will be involved in the process or people who don’t oppose change to help set up a vision for the project and communicate that vision. Once you get empowerment to do the project, go for a short, early win that shows the concept is viable and can make it.

Q: How did you develop your interest in information systems?

A: I’ve always been interested in computers and how we can use computerization and informatic systems to improve patient care. When I became a hospitalist, I got much more involved. Decatur Memorial implemented computer physician order entry (CPOE). I became the physician champion for that, and my interest grew from there. I’m fortunate our administration is very good at pushing to improve our information systems.

Q: Does that interest fit with your approach toward medicine?

A: Absolutely. I’m a big believer in evidenced-based medicine. I think computer systems complement that very well.

Q: You were a finalist for McKesson’s Distinguished Achieve-ment Award and received an award this year from the Association of Medical Directors of Information Systems. What were those honors for?

A: We did a complete cultural change with nurses and physicians in terms of how they deal with diabetes. As part of that project, I developed a CPOE order set that automatically calculated the basal, nutritional, and correctional insulin dosage for the physician based on the patient’s weight and height. It made the right thing to do the easy thing to do. The concept involved the use of evidence-based medicine, project improvement with the Six Sigma process, and the high-level use of informatics.

Q: Has that improved patient care?

A: I was able to demonstrate a statistically significant improvement in glucose control without a change in hypoglycemia, so I did demonstrate an improved clinical outcome.

Q: What’s next for you professionally?

A: I have no intention of changing jobs, but I will continue to be very involved in quality projects. The biggest long-term project is developing more patient- and family-centered care at our hospital. I went to a national conference in February, and a big component was patient-centered care. I was very intrigued by it and brought the vision back to our hospital.

Q: Where does the effort stand?

A: I thought our hospitalist group would be a good group to do an initial component of the project. It went over really well, and people started asking me to present it to others. It took on a life of its own, and I wound up on a bit of a lecture series. It has since become an official Six Sigma project. We got the charter for it and it’s going in the hospital’s strategic plan, which I’m very pleased about.

Q: You earned FHM designation earlier this year. What does that mean to you?

A: It means a great deal. It’s tremendous recognition for the work I’ve done, the quality improvement projects I’ve been involved with, and the leadership roles I’ve taken on. At the same time, when you are able to show a national society views your work as important, I think it gives me even more credibility with the administration and the support staff.

Mark Leiser is a freelance writer based in New Jersey.

Like many physicians, Larry Holder, MD, FACP, FHM, entered the medical profession with the desire to make a difference. After completing a fellowship in hematology and oncology in 1988, he joined Cancer Care Specialists of Central Illinois, a community oncology practice based in Decatur, and anticipated a lengthy career in which he would contribute to significant breakthroughs in cancer treatment.

After 12 years, however, he changed direction.

“I had become a bit disillusioned and realized we weren’t making big impacts, especially on the more common cancers,” he says. “I also got very attached to my patients, and in oncology, that’s not always a good thing. It became very trying emotionally.”

Dr. Holder spent the next five years practicing internal medicine at Community Health Improvement Center in Decatur. In 2005, he joined the hospitalist program at Decatur Memorial Hospital. Last year, he became medical director of hospitalist services, chief medical informatics officer (CMIO), and medical director of information systems.

Although he has found a new niche, his philosophy remains the same.

“Everything I do comes down to the fact I still love taking care of patients,” says Dr. Holder, one of six new members of Team Hospitalist. “That’s why I became a doctor. It’s very rewarding, and I never want to give that up.”

As a physician, I still find [clinical work] extremely rewarding. As medical director, I need to be in the trenches to know what the hospitalists are going through and what problems they are having. As CMIO, it’s very important that I use the system I’m in charge of trying to optimize.

Question: You left oncology partly because you became attached to your patients. Does that approach help you as a hospitalist?

Answer: Definitely. I try to teach younger hospitalists the value of developing a rapport with patients. I enjoy building that emotional or intellectual attachment. I’m a big believer in the human aspect of what we do, and it’s one of the aspects of my job I love the most.

Q: Did you join Decatur Memorial with aspirations of leading its hospitalist program?

A: No. My plan was to focus on giving good patient care, get involved on the quality side, and become the CMIO for the hospital. When the medical director role opened up, it seemed to be sitting there waiting to be filled. I structured it so I could continue to see patients and split my administrative time between being the medical director of the hospitalists and being the CMIO.

Q: Why is it so important for you to still see patients?

A: As a physician, I still find it extremely rewarding. As medical director, I need to be in the trenches to know what the hospitalists are going through and what problems they are having. As CMIO, it’s very important that I use the system I’m in charge of trying to optimize.

Q: What advice would you give to a physician who is about to become leader of a program?

A: You need to anticipate growth. I was caught off guard by how fast our program continued to grow, and how quickly we reached the point where we needed more hospitalists. In retrospect, I should have immediately started looking to recruit. I also was not prepared for the financial aspect. If you don’t have a financial background, I would very quickly get training in that area.

Q: What is your biggest challenge as medical director?

A: Getting others in the hospital to accept change, even when all indications are it’s for the better.

Q: Have you identified a strategy that helps make that process easier?

A: The first step is to establish a sense of urgency. Then I try to get people who will be involved in the process or people who don’t oppose change to help set up a vision for the project and communicate that vision. Once you get empowerment to do the project, go for a short, early win that shows the concept is viable and can make it.

Q: How did you develop your interest in information systems?

A: I’ve always been interested in computers and how we can use computerization and informatic systems to improve patient care. When I became a hospitalist, I got much more involved. Decatur Memorial implemented computer physician order entry (CPOE). I became the physician champion for that, and my interest grew from there. I’m fortunate our administration is very good at pushing to improve our information systems.

Q: Does that interest fit with your approach toward medicine?

A: Absolutely. I’m a big believer in evidenced-based medicine. I think computer systems complement that very well.

Q: You were a finalist for McKesson’s Distinguished Achieve-ment Award and received an award this year from the Association of Medical Directors of Information Systems. What were those honors for?

A: We did a complete cultural change with nurses and physicians in terms of how they deal with diabetes. As part of that project, I developed a CPOE order set that automatically calculated the basal, nutritional, and correctional insulin dosage for the physician based on the patient’s weight and height. It made the right thing to do the easy thing to do. The concept involved the use of evidence-based medicine, project improvement with the Six Sigma process, and the high-level use of informatics.

Q: Has that improved patient care?

A: I was able to demonstrate a statistically significant improvement in glucose control without a change in hypoglycemia, so I did demonstrate an improved clinical outcome.

Q: What’s next for you professionally?

A: I have no intention of changing jobs, but I will continue to be very involved in quality projects. The biggest long-term project is developing more patient- and family-centered care at our hospital. I went to a national conference in February, and a big component was patient-centered care. I was very intrigued by it and brought the vision back to our hospital.

Q: Where does the effort stand?

A: I thought our hospitalist group would be a good group to do an initial component of the project. It went over really well, and people started asking me to present it to others. It took on a life of its own, and I wound up on a bit of a lecture series. It has since become an official Six Sigma project. We got the charter for it and it’s going in the hospital’s strategic plan, which I’m very pleased about.

Q: You earned FHM designation earlier this year. What does that mean to you?

A: It means a great deal. It’s tremendous recognition for the work I’ve done, the quality improvement projects I’ve been involved with, and the leadership roles I’ve taken on. At the same time, when you are able to show a national society views your work as important, I think it gives me even more credibility with the administration and the support staff.

Mark Leiser is a freelance writer based in New Jersey.

Like many physicians, Larry Holder, MD, FACP, FHM, entered the medical profession with the desire to make a difference. After completing a fellowship in hematology and oncology in 1988, he joined Cancer Care Specialists of Central Illinois, a community oncology practice based in Decatur, and anticipated a lengthy career in which he would contribute to significant breakthroughs in cancer treatment.

After 12 years, however, he changed direction.

“I had become a bit disillusioned and realized we weren’t making big impacts, especially on the more common cancers,” he says. “I also got very attached to my patients, and in oncology, that’s not always a good thing. It became very trying emotionally.”

Dr. Holder spent the next five years practicing internal medicine at Community Health Improvement Center in Decatur. In 2005, he joined the hospitalist program at Decatur Memorial Hospital. Last year, he became medical director of hospitalist services, chief medical informatics officer (CMIO), and medical director of information systems.

Although he has found a new niche, his philosophy remains the same.

“Everything I do comes down to the fact I still love taking care of patients,” says Dr. Holder, one of six new members of Team Hospitalist. “That’s why I became a doctor. It’s very rewarding, and I never want to give that up.”

As a physician, I still find [clinical work] extremely rewarding. As medical director, I need to be in the trenches to know what the hospitalists are going through and what problems they are having. As CMIO, it’s very important that I use the system I’m in charge of trying to optimize.

Question: You left oncology partly because you became attached to your patients. Does that approach help you as a hospitalist?

Answer: Definitely. I try to teach younger hospitalists the value of developing a rapport with patients. I enjoy building that emotional or intellectual attachment. I’m a big believer in the human aspect of what we do, and it’s one of the aspects of my job I love the most.

Q: Did you join Decatur Memorial with aspirations of leading its hospitalist program?

A: No. My plan was to focus on giving good patient care, get involved on the quality side, and become the CMIO for the hospital. When the medical director role opened up, it seemed to be sitting there waiting to be filled. I structured it so I could continue to see patients and split my administrative time between being the medical director of the hospitalists and being the CMIO.

Q: Why is it so important for you to still see patients?

A: As a physician, I still find it extremely rewarding. As medical director, I need to be in the trenches to know what the hospitalists are going through and what problems they are having. As CMIO, it’s very important that I use the system I’m in charge of trying to optimize.

Q: What advice would you give to a physician who is about to become leader of a program?

A: You need to anticipate growth. I was caught off guard by how fast our program continued to grow, and how quickly we reached the point where we needed more hospitalists. In retrospect, I should have immediately started looking to recruit. I also was not prepared for the financial aspect. If you don’t have a financial background, I would very quickly get training in that area.

Q: What is your biggest challenge as medical director?

A: Getting others in the hospital to accept change, even when all indications are it’s for the better.

Q: Have you identified a strategy that helps make that process easier?

A: The first step is to establish a sense of urgency. Then I try to get people who will be involved in the process or people who don’t oppose change to help set up a vision for the project and communicate that vision. Once you get empowerment to do the project, go for a short, early win that shows the concept is viable and can make it.

Q: How did you develop your interest in information systems?

A: I’ve always been interested in computers and how we can use computerization and informatic systems to improve patient care. When I became a hospitalist, I got much more involved. Decatur Memorial implemented computer physician order entry (CPOE). I became the physician champion for that, and my interest grew from there. I’m fortunate our administration is very good at pushing to improve our information systems.

Q: Does that interest fit with your approach toward medicine?

A: Absolutely. I’m a big believer in evidenced-based medicine. I think computer systems complement that very well.

Q: You were a finalist for McKesson’s Distinguished Achieve-ment Award and received an award this year from the Association of Medical Directors of Information Systems. What were those honors for?

A: We did a complete cultural change with nurses and physicians in terms of how they deal with diabetes. As part of that project, I developed a CPOE order set that automatically calculated the basal, nutritional, and correctional insulin dosage for the physician based on the patient’s weight and height. It made the right thing to do the easy thing to do. The concept involved the use of evidence-based medicine, project improvement with the Six Sigma process, and the high-level use of informatics.

Q: Has that improved patient care?

A: I was able to demonstrate a statistically significant improvement in glucose control without a change in hypoglycemia, so I did demonstrate an improved clinical outcome.

Q: What’s next for you professionally?

A: I have no intention of changing jobs, but I will continue to be very involved in quality projects. The biggest long-term project is developing more patient- and family-centered care at our hospital. I went to a national conference in February, and a big component was patient-centered care. I was very intrigued by it and brought the vision back to our hospital.

Q: Where does the effort stand?

A: I thought our hospitalist group would be a good group to do an initial component of the project. It went over really well, and people started asking me to present it to others. It took on a life of its own, and I wound up on a bit of a lecture series. It has since become an official Six Sigma project. We got the charter for it and it’s going in the hospital’s strategic plan, which I’m very pleased about.

Q: You earned FHM designation earlier this year. What does that mean to you?

A: It means a great deal. It’s tremendous recognition for the work I’ve done, the quality improvement projects I’ve been involved with, and the leadership roles I’ve taken on. At the same time, when you are able to show a national society views your work as important, I think it gives me even more credibility with the administration and the support staff.

Mark Leiser is a freelance writer based in New Jersey.

An abstract presented at HM11, “Purposeful Visits for Hospitalized Elderly Patients,” describes a service at the University of Colorado Hospital (UCH) in Denver that has shown improvements in participating patients’ mood, agitation, and orientation.

The purposeful-visit program was started, says senior author Ethan Cumbler, MD, a hospitalist at UCH and director of its Acute Care for the Elderly Service, because hospitals often are a profoundly unfriendly environment, especially for vulnerable, chronically ill patients. “It’s a social and intellectual desert where patients don’t get the stimulation they would receive at home,” he adds.

The program was established to leverage professional resources by training a core cadre of four to six volunteers in communication techniques (e.g. open-ended questioning), says the hospital’s recreational therapist, William Mramor, CTRS, MS. Charge nurses help identify patients and topics to explore, and the volunteers use a prepared script to help guide interactions, Mramor says.

“The purposeful visit directly addresses issues of patients’ feelings and promotes a patient-centered hospital experience,” he says.

Based on assessments using a five-point scale, with scores ranging from “worsening” (1 or 2) to “improving” (4 or 5), patient mood was rated 3.94 by the volunteers and 3.65 by the nurses. Slightly lower scores were recorded for patient agitation and patient orientation but in every case showed improvement.

“What distinguishes these purposeful visits is their goal of enhancing patients’ memory, decreasing their loneliness, and helping them understand the value of reconnecting to things they enjoy,” says Dr. Cumbler. —LB

Technology

New E-Pillbox Actively Monitors Med-Recon, Fights Readmissions

Electronic pillboxes are nothing new, but some hospitalists might not have seen the latest one.

Earlier this year, the FDA approved PillStation, a traditional pillbox married to a software system that uploads data to the system’s maker, SentiCare Inc., which then monitors how well a patient is following their medication regimen. The four-year-old medical firm is pitching the product to hospitals and accountable-care organizations (ACOs), among other potential clients.

And in a sales pitch practically tailored to HM, SentiCare bills itself as a medication adherence system that can help fight readmissions, particularly in cases of chronic disease or congestive heart failure. The device actually takes photographs of the pills to be taken and can record whether a patient has removed them from the device.

“Hospitals need to dramatically reduce their readmissions rates,” Yogendra Jain, chief technology officer and cofounder of SentiCare, wrote in an email to The Hospitalist. “One critical factor is medication and hospital discharge instruction adherence. Through its embedded camera, PillStation can confirm that from day one of departing the hospital... medications are loaded correctly and that the patient is taking it on time.”—RQ

Quality

Home Healthcare Has Fewer Rehospitalizations

A recent study by Avalere Health, a healthcare advisory firm based in Washington, D.C., found that providing home healthcare after hospital discharge for patients with three common conditions resulted in fewer hospital readmissions than for similar patients receiving other post-acute services. Those comparable services included long-term acute-care hospitals, inpatient rehabilitation facilities, skilled nursing facilities, and hospices.

“We tried to control for hospital DRG, severity of illness, and comorbidities,” says Emil Parker, Avalere’s director of post-acute and long-term-care practice, although he acknowledges the complexities of risk adjustment.

In comparing Medicare spending and rehospitalization rates after initial hospital visits for patients with diabetes, COPD, and congestive heart failure from 2006 to 2009, the study estimated that referrals to home healthcare resulted in $670 million in Medicare savings from 20,426 fewer readmissions.

“Hospitalists should think about the continuum of institutional support for patients discharged from the hospital with significant support needs,” Parker says. “Our study shows that in this population, provision of home healthcare is cost-effective and benefits patients by improving the continuity of their care.” —LB

Patient Safety

L.A. Hospitals Add HM for Medicaid Patients

In June, Anthem Blue Cross of Woodland Hills, Calif., began offering covered hospitalist services to its adult managed-care members covered by Medi-Cal, the Medicaid program for California residents, at 24 hospitals in Los Angeles County. The service is designed to take advantage of the existing hospitalist presence in those hospitals, which is provided by ApolloMed, a Glendale, Calif.-based medical management services company.

The hospitalist service is designed to enhance quality of care during hospitalization, reduce costs, and plan for more timely discharges and transitions to outpatient care. ApolloMed plans to add more hospitals in the region to the program, as well as additional post-discharge outpatient clinics. —LB

Technology

By the Numbers: 5.9

The percentage of total national health expenditures spent on medical devices in 2009, according to a report released in June by the Advanced Medical Technology Association.

The report highlights that while technology is washing over medicine, and HM in particular, with the adoption of electronic health records, portable ultrasounds, and tablet computing, the $147 billion spent on medical devices in 2009 represented just 5.9% of the $2.5 trillion in national health spending.

The trade group also reported that the average annual rate for medical device spending increased 7.5% in the 20-year period that ended in 2009. That outpaced the average annual rate for overall national heath expenditures, which ticked up 7% over the same time period. —RQ

An abstract presented at HM11, “Purposeful Visits for Hospitalized Elderly Patients,” describes a service at the University of Colorado Hospital (UCH) in Denver that has shown improvements in participating patients’ mood, agitation, and orientation.

The purposeful-visit program was started, says senior author Ethan Cumbler, MD, a hospitalist at UCH and director of its Acute Care for the Elderly Service, because hospitals often are a profoundly unfriendly environment, especially for vulnerable, chronically ill patients. “It’s a social and intellectual desert where patients don’t get the stimulation they would receive at home,” he adds.

The program was established to leverage professional resources by training a core cadre of four to six volunteers in communication techniques (e.g. open-ended questioning), says the hospital’s recreational therapist, William Mramor, CTRS, MS. Charge nurses help identify patients and topics to explore, and the volunteers use a prepared script to help guide interactions, Mramor says.

“The purposeful visit directly addresses issues of patients’ feelings and promotes a patient-centered hospital experience,” he says.

Based on assessments using a five-point scale, with scores ranging from “worsening” (1 or 2) to “improving” (4 or 5), patient mood was rated 3.94 by the volunteers and 3.65 by the nurses. Slightly lower scores were recorded for patient agitation and patient orientation but in every case showed improvement.

“What distinguishes these purposeful visits is their goal of enhancing patients’ memory, decreasing their loneliness, and helping them understand the value of reconnecting to things they enjoy,” says Dr. Cumbler. —LB

Technology

New E-Pillbox Actively Monitors Med-Recon, Fights Readmissions

Electronic pillboxes are nothing new, but some hospitalists might not have seen the latest one.

Earlier this year, the FDA approved PillStation, a traditional pillbox married to a software system that uploads data to the system’s maker, SentiCare Inc., which then monitors how well a patient is following their medication regimen. The four-year-old medical firm is pitching the product to hospitals and accountable-care organizations (ACOs), among other potential clients.

And in a sales pitch practically tailored to HM, SentiCare bills itself as a medication adherence system that can help fight readmissions, particularly in cases of chronic disease or congestive heart failure. The device actually takes photographs of the pills to be taken and can record whether a patient has removed them from the device.

“Hospitals need to dramatically reduce their readmissions rates,” Yogendra Jain, chief technology officer and cofounder of SentiCare, wrote in an email to The Hospitalist. “One critical factor is medication and hospital discharge instruction adherence. Through its embedded camera, PillStation can confirm that from day one of departing the hospital... medications are loaded correctly and that the patient is taking it on time.”—RQ

Quality

Home Healthcare Has Fewer Rehospitalizations

A recent study by Avalere Health, a healthcare advisory firm based in Washington, D.C., found that providing home healthcare after hospital discharge for patients with three common conditions resulted in fewer hospital readmissions than for similar patients receiving other post-acute services. Those comparable services included long-term acute-care hospitals, inpatient rehabilitation facilities, skilled nursing facilities, and hospices.

“We tried to control for hospital DRG, severity of illness, and comorbidities,” says Emil Parker, Avalere’s director of post-acute and long-term-care practice, although he acknowledges the complexities of risk adjustment.

In comparing Medicare spending and rehospitalization rates after initial hospital visits for patients with diabetes, COPD, and congestive heart failure from 2006 to 2009, the study estimated that referrals to home healthcare resulted in $670 million in Medicare savings from 20,426 fewer readmissions.

“Hospitalists should think about the continuum of institutional support for patients discharged from the hospital with significant support needs,” Parker says. “Our study shows that in this population, provision of home healthcare is cost-effective and benefits patients by improving the continuity of their care.” —LB

Patient Safety

L.A. Hospitals Add HM for Medicaid Patients

In June, Anthem Blue Cross of Woodland Hills, Calif., began offering covered hospitalist services to its adult managed-care members covered by Medi-Cal, the Medicaid program for California residents, at 24 hospitals in Los Angeles County. The service is designed to take advantage of the existing hospitalist presence in those hospitals, which is provided by ApolloMed, a Glendale, Calif.-based medical management services company.

The hospitalist service is designed to enhance quality of care during hospitalization, reduce costs, and plan for more timely discharges and transitions to outpatient care. ApolloMed plans to add more hospitals in the region to the program, as well as additional post-discharge outpatient clinics. —LB

Technology

By the Numbers: 5.9

The percentage of total national health expenditures spent on medical devices in 2009, according to a report released in June by the Advanced Medical Technology Association.

The report highlights that while technology is washing over medicine, and HM in particular, with the adoption of electronic health records, portable ultrasounds, and tablet computing, the $147 billion spent on medical devices in 2009 represented just 5.9% of the $2.5 trillion in national health spending.

The trade group also reported that the average annual rate for medical device spending increased 7.5% in the 20-year period that ended in 2009. That outpaced the average annual rate for overall national heath expenditures, which ticked up 7% over the same time period. —RQ

An abstract presented at HM11, “Purposeful Visits for Hospitalized Elderly Patients,” describes a service at the University of Colorado Hospital (UCH) in Denver that has shown improvements in participating patients’ mood, agitation, and orientation.

The purposeful-visit program was started, says senior author Ethan Cumbler, MD, a hospitalist at UCH and director of its Acute Care for the Elderly Service, because hospitals often are a profoundly unfriendly environment, especially for vulnerable, chronically ill patients. “It’s a social and intellectual desert where patients don’t get the stimulation they would receive at home,” he adds.

The program was established to leverage professional resources by training a core cadre of four to six volunteers in communication techniques (e.g. open-ended questioning), says the hospital’s recreational therapist, William Mramor, CTRS, MS. Charge nurses help identify patients and topics to explore, and the volunteers use a prepared script to help guide interactions, Mramor says.

“The purposeful visit directly addresses issues of patients’ feelings and promotes a patient-centered hospital experience,” he says.

Based on assessments using a five-point scale, with scores ranging from “worsening” (1 or 2) to “improving” (4 or 5), patient mood was rated 3.94 by the volunteers and 3.65 by the nurses. Slightly lower scores were recorded for patient agitation and patient orientation but in every case showed improvement.

“What distinguishes these purposeful visits is their goal of enhancing patients’ memory, decreasing their loneliness, and helping them understand the value of reconnecting to things they enjoy,” says Dr. Cumbler. —LB

Technology

New E-Pillbox Actively Monitors Med-Recon, Fights Readmissions

Electronic pillboxes are nothing new, but some hospitalists might not have seen the latest one.

Earlier this year, the FDA approved PillStation, a traditional pillbox married to a software system that uploads data to the system’s maker, SentiCare Inc., which then monitors how well a patient is following their medication regimen. The four-year-old medical firm is pitching the product to hospitals and accountable-care organizations (ACOs), among other potential clients.

And in a sales pitch practically tailored to HM, SentiCare bills itself as a medication adherence system that can help fight readmissions, particularly in cases of chronic disease or congestive heart failure. The device actually takes photographs of the pills to be taken and can record whether a patient has removed them from the device.

“Hospitals need to dramatically reduce their readmissions rates,” Yogendra Jain, chief technology officer and cofounder of SentiCare, wrote in an email to The Hospitalist. “One critical factor is medication and hospital discharge instruction adherence. Through its embedded camera, PillStation can confirm that from day one of departing the hospital... medications are loaded correctly and that the patient is taking it on time.”—RQ

Quality

Home Healthcare Has Fewer Rehospitalizations

A recent study by Avalere Health, a healthcare advisory firm based in Washington, D.C., found that providing home healthcare after hospital discharge for patients with three common conditions resulted in fewer hospital readmissions than for similar patients receiving other post-acute services. Those comparable services included long-term acute-care hospitals, inpatient rehabilitation facilities, skilled nursing facilities, and hospices.

“We tried to control for hospital DRG, severity of illness, and comorbidities,” says Emil Parker, Avalere’s director of post-acute and long-term-care practice, although he acknowledges the complexities of risk adjustment.

In comparing Medicare spending and rehospitalization rates after initial hospital visits for patients with diabetes, COPD, and congestive heart failure from 2006 to 2009, the study estimated that referrals to home healthcare resulted in $670 million in Medicare savings from 20,426 fewer readmissions.

“Hospitalists should think about the continuum of institutional support for patients discharged from the hospital with significant support needs,” Parker says. “Our study shows that in this population, provision of home healthcare is cost-effective and benefits patients by improving the continuity of their care.” —LB

Patient Safety

L.A. Hospitals Add HM for Medicaid Patients

In June, Anthem Blue Cross of Woodland Hills, Calif., began offering covered hospitalist services to its adult managed-care members covered by Medi-Cal, the Medicaid program for California residents, at 24 hospitals in Los Angeles County. The service is designed to take advantage of the existing hospitalist presence in those hospitals, which is provided by ApolloMed, a Glendale, Calif.-based medical management services company.

The hospitalist service is designed to enhance quality of care during hospitalization, reduce costs, and plan for more timely discharges and transitions to outpatient care. ApolloMed plans to add more hospitals in the region to the program, as well as additional post-discharge outpatient clinics. —LB

Technology

By the Numbers: 5.9

The percentage of total national health expenditures spent on medical devices in 2009, according to a report released in June by the Advanced Medical Technology Association.

The report highlights that while technology is washing over medicine, and HM in particular, with the adoption of electronic health records, portable ultrasounds, and tablet computing, the $147 billion spent on medical devices in 2009 represented just 5.9% of the $2.5 trillion in national health spending.

The trade group also reported that the average annual rate for medical device spending increased 7.5% in the 20-year period that ended in 2009. That outpaced the average annual rate for overall national heath expenditures, which ticked up 7% over the same time period. —RQ

It’s been a hectic week, as the Annals of Internal Medicine paper regarding hospitalist outcomes was published.¹ I cannot escape the fallout of the paper showing that the hospitalist model is associated with increased costs of care. The Internet, the phone, my email, the radio, the hallways all are abuzz with excitement about the implications of this paper. Everyone, it seems, has an opinion. The viewpoints range from “the article is methodologically flawed” to “yeah, but that data is old and things are different now,” to “I knew the model was bunk” to “it’s time to bring back the traditional model of care.”

Moreover, nobody is afraid to share.

Wherever you stand on this continuum, it isn’t hard to find a supporting opinion. NPR covered it, newspapers reported it, and bloggers blogged it. Thousands of words were typed, printed, tweeted, spoken. However, one word seemed conspicuously absent. That word? Thanks.

The Study

The study authors examined more than 58,000 admissions at 454 hospitals and compared the impact of hospitalist versus PCP care on in-hospital and post-discharge outcomes. Predictably, hospital length of stay (LOS) was shorter (0.64 days) and less costly ($282) with the hospitalist model. This has been shown, albeit generally with more robust outcomes, in nearly all-previous studies. Importantly, however, this study lifted the veil on what happens after discharge—and the findings have rocked the foundation of the HM field.

Hospitalist patients were less likely to follow up with their PCP, more likely to go to a skilled nursing facility, more likely to return to the ED, and had higher rates of 30-day readmission. All of this post-discharge care came with a price tag—$332 more than the PCP model—making the bundled in- and outpatient costs of care about $50 more per patient in the hospitalist model.

And this is where the controversy—and the words—begins. Connecting the earlier discharge, the added SNF utilization, and the higher readmission rate could only mean only one thing to those that favor the traditional model—a cost shift. Clearly hospitalists, motivated by saving money, are shifting the financial costs just beyond the hospital confines, discharging patients so early that they require nursing home and, ultimately, more ED visits and hospital care.

On the other side of the ledger, HM supporters have pointed out that the patients in the two arms were not the same. The HM patients were more likely to be admitted from a nursing home, more comorbid, poorer, and more likely to be admitted on a weekend—all valid points, which are hard to control for in an observational study. They argue that patients in an SNF are, of course, less likely to see their PCP than patients at home and, therefore, more likely to be sent to an ED (and admitted) when issues arise. Perhaps, the argument goes, in this scenario the system is actually working. Without indicators of quality of life and functional status, it’s hard to know that HM patients didn’t do better. Sure, there were more readmissions and it cost more, but perhaps that’s the cost of better, longer-term outcomes.

My take: Let’s move beyond debating the study merits and its implications. HM is here to stay. No matter how much we conjure Osler, we aren’t going back to the traditional model. In the debate we miss the point. Rome is afire; it’s time to stop fiddling.

So, let’s put our preconceived biases, the potential methodological flaws, the conspiratorial overtones, the vitriolic banter, and the fruitless debates behind us. This study was generally well done. It focuses on a (perhaps, the) crucial issue for HM. And its findings are plausible. For that I say “thanks”: for exposing this issue so we can tackle it head on by moving in at least three distinct directions—quality, training, and retraining.

Now let’s put down the fiddle and pick up the extinguisher.

$50: The Price of Quality?

First, I hope this study finally pushes our field beyond the cost discussion. We simply can and should not be a field that is about saving money. Yes, it is great to save money. But more important, we have to enhance the quality and safety of hospital (and post-hospital) care.

The piece missing from the Annals paper is any significant look at quality metrics, beyond perhaps readmission. It is possible, and maybe probable, that hospitalists in this study reduced complications, avoided harm, and improved inpatient mortality. Perhaps this, and not a zeal for too-early discharges, is what fueled the lower hospital cost and shorter LOS.

How much is that worth? It’s hard to say, but I’d venture much more than the $50 more per patient associated with the hospitalist model. Quality, even at higher costs, needs to be our primary focus moving forward. We must improve the quality of care to levels that, if necessary, Medicare would happily pay more for. This must be our singular goal. I’d also argue that we include the post-discharge period in our quality reach.

More QI, Less MEN

We cannot continue to train square pegs and struggle to cram them into round holes. We need more systems thinkers. We do a tremendous job teaching our students and residents about the interplay of pathophysiology and pharmacology, but spend very little time with the interplay between our patients and the system. We simply must triage process improvement, quality, safety, and efficiency training closer to the top of our medical curricula.

As such, it shouldn’t be that surprising that two groups of providers with the exact same background and training should have similar outcomes as seen in this study. The reality is that these providers came from very similar training backgrounds. Yes, they have chosen different practice models, but we all learned how to treat pneumonia and heart failure. It’s not about the model as much as what you do with the model. Cohorting patients to providers who just care for hospitalized patients will lead to efficiencies, but if we want to fundamentally improve patient outcomes, both during and after their hospital stay, we need to train hospitalists to transform that model through systematic process improvement.

And I firmly believe that hospitalists should lead this sea change. Our teaching brethren are perfectly positioned to develop hospitalist-focused training models that better prepare future hospitalists to fundamentally improve not just transitions of care but indeed all systems of care. Training that emphasizes systems thinking, mentored process improvement, and patient safety across the continuum of care.

BOOSTing Outcomes

This paper highlights HM’s Achilles’ heel. It has always been transitions of care—specifically, communication with PCPs. HM is by its very nature a fractured care model. And that discontinuity results in information drop on transitions. A PCP who knows a patient and admits and follows them after discharge is better positioned to reduce readmissions because there is no information drop in that model. The success of the HM model hinges on hospitalists efficiently and effectively approximating that level of knowledge transfer to PCPs. And to be honest, we don’t need an NIH-funded study to tell us that we have not been doing a great job with this.

This is not necessarily from a lack of effort but rather because we lack systems that simplify information transfer on transitions. It is incumbent these systems be built. It is incumbent we lead this. Whether you choose Project BOOST, Project RED, or a homegrown solution, it is no longer acceptable to ignore the transitions of care issue.

And with that I’ve just typed my 1,319th word about an article that has already commanded too many words. Don’t get me wrong, the discussion is important, and for that we must thank the study’s authors. But it’s time to move beyond the discussion, the debate, the words.

It’s time to turn words into deeds.

Dr. Glasheen is physician editor of The Hospitalist.

Reference

1. Kuo YF, Goodwin JS. Association of hospitalist care with medical utilization after discharge: evidence of cost shift from a cohort study. Ann Intern Med. 2011;155:152-159.

It’s been a hectic week, as the Annals of Internal Medicine paper regarding hospitalist outcomes was published.¹ I cannot escape the fallout of the paper showing that the hospitalist model is associated with increased costs of care. The Internet, the phone, my email, the radio, the hallways all are abuzz with excitement about the implications of this paper. Everyone, it seems, has an opinion. The viewpoints range from “the article is methodologically flawed” to “yeah, but that data is old and things are different now,” to “I knew the model was bunk” to “it’s time to bring back the traditional model of care.”

Moreover, nobody is afraid to share.

Wherever you stand on this continuum, it isn’t hard to find a supporting opinion. NPR covered it, newspapers reported it, and bloggers blogged it. Thousands of words were typed, printed, tweeted, spoken. However, one word seemed conspicuously absent. That word? Thanks.

The Study

The study authors examined more than 58,000 admissions at 454 hospitals and compared the impact of hospitalist versus PCP care on in-hospital and post-discharge outcomes. Predictably, hospital length of stay (LOS) was shorter (0.64 days) and less costly ($282) with the hospitalist model. This has been shown, albeit generally with more robust outcomes, in nearly all-previous studies. Importantly, however, this study lifted the veil on what happens after discharge—and the findings have rocked the foundation of the HM field.

Hospitalist patients were less likely to follow up with their PCP, more likely to go to a skilled nursing facility, more likely to return to the ED, and had higher rates of 30-day readmission. All of this post-discharge care came with a price tag—$332 more than the PCP model—making the bundled in- and outpatient costs of care about $50 more per patient in the hospitalist model.

And this is where the controversy—and the words—begins. Connecting the earlier discharge, the added SNF utilization, and the higher readmission rate could only mean only one thing to those that favor the traditional model—a cost shift. Clearly hospitalists, motivated by saving money, are shifting the financial costs just beyond the hospital confines, discharging patients so early that they require nursing home and, ultimately, more ED visits and hospital care.

On the other side of the ledger, HM supporters have pointed out that the patients in the two arms were not the same. The HM patients were more likely to be admitted from a nursing home, more comorbid, poorer, and more likely to be admitted on a weekend—all valid points, which are hard to control for in an observational study. They argue that patients in an SNF are, of course, less likely to see their PCP than patients at home and, therefore, more likely to be sent to an ED (and admitted) when issues arise. Perhaps, the argument goes, in this scenario the system is actually working. Without indicators of quality of life and functional status, it’s hard to know that HM patients didn’t do better. Sure, there were more readmissions and it cost more, but perhaps that’s the cost of better, longer-term outcomes.

My take: Let’s move beyond debating the study merits and its implications. HM is here to stay. No matter how much we conjure Osler, we aren’t going back to the traditional model. In the debate we miss the point. Rome is afire; it’s time to stop fiddling.

So, let’s put our preconceived biases, the potential methodological flaws, the conspiratorial overtones, the vitriolic banter, and the fruitless debates behind us. This study was generally well done. It focuses on a (perhaps, the) crucial issue for HM. And its findings are plausible. For that I say “thanks”: for exposing this issue so we can tackle it head on by moving in at least three distinct directions—quality, training, and retraining.

Now let’s put down the fiddle and pick up the extinguisher.

$50: The Price of Quality?

First, I hope this study finally pushes our field beyond the cost discussion. We simply can and should not be a field that is about saving money. Yes, it is great to save money. But more important, we have to enhance the quality and safety of hospital (and post-hospital) care.

The piece missing from the Annals paper is any significant look at quality metrics, beyond perhaps readmission. It is possible, and maybe probable, that hospitalists in this study reduced complications, avoided harm, and improved inpatient mortality. Perhaps this, and not a zeal for too-early discharges, is what fueled the lower hospital cost and shorter LOS.

How much is that worth? It’s hard to say, but I’d venture much more than the $50 more per patient associated with the hospitalist model. Quality, even at higher costs, needs to be our primary focus moving forward. We must improve the quality of care to levels that, if necessary, Medicare would happily pay more for. This must be our singular goal. I’d also argue that we include the post-discharge period in our quality reach.

More QI, Less MEN

We cannot continue to train square pegs and struggle to cram them into round holes. We need more systems thinkers. We do a tremendous job teaching our students and residents about the interplay of pathophysiology and pharmacology, but spend very little time with the interplay between our patients and the system. We simply must triage process improvement, quality, safety, and efficiency training closer to the top of our medical curricula.

As such, it shouldn’t be that surprising that two groups of providers with the exact same background and training should have similar outcomes as seen in this study. The reality is that these providers came from very similar training backgrounds. Yes, they have chosen different practice models, but we all learned how to treat pneumonia and heart failure. It’s not about the model as much as what you do with the model. Cohorting patients to providers who just care for hospitalized patients will lead to efficiencies, but if we want to fundamentally improve patient outcomes, both during and after their hospital stay, we need to train hospitalists to transform that model through systematic process improvement.

And I firmly believe that hospitalists should lead this sea change. Our teaching brethren are perfectly positioned to develop hospitalist-focused training models that better prepare future hospitalists to fundamentally improve not just transitions of care but indeed all systems of care. Training that emphasizes systems thinking, mentored process improvement, and patient safety across the continuum of care.

BOOSTing Outcomes

This paper highlights HM’s Achilles’ heel. It has always been transitions of care—specifically, communication with PCPs. HM is by its very nature a fractured care model. And that discontinuity results in information drop on transitions. A PCP who knows a patient and admits and follows them after discharge is better positioned to reduce readmissions because there is no information drop in that model. The success of the HM model hinges on hospitalists efficiently and effectively approximating that level of knowledge transfer to PCPs. And to be honest, we don’t need an NIH-funded study to tell us that we have not been doing a great job with this.

This is not necessarily from a lack of effort but rather because we lack systems that simplify information transfer on transitions. It is incumbent these systems be built. It is incumbent we lead this. Whether you choose Project BOOST, Project RED, or a homegrown solution, it is no longer acceptable to ignore the transitions of care issue.

And with that I’ve just typed my 1,319th word about an article that has already commanded too many words. Don’t get me wrong, the discussion is important, and for that we must thank the study’s authors. But it’s time to move beyond the discussion, the debate, the words.

It’s time to turn words into deeds.

Dr. Glasheen is physician editor of The Hospitalist.

Reference

1. Kuo YF, Goodwin JS. Association of hospitalist care with medical utilization after discharge: evidence of cost shift from a cohort study. Ann Intern Med. 2011;155:152-159.

It’s been a hectic week, as the Annals of Internal Medicine paper regarding hospitalist outcomes was published.¹ I cannot escape the fallout of the paper showing that the hospitalist model is associated with increased costs of care. The Internet, the phone, my email, the radio, the hallways all are abuzz with excitement about the implications of this paper. Everyone, it seems, has an opinion. The viewpoints range from “the article is methodologically flawed” to “yeah, but that data is old and things are different now,” to “I knew the model was bunk” to “it’s time to bring back the traditional model of care.”

Moreover, nobody is afraid to share.

Wherever you stand on this continuum, it isn’t hard to find a supporting opinion. NPR covered it, newspapers reported it, and bloggers blogged it. Thousands of words were typed, printed, tweeted, spoken. However, one word seemed conspicuously absent. That word? Thanks.

The Study

The study authors examined more than 58,000 admissions at 454 hospitals and compared the impact of hospitalist versus PCP care on in-hospital and post-discharge outcomes. Predictably, hospital length of stay (LOS) was shorter (0.64 days) and less costly ($282) with the hospitalist model. This has been shown, albeit generally with more robust outcomes, in nearly all-previous studies. Importantly, however, this study lifted the veil on what happens after discharge—and the findings have rocked the foundation of the HM field.

Hospitalist patients were less likely to follow up with their PCP, more likely to go to a skilled nursing facility, more likely to return to the ED, and had higher rates of 30-day readmission. All of this post-discharge care came with a price tag—$332 more than the PCP model—making the bundled in- and outpatient costs of care about $50 more per patient in the hospitalist model.

And this is where the controversy—and the words—begins. Connecting the earlier discharge, the added SNF utilization, and the higher readmission rate could only mean only one thing to those that favor the traditional model—a cost shift. Clearly hospitalists, motivated by saving money, are shifting the financial costs just beyond the hospital confines, discharging patients so early that they require nursing home and, ultimately, more ED visits and hospital care.

On the other side of the ledger, HM supporters have pointed out that the patients in the two arms were not the same. The HM patients were more likely to be admitted from a nursing home, more comorbid, poorer, and more likely to be admitted on a weekend—all valid points, which are hard to control for in an observational study. They argue that patients in an SNF are, of course, less likely to see their PCP than patients at home and, therefore, more likely to be sent to an ED (and admitted) when issues arise. Perhaps, the argument goes, in this scenario the system is actually working. Without indicators of quality of life and functional status, it’s hard to know that HM patients didn’t do better. Sure, there were more readmissions and it cost more, but perhaps that’s the cost of better, longer-term outcomes.

My take: Let’s move beyond debating the study merits and its implications. HM is here to stay. No matter how much we conjure Osler, we aren’t going back to the traditional model. In the debate we miss the point. Rome is afire; it’s time to stop fiddling.

So, let’s put our preconceived biases, the potential methodological flaws, the conspiratorial overtones, the vitriolic banter, and the fruitless debates behind us. This study was generally well done. It focuses on a (perhaps, the) crucial issue for HM. And its findings are plausible. For that I say “thanks”: for exposing this issue so we can tackle it head on by moving in at least three distinct directions—quality, training, and retraining.

Now let’s put down the fiddle and pick up the extinguisher.

$50: The Price of Quality?

First, I hope this study finally pushes our field beyond the cost discussion. We simply can and should not be a field that is about saving money. Yes, it is great to save money. But more important, we have to enhance the quality and safety of hospital (and post-hospital) care.

The piece missing from the Annals paper is any significant look at quality metrics, beyond perhaps readmission. It is possible, and maybe probable, that hospitalists in this study reduced complications, avoided harm, and improved inpatient mortality. Perhaps this, and not a zeal for too-early discharges, is what fueled the lower hospital cost and shorter LOS.

How much is that worth? It’s hard to say, but I’d venture much more than the $50 more per patient associated with the hospitalist model. Quality, even at higher costs, needs to be our primary focus moving forward. We must improve the quality of care to levels that, if necessary, Medicare would happily pay more for. This must be our singular goal. I’d also argue that we include the post-discharge period in our quality reach.

More QI, Less MEN

We cannot continue to train square pegs and struggle to cram them into round holes. We need more systems thinkers. We do a tremendous job teaching our students and residents about the interplay of pathophysiology and pharmacology, but spend very little time with the interplay between our patients and the system. We simply must triage process improvement, quality, safety, and efficiency training closer to the top of our medical curricula.

As such, it shouldn’t be that surprising that two groups of providers with the exact same background and training should have similar outcomes as seen in this study. The reality is that these providers came from very similar training backgrounds. Yes, they have chosen different practice models, but we all learned how to treat pneumonia and heart failure. It’s not about the model as much as what you do with the model. Cohorting patients to providers who just care for hospitalized patients will lead to efficiencies, but if we want to fundamentally improve patient outcomes, both during and after their hospital stay, we need to train hospitalists to transform that model through systematic process improvement.

And I firmly believe that hospitalists should lead this sea change. Our teaching brethren are perfectly positioned to develop hospitalist-focused training models that better prepare future hospitalists to fundamentally improve not just transitions of care but indeed all systems of care. Training that emphasizes systems thinking, mentored process improvement, and patient safety across the continuum of care.

BOOSTing Outcomes

This paper highlights HM’s Achilles’ heel. It has always been transitions of care—specifically, communication with PCPs. HM is by its very nature a fractured care model. And that discontinuity results in information drop on transitions. A PCP who knows a patient and admits and follows them after discharge is better positioned to reduce readmissions because there is no information drop in that model. The success of the HM model hinges on hospitalists efficiently and effectively approximating that level of knowledge transfer to PCPs. And to be honest, we don’t need an NIH-funded study to tell us that we have not been doing a great job with this.

This is not necessarily from a lack of effort but rather because we lack systems that simplify information transfer on transitions. It is incumbent these systems be built. It is incumbent we lead this. Whether you choose Project BOOST, Project RED, or a homegrown solution, it is no longer acceptable to ignore the transitions of care issue.

And with that I’ve just typed my 1,319th word about an article that has already commanded too many words. Don’t get me wrong, the discussion is important, and for that we must thank the study’s authors. But it’s time to move beyond the discussion, the debate, the words.

It’s time to turn words into deeds.

Dr. Glasheen is physician editor of The Hospitalist.

Reference

1. Kuo YF, Goodwin JS. Association of hospitalist care with medical utilization after discharge: evidence of cost shift from a cohort study. Ann Intern Med. 2011;155:152-159.

What I am curious about are the current issues around using length of stay (LOS) or cost/case or the like as part of compensation packages. I have had discussions with several other folks, and I think I am getting the picture. However, it sounds like there has been some new interpretation of the laws around gainsharing, and that is what I am curious about.

K.S., Ohio

Dr. Hospitalist responds:

Tough question, and let me start by saying that I’m not a healthcare lawyer: This stuff is tricky. I’ll do my best to explain the current situation as I understand it, but I’m no expert on this.

So gainsharing, as generally defined in healthcare, is where a hospital and a group of physicians design a contract around services for which the two sides can share in any savings. Physicians are paid fee-for-service by Medicare, thus they are reimbursed per unit of work, with no incentive for cost control. Hospitals are paid on a per-case (or per-procedure) basis, so cost control means a lot to them: Because they get a set payment, any savings generated, they get to keep. Ideally, this means that better performance leads to more efficient care, less waste, and better outcomes. Unfortunately, that’s not always what happens, especially in the view of the federal government (you know, the guys who issue the bright orange jumpsuits for you to wear when you break the law).

Gainsharing has an interesting history as interpreted by the Office of the Inspector General (OIG) and the Centers for Medicare & Medicaid Services (CMS). Back in 1999, the OIG explicitly stopped any gainsharing models between physicians and hospitals based on concerns that these contracts might reduce the care provided to patients. The opinion was that there might be a “race to the bottom” in terms of cutting expenses (read: services).

Since then, there has been only incremental movement forward in the form of demonstration projects. One project looked at two very specific procedures: cardiac catheterization and coronary artery bypass grafting (CABG). The results showed that gainsharing could be beneficial to the hospital-physician relationship, and, more important, not harmful to the patient. There has since been some movement toward gainsharing, but only in the context of specific procedures, with very clear safeguards around it, including an independent auditor. Nothing to this point has suggested that a cost per case or adjusted LOS gainsharing agreement would pass muster with the OIG.

So, at this point in time, I would caution against any contract that contained explicit references connecting compensation to a change in hospital costs, such as reducing LOS or cost per case. The new accountable-care organization (ACO) model might be a different prism through which to view this, but it’s a world apart from an individual physician or hospitalist group contract (see “A Chilly Reception,” August 2011, p. 23).

For contractual compensation, I think that quality metrics can fill a need, and there are lots of ways to be creative here. You could set a target around something measurable (appropriate DVT prophylaxis is just one example) and tie dollars to that specific performance. The key is avoiding any language that would imply additional physician compensation for a reduction in patient services.

Might things change in the future? Your guess is as good as mine.

What I am curious about are the current issues around using length of stay (LOS) or cost/case or the like as part of compensation packages. I have had discussions with several other folks, and I think I am getting the picture. However, it sounds like there has been some new interpretation of the laws around gainsharing, and that is what I am curious about.

K.S., Ohio

Dr. Hospitalist responds:

Tough question, and let me start by saying that I’m not a healthcare lawyer: This stuff is tricky. I’ll do my best to explain the current situation as I understand it, but I’m no expert on this.

So gainsharing, as generally defined in healthcare, is where a hospital and a group of physicians design a contract around services for which the two sides can share in any savings. Physicians are paid fee-for-service by Medicare, thus they are reimbursed per unit of work, with no incentive for cost control. Hospitals are paid on a per-case (or per-procedure) basis, so cost control means a lot to them: Because they get a set payment, any savings generated, they get to keep. Ideally, this means that better performance leads to more efficient care, less waste, and better outcomes. Unfortunately, that’s not always what happens, especially in the view of the federal government (you know, the guys who issue the bright orange jumpsuits for you to wear when you break the law).

Gainsharing has an interesting history as interpreted by the Office of the Inspector General (OIG) and the Centers for Medicare & Medicaid Services (CMS). Back in 1999, the OIG explicitly stopped any gainsharing models between physicians and hospitals based on concerns that these contracts might reduce the care provided to patients. The opinion was that there might be a “race to the bottom” in terms of cutting expenses (read: services).

Since then, there has been only incremental movement forward in the form of demonstration projects. One project looked at two very specific procedures: cardiac catheterization and coronary artery bypass grafting (CABG). The results showed that gainsharing could be beneficial to the hospital-physician relationship, and, more important, not harmful to the patient. There has since been some movement toward gainsharing, but only in the context of specific procedures, with very clear safeguards around it, including an independent auditor. Nothing to this point has suggested that a cost per case or adjusted LOS gainsharing agreement would pass muster with the OIG.

So, at this point in time, I would caution against any contract that contained explicit references connecting compensation to a change in hospital costs, such as reducing LOS or cost per case. The new accountable-care organization (ACO) model might be a different prism through which to view this, but it’s a world apart from an individual physician or hospitalist group contract (see “A Chilly Reception,” August 2011, p. 23).

For contractual compensation, I think that quality metrics can fill a need, and there are lots of ways to be creative here. You could set a target around something measurable (appropriate DVT prophylaxis is just one example) and tie dollars to that specific performance. The key is avoiding any language that would imply additional physician compensation for a reduction in patient services.

Might things change in the future? Your guess is as good as mine.

What I am curious about are the current issues around using length of stay (LOS) or cost/case or the like as part of compensation packages. I have had discussions with several other folks, and I think I am getting the picture. However, it sounds like there has been some new interpretation of the laws around gainsharing, and that is what I am curious about.

K.S., Ohio

Dr. Hospitalist responds:

Tough question, and let me start by saying that I’m not a healthcare lawyer: This stuff is tricky. I’ll do my best to explain the current situation as I understand it, but I’m no expert on this.

So gainsharing, as generally defined in healthcare, is where a hospital and a group of physicians design a contract around services for which the two sides can share in any savings. Physicians are paid fee-for-service by Medicare, thus they are reimbursed per unit of work, with no incentive for cost control. Hospitals are paid on a per-case (or per-procedure) basis, so cost control means a lot to them: Because they get a set payment, any savings generated, they get to keep. Ideally, this means that better performance leads to more efficient care, less waste, and better outcomes. Unfortunately, that’s not always what happens, especially in the view of the federal government (you know, the guys who issue the bright orange jumpsuits for you to wear when you break the law).

Gainsharing has an interesting history as interpreted by the Office of the Inspector General (OIG) and the Centers for Medicare & Medicaid Services (CMS). Back in 1999, the OIG explicitly stopped any gainsharing models between physicians and hospitals based on concerns that these contracts might reduce the care provided to patients. The opinion was that there might be a “race to the bottom” in terms of cutting expenses (read: services).

Since then, there has been only incremental movement forward in the form of demonstration projects. One project looked at two very specific procedures: cardiac catheterization and coronary artery bypass grafting (CABG). The results showed that gainsharing could be beneficial to the hospital-physician relationship, and, more important, not harmful to the patient. There has since been some movement toward gainsharing, but only in the context of specific procedures, with very clear safeguards around it, including an independent auditor. Nothing to this point has suggested that a cost per case or adjusted LOS gainsharing agreement would pass muster with the OIG.

So, at this point in time, I would caution against any contract that contained explicit references connecting compensation to a change in hospital costs, such as reducing LOS or cost per case. The new accountable-care organization (ACO) model might be a different prism through which to view this, but it’s a world apart from an individual physician or hospitalist group contract (see “A Chilly Reception,” August 2011, p. 23).

For contractual compensation, I think that quality metrics can fill a need, and there are lots of ways to be creative here. You could set a target around something measurable (appropriate DVT prophylaxis is just one example) and tie dollars to that specific performance. The key is avoiding any language that would imply additional physician compensation for a reduction in patient services.

Might things change in the future? Your guess is as good as mine.

Click here to listen to Dr. Meltzer

Click here to listen to Dr. Lundberg

Click here to listen to Dr. Meltzer

Click here to listen to Dr. Lundberg

Click here to listen to Dr. Meltzer

Click here to listen to Dr. Lundberg

Increased handoffs are often viewed as a byproduct of the growth in hospital medicine, with heightened scrutiny on the quality of communication that accompanies these transfers of care. As research suggests, though, finding and fixing the weak links can require persistence.

A study led by Siddhartha Singh, MD, MS, associate chief medical officer of Medical College Physicians, the adult practice for Medical College of Wisconsin in Milwaukee, compared a traditional, resident-based model of care to one involving a hospitalist-physician assistant team. Initially, his study found a 6% higher length of stay (LOS) for the hospitalist-physician assistant teams, with no differences in costs or readmission rates.1

But when the researchers pored over their results, they discovered that the increased LOS was limited to patients admitted overnight. Those patients, Dr. Singh says, were admitted by other providers—a night-float resident or faculty hospitalist—and then transferred to the hospitalist-physician assistant teams when they arrived in the morning. These “overflow patients” also were admitted only during busy periods, when limits on the number of admissions by house staff required other arrangements.

To make a direct comparison, Dr. Singh focused on a window from 11 a.m. to 4 p.m., when patients would have an equal probability of being admitted by a resident team or a hospitalist-physician assistant team. From a pool of about 3,000 admitted patients, the study found no significant difference in LOS, cost, readmission rates, or mortality. Instead of highlighting significant differences in models of care, then, Dr. Singh says, his study highlighted a potential weak link in the “treacherous” overnight-to-morning handoffs during busy periods that should be addressed.

“There have been a lot of studies implicating poor communication as a cause of patient-safety issues,” notes Sunil Kripalani, MD, MSc, FHM, chief of the section of hospital medicine and an associate professor of medicine at Vanderbilt University Medical Center in Nashville, Tenn. But fewer studies, he says, have shown how to effectively improve communication in a way that improves patient safety.

One focal point is the often incomplete and inadequate nature of discharge summaries. Several models are emerging on how to build a better discharge summary, Dr. Kripalani says, with researchers offering solid recommendations (as multiple presentations at SHM’s annual meeting suggest). The trick is ensuring that those plans can be implemented into practice on a consistent and timely basis.

Dr. Kripalani says at least one straightforward strategy might help improve handoffs, however: building time into the schedule for them, such as 15-minute overlaps between shifts.—BN

Increased handoffs are often viewed as a byproduct of the growth in hospital medicine, with heightened scrutiny on the quality of communication that accompanies these transfers of care. As research suggests, though, finding and fixing the weak links can require persistence.

A study led by Siddhartha Singh, MD, MS, associate chief medical officer of Medical College Physicians, the adult practice for Medical College of Wisconsin in Milwaukee, compared a traditional, resident-based model of care to one involving a hospitalist-physician assistant team. Initially, his study found a 6% higher length of stay (LOS) for the hospitalist-physician assistant teams, with no differences in costs or readmission rates.1

But when the researchers pored over their results, they discovered that the increased LOS was limited to patients admitted overnight. Those patients, Dr. Singh says, were admitted by other providers—a night-float resident or faculty hospitalist—and then transferred to the hospitalist-physician assistant teams when they arrived in the morning. These “overflow patients” also were admitted only during busy periods, when limits on the number of admissions by house staff required other arrangements.

To make a direct comparison, Dr. Singh focused on a window from 11 a.m. to 4 p.m., when patients would have an equal probability of being admitted by a resident team or a hospitalist-physician assistant team. From a pool of about 3,000 admitted patients, the study found no significant difference in LOS, cost, readmission rates, or mortality. Instead of highlighting significant differences in models of care, then, Dr. Singh says, his study highlighted a potential weak link in the “treacherous” overnight-to-morning handoffs during busy periods that should be addressed.

“There have been a lot of studies implicating poor communication as a cause of patient-safety issues,” notes Sunil Kripalani, MD, MSc, FHM, chief of the section of hospital medicine and an associate professor of medicine at Vanderbilt University Medical Center in Nashville, Tenn. But fewer studies, he says, have shown how to effectively improve communication in a way that improves patient safety.

One focal point is the often incomplete and inadequate nature of discharge summaries. Several models are emerging on how to build a better discharge summary, Dr. Kripalani says, with researchers offering solid recommendations (as multiple presentations at SHM’s annual meeting suggest). The trick is ensuring that those plans can be implemented into practice on a consistent and timely basis.

Dr. Kripalani says at least one straightforward strategy might help improve handoffs, however: building time into the schedule for them, such as 15-minute overlaps between shifts.—BN

Increased handoffs are often viewed as a byproduct of the growth in hospital medicine, with heightened scrutiny on the quality of communication that accompanies these transfers of care. As research suggests, though, finding and fixing the weak links can require persistence.

A study led by Siddhartha Singh, MD, MS, associate chief medical officer of Medical College Physicians, the adult practice for Medical College of Wisconsin in Milwaukee, compared a traditional, resident-based model of care to one involving a hospitalist-physician assistant team. Initially, his study found a 6% higher length of stay (LOS) for the hospitalist-physician assistant teams, with no differences in costs or readmission rates.1

But when the researchers pored over their results, they discovered that the increased LOS was limited to patients admitted overnight. Those patients, Dr. Singh says, were admitted by other providers—a night-float resident or faculty hospitalist—and then transferred to the hospitalist-physician assistant teams when they arrived in the morning. These “overflow patients” also were admitted only during busy periods, when limits on the number of admissions by house staff required other arrangements.

To make a direct comparison, Dr. Singh focused on a window from 11 a.m. to 4 p.m., when patients would have an equal probability of being admitted by a resident team or a hospitalist-physician assistant team. From a pool of about 3,000 admitted patients, the study found no significant difference in LOS, cost, readmission rates, or mortality. Instead of highlighting significant differences in models of care, then, Dr. Singh says, his study highlighted a potential weak link in the “treacherous” overnight-to-morning handoffs during busy periods that should be addressed.

“There have been a lot of studies implicating poor communication as a cause of patient-safety issues,” notes Sunil Kripalani, MD, MSc, FHM, chief of the section of hospital medicine and an associate professor of medicine at Vanderbilt University Medical Center in Nashville, Tenn. But fewer studies, he says, have shown how to effectively improve communication in a way that improves patient safety.

One focal point is the often incomplete and inadequate nature of discharge summaries. Several models are emerging on how to build a better discharge summary, Dr. Kripalani says, with researchers offering solid recommendations (as multiple presentations at SHM’s annual meeting suggest). The trick is ensuring that those plans can be implemented into practice on a consistent and timely basis.

Dr. Kripalani says at least one straightforward strategy might help improve handoffs, however: building time into the schedule for them, such as 15-minute overlaps between shifts.—BN

For those of you who were kind enough to catch my column in last month’s issue of The Hospitalist (see “What Is Your Value,” p. 56), you spent a few minutes reading my thoughts on the value of hospitalists. I mentioned the fact that the U.S. is moving rapidly toward a value-based system of purchasing healthcare, and that all healthcare providers, including hospitalists, increasingly will be judged on the value of care they deliver to their patients and the healthcare system. (Remember, value=quality/cost.)

Hospitalists, like all other healthcare providers, can increase their “value” by improving the quality of care they provide and decreasing the cost of healthcare delivery. Seems simple enough, right? Take better care of patients and do so while minimizing unnecessary costs. (If you have figured out how to do this, I want to learn from you!)

As a doctor and as the leader of the hospitalist group at Beth Israel Deaconess Medical Center in Boston, I have given this topic considerable thought. How do I become a “high value” provider? How do I help my hospitalist colleagues become “high value” hospitalists? Another persistent thought that has crossed my mind is: “How do I know that I am not already a high-value hospitalist?”

Maybe all of my hospitalist colleagues at Beth Israel Deaconess Medical Center are high-value providers. Seems fair enough, right? Maybe each of us is providing “high quality” care and doing so while minimizing unnecessary costs.

I mean, who really wants to think of themselves as low-quality doctors spending a considerable amount of unnecessary resources?

Like many of you, it became evident to me that the first step to improving quality and/or decreasing cost is to define “quality” and “cost.”

The First Step

Although it might seem difficult for the individual hospitalist to know the cost of a patient’s hospitalization, such information is available, and your hospital administrator might be willing to share such information with you and your group. But when it comes to quality of care, I think most patients would expect that doctors should understand the definition of “high-quality care.”

So, what is the definition of “high-quality care?” Try asking this question of patients and doctors, and you are likely to get very different answers. Not surprised? Try asking this question just to doctors, and you are likely to get some different answers. (For fun, you could try this exercise with your hospitalist colleagues; I have.)

Honestly, none of us should be alarmed if a group of doctors cannot easily define “high-quality care.” Not being able to do so does not mean these are “bad” doctors. While it may not be easy to define high-quality care, I suspect most of us recognize it when we see it.

The process of defining the quality of care involves capturing the essence of what we see. For example, can we agree that prescribing aspirin for patients with acute coronary syndrome is optimal care? If so, it stands to reason that a patient with acute coronary syndrome who did not receive aspirin received suboptimal care.

This is how a group of hospitalists can go about creating a quality standard. If you are a hospitalist or HM group leader who is interested in improving the quality of care you and your colleagues are providing to your patients, defining a quality standard is the critical first step to process improvement. Do not limit yourself to clinical processes. Although clinical processes are important, so are communication and documentation processes.

For example, most of us, as hospitalists, believe that communication with outpatient providers is important to the provision of high-quality inpatient care. How often do your hospitalists communicate with patients’ primary-care providers? Is this a quality standard for your hospitalist group? What about the documentation of a patient’s code status at the time of admission or documentation of a patient’s functional status in the discharge summary?

If you believe these are important, your group should include these as quality standards. You should be measuring them and reporting the results to individual providers.

Start with Definition

At this point, some of us might be tempted to get ahead of ourselves and worry about what standards we can or cannot measure, but I urge you to complete this first step of defining “high-quality care” before worrying about anything else. (In other words, don’t start running before you can walk.)

Another suggestion: Please don’t try to do too much all at once. Nobody is going to argue that patients with acute coronary syndrome should not receive aspirin. Reaching consensus on other quality standards might not be as easy. But do not get bogged down trying to create too many quality standards all at once. Start with a few and get yourself and your colleagues accustomed to the process.

Remember, when it comes to doctors, we have centuries of history of not knowing exactly what we are doing. I hope it won’t take centuries to fix this problem, but I also know we are not going to fix this in a few days or weeks. Small victories along the way are important if we hope to succeed.

Once you and your hospitalist colleagues arrive at a mutually agreed upon quality standard, the next step is performance measurement. I honestly believe performance measurement is easy when we spend the time understanding and agreeing to the most appropriate quality standards for our hospitalist groups.

I am interested in learning about your efforts to define the quality standards for your hospitalist group. Feel free to email me at [email protected].

Dr. Li is president of SHM.

For those of you who were kind enough to catch my column in last month’s issue of The Hospitalist (see “What Is Your Value,” p. 56), you spent a few minutes reading my thoughts on the value of hospitalists. I mentioned the fact that the U.S. is moving rapidly toward a value-based system of purchasing healthcare, and that all healthcare providers, including hospitalists, increasingly will be judged on the value of care they deliver to their patients and the healthcare system. (Remember, value=quality/cost.)

Hospitalists, like all other healthcare providers, can increase their “value” by improving the quality of care they provide and decreasing the cost of healthcare delivery. Seems simple enough, right? Take better care of patients and do so while minimizing unnecessary costs. (If you have figured out how to do this, I want to learn from you!)

As a doctor and as the leader of the hospitalist group at Beth Israel Deaconess Medical Center in Boston, I have given this topic considerable thought. How do I become a “high value” provider? How do I help my hospitalist colleagues become “high value” hospitalists? Another persistent thought that has crossed my mind is: “How do I know that I am not already a high-value hospitalist?”

Maybe all of my hospitalist colleagues at Beth Israel Deaconess Medical Center are high-value providers. Seems fair enough, right? Maybe each of us is providing “high quality” care and doing so while minimizing unnecessary costs.

I mean, who really wants to think of themselves as low-quality doctors spending a considerable amount of unnecessary resources?

Like many of you, it became evident to me that the first step to improving quality and/or decreasing cost is to define “quality” and “cost.”

The First Step

Although it might seem difficult for the individual hospitalist to know the cost of a patient’s hospitalization, such information is available, and your hospital administrator might be willing to share such information with you and your group. But when it comes to quality of care, I think most patients would expect that doctors should understand the definition of “high-quality care.”

So, what is the definition of “high-quality care?” Try asking this question of patients and doctors, and you are likely to get very different answers. Not surprised? Try asking this question just to doctors, and you are likely to get some different answers. (For fun, you could try this exercise with your hospitalist colleagues; I have.)

Honestly, none of us should be alarmed if a group of doctors cannot easily define “high-quality care.” Not being able to do so does not mean these are “bad” doctors. While it may not be easy to define high-quality care, I suspect most of us recognize it when we see it.

The process of defining the quality of care involves capturing the essence of what we see. For example, can we agree that prescribing aspirin for patients with acute coronary syndrome is optimal care? If so, it stands to reason that a patient with acute coronary syndrome who did not receive aspirin received suboptimal care.

This is how a group of hospitalists can go about creating a quality standard. If you are a hospitalist or HM group leader who is interested in improving the quality of care you and your colleagues are providing to your patients, defining a quality standard is the critical first step to process improvement. Do not limit yourself to clinical processes. Although clinical processes are important, so are communication and documentation processes.

For example, most of us, as hospitalists, believe that communication with outpatient providers is important to the provision of high-quality inpatient care. How often do your hospitalists communicate with patients’ primary-care providers? Is this a quality standard for your hospitalist group? What about the documentation of a patient’s code status at the time of admission or documentation of a patient’s functional status in the discharge summary?

If you believe these are important, your group should include these as quality standards. You should be measuring them and reporting the results to individual providers.

Start with Definition

At this point, some of us might be tempted to get ahead of ourselves and worry about what standards we can or cannot measure, but I urge you to complete this first step of defining “high-quality care” before worrying about anything else. (In other words, don’t start running before you can walk.)

Another suggestion: Please don’t try to do too much all at once. Nobody is going to argue that patients with acute coronary syndrome should not receive aspirin. Reaching consensus on other quality standards might not be as easy. But do not get bogged down trying to create too many quality standards all at once. Start with a few and get yourself and your colleagues accustomed to the process.

Remember, when it comes to doctors, we have centuries of history of not knowing exactly what we are doing. I hope it won’t take centuries to fix this problem, but I also know we are not going to fix this in a few days or weeks. Small victories along the way are important if we hope to succeed.

Once you and your hospitalist colleagues arrive at a mutually agreed upon quality standard, the next step is performance measurement. I honestly believe performance measurement is easy when we spend the time understanding and agreeing to the most appropriate quality standards for our hospitalist groups.

I am interested in learning about your efforts to define the quality standards for your hospitalist group. Feel free to email me at [email protected].

Dr. Li is president of SHM.

For those of you who were kind enough to catch my column in last month’s issue of The Hospitalist (see “What Is Your Value,” p. 56), you spent a few minutes reading my thoughts on the value of hospitalists. I mentioned the fact that the U.S. is moving rapidly toward a value-based system of purchasing healthcare, and that all healthcare providers, including hospitalists, increasingly will be judged on the value of care they deliver to their patients and the healthcare system. (Remember, value=quality/cost.)

Hospitalists, like all other healthcare providers, can increase their “value” by improving the quality of care they provide and decreasing the cost of healthcare delivery. Seems simple enough, right? Take better care of patients and do so while minimizing unnecessary costs. (If you have figured out how to do this, I want to learn from you!)

As a doctor and as the leader of the hospitalist group at Beth Israel Deaconess Medical Center in Boston, I have given this topic considerable thought. How do I become a “high value” provider? How do I help my hospitalist colleagues become “high value” hospitalists? Another persistent thought that has crossed my mind is: “How do I know that I am not already a high-value hospitalist?”

Maybe all of my hospitalist colleagues at Beth Israel Deaconess Medical Center are high-value providers. Seems fair enough, right? Maybe each of us is providing “high quality” care and doing so while minimizing unnecessary costs.

I mean, who really wants to think of themselves as low-quality doctors spending a considerable amount of unnecessary resources?

Like many of you, it became evident to me that the first step to improving quality and/or decreasing cost is to define “quality” and “cost.”

The First Step

Although it might seem difficult for the individual hospitalist to know the cost of a patient’s hospitalization, such information is available, and your hospital administrator might be willing to share such information with you and your group. But when it comes to quality of care, I think most patients would expect that doctors should understand the definition of “high-quality care.”

So, what is the definition of “high-quality care?” Try asking this question of patients and doctors, and you are likely to get very different answers. Not surprised? Try asking this question just to doctors, and you are likely to get some different answers. (For fun, you could try this exercise with your hospitalist colleagues; I have.)

Honestly, none of us should be alarmed if a group of doctors cannot easily define “high-quality care.” Not being able to do so does not mean these are “bad” doctors. While it may not be easy to define high-quality care, I suspect most of us recognize it when we see it.

The process of defining the quality of care involves capturing the essence of what we see. For example, can we agree that prescribing aspirin for patients with acute coronary syndrome is optimal care? If so, it stands to reason that a patient with acute coronary syndrome who did not receive aspirin received suboptimal care.

This is how a group of hospitalists can go about creating a quality standard. If you are a hospitalist or HM group leader who is interested in improving the quality of care you and your colleagues are providing to your patients, defining a quality standard is the critical first step to process improvement. Do not limit yourself to clinical processes. Although clinical processes are important, so are communication and documentation processes.

For example, most of us, as hospitalists, believe that communication with outpatient providers is important to the provision of high-quality inpatient care. How often do your hospitalists communicate with patients’ primary-care providers? Is this a quality standard for your hospitalist group? What about the documentation of a patient’s code status at the time of admission or documentation of a patient’s functional status in the discharge summary?

If you believe these are important, your group should include these as quality standards. You should be measuring them and reporting the results to individual providers.

Start with Definition

At this point, some of us might be tempted to get ahead of ourselves and worry about what standards we can or cannot measure, but I urge you to complete this first step of defining “high-quality care” before worrying about anything else. (In other words, don’t start running before you can walk.)

Another suggestion: Please don’t try to do too much all at once. Nobody is going to argue that patients with acute coronary syndrome should not receive aspirin. Reaching consensus on other quality standards might not be as easy. But do not get bogged down trying to create too many quality standards all at once. Start with a few and get yourself and your colleagues accustomed to the process.

Remember, when it comes to doctors, we have centuries of history of not knowing exactly what we are doing. I hope it won’t take centuries to fix this problem, but I also know we are not going to fix this in a few days or weeks. Small victories along the way are important if we hope to succeed.

Once you and your hospitalist colleagues arrive at a mutually agreed upon quality standard, the next step is performance measurement. I honestly believe performance measurement is easy when we spend the time understanding and agreeing to the most appropriate quality standards for our hospitalist groups.

I am interested in learning about your efforts to define the quality standards for your hospitalist group. Feel free to email me at [email protected].

Dr. Li is president of SHM.

In his June 3 blog post at CIO.com, Tom Kaneshige asks: “Can the iPad cure what ails us?” He goes on to describe new applications for iPads in Texas hospitals, including the remote monitoring of patients’ EKGs by nurses roaming the hospital.

“The big revolution in tablet computing for hospitalists, which has been right around the corner for the past decade, hasn’t quite arrived yet,” says Russ Cucina, MD, MS, hospitalist and medical director of information technology at the University of California San Francisco Medical Center. “But I think we’re getting close, even though I’m not convinced that the iPad will be the vehicle.”

One of the hallmarks of such a technological revolution will be to free up hospitalists and other workers from computer work stations, where they are increasingly removed from face-to-face interactions. “Something gets lost in the name of efficiency,” Dr. Cucina says.

Hurdles to the tablet revolution include:

• Short battery life and the lack of rechargeable batteries. “Doctors need to be on the floor longer than eight hours,” Dr. Cucina says.
• Interacting with a tablet using thumbs and a touchscreen is fundamentally different from using a laptop, and applications should recognize the differences.
• Wireless access to secure electronic health records (EHR) throughout the hospital. “This is more of a cost issue than a technical problem,” Dr. Cucina explains. “It’s also incumbent upon us as physicians to develop good security practices with our tablets.”
• The skills to use the screen in the presence of others—in other words, What is the proper etiquette in front of care team members, patients, their families, etc.?

Hospitalists Look to Partner with New Quality Institute

Don’t be surprised if HM eventually gets a piece of the new Armstrong Institute for Patient Safety and Quality at Johns Hopkins University School of Medicine in Baltimore.

The center, funded through a $10 million gift from Johns Hopkins Medicine board of trustees chairman C. Michael Armstrong, will become the umbrella arm in charge of reducing preventable harm and improving healthcare quality.

Eric Howell, MD, SFHM, associate professor of medicine at Johns Hopkins University and director of Johns Hopkins Bayview Medical Center’s HM division, already sees that as hospitalist turf and could easily see HM partnering with the new institute. Dr. Howell, who already has reached out to the institute’s head, checklist guru Peter Pronovost, MD, PhD, wrote in an email to The Hospitalist: “Hospitalists at Hopkins have a long tradition of exactly this type of work.”

Dr. Howell points to recent HM-driven research and initiatives to reduce “red alerts,” the term for ambulance diversions in the ICU, and streamlining the admission process to allow outpatient doctors to bypass the ED for patients for whom hospitalist admission is needed. At Howard County General Hospital, a suburb about 15 miles southwest of Baltimore, the HM group is running all rapid response team (RRT) events.

“In short,” Dr. Howell writes, “the Armstrong Institute will find hospitalists to be a willing partner.”

Hospitalists Must Prepare for Primary-Care Shortfalls

The Milwaukee-based American Society for Quality (ASQ) recently surveyed healthcare quality professionals about anticipated shortages of primary-care physicians (PCPs) and other medical staff, particularly as more Americans gain health insurance under the Accountable Care Act and Medicare). The trend is real, says Joseph Fortuna, MD, chair of ASQ’s Health Care Division, and hospitalists will face challenges in discharging patients who lack a defined PCP.

Survey respondents highlighted some strategies for dealing with the primary-care shortage, including the EHR for improving efficiency, teamwork, and checklists. Dr. Fortuna suggests HM groups:

• Work with PCPs and federally qualified health centers to enhance integrated relationships and improve handoffs. Local public health departments will be important collaborators.
• Define quality not just clinically, but also in terms of financial, operational, and cultural domains, using techniques of change management, root cause analysis, and other quality tools.
• Be involved in patient-centered medical homes as “catalysts, coordinators, and facilitators.”

HM Group Redesigns Workflow to Comply with ACGME Rules and Improve Continuity

As academic HM groups react to the new Accreditation Council for Graduation Medical Education (ACGME) guidelines on how long residents can work, they might want to keep the Toyota Production System (TPS) in mind.

Diana Mancini, MD, a hospitalist at Denver Health Medical Center and associate program director of the University of Colorado Internal Medicine Residency, presented data in the Research, Innovations, and Clinical Vignettes competition at HM11 that showed how the use of continuous workflow and standardized tasks—hallmarks of TPS—helped redesign the medicine ward system to both comply with the ACGME rules and improve continuity of care.

The project replaced the traditional call system, and its corresponding floats and moonlighters, with a shift system comprised of two teams of six interns and three residents. At night, one intern worked a “continuity shift.” Using administrative data, Dr. Mancini and colleagues projected that 89% of patients admitted on a continuity shift would be discharged by the end of that intern’s five consecutive shifts. And, by dividing admissions among two teams, the “bolus” effect was halved, she says.

“The continuity shift is crucial for both the patient safety/continuity and educational content/value for the housestaff,” Dr. Mancini wrote in an email. “With the new work hours coming ... the hours would have to be adjusted … but the continuity could most certainly be maintained.”

Feds Delay Deadline for Stage 2 “Meaningful Use” Application Process

If your HM group is among the first cohort that reaches Stage 1 attestation this year for meaningful use of electronic health records (EHR), you may get more time to reach Stage 2. The federal Health Information Technology (HIT) policy committee has voted for a 12-month delay in implementing the criteria for that second stage, agreeing with those who say the current deadline of October 2013 “poses a nearly insurmountable timing challenge.”

The HIT is pushing to delay the deadline until 2014, which would mean providers have three years to verify that they have met Stage 1 meaningful use requirements, according to Government HealthIT. A cadre of medical trade groups, led by the AMA, is now pushing the Department of Health and Human Services to adopt the new timeline.

The ultimate decision rests with the Centers for Medicaid & Medicare Services (CMS).

By the numbers

Number of months without a central-line-associated bloodstream infection (BSI) on the eight-bed ICU at Beaufort Memorial Hospital, a 197-bed community hospital in Beaufort, S.C.

The hospital, which had a higher rate of BSIs than the national average in 2005, created a team to reduce its BSIs, led by infection-prevention specialist Beverly Yoder, RN, and involving hospitalists. Beaufort joined the Institute for Healthcare Improvement’s 100K Lives Campaign and the South Carolina Hospital Association’s Stop BSI Project.

The team implemented a central-line “bundle” of quality practices, then simplified the bundle and incorporated it into its EHR. The unit celebrated its 30-month achievement with a luncheon in June.

For information, contact critical-care director Diane Razo, RN, MSN, PCCN, at [email protected]. (For more information about central-line infection prevention, visit SHM's Resource Room (www.hospitalmedicine.org/resource)

In his June 3 blog post at CIO.com, Tom Kaneshige asks: “Can the iPad cure what ails us?” He goes on to describe new applications for iPads in Texas hospitals, including the remote monitoring of patients’ EKGs by nurses roaming the hospital.

“The big revolution in tablet computing for hospitalists, which has been right around the corner for the past decade, hasn’t quite arrived yet,” says Russ Cucina, MD, MS, hospitalist and medical director of information technology at the University of California San Francisco Medical Center. “But I think we’re getting close, even though I’m not convinced that the iPad will be the vehicle.”

One of the hallmarks of such a technological revolution will be to free up hospitalists and other workers from computer work stations, where they are increasingly removed from face-to-face interactions. “Something gets lost in the name of efficiency,” Dr. Cucina says.

Hurdles to the tablet revolution include:

• Short battery life and the lack of rechargeable batteries. “Doctors need to be on the floor longer than eight hours,” Dr. Cucina says.
• Interacting with a tablet using thumbs and a touchscreen is fundamentally different from using a laptop, and applications should recognize the differences.
• Wireless access to secure electronic health records (EHR) throughout the hospital. “This is more of a cost issue than a technical problem,” Dr. Cucina explains. “It’s also incumbent upon us as physicians to develop good security practices with our tablets.”
• The skills to use the screen in the presence of others—in other words, What is the proper etiquette in front of care team members, patients, their families, etc.?

Hospitalists Look to Partner with New Quality Institute

Don’t be surprised if HM eventually gets a piece of the new Armstrong Institute for Patient Safety and Quality at Johns Hopkins University School of Medicine in Baltimore.

The center, funded through a $10 million gift from Johns Hopkins Medicine board of trustees chairman C. Michael Armstrong, will become the umbrella arm in charge of reducing preventable harm and improving healthcare quality.

Eric Howell, MD, SFHM, associate professor of medicine at Johns Hopkins University and director of Johns Hopkins Bayview Medical Center’s HM division, already sees that as hospitalist turf and could easily see HM partnering with the new institute. Dr. Howell, who already has reached out to the institute’s head, checklist guru Peter Pronovost, MD, PhD, wrote in an email to The Hospitalist: “Hospitalists at Hopkins have a long tradition of exactly this type of work.”

Dr. Howell points to recent HM-driven research and initiatives to reduce “red alerts,” the term for ambulance diversions in the ICU, and streamlining the admission process to allow outpatient doctors to bypass the ED for patients for whom hospitalist admission is needed. At Howard County General Hospital, a suburb about 15 miles southwest of Baltimore, the HM group is running all rapid response team (RRT) events.

“In short,” Dr. Howell writes, “the Armstrong Institute will find hospitalists to be a willing partner.”

Hospitalists Must Prepare for Primary-Care Shortfalls

The Milwaukee-based American Society for Quality (ASQ) recently surveyed healthcare quality professionals about anticipated shortages of primary-care physicians (PCPs) and other medical staff, particularly as more Americans gain health insurance under the Accountable Care Act and Medicare). The trend is real, says Joseph Fortuna, MD, chair of ASQ’s Health Care Division, and hospitalists will face challenges in discharging patients who lack a defined PCP.

Survey respondents highlighted some strategies for dealing with the primary-care shortage, including the EHR for improving efficiency, teamwork, and checklists. Dr. Fortuna suggests HM groups:

• Work with PCPs and federally qualified health centers to enhance integrated relationships and improve handoffs. Local public health departments will be important collaborators.
• Define quality not just clinically, but also in terms of financial, operational, and cultural domains, using techniques of change management, root cause analysis, and other quality tools.
• Be involved in patient-centered medical homes as “catalysts, coordinators, and facilitators.”

HM Group Redesigns Workflow to Comply with ACGME Rules and Improve Continuity

As academic HM groups react to the new Accreditation Council for Graduation Medical Education (ACGME) guidelines on how long residents can work, they might want to keep the Toyota Production System (TPS) in mind.

Diana Mancini, MD, a hospitalist at Denver Health Medical Center and associate program director of the University of Colorado Internal Medicine Residency, presented data in the Research, Innovations, and Clinical Vignettes competition at HM11 that showed how the use of continuous workflow and standardized tasks—hallmarks of TPS—helped redesign the medicine ward system to both comply with the ACGME rules and improve continuity of care.

The project replaced the traditional call system, and its corresponding floats and moonlighters, with a shift system comprised of two teams of six interns and three residents. At night, one intern worked a “continuity shift.” Using administrative data, Dr. Mancini and colleagues projected that 89% of patients admitted on a continuity shift would be discharged by the end of that intern’s five consecutive shifts. And, by dividing admissions among two teams, the “bolus” effect was halved, she says.

“The continuity shift is crucial for both the patient safety/continuity and educational content/value for the housestaff,” Dr. Mancini wrote in an email. “With the new work hours coming ... the hours would have to be adjusted … but the continuity could most certainly be maintained.”

Feds Delay Deadline for Stage 2 “Meaningful Use” Application Process

If your HM group is among the first cohort that reaches Stage 1 attestation this year for meaningful use of electronic health records (EHR), you may get more time to reach Stage 2. The federal Health Information Technology (HIT) policy committee has voted for a 12-month delay in implementing the criteria for that second stage, agreeing with those who say the current deadline of October 2013 “poses a nearly insurmountable timing challenge.”

The HIT is pushing to delay the deadline until 2014, which would mean providers have three years to verify that they have met Stage 1 meaningful use requirements, according to Government HealthIT. A cadre of medical trade groups, led by the AMA, is now pushing the Department of Health and Human Services to adopt the new timeline.

The ultimate decision rests with the Centers for Medicaid & Medicare Services (CMS).

By the numbers

Number of months without a central-line-associated bloodstream infection (BSI) on the eight-bed ICU at Beaufort Memorial Hospital, a 197-bed community hospital in Beaufort, S.C.

The hospital, which had a higher rate of BSIs than the national average in 2005, created a team to reduce its BSIs, led by infection-prevention specialist Beverly Yoder, RN, and involving hospitalists. Beaufort joined the Institute for Healthcare Improvement’s 100K Lives Campaign and the South Carolina Hospital Association’s Stop BSI Project.

The team implemented a central-line “bundle” of quality practices, then simplified the bundle and incorporated it into its EHR. The unit celebrated its 30-month achievement with a luncheon in June.

For information, contact critical-care director Diane Razo, RN, MSN, PCCN, at [email protected]. (For more information about central-line infection prevention, visit SHM's Resource Room (www.hospitalmedicine.org/resource)

In his June 3 blog post at CIO.com, Tom Kaneshige asks: “Can the iPad cure what ails us?” He goes on to describe new applications for iPads in Texas hospitals, including the remote monitoring of patients’ EKGs by nurses roaming the hospital.

“The big revolution in tablet computing for hospitalists, which has been right around the corner for the past decade, hasn’t quite arrived yet,” says Russ Cucina, MD, MS, hospitalist and medical director of information technology at the University of California San Francisco Medical Center. “But I think we’re getting close, even though I’m not convinced that the iPad will be the vehicle.”

One of the hallmarks of such a technological revolution will be to free up hospitalists and other workers from computer work stations, where they are increasingly removed from face-to-face interactions. “Something gets lost in the name of efficiency,” Dr. Cucina says.

Hurdles to the tablet revolution include:

• Short battery life and the lack of rechargeable batteries. “Doctors need to be on the floor longer than eight hours,” Dr. Cucina says.
• Interacting with a tablet using thumbs and a touchscreen is fundamentally different from using a laptop, and applications should recognize the differences.
• Wireless access to secure electronic health records (EHR) throughout the hospital. “This is more of a cost issue than a technical problem,” Dr. Cucina explains. “It’s also incumbent upon us as physicians to develop good security practices with our tablets.”
• The skills to use the screen in the presence of others—in other words, What is the proper etiquette in front of care team members, patients, their families, etc.?

Hospitalists Look to Partner with New Quality Institute

Don’t be surprised if HM eventually gets a piece of the new Armstrong Institute for Patient Safety and Quality at Johns Hopkins University School of Medicine in Baltimore.

The center, funded through a $10 million gift from Johns Hopkins Medicine board of trustees chairman C. Michael Armstrong, will become the umbrella arm in charge of reducing preventable harm and improving healthcare quality.

Eric Howell, MD, SFHM, associate professor of medicine at Johns Hopkins University and director of Johns Hopkins Bayview Medical Center’s HM division, already sees that as hospitalist turf and could easily see HM partnering with the new institute. Dr. Howell, who already has reached out to the institute’s head, checklist guru Peter Pronovost, MD, PhD, wrote in an email to The Hospitalist: “Hospitalists at Hopkins have a long tradition of exactly this type of work.”

Dr. Howell points to recent HM-driven research and initiatives to reduce “red alerts,” the term for ambulance diversions in the ICU, and streamlining the admission process to allow outpatient doctors to bypass the ED for patients for whom hospitalist admission is needed. At Howard County General Hospital, a suburb about 15 miles southwest of Baltimore, the HM group is running all rapid response team (RRT) events.

“In short,” Dr. Howell writes, “the Armstrong Institute will find hospitalists to be a willing partner.”

Hospitalists Must Prepare for Primary-Care Shortfalls

The Milwaukee-based American Society for Quality (ASQ) recently surveyed healthcare quality professionals about anticipated shortages of primary-care physicians (PCPs) and other medical staff, particularly as more Americans gain health insurance under the Accountable Care Act and Medicare). The trend is real, says Joseph Fortuna, MD, chair of ASQ’s Health Care Division, and hospitalists will face challenges in discharging patients who lack a defined PCP.

Survey respondents highlighted some strategies for dealing with the primary-care shortage, including the EHR for improving efficiency, teamwork, and checklists. Dr. Fortuna suggests HM groups:

• Work with PCPs and federally qualified health centers to enhance integrated relationships and improve handoffs. Local public health departments will be important collaborators.
• Define quality not just clinically, but also in terms of financial, operational, and cultural domains, using techniques of change management, root cause analysis, and other quality tools.
• Be involved in patient-centered medical homes as “catalysts, coordinators, and facilitators.”

HM Group Redesigns Workflow to Comply with ACGME Rules and Improve Continuity

As academic HM groups react to the new Accreditation Council for Graduation Medical Education (ACGME) guidelines on how long residents can work, they might want to keep the Toyota Production System (TPS) in mind.

Diana Mancini, MD, a hospitalist at Denver Health Medical Center and associate program director of the University of Colorado Internal Medicine Residency, presented data in the Research, Innovations, and Clinical Vignettes competition at HM11 that showed how the use of continuous workflow and standardized tasks—hallmarks of TPS—helped redesign the medicine ward system to both comply with the ACGME rules and improve continuity of care.

The project replaced the traditional call system, and its corresponding floats and moonlighters, with a shift system comprised of two teams of six interns and three residents. At night, one intern worked a “continuity shift.” Using administrative data, Dr. Mancini and colleagues projected that 89% of patients admitted on a continuity shift would be discharged by the end of that intern’s five consecutive shifts. And, by dividing admissions among two teams, the “bolus” effect was halved, she says.

“The continuity shift is crucial for both the patient safety/continuity and educational content/value for the housestaff,” Dr. Mancini wrote in an email. “With the new work hours coming ... the hours would have to be adjusted … but the continuity could most certainly be maintained.”

Feds Delay Deadline for Stage 2 “Meaningful Use” Application Process

If your HM group is among the first cohort that reaches Stage 1 attestation this year for meaningful use of electronic health records (EHR), you may get more time to reach Stage 2. The federal Health Information Technology (HIT) policy committee has voted for a 12-month delay in implementing the criteria for that second stage, agreeing with those who say the current deadline of October 2013 “poses a nearly insurmountable timing challenge.”

The HIT is pushing to delay the deadline until 2014, which would mean providers have three years to verify that they have met Stage 1 meaningful use requirements, according to Government HealthIT. A cadre of medical trade groups, led by the AMA, is now pushing the Department of Health and Human Services to adopt the new timeline.

The ultimate decision rests with the Centers for Medicaid & Medicare Services (CMS).

By the numbers

Number of months without a central-line-associated bloodstream infection (BSI) on the eight-bed ICU at Beaufort Memorial Hospital, a 197-bed community hospital in Beaufort, S.C.

The hospital, which had a higher rate of BSIs than the national average in 2005, created a team to reduce its BSIs, led by infection-prevention specialist Beverly Yoder, RN, and involving hospitalists. Beaufort joined the Institute for Healthcare Improvement’s 100K Lives Campaign and the South Carolina Hospital Association’s Stop BSI Project.

The team implemented a central-line “bundle” of quality practices, then simplified the bundle and incorporated it into its EHR. The unit celebrated its 30-month achievement with a luncheon in June.

For information, contact critical-care director Diane Razo, RN, MSN, PCCN, at [email protected]. (For more information about central-line infection prevention, visit SHM's Resource Room (www.hospitalmedicine.org/resource)

Starting a new, hospital-based quality-improvement (QI) program can be a lonely task for hospitalists. What can begin with a rush of enthusiasm to solve a critical problem on your hospital floor quickly can lead to a single hospitalist in front of a computer screen wondering, "Has anyone else ever done this before?"

Unlike clinical knowledge, most of which comes from years of specialized formal training and volumes of peer-reviewed evidence on procedures, starting QI programs often presents a special challenge: a blank page and limited access to those who’ve taken on similar projects.

Those challenges, and the need to better understand what other hospitalists have already tried, motivated SHM’s Center for Hospital Innovation & Improvement, also known as The Center, to develop SQUINT, a new user-generated online repository of hospital-based QI programs.

"Being asked to lead a quality-improvement project is a daunting and difficult task," says Andrew Dunn, MD, FACP, professor of medicine and acting chief for Mount Sinai School of Medicine’s hospital medicine division in New York City. "Getting ideas on methods that have worked elsewhere is a great way to start. SQUINT is an easy way for hospitalists to get a head start on a project rather than start from scratch."

Access to SQUINT (SHM’s QUality Improve-ment NeTwork) is free to SHM members. Log in and gain access to summaries of QI programs from around the country. Because the summaries are searchable based on type, size, location, and specific kinds of topics, hospitalists can quickly find out whether projects similar to theirs are available through SQUINT.

For instance, a user could search for projects specifically related to transitions of care during discharge at community hospitals with 200-299 beds; a user in Oklahoma could search for all QI projects that have been uploaded from hospitals in the Sooner State. SQUINT also affords users keyword searches and browsing options.

For Hasan F. Shabbir, MD, SFHM, chief quality officer at Emory Johns Creek Hospital and assistant professor of medicine for Emory University School of Medicine’s division of hospital medicine in Atlanta, the ability to search user-generated, user-posted project files is especially important. Dr. Shabbir is no stranger to starting a QI project cold, or poring through literature and searching the Internet, worried that the materials don’t always explain the outcomes of a QI project that can be found through Google.

"You may just find a PDF on the Web and not know if it was a success," he says. "What’s unique about SQUINT is that it gives you a product, describes how it was utilized, and describes how it was—or wasn’t—effective. A lot of the work that needs to be done doesn’t always achieve the intended result."

Understanding the pitfalls and challenges of QI programs can save time and effort, he explains. "It’s equally important," he says. "Typically, only the successful stuff gets published in journals."

One of the first projects shared via SQUINT is a case study in using local resources to improve transitions of care for diabetic patients, submitted by medical director Jordan Messler, MD, SFHM, and his colleagues at Morton Plant Hospital in Clearwater, Fla.

"This was a project that we have done that we were probably not going to publish, but came up with some neat process things that we can share," says Dr. Messler, who hopes his team’s progress could help others get started. "If just one other program finds it and it saves them some time, that would be great."

Uploading descriptions of the QI programs can take as little as 15 minutes. Once project details and supporting documents are loaded into SQUINT, submissions are reviewed by members of SHM’s Health Quality and Patient Safety committee for clarity, the involvement of multidisciplinary team members, presentation of details, and the description of impacts and barriers to success.

Dr. Messler found the process of uploading simple and easy to use. He plans to add more.

"We have a variety of programs that we’ll probably upload," he says, including other recent QI programs addressing diabetes and DVT. "There’s no harm in putting them up there."

Like other online user-submitted forums, submitting accepted content has added benefits: increased visibility among a community dedicated to improving the care of hospitalized patients and career advancement.

"This is a portal for you to spread what you’ve learned," Dr. Messler says. "Then, over time, this could be something that could be added to a resume or get to the point that folks will be proud of having a list of submissions to SQUINT."

For Dr. Shabbir, the utility of SQUINT extends beyond his own use.

"I have a junior colleague who is working on a new quality-improvement program. I’m going to tell her to look into SQUINT to see if others have worked on similar programs," he says. "If they have, that will put you two or three steps forward. For the novice, it also teaches the language and structure of how quality improvement happens."

Teaching and changing patient safety is a big part of SQUINT’s goal, according to Dr. Dunn.

"Hospitals should not need to start at ground zero, take months to get started and re-create every mistake made at other institutions," he says. "By sharing successful projects and learning from our errors, we can move patient safety initiatives along faster and better. … And that will, hopefully, improve outcomes across the country."

Brendon Shank is associate vice president of communications at SHM.

Starting a new, hospital-based quality-improvement (QI) program can be a lonely task for hospitalists. What can begin with a rush of enthusiasm to solve a critical problem on your hospital floor quickly can lead to a single hospitalist in front of a computer screen wondering, "Has anyone else ever done this before?"

Unlike clinical knowledge, most of which comes from years of specialized formal training and volumes of peer-reviewed evidence on procedures, starting QI programs often presents a special challenge: a blank page and limited access to those who’ve taken on similar projects.

Those challenges, and the need to better understand what other hospitalists have already tried, motivated SHM’s Center for Hospital Innovation & Improvement, also known as The Center, to develop SQUINT, a new user-generated online repository of hospital-based QI programs.

"Being asked to lead a quality-improvement project is a daunting and difficult task," says Andrew Dunn, MD, FACP, professor of medicine and acting chief for Mount Sinai School of Medicine’s hospital medicine division in New York City. "Getting ideas on methods that have worked elsewhere is a great way to start. SQUINT is an easy way for hospitalists to get a head start on a project rather than start from scratch."

Access to SQUINT (SHM’s QUality Improve-ment NeTwork) is free to SHM members. Log in and gain access to summaries of QI programs from around the country. Because the summaries are searchable based on type, size, location, and specific kinds of topics, hospitalists can quickly find out whether projects similar to theirs are available through SQUINT.

For instance, a user could search for projects specifically related to transitions of care during discharge at community hospitals with 200-299 beds; a user in Oklahoma could search for all QI projects that have been uploaded from hospitals in the Sooner State. SQUINT also affords users keyword searches and browsing options.

For Hasan F. Shabbir, MD, SFHM, chief quality officer at Emory Johns Creek Hospital and assistant professor of medicine for Emory University School of Medicine’s division of hospital medicine in Atlanta, the ability to search user-generated, user-posted project files is especially important. Dr. Shabbir is no stranger to starting a QI project cold, or poring through literature and searching the Internet, worried that the materials don’t always explain the outcomes of a QI project that can be found through Google.

"You may just find a PDF on the Web and not know if it was a success," he says. "What’s unique about SQUINT is that it gives you a product, describes how it was utilized, and describes how it was—or wasn’t—effective. A lot of the work that needs to be done doesn’t always achieve the intended result."

Understanding the pitfalls and challenges of QI programs can save time and effort, he explains. "It’s equally important," he says. "Typically, only the successful stuff gets published in journals."

One of the first projects shared via SQUINT is a case study in using local resources to improve transitions of care for diabetic patients, submitted by medical director Jordan Messler, MD, SFHM, and his colleagues at Morton Plant Hospital in Clearwater, Fla.

"This was a project that we have done that we were probably not going to publish, but came up with some neat process things that we can share," says Dr. Messler, who hopes his team’s progress could help others get started. "If just one other program finds it and it saves them some time, that would be great."

Uploading descriptions of the QI programs can take as little as 15 minutes. Once project details and supporting documents are loaded into SQUINT, submissions are reviewed by members of SHM’s Health Quality and Patient Safety committee for clarity, the involvement of multidisciplinary team members, presentation of details, and the description of impacts and barriers to success.

Dr. Messler found the process of uploading simple and easy to use. He plans to add more.

"We have a variety of programs that we’ll probably upload," he says, including other recent QI programs addressing diabetes and DVT. "There’s no harm in putting them up there."

Like other online user-submitted forums, submitting accepted content has added benefits: increased visibility among a community dedicated to improving the care of hospitalized patients and career advancement.

"This is a portal for you to spread what you’ve learned," Dr. Messler says. "Then, over time, this could be something that could be added to a resume or get to the point that folks will be proud of having a list of submissions to SQUINT."

For Dr. Shabbir, the utility of SQUINT extends beyond his own use.

"I have a junior colleague who is working on a new quality-improvement program. I’m going to tell her to look into SQUINT to see if others have worked on similar programs," he says. "If they have, that will put you two or three steps forward. For the novice, it also teaches the language and structure of how quality improvement happens."

Teaching and changing patient safety is a big part of SQUINT’s goal, according to Dr. Dunn.

"Hospitals should not need to start at ground zero, take months to get started and re-create every mistake made at other institutions," he says. "By sharing successful projects and learning from our errors, we can move patient safety initiatives along faster and better. … And that will, hopefully, improve outcomes across the country."

Brendon Shank is associate vice president of communications at SHM.

Starting a new, hospital-based quality-improvement (QI) program can be a lonely task for hospitalists. What can begin with a rush of enthusiasm to solve a critical problem on your hospital floor quickly can lead to a single hospitalist in front of a computer screen wondering, "Has anyone else ever done this before?"

Unlike clinical knowledge, most of which comes from years of specialized formal training and volumes of peer-reviewed evidence on procedures, starting QI programs often presents a special challenge: a blank page and limited access to those who’ve taken on similar projects.

Those challenges, and the need to better understand what other hospitalists have already tried, motivated SHM’s Center for Hospital Innovation & Improvement, also known as The Center, to develop SQUINT, a new user-generated online repository of hospital-based QI programs.

"Being asked to lead a quality-improvement project is a daunting and difficult task," says Andrew Dunn, MD, FACP, professor of medicine and acting chief for Mount Sinai School of Medicine’s hospital medicine division in New York City. "Getting ideas on methods that have worked elsewhere is a great way to start. SQUINT is an easy way for hospitalists to get a head start on a project rather than start from scratch."

Access to SQUINT (SHM’s QUality Improve-ment NeTwork) is free to SHM members. Log in and gain access to summaries of QI programs from around the country. Because the summaries are searchable based on type, size, location, and specific kinds of topics, hospitalists can quickly find out whether projects similar to theirs are available through SQUINT.

For instance, a user could search for projects specifically related to transitions of care during discharge at community hospitals with 200-299 beds; a user in Oklahoma could search for all QI projects that have been uploaded from hospitals in the Sooner State. SQUINT also affords users keyword searches and browsing options.

For Hasan F. Shabbir, MD, SFHM, chief quality officer at Emory Johns Creek Hospital and assistant professor of medicine for Emory University School of Medicine’s division of hospital medicine in Atlanta, the ability to search user-generated, user-posted project files is especially important. Dr. Shabbir is no stranger to starting a QI project cold, or poring through literature and searching the Internet, worried that the materials don’t always explain the outcomes of a QI project that can be found through Google.

"You may just find a PDF on the Web and not know if it was a success," he says. "What’s unique about SQUINT is that it gives you a product, describes how it was utilized, and describes how it was—or wasn’t—effective. A lot of the work that needs to be done doesn’t always achieve the intended result."

Understanding the pitfalls and challenges of QI programs can save time and effort, he explains. "It’s equally important," he says. "Typically, only the successful stuff gets published in journals."

One of the first projects shared via SQUINT is a case study in using local resources to improve transitions of care for diabetic patients, submitted by medical director Jordan Messler, MD, SFHM, and his colleagues at Morton Plant Hospital in Clearwater, Fla.

"This was a project that we have done that we were probably not going to publish, but came up with some neat process things that we can share," says Dr. Messler, who hopes his team’s progress could help others get started. "If just one other program finds it and it saves them some time, that would be great."

Uploading descriptions of the QI programs can take as little as 15 minutes. Once project details and supporting documents are loaded into SQUINT, submissions are reviewed by members of SHM’s Health Quality and Patient Safety committee for clarity, the involvement of multidisciplinary team members, presentation of details, and the description of impacts and barriers to success.

Dr. Messler found the process of uploading simple and easy to use. He plans to add more.

"We have a variety of programs that we’ll probably upload," he says, including other recent QI programs addressing diabetes and DVT. "There’s no harm in putting them up there."

Like other online user-submitted forums, submitting accepted content has added benefits: increased visibility among a community dedicated to improving the care of hospitalized patients and career advancement.

"This is a portal for you to spread what you’ve learned," Dr. Messler says. "Then, over time, this could be something that could be added to a resume or get to the point that folks will be proud of having a list of submissions to SQUINT."

For Dr. Shabbir, the utility of SQUINT extends beyond his own use.

"I have a junior colleague who is working on a new quality-improvement program. I’m going to tell her to look into SQUINT to see if others have worked on similar programs," he says. "If they have, that will put you two or three steps forward. For the novice, it also teaches the language and structure of how quality improvement happens."

Teaching and changing patient safety is a big part of SQUINT’s goal, according to Dr. Dunn.

"Hospitals should not need to start at ground zero, take months to get started and re-create every mistake made at other institutions," he says. "By sharing successful projects and learning from our errors, we can move patient safety initiatives along faster and better. … And that will, hopefully, improve outcomes across the country."

Brendon Shank is associate vice president of communications at SHM.