Improving quality while reducing costs remains important for hospitals across the United States, including the approximately 150 hospitals that are part of the Veterans Affairs (VA) healthcare system.[1, 2] The field of hospital medicine has grown rapidly, leading to predictions that the majority of inpatient care in the United States eventually will be delivered by hospitalists.[3, 4] In 2010, 57% of US hospitals had hospitalists on staff, including 87% of hospitals with 200 beds,[5] and nearly 80% of VA hospitals.[6]

The demand for hospitalists within teaching hospitals has grown in part as a response to the mandate to reduce residency work hours.[7] Furthermore, previous research has found that hospitalist care is associated with modest reductions in length of stay (LOS) and weak but inconsistent differences in quality.[8] The educational effect of hospitalists has been far less examined. The limited number of studies published to date suggests that hospitalists may improve resident learning and house‐officer satisfaction in academic medical centers and community teaching hospitals[9, 10, 11] and provide positive experiences for medical students^12,13; however, Wachter et al reported no significant changes in clinical outcomes or patient, faculty, and house‐staff satisfaction in a newly designed hospital medicine service in San Francisco.[14] Additionally, whether using hospitalists influences nurse‐physician communication[15] is unknown.

Recognizing the limited and sometimes conflicting evidence about the hospitalist model, we report the results of a 3‐year quasi‐experimental evaluation of the experience at our medical center with academic hospitalists. As part of a VA Systems Redesign Improvement Capability Grantknown as the Hospital Outcomes Program of Excellence (HOPE) Initiativewe created a hospitalist‐based medicine team focused on quality improvement, medical education, and patient outcomes.

METHODS

RESULTS

Clinical Outcomes

Patient Outcomes

Our multivariable linear regression analysis, controlling for time, showed a significant reduction in LOS of approximately 0.3 days on all teams after the HOPE Initiative began (P=0.004). There were no significant differences between the Gold and non‐Gold teams in the multivariate models when controlling for time for any of the patient‐outcome measures. The number of admissions increased for all 4 medical teams (Figure 1), but, as shown in Figures 2 and 3, the readmission rates for all teams remained relatively stable over this same period of time.

Figure 1

Figure 2

Figure 3

Clinical Pharmacist on Gold Team Rounds

The inpatient clinical pharmacist changed the management plan for 22% of the patients seen on rounds. Contributions from the clinical pharmacist included adjusting the dosing of ordered medication and correcting medication reconciliation. Education and pharmaceutical information was provided to the team in another 6% of the 170 consecutive patient encounters evaluated.

Perception of Circle of Concern Rounds

Circle of Concern rounds were generally well‐received by both nurses and physicians. In a healthcare‐worker communication survey, completed by 38 physicians (62% response rate) and 48 nurses (54% response rate), the majority of both physicians (83%) and nurses (68%) felt Circle of Concern rounds improved communication.

Nurse Perception of Communication

The healthcare‐worker communication survey asked inpatient nurses to rate communication between nurses and physicians on each of the 4 medicine teams. Significantly more nurses were satisfied with communication with the Gold team (71%) compared with the other 3 medicine teams (53%; P=0.02) (Figure 4).

Figure 4

Perception of the Clinical Care Coordinator

In total, 20 physicians (87% response rate) and 10 nurses (56% response rate) completed the Clinical Care Coordinator survey. The physician results were overwhelmingly positive: 100% were satisfied or very satisfied with the role; 100% felt each team should have a Clinical Care Coordinator; and 100% agreed or strongly agreed that the Clinical Care Coordinator ensures that appropriate follow‐up is arranged, provides continuity of care, assists with interdisciplinary communication, and helps facilitate discharge. The majority of nurses was also satisfied or very satisfied with the Clinical Care Coordinator role and felt each team should have one.

Educational Outcomes

House Officer Evaluation of Attendings

Monthly evaluations of attending physicians by house officers (Figure 5) revealed that prior to the HOPE Initiative, little differences were observed between teams, as would be expected because attending assignment was largely random. After the intervention date of July 2009, however, significant differences were noted, with Gold team attendings receiving significantly higher teaching evaluations immediately after the introduction of the HOPE Initiative. Although ratings for Gold attendings remained more favorable, the difference was no longer statistically significant in the second and third year of the initiative, likely due to Gold attendings serving on other medicine teams, which contributed to an improvement in ratings of all attendings.

Figure 5

Medical Student Evaluation of Attendings

Monthly evaluations of attending physicians by third‐year medical students (Figure 6) revealed differences between the Gold attendings and all others, with the attendings that joined the Gold team in 2009 receiving higher teaching evaluations even before the HOPE Initiative started. However, this difference remained statistically significant in years 2 and 3 postinitiative, despite the addition of 4 new junior attendings.

Figure 6

Medical Student Medicine Shelf Scores

The national average on the shelf exam, which reflects learning after the internal medicine third‐year clerkship, has ranged from 75 to 78 for the past several years, with University of Michigan students averaging significantly higher scores prior to and after the HOPE Initiative. However, following the HOPE Initiative, third‐year medical students on the Gold team scored significantly higher on the shelf exam compared with their colleagues on the non‐Gold teams (84 vs 82; P=0.006). This difference in the shelf exam scores, although small, is statistically significant. It represents a measurable improvement in shelf scores in our system and demonstrates the potential educational benefit for the students. Over this same time period, scores on the United States Medical Licensing Exam, given to medical students at the beginning of their third year, remained stable (233 preHOPE Initiative; 234 postHOPE Initiative).

DISCUSSION

Within academic medical centers, hospitalists are expected to care for patients, teach, and help improve the quality and efficiency of hospital‐based care.[7] The Department of Veterans Affairs runs the largest integrated healthcare system in the United States, with approximately 80% of VA hospitals having hospital medicine programs. Overall, one‐third of US residents perform part of their residency training at a VA hospital.[22, 23] Thus, the effects of a system‐wide change at a VA hospital may have implications throughout the country. We studied one such intervention. Our primary findings are that we were able to improve communication and learner education with minimal effects on patient outcomes. While overall LOS decreased slightly postintervention, after taking into account secular trends, readmission rates did not.

We are not the first to evaluate a hospital medicine team using a quasi‐experimental design. For example, Meltzer and colleagues evaluated a hospitalist program at the University of Chicago Medical Center and found that, by the second year of operation, hospitalist care was associated with significantly shorter LOS (0.49 days), reduced costs, and decreased mortality.[24] Auerbach also evaluated a newly created hospital medicine service, finding decreased LOS (0.61 days), lower costs, and lower risk of mortality by the second year of the program.[25]

Improving nurse‐physician communication is considered important for avoiding medical error,[26] yet there has been limited empirical study of methods to improve communication within the medical profession.[27] Based both on our surveys and qualitative interviews, healthcare‐worker communication appeared to improve on the Gold team during the study. A key component of this improvement is likely related to instituting Circle of Concern rounds, in which nurses joined the medical team during attending rounds. Such an intervention likely helped to address organizational silence[28] and enhance the psychological safety of the nursing staff, because the attending physician was proactive about soliciting the input of nurses during rounds.[29] Such leader inclusivenesswords and deeds exhibited by leaders that invite and appreciate others' contributionscan aid interdisciplinary teams in overcoming the negative effects of status differences, thereby promoting collaboration.[29] The inclusion of nurses on rounds is also relationship‐building, which Gotlib Conn and colleagues found was important to improved interprofessional communication and collaboration.[30] In the future, using a tool such as the Teamwork Effectiveness Assessment Module (TEAM) developed by the American Board of Internal Medicine[31] could provide further evaluation of the impact on interprofessional teamwork and communication.

The focus on learner education, though evaluated in prior studies, is also novel. One previous survey of medical students showed that engaging students in substantive discussions is associated with greater student satisfaction.[32] Another survey of medical students found that attendings who were enthusiastic about teaching, inspired confidence in knowledge and skills, provided useful feedback, and encouraged increased student responsibility were viewed as more effective teachers.[33] No previous study that we are aware of, however, has looked at actual educational outcomes, such as shelf scores. The National Board of Medical Examiners reports that the Medicine subject exam is scaled to have a mean of 70 and a standard deviation of 8.[34] Thus, a mean increase in score of 2 points is small, but not trivial. This shows improvement in a hard educational outcome. Additionally, 2 points, although small in the context of total score and standard deviation, may make a substantial difference to an individual student in terms of overall grade, and, thus, residency applications. Our finding that third‐year medical students on the Gold team performed significantly better than University of Michigan third‐year medical students on other teams is an intriguing finding that warrants confirmation. On the other hand, this finding is consistent with a previous report evaluating learner satisfaction in which Bodnar et al found improved ratings of quantity and quality of teaching on teams with a nontraditional structure (Gold team).[21] Moreover, despite relatively few studies, the reason underlying the educational benefit of hospitalists should surprise few. The hospitalist model ensures that learners are supervised by physicians who are experts in the care of hospitalized patients.[35] Hospitalists hired at teaching hospitals to work on services with learners are generally chosen because they possess superior educational skills.[7]

Our findings should be interpreted in the context of the following limitations. First, our study focused on a single academically affiliated VA hospital. As other VA hospitals are pursuing a similar approach (eg, the Houston and Detroit VA medical centers), replicating our results will be important. Second, the VA system, although the largest integrated healthcare system in the United States, has unique characteristicssuch as an integrated electronic health record and predominantly male patient populationthat may make generalizations to the larger US healthcare system challenging. Third, there was a slightly lower response rate among nurses on a few of the surveys to evaluate our efforts; however, this rate of response is standard at our facility. Finally, our evaluation lacks an empirical measure of healthcare‐worker communication, such as incident reports.

Despite these limitations, our results have important implications. Using both quantitative and qualitative assessment, we found that academic hospitalists have the ability to improve healthcare‐worker communication and enhance learner education without increasing LOS. These findings are directly applicable to VA medical centers and potentially applicable to other academic medical centers.

Improving quality while reducing costs remains important for hospitals across the United States, including the approximately 150 hospitals that are part of the Veterans Affairs (VA) healthcare system.[1, 2] The field of hospital medicine has grown rapidly, leading to predictions that the majority of inpatient care in the United States eventually will be delivered by hospitalists.[3, 4] In 2010, 57% of US hospitals had hospitalists on staff, including 87% of hospitals with 200 beds,[5] and nearly 80% of VA hospitals.[6]

The demand for hospitalists within teaching hospitals has grown in part as a response to the mandate to reduce residency work hours.[7] Furthermore, previous research has found that hospitalist care is associated with modest reductions in length of stay (LOS) and weak but inconsistent differences in quality.[8] The educational effect of hospitalists has been far less examined. The limited number of studies published to date suggests that hospitalists may improve resident learning and house‐officer satisfaction in academic medical centers and community teaching hospitals[9, 10, 11] and provide positive experiences for medical students^12,13; however, Wachter et al reported no significant changes in clinical outcomes or patient, faculty, and house‐staff satisfaction in a newly designed hospital medicine service in San Francisco.[14] Additionally, whether using hospitalists influences nurse‐physician communication[15] is unknown.

Recognizing the limited and sometimes conflicting evidence about the hospitalist model, we report the results of a 3‐year quasi‐experimental evaluation of the experience at our medical center with academic hospitalists. As part of a VA Systems Redesign Improvement Capability Grantknown as the Hospital Outcomes Program of Excellence (HOPE) Initiativewe created a hospitalist‐based medicine team focused on quality improvement, medical education, and patient outcomes.

METHODS

RESULTS

Clinical Outcomes

Patient Outcomes

Our multivariable linear regression analysis, controlling for time, showed a significant reduction in LOS of approximately 0.3 days on all teams after the HOPE Initiative began (P=0.004). There were no significant differences between the Gold and non‐Gold teams in the multivariate models when controlling for time for any of the patient‐outcome measures. The number of admissions increased for all 4 medical teams (Figure 1), but, as shown in Figures 2 and 3, the readmission rates for all teams remained relatively stable over this same period of time.

Figure 1

Figure 2

Figure 3

Clinical Pharmacist on Gold Team Rounds

The inpatient clinical pharmacist changed the management plan for 22% of the patients seen on rounds. Contributions from the clinical pharmacist included adjusting the dosing of ordered medication and correcting medication reconciliation. Education and pharmaceutical information was provided to the team in another 6% of the 170 consecutive patient encounters evaluated.

Perception of Circle of Concern Rounds

Circle of Concern rounds were generally well‐received by both nurses and physicians. In a healthcare‐worker communication survey, completed by 38 physicians (62% response rate) and 48 nurses (54% response rate), the majority of both physicians (83%) and nurses (68%) felt Circle of Concern rounds improved communication.

Nurse Perception of Communication

The healthcare‐worker communication survey asked inpatient nurses to rate communication between nurses and physicians on each of the 4 medicine teams. Significantly more nurses were satisfied with communication with the Gold team (71%) compared with the other 3 medicine teams (53%; P=0.02) (Figure 4).

Figure 4

Perception of the Clinical Care Coordinator

In total, 20 physicians (87% response rate) and 10 nurses (56% response rate) completed the Clinical Care Coordinator survey. The physician results were overwhelmingly positive: 100% were satisfied or very satisfied with the role; 100% felt each team should have a Clinical Care Coordinator; and 100% agreed or strongly agreed that the Clinical Care Coordinator ensures that appropriate follow‐up is arranged, provides continuity of care, assists with interdisciplinary communication, and helps facilitate discharge. The majority of nurses was also satisfied or very satisfied with the Clinical Care Coordinator role and felt each team should have one.

Educational Outcomes

House Officer Evaluation of Attendings

Monthly evaluations of attending physicians by house officers (Figure 5) revealed that prior to the HOPE Initiative, little differences were observed between teams, as would be expected because attending assignment was largely random. After the intervention date of July 2009, however, significant differences were noted, with Gold team attendings receiving significantly higher teaching evaluations immediately after the introduction of the HOPE Initiative. Although ratings for Gold attendings remained more favorable, the difference was no longer statistically significant in the second and third year of the initiative, likely due to Gold attendings serving on other medicine teams, which contributed to an improvement in ratings of all attendings.

Figure 5

Medical Student Evaluation of Attendings

Monthly evaluations of attending physicians by third‐year medical students (Figure 6) revealed differences between the Gold attendings and all others, with the attendings that joined the Gold team in 2009 receiving higher teaching evaluations even before the HOPE Initiative started. However, this difference remained statistically significant in years 2 and 3 postinitiative, despite the addition of 4 new junior attendings.

Figure 6

Medical Student Medicine Shelf Scores

The national average on the shelf exam, which reflects learning after the internal medicine third‐year clerkship, has ranged from 75 to 78 for the past several years, with University of Michigan students averaging significantly higher scores prior to and after the HOPE Initiative. However, following the HOPE Initiative, third‐year medical students on the Gold team scored significantly higher on the shelf exam compared with their colleagues on the non‐Gold teams (84 vs 82; P=0.006). This difference in the shelf exam scores, although small, is statistically significant. It represents a measurable improvement in shelf scores in our system and demonstrates the potential educational benefit for the students. Over this same time period, scores on the United States Medical Licensing Exam, given to medical students at the beginning of their third year, remained stable (233 preHOPE Initiative; 234 postHOPE Initiative).

DISCUSSION

Within academic medical centers, hospitalists are expected to care for patients, teach, and help improve the quality and efficiency of hospital‐based care.[7] The Department of Veterans Affairs runs the largest integrated healthcare system in the United States, with approximately 80% of VA hospitals having hospital medicine programs. Overall, one‐third of US residents perform part of their residency training at a VA hospital.[22, 23] Thus, the effects of a system‐wide change at a VA hospital may have implications throughout the country. We studied one such intervention. Our primary findings are that we were able to improve communication and learner education with minimal effects on patient outcomes. While overall LOS decreased slightly postintervention, after taking into account secular trends, readmission rates did not.

We are not the first to evaluate a hospital medicine team using a quasi‐experimental design. For example, Meltzer and colleagues evaluated a hospitalist program at the University of Chicago Medical Center and found that, by the second year of operation, hospitalist care was associated with significantly shorter LOS (0.49 days), reduced costs, and decreased mortality.[24] Auerbach also evaluated a newly created hospital medicine service, finding decreased LOS (0.61 days), lower costs, and lower risk of mortality by the second year of the program.[25]

Improving nurse‐physician communication is considered important for avoiding medical error,[26] yet there has been limited empirical study of methods to improve communication within the medical profession.[27] Based both on our surveys and qualitative interviews, healthcare‐worker communication appeared to improve on the Gold team during the study. A key component of this improvement is likely related to instituting Circle of Concern rounds, in which nurses joined the medical team during attending rounds. Such an intervention likely helped to address organizational silence[28] and enhance the psychological safety of the nursing staff, because the attending physician was proactive about soliciting the input of nurses during rounds.[29] Such leader inclusivenesswords and deeds exhibited by leaders that invite and appreciate others' contributionscan aid interdisciplinary teams in overcoming the negative effects of status differences, thereby promoting collaboration.[29] The inclusion of nurses on rounds is also relationship‐building, which Gotlib Conn and colleagues found was important to improved interprofessional communication and collaboration.[30] In the future, using a tool such as the Teamwork Effectiveness Assessment Module (TEAM) developed by the American Board of Internal Medicine[31] could provide further evaluation of the impact on interprofessional teamwork and communication.

The focus on learner education, though evaluated in prior studies, is also novel. One previous survey of medical students showed that engaging students in substantive discussions is associated with greater student satisfaction.[32] Another survey of medical students found that attendings who were enthusiastic about teaching, inspired confidence in knowledge and skills, provided useful feedback, and encouraged increased student responsibility were viewed as more effective teachers.[33] No previous study that we are aware of, however, has looked at actual educational outcomes, such as shelf scores. The National Board of Medical Examiners reports that the Medicine subject exam is scaled to have a mean of 70 and a standard deviation of 8.[34] Thus, a mean increase in score of 2 points is small, but not trivial. This shows improvement in a hard educational outcome. Additionally, 2 points, although small in the context of total score and standard deviation, may make a substantial difference to an individual student in terms of overall grade, and, thus, residency applications. Our finding that third‐year medical students on the Gold team performed significantly better than University of Michigan third‐year medical students on other teams is an intriguing finding that warrants confirmation. On the other hand, this finding is consistent with a previous report evaluating learner satisfaction in which Bodnar et al found improved ratings of quantity and quality of teaching on teams with a nontraditional structure (Gold team).[21] Moreover, despite relatively few studies, the reason underlying the educational benefit of hospitalists should surprise few. The hospitalist model ensures that learners are supervised by physicians who are experts in the care of hospitalized patients.[35] Hospitalists hired at teaching hospitals to work on services with learners are generally chosen because they possess superior educational skills.[7]

Our findings should be interpreted in the context of the following limitations. First, our study focused on a single academically affiliated VA hospital. As other VA hospitals are pursuing a similar approach (eg, the Houston and Detroit VA medical centers), replicating our results will be important. Second, the VA system, although the largest integrated healthcare system in the United States, has unique characteristicssuch as an integrated electronic health record and predominantly male patient populationthat may make generalizations to the larger US healthcare system challenging. Third, there was a slightly lower response rate among nurses on a few of the surveys to evaluate our efforts; however, this rate of response is standard at our facility. Finally, our evaluation lacks an empirical measure of healthcare‐worker communication, such as incident reports.

Despite these limitations, our results have important implications. Using both quantitative and qualitative assessment, we found that academic hospitalists have the ability to improve healthcare‐worker communication and enhance learner education without increasing LOS. These findings are directly applicable to VA medical centers and potentially applicable to other academic medical centers.

Improving quality while reducing costs remains important for hospitals across the United States, including the approximately 150 hospitals that are part of the Veterans Affairs (VA) healthcare system.[1, 2] The field of hospital medicine has grown rapidly, leading to predictions that the majority of inpatient care in the United States eventually will be delivered by hospitalists.[3, 4] In 2010, 57% of US hospitals had hospitalists on staff, including 87% of hospitals with 200 beds,[5] and nearly 80% of VA hospitals.[6]

The demand for hospitalists within teaching hospitals has grown in part as a response to the mandate to reduce residency work hours.[7] Furthermore, previous research has found that hospitalist care is associated with modest reductions in length of stay (LOS) and weak but inconsistent differences in quality.[8] The educational effect of hospitalists has been far less examined. The limited number of studies published to date suggests that hospitalists may improve resident learning and house‐officer satisfaction in academic medical centers and community teaching hospitals[9, 10, 11] and provide positive experiences for medical students^12,13; however, Wachter et al reported no significant changes in clinical outcomes or patient, faculty, and house‐staff satisfaction in a newly designed hospital medicine service in San Francisco.[14] Additionally, whether using hospitalists influences nurse‐physician communication[15] is unknown.

Recognizing the limited and sometimes conflicting evidence about the hospitalist model, we report the results of a 3‐year quasi‐experimental evaluation of the experience at our medical center with academic hospitalists. As part of a VA Systems Redesign Improvement Capability Grantknown as the Hospital Outcomes Program of Excellence (HOPE) Initiativewe created a hospitalist‐based medicine team focused on quality improvement, medical education, and patient outcomes.

METHODS

RESULTS

Clinical Outcomes

Patient Outcomes

Our multivariable linear regression analysis, controlling for time, showed a significant reduction in LOS of approximately 0.3 days on all teams after the HOPE Initiative began (P=0.004). There were no significant differences between the Gold and non‐Gold teams in the multivariate models when controlling for time for any of the patient‐outcome measures. The number of admissions increased for all 4 medical teams (Figure 1), but, as shown in Figures 2 and 3, the readmission rates for all teams remained relatively stable over this same period of time.

Figure 1

Figure 2

Figure 3

Clinical Pharmacist on Gold Team Rounds

The inpatient clinical pharmacist changed the management plan for 22% of the patients seen on rounds. Contributions from the clinical pharmacist included adjusting the dosing of ordered medication and correcting medication reconciliation. Education and pharmaceutical information was provided to the team in another 6% of the 170 consecutive patient encounters evaluated.

Perception of Circle of Concern Rounds

Circle of Concern rounds were generally well‐received by both nurses and physicians. In a healthcare‐worker communication survey, completed by 38 physicians (62% response rate) and 48 nurses (54% response rate), the majority of both physicians (83%) and nurses (68%) felt Circle of Concern rounds improved communication.

Nurse Perception of Communication

The healthcare‐worker communication survey asked inpatient nurses to rate communication between nurses and physicians on each of the 4 medicine teams. Significantly more nurses were satisfied with communication with the Gold team (71%) compared with the other 3 medicine teams (53%; P=0.02) (Figure 4).

Figure 4

Perception of the Clinical Care Coordinator

In total, 20 physicians (87% response rate) and 10 nurses (56% response rate) completed the Clinical Care Coordinator survey. The physician results were overwhelmingly positive: 100% were satisfied or very satisfied with the role; 100% felt each team should have a Clinical Care Coordinator; and 100% agreed or strongly agreed that the Clinical Care Coordinator ensures that appropriate follow‐up is arranged, provides continuity of care, assists with interdisciplinary communication, and helps facilitate discharge. The majority of nurses was also satisfied or very satisfied with the Clinical Care Coordinator role and felt each team should have one.

Educational Outcomes

House Officer Evaluation of Attendings

Monthly evaluations of attending physicians by house officers (Figure 5) revealed that prior to the HOPE Initiative, little differences were observed between teams, as would be expected because attending assignment was largely random. After the intervention date of July 2009, however, significant differences were noted, with Gold team attendings receiving significantly higher teaching evaluations immediately after the introduction of the HOPE Initiative. Although ratings for Gold attendings remained more favorable, the difference was no longer statistically significant in the second and third year of the initiative, likely due to Gold attendings serving on other medicine teams, which contributed to an improvement in ratings of all attendings.

Figure 5

Medical Student Evaluation of Attendings

Monthly evaluations of attending physicians by third‐year medical students (Figure 6) revealed differences between the Gold attendings and all others, with the attendings that joined the Gold team in 2009 receiving higher teaching evaluations even before the HOPE Initiative started. However, this difference remained statistically significant in years 2 and 3 postinitiative, despite the addition of 4 new junior attendings.

Figure 6

Medical Student Medicine Shelf Scores

The national average on the shelf exam, which reflects learning after the internal medicine third‐year clerkship, has ranged from 75 to 78 for the past several years, with University of Michigan students averaging significantly higher scores prior to and after the HOPE Initiative. However, following the HOPE Initiative, third‐year medical students on the Gold team scored significantly higher on the shelf exam compared with their colleagues on the non‐Gold teams (84 vs 82; P=0.006). This difference in the shelf exam scores, although small, is statistically significant. It represents a measurable improvement in shelf scores in our system and demonstrates the potential educational benefit for the students. Over this same time period, scores on the United States Medical Licensing Exam, given to medical students at the beginning of their third year, remained stable (233 preHOPE Initiative; 234 postHOPE Initiative).

DISCUSSION

Within academic medical centers, hospitalists are expected to care for patients, teach, and help improve the quality and efficiency of hospital‐based care.[7] The Department of Veterans Affairs runs the largest integrated healthcare system in the United States, with approximately 80% of VA hospitals having hospital medicine programs. Overall, one‐third of US residents perform part of their residency training at a VA hospital.[22, 23] Thus, the effects of a system‐wide change at a VA hospital may have implications throughout the country. We studied one such intervention. Our primary findings are that we were able to improve communication and learner education with minimal effects on patient outcomes. While overall LOS decreased slightly postintervention, after taking into account secular trends, readmission rates did not.

We are not the first to evaluate a hospital medicine team using a quasi‐experimental design. For example, Meltzer and colleagues evaluated a hospitalist program at the University of Chicago Medical Center and found that, by the second year of operation, hospitalist care was associated with significantly shorter LOS (0.49 days), reduced costs, and decreased mortality.[24] Auerbach also evaluated a newly created hospital medicine service, finding decreased LOS (0.61 days), lower costs, and lower risk of mortality by the second year of the program.[25]

Improving nurse‐physician communication is considered important for avoiding medical error,[26] yet there has been limited empirical study of methods to improve communication within the medical profession.[27] Based both on our surveys and qualitative interviews, healthcare‐worker communication appeared to improve on the Gold team during the study. A key component of this improvement is likely related to instituting Circle of Concern rounds, in which nurses joined the medical team during attending rounds. Such an intervention likely helped to address organizational silence[28] and enhance the psychological safety of the nursing staff, because the attending physician was proactive about soliciting the input of nurses during rounds.[29] Such leader inclusivenesswords and deeds exhibited by leaders that invite and appreciate others' contributionscan aid interdisciplinary teams in overcoming the negative effects of status differences, thereby promoting collaboration.[29] The inclusion of nurses on rounds is also relationship‐building, which Gotlib Conn and colleagues found was important to improved interprofessional communication and collaboration.[30] In the future, using a tool such as the Teamwork Effectiveness Assessment Module (TEAM) developed by the American Board of Internal Medicine[31] could provide further evaluation of the impact on interprofessional teamwork and communication.

The focus on learner education, though evaluated in prior studies, is also novel. One previous survey of medical students showed that engaging students in substantive discussions is associated with greater student satisfaction.[32] Another survey of medical students found that attendings who were enthusiastic about teaching, inspired confidence in knowledge and skills, provided useful feedback, and encouraged increased student responsibility were viewed as more effective teachers.[33] No previous study that we are aware of, however, has looked at actual educational outcomes, such as shelf scores. The National Board of Medical Examiners reports that the Medicine subject exam is scaled to have a mean of 70 and a standard deviation of 8.[34] Thus, a mean increase in score of 2 points is small, but not trivial. This shows improvement in a hard educational outcome. Additionally, 2 points, although small in the context of total score and standard deviation, may make a substantial difference to an individual student in terms of overall grade, and, thus, residency applications. Our finding that third‐year medical students on the Gold team performed significantly better than University of Michigan third‐year medical students on other teams is an intriguing finding that warrants confirmation. On the other hand, this finding is consistent with a previous report evaluating learner satisfaction in which Bodnar et al found improved ratings of quantity and quality of teaching on teams with a nontraditional structure (Gold team).[21] Moreover, despite relatively few studies, the reason underlying the educational benefit of hospitalists should surprise few. The hospitalist model ensures that learners are supervised by physicians who are experts in the care of hospitalized patients.[35] Hospitalists hired at teaching hospitals to work on services with learners are generally chosen because they possess superior educational skills.[7]

Our findings should be interpreted in the context of the following limitations. First, our study focused on a single academically affiliated VA hospital. As other VA hospitals are pursuing a similar approach (eg, the Houston and Detroit VA medical centers), replicating our results will be important. Second, the VA system, although the largest integrated healthcare system in the United States, has unique characteristicssuch as an integrated electronic health record and predominantly male patient populationthat may make generalizations to the larger US healthcare system challenging. Third, there was a slightly lower response rate among nurses on a few of the surveys to evaluate our efforts; however, this rate of response is standard at our facility. Finally, our evaluation lacks an empirical measure of healthcare‐worker communication, such as incident reports.

Despite these limitations, our results have important implications. Using both quantitative and qualitative assessment, we found that academic hospitalists have the ability to improve healthcare‐worker communication and enhance learner education without increasing LOS. These findings are directly applicable to VA medical centers and potentially applicable to other academic medical centers.

Pediatric hospitalists are increasingly following their adult counterparts' lead in participating in comanagement programs with surgeons. In the 20112012 Society of Hospital Medicine survey of hospitalist practice models, 94% of adult hospitalists and 72% of pediatric hospitalists reported comanaging surgical patients.[1] Adult patients comanaged postoperatively have shown equivalent clinical outcomes with strong endorsement from nurses and surgeons in 1 study[2] and reduced morbidity, mortality, and length of stay in other studies.[3, 4]

One of the drivers of pediatric hospitalists comanaging surgical patients may be the increased complexity of hospitalized children.[5, 6, 7, 8] Two pediatric studies have assessed hospitalistsurgeon comanagement of medically complex children in the postoperative period. One study evaluating 14 patients undergoing spinal fusion surgery for neuromuscular scoliosis showed an association between pediatric hospitalist comanagement and a decreased length of stay, with decreased variability in postoperative length of stay.[9] A study of 207 medically complex children undergoing spinal fusion surgery for neuromuscular scoliosis suggested an association between comanagement and reduced laboratory studies and parenteral nutrition but an initial increase in costs.[10]

Pediatric hospitalist programs have also followed adult programs' lead in evaluating surgical patients preoperatively. Studies of preoperative medical evaluations for adult surgical patients have reported mixed results, with improved use of recommended medical therapies, length of stay, and mortality postoperatively in 1 study,[11] whereas other studies have reported longer lengths of stay and higher costs.[12, 13] One adult study described a protocol‐based approach in which hospitalists coordinated pulmonary and cardiac evaluations for high‐risk spine patients but did not report any outcomes.[14] A pediatric study from the Netherlands described a multidisciplinary team approach to these patients, including both preoperative and postoperative evaluation, but did not include a hospitalist or general pediatrician nor present data on outcomes.[15]

In 2009, we began a hospitalist preoperative evaluation program for patients with neuromuscular scoliosis in anticipation of spinal fusion surgery. This program was established by the hospital administration in response to 2 sentinel events. Hospitalists, who had already begun comanaging surgical patients postoperatively, were required to see patients with neuromuscular scoliosis preoperatively. Hospitalists were felt to be knowledgeable about postoperative complications of spinal fusion surgery and were thought to perhaps be able to prevent certain postoperative complications.

In the current study, we sought to evaluate certain outcomes associated with this preoperative program. We hypothesized that evaluations for more complex patients would be more likely to be associated with preoperative changes. We evaluated how frequently hospitalists make recommendations for changes in patients' medical regimens or request further diagnostic evaluations and if any clinical characteristics were associated with hospitalists making these recommendations.

METHODS

RESULTS

Overall, 214 patients were included in our study. Typical patients included those with cerebral palsy scheduled to undergo posterior spinal fusion surgery. Many had significant comorbidities, including seizures and gastrointestinal (GI) disease, and were dependent on medical technology.

Regarding hospitalist recommendations, overall 155 patients (72%) received at least 1 recommendation. Types of recommendations are listed in Table 1. The most common type of recommendation regarding the patient's current regimen was medication change (82 patients, 38%). Recommendations for changes in nutrition were made in 46 patients (21%). Subspecialist input was elicited in 76 patients (36%); a subspecialist appointment was suggested most commonly (36 patients, 17%), whereas a telephone consultation occurred in 15 patients (7%). Hospitalists also frequently requested further diagnostic evaluation, especially laboratory studies (41 patients, 19%). Imaging studies were requested less frequently (11 patients, 5.1%) as were other studies such as electrocardiograms and pulmonary function tests (6 patients, 2.8%, each). No patient received a preoperative hospitalist recommendation to cancel or postpone surgery.

Certain patient characteristics were associated with a statistically significant increase in likelihood of a preoperative intervention by the pediatric hospitalist (Table 2). These included type of surgery (OR: 2.70, 95% CI: 1.22‐5.97 for posterior spinal fusion), number of preoperative prescription medications (OR: 1.19, 95% CI: 1.06‐1.34), and nonambulatory status (OR: 2.02, 95% CI: 1.09‐3.74). Underlying disease also showed a statistically significant association with recommendations being made; patients were more likely to receive recommendations if they had cerebral palsy (OR: 2.01, 95% CI: 1.03‐3.92), spina bifida (OR: 2.33, 95% CI: 1.90‐3.48), and neuropathy (all had recommendations). An underlying diagnosis of skeletal dysplasia was statistically significantly associated with a decreased rate of recommendations being made (OR: 0.29, 95% CI: 0.14‐0.61). Patients with seizures (OR: 2.68, 95% CI: 1.29‐5.57) or GI comorbidity were more likely to receive a preoperative recommendation made by the hospitalist (OR: 3.35, 95% CI: 1.74‐6.45), but patients with cardiac and pulmonary comorbidities were not.

DISCUSSION

This is the first large study to examine the role of the pediatric hospitalist in preoperative evaluation of complex surgical patients. Our program developed as an evolution of a postoperative program that we have described previously.[10] The postoperative component of our comanagement program began in 2003, and the preoperative aspect was added in 2009. We believe that the preoperative component to our program contributed in some degree to the decrease in utilization of certain aspects of postoperative care over time such as parenteral nutrition. This change may have occurred because of improved bowel management perioperatively, for instance. Although the preoperative hospitalist evaluation program was instituted by our hospital administration, we felt a preoperative hospitalist evaluation represented a standardized, comprehensive way to evaluate patients before surgery. By 2009, the hospitalists at our hospital had already developed some expertise in managing patients after undergoing spinal fusion surgery.

The fact that hospitalists made recommendations for changes in medications, nutritional management, or diagnostic tests at such a high rate (72%) is interesting. We were not surprised by this finding based on anecdotal evidence because we feel that many of these patients may receive somewhat fragmented care because they often see multiple medical specialists. The high rate of interventions noted in our study may result from the fact that hospitalists who comanage these patients frequently after spinal fusion surgery were attempting to prevent postoperative complications that they see after this type of surgery. Many pediatric hospitalists have developed significant experience in caring for medically complex children and thus may feel more comfortable making preoperative recommendations than other general pediatricians.

We were not surprised to find that hospitalists made preoperative recommendations more frequently in children who had seizures, significant GI comorbidity, and who were nonambulatory. We also noted a statistically significant increased rate of recommendations when patients were on more preoperative medications. We believe that these variables suggest a population that is more medically complex. The importance of selecting medically complex patients for hospitalist comanagement has been noted previously.[16] Therefore, comanagement programs looking to maximize patient benefit for a preoperative hospitalist evaluation program might limit these visits to those who are most medically complex. We found a particularly low yield in evaluation of patients with skeletal dysplasia for example and may discontinue seeing these patients preoperatively.

We found the lack of statistically significant change in rate of hospitalist recommendations among patients with cardiac and pulmonary comorbidities interesting. Whether this was related to the mandatory preoperative pulmonology and cardiology visits is not certain. We hope to study the impact of these preoperative visits in the future as we continue to evaluate our perioperative program.

Several limitations of this study deserve note. This study was performed at 1 institution with 1 group of hospitalists and 1 group of orthopedic surgeons. Two of the study authors (D.R. and D.P.) were among the hospitalists involved with the clinical program. The study was retrospective and nonrandomized. We did not contact primary care physicians as a rule for further information about these patients. In this study, we did not specifically study the impact of hospitalist preoperative evaluations on postoperative outcomes, although the preoperative component represented an important aspect of the more systematic intervention described elsewhere.[10]

CONCLUSIONS

A preoperative program for pediatric hospitalists to see children in anticipation of spinal surgery for neuromuscular scoliosis leads to a high rate of recommendations for changes in medical management or diagnostic evaluation. Certain patient characteristics are more highly associated with hospitalists making these recommendations prior to surgery.

Pediatric hospitalists are increasingly following their adult counterparts' lead in participating in comanagement programs with surgeons. In the 20112012 Society of Hospital Medicine survey of hospitalist practice models, 94% of adult hospitalists and 72% of pediatric hospitalists reported comanaging surgical patients.[1] Adult patients comanaged postoperatively have shown equivalent clinical outcomes with strong endorsement from nurses and surgeons in 1 study[2] and reduced morbidity, mortality, and length of stay in other studies.[3, 4]

One of the drivers of pediatric hospitalists comanaging surgical patients may be the increased complexity of hospitalized children.[5, 6, 7, 8] Two pediatric studies have assessed hospitalistsurgeon comanagement of medically complex children in the postoperative period. One study evaluating 14 patients undergoing spinal fusion surgery for neuromuscular scoliosis showed an association between pediatric hospitalist comanagement and a decreased length of stay, with decreased variability in postoperative length of stay.[9] A study of 207 medically complex children undergoing spinal fusion surgery for neuromuscular scoliosis suggested an association between comanagement and reduced laboratory studies and parenteral nutrition but an initial increase in costs.[10]

Pediatric hospitalist programs have also followed adult programs' lead in evaluating surgical patients preoperatively. Studies of preoperative medical evaluations for adult surgical patients have reported mixed results, with improved use of recommended medical therapies, length of stay, and mortality postoperatively in 1 study,[11] whereas other studies have reported longer lengths of stay and higher costs.[12, 13] One adult study described a protocol‐based approach in which hospitalists coordinated pulmonary and cardiac evaluations for high‐risk spine patients but did not report any outcomes.[14] A pediatric study from the Netherlands described a multidisciplinary team approach to these patients, including both preoperative and postoperative evaluation, but did not include a hospitalist or general pediatrician nor present data on outcomes.[15]

In 2009, we began a hospitalist preoperative evaluation program for patients with neuromuscular scoliosis in anticipation of spinal fusion surgery. This program was established by the hospital administration in response to 2 sentinel events. Hospitalists, who had already begun comanaging surgical patients postoperatively, were required to see patients with neuromuscular scoliosis preoperatively. Hospitalists were felt to be knowledgeable about postoperative complications of spinal fusion surgery and were thought to perhaps be able to prevent certain postoperative complications.

In the current study, we sought to evaluate certain outcomes associated with this preoperative program. We hypothesized that evaluations for more complex patients would be more likely to be associated with preoperative changes. We evaluated how frequently hospitalists make recommendations for changes in patients' medical regimens or request further diagnostic evaluations and if any clinical characteristics were associated with hospitalists making these recommendations.

METHODS

RESULTS

Overall, 214 patients were included in our study. Typical patients included those with cerebral palsy scheduled to undergo posterior spinal fusion surgery. Many had significant comorbidities, including seizures and gastrointestinal (GI) disease, and were dependent on medical technology.

Regarding hospitalist recommendations, overall 155 patients (72%) received at least 1 recommendation. Types of recommendations are listed in Table 1. The most common type of recommendation regarding the patient's current regimen was medication change (82 patients, 38%). Recommendations for changes in nutrition were made in 46 patients (21%). Subspecialist input was elicited in 76 patients (36%); a subspecialist appointment was suggested most commonly (36 patients, 17%), whereas a telephone consultation occurred in 15 patients (7%). Hospitalists also frequently requested further diagnostic evaluation, especially laboratory studies (41 patients, 19%). Imaging studies were requested less frequently (11 patients, 5.1%) as were other studies such as electrocardiograms and pulmonary function tests (6 patients, 2.8%, each). No patient received a preoperative hospitalist recommendation to cancel or postpone surgery.

Certain patient characteristics were associated with a statistically significant increase in likelihood of a preoperative intervention by the pediatric hospitalist (Table 2). These included type of surgery (OR: 2.70, 95% CI: 1.22‐5.97 for posterior spinal fusion), number of preoperative prescription medications (OR: 1.19, 95% CI: 1.06‐1.34), and nonambulatory status (OR: 2.02, 95% CI: 1.09‐3.74). Underlying disease also showed a statistically significant association with recommendations being made; patients were more likely to receive recommendations if they had cerebral palsy (OR: 2.01, 95% CI: 1.03‐3.92), spina bifida (OR: 2.33, 95% CI: 1.90‐3.48), and neuropathy (all had recommendations). An underlying diagnosis of skeletal dysplasia was statistically significantly associated with a decreased rate of recommendations being made (OR: 0.29, 95% CI: 0.14‐0.61). Patients with seizures (OR: 2.68, 95% CI: 1.29‐5.57) or GI comorbidity were more likely to receive a preoperative recommendation made by the hospitalist (OR: 3.35, 95% CI: 1.74‐6.45), but patients with cardiac and pulmonary comorbidities were not.

DISCUSSION

This is the first large study to examine the role of the pediatric hospitalist in preoperative evaluation of complex surgical patients. Our program developed as an evolution of a postoperative program that we have described previously.[10] The postoperative component of our comanagement program began in 2003, and the preoperative aspect was added in 2009. We believe that the preoperative component to our program contributed in some degree to the decrease in utilization of certain aspects of postoperative care over time such as parenteral nutrition. This change may have occurred because of improved bowel management perioperatively, for instance. Although the preoperative hospitalist evaluation program was instituted by our hospital administration, we felt a preoperative hospitalist evaluation represented a standardized, comprehensive way to evaluate patients before surgery. By 2009, the hospitalists at our hospital had already developed some expertise in managing patients after undergoing spinal fusion surgery.

The fact that hospitalists made recommendations for changes in medications, nutritional management, or diagnostic tests at such a high rate (72%) is interesting. We were not surprised by this finding based on anecdotal evidence because we feel that many of these patients may receive somewhat fragmented care because they often see multiple medical specialists. The high rate of interventions noted in our study may result from the fact that hospitalists who comanage these patients frequently after spinal fusion surgery were attempting to prevent postoperative complications that they see after this type of surgery. Many pediatric hospitalists have developed significant experience in caring for medically complex children and thus may feel more comfortable making preoperative recommendations than other general pediatricians.

We were not surprised to find that hospitalists made preoperative recommendations more frequently in children who had seizures, significant GI comorbidity, and who were nonambulatory. We also noted a statistically significant increased rate of recommendations when patients were on more preoperative medications. We believe that these variables suggest a population that is more medically complex. The importance of selecting medically complex patients for hospitalist comanagement has been noted previously.[16] Therefore, comanagement programs looking to maximize patient benefit for a preoperative hospitalist evaluation program might limit these visits to those who are most medically complex. We found a particularly low yield in evaluation of patients with skeletal dysplasia for example and may discontinue seeing these patients preoperatively.

We found the lack of statistically significant change in rate of hospitalist recommendations among patients with cardiac and pulmonary comorbidities interesting. Whether this was related to the mandatory preoperative pulmonology and cardiology visits is not certain. We hope to study the impact of these preoperative visits in the future as we continue to evaluate our perioperative program.

Several limitations of this study deserve note. This study was performed at 1 institution with 1 group of hospitalists and 1 group of orthopedic surgeons. Two of the study authors (D.R. and D.P.) were among the hospitalists involved with the clinical program. The study was retrospective and nonrandomized. We did not contact primary care physicians as a rule for further information about these patients. In this study, we did not specifically study the impact of hospitalist preoperative evaluations on postoperative outcomes, although the preoperative component represented an important aspect of the more systematic intervention described elsewhere.[10]

CONCLUSIONS

A preoperative program for pediatric hospitalists to see children in anticipation of spinal surgery for neuromuscular scoliosis leads to a high rate of recommendations for changes in medical management or diagnostic evaluation. Certain patient characteristics are more highly associated with hospitalists making these recommendations prior to surgery.

Pediatric hospitalists are increasingly following their adult counterparts' lead in participating in comanagement programs with surgeons. In the 20112012 Society of Hospital Medicine survey of hospitalist practice models, 94% of adult hospitalists and 72% of pediatric hospitalists reported comanaging surgical patients.[1] Adult patients comanaged postoperatively have shown equivalent clinical outcomes with strong endorsement from nurses and surgeons in 1 study[2] and reduced morbidity, mortality, and length of stay in other studies.[3, 4]

One of the drivers of pediatric hospitalists comanaging surgical patients may be the increased complexity of hospitalized children.[5, 6, 7, 8] Two pediatric studies have assessed hospitalistsurgeon comanagement of medically complex children in the postoperative period. One study evaluating 14 patients undergoing spinal fusion surgery for neuromuscular scoliosis showed an association between pediatric hospitalist comanagement and a decreased length of stay, with decreased variability in postoperative length of stay.[9] A study of 207 medically complex children undergoing spinal fusion surgery for neuromuscular scoliosis suggested an association between comanagement and reduced laboratory studies and parenteral nutrition but an initial increase in costs.[10]

Pediatric hospitalist programs have also followed adult programs' lead in evaluating surgical patients preoperatively. Studies of preoperative medical evaluations for adult surgical patients have reported mixed results, with improved use of recommended medical therapies, length of stay, and mortality postoperatively in 1 study,[11] whereas other studies have reported longer lengths of stay and higher costs.[12, 13] One adult study described a protocol‐based approach in which hospitalists coordinated pulmonary and cardiac evaluations for high‐risk spine patients but did not report any outcomes.[14] A pediatric study from the Netherlands described a multidisciplinary team approach to these patients, including both preoperative and postoperative evaluation, but did not include a hospitalist or general pediatrician nor present data on outcomes.[15]

In 2009, we began a hospitalist preoperative evaluation program for patients with neuromuscular scoliosis in anticipation of spinal fusion surgery. This program was established by the hospital administration in response to 2 sentinel events. Hospitalists, who had already begun comanaging surgical patients postoperatively, were required to see patients with neuromuscular scoliosis preoperatively. Hospitalists were felt to be knowledgeable about postoperative complications of spinal fusion surgery and were thought to perhaps be able to prevent certain postoperative complications.

In the current study, we sought to evaluate certain outcomes associated with this preoperative program. We hypothesized that evaluations for more complex patients would be more likely to be associated with preoperative changes. We evaluated how frequently hospitalists make recommendations for changes in patients' medical regimens or request further diagnostic evaluations and if any clinical characteristics were associated with hospitalists making these recommendations.

METHODS

RESULTS

Overall, 214 patients were included in our study. Typical patients included those with cerebral palsy scheduled to undergo posterior spinal fusion surgery. Many had significant comorbidities, including seizures and gastrointestinal (GI) disease, and were dependent on medical technology.

Regarding hospitalist recommendations, overall 155 patients (72%) received at least 1 recommendation. Types of recommendations are listed in Table 1. The most common type of recommendation regarding the patient's current regimen was medication change (82 patients, 38%). Recommendations for changes in nutrition were made in 46 patients (21%). Subspecialist input was elicited in 76 patients (36%); a subspecialist appointment was suggested most commonly (36 patients, 17%), whereas a telephone consultation occurred in 15 patients (7%). Hospitalists also frequently requested further diagnostic evaluation, especially laboratory studies (41 patients, 19%). Imaging studies were requested less frequently (11 patients, 5.1%) as were other studies such as electrocardiograms and pulmonary function tests (6 patients, 2.8%, each). No patient received a preoperative hospitalist recommendation to cancel or postpone surgery.

Certain patient characteristics were associated with a statistically significant increase in likelihood of a preoperative intervention by the pediatric hospitalist (Table 2). These included type of surgery (OR: 2.70, 95% CI: 1.22‐5.97 for posterior spinal fusion), number of preoperative prescription medications (OR: 1.19, 95% CI: 1.06‐1.34), and nonambulatory status (OR: 2.02, 95% CI: 1.09‐3.74). Underlying disease also showed a statistically significant association with recommendations being made; patients were more likely to receive recommendations if they had cerebral palsy (OR: 2.01, 95% CI: 1.03‐3.92), spina bifida (OR: 2.33, 95% CI: 1.90‐3.48), and neuropathy (all had recommendations). An underlying diagnosis of skeletal dysplasia was statistically significantly associated with a decreased rate of recommendations being made (OR: 0.29, 95% CI: 0.14‐0.61). Patients with seizures (OR: 2.68, 95% CI: 1.29‐5.57) or GI comorbidity were more likely to receive a preoperative recommendation made by the hospitalist (OR: 3.35, 95% CI: 1.74‐6.45), but patients with cardiac and pulmonary comorbidities were not.

DISCUSSION

This is the first large study to examine the role of the pediatric hospitalist in preoperative evaluation of complex surgical patients. Our program developed as an evolution of a postoperative program that we have described previously.[10] The postoperative component of our comanagement program began in 2003, and the preoperative aspect was added in 2009. We believe that the preoperative component to our program contributed in some degree to the decrease in utilization of certain aspects of postoperative care over time such as parenteral nutrition. This change may have occurred because of improved bowel management perioperatively, for instance. Although the preoperative hospitalist evaluation program was instituted by our hospital administration, we felt a preoperative hospitalist evaluation represented a standardized, comprehensive way to evaluate patients before surgery. By 2009, the hospitalists at our hospital had already developed some expertise in managing patients after undergoing spinal fusion surgery.

The fact that hospitalists made recommendations for changes in medications, nutritional management, or diagnostic tests at such a high rate (72%) is interesting. We were not surprised by this finding based on anecdotal evidence because we feel that many of these patients may receive somewhat fragmented care because they often see multiple medical specialists. The high rate of interventions noted in our study may result from the fact that hospitalists who comanage these patients frequently after spinal fusion surgery were attempting to prevent postoperative complications that they see after this type of surgery. Many pediatric hospitalists have developed significant experience in caring for medically complex children and thus may feel more comfortable making preoperative recommendations than other general pediatricians.

We were not surprised to find that hospitalists made preoperative recommendations more frequently in children who had seizures, significant GI comorbidity, and who were nonambulatory. We also noted a statistically significant increased rate of recommendations when patients were on more preoperative medications. We believe that these variables suggest a population that is more medically complex. The importance of selecting medically complex patients for hospitalist comanagement has been noted previously.[16] Therefore, comanagement programs looking to maximize patient benefit for a preoperative hospitalist evaluation program might limit these visits to those who are most medically complex. We found a particularly low yield in evaluation of patients with skeletal dysplasia for example and may discontinue seeing these patients preoperatively.

We found the lack of statistically significant change in rate of hospitalist recommendations among patients with cardiac and pulmonary comorbidities interesting. Whether this was related to the mandatory preoperative pulmonology and cardiology visits is not certain. We hope to study the impact of these preoperative visits in the future as we continue to evaluate our perioperative program.

Several limitations of this study deserve note. This study was performed at 1 institution with 1 group of hospitalists and 1 group of orthopedic surgeons. Two of the study authors (D.R. and D.P.) were among the hospitalists involved with the clinical program. The study was retrospective and nonrandomized. We did not contact primary care physicians as a rule for further information about these patients. In this study, we did not specifically study the impact of hospitalist preoperative evaluations on postoperative outcomes, although the preoperative component represented an important aspect of the more systematic intervention described elsewhere.[10]

CONCLUSIONS

A preoperative program for pediatric hospitalists to see children in anticipation of spinal surgery for neuromuscular scoliosis leads to a high rate of recommendations for changes in medical management or diagnostic evaluation. Certain patient characteristics are more highly associated with hospitalists making these recommendations prior to surgery.

Acute illness requiring hospitalization can be overwhelming for children and their families who are coping with illness and the synthesis of information from a variety of healthcare providers.[1] Patient and family centeredness is endorsed by the Institute of Medicine and the American Academy of Pediatrics[2, 3] as central to quality healthcare. In academic institutions, the presence of medical students and residents adds to the number of providers families encounter. In July 2011, the Accreditation Council for Graduate Medical Education implemented new duty hour restrictions, limiting first year residents to a maximum of 16 hour shifts.[4] Consequently, caregivers and patients may be in contact with more healthcare providers; this fractured care may confuse patients and caregivers, and increase dissatisfaction with care.[5]

The primary objective of our study was to determine the effect of a face sheet tool on the percentage of medical team members correctly identified by caregivers. The secondary objective was to determine the effect of a face sheet tool on the evaluation and satisfaction rating of the medical team by caregivers. We hypothesized that caregivers who receive the face sheet tool will correctly identify a greater percentage of team members by name and role and have higher overall satisfaction with their hospital stay.

METHODS

We performed a prospective controlled study on 2 general pediatric units at Cincinnati Children's Hospital Medical Center (CCHMC). Patients on the intervention unit received the face sheet tool, whereas the concurrent control unit maintained usual procedures. Both units have 24 beds and care for general pediatric patients primarily covered by 4 resident teams and the hospital medicine faculty. Two paired resident teams composed of 2 senior residents, 3 to 4 interns, and 4 medical students primarily admit to each general pediatric unit. Team members rotate through day and night shifts. All employees and rotating students are required to wear the hospital issued identification badge that includes their names, photos, credentials, and role. The study was conducted from November 1, 2011 to November 30, 2011.

Included patients were admitted to the study units by the usual protocol at our hospital, in which nurse patient‐flow coordinators determine bed assignments. We excluded families whose children had an inpatient hospital stay of <12 hours and families who did not speak English. All patient families scheduled to be discharged later in the day on weekday mornings from the 2 study units were approached for study participation. Families were not compensated for their participation.

A face sheet tool, which is a sheet of paper with pictures and names of the intervention team attendings, senior residents, interns, and medical students as well as a description of team member roles, was distributed to patients and their caregivers. The face sheet tools were created using Microsoft Publisher (Microsoft Corp., Redmond, WA). Neither families nor providers were blinded to the intervention, and the residents assumed responsibility for introducing the face sheet tool to families.

For our primary outcome measure, the research coordinator asked participating caregivers to match provider photographs with names and roles by placing laminated pictures backed with Velcro tape in the appropriate position on a laminated poster sheet. Initially, we collected overall accuracy of identification by name and role. In the second week, we began collecting specific data on the attending physician.

The satisfaction survey consisted of the American Board of Internal Medicine (ABIM) patient satisfaction questionnaire, composed of 10, 5‐point Likert scale questions,[6, 7] and an overall rating of hospital question, On a scale from 1 to 10, with 1 being the worst possible hospital and 10 being the best possible hospital, what number would you rate this hospital? from the Hospital Consumer Assessment of Health Plans Survey.[8] Questions were asked aloud and families responded to the questions orally. A written list was also provided to families. We collected data on length of stay (LOS) at the time of outcome assessment as well as previous hospitalizations.

RESULTS

A total of 96 families were approached for enrollment (50 in the intervention and 46 in the control). Of these, 86 families agreed to participate. Three families in the intervention group did not receive the face sheet tool and were excluded from analysis, leaving an analytic cohort of 83 (41 in intervention and 42 in control). Attending recognition by role was collected from 54 families (28 in intervention group and 26 in control group) and by name from 34 families (15 in intervention group and 19 in control group). Table 1 displays characteristics of each group. Among the 83 study participants, LOS at time of outcome assessment ranged from 0.4 to 12.0 days, and the number of medical team members that cared for these patients ranged from 3 to 14.

Families in the intervention group had a higher percentage of correctly identified members of the medical team by name and role as compared to the control group (Table 2). These findings remained significant after adjusting for LOS and prior hospitalization. In addition, in a subset of families with attending data available, more families accurately identified attending name and attending role in the intervention as compared to control group.

No significant differences were noted between the groups when comparing all individual ABIM survey question scores or the overall hospital satisfaction rating (Table 2). Scores in both intervention and control groups were high in all categories.

DISCUSSION

Caregivers given the face sheet tool were better able to identify medical team members by name and role than caregivers in the control group. Previous studies have shown similar results.[9, 10] Families encountered a large number of providers (median of 8) during stays that were on average quite brief (median LOS of 23.6 hours). Despite the significant increase in caregivers' ability to identify providers, the effect was modest.

Our findings add to prior work on face sheet tools in pediatrics and internal medicine.[9, 10, 11] Our study occurred after the residency duty hour restrictions. We described the high number of providers that families encounter in this context. It is the first study to our knowledge to quantify the number of providers that families encounter after these changes and to report on how well families can identify these clinicians by name and role. Unlike other studies, satisfaction scores were not improved.[9] Potential reasons for this include: (1) caregiver knowledge of 2 to 4 key members of the team and not the whole team may be the primary driver of satisfaction, (2) caregiver activation or empowerment may be a more responsive measure than overall satisfaction, and (3) our satisfaction measures may have ceiling effects and/or be elevated in both groups by social desirability bias.

Our study highlights the need for further investigation of quality outcomes associated with residency work hour changes.[12, 13, 14] Specifically, exposure to large numbers of providers may hinder families from accurately identifying those entrusted with the care of their loved one. Of note, our research coordinator needed to present as many as 14 provider pictures to 1 family with a hospital stay of <24 hours. Large numbers of providers may create challenges in building rapport, ensuring effective communication and developing trust with families. We chose to evaluate identification of each team member by caregivers; our findings are suggestive of the need for alternative strategies. A more valuable intervention might target identification of key team members (eg, attending, primary intern, primary senior resident). A policy statement regarding transitions of care recommended the establishment of mechanisms to ensure patients and their families know who is responsible for their care.[15] Efforts toward achieving this goal are essential.

This study has several limitations. The study was completed at a single institution, and thus generalizability may be limited. Although the intervention and control units have similar characteristics, randomization did not occur at the patient level. The control group had significantly more patients who had greater than 1 admission compared to the intervention group. Patients enrolled in the study were from a weekday convenience sample; therefore, potential differences in results based on weekend admissions were unable to be assessed. The exclusion of nonEnglish‐speaking families could limit generalizability to this population. Social desirability bias may have elevated the scores in both groups. Providers tasked with the responsibility of introducing the face sheet tool to families did so in a nonstandardized way and may have interacted differently with families compared to the control team. Finally, our project's aim was focused on the effect of a face sheet tool on the identification and satisfaction rating of the medical team by caregivers. Truly family‐centered care would include efforts to improve families' knowledge of and satisfaction with all members of the healthcare team.

A photo‐based face sheet tool helped caregivers better identify their child's care providers by name and role in the hospital. Satisfaction scores were similar in both groups.

Acute illness requiring hospitalization can be overwhelming for children and their families who are coping with illness and the synthesis of information from a variety of healthcare providers.[1] Patient and family centeredness is endorsed by the Institute of Medicine and the American Academy of Pediatrics[2, 3] as central to quality healthcare. In academic institutions, the presence of medical students and residents adds to the number of providers families encounter. In July 2011, the Accreditation Council for Graduate Medical Education implemented new duty hour restrictions, limiting first year residents to a maximum of 16 hour shifts.[4] Consequently, caregivers and patients may be in contact with more healthcare providers; this fractured care may confuse patients and caregivers, and increase dissatisfaction with care.[5]

The primary objective of our study was to determine the effect of a face sheet tool on the percentage of medical team members correctly identified by caregivers. The secondary objective was to determine the effect of a face sheet tool on the evaluation and satisfaction rating of the medical team by caregivers. We hypothesized that caregivers who receive the face sheet tool will correctly identify a greater percentage of team members by name and role and have higher overall satisfaction with their hospital stay.

METHODS

We performed a prospective controlled study on 2 general pediatric units at Cincinnati Children's Hospital Medical Center (CCHMC). Patients on the intervention unit received the face sheet tool, whereas the concurrent control unit maintained usual procedures. Both units have 24 beds and care for general pediatric patients primarily covered by 4 resident teams and the hospital medicine faculty. Two paired resident teams composed of 2 senior residents, 3 to 4 interns, and 4 medical students primarily admit to each general pediatric unit. Team members rotate through day and night shifts. All employees and rotating students are required to wear the hospital issued identification badge that includes their names, photos, credentials, and role. The study was conducted from November 1, 2011 to November 30, 2011.

Included patients were admitted to the study units by the usual protocol at our hospital, in which nurse patient‐flow coordinators determine bed assignments. We excluded families whose children had an inpatient hospital stay of <12 hours and families who did not speak English. All patient families scheduled to be discharged later in the day on weekday mornings from the 2 study units were approached for study participation. Families were not compensated for their participation.

A face sheet tool, which is a sheet of paper with pictures and names of the intervention team attendings, senior residents, interns, and medical students as well as a description of team member roles, was distributed to patients and their caregivers. The face sheet tools were created using Microsoft Publisher (Microsoft Corp., Redmond, WA). Neither families nor providers were blinded to the intervention, and the residents assumed responsibility for introducing the face sheet tool to families.

For our primary outcome measure, the research coordinator asked participating caregivers to match provider photographs with names and roles by placing laminated pictures backed with Velcro tape in the appropriate position on a laminated poster sheet. Initially, we collected overall accuracy of identification by name and role. In the second week, we began collecting specific data on the attending physician.

The satisfaction survey consisted of the American Board of Internal Medicine (ABIM) patient satisfaction questionnaire, composed of 10, 5‐point Likert scale questions,[6, 7] and an overall rating of hospital question, On a scale from 1 to 10, with 1 being the worst possible hospital and 10 being the best possible hospital, what number would you rate this hospital? from the Hospital Consumer Assessment of Health Plans Survey.[8] Questions were asked aloud and families responded to the questions orally. A written list was also provided to families. We collected data on length of stay (LOS) at the time of outcome assessment as well as previous hospitalizations.

RESULTS

A total of 96 families were approached for enrollment (50 in the intervention and 46 in the control). Of these, 86 families agreed to participate. Three families in the intervention group did not receive the face sheet tool and were excluded from analysis, leaving an analytic cohort of 83 (41 in intervention and 42 in control). Attending recognition by role was collected from 54 families (28 in intervention group and 26 in control group) and by name from 34 families (15 in intervention group and 19 in control group). Table 1 displays characteristics of each group. Among the 83 study participants, LOS at time of outcome assessment ranged from 0.4 to 12.0 days, and the number of medical team members that cared for these patients ranged from 3 to 14.

Families in the intervention group had a higher percentage of correctly identified members of the medical team by name and role as compared to the control group (Table 2). These findings remained significant after adjusting for LOS and prior hospitalization. In addition, in a subset of families with attending data available, more families accurately identified attending name and attending role in the intervention as compared to control group.

No significant differences were noted between the groups when comparing all individual ABIM survey question scores or the overall hospital satisfaction rating (Table 2). Scores in both intervention and control groups were high in all categories.

DISCUSSION

Caregivers given the face sheet tool were better able to identify medical team members by name and role than caregivers in the control group. Previous studies have shown similar results.[9, 10] Families encountered a large number of providers (median of 8) during stays that were on average quite brief (median LOS of 23.6 hours). Despite the significant increase in caregivers' ability to identify providers, the effect was modest.

Our findings add to prior work on face sheet tools in pediatrics and internal medicine.[9, 10, 11] Our study occurred after the residency duty hour restrictions. We described the high number of providers that families encounter in this context. It is the first study to our knowledge to quantify the number of providers that families encounter after these changes and to report on how well families can identify these clinicians by name and role. Unlike other studies, satisfaction scores were not improved.[9] Potential reasons for this include: (1) caregiver knowledge of 2 to 4 key members of the team and not the whole team may be the primary driver of satisfaction, (2) caregiver activation or empowerment may be a more responsive measure than overall satisfaction, and (3) our satisfaction measures may have ceiling effects and/or be elevated in both groups by social desirability bias.

Our study highlights the need for further investigation of quality outcomes associated with residency work hour changes.[12, 13, 14] Specifically, exposure to large numbers of providers may hinder families from accurately identifying those entrusted with the care of their loved one. Of note, our research coordinator needed to present as many as 14 provider pictures to 1 family with a hospital stay of <24 hours. Large numbers of providers may create challenges in building rapport, ensuring effective communication and developing trust with families. We chose to evaluate identification of each team member by caregivers; our findings are suggestive of the need for alternative strategies. A more valuable intervention might target identification of key team members (eg, attending, primary intern, primary senior resident). A policy statement regarding transitions of care recommended the establishment of mechanisms to ensure patients and their families know who is responsible for their care.[15] Efforts toward achieving this goal are essential.

This study has several limitations. The study was completed at a single institution, and thus generalizability may be limited. Although the intervention and control units have similar characteristics, randomization did not occur at the patient level. The control group had significantly more patients who had greater than 1 admission compared to the intervention group. Patients enrolled in the study were from a weekday convenience sample; therefore, potential differences in results based on weekend admissions were unable to be assessed. The exclusion of nonEnglish‐speaking families could limit generalizability to this population. Social desirability bias may have elevated the scores in both groups. Providers tasked with the responsibility of introducing the face sheet tool to families did so in a nonstandardized way and may have interacted differently with families compared to the control team. Finally, our project's aim was focused on the effect of a face sheet tool on the identification and satisfaction rating of the medical team by caregivers. Truly family‐centered care would include efforts to improve families' knowledge of and satisfaction with all members of the healthcare team.

A photo‐based face sheet tool helped caregivers better identify their child's care providers by name and role in the hospital. Satisfaction scores were similar in both groups.

Acute illness requiring hospitalization can be overwhelming for children and their families who are coping with illness and the synthesis of information from a variety of healthcare providers.[1] Patient and family centeredness is endorsed by the Institute of Medicine and the American Academy of Pediatrics[2, 3] as central to quality healthcare. In academic institutions, the presence of medical students and residents adds to the number of providers families encounter. In July 2011, the Accreditation Council for Graduate Medical Education implemented new duty hour restrictions, limiting first year residents to a maximum of 16 hour shifts.[4] Consequently, caregivers and patients may be in contact with more healthcare providers; this fractured care may confuse patients and caregivers, and increase dissatisfaction with care.[5]

The primary objective of our study was to determine the effect of a face sheet tool on the percentage of medical team members correctly identified by caregivers. The secondary objective was to determine the effect of a face sheet tool on the evaluation and satisfaction rating of the medical team by caregivers. We hypothesized that caregivers who receive the face sheet tool will correctly identify a greater percentage of team members by name and role and have higher overall satisfaction with their hospital stay.

METHODS

We performed a prospective controlled study on 2 general pediatric units at Cincinnati Children's Hospital Medical Center (CCHMC). Patients on the intervention unit received the face sheet tool, whereas the concurrent control unit maintained usual procedures. Both units have 24 beds and care for general pediatric patients primarily covered by 4 resident teams and the hospital medicine faculty. Two paired resident teams composed of 2 senior residents, 3 to 4 interns, and 4 medical students primarily admit to each general pediatric unit. Team members rotate through day and night shifts. All employees and rotating students are required to wear the hospital issued identification badge that includes their names, photos, credentials, and role. The study was conducted from November 1, 2011 to November 30, 2011.

Included patients were admitted to the study units by the usual protocol at our hospital, in which nurse patient‐flow coordinators determine bed assignments. We excluded families whose children had an inpatient hospital stay of <12 hours and families who did not speak English. All patient families scheduled to be discharged later in the day on weekday mornings from the 2 study units were approached for study participation. Families were not compensated for their participation.

A face sheet tool, which is a sheet of paper with pictures and names of the intervention team attendings, senior residents, interns, and medical students as well as a description of team member roles, was distributed to patients and their caregivers. The face sheet tools were created using Microsoft Publisher (Microsoft Corp., Redmond, WA). Neither families nor providers were blinded to the intervention, and the residents assumed responsibility for introducing the face sheet tool to families.

For our primary outcome measure, the research coordinator asked participating caregivers to match provider photographs with names and roles by placing laminated pictures backed with Velcro tape in the appropriate position on a laminated poster sheet. Initially, we collected overall accuracy of identification by name and role. In the second week, we began collecting specific data on the attending physician.

The satisfaction survey consisted of the American Board of Internal Medicine (ABIM) patient satisfaction questionnaire, composed of 10, 5‐point Likert scale questions,[6, 7] and an overall rating of hospital question, On a scale from 1 to 10, with 1 being the worst possible hospital and 10 being the best possible hospital, what number would you rate this hospital? from the Hospital Consumer Assessment of Health Plans Survey.[8] Questions were asked aloud and families responded to the questions orally. A written list was also provided to families. We collected data on length of stay (LOS) at the time of outcome assessment as well as previous hospitalizations.

RESULTS

A total of 96 families were approached for enrollment (50 in the intervention and 46 in the control). Of these, 86 families agreed to participate. Three families in the intervention group did not receive the face sheet tool and were excluded from analysis, leaving an analytic cohort of 83 (41 in intervention and 42 in control). Attending recognition by role was collected from 54 families (28 in intervention group and 26 in control group) and by name from 34 families (15 in intervention group and 19 in control group). Table 1 displays characteristics of each group. Among the 83 study participants, LOS at time of outcome assessment ranged from 0.4 to 12.0 days, and the number of medical team members that cared for these patients ranged from 3 to 14.

Families in the intervention group had a higher percentage of correctly identified members of the medical team by name and role as compared to the control group (Table 2). These findings remained significant after adjusting for LOS and prior hospitalization. In addition, in a subset of families with attending data available, more families accurately identified attending name and attending role in the intervention as compared to control group.

No significant differences were noted between the groups when comparing all individual ABIM survey question scores or the overall hospital satisfaction rating (Table 2). Scores in both intervention and control groups were high in all categories.

DISCUSSION

Caregivers given the face sheet tool were better able to identify medical team members by name and role than caregivers in the control group. Previous studies have shown similar results.[9, 10] Families encountered a large number of providers (median of 8) during stays that were on average quite brief (median LOS of 23.6 hours). Despite the significant increase in caregivers' ability to identify providers, the effect was modest.

Our findings add to prior work on face sheet tools in pediatrics and internal medicine.[9, 10, 11] Our study occurred after the residency duty hour restrictions. We described the high number of providers that families encounter in this context. It is the first study to our knowledge to quantify the number of providers that families encounter after these changes and to report on how well families can identify these clinicians by name and role. Unlike other studies, satisfaction scores were not improved.[9] Potential reasons for this include: (1) caregiver knowledge of 2 to 4 key members of the team and not the whole team may be the primary driver of satisfaction, (2) caregiver activation or empowerment may be a more responsive measure than overall satisfaction, and (3) our satisfaction measures may have ceiling effects and/or be elevated in both groups by social desirability bias.

Our study highlights the need for further investigation of quality outcomes associated with residency work hour changes.[12, 13, 14] Specifically, exposure to large numbers of providers may hinder families from accurately identifying those entrusted with the care of their loved one. Of note, our research coordinator needed to present as many as 14 provider pictures to 1 family with a hospital stay of <24 hours. Large numbers of providers may create challenges in building rapport, ensuring effective communication and developing trust with families. We chose to evaluate identification of each team member by caregivers; our findings are suggestive of the need for alternative strategies. A more valuable intervention might target identification of key team members (eg, attending, primary intern, primary senior resident). A policy statement regarding transitions of care recommended the establishment of mechanisms to ensure patients and their families know who is responsible for their care.[15] Efforts toward achieving this goal are essential.