This article is the second in a two-part series on the CMS Physician Voluntary Reporting Program. Part one appeared on p. 11 of the May 2006 issue.

Changes in Medicare reporting and payment are coming, and they’re coming fast. Regardless of whether you agree with where Medicare is heading or plan to participate in the first stage of these changes, you’re better off knowing what’s in store.

The first part of this article provided an overview of the Physician Voluntary Reporting Program (PVRP) that the Centers for Medicare and Medicaid (CMS) initiated at the beginning of 2006, including how the reported quality measures apply—or don’t apply—to hospitalists.

Benefits of Reporting

Eric Siegal, MD, chair of SHM’s Public Policy Committee, is convinced that hospitalists should participate in PVRP, although he stresses that he does not speak for SHM on the matter.

“Hospital medicine has positioned itself as a champion of quality improvement,” he points out. “We talk the talk, so now we need to walk the walk [with voluntary reporting]. As a group of physicians who live and breathe this issue, we’ll have that much more credibility for supporting this program.”

Dr. Siegal not only believes hospitalists should report through PVRP, he thinks they will excel at doing so: “Because we’re already used to being measured, I have a suspicion that our adherence to these metrics is going to look very good. This will serve to bolster the argument that hospitalists add value to the care of hospitalized patients.”

Potential Problem Areas for Hospitalists

Hospitalists who participate in PVRP may face a bumpy road. “There are small problems,” admits Dr. Siegal. One of those is the disconnect between the 16 quality measures that physicians can report on and the role that hospitalists play.

“Of the 16 metrics in the starter set, maybe seven apply to hospitalists,” he explains.

Hospitalists may face another unique problem in meeting those measures: “We may have dilemmas over responsibility and reporting,” predicts Dr. Siegal. “For instance, we’re increasingly co-managing patients with surgeons. If a hospitalist wants to comply with a metric, but the surgeon disagrees, does the hospitalist take the hit? The same is true with something like administering aspirin on arrival for acute myocardial infarction. Is that my responsibility or the emergency physician’s?”

Another issue is the Healthcare Common Procedure Coding System (HCPCS) codes—or G-codes—that comprise each of the current PVRP’s 16 quality measures.

“The G-codes are cumbersome,” says Dr. Siegal. “There are G-codes for each measure, and there is talk about changing to a different system. So you may set up to report G-codes only to have the system change. But get used to it—this is a dynamic process that is definitely going to evolve.”

PVRP Is the Future

Dr. Siegal—and many others—believe that the PVRP will evolve into a broader reporting program and will ultimately transform into a mandatory pay-for-performance system for CMS. This may happen faster than CMS usually moves.

“Eventually there will be money tied to this,” he says. “Rumors are that payment modifiers may be tied to reporting as early as the fourth quarter of this year. As things go in the federal government, the evolution to value-based purchasing is moving at a lightning-fast pace—CMS is actually getting pushback from medical groups for moving too fast.”

Dr. Siegal adds that, “CMS is very interested in engaging physician organizations for their input. [CMS Administrator Mark B.] McClellan has done an admirable job of making this an interactive process.”

As PRVP evolves, it is likely to become more applicable to hospitalists.

“This is all part of a larger evolutionary trend in medicine,” explains Dr. Siegal. “Currently, hospitals and physicians are treated separately by CMS, and paid and incentivized differently. There’s growing realization that with rising costs and increased need for quality improvement hospitals and physicians need to have their incentives aligned. Things are going to change and it will take a long time for this to shake out.”

Because PVRP is the wave of the future for CMS payment, Dr. Siegal believes that hospitalists will be better off if they join in now. Voluntary reporting requires hospitalists to develop a new reporting infrastructure, and, as he says, “It’s better to do that now, with only 16 measures, than to have to do it later when there are 36 or 42.”

Dr. Siegal is convinced that hospitalists should support PVRP now, in its first stage. He also believes that SHM will begin to get involved. “We clearly need to be at this table,” he emphasizes. “Hospitalists are going to be the dominant providers of care to hospitalized Medicare patients. That said, SHM is still a relatively small society, and we don’t have the resources to engage every aspect of this debate. This is a huge and complex issue and SHM needs to use its limited resources wisely.”

SHM’s Public Policy Committee will continue to monitor what happens with PVRP and CMS, and SHM may eventually pursue membership in the national quality forums that are developing new metrics.

CMS provides details on the PVRP, including instructions on how to sign up, on their Web site at www.cms.hhs.gov/PVRP/01_Overview.asp. TH

Jane Jerrard regularly writes the “Public Policy” department.

This article is the second in a two-part series on the CMS Physician Voluntary Reporting Program. Part one appeared on p. 11 of the May 2006 issue.

Changes in Medicare reporting and payment are coming, and they’re coming fast. Regardless of whether you agree with where Medicare is heading or plan to participate in the first stage of these changes, you’re better off knowing what’s in store.

The first part of this article provided an overview of the Physician Voluntary Reporting Program (PVRP) that the Centers for Medicare and Medicaid (CMS) initiated at the beginning of 2006, including how the reported quality measures apply—or don’t apply—to hospitalists.

Benefits of Reporting

Eric Siegal, MD, chair of SHM’s Public Policy Committee, is convinced that hospitalists should participate in PVRP, although he stresses that he does not speak for SHM on the matter.

“Hospital medicine has positioned itself as a champion of quality improvement,” he points out. “We talk the talk, so now we need to walk the walk [with voluntary reporting]. As a group of physicians who live and breathe this issue, we’ll have that much more credibility for supporting this program.”

Dr. Siegal not only believes hospitalists should report through PVRP, he thinks they will excel at doing so: “Because we’re already used to being measured, I have a suspicion that our adherence to these metrics is going to look very good. This will serve to bolster the argument that hospitalists add value to the care of hospitalized patients.”

Potential Problem Areas for Hospitalists

Hospitalists who participate in PVRP may face a bumpy road. “There are small problems,” admits Dr. Siegal. One of those is the disconnect between the 16 quality measures that physicians can report on and the role that hospitalists play.

“Of the 16 metrics in the starter set, maybe seven apply to hospitalists,” he explains.

Hospitalists may face another unique problem in meeting those measures: “We may have dilemmas over responsibility and reporting,” predicts Dr. Siegal. “For instance, we’re increasingly co-managing patients with surgeons. If a hospitalist wants to comply with a metric, but the surgeon disagrees, does the hospitalist take the hit? The same is true with something like administering aspirin on arrival for acute myocardial infarction. Is that my responsibility or the emergency physician’s?”

Another issue is the Healthcare Common Procedure Coding System (HCPCS) codes—or G-codes—that comprise each of the current PVRP’s 16 quality measures.

“The G-codes are cumbersome,” says Dr. Siegal. “There are G-codes for each measure, and there is talk about changing to a different system. So you may set up to report G-codes only to have the system change. But get used to it—this is a dynamic process that is definitely going to evolve.”

PVRP Is the Future

Dr. Siegal—and many others—believe that the PVRP will evolve into a broader reporting program and will ultimately transform into a mandatory pay-for-performance system for CMS. This may happen faster than CMS usually moves.

“Eventually there will be money tied to this,” he says. “Rumors are that payment modifiers may be tied to reporting as early as the fourth quarter of this year. As things go in the federal government, the evolution to value-based purchasing is moving at a lightning-fast pace—CMS is actually getting pushback from medical groups for moving too fast.”

Dr. Siegal adds that, “CMS is very interested in engaging physician organizations for their input. [CMS Administrator Mark B.] McClellan has done an admirable job of making this an interactive process.”

As PRVP evolves, it is likely to become more applicable to hospitalists.

“This is all part of a larger evolutionary trend in medicine,” explains Dr. Siegal. “Currently, hospitals and physicians are treated separately by CMS, and paid and incentivized differently. There’s growing realization that with rising costs and increased need for quality improvement hospitals and physicians need to have their incentives aligned. Things are going to change and it will take a long time for this to shake out.”

Because PVRP is the wave of the future for CMS payment, Dr. Siegal believes that hospitalists will be better off if they join in now. Voluntary reporting requires hospitalists to develop a new reporting infrastructure, and, as he says, “It’s better to do that now, with only 16 measures, than to have to do it later when there are 36 or 42.”

Dr. Siegal is convinced that hospitalists should support PVRP now, in its first stage. He also believes that SHM will begin to get involved. “We clearly need to be at this table,” he emphasizes. “Hospitalists are going to be the dominant providers of care to hospitalized Medicare patients. That said, SHM is still a relatively small society, and we don’t have the resources to engage every aspect of this debate. This is a huge and complex issue and SHM needs to use its limited resources wisely.”

SHM’s Public Policy Committee will continue to monitor what happens with PVRP and CMS, and SHM may eventually pursue membership in the national quality forums that are developing new metrics.

CMS provides details on the PVRP, including instructions on how to sign up, on their Web site at www.cms.hhs.gov/PVRP/01_Overview.asp. TH

Jane Jerrard regularly writes the “Public Policy” department.

This article is the second in a two-part series on the CMS Physician Voluntary Reporting Program. Part one appeared on p. 11 of the May 2006 issue.

Changes in Medicare reporting and payment are coming, and they’re coming fast. Regardless of whether you agree with where Medicare is heading or plan to participate in the first stage of these changes, you’re better off knowing what’s in store.

The first part of this article provided an overview of the Physician Voluntary Reporting Program (PVRP) that the Centers for Medicare and Medicaid (CMS) initiated at the beginning of 2006, including how the reported quality measures apply—or don’t apply—to hospitalists.

Benefits of Reporting

Eric Siegal, MD, chair of SHM’s Public Policy Committee, is convinced that hospitalists should participate in PVRP, although he stresses that he does not speak for SHM on the matter.

“Hospital medicine has positioned itself as a champion of quality improvement,” he points out. “We talk the talk, so now we need to walk the walk [with voluntary reporting]. As a group of physicians who live and breathe this issue, we’ll have that much more credibility for supporting this program.”

Dr. Siegal not only believes hospitalists should report through PVRP, he thinks they will excel at doing so: “Because we’re already used to being measured, I have a suspicion that our adherence to these metrics is going to look very good. This will serve to bolster the argument that hospitalists add value to the care of hospitalized patients.”

Potential Problem Areas for Hospitalists

Hospitalists who participate in PVRP may face a bumpy road. “There are small problems,” admits Dr. Siegal. One of those is the disconnect between the 16 quality measures that physicians can report on and the role that hospitalists play.

“Of the 16 metrics in the starter set, maybe seven apply to hospitalists,” he explains.

Hospitalists may face another unique problem in meeting those measures: “We may have dilemmas over responsibility and reporting,” predicts Dr. Siegal. “For instance, we’re increasingly co-managing patients with surgeons. If a hospitalist wants to comply with a metric, but the surgeon disagrees, does the hospitalist take the hit? The same is true with something like administering aspirin on arrival for acute myocardial infarction. Is that my responsibility or the emergency physician’s?”

Another issue is the Healthcare Common Procedure Coding System (HCPCS) codes—or G-codes—that comprise each of the current PVRP’s 16 quality measures.

“The G-codes are cumbersome,” says Dr. Siegal. “There are G-codes for each measure, and there is talk about changing to a different system. So you may set up to report G-codes only to have the system change. But get used to it—this is a dynamic process that is definitely going to evolve.”

PVRP Is the Future

Dr. Siegal—and many others—believe that the PVRP will evolve into a broader reporting program and will ultimately transform into a mandatory pay-for-performance system for CMS. This may happen faster than CMS usually moves.

“Eventually there will be money tied to this,” he says. “Rumors are that payment modifiers may be tied to reporting as early as the fourth quarter of this year. As things go in the federal government, the evolution to value-based purchasing is moving at a lightning-fast pace—CMS is actually getting pushback from medical groups for moving too fast.”

Dr. Siegal adds that, “CMS is very interested in engaging physician organizations for their input. [CMS Administrator Mark B.] McClellan has done an admirable job of making this an interactive process.”

As PRVP evolves, it is likely to become more applicable to hospitalists.

“This is all part of a larger evolutionary trend in medicine,” explains Dr. Siegal. “Currently, hospitals and physicians are treated separately by CMS, and paid and incentivized differently. There’s growing realization that with rising costs and increased need for quality improvement hospitals and physicians need to have their incentives aligned. Things are going to change and it will take a long time for this to shake out.”

Because PVRP is the wave of the future for CMS payment, Dr. Siegal believes that hospitalists will be better off if they join in now. Voluntary reporting requires hospitalists to develop a new reporting infrastructure, and, as he says, “It’s better to do that now, with only 16 measures, than to have to do it later when there are 36 or 42.”

Dr. Siegal is convinced that hospitalists should support PVRP now, in its first stage. He also believes that SHM will begin to get involved. “We clearly need to be at this table,” he emphasizes. “Hospitalists are going to be the dominant providers of care to hospitalized Medicare patients. That said, SHM is still a relatively small society, and we don’t have the resources to engage every aspect of this debate. This is a huge and complex issue and SHM needs to use its limited resources wisely.”

SHM’s Public Policy Committee will continue to monitor what happens with PVRP and CMS, and SHM may eventually pursue membership in the national quality forums that are developing new metrics.

CMS provides details on the PVRP, including instructions on how to sign up, on their Web site at www.cms.hhs.gov/PVRP/01_Overview.asp. TH

Jane Jerrard regularly writes the “Public Policy” department.

Each year a new team of SHM officers is elected to lend their wisdom, time, experience, and skills in a collaborative effort to help manage the business of our organization, drive new initiatives, and support the society’s mission. At this year’s annual meeting in Washington, D.C., we again witnessed that familiar changing of the guard with the following inductions:

• President Mary Jo Gorman, MD, MBA;
• President-Elect Russell Holman, MD;
• Treasurer Patrick Cawley, MD; and
• Secretary Jack Percelay, MD, MPH.

“Hospitalists are squarely in the spotlight today on key issues affecting patient care, quality of hospital care, hospital leadership, and other concerns. So it is important that we have a strong, hands-on leadership team that is committed to continuing the positive momentum SHM has generated for hospitalists,” says Larry Wellikson, MD, FACP, CEO of SHM. “I couldn’t be more thrilled with our slate of newly appointed officers. Time and again through the years Mary Jo, Rusty, Pat, and Jack have proven that they are active participants, and that they are leaders who will rise to the occasion to help us meet our objectives.”

President Mary Jo Gorman, MD, MBA

Dr. Gorman, a charter member of SHM, has been a practicing hospitalist since 1997, when she founded the first hospitalist practice in St. Louis. In early 1999, her group merged into IPC—The Hospitalist Company and grew to become the dominant hospitalist group in the city. In 2001, Dr. Gorman was promoted to vice-president of medical affairs for IPC, responsible for the design and implementation of company-wide programs involving business development, recruitment, physician training, and operations in all of IPC’s markets. In 2003, she was named chief medical officer and today works with more than 300 physicians nationwide to develop programs and strategies that enhance clinical performance and drive the delivery system towards more efficient care and greater patient satisfaction. She also oversees IPC’s physician training, mentoring and retention programs, as well as IPC’s call center nurses, healthcare services and clinical studies.

A cum laude graduate of St. Louis University, Dr. Gorman earned a BA in Chemistry/Biology in 1981, then went on to earn her MD in 1984 from Southern Illinois University School of Medicine in Springfield. In 1996, she earned a MBA from Washington University, Olin School of Business, in St. Louis.

President-Elect Russell Holman, MD

SHM’s new President-Elect Dr. Holman is senior vice president and national medical director for Cogent Healthcare, an organization that manages hospital medicine programs throughout the country. He is responsible for program implementation and management, quality systems reporting and auditing, physician leadership development, and data systems integration. Formerly, Dr. Holman was the medical director of Hospital Services for HealthPartners Medical Group & Clinics, part of HealthPartners, Inc. in Minnesota. There he also was the founder and director of the HPMG Fellowship Program in Hospital Medicine.

A long-time member of SHM, Dr. Holman served on the Board of Directors as treasurer from 2004-2005. He was previously chair of the Leadership Development Committee, chair of the Midwest Council, course director of the SHM Leadership Academy, and a member of the Public Policy Committee. In February 2006 he co-authored the “Update in Hospital Medicine,” which appeared in Annals of Internal Medicine. In 2002, he received the SHM Award for Outstanding Service in Hospital Medicine.

Through the years, Dr. Holman’s commitment to hospital medicine has helped produce nationally recognized standards in the areas of quality improvement activities, models of medical education, observation units, communication systems, compensation plans, case management, surgical co-management collaborations, and patient flow initiatives. Dr. Holman serves on two national editorial boards for medical publications and is currently co-authoring a comprehensive textbook and electronic decision support tool in hospital medicine.

Dr. Holman earned his MD from Washington University School of Medicine in St. Louis and trained as a resident and chief medical resident at the University of Minnesota in Minneapolis.

Treasurer Patrick Cawley, MD

New Treasurer Dr. Cawley is a hospitalist at the Medical University of South Carolina in Charleston, where he currently serves as interim executive medical director of MUSC Medical Center. He previously served as the chief of the Section of Hospital Medicine, vice chairman of clinical affairs in the Department of Medicine, and associate executive medical director at MUSC Medical Center.

A charter member of SHM, Dr. Cawley has served on numerous committees and was previously secretary of the Board for the 2004-2005 term. He has worked in both academic and nonacademic hospitals and has served as a consultant to numerous hospitals in the development of hospital medicine programs.

Dr. Cawley received his Bachelor of Science in 1988 from the University of Scranton (Pa.) and his MD from Georgetown University School of Medicine in Washington, D.C. He completed an internal medicine residency at Duke University in Durham, N.C. Later this year, he will complete his MBA from the University of Massachusetts-Amherst.

Secretary Jack Percelay, MD, MPH

SHM’s new secretary is Dr. Percelay. He is director of Virtua Inpatient Pediatrics, a large pediatric hospital medicine group in Southern New Jersey with 14 full-time hospitalists covering two hospitals. Since 1991, Dr. Percelay has worked in a variety of community-based settings including the general pediatric ward, pediatric sub-specialty units, pediatric intensive care unit (PICU), neonatal intensive care unit (NICU), and the emergency department.

A charter member of SHM and one of the nation’s first pediatric hospitalists, Dr. Percelay currently holds the Pediatric Seat on the SHM Board, in addition to serving on the Public Policy Committee and co-chairing the Pediatric Committee. He has been intimately involved in collaborative Pediatric hospital medicine projects such as the PRIS research network and the Denver 2005 and 2007 Pediatric Hospital Medicine conferences.

Dr. Percelay is also the founding chairperson and immediate past chair of the American Academy of Pediatrics Section on Hospital Medicine and co-authored the AAP policy statement on pediatric hospitalists. He completed his medical school and pediatric training at the University of California at San Francisco, along with an MPH at the University of California at Berkeley.

SHM congratulates these new officers and thanks our 2005 officers (Steve Pantilat, MD, president, William Atchley, MD, FACP, treasurer, and Lisa Kettering, MD, FACP, secretary) for their exemplary work.

Annual Meeting e-Community a Success

If the feedback from attendees at this year’s Annual Meeting was any indication, the inaugural launch of SHM’s Annual Meeting e-Community was a success.

Each year, SHM’s Annual Meeting provides an opportunity for hospital medicine professionals to network with colleagues and take advantage of more than 40 educational sessions during the course of three days.

While the location for the meeting changes regularly, there is a constant desire within the Annual Meeting planning committee (a group of volunteer members) to improve the attendee experience. The Annual Meeting e-Community (AMeC) was designed with that in mind.

The AMeC effectively extended the reach of the annual meeting both before and after the event. Since early April, attendees have been able to access the handouts for the presentations that were given at the event and network with colleagues thanks to dedicated discussion communities. There are also listings of exhibitors scheduled to be in attendance and general information about Washington, D.C., on the AMeC.

Because of the positive feedback received, the e-Community will stay online through early July, giving attendees the chance to download presentations from sessions that they didn’t attend and make contact with colleagues they met while in Washington, D.C.

Attendees appreciated the ability to access meeting materials prior to the event. “The Annual Meeting e-Community gave me a great opportunity to really plan out the sessions that I wanted to attend prior to the meeting,” says William Rifkin, MD, a hospitalist from the Yale School of Medicine.

According to Joy Wittnebert, AMeC project manager, the site was launched in response to feedback from past annual meetings. “Attendees have been consistently telling us that they want to be able to customize their experience and have more opportunities to network with colleagues before and after the event,” she says.

In the coming months, SHM staff will work with the Annual Meeting Committee to analyze additional feedback and begin making plans for the 2007 version of the site.

SHM Education Committee Launches 18-Month Strategic Plan

Helping our members and the hospital medicine community advance in professional growth and development has been on center stage as seen in the SHM Education Committee’s recent completion of an 18-month strategic plan. The plan is a framework designed to guide staff and volunteer leadership as they work to expand the society’s current slate of educational offerings. Inherent in the framework’s design is a focus on taking advantage of the myriad new channels that have come online for delivering educational content.

The plan is rooted primarily in the recently released Core Competencies in Hospital Medicine. The Core Competencies are a benchmark for the development of curricula within the hospital medicine specialty.

“One of the most exciting parts of this plan is its connection to the Core Competencies,” says Geri Barnes, SHM’s director of education and quality initiatives. “The connection means that this is one of the strongest educational plans that the society has put forward.”

A driving force in the creation of this plan was the committee’s desire to expand SHM’s educational offerings through a variety of technologic venues. “In the coming year, our educational offerings will truly become multi-dimensional,” says Scott Johnson, SHM’s director of information services. “As we expand into audio CDs, podcasts, and Web-based offerings, more hospitalists will be able to take advantage of these learning opportunities, which will have profound effects on the hospital medicine movement.”

With the education plan approved by SHM’s Board of Directors at its recent meeting, the Education Committee, chaired by Preetha Basaviah, MD, from Stanford University, will turn its attention to the first stage of implementation—a complete needs analysis. Some research has already taken place as part of SHM’s ongoing internal quality improvement processes.

“The key to the success of our plan is that we will be integrating feedback from hospitalists throughout North America as we move forward,” says Dr. Basaviah. “Ultimately, this kind of communication will ensure that we reach our primary goal: to provide tools and resources that help hospital medicine professionals improve the quality of care that they provide.”

Stay tuned to The Hospitalist for updates on the committee’s progress and an advanced look at new educational products.

Palliative Care: a Core Competency for Hospitalists

By Theresa Kristopaitis, MD, with input from Howard Epstein, MD, and the SHM Palliative Care Task Force

Palliative care is focused on the relief of suffering and support for the best quality of life for patients facing serious, life-threatening, or advanced illness, as well as their families. Palliative care is a general approach to healthcare that should be routinely integrated with disease modifying therapies. It is also a growing practice specialty for appropriately trained healthcare professionals dedicating their practice to the delivery of palliative care services.1

Optimally palliative care is delivered through an interdisciplinary team consisting of physicians, nurses, chaplains, social workers, pharmacists, as well as other disciplines as patient/family needs warrant. Models of palliative care delivery include hospital-based inpatient consultation services, inpatient palliative care units, outpatient and home-based consultation services, and ambulatory clinics. Hospitalists are ideally positioned to start inpatient palliative care services and reap the professional and institutional benefits that palliative care offers. Tools to develop a program can be obtained through the Center to Advance Palliative Care (www.capc.org).

A Core Competency

The skills gained from developing expertise in palliative care are indispensable to hospitalists—even if they don’t formally work with a palliative care team. Palliative care itself is identified as a healthcare systems core competency of hospital medicine.2 In addition, other hospital medicine competencies overlap with those key to palliative care: pain management, care of the elderly patient and vulnerable populations, communication, hospitalist as consultant, team approach and multidisciplinary care, transitions of care, and medical ethics.3 For some of the most challenging, yet common, inpatient clinical scenarios, palliative care and hospital practice can become indistinguishable.

Inpatient Scenarios: How Can Palliative Care Help?

Scenario 1: A patient on chronic long-acting opiate therapy is admitted to the hospital with complaints of pain, nausea, and vomiting.

The appropriate assessment and management of pain is a patient’s right and an institution’s responsibility, yet it is often inadequate.4 Many barriers to effective pain management have been identified, including limited physician undergraduate and graduate training.4,5 A fundamental goal of palliative care is pain relief. In turn, expertise in the pathophysiology of pain and safe prescribing of opioid, non-opioid, and adjuvant analgesics is critical for palliative care physicians. Palliative care training and resources focus on principles of analgesic pharmacology, equianalgesia, changing routes of administration, control of continuous and breakthrough pain, opioid rotation, and adverse effects of analgesics. A comprehensive introduction to the fundamentals of pain management can be obtained via Education on Palliative and End of Life Care (www.epec.net.) Pain Management Module.

Non-pain symptoms can be as troubling for patients with advanced illness as pain. The formal assessment, reassessment, and management of common symptoms, including nausea, vomiting, dyspnea, constipation, fatigue, and delirium, are a primary domain of palliative medicine. Nausea and vomiting, for example, can become a demoralizing symptom complex. Stimuli to the vomiting center can arise from the cerebral cortex, vestibular apparatus, chemoreceptor zone, and gastrointestinal tract resulting in a broad etiologic differential diagnosis.

With a solid understanding of its pathogenesis and pharmacologic and non-pharmacologic therapeutic principles, nausea and vomiting can be treated in the vast majority of patients. Multiple agents addressing multiple mechanisms may be required. Even the nausea associated with complete bowel obstruction often can be successfully palliated, without the use of nasogastric tubes or surgery.6 The End of Life/Palliative Education Resource Center (www.eperc.mcw.edu) is one of many resources with tools to improve a hospitalist’s evaluation and treatment of non-pain physical symptoms.

Scenario 2: A patient with advanced heart failure and his family are overwhelmed by differing consultant opinions on the appropriateness of implantable cardioverter defibrillator (ICD) insertion.

Effective communication with patients is a core responsibility of both hospitalists and palliative care physicians. A complementary—and at times challenging—skill is the ability to promote communication and consensus about care among multiple specialist consultants. Ripamonti and colleagues write, “Almost invariably, the act of communication is an important part of therapy: Occasionally it is the only constituent. It usually requires greater thought and planning than a drug prescription, and unfortunately it is commonly administered in subtherapeutic doses.”6

The American Academy of Hospice and Palliative Medicine UNIPAC series is a resource for physicians to hone their general communication skills, as well as those more specific to palliative care, such as sharing news (often bad) with patients and families and engaging in therapeutic dialogue.8

Palliative care begins with establishing the goals of care with a patient.9 All physicians bring great value to patient care when they are skilled at negotiating goals of care. There are numerous possible goals of care, from prevention, to cure, to prolongation of life, to achieving a good death. Ideally, goals of care should be discussed with patients and families as early as possible in the course of a serious, life-threatening illness. Establishing realistic and attainable goals of care assumes increased importance in the setting of advanced disease, where treatments intended to prolong life may become more burdensome than beneficial.9

As the reader may have experienced, too often these discussions have not taken place or are held late in the trajectory of illness, such as when patients are hospitalized for severe progressive disease or are facing imminent death.10 In the scenario of potential ICD insertion, conversations with patients to clarify device-specific goals are best accomplished before they are placed and in the context of a broader discussion of the patient’s general medical condition and overall goals for care.11 This type of discussion ultimately improves the informed consent process for ICDs and other technologies. ICD recipients should be guided to periodically revisit their goals, particularly when their health status significantly changes.11 Unlike for initial ICD placement, there are no guidelines for disabling already implanted ICDs. The opportunity to discuss this issue with a patient before a crisis or before they lose decision-making capacity is frequently lost and occurs all too often at life’s end.12

Scenario 3: An elderly debilitated woman with advanced cervical cancer has been hospitalized six times in the past two months. She is cared for at home. Her family is tired but they are doing “the best they can.” She is brought to the emergency department again with weakness.

Effective implementation of care management strategies for patients with life-threatening and advanced disease requires assessment of their physical, social, emotional, and spiritual concerns.1 Similarly, family caregivers have their own—often unvoiced—biopsychosocial stressors.13 Physicians directing patient care must appreciate the significance of these multiple issues, even if they are not comfortable or are ill-equipped to handle them on their own. The power of the interdisciplinary palliative care model is that team members evaluate the patient from different perspectives and pool their expertise in addressing the complex needs of their patients and families.8

In some multidisciplinary models, the onus may lie on the physician to recognize the patient and family needs and mobilize the appropriate resources. Coordination of care at home for patients in the later stages of chronic illness may seem daunting during hospital stays. However, by employing measures utilized by palliative care teams, such as reviewing the goals of care, introducing community resources to help patients and families manage at home, providing anticipatory grief and bereavement support, and considering hospice referral, discharge planning and transitions in care can be much more sustainable.14 With these interventions, patients, families, physicians, and hospitals all benefit.

Conclusion

Hospital-based palliative care programs are growing exponentially.15 Hospitalists are in a unique position to continue their development. Even if the time or circumstances are not yet right for you to become a part of a formal palliative care program, there are daily opportunities to reap rewards from the knowledge, attitudes, and skills that palliative care training offers.

References

1. National Consensus Project for Quality Palliative Care: The development of practice guidelines 2004. Available at www.nationalconsensusproject.org. Last accessed April 28, 2006.
2. Pistoria MJ, Amin AN, Dressler DD, et al. The core competencies in hospital medicine. J Hosp Med. 2006;1:2(S1).
3. American Board of Hospice and Palliative Medicine. Available at www.abhpm.org. Last accessed April 28, 2006.
4. Phillips DM. JCAHO pain management standards unveiled. JAMA. 2000;284:428-429.
5. Sullivan AM, Lakoma MD, Block SD. The status of medical education in end-of-life care: a national report. J Gen Intern Med. 2003;18:685-695.
6. Ripamonti C, De Conno F, Ventafridda V, et al. Management of bowel obstruction in advanced and terminal cancer patients. Ann Oncol. 1993 Jan;4(1):15-21.
7. Buckman R. Communication in palliative care: a practical guide. In: Doyle D, Hanks GWC, MacDonald N, eds. Oxford Textbook of Palliative Medicine. New York: Oxford Community Press; 1993:47-61.
8. Storey P, Knight CF. UNIPAC five—caring for the terminally ill—communication and the physician’s role in the interdisciplinary team. In: Hospice/Palliative Care Training for Physicians—A Self Study Program. New York: Mary Ann Liebert; 2003:1-147.
9. Morrison RS, Meier DE. Palliative care. NEJM. 2004;350:2582-2590.
10. Quill TE. Initiating end of life discussion with seriously ill patients: addressing the “elephant in the room.” JAMA. 2000;284:2502-2507.
11. Berger, JT. The ethics of deactivating implanted cardioverter defibrillators. Ann Intern Med. 2005;142:631-634.
12. Goldstein NE, Lampert R, Bradely E, et al. Management of implantable cardioverter defibrillators in end-of-life care. Ann Intern Med. 2004;141:835-838.
13. Levine C. The loneliness of the long-term caregiver. NEJM. 1999;340:1587-1590.
14. Meier D. Palliative care in hospitals. J Hosp Med. 2006;1:21-28.
15. Morrison RS, et al. The growth of palliative care programs in United States hospitals. J Pall Med. 2006; 8 (6):1127-1133.

Get a Job!

SHM Launches the first-ever career Web site exclusively for hospitalists

By Jeannette Wick

Job boards—Internet sites designed to allow employers and prospective employees to find each other electronically—are among the most active Internet sites. For many job seekers Monster.com, CareerBuilder.com, and Indeed.com (among others) have become essential job search tools. Until now, however, no site has catered to healthcare professionals in general—much less to hospitalists in particular.

Thanks to the new SHM Career Center (http://hospitalmedicine.org/careercenter), though, things are about to change. The Career Center is part of a comprehensive, “cradle-to-grave” approach SHM is taking to assist hospital medicine professionals in their career development pursuits. The site offers numerous advantages over traditional job-hunting tools, such as classified advertisements, personal contacts, and randomly mailing resumes to interesting employers—advantages such as the ability to post your resume in a searchable database, a database of open positions across North America that you can search using a variety of variables and the opportunity to receive a notification when a job that matches your criteria is posted online.

The Career Center also represents an improvement over general job boards because the pool of positions offered and solicited on the site is restricted to those only for hospital medicine professionals. The site is free for all, although SHM members are able to take advantage of certain “members-only” functionality (resume posting, e-mail notification of new job postings). “Career opportunists,” or hospitalists who are gainfully employed but constantly curious about what else is available, will enjoy this site, too.

The Way it Works

SHM’s Career Center matches applicants and jobs using search features that allow applicants to tailor their search. As an applicant, you enter your job preferences as you would when searching for an article in PubMed or when looking online for a board-certified specialist in a specific geographic region when referring a patient. The boxes prompt you to provide the minimum information necessary for an acceptable search. For example, you need to provide geographical preferences, the type of position you’re looking for, and the specialty area you’re interested in to best tailor your search.

Visitors can browse all jobs by specialty or state—or view the complete list of jobs. The advanced search option augments the specialty and state fields with the ability to specify keywords (see “Hospitalists and Keywords,” p. 10), specialty, employment type (full time, moonlighting, and so on), and the announcement opening date. (The latter is important to applicants who believe older announcements raise a red flag indicating conditions that make it unattractive to candidates.)

The advanced search option also allows you to look at job summaries with the results. So instead of receiving a simple list of the job title, the location, and the announcement date, the summary includes a short description of the position. But visitor beware: You have to click a box to make this happen. Otherwise, your search will create a simple list of jobs, and clicking on any individual job will bring up the job summary. The information is accessible either way.

Get Started

Most job seekers will find the site quite easy to navigate, although a few may be impeded by cookies. (For more information, see “Got Cookies,” p. 10.) The FAQ area is a site strength and will help you eliminate hurdles, from inability to navigate the site, to figuring out how to be notified electronically when new jobs are added.

Once you enter your search criteria, a list of jobs displays. Then click on a specific job to open another page describing the position in great detail. After seeing the array of positions available, SHM non-members are likely to join the society just to have access to the full functionality of the Career Center.

Your next step is to create an account; doing so allows you to apply for positions with just a click. Once you establish an account (a process that takes just a few minutes), click on “Edit My Profile.” In this area, you’ll establish your profile.

Meat and Potatoes: Post Your Resume

The Career Center’s features are state-of-the-art. You can create a resume and a cover letter. To post your resume in “My Account,” for example, select “Post My Resume,” then “Document Management,” and then “Resume.” You’ll need to open a plain text version (no bold, underlining, italics, or bullets) of your current resume on your computer, and then copy your resume to the clipboard.

Never done this before? Here again, you can open a guidance window or a printable FAQ to walk you through the process. Two minor system limitations appear here: You must click a box to make the text wrap automatically, and the site has no spell-check function. You have to spell check your cover letter and resume before you copy and paste. If you edit your text at any time while in the Career Center boxes, then be sure to proofread to ensure you haven’t introduced any errors. After you create your resume, you can open a text version (a file that ends in the suffix .txt) to see how employers will view it.

In the past, hospital medicine applicants could stand out with a well-formatted resume on quality paper. Online documents force every applicant’s information into the same mold, and this often concerns applicants. Will a skilled, tri-lingual, well-published hospitalist look like every other applicant when an employer is looking at a simple text version of your resume?

The Career Center allows you to upload up to three formatted documents that can be attached to applications. If you are unable to upload your documents, you may e-mail them to the site, which will then attach them to your account. Some applicants find it useful to have two specific types of resumes on hand: a traditional reverse chronological resume that emphasizes experience, and a less structured functional resume that describes transferable skills.

Depending on your computer savvy, the time it takes to set up your account and load your resume will vary. Hospitalists with robust skills may be able to load a resume in fewer than 30 minutes, but it may take longer for others. Regardless, the return on investment is large because the information you enter will form the foundation of your materials that a perspective employer will review. Once your resume is loaded, applying for a position only requires a few clicks.

Benefits That Make Your Search Sizzle

If you are an SHM member, the “Job Agent” functionality allows you to receive weekly updates of new jobs added that match your search criteria. (Note: You can join SHM online through the Career Center or by visiting www.joinshm.org) This function is located in your account. It allows you to specify the date you would like to stop receiving notification e-mails. Your account also tracks applications submitted.

After you log in, click “Job Applications” to display any jobs you have applied for and the date that the application was submitted. When a job posting expires (according to a pre-established date set by the employer) a strikethrough line will appear through the job application. Applications remain in your account for 90 days from the submission date. Clicking on the “Apply for this Job” icon opens a new screen, and it allows applicants to edit applications even after you’ve sent it and until the job posting closes. Once the job posting is closed, no application changes can be made.

Employers post their vacancies for 30 days at a time, and they can select packages that include print advertisements in The Hospitalist and/or the Journal of Hospital Medicine. Approximately 85% of employers who advertise in print media also advertise on the Career Center, although a few advertise only on the Career Center. To cover your bases, look in all three places.

Just as some applicants prefer anonymity, some companies choose to list their ads confidentially. In these cases, you will submit your online application, and the employer will contact you via the system with more information if you are a good match.

Employer responses will be forwarded to your e-mail account through the Career Center. Once you begin talking with a prospective employer, it is up to you to use good research and interview skills to ensure that this is indeed a good match. When you find a position, you can remove your resume from circulation. Or, you can store it in the Career Center database for future opportunities by clicking “No, do not post my resume.”

Alternatively, you can remove your information from the database permanently: Go to “My Account” and select “Delete Account.”

What the Future Holds

SHM’s information services team will keep tabs on the recently launched SHM Career Center Web site and invites user feedback—specifically any demographic information that will help them build the most practical, useful career site for hospitalists.

With the average age of a hospitalist about 37, SHM expects that visitors and users to comprise a youthful, computer savvy group. Eventually, SHM wants to expand the site so it tells you more than just what jobs are available (e.g., how to create a resume, interview techniques, and how to build desirable hospital medicine skill sets). They will also track how many employer-employee matches are made using the Career Center.

Conclusion

When unemployment is low, as it most certainly is for hospitalists, leverage rests with job seekers, not employers. While employers are looking for talent and availability, career opportunists crave convenience. The SHM Career Center represents the most comprehensive collection of hospitalist opportunities available on the Internet.

Users will find site navigation easy, and prompts and cues offered by the site designers clear and accurate. Traffic on the site is expected to grow quickly as it becomes what SHM hopes is the most indispensable tool for hospitalists conducting job searches.TH

Jeannette Yeznach Wick, RPh, MBA, FASCP, is a freelance medical writer based in Arlington, Va.

SHM: BEHIND THE SCENES

Membership: Listen, Then Act

By Todd Von Deak

As I write this column, there are only seven days left before the start of this year’s annual meeting. At last check, more 1,100 hospital medicine professionals were registered to join us in Washington, D.C., for the most important meeting in hospital medicine. Our office is abuzz with activity and last minute preparations. I’m sure there’s something else that I’m supposed to be doing right now, but I need the break.

While I take my break and write, I can’t help but think, “what’s next,” once the Annual Meeting is over? SHM is fast approaching the start of a new fiscal year, and, like any membership director, I am eager to hit the ground running.

The more I reflect on what’s next, the more I realize that part of my answer lies within the pages of The Hospitalist. Our research continues to show that you consider The Hospitalist to be one of the most valuable benefits of membership.

What strikes me as I read through past issues is that we have another story to tell. So this month we’re launching “SHM: Behind the Scenes.”

There are many reasons why we need to share this story. Key to those reasons is the fact that our sole purpose is to serve the hospital medicine community. You entrust us with your dues and meeting registrations to provide resources that will enable you to better serve your patients and grow your careers in the process. So it’s important that we, the staff, tell you firsthand what we are doing with your investment, and how we plan on continuing to earn your trust in the years to come.

Each month a different member of our senior staff will take turns writing this column. During the coming year you’ll hear from the heads of education and quality initiatives, business operations, membership, information services, marketing, legislative affairs, and research. In each column you’ll find a mix of current news, future plans, and tips for maximizing the value of your membership. If we do our jobs correctly, each month you will have a clearer picture on the true return of your membership investment.

We want you to clearly understand why—if you only belong to one organization—it has to be SHM.

This month I’ll focus on membership and our plans for the coming year. (See below.) Next month you’ll hear from Scott Johnson, SHM’s director of information services. Scott is our chief technologist in many ways and is leading the charge to use today’s latest technology to expand the reach of our educational products and enhance your membership investment as well.

Each year, membership departments at non-profit organizations write their strategic plans for the coming year. SHM is no exception.

For most, these strategic plans are based on a set of assumptions. In more offices than you’d like to believe, the staff just sits around and makes their best guesses in order to answer critical questions, including “what do members want to get out of their membership?”

Based on these guesses, the staff then plots their course expansion and enhances the benefits and services that the organization offers. These organizations are doomed to mediocrity.

Successful organizations, including SHM, actively seek to better understand their membership and use a variety of media to get to the heart of the questions that matter. I am proud to say that SHM is among the second group.

Building on previous efforts, the SHM Membership Department has been actively engaged in a “listening tour.” Our goal is to not rely on assumptions but rather to use your feedback in formulating our plans for the coming year.

Here’s some of what we’ve identified.

Top reasons for being a member:

• Education and quality improvement resources;
• The ability to affect the hospital medicine movement; and
• Subscriptions to The Hospitalist and Journal of Hospital Medicine.

Your main goals as a member:

• To learn from educational and quality improvement resources;
• Take advantage of networking opportunities; and
• Gain exposure for career advancement.

The benefits of membership that matter most:

• Information on www.hospitalmedicine.org;
• Access to results from SHM’s “Authoritative Source on the State of the Hospital Medicine Movement;” and
• The Hospitalist.

We’re already using this data, along with other information that we’ve gathered, to enhance the SHM experience and increase the return on your investment. Just look at the new SHM Career Center (www.hospitalmedicine.org/careercenter).

Like any good membership department, we realize that our data collection has just begun. So I’d like to pose a couple of questions:

• Do you agree with our findings?
• Should we offer a new benefit of membership?
• What can we do to enhance your SHM experience?

I’d love to hear your thoughts. Send them to me via e-mail at [email protected]. Anyone who e-mails will be entered in a prize drawing.

In my next column, I will share a selection of the responses I receive and tell you the concrete steps we’re taking to improve communication with you and other members.

Von Deak is SHM’s director of membership and marketing.

Each year a new team of SHM officers is elected to lend their wisdom, time, experience, and skills in a collaborative effort to help manage the business of our organization, drive new initiatives, and support the society’s mission. At this year’s annual meeting in Washington, D.C., we again witnessed that familiar changing of the guard with the following inductions:

• President Mary Jo Gorman, MD, MBA;
• President-Elect Russell Holman, MD;
• Treasurer Patrick Cawley, MD; and
• Secretary Jack Percelay, MD, MPH.

“Hospitalists are squarely in the spotlight today on key issues affecting patient care, quality of hospital care, hospital leadership, and other concerns. So it is important that we have a strong, hands-on leadership team that is committed to continuing the positive momentum SHM has generated for hospitalists,” says Larry Wellikson, MD, FACP, CEO of SHM. “I couldn’t be more thrilled with our slate of newly appointed officers. Time and again through the years Mary Jo, Rusty, Pat, and Jack have proven that they are active participants, and that they are leaders who will rise to the occasion to help us meet our objectives.”

President Mary Jo Gorman, MD, MBA

Dr. Gorman, a charter member of SHM, has been a practicing hospitalist since 1997, when she founded the first hospitalist practice in St. Louis. In early 1999, her group merged into IPC—The Hospitalist Company and grew to become the dominant hospitalist group in the city. In 2001, Dr. Gorman was promoted to vice-president of medical affairs for IPC, responsible for the design and implementation of company-wide programs involving business development, recruitment, physician training, and operations in all of IPC’s markets. In 2003, she was named chief medical officer and today works with more than 300 physicians nationwide to develop programs and strategies that enhance clinical performance and drive the delivery system towards more efficient care and greater patient satisfaction. She also oversees IPC’s physician training, mentoring and retention programs, as well as IPC’s call center nurses, healthcare services and clinical studies.

A cum laude graduate of St. Louis University, Dr. Gorman earned a BA in Chemistry/Biology in 1981, then went on to earn her MD in 1984 from Southern Illinois University School of Medicine in Springfield. In 1996, she earned a MBA from Washington University, Olin School of Business, in St. Louis.

President-Elect Russell Holman, MD

SHM’s new President-Elect Dr. Holman is senior vice president and national medical director for Cogent Healthcare, an organization that manages hospital medicine programs throughout the country. He is responsible for program implementation and management, quality systems reporting and auditing, physician leadership development, and data systems integration. Formerly, Dr. Holman was the medical director of Hospital Services for HealthPartners Medical Group & Clinics, part of HealthPartners, Inc. in Minnesota. There he also was the founder and director of the HPMG Fellowship Program in Hospital Medicine.

A long-time member of SHM, Dr. Holman served on the Board of Directors as treasurer from 2004-2005. He was previously chair of the Leadership Development Committee, chair of the Midwest Council, course director of the SHM Leadership Academy, and a member of the Public Policy Committee. In February 2006 he co-authored the “Update in Hospital Medicine,” which appeared in Annals of Internal Medicine. In 2002, he received the SHM Award for Outstanding Service in Hospital Medicine.

Through the years, Dr. Holman’s commitment to hospital medicine has helped produce nationally recognized standards in the areas of quality improvement activities, models of medical education, observation units, communication systems, compensation plans, case management, surgical co-management collaborations, and patient flow initiatives. Dr. Holman serves on two national editorial boards for medical publications and is currently co-authoring a comprehensive textbook and electronic decision support tool in hospital medicine.

Dr. Holman earned his MD from Washington University School of Medicine in St. Louis and trained as a resident and chief medical resident at the University of Minnesota in Minneapolis.

Treasurer Patrick Cawley, MD

New Treasurer Dr. Cawley is a hospitalist at the Medical University of South Carolina in Charleston, where he currently serves as interim executive medical director of MUSC Medical Center. He previously served as the chief of the Section of Hospital Medicine, vice chairman of clinical affairs in the Department of Medicine, and associate executive medical director at MUSC Medical Center.

A charter member of SHM, Dr. Cawley has served on numerous committees and was previously secretary of the Board for the 2004-2005 term. He has worked in both academic and nonacademic hospitals and has served as a consultant to numerous hospitals in the development of hospital medicine programs.

Dr. Cawley received his Bachelor of Science in 1988 from the University of Scranton (Pa.) and his MD from Georgetown University School of Medicine in Washington, D.C. He completed an internal medicine residency at Duke University in Durham, N.C. Later this year, he will complete his MBA from the University of Massachusetts-Amherst.

Secretary Jack Percelay, MD, MPH

SHM’s new secretary is Dr. Percelay. He is director of Virtua Inpatient Pediatrics, a large pediatric hospital medicine group in Southern New Jersey with 14 full-time hospitalists covering two hospitals. Since 1991, Dr. Percelay has worked in a variety of community-based settings including the general pediatric ward, pediatric sub-specialty units, pediatric intensive care unit (PICU), neonatal intensive care unit (NICU), and the emergency department.

A charter member of SHM and one of the nation’s first pediatric hospitalists, Dr. Percelay currently holds the Pediatric Seat on the SHM Board, in addition to serving on the Public Policy Committee and co-chairing the Pediatric Committee. He has been intimately involved in collaborative Pediatric hospital medicine projects such as the PRIS research network and the Denver 2005 and 2007 Pediatric Hospital Medicine conferences.

Dr. Percelay is also the founding chairperson and immediate past chair of the American Academy of Pediatrics Section on Hospital Medicine and co-authored the AAP policy statement on pediatric hospitalists. He completed his medical school and pediatric training at the University of California at San Francisco, along with an MPH at the University of California at Berkeley.

SHM congratulates these new officers and thanks our 2005 officers (Steve Pantilat, MD, president, William Atchley, MD, FACP, treasurer, and Lisa Kettering, MD, FACP, secretary) for their exemplary work.

Annual Meeting e-Community a Success

If the feedback from attendees at this year’s Annual Meeting was any indication, the inaugural launch of SHM’s Annual Meeting e-Community was a success.

Each year, SHM’s Annual Meeting provides an opportunity for hospital medicine professionals to network with colleagues and take advantage of more than 40 educational sessions during the course of three days.

While the location for the meeting changes regularly, there is a constant desire within the Annual Meeting planning committee (a group of volunteer members) to improve the attendee experience. The Annual Meeting e-Community (AMeC) was designed with that in mind.

The AMeC effectively extended the reach of the annual meeting both before and after the event. Since early April, attendees have been able to access the handouts for the presentations that were given at the event and network with colleagues thanks to dedicated discussion communities. There are also listings of exhibitors scheduled to be in attendance and general information about Washington, D.C., on the AMeC.

Because of the positive feedback received, the e-Community will stay online through early July, giving attendees the chance to download presentations from sessions that they didn’t attend and make contact with colleagues they met while in Washington, D.C.

Attendees appreciated the ability to access meeting materials prior to the event. “The Annual Meeting e-Community gave me a great opportunity to really plan out the sessions that I wanted to attend prior to the meeting,” says William Rifkin, MD, a hospitalist from the Yale School of Medicine.

According to Joy Wittnebert, AMeC project manager, the site was launched in response to feedback from past annual meetings. “Attendees have been consistently telling us that they want to be able to customize their experience and have more opportunities to network with colleagues before and after the event,” she says.

In the coming months, SHM staff will work with the Annual Meeting Committee to analyze additional feedback and begin making plans for the 2007 version of the site.

SHM Education Committee Launches 18-Month Strategic Plan

Helping our members and the hospital medicine community advance in professional growth and development has been on center stage as seen in the SHM Education Committee’s recent completion of an 18-month strategic plan. The plan is a framework designed to guide staff and volunteer leadership as they work to expand the society’s current slate of educational offerings. Inherent in the framework’s design is a focus on taking advantage of the myriad new channels that have come online for delivering educational content.

The plan is rooted primarily in the recently released Core Competencies in Hospital Medicine. The Core Competencies are a benchmark for the development of curricula within the hospital medicine specialty.

“One of the most exciting parts of this plan is its connection to the Core Competencies,” says Geri Barnes, SHM’s director of education and quality initiatives. “The connection means that this is one of the strongest educational plans that the society has put forward.”

A driving force in the creation of this plan was the committee’s desire to expand SHM’s educational offerings through a variety of technologic venues. “In the coming year, our educational offerings will truly become multi-dimensional,” says Scott Johnson, SHM’s director of information services. “As we expand into audio CDs, podcasts, and Web-based offerings, more hospitalists will be able to take advantage of these learning opportunities, which will have profound effects on the hospital medicine movement.”

With the education plan approved by SHM’s Board of Directors at its recent meeting, the Education Committee, chaired by Preetha Basaviah, MD, from Stanford University, will turn its attention to the first stage of implementation—a complete needs analysis. Some research has already taken place as part of SHM’s ongoing internal quality improvement processes.

“The key to the success of our plan is that we will be integrating feedback from hospitalists throughout North America as we move forward,” says Dr. Basaviah. “Ultimately, this kind of communication will ensure that we reach our primary goal: to provide tools and resources that help hospital medicine professionals improve the quality of care that they provide.”

Stay tuned to The Hospitalist for updates on the committee’s progress and an advanced look at new educational products.

Palliative Care: a Core Competency for Hospitalists

By Theresa Kristopaitis, MD, with input from Howard Epstein, MD, and the SHM Palliative Care Task Force

Palliative care is focused on the relief of suffering and support for the best quality of life for patients facing serious, life-threatening, or advanced illness, as well as their families. Palliative care is a general approach to healthcare that should be routinely integrated with disease modifying therapies. It is also a growing practice specialty for appropriately trained healthcare professionals dedicating their practice to the delivery of palliative care services.1

Optimally palliative care is delivered through an interdisciplinary team consisting of physicians, nurses, chaplains, social workers, pharmacists, as well as other disciplines as patient/family needs warrant. Models of palliative care delivery include hospital-based inpatient consultation services, inpatient palliative care units, outpatient and home-based consultation services, and ambulatory clinics. Hospitalists are ideally positioned to start inpatient palliative care services and reap the professional and institutional benefits that palliative care offers. Tools to develop a program can be obtained through the Center to Advance Palliative Care (www.capc.org).

A Core Competency

The skills gained from developing expertise in palliative care are indispensable to hospitalists—even if they don’t formally work with a palliative care team. Palliative care itself is identified as a healthcare systems core competency of hospital medicine.2 In addition, other hospital medicine competencies overlap with those key to palliative care: pain management, care of the elderly patient and vulnerable populations, communication, hospitalist as consultant, team approach and multidisciplinary care, transitions of care, and medical ethics.3 For some of the most challenging, yet common, inpatient clinical scenarios, palliative care and hospital practice can become indistinguishable.

Inpatient Scenarios: How Can Palliative Care Help?

Scenario 1: A patient on chronic long-acting opiate therapy is admitted to the hospital with complaints of pain, nausea, and vomiting.

The appropriate assessment and management of pain is a patient’s right and an institution’s responsibility, yet it is often inadequate.4 Many barriers to effective pain management have been identified, including limited physician undergraduate and graduate training.4,5 A fundamental goal of palliative care is pain relief. In turn, expertise in the pathophysiology of pain and safe prescribing of opioid, non-opioid, and adjuvant analgesics is critical for palliative care physicians. Palliative care training and resources focus on principles of analgesic pharmacology, equianalgesia, changing routes of administration, control of continuous and breakthrough pain, opioid rotation, and adverse effects of analgesics. A comprehensive introduction to the fundamentals of pain management can be obtained via Education on Palliative and End of Life Care (www.epec.net.) Pain Management Module.

Non-pain symptoms can be as troubling for patients with advanced illness as pain. The formal assessment, reassessment, and management of common symptoms, including nausea, vomiting, dyspnea, constipation, fatigue, and delirium, are a primary domain of palliative medicine. Nausea and vomiting, for example, can become a demoralizing symptom complex. Stimuli to the vomiting center can arise from the cerebral cortex, vestibular apparatus, chemoreceptor zone, and gastrointestinal tract resulting in a broad etiologic differential diagnosis.

With a solid understanding of its pathogenesis and pharmacologic and non-pharmacologic therapeutic principles, nausea and vomiting can be treated in the vast majority of patients. Multiple agents addressing multiple mechanisms may be required. Even the nausea associated with complete bowel obstruction often can be successfully palliated, without the use of nasogastric tubes or surgery.6 The End of Life/Palliative Education Resource Center (www.eperc.mcw.edu) is one of many resources with tools to improve a hospitalist’s evaluation and treatment of non-pain physical symptoms.

Scenario 2: A patient with advanced heart failure and his family are overwhelmed by differing consultant opinions on the appropriateness of implantable cardioverter defibrillator (ICD) insertion.

Effective communication with patients is a core responsibility of both hospitalists and palliative care physicians. A complementary—and at times challenging—skill is the ability to promote communication and consensus about care among multiple specialist consultants. Ripamonti and colleagues write, “Almost invariably, the act of communication is an important part of therapy: Occasionally it is the only constituent. It usually requires greater thought and planning than a drug prescription, and unfortunately it is commonly administered in subtherapeutic doses.”6

The American Academy of Hospice and Palliative Medicine UNIPAC series is a resource for physicians to hone their general communication skills, as well as those more specific to palliative care, such as sharing news (often bad) with patients and families and engaging in therapeutic dialogue.8

Palliative care begins with establishing the goals of care with a patient.9 All physicians bring great value to patient care when they are skilled at negotiating goals of care. There are numerous possible goals of care, from prevention, to cure, to prolongation of life, to achieving a good death. Ideally, goals of care should be discussed with patients and families as early as possible in the course of a serious, life-threatening illness. Establishing realistic and attainable goals of care assumes increased importance in the setting of advanced disease, where treatments intended to prolong life may become more burdensome than beneficial.9

As the reader may have experienced, too often these discussions have not taken place or are held late in the trajectory of illness, such as when patients are hospitalized for severe progressive disease or are facing imminent death.10 In the scenario of potential ICD insertion, conversations with patients to clarify device-specific goals are best accomplished before they are placed and in the context of a broader discussion of the patient’s general medical condition and overall goals for care.11 This type of discussion ultimately improves the informed consent process for ICDs and other technologies. ICD recipients should be guided to periodically revisit their goals, particularly when their health status significantly changes.11 Unlike for initial ICD placement, there are no guidelines for disabling already implanted ICDs. The opportunity to discuss this issue with a patient before a crisis or before they lose decision-making capacity is frequently lost and occurs all too often at life’s end.12

Scenario 3: An elderly debilitated woman with advanced cervical cancer has been hospitalized six times in the past two months. She is cared for at home. Her family is tired but they are doing “the best they can.” She is brought to the emergency department again with weakness.

Effective implementation of care management strategies for patients with life-threatening and advanced disease requires assessment of their physical, social, emotional, and spiritual concerns.1 Similarly, family caregivers have their own—often unvoiced—biopsychosocial stressors.13 Physicians directing patient care must appreciate the significance of these multiple issues, even if they are not comfortable or are ill-equipped to handle them on their own. The power of the interdisciplinary palliative care model is that team members evaluate the patient from different perspectives and pool their expertise in addressing the complex needs of their patients and families.8

In some multidisciplinary models, the onus may lie on the physician to recognize the patient and family needs and mobilize the appropriate resources. Coordination of care at home for patients in the later stages of chronic illness may seem daunting during hospital stays. However, by employing measures utilized by palliative care teams, such as reviewing the goals of care, introducing community resources to help patients and families manage at home, providing anticipatory grief and bereavement support, and considering hospice referral, discharge planning and transitions in care can be much more sustainable.14 With these interventions, patients, families, physicians, and hospitals all benefit.

Conclusion

Hospital-based palliative care programs are growing exponentially.15 Hospitalists are in a unique position to continue their development. Even if the time or circumstances are not yet right for you to become a part of a formal palliative care program, there are daily opportunities to reap rewards from the knowledge, attitudes, and skills that palliative care training offers.

References

1. National Consensus Project for Quality Palliative Care: The development of practice guidelines 2004. Available at www.nationalconsensusproject.org. Last accessed April 28, 2006.
2. Pistoria MJ, Amin AN, Dressler DD, et al. The core competencies in hospital medicine. J Hosp Med. 2006;1:2(S1).
3. American Board of Hospice and Palliative Medicine. Available at www.abhpm.org. Last accessed April 28, 2006.
4. Phillips DM. JCAHO pain management standards unveiled. JAMA. 2000;284:428-429.
5. Sullivan AM, Lakoma MD, Block SD. The status of medical education in end-of-life care: a national report. J Gen Intern Med. 2003;18:685-695.
6. Ripamonti C, De Conno F, Ventafridda V, et al. Management of bowel obstruction in advanced and terminal cancer patients. Ann Oncol. 1993 Jan;4(1):15-21.
7. Buckman R. Communication in palliative care: a practical guide. In: Doyle D, Hanks GWC, MacDonald N, eds. Oxford Textbook of Palliative Medicine. New York: Oxford Community Press; 1993:47-61.
8. Storey P, Knight CF. UNIPAC five—caring for the terminally ill—communication and the physician’s role in the interdisciplinary team. In: Hospice/Palliative Care Training for Physicians—A Self Study Program. New York: Mary Ann Liebert; 2003:1-147.
9. Morrison RS, Meier DE. Palliative care. NEJM. 2004;350:2582-2590.
10. Quill TE. Initiating end of life discussion with seriously ill patients: addressing the “elephant in the room.” JAMA. 2000;284:2502-2507.
11. Berger, JT. The ethics of deactivating implanted cardioverter defibrillators. Ann Intern Med. 2005;142:631-634.
12. Goldstein NE, Lampert R, Bradely E, et al. Management of implantable cardioverter defibrillators in end-of-life care. Ann Intern Med. 2004;141:835-838.
13. Levine C. The loneliness of the long-term caregiver. NEJM. 1999;340:1587-1590.
14. Meier D. Palliative care in hospitals. J Hosp Med. 2006;1:21-28.
15. Morrison RS, et al. The growth of palliative care programs in United States hospitals. J Pall Med. 2006; 8 (6):1127-1133.

Get a Job!

SHM Launches the first-ever career Web site exclusively for hospitalists

By Jeannette Wick

Job boards—Internet sites designed to allow employers and prospective employees to find each other electronically—are among the most active Internet sites. For many job seekers Monster.com, CareerBuilder.com, and Indeed.com (among others) have become essential job search tools. Until now, however, no site has catered to healthcare professionals in general—much less to hospitalists in particular.

Thanks to the new SHM Career Center (http://hospitalmedicine.org/careercenter), though, things are about to change. The Career Center is part of a comprehensive, “cradle-to-grave” approach SHM is taking to assist hospital medicine professionals in their career development pursuits. The site offers numerous advantages over traditional job-hunting tools, such as classified advertisements, personal contacts, and randomly mailing resumes to interesting employers—advantages such as the ability to post your resume in a searchable database, a database of open positions across North America that you can search using a variety of variables and the opportunity to receive a notification when a job that matches your criteria is posted online.

The Career Center also represents an improvement over general job boards because the pool of positions offered and solicited on the site is restricted to those only for hospital medicine professionals. The site is free for all, although SHM members are able to take advantage of certain “members-only” functionality (resume posting, e-mail notification of new job postings). “Career opportunists,” or hospitalists who are gainfully employed but constantly curious about what else is available, will enjoy this site, too.

The Way it Works

SHM’s Career Center matches applicants and jobs using search features that allow applicants to tailor their search. As an applicant, you enter your job preferences as you would when searching for an article in PubMed or when looking online for a board-certified specialist in a specific geographic region when referring a patient. The boxes prompt you to provide the minimum information necessary for an acceptable search. For example, you need to provide geographical preferences, the type of position you’re looking for, and the specialty area you’re interested in to best tailor your search.

Visitors can browse all jobs by specialty or state—or view the complete list of jobs. The advanced search option augments the specialty and state fields with the ability to specify keywords (see “Hospitalists and Keywords,” p. 10), specialty, employment type (full time, moonlighting, and so on), and the announcement opening date. (The latter is important to applicants who believe older announcements raise a red flag indicating conditions that make it unattractive to candidates.)

The advanced search option also allows you to look at job summaries with the results. So instead of receiving a simple list of the job title, the location, and the announcement date, the summary includes a short description of the position. But visitor beware: You have to click a box to make this happen. Otherwise, your search will create a simple list of jobs, and clicking on any individual job will bring up the job summary. The information is accessible either way.

Get Started

Most job seekers will find the site quite easy to navigate, although a few may be impeded by cookies. (For more information, see “Got Cookies,” p. 10.) The FAQ area is a site strength and will help you eliminate hurdles, from inability to navigate the site, to figuring out how to be notified electronically when new jobs are added.

Once you enter your search criteria, a list of jobs displays. Then click on a specific job to open another page describing the position in great detail. After seeing the array of positions available, SHM non-members are likely to join the society just to have access to the full functionality of the Career Center.

Your next step is to create an account; doing so allows you to apply for positions with just a click. Once you establish an account (a process that takes just a few minutes), click on “Edit My Profile.” In this area, you’ll establish your profile.

Meat and Potatoes: Post Your Resume

The Career Center’s features are state-of-the-art. You can create a resume and a cover letter. To post your resume in “My Account,” for example, select “Post My Resume,” then “Document Management,” and then “Resume.” You’ll need to open a plain text version (no bold, underlining, italics, or bullets) of your current resume on your computer, and then copy your resume to the clipboard.

Never done this before? Here again, you can open a guidance window or a printable FAQ to walk you through the process. Two minor system limitations appear here: You must click a box to make the text wrap automatically, and the site has no spell-check function. You have to spell check your cover letter and resume before you copy and paste. If you edit your text at any time while in the Career Center boxes, then be sure to proofread to ensure you haven’t introduced any errors. After you create your resume, you can open a text version (a file that ends in the suffix .txt) to see how employers will view it.

In the past, hospital medicine applicants could stand out with a well-formatted resume on quality paper. Online documents force every applicant’s information into the same mold, and this often concerns applicants. Will a skilled, tri-lingual, well-published hospitalist look like every other applicant when an employer is looking at a simple text version of your resume?

The Career Center allows you to upload up to three formatted documents that can be attached to applications. If you are unable to upload your documents, you may e-mail them to the site, which will then attach them to your account. Some applicants find it useful to have two specific types of resumes on hand: a traditional reverse chronological resume that emphasizes experience, and a less structured functional resume that describes transferable skills.

Depending on your computer savvy, the time it takes to set up your account and load your resume will vary. Hospitalists with robust skills may be able to load a resume in fewer than 30 minutes, but it may take longer for others. Regardless, the return on investment is large because the information you enter will form the foundation of your materials that a perspective employer will review. Once your resume is loaded, applying for a position only requires a few clicks.

Benefits That Make Your Search Sizzle

If you are an SHM member, the “Job Agent” functionality allows you to receive weekly updates of new jobs added that match your search criteria. (Note: You can join SHM online through the Career Center or by visiting www.joinshm.org) This function is located in your account. It allows you to specify the date you would like to stop receiving notification e-mails. Your account also tracks applications submitted.

After you log in, click “Job Applications” to display any jobs you have applied for and the date that the application was submitted. When a job posting expires (according to a pre-established date set by the employer) a strikethrough line will appear through the job application. Applications remain in your account for 90 days from the submission date. Clicking on the “Apply for this Job” icon opens a new screen, and it allows applicants to edit applications even after you’ve sent it and until the job posting closes. Once the job posting is closed, no application changes can be made.

Employers post their vacancies for 30 days at a time, and they can select packages that include print advertisements in The Hospitalist and/or the Journal of Hospital Medicine. Approximately 85% of employers who advertise in print media also advertise on the Career Center, although a few advertise only on the Career Center. To cover your bases, look in all three places.

Just as some applicants prefer anonymity, some companies choose to list their ads confidentially. In these cases, you will submit your online application, and the employer will contact you via the system with more information if you are a good match.

Employer responses will be forwarded to your e-mail account through the Career Center. Once you begin talking with a prospective employer, it is up to you to use good research and interview skills to ensure that this is indeed a good match. When you find a position, you can remove your resume from circulation. Or, you can store it in the Career Center database for future opportunities by clicking “No, do not post my resume.”

Alternatively, you can remove your information from the database permanently: Go to “My Account” and select “Delete Account.”

What the Future Holds

SHM’s information services team will keep tabs on the recently launched SHM Career Center Web site and invites user feedback—specifically any demographic information that will help them build the most practical, useful career site for hospitalists.

With the average age of a hospitalist about 37, SHM expects that visitors and users to comprise a youthful, computer savvy group. Eventually, SHM wants to expand the site so it tells you more than just what jobs are available (e.g., how to create a resume, interview techniques, and how to build desirable hospital medicine skill sets). They will also track how many employer-employee matches are made using the Career Center.

Conclusion

When unemployment is low, as it most certainly is for hospitalists, leverage rests with job seekers, not employers. While employers are looking for talent and availability, career opportunists crave convenience. The SHM Career Center represents the most comprehensive collection of hospitalist opportunities available on the Internet.

Users will find site navigation easy, and prompts and cues offered by the site designers clear and accurate. Traffic on the site is expected to grow quickly as it becomes what SHM hopes is the most indispensable tool for hospitalists conducting job searches.TH

Jeannette Yeznach Wick, RPh, MBA, FASCP, is a freelance medical writer based in Arlington, Va.

SHM: BEHIND THE SCENES

Membership: Listen, Then Act

By Todd Von Deak

As I write this column, there are only seven days left before the start of this year’s annual meeting. At last check, more 1,100 hospital medicine professionals were registered to join us in Washington, D.C., for the most important meeting in hospital medicine. Our office is abuzz with activity and last minute preparations. I’m sure there’s something else that I’m supposed to be doing right now, but I need the break.

While I take my break and write, I can’t help but think, “what’s next,” once the Annual Meeting is over? SHM is fast approaching the start of a new fiscal year, and, like any membership director, I am eager to hit the ground running.

The more I reflect on what’s next, the more I realize that part of my answer lies within the pages of The Hospitalist. Our research continues to show that you consider The Hospitalist to be one of the most valuable benefits of membership.

What strikes me as I read through past issues is that we have another story to tell. So this month we’re launching “SHM: Behind the Scenes.”

There are many reasons why we need to share this story. Key to those reasons is the fact that our sole purpose is to serve the hospital medicine community. You entrust us with your dues and meeting registrations to provide resources that will enable you to better serve your patients and grow your careers in the process. So it’s important that we, the staff, tell you firsthand what we are doing with your investment, and how we plan on continuing to earn your trust in the years to come.

Each month a different member of our senior staff will take turns writing this column. During the coming year you’ll hear from the heads of education and quality initiatives, business operations, membership, information services, marketing, legislative affairs, and research. In each column you’ll find a mix of current news, future plans, and tips for maximizing the value of your membership. If we do our jobs correctly, each month you will have a clearer picture on the true return of your membership investment.

We want you to clearly understand why—if you only belong to one organization—it has to be SHM.

This month I’ll focus on membership and our plans for the coming year. (See below.) Next month you’ll hear from Scott Johnson, SHM’s director of information services. Scott is our chief technologist in many ways and is leading the charge to use today’s latest technology to expand the reach of our educational products and enhance your membership investment as well.

Each year, membership departments at non-profit organizations write their strategic plans for the coming year. SHM is no exception.

For most, these strategic plans are based on a set of assumptions. In more offices than you’d like to believe, the staff just sits around and makes their best guesses in order to answer critical questions, including “what do members want to get out of their membership?”

Based on these guesses, the staff then plots their course expansion and enhances the benefits and services that the organization offers. These organizations are doomed to mediocrity.

Successful organizations, including SHM, actively seek to better understand their membership and use a variety of media to get to the heart of the questions that matter. I am proud to say that SHM is among the second group.

Building on previous efforts, the SHM Membership Department has been actively engaged in a “listening tour.” Our goal is to not rely on assumptions but rather to use your feedback in formulating our plans for the coming year.

Here’s some of what we’ve identified.

Top reasons for being a member:

• Education and quality improvement resources;
• The ability to affect the hospital medicine movement; and
• Subscriptions to The Hospitalist and Journal of Hospital Medicine.

Your main goals as a member:

• To learn from educational and quality improvement resources;
• Take advantage of networking opportunities; and
• Gain exposure for career advancement.

The benefits of membership that matter most:

• Information on www.hospitalmedicine.org;
• Access to results from SHM’s “Authoritative Source on the State of the Hospital Medicine Movement;” and
• The Hospitalist.

We’re already using this data, along with other information that we’ve gathered, to enhance the SHM experience and increase the return on your investment. Just look at the new SHM Career Center (www.hospitalmedicine.org/careercenter).

Like any good membership department, we realize that our data collection has just begun. So I’d like to pose a couple of questions:

• Do you agree with our findings?
• Should we offer a new benefit of membership?
• What can we do to enhance your SHM experience?

I’d love to hear your thoughts. Send them to me via e-mail at [email protected]. Anyone who e-mails will be entered in a prize drawing.

In my next column, I will share a selection of the responses I receive and tell you the concrete steps we’re taking to improve communication with you and other members.

Von Deak is SHM’s director of membership and marketing.

Each year a new team of SHM officers is elected to lend their wisdom, time, experience, and skills in a collaborative effort to help manage the business of our organization, drive new initiatives, and support the society’s mission. At this year’s annual meeting in Washington, D.C., we again witnessed that familiar changing of the guard with the following inductions:

• President Mary Jo Gorman, MD, MBA;
• President-Elect Russell Holman, MD;
• Treasurer Patrick Cawley, MD; and
• Secretary Jack Percelay, MD, MPH.

“Hospitalists are squarely in the spotlight today on key issues affecting patient care, quality of hospital care, hospital leadership, and other concerns. So it is important that we have a strong, hands-on leadership team that is committed to continuing the positive momentum SHM has generated for hospitalists,” says Larry Wellikson, MD, FACP, CEO of SHM. “I couldn’t be more thrilled with our slate of newly appointed officers. Time and again through the years Mary Jo, Rusty, Pat, and Jack have proven that they are active participants, and that they are leaders who will rise to the occasion to help us meet our objectives.”

President Mary Jo Gorman, MD, MBA

Dr. Gorman, a charter member of SHM, has been a practicing hospitalist since 1997, when she founded the first hospitalist practice in St. Louis. In early 1999, her group merged into IPC—The Hospitalist Company and grew to become the dominant hospitalist group in the city. In 2001, Dr. Gorman was promoted to vice-president of medical affairs for IPC, responsible for the design and implementation of company-wide programs involving business development, recruitment, physician training, and operations in all of IPC’s markets. In 2003, she was named chief medical officer and today works with more than 300 physicians nationwide to develop programs and strategies that enhance clinical performance and drive the delivery system towards more efficient care and greater patient satisfaction. She also oversees IPC’s physician training, mentoring and retention programs, as well as IPC’s call center nurses, healthcare services and clinical studies.

A cum laude graduate of St. Louis University, Dr. Gorman earned a BA in Chemistry/Biology in 1981, then went on to earn her MD in 1984 from Southern Illinois University School of Medicine in Springfield. In 1996, she earned a MBA from Washington University, Olin School of Business, in St. Louis.

President-Elect Russell Holman, MD

SHM’s new President-Elect Dr. Holman is senior vice president and national medical director for Cogent Healthcare, an organization that manages hospital medicine programs throughout the country. He is responsible for program implementation and management, quality systems reporting and auditing, physician leadership development, and data systems integration. Formerly, Dr. Holman was the medical director of Hospital Services for HealthPartners Medical Group & Clinics, part of HealthPartners, Inc. in Minnesota. There he also was the founder and director of the HPMG Fellowship Program in Hospital Medicine.

A long-time member of SHM, Dr. Holman served on the Board of Directors as treasurer from 2004-2005. He was previously chair of the Leadership Development Committee, chair of the Midwest Council, course director of the SHM Leadership Academy, and a member of the Public Policy Committee. In February 2006 he co-authored the “Update in Hospital Medicine,” which appeared in Annals of Internal Medicine. In 2002, he received the SHM Award for Outstanding Service in Hospital Medicine.

Through the years, Dr. Holman’s commitment to hospital medicine has helped produce nationally recognized standards in the areas of quality improvement activities, models of medical education, observation units, communication systems, compensation plans, case management, surgical co-management collaborations, and patient flow initiatives. Dr. Holman serves on two national editorial boards for medical publications and is currently co-authoring a comprehensive textbook and electronic decision support tool in hospital medicine.

Dr. Holman earned his MD from Washington University School of Medicine in St. Louis and trained as a resident and chief medical resident at the University of Minnesota in Minneapolis.

Treasurer Patrick Cawley, MD

New Treasurer Dr. Cawley is a hospitalist at the Medical University of South Carolina in Charleston, where he currently serves as interim executive medical director of MUSC Medical Center. He previously served as the chief of the Section of Hospital Medicine, vice chairman of clinical affairs in the Department of Medicine, and associate executive medical director at MUSC Medical Center.

A charter member of SHM, Dr. Cawley has served on numerous committees and was previously secretary of the Board for the 2004-2005 term. He has worked in both academic and nonacademic hospitals and has served as a consultant to numerous hospitals in the development of hospital medicine programs.

Dr. Cawley received his Bachelor of Science in 1988 from the University of Scranton (Pa.) and his MD from Georgetown University School of Medicine in Washington, D.C. He completed an internal medicine residency at Duke University in Durham, N.C. Later this year, he will complete his MBA from the University of Massachusetts-Amherst.

Secretary Jack Percelay, MD, MPH

SHM’s new secretary is Dr. Percelay. He is director of Virtua Inpatient Pediatrics, a large pediatric hospital medicine group in Southern New Jersey with 14 full-time hospitalists covering two hospitals. Since 1991, Dr. Percelay has worked in a variety of community-based settings including the general pediatric ward, pediatric sub-specialty units, pediatric intensive care unit (PICU), neonatal intensive care unit (NICU), and the emergency department.

A charter member of SHM and one of the nation’s first pediatric hospitalists, Dr. Percelay currently holds the Pediatric Seat on the SHM Board, in addition to serving on the Public Policy Committee and co-chairing the Pediatric Committee. He has been intimately involved in collaborative Pediatric hospital medicine projects such as the PRIS research network and the Denver 2005 and 2007 Pediatric Hospital Medicine conferences.

Dr. Percelay is also the founding chairperson and immediate past chair of the American Academy of Pediatrics Section on Hospital Medicine and co-authored the AAP policy statement on pediatric hospitalists. He completed his medical school and pediatric training at the University of California at San Francisco, along with an MPH at the University of California at Berkeley.

SHM congratulates these new officers and thanks our 2005 officers (Steve Pantilat, MD, president, William Atchley, MD, FACP, treasurer, and Lisa Kettering, MD, FACP, secretary) for their exemplary work.

Annual Meeting e-Community a Success

If the feedback from attendees at this year’s Annual Meeting was any indication, the inaugural launch of SHM’s Annual Meeting e-Community was a success.

Each year, SHM’s Annual Meeting provides an opportunity for hospital medicine professionals to network with colleagues and take advantage of more than 40 educational sessions during the course of three days.

While the location for the meeting changes regularly, there is a constant desire within the Annual Meeting planning committee (a group of volunteer members) to improve the attendee experience. The Annual Meeting e-Community (AMeC) was designed with that in mind.

The AMeC effectively extended the reach of the annual meeting both before and after the event. Since early April, attendees have been able to access the handouts for the presentations that were given at the event and network with colleagues thanks to dedicated discussion communities. There are also listings of exhibitors scheduled to be in attendance and general information about Washington, D.C., on the AMeC.

Because of the positive feedback received, the e-Community will stay online through early July, giving attendees the chance to download presentations from sessions that they didn’t attend and make contact with colleagues they met while in Washington, D.C.

Attendees appreciated the ability to access meeting materials prior to the event. “The Annual Meeting e-Community gave me a great opportunity to really plan out the sessions that I wanted to attend prior to the meeting,” says William Rifkin, MD, a hospitalist from the Yale School of Medicine.

According to Joy Wittnebert, AMeC project manager, the site was launched in response to feedback from past annual meetings. “Attendees have been consistently telling us that they want to be able to customize their experience and have more opportunities to network with colleagues before and after the event,” she says.

In the coming months, SHM staff will work with the Annual Meeting Committee to analyze additional feedback and begin making plans for the 2007 version of the site.

SHM Education Committee Launches 18-Month Strategic Plan

Helping our members and the hospital medicine community advance in professional growth and development has been on center stage as seen in the SHM Education Committee’s recent completion of an 18-month strategic plan. The plan is a framework designed to guide staff and volunteer leadership as they work to expand the society’s current slate of educational offerings. Inherent in the framework’s design is a focus on taking advantage of the myriad new channels that have come online for delivering educational content.

The plan is rooted primarily in the recently released Core Competencies in Hospital Medicine. The Core Competencies are a benchmark for the development of curricula within the hospital medicine specialty.

“One of the most exciting parts of this plan is its connection to the Core Competencies,” says Geri Barnes, SHM’s director of education and quality initiatives. “The connection means that this is one of the strongest educational plans that the society has put forward.”

A driving force in the creation of this plan was the committee’s desire to expand SHM’s educational offerings through a variety of technologic venues. “In the coming year, our educational offerings will truly become multi-dimensional,” says Scott Johnson, SHM’s director of information services. “As we expand into audio CDs, podcasts, and Web-based offerings, more hospitalists will be able to take advantage of these learning opportunities, which will have profound effects on the hospital medicine movement.”

With the education plan approved by SHM’s Board of Directors at its recent meeting, the Education Committee, chaired by Preetha Basaviah, MD, from Stanford University, will turn its attention to the first stage of implementation—a complete needs analysis. Some research has already taken place as part of SHM’s ongoing internal quality improvement processes.

“The key to the success of our plan is that we will be integrating feedback from hospitalists throughout North America as we move forward,” says Dr. Basaviah. “Ultimately, this kind of communication will ensure that we reach our primary goal: to provide tools and resources that help hospital medicine professionals improve the quality of care that they provide.”

Stay tuned to The Hospitalist for updates on the committee’s progress and an advanced look at new educational products.

Palliative Care: a Core Competency for Hospitalists

By Theresa Kristopaitis, MD, with input from Howard Epstein, MD, and the SHM Palliative Care Task Force

Palliative care is focused on the relief of suffering and support for the best quality of life for patients facing serious, life-threatening, or advanced illness, as well as their families. Palliative care is a general approach to healthcare that should be routinely integrated with disease modifying therapies. It is also a growing practice specialty for appropriately trained healthcare professionals dedicating their practice to the delivery of palliative care services.1

Optimally palliative care is delivered through an interdisciplinary team consisting of physicians, nurses, chaplains, social workers, pharmacists, as well as other disciplines as patient/family needs warrant. Models of palliative care delivery include hospital-based inpatient consultation services, inpatient palliative care units, outpatient and home-based consultation services, and ambulatory clinics. Hospitalists are ideally positioned to start inpatient palliative care services and reap the professional and institutional benefits that palliative care offers. Tools to develop a program can be obtained through the Center to Advance Palliative Care (www.capc.org).

A Core Competency

The skills gained from developing expertise in palliative care are indispensable to hospitalists—even if they don’t formally work with a palliative care team. Palliative care itself is identified as a healthcare systems core competency of hospital medicine.2 In addition, other hospital medicine competencies overlap with those key to palliative care: pain management, care of the elderly patient and vulnerable populations, communication, hospitalist as consultant, team approach and multidisciplinary care, transitions of care, and medical ethics.3 For some of the most challenging, yet common, inpatient clinical scenarios, palliative care and hospital practice can become indistinguishable.

Inpatient Scenarios: How Can Palliative Care Help?

Scenario 1: A patient on chronic long-acting opiate therapy is admitted to the hospital with complaints of pain, nausea, and vomiting.

The appropriate assessment and management of pain is a patient’s right and an institution’s responsibility, yet it is often inadequate.4 Many barriers to effective pain management have been identified, including limited physician undergraduate and graduate training.4,5 A fundamental goal of palliative care is pain relief. In turn, expertise in the pathophysiology of pain and safe prescribing of opioid, non-opioid, and adjuvant analgesics is critical for palliative care physicians. Palliative care training and resources focus on principles of analgesic pharmacology, equianalgesia, changing routes of administration, control of continuous and breakthrough pain, opioid rotation, and adverse effects of analgesics. A comprehensive introduction to the fundamentals of pain management can be obtained via Education on Palliative and End of Life Care (www.epec.net.) Pain Management Module.

Non-pain symptoms can be as troubling for patients with advanced illness as pain. The formal assessment, reassessment, and management of common symptoms, including nausea, vomiting, dyspnea, constipation, fatigue, and delirium, are a primary domain of palliative medicine. Nausea and vomiting, for example, can become a demoralizing symptom complex. Stimuli to the vomiting center can arise from the cerebral cortex, vestibular apparatus, chemoreceptor zone, and gastrointestinal tract resulting in a broad etiologic differential diagnosis.

With a solid understanding of its pathogenesis and pharmacologic and non-pharmacologic therapeutic principles, nausea and vomiting can be treated in the vast majority of patients. Multiple agents addressing multiple mechanisms may be required. Even the nausea associated with complete bowel obstruction often can be successfully palliated, without the use of nasogastric tubes or surgery.6 The End of Life/Palliative Education Resource Center (www.eperc.mcw.edu) is one of many resources with tools to improve a hospitalist’s evaluation and treatment of non-pain physical symptoms.

Scenario 2: A patient with advanced heart failure and his family are overwhelmed by differing consultant opinions on the appropriateness of implantable cardioverter defibrillator (ICD) insertion.

Effective communication with patients is a core responsibility of both hospitalists and palliative care physicians. A complementary—and at times challenging—skill is the ability to promote communication and consensus about care among multiple specialist consultants. Ripamonti and colleagues write, “Almost invariably, the act of communication is an important part of therapy: Occasionally it is the only constituent. It usually requires greater thought and planning than a drug prescription, and unfortunately it is commonly administered in subtherapeutic doses.”6

The American Academy of Hospice and Palliative Medicine UNIPAC series is a resource for physicians to hone their general communication skills, as well as those more specific to palliative care, such as sharing news (often bad) with patients and families and engaging in therapeutic dialogue.8

Palliative care begins with establishing the goals of care with a patient.9 All physicians bring great value to patient care when they are skilled at negotiating goals of care. There are numerous possible goals of care, from prevention, to cure, to prolongation of life, to achieving a good death. Ideally, goals of care should be discussed with patients and families as early as possible in the course of a serious, life-threatening illness. Establishing realistic and attainable goals of care assumes increased importance in the setting of advanced disease, where treatments intended to prolong life may become more burdensome than beneficial.9

As the reader may have experienced, too often these discussions have not taken place or are held late in the trajectory of illness, such as when patients are hospitalized for severe progressive disease or are facing imminent death.10 In the scenario of potential ICD insertion, conversations with patients to clarify device-specific goals are best accomplished before they are placed and in the context of a broader discussion of the patient’s general medical condition and overall goals for care.11 This type of discussion ultimately improves the informed consent process for ICDs and other technologies. ICD recipients should be guided to periodically revisit their goals, particularly when their health status significantly changes.11 Unlike for initial ICD placement, there are no guidelines for disabling already implanted ICDs. The opportunity to discuss this issue with a patient before a crisis or before they lose decision-making capacity is frequently lost and occurs all too often at life’s end.12

Scenario 3: An elderly debilitated woman with advanced cervical cancer has been hospitalized six times in the past two months. She is cared for at home. Her family is tired but they are doing “the best they can.” She is brought to the emergency department again with weakness.

Effective implementation of care management strategies for patients with life-threatening and advanced disease requires assessment of their physical, social, emotional, and spiritual concerns.1 Similarly, family caregivers have their own—often unvoiced—biopsychosocial stressors.13 Physicians directing patient care must appreciate the significance of these multiple issues, even if they are not comfortable or are ill-equipped to handle them on their own. The power of the interdisciplinary palliative care model is that team members evaluate the patient from different perspectives and pool their expertise in addressing the complex needs of their patients and families.8

In some multidisciplinary models, the onus may lie on the physician to recognize the patient and family needs and mobilize the appropriate resources. Coordination of care at home for patients in the later stages of chronic illness may seem daunting during hospital stays. However, by employing measures utilized by palliative care teams, such as reviewing the goals of care, introducing community resources to help patients and families manage at home, providing anticipatory grief and bereavement support, and considering hospice referral, discharge planning and transitions in care can be much more sustainable.14 With these interventions, patients, families, physicians, and hospitals all benefit.

Conclusion

Hospital-based palliative care programs are growing exponentially.15 Hospitalists are in a unique position to continue their development. Even if the time or circumstances are not yet right for you to become a part of a formal palliative care program, there are daily opportunities to reap rewards from the knowledge, attitudes, and skills that palliative care training offers.

References

1. National Consensus Project for Quality Palliative Care: The development of practice guidelines 2004. Available at www.nationalconsensusproject.org. Last accessed April 28, 2006.
2. Pistoria MJ, Amin AN, Dressler DD, et al. The core competencies in hospital medicine. J Hosp Med. 2006;1:2(S1).
3. American Board of Hospice and Palliative Medicine. Available at www.abhpm.org. Last accessed April 28, 2006.
4. Phillips DM. JCAHO pain management standards unveiled. JAMA. 2000;284:428-429.
5. Sullivan AM, Lakoma MD, Block SD. The status of medical education in end-of-life care: a national report. J Gen Intern Med. 2003;18:685-695.
6. Ripamonti C, De Conno F, Ventafridda V, et al. Management of bowel obstruction in advanced and terminal cancer patients. Ann Oncol. 1993 Jan;4(1):15-21.
7. Buckman R. Communication in palliative care: a practical guide. In: Doyle D, Hanks GWC, MacDonald N, eds. Oxford Textbook of Palliative Medicine. New York: Oxford Community Press; 1993:47-61.
8. Storey P, Knight CF. UNIPAC five—caring for the terminally ill—communication and the physician’s role in the interdisciplinary team. In: Hospice/Palliative Care Training for Physicians—A Self Study Program. New York: Mary Ann Liebert; 2003:1-147.
9. Morrison RS, Meier DE. Palliative care. NEJM. 2004;350:2582-2590.
10. Quill TE. Initiating end of life discussion with seriously ill patients: addressing the “elephant in the room.” JAMA. 2000;284:2502-2507.
11. Berger, JT. The ethics of deactivating implanted cardioverter defibrillators. Ann Intern Med. 2005;142:631-634.
12. Goldstein NE, Lampert R, Bradely E, et al. Management of implantable cardioverter defibrillators in end-of-life care. Ann Intern Med. 2004;141:835-838.
13. Levine C. The loneliness of the long-term caregiver. NEJM. 1999;340:1587-1590.
14. Meier D. Palliative care in hospitals. J Hosp Med. 2006;1:21-28.
15. Morrison RS, et al. The growth of palliative care programs in United States hospitals. J Pall Med. 2006; 8 (6):1127-1133.

Get a Job!

SHM Launches the first-ever career Web site exclusively for hospitalists

By Jeannette Wick

Job boards—Internet sites designed to allow employers and prospective employees to find each other electronically—are among the most active Internet sites. For many job seekers Monster.com, CareerBuilder.com, and Indeed.com (among others) have become essential job search tools. Until now, however, no site has catered to healthcare professionals in general—much less to hospitalists in particular.

Thanks to the new SHM Career Center (http://hospitalmedicine.org/careercenter), though, things are about to change. The Career Center is part of a comprehensive, “cradle-to-grave” approach SHM is taking to assist hospital medicine professionals in their career development pursuits. The site offers numerous advantages over traditional job-hunting tools, such as classified advertisements, personal contacts, and randomly mailing resumes to interesting employers—advantages such as the ability to post your resume in a searchable database, a database of open positions across North America that you can search using a variety of variables and the opportunity to receive a notification when a job that matches your criteria is posted online.

The Career Center also represents an improvement over general job boards because the pool of positions offered and solicited on the site is restricted to those only for hospital medicine professionals. The site is free for all, although SHM members are able to take advantage of certain “members-only” functionality (resume posting, e-mail notification of new job postings). “Career opportunists,” or hospitalists who are gainfully employed but constantly curious about what else is available, will enjoy this site, too.

The Way it Works

SHM’s Career Center matches applicants and jobs using search features that allow applicants to tailor their search. As an applicant, you enter your job preferences as you would when searching for an article in PubMed or when looking online for a board-certified specialist in a specific geographic region when referring a patient. The boxes prompt you to provide the minimum information necessary for an acceptable search. For example, you need to provide geographical preferences, the type of position you’re looking for, and the specialty area you’re interested in to best tailor your search.

Visitors can browse all jobs by specialty or state—or view the complete list of jobs. The advanced search option augments the specialty and state fields with the ability to specify keywords (see “Hospitalists and Keywords,” p. 10), specialty, employment type (full time, moonlighting, and so on), and the announcement opening date. (The latter is important to applicants who believe older announcements raise a red flag indicating conditions that make it unattractive to candidates.)

The advanced search option also allows you to look at job summaries with the results. So instead of receiving a simple list of the job title, the location, and the announcement date, the summary includes a short description of the position. But visitor beware: You have to click a box to make this happen. Otherwise, your search will create a simple list of jobs, and clicking on any individual job will bring up the job summary. The information is accessible either way.

Get Started

Most job seekers will find the site quite easy to navigate, although a few may be impeded by cookies. (For more information, see “Got Cookies,” p. 10.) The FAQ area is a site strength and will help you eliminate hurdles, from inability to navigate the site, to figuring out how to be notified electronically when new jobs are added.

Once you enter your search criteria, a list of jobs displays. Then click on a specific job to open another page describing the position in great detail. After seeing the array of positions available, SHM non-members are likely to join the society just to have access to the full functionality of the Career Center.

Your next step is to create an account; doing so allows you to apply for positions with just a click. Once you establish an account (a process that takes just a few minutes), click on “Edit My Profile.” In this area, you’ll establish your profile.

Meat and Potatoes: Post Your Resume

The Career Center’s features are state-of-the-art. You can create a resume and a cover letter. To post your resume in “My Account,” for example, select “Post My Resume,” then “Document Management,” and then “Resume.” You’ll need to open a plain text version (no bold, underlining, italics, or bullets) of your current resume on your computer, and then copy your resume to the clipboard.

Never done this before? Here again, you can open a guidance window or a printable FAQ to walk you through the process. Two minor system limitations appear here: You must click a box to make the text wrap automatically, and the site has no spell-check function. You have to spell check your cover letter and resume before you copy and paste. If you edit your text at any time while in the Career Center boxes, then be sure to proofread to ensure you haven’t introduced any errors. After you create your resume, you can open a text version (a file that ends in the suffix .txt) to see how employers will view it.

In the past, hospital medicine applicants could stand out with a well-formatted resume on quality paper. Online documents force every applicant’s information into the same mold, and this often concerns applicants. Will a skilled, tri-lingual, well-published hospitalist look like every other applicant when an employer is looking at a simple text version of your resume?

The Career Center allows you to upload up to three formatted documents that can be attached to applications. If you are unable to upload your documents, you may e-mail them to the site, which will then attach them to your account. Some applicants find it useful to have two specific types of resumes on hand: a traditional reverse chronological resume that emphasizes experience, and a less structured functional resume that describes transferable skills.

Depending on your computer savvy, the time it takes to set up your account and load your resume will vary. Hospitalists with robust skills may be able to load a resume in fewer than 30 minutes, but it may take longer for others. Regardless, the return on investment is large because the information you enter will form the foundation of your materials that a perspective employer will review. Once your resume is loaded, applying for a position only requires a few clicks.

Benefits That Make Your Search Sizzle

If you are an SHM member, the “Job Agent” functionality allows you to receive weekly updates of new jobs added that match your search criteria. (Note: You can join SHM online through the Career Center or by visiting www.joinshm.org) This function is located in your account. It allows you to specify the date you would like to stop receiving notification e-mails. Your account also tracks applications submitted.

After you log in, click “Job Applications” to display any jobs you have applied for and the date that the application was submitted. When a job posting expires (according to a pre-established date set by the employer) a strikethrough line will appear through the job application. Applications remain in your account for 90 days from the submission date. Clicking on the “Apply for this Job” icon opens a new screen, and it allows applicants to edit applications even after you’ve sent it and until the job posting closes. Once the job posting is closed, no application changes can be made.

Employers post their vacancies for 30 days at a time, and they can select packages that include print advertisements in The Hospitalist and/or the Journal of Hospital Medicine. Approximately 85% of employers who advertise in print media also advertise on the Career Center, although a few advertise only on the Career Center. To cover your bases, look in all three places.

Just as some applicants prefer anonymity, some companies choose to list their ads confidentially. In these cases, you will submit your online application, and the employer will contact you via the system with more information if you are a good match.

Employer responses will be forwarded to your e-mail account through the Career Center. Once you begin talking with a prospective employer, it is up to you to use good research and interview skills to ensure that this is indeed a good match. When you find a position, you can remove your resume from circulation. Or, you can store it in the Career Center database for future opportunities by clicking “No, do not post my resume.”

Alternatively, you can remove your information from the database permanently: Go to “My Account” and select “Delete Account.”

What the Future Holds

SHM’s information services team will keep tabs on the recently launched SHM Career Center Web site and invites user feedback—specifically any demographic information that will help them build the most practical, useful career site for hospitalists.

With the average age of a hospitalist about 37, SHM expects that visitors and users to comprise a youthful, computer savvy group. Eventually, SHM wants to expand the site so it tells you more than just what jobs are available (e.g., how to create a resume, interview techniques, and how to build desirable hospital medicine skill sets). They will also track how many employer-employee matches are made using the Career Center.

Conclusion

When unemployment is low, as it most certainly is for hospitalists, leverage rests with job seekers, not employers. While employers are looking for talent and availability, career opportunists crave convenience. The SHM Career Center represents the most comprehensive collection of hospitalist opportunities available on the Internet.

Users will find site navigation easy, and prompts and cues offered by the site designers clear and accurate. Traffic on the site is expected to grow quickly as it becomes what SHM hopes is the most indispensable tool for hospitalists conducting job searches.TH

Jeannette Yeznach Wick, RPh, MBA, FASCP, is a freelance medical writer based in Arlington, Va.

SHM: BEHIND THE SCENES

Membership: Listen, Then Act

By Todd Von Deak

As I write this column, there are only seven days left before the start of this year’s annual meeting. At last check, more 1,100 hospital medicine professionals were registered to join us in Washington, D.C., for the most important meeting in hospital medicine. Our office is abuzz with activity and last minute preparations. I’m sure there’s something else that I’m supposed to be doing right now, but I need the break.

While I take my break and write, I can’t help but think, “what’s next,” once the Annual Meeting is over? SHM is fast approaching the start of a new fiscal year, and, like any membership director, I am eager to hit the ground running.

The more I reflect on what’s next, the more I realize that part of my answer lies within the pages of The Hospitalist. Our research continues to show that you consider The Hospitalist to be one of the most valuable benefits of membership.

What strikes me as I read through past issues is that we have another story to tell. So this month we’re launching “SHM: Behind the Scenes.”

There are many reasons why we need to share this story. Key to those reasons is the fact that our sole purpose is to serve the hospital medicine community. You entrust us with your dues and meeting registrations to provide resources that will enable you to better serve your patients and grow your careers in the process. So it’s important that we, the staff, tell you firsthand what we are doing with your investment, and how we plan on continuing to earn your trust in the years to come.

Each month a different member of our senior staff will take turns writing this column. During the coming year you’ll hear from the heads of education and quality initiatives, business operations, membership, information services, marketing, legislative affairs, and research. In each column you’ll find a mix of current news, future plans, and tips for maximizing the value of your membership. If we do our jobs correctly, each month you will have a clearer picture on the true return of your membership investment.

We want you to clearly understand why—if you only belong to one organization—it has to be SHM.

This month I’ll focus on membership and our plans for the coming year. (See below.) Next month you’ll hear from Scott Johnson, SHM’s director of information services. Scott is our chief technologist in many ways and is leading the charge to use today’s latest technology to expand the reach of our educational products and enhance your membership investment as well.

Each year, membership departments at non-profit organizations write their strategic plans for the coming year. SHM is no exception.

For most, these strategic plans are based on a set of assumptions. In more offices than you’d like to believe, the staff just sits around and makes their best guesses in order to answer critical questions, including “what do members want to get out of their membership?”

Based on these guesses, the staff then plots their course expansion and enhances the benefits and services that the organization offers. These organizations are doomed to mediocrity.

Successful organizations, including SHM, actively seek to better understand their membership and use a variety of media to get to the heart of the questions that matter. I am proud to say that SHM is among the second group.

Building on previous efforts, the SHM Membership Department has been actively engaged in a “listening tour.” Our goal is to not rely on assumptions but rather to use your feedback in formulating our plans for the coming year.

Here’s some of what we’ve identified.

Top reasons for being a member:

• Education and quality improvement resources;
• The ability to affect the hospital medicine movement; and
• Subscriptions to The Hospitalist and Journal of Hospital Medicine.

Your main goals as a member:

• To learn from educational and quality improvement resources;
• Take advantage of networking opportunities; and
• Gain exposure for career advancement.

The benefits of membership that matter most:

• Information on www.hospitalmedicine.org;
• Access to results from SHM’s “Authoritative Source on the State of the Hospital Medicine Movement;” and
• The Hospitalist.

We’re already using this data, along with other information that we’ve gathered, to enhance the SHM experience and increase the return on your investment. Just look at the new SHM Career Center (www.hospitalmedicine.org/careercenter).

Like any good membership department, we realize that our data collection has just begun. So I’d like to pose a couple of questions:

• Do you agree with our findings?
• Should we offer a new benefit of membership?
• What can we do to enhance your SHM experience?

I’d love to hear your thoughts. Send them to me via e-mail at [email protected]. Anyone who e-mails will be entered in a prize drawing.

In my next column, I will share a selection of the responses I receive and tell you the concrete steps we’re taking to improve communication with you and other members.

Von Deak is SHM’s director of membership and marketing.

Spring and summer are the seasons of hope and promise. A time when seedlings turn into harvests, when every baseball team has hope, when things seem fresh and new. Hospital medicine is a specialty of hope and promise, of better things in the future. Hospitalists have the potential to change the course of medical care in the acute setting. Right now there are glimmers of this promise turning into realities.

We are seeing centers of experimentation as healthcare institutions and their visionary leaders use their ideas and energies to pilot test what may eventually be common changes throughout the country.

First Hospital Medicine Unit Being Built

In Rockford, Ill., the first Hospital Medicine Unit in Illinois—and possibly the country—is under construction. With a heritage as one of the first hospital medicine groups in Illinois, Rockford Health System is no stranger to innovation. They are currently framing the physical plant for a 17-bed hospital medicine unit and putting this right next to an ICU.

This unit will incorporate many of the accoutrements central to the design elements from the Hospital of the Future project that SHM is involved in with JCAHO and the Robert Wood Johnson Foundation. This plays into the SHM vision of the hospital of the future as patient centered, built on measurable quality, and delivered by teams.

All the rooms will be private with a healing environment incorporating the values of aesthetics, including restful light and sound. The design is set to promote communication and contact between the healthcare team and the patients and their families.

This unit will enhance efficiencies and quality care by concentrating hospitalists’ patients on one dedicated unit. The intent is to use this physical environment to create and reinforce a stronger team approach among hospitalists, nurses, pharmacists, therapists, and the rest of the healthcare team. There will be an opportunity to pilot new technology and treatment protocols to find out what works and what doesn’t. There will also be an opportunity to increase patient and family satisfaction.

As Lars Armainsson, chairman of the Rockford Hospital Medicine Department, says, “We’re pioneers in the way that we are transforming the way care is delivered, using the most advanced and sophisticated practice model to accommodate the 21st century.”

SHM, the rest of hospital medicine, and the C-suite of other hospitals will be waiting to hear how the Rockford Hospital Medicine Unit plays out. We hope the lessons learned there will soon provide a beacon of clarity for others to follow.

Three-Year Hospital Medicine Residency Track

The crisis in internal medicine residency training and the poor results in the recent intern match have at least one internal medicine residency program taking extreme measures to redesign and remarket its program to today’s medical students.

A residency program director in the West has contacted SHM about the feasibility of creating the first internal medicine residency to train only future hospitalists. This program has experienced more than 75% of its recent graduates going into hospital medicine careers. The program leaders also believe that with a continually shrinking pool of applicants for all of internal medicine their resident recruitment would be enhanced if they marketed their residency as a dedicated training program for the future hospitalists; cardiologists and outpatient internists need not apply.

The program leaders envision basing the new internal medicine residency curriculum on the SHM Core Competencies in Hospital Medicine and meeting RRC requirements for 33% of the training being outpatient in focus by training the future hospitalists in working to help the emergency department physicians with decision making, opening an outpatient clinic for the first one to two post-discharge follow-up visits, and starting an IMPACT clinic (such as the one started by hospitalists at the Cleveland Clinic) to evaluate preoperative patients.

This new residency program would also promote training in systems approaches, epidemiology, quality improvement, information technology, team building, leadership, and management.

The hope is that by narrowing the focus, this residency can attract better applicants, focus the training on a specific type of future internist, and have their graduates viewed by hospitalist employers as very desirable candidates for future hospitalist jobs.

Obviously, this revolutionary approach is a delicate path to walk. Because this is an idea working its way through its home institution, I have agreed to be purposely vague about where this is being investigated for now. Like the executive leadership at Rockford Health System, if the leadership of this hospital and medical staff can be equally visionary, I expect they will be looking for SHM and everyone else to promote this unique internal medicine residency and get the word out.

Mentored Implementation for QI

Not to be left out, SHM is doing its part in creating innovations to move forward hospital medicine’s agenda of change.

SHM has recently obtained two years’ worth of support from The Sanofi-Aventis Group to create and implement a mentored process to develop the hospitalist leaders who will be trained to measure and improve the quality of care that their hospitals deliver—especially in DVT prevention and treatment. Once these skills are learned, we hope that the same precepts can be used for other disease states that hospitalists manage.

This approach is modeled on similar approaches that have been successful in extending the reach of palliative care training. SHM’s idea is to select 10 outstanding hospitalist leaders and train them to do two fundamental things:

1. Use SHM QI tools to measure and improve quality at their institutions; and
2. Be trained to mentor future hospitalist leaders.

SHM would then use these initial 10 mentors to train another 30 hospitalist leaders (three for each initial mentor) in QI and potentially as future mentors.

Using this initial two-year project as a learning guide for process improvement and to develop the first cadre of quality mentors, the next step might be to ask for support from a foundation such as Hartford Foundation or Robert Wood Johnson Foundation—or a governmental agency such as the Agency for Healthcare Quality and Research—for broader funding to expand this initiative to 100 or even 500 sites. The goal would be to create a framework that would develop a hospitalist leader trained to lead the quality initiatives at every hospital in the country.

There are other partnerships that SHM is exploring to make this a reality. Recently SHM senior staff and leadership traveled to Boston to meet with senior leadership at the Institute for Healthcare Improvement (IHI). During those meetings, IHI CEO Don Berwick called hospitalists the “army for quality improvement implementation in our nation’s hospitals.” Ambitious undertakings like SHM’s mentored implementation project will be needed to export the well-known and well-documented knowledge of quality improvement and translate this down to the bedside.

Hospital medicine today is much more potential than reality. The history of American innovation is littered with ideas that failed because of issues with scope, scalability, or poor timing. In an era calling for evidence-based medicine, accountability, measured quality, teamwork, and a renewed emphasis on the patient, there are many stakeholders in healthcare rooting for (and even counting on) hospital medicine to turn promise into performance. We must not let the perfect be the enemy of the good. The status quo is just not good enough, and we will need to be risk takers and adventuresome to achieve great things.

In his book Organizing Genius: The Secrets of Creative Collaboration, Warren Bennis explores the success of such diverse enterprises as the development by Apple of the Macintosh, the engineering mastery at Lockheed Martin’s Skunk Works of the stealth aircraft, the Manhattan Project that developed the nuclear bomb, and Disney’s creation of animated feature films (e.g., “Snow White”) and found that an adventurous spirit was critical element. Adventure was defined as “risk, jeopardy, a daring feat, encountering a hazardous enterprise.”

Hospital medicine is on no less of an adventure. The prize at the end of the journey is better healthcare for our communities. Hospitalists are the soldiers in this battle. Whether you are the general or the foot soldier, we must all help prevail. SHM will be there to do its part. TH

Dr. Wellikson has been CEO of SHM since 2000.

Spring and summer are the seasons of hope and promise. A time when seedlings turn into harvests, when every baseball team has hope, when things seem fresh and new. Hospital medicine is a specialty of hope and promise, of better things in the future. Hospitalists have the potential to change the course of medical care in the acute setting. Right now there are glimmers of this promise turning into realities.

We are seeing centers of experimentation as healthcare institutions and their visionary leaders use their ideas and energies to pilot test what may eventually be common changes throughout the country.

First Hospital Medicine Unit Being Built

In Rockford, Ill., the first Hospital Medicine Unit in Illinois—and possibly the country—is under construction. With a heritage as one of the first hospital medicine groups in Illinois, Rockford Health System is no stranger to innovation. They are currently framing the physical plant for a 17-bed hospital medicine unit and putting this right next to an ICU.

This unit will incorporate many of the accoutrements central to the design elements from the Hospital of the Future project that SHM is involved in with JCAHO and the Robert Wood Johnson Foundation. This plays into the SHM vision of the hospital of the future as patient centered, built on measurable quality, and delivered by teams.

All the rooms will be private with a healing environment incorporating the values of aesthetics, including restful light and sound. The design is set to promote communication and contact between the healthcare team and the patients and their families.

This unit will enhance efficiencies and quality care by concentrating hospitalists’ patients on one dedicated unit. The intent is to use this physical environment to create and reinforce a stronger team approach among hospitalists, nurses, pharmacists, therapists, and the rest of the healthcare team. There will be an opportunity to pilot new technology and treatment protocols to find out what works and what doesn’t. There will also be an opportunity to increase patient and family satisfaction.

As Lars Armainsson, chairman of the Rockford Hospital Medicine Department, says, “We’re pioneers in the way that we are transforming the way care is delivered, using the most advanced and sophisticated practice model to accommodate the 21st century.”

SHM, the rest of hospital medicine, and the C-suite of other hospitals will be waiting to hear how the Rockford Hospital Medicine Unit plays out. We hope the lessons learned there will soon provide a beacon of clarity for others to follow.

Three-Year Hospital Medicine Residency Track

The crisis in internal medicine residency training and the poor results in the recent intern match have at least one internal medicine residency program taking extreme measures to redesign and remarket its program to today’s medical students.

A residency program director in the West has contacted SHM about the feasibility of creating the first internal medicine residency to train only future hospitalists. This program has experienced more than 75% of its recent graduates going into hospital medicine careers. The program leaders also believe that with a continually shrinking pool of applicants for all of internal medicine their resident recruitment would be enhanced if they marketed their residency as a dedicated training program for the future hospitalists; cardiologists and outpatient internists need not apply.

The program leaders envision basing the new internal medicine residency curriculum on the SHM Core Competencies in Hospital Medicine and meeting RRC requirements for 33% of the training being outpatient in focus by training the future hospitalists in working to help the emergency department physicians with decision making, opening an outpatient clinic for the first one to two post-discharge follow-up visits, and starting an IMPACT clinic (such as the one started by hospitalists at the Cleveland Clinic) to evaluate preoperative patients.

This new residency program would also promote training in systems approaches, epidemiology, quality improvement, information technology, team building, leadership, and management.

The hope is that by narrowing the focus, this residency can attract better applicants, focus the training on a specific type of future internist, and have their graduates viewed by hospitalist employers as very desirable candidates for future hospitalist jobs.

Obviously, this revolutionary approach is a delicate path to walk. Because this is an idea working its way through its home institution, I have agreed to be purposely vague about where this is being investigated for now. Like the executive leadership at Rockford Health System, if the leadership of this hospital and medical staff can be equally visionary, I expect they will be looking for SHM and everyone else to promote this unique internal medicine residency and get the word out.

Mentored Implementation for QI

Not to be left out, SHM is doing its part in creating innovations to move forward hospital medicine’s agenda of change.

SHM has recently obtained two years’ worth of support from The Sanofi-Aventis Group to create and implement a mentored process to develop the hospitalist leaders who will be trained to measure and improve the quality of care that their hospitals deliver—especially in DVT prevention and treatment. Once these skills are learned, we hope that the same precepts can be used for other disease states that hospitalists manage.

This approach is modeled on similar approaches that have been successful in extending the reach of palliative care training. SHM’s idea is to select 10 outstanding hospitalist leaders and train them to do two fundamental things:

1. Use SHM QI tools to measure and improve quality at their institutions; and
2. Be trained to mentor future hospitalist leaders.

SHM would then use these initial 10 mentors to train another 30 hospitalist leaders (three for each initial mentor) in QI and potentially as future mentors.

Using this initial two-year project as a learning guide for process improvement and to develop the first cadre of quality mentors, the next step might be to ask for support from a foundation such as Hartford Foundation or Robert Wood Johnson Foundation—or a governmental agency such as the Agency for Healthcare Quality and Research—for broader funding to expand this initiative to 100 or even 500 sites. The goal would be to create a framework that would develop a hospitalist leader trained to lead the quality initiatives at every hospital in the country.

There are other partnerships that SHM is exploring to make this a reality. Recently SHM senior staff and leadership traveled to Boston to meet with senior leadership at the Institute for Healthcare Improvement (IHI). During those meetings, IHI CEO Don Berwick called hospitalists the “army for quality improvement implementation in our nation’s hospitals.” Ambitious undertakings like SHM’s mentored implementation project will be needed to export the well-known and well-documented knowledge of quality improvement and translate this down to the bedside.

Hospital medicine today is much more potential than reality. The history of American innovation is littered with ideas that failed because of issues with scope, scalability, or poor timing. In an era calling for evidence-based medicine, accountability, measured quality, teamwork, and a renewed emphasis on the patient, there are many stakeholders in healthcare rooting for (and even counting on) hospital medicine to turn promise into performance. We must not let the perfect be the enemy of the good. The status quo is just not good enough, and we will need to be risk takers and adventuresome to achieve great things.

In his book Organizing Genius: The Secrets of Creative Collaboration, Warren Bennis explores the success of such diverse enterprises as the development by Apple of the Macintosh, the engineering mastery at Lockheed Martin’s Skunk Works of the stealth aircraft, the Manhattan Project that developed the nuclear bomb, and Disney’s creation of animated feature films (e.g., “Snow White”) and found that an adventurous spirit was critical element. Adventure was defined as “risk, jeopardy, a daring feat, encountering a hazardous enterprise.”

Hospital medicine is on no less of an adventure. The prize at the end of the journey is better healthcare for our communities. Hospitalists are the soldiers in this battle. Whether you are the general or the foot soldier, we must all help prevail. SHM will be there to do its part. TH

Dr. Wellikson has been CEO of SHM since 2000.

Spring and summer are the seasons of hope and promise. A time when seedlings turn into harvests, when every baseball team has hope, when things seem fresh and new. Hospital medicine is a specialty of hope and promise, of better things in the future. Hospitalists have the potential to change the course of medical care in the acute setting. Right now there are glimmers of this promise turning into realities.

We are seeing centers of experimentation as healthcare institutions and their visionary leaders use their ideas and energies to pilot test what may eventually be common changes throughout the country.

First Hospital Medicine Unit Being Built

In Rockford, Ill., the first Hospital Medicine Unit in Illinois—and possibly the country—is under construction. With a heritage as one of the first hospital medicine groups in Illinois, Rockford Health System is no stranger to innovation. They are currently framing the physical plant for a 17-bed hospital medicine unit and putting this right next to an ICU.

This unit will incorporate many of the accoutrements central to the design elements from the Hospital of the Future project that SHM is involved in with JCAHO and the Robert Wood Johnson Foundation. This plays into the SHM vision of the hospital of the future as patient centered, built on measurable quality, and delivered by teams.

All the rooms will be private with a healing environment incorporating the values of aesthetics, including restful light and sound. The design is set to promote communication and contact between the healthcare team and the patients and their families.

This unit will enhance efficiencies and quality care by concentrating hospitalists’ patients on one dedicated unit. The intent is to use this physical environment to create and reinforce a stronger team approach among hospitalists, nurses, pharmacists, therapists, and the rest of the healthcare team. There will be an opportunity to pilot new technology and treatment protocols to find out what works and what doesn’t. There will also be an opportunity to increase patient and family satisfaction.

As Lars Armainsson, chairman of the Rockford Hospital Medicine Department, says, “We’re pioneers in the way that we are transforming the way care is delivered, using the most advanced and sophisticated practice model to accommodate the 21st century.”

SHM, the rest of hospital medicine, and the C-suite of other hospitals will be waiting to hear how the Rockford Hospital Medicine Unit plays out. We hope the lessons learned there will soon provide a beacon of clarity for others to follow.

Three-Year Hospital Medicine Residency Track

The crisis in internal medicine residency training and the poor results in the recent intern match have at least one internal medicine residency program taking extreme measures to redesign and remarket its program to today’s medical students.

A residency program director in the West has contacted SHM about the feasibility of creating the first internal medicine residency to train only future hospitalists. This program has experienced more than 75% of its recent graduates going into hospital medicine careers. The program leaders also believe that with a continually shrinking pool of applicants for all of internal medicine their resident recruitment would be enhanced if they marketed their residency as a dedicated training program for the future hospitalists; cardiologists and outpatient internists need not apply.

The program leaders envision basing the new internal medicine residency curriculum on the SHM Core Competencies in Hospital Medicine and meeting RRC requirements for 33% of the training being outpatient in focus by training the future hospitalists in working to help the emergency department physicians with decision making, opening an outpatient clinic for the first one to two post-discharge follow-up visits, and starting an IMPACT clinic (such as the one started by hospitalists at the Cleveland Clinic) to evaluate preoperative patients.

This new residency program would also promote training in systems approaches, epidemiology, quality improvement, information technology, team building, leadership, and management.

The hope is that by narrowing the focus, this residency can attract better applicants, focus the training on a specific type of future internist, and have their graduates viewed by hospitalist employers as very desirable candidates for future hospitalist jobs.

Obviously, this revolutionary approach is a delicate path to walk. Because this is an idea working its way through its home institution, I have agreed to be purposely vague about where this is being investigated for now. Like the executive leadership at Rockford Health System, if the leadership of this hospital and medical staff can be equally visionary, I expect they will be looking for SHM and everyone else to promote this unique internal medicine residency and get the word out.

Mentored Implementation for QI

Not to be left out, SHM is doing its part in creating innovations to move forward hospital medicine’s agenda of change.

SHM has recently obtained two years’ worth of support from The Sanofi-Aventis Group to create and implement a mentored process to develop the hospitalist leaders who will be trained to measure and improve the quality of care that their hospitals deliver—especially in DVT prevention and treatment. Once these skills are learned, we hope that the same precepts can be used for other disease states that hospitalists manage.

This approach is modeled on similar approaches that have been successful in extending the reach of palliative care training. SHM’s idea is to select 10 outstanding hospitalist leaders and train them to do two fundamental things:

1. Use SHM QI tools to measure and improve quality at their institutions; and
2. Be trained to mentor future hospitalist leaders.

SHM would then use these initial 10 mentors to train another 30 hospitalist leaders (three for each initial mentor) in QI and potentially as future mentors.

Using this initial two-year project as a learning guide for process improvement and to develop the first cadre of quality mentors, the next step might be to ask for support from a foundation such as Hartford Foundation or Robert Wood Johnson Foundation—or a governmental agency such as the Agency for Healthcare Quality and Research—for broader funding to expand this initiative to 100 or even 500 sites. The goal would be to create a framework that would develop a hospitalist leader trained to lead the quality initiatives at every hospital in the country.

There are other partnerships that SHM is exploring to make this a reality. Recently SHM senior staff and leadership traveled to Boston to meet with senior leadership at the Institute for Healthcare Improvement (IHI). During those meetings, IHI CEO Don Berwick called hospitalists the “army for quality improvement implementation in our nation’s hospitals.” Ambitious undertakings like SHM’s mentored implementation project will be needed to export the well-known and well-documented knowledge of quality improvement and translate this down to the bedside.

Hospital medicine today is much more potential than reality. The history of American innovation is littered with ideas that failed because of issues with scope, scalability, or poor timing. In an era calling for evidence-based medicine, accountability, measured quality, teamwork, and a renewed emphasis on the patient, there are many stakeholders in healthcare rooting for (and even counting on) hospital medicine to turn promise into performance. We must not let the perfect be the enemy of the good. The status quo is just not good enough, and we will need to be risk takers and adventuresome to achieve great things.

In his book Organizing Genius: The Secrets of Creative Collaboration, Warren Bennis explores the success of such diverse enterprises as the development by Apple of the Macintosh, the engineering mastery at Lockheed Martin’s Skunk Works of the stealth aircraft, the Manhattan Project that developed the nuclear bomb, and Disney’s creation of animated feature films (e.g., “Snow White”) and found that an adventurous spirit was critical element. Adventure was defined as “risk, jeopardy, a daring feat, encountering a hazardous enterprise.”

Hospital medicine is on no less of an adventure. The prize at the end of the journey is better healthcare for our communities. Hospitalists are the soldiers in this battle. Whether you are the general or the foot soldier, we must all help prevail. SHM will be there to do its part. TH

Dr. Wellikson has been CEO of SHM since 2000.

“There’s no limit to how complicated things can get, on account of one thing always leading to another.”—E.B. White, Charlotte’s Web

E.B. White may not have been talking about hospitalists and their facilities, but he could have been. We are intricately involved in our facilities and, as we begin to make changes for our patients by changing the system and its processes, one thing leads to another.

Why should we bother to have partnerships with our facilities?

Hospitalist medicine has a unique feature: We need a facility to practice in. An ambulatory physician, while maintaining an office, can choose from a number of facilities. Unlike some procedural specialists, we cannot take our patients to an outpatient surgical center or other venue. If our hospital is not performing well, we have a difficult practice situation. It is imperative that we work with our facilities to ensure their success. We can create a rewarding practice environment by creating a highly functioning partnership.

If our goal is to deliver great care to patient populations, we cannot do this alone. In order for us to leverage our specialized knowledge we must leverage and master our partnerships with our facility. Ideally, in a partnership the objectives, values, and approaches are mutually reinforcing. There is agreement on the short-term and long-term goals. By operating with others in this partnership, new levels of unexpected performance are generated.

But partnership is a difficult thing. Though we are intricately entwined with the hospitals in which we practice, often we are not partnering. Partnerships occur at different levels. We may be partnering at a level that does not encourage results. In the dysfunctional partnership, the parties perceive little or no mutual benefit. They apply competitive negotiation skills to get their way regardless of the impact on relationships or outcomes. No one is really committed to anyone. Many times in a partnership, we demand what we want:

• A case manager for our team, seven days a week;
• A better office or computer system;
• Better emergency department procedures; or
• More time off.

Such demands without discussion and without consideration of the other’s point of view occur in a dysfunctional partnership.

But we have the opportunity to move these discussions in a positive manner because there are so many things that we directly control that cause the success or failure of our facilities. Our recognition of these needs can create an opportunity for us to prove our ability to partner. Typically, physicians have not supported administrative initiatives. It is well known that most administrators see the doctors as a project to work around instead of a partner in their success. Indeed for years many doctors established a sport of thwarting administrative plans and ideas; however, we need to proactively establish a new paradigm where we are the partners in improving care for our patient populations. Stuck for ideas on overlapping opportunity? Here are a few thoughts.

Everyone hears about medical record timeliness at their facilities. But why does anyone care about this? Does the Medical Executive Committee like to send out suspension letters? Do the individuals in medical records like to harass doctors? Of course not; this is a matter of vital financial interest to the hospital. The medical record cannot be billed until the record is complete: all consultations, discharge information, admission dictations, and all signatures.

Imagine how it must be to have your income held up because of someone else’s failure to perform. Imagine how frustrated you would be if your paycheck was held up because a nurse had not finish charting. A proactive stance on this mission-critical issue for the hospital demonstrates the group’s commitment to its partner. Taking a proactive stance on this often leads to reorganizing and reworking the medical records department processes. Taking the first step demonstrates your interest in the needs of others. It may lead to an electronic medical record or new systems. A partnership starts to evolve.

Patient satisfaction is a tricky item. It varies greatly and is based on how and when information is collected. We can take the stance that these are flawed results and of no interest to us, or we can choose to identify the key elements that we can affect. By choosing to participate in a project, our partnership can grow. This may mean learning a great detail about something non-medical and then figuring out how to best communicate that to the physician team. It may involve learning from other experts: risk management specialists, skilled executives, and statisticians. It may result in changing the system of collection, reporting, and feedback. This change benefits all parties, not just one over the other.

A project that has great value for our partners is to improve their financial performance by collaborating on documentation. A hospital is paid very differently than a physician. The hospital’s income depends on what physicians write in the chart. This puts them in a position of dependence on physician handwriting! The difficulty for doctors is that the term definitions in some cases do not correspond to medical terms. By creating a program where the physicians meet weekly with a facility expert, dialogue can foster a partnership. The physicians provide the willingness to learn and the facility provides the expertise and time in a supportive manner. The physician gains an appreciation for the idiosyncrasies of hospital payments and can assist in improving the case mix index and diagnosis capture. When hospitalists and the hospital work together the facility becomes more financially stable and, therefore, the future jobs of the hospitalist group become more secure.

Everyone likes working in a happy and safe environment. As part of that environment, we have responsibilities to our fellow workers. We can complain about performance of our non-physicians colleagues or we can proactively partner to improve our relationships with them. In addition to the obvious—treating them with respect and as part of the team—we can create processes to improve their daily work.

How much variation is there among the way your group approaches diagnoses? Can the nursing and pharmacy staff assume a consistent approach for each patient? Our goal—to create care for patient populations not individual patients—must address this. Do you extract their expertise when designing these care programs? It can be of great value to us in assisting our patients and redesigning care. It creates an environment of value and satisfaction that leads to retention. Why do we care about retention? A stable nursing, therapy, social work, and case management staff adds to our daily satisfaction. We can’t get there alone. We need to partner with our co-workers with inclusion and education.

How about the emergency department? There is often a strain in our relationship with these important colleagues. Are we creating programs, process, and guidelines with our professional colleagues that work for everyone? There are many important points of collaboration, and sometimes we need to extend a hand first to get forward momentum.

Some partnerships are characterized by an integration of value and skills—interdependence. Commitment and coordination across activities is a common factor. If our goal is to achieve an excellence in partnering with our facilities, we need to begin the dialogue about what we can accomplish in common that supports both parties. It appears we are interdependent, but moving to partnership is a more mature step.

There are endless projects on which we can collaborate to move our patients, our communities, our facilities, and ourselves to a better place. Let’s start with one action toward one goal. As one thing leads to another, we can achieve things that we never thought possible. TH

Dr. Gorman is the president of SHM.

“There’s no limit to how complicated things can get, on account of one thing always leading to another.”—E.B. White, Charlotte’s Web

E.B. White may not have been talking about hospitalists and their facilities, but he could have been. We are intricately involved in our facilities and, as we begin to make changes for our patients by changing the system and its processes, one thing leads to another.

Why should we bother to have partnerships with our facilities?

Hospitalist medicine has a unique feature: We need a facility to practice in. An ambulatory physician, while maintaining an office, can choose from a number of facilities. Unlike some procedural specialists, we cannot take our patients to an outpatient surgical center or other venue. If our hospital is not performing well, we have a difficult practice situation. It is imperative that we work with our facilities to ensure their success. We can create a rewarding practice environment by creating a highly functioning partnership.

If our goal is to deliver great care to patient populations, we cannot do this alone. In order for us to leverage our specialized knowledge we must leverage and master our partnerships with our facility. Ideally, in a partnership the objectives, values, and approaches are mutually reinforcing. There is agreement on the short-term and long-term goals. By operating with others in this partnership, new levels of unexpected performance are generated.

But partnership is a difficult thing. Though we are intricately entwined with the hospitals in which we practice, often we are not partnering. Partnerships occur at different levels. We may be partnering at a level that does not encourage results. In the dysfunctional partnership, the parties perceive little or no mutual benefit. They apply competitive negotiation skills to get their way regardless of the impact on relationships or outcomes. No one is really committed to anyone. Many times in a partnership, we demand what we want:

• A case manager for our team, seven days a week;
• A better office or computer system;
• Better emergency department procedures; or
• More time off.

Such demands without discussion and without consideration of the other’s point of view occur in a dysfunctional partnership.

But we have the opportunity to move these discussions in a positive manner because there are so many things that we directly control that cause the success or failure of our facilities. Our recognition of these needs can create an opportunity for us to prove our ability to partner. Typically, physicians have not supported administrative initiatives. It is well known that most administrators see the doctors as a project to work around instead of a partner in their success. Indeed for years many doctors established a sport of thwarting administrative plans and ideas; however, we need to proactively establish a new paradigm where we are the partners in improving care for our patient populations. Stuck for ideas on overlapping opportunity? Here are a few thoughts.

Everyone hears about medical record timeliness at their facilities. But why does anyone care about this? Does the Medical Executive Committee like to send out suspension letters? Do the individuals in medical records like to harass doctors? Of course not; this is a matter of vital financial interest to the hospital. The medical record cannot be billed until the record is complete: all consultations, discharge information, admission dictations, and all signatures.

Imagine how it must be to have your income held up because of someone else’s failure to perform. Imagine how frustrated you would be if your paycheck was held up because a nurse had not finish charting. A proactive stance on this mission-critical issue for the hospital demonstrates the group’s commitment to its partner. Taking a proactive stance on this often leads to reorganizing and reworking the medical records department processes. Taking the first step demonstrates your interest in the needs of others. It may lead to an electronic medical record or new systems. A partnership starts to evolve.

Patient satisfaction is a tricky item. It varies greatly and is based on how and when information is collected. We can take the stance that these are flawed results and of no interest to us, or we can choose to identify the key elements that we can affect. By choosing to participate in a project, our partnership can grow. This may mean learning a great detail about something non-medical and then figuring out how to best communicate that to the physician team. It may involve learning from other experts: risk management specialists, skilled executives, and statisticians. It may result in changing the system of collection, reporting, and feedback. This change benefits all parties, not just one over the other.

A project that has great value for our partners is to improve their financial performance by collaborating on documentation. A hospital is paid very differently than a physician. The hospital’s income depends on what physicians write in the chart. This puts them in a position of dependence on physician handwriting! The difficulty for doctors is that the term definitions in some cases do not correspond to medical terms. By creating a program where the physicians meet weekly with a facility expert, dialogue can foster a partnership. The physicians provide the willingness to learn and the facility provides the expertise and time in a supportive manner. The physician gains an appreciation for the idiosyncrasies of hospital payments and can assist in improving the case mix index and diagnosis capture. When hospitalists and the hospital work together the facility becomes more financially stable and, therefore, the future jobs of the hospitalist group become more secure.

Everyone likes working in a happy and safe environment. As part of that environment, we have responsibilities to our fellow workers. We can complain about performance of our non-physicians colleagues or we can proactively partner to improve our relationships with them. In addition to the obvious—treating them with respect and as part of the team—we can create processes to improve their daily work.

How much variation is there among the way your group approaches diagnoses? Can the nursing and pharmacy staff assume a consistent approach for each patient? Our goal—to create care for patient populations not individual patients—must address this. Do you extract their expertise when designing these care programs? It can be of great value to us in assisting our patients and redesigning care. It creates an environment of value and satisfaction that leads to retention. Why do we care about retention? A stable nursing, therapy, social work, and case management staff adds to our daily satisfaction. We can’t get there alone. We need to partner with our co-workers with inclusion and education.

How about the emergency department? There is often a strain in our relationship with these important colleagues. Are we creating programs, process, and guidelines with our professional colleagues that work for everyone? There are many important points of collaboration, and sometimes we need to extend a hand first to get forward momentum.

Some partnerships are characterized by an integration of value and skills—interdependence. Commitment and coordination across activities is a common factor. If our goal is to achieve an excellence in partnering with our facilities, we need to begin the dialogue about what we can accomplish in common that supports both parties. It appears we are interdependent, but moving to partnership is a more mature step.

There are endless projects on which we can collaborate to move our patients, our communities, our facilities, and ourselves to a better place. Let’s start with one action toward one goal. As one thing leads to another, we can achieve things that we never thought possible. TH

Dr. Gorman is the president of SHM.

“There’s no limit to how complicated things can get, on account of one thing always leading to another.”—E.B. White, Charlotte’s Web

E.B. White may not have been talking about hospitalists and their facilities, but he could have been. We are intricately involved in our facilities and, as we begin to make changes for our patients by changing the system and its processes, one thing leads to another.

Why should we bother to have partnerships with our facilities?

Hospitalist medicine has a unique feature: We need a facility to practice in. An ambulatory physician, while maintaining an office, can choose from a number of facilities. Unlike some procedural specialists, we cannot take our patients to an outpatient surgical center or other venue. If our hospital is not performing well, we have a difficult practice situation. It is imperative that we work with our facilities to ensure their success. We can create a rewarding practice environment by creating a highly functioning partnership.

If our goal is to deliver great care to patient populations, we cannot do this alone. In order for us to leverage our specialized knowledge we must leverage and master our partnerships with our facility. Ideally, in a partnership the objectives, values, and approaches are mutually reinforcing. There is agreement on the short-term and long-term goals. By operating with others in this partnership, new levels of unexpected performance are generated.

But partnership is a difficult thing. Though we are intricately entwined with the hospitals in which we practice, often we are not partnering. Partnerships occur at different levels. We may be partnering at a level that does not encourage results. In the dysfunctional partnership, the parties perceive little or no mutual benefit. They apply competitive negotiation skills to get their way regardless of the impact on relationships or outcomes. No one is really committed to anyone. Many times in a partnership, we demand what we want:

• A case manager for our team, seven days a week;
• A better office or computer system;
• Better emergency department procedures; or
• More time off.

Such demands without discussion and without consideration of the other’s point of view occur in a dysfunctional partnership.

But we have the opportunity to move these discussions in a positive manner because there are so many things that we directly control that cause the success or failure of our facilities. Our recognition of these needs can create an opportunity for us to prove our ability to partner. Typically, physicians have not supported administrative initiatives. It is well known that most administrators see the doctors as a project to work around instead of a partner in their success. Indeed for years many doctors established a sport of thwarting administrative plans and ideas; however, we need to proactively establish a new paradigm where we are the partners in improving care for our patient populations. Stuck for ideas on overlapping opportunity? Here are a few thoughts.

Everyone hears about medical record timeliness at their facilities. But why does anyone care about this? Does the Medical Executive Committee like to send out suspension letters? Do the individuals in medical records like to harass doctors? Of course not; this is a matter of vital financial interest to the hospital. The medical record cannot be billed until the record is complete: all consultations, discharge information, admission dictations, and all signatures.

Imagine how it must be to have your income held up because of someone else’s failure to perform. Imagine how frustrated you would be if your paycheck was held up because a nurse had not finish charting. A proactive stance on this mission-critical issue for the hospital demonstrates the group’s commitment to its partner. Taking a proactive stance on this often leads to reorganizing and reworking the medical records department processes. Taking the first step demonstrates your interest in the needs of others. It may lead to an electronic medical record or new systems. A partnership starts to evolve.

Patient satisfaction is a tricky item. It varies greatly and is based on how and when information is collected. We can take the stance that these are flawed results and of no interest to us, or we can choose to identify the key elements that we can affect. By choosing to participate in a project, our partnership can grow. This may mean learning a great detail about something non-medical and then figuring out how to best communicate that to the physician team. It may involve learning from other experts: risk management specialists, skilled executives, and statisticians. It may result in changing the system of collection, reporting, and feedback. This change benefits all parties, not just one over the other.

A project that has great value for our partners is to improve their financial performance by collaborating on documentation. A hospital is paid very differently than a physician. The hospital’s income depends on what physicians write in the chart. This puts them in a position of dependence on physician handwriting! The difficulty for doctors is that the term definitions in some cases do not correspond to medical terms. By creating a program where the physicians meet weekly with a facility expert, dialogue can foster a partnership. The physicians provide the willingness to learn and the facility provides the expertise and time in a supportive manner. The physician gains an appreciation for the idiosyncrasies of hospital payments and can assist in improving the case mix index and diagnosis capture. When hospitalists and the hospital work together the facility becomes more financially stable and, therefore, the future jobs of the hospitalist group become more secure.

Everyone likes working in a happy and safe environment. As part of that environment, we have responsibilities to our fellow workers. We can complain about performance of our non-physicians colleagues or we can proactively partner to improve our relationships with them. In addition to the obvious—treating them with respect and as part of the team—we can create processes to improve their daily work.

How much variation is there among the way your group approaches diagnoses? Can the nursing and pharmacy staff assume a consistent approach for each patient? Our goal—to create care for patient populations not individual patients—must address this. Do you extract their expertise when designing these care programs? It can be of great value to us in assisting our patients and redesigning care. It creates an environment of value and satisfaction that leads to retention. Why do we care about retention? A stable nursing, therapy, social work, and case management staff adds to our daily satisfaction. We can’t get there alone. We need to partner with our co-workers with inclusion and education.

How about the emergency department? There is often a strain in our relationship with these important colleagues. Are we creating programs, process, and guidelines with our professional colleagues that work for everyone? There are many important points of collaboration, and sometimes we need to extend a hand first to get forward momentum.

Some partnerships are characterized by an integration of value and skills—interdependence. Commitment and coordination across activities is a common factor. If our goal is to achieve an excellence in partnering with our facilities, we need to begin the dialogue about what we can accomplish in common that supports both parties. It appears we are interdependent, but moving to partnership is a more mature step.

There are endless projects on which we can collaborate to move our patients, our communities, our facilities, and ourselves to a better place. Let’s start with one action toward one goal. As one thing leads to another, we can achieve things that we never thought possible. TH

Dr. Gorman is the president of SHM.

The devastation of American cities caused by Hurricane Katrina, combined with World Health Organization warnings about the possibility of an influenza pandemic and a continued heightened awareness of potential terrorist attacks, raise new concerns about the ability of the healthcare system to effectively respond to disasters. During crises, healthcare organizations must act quickly to meet the demands of their communities.

Makeshift—or “surge”—facilities provide care for the surging number of patients until normal operations can resume. These care sites can’t be thought of in traditional terms of brick-and-mortar hospitals. Instead, surge facilities protect brick-and-mortar facilities from a surge of patients who do not require acute intervention, or to protect brick-and-mortar facilities attempting to recover from damage.

Hurricane Katrina demonstrated, however, that even those communities with comprehensive plans for emergency response face considerable difficulties when major parts of infrastructure for medical care are significantly damaged. If almost all healthcare capabilities in a neighborhood, city, or even an entire region are damaged and the water supply, sewage system, and electricity are affected, how do communities cope with the surge? Such destruction also may force surge facilities to continue operations for weeks or months—instead of the hours or days that have typically been contemplated in the past.

The challenge for healthcare organizations is to work with local, state, and federal officials to develop comprehensive plans for meeting medical needs during community-wide emergencies. This article explores the obstacles and strategies to developing comprehensive, community-wide emergency plans, how healthcare and community leaders can understand the role of surge facilities, and how to establish these critical links to maintaining care. The goal of emergency planning is mitigation, preparedness, response, and recovery. Surge facilities may have a role in most of the components of emergency planning.

Planning for Emergencies

The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) and the federal government have long required thorough accreditation standards and Conditions of Participation, respectively, in order to help hospitals plan for emergencies. JCAHO, which has been actively involved in disaster preparedness for more than 30 years, increased its focus on emergency management in January 2001—nine months prior to the September 11 attacks on New York City and Washington, D.C. It has since worked even more closely with emergency management experts and healthcare organizations to make this issue a priority.

The resulting modified accreditation standards and overall guidelines developed by expert consensus reflect the need for hospitals and other healthcare organizations to be involved in community-wide planning, in addition to planning for an emergency at that particular institution.

Develop Emergency Management Plans

JCAHO’s Management of the Environment of Care (EC) standards call on hospitals to develop an emergency management plan that—among other requirements—ensures an effective response to emergencies through the implementation of the plan and execution of the plan by conducting emergency management drills. Hospitals also must participate with the community to establish priorities among potential emergencies, define the organization’s role in the community’s emergency management program, and link with the community’s command structure. (Note: EC.4.10, which addresses the entire topic of emergency management, also calls for hospitals to conduct a hazard-vulnerability analysis, which is discussed below.)

While recent national attention has focused on the emergencies created by Hurricane Katrina and the perceived lack of rapid federal response, JCAHO standards emphasize the need to consider a variety of natural or manmade events that suddenly or significantly disrupt the environment of care, disrupt care and treatment, and change or increase demands for the organization’s services.

Use an All-Hazards Approach

In order to plan for and respond to a variety of emergencies, hospitals must conduct a hazard vulnerability analysis (EC.4.10). This analysis is best done with community leadership to ensure that there is continuity at all levels of planning. This formal process for conducting a hazard vulnerability analysis has been a JCAHO requirement since 2001, although hospital standards previously had called for planning to address a variety of disasters.

The change in requirements simply provides a method—the hazard vulnerability analysis—for a hospital to focus attention on the disasters or catastrophes likely to have an effect on its operations. This analysis should be a dynamic document that is regularly reviewed and revised to reflect the latest information on the probability of events or threats and their effects.

By considering a complete list of potential hazards, hospital leaders can determine the effects that specific types of emergencies will have on their facility and the community. The hazard-vulnerabilities analysis also should take into account the fact that an emergency may have a cascading effect. Example: The hurricane in New Orleans did not initially cause as much damage as feared, but breaches in the levees from the hurricane’s rains caused massive flooding that resulted in nearly complete communications failures, loss of power, transportation breakdowns, and so forth.

After compiling as complete a list as possible of potential emergencies, hospital leaders [must work] with the community to prioritize the list considering likelihood and effect of such an occurrence. Then, the areas of vulnerability that most demand community and organizational attention can be addressed. Dealing with these issues requires hospitals to work with local and regional government agencies, emergency responders such as local fire and police departments, and other hospitals and healthcare organizations in the community.

By working together with other healthcare professionals and with community experts charged with responding to emergencies, hospitals can ensure that the full spectrum of likely emergencies and contingencies has been considered. The collaboration also allows the many organizations involved to understand their role in a larger crisis and anticipate how other partners will respond. An emergency affects the entire community, making it important for hospitals and other organizations to avoid “silo” approaches that leave each component of the community vulnerable if they are standing alone.

Surge Facilities

Recent experiences have shown that community-wide emergency management plans should include preparations to establish temporary healthcare facilities when a major disaster—or series of disasters as occurred in New Orleans—creates a surge of patients or cripples hospitals and forces patients and staff to evacuate. When an emergency occurs, the demands placed on a hospital escalate beyond the normal level of services required. Surge facilities provide care when permanent facilities exhaust their capacity or cannot operate because of damage or other conditions. Surge facilities also act as a buffer for lower acuity patients to protect the scarce resources of the operating hospital.

Some surges are such that a hospital can meet community needs within its own walls. For example, a hospital may be able to handle a commuter train accident that brings 30 injured patients through its doors. But, in many instances, economic factors operating over the past decade mean that hospitals are already operating at capacity and have little room for surge. Remember that “room” for surge is not just the number of beds, but the number of beds that can be adequately staffed and supplied. Where would patients already in an at-capacity organization go if a significant number of new patients—whether 30, 300, or 3,000—need treatment?

This scenario occurred during the aftermath of Hurricane Katrina when the Louisiana Department of Health and Hospitals (DHH) determined that it needed to establish an acute care surge facility at the Louisiana State University Pete Maravich Assembly Center in Baton Rouge because existing hospitals in the area would be inundated with patients.1

This recent example of coordination shows the imperative for hospitals and health officials to plan with community organizations to increase surge capacity at temporary locations. Off-site locations, which may be at facilities as diverse as civic centers, schools, or even veterinary hospitals, must be part of community-wide emergency management plans.

While there is general consensus about this idea and the need for a community-wide response plan to emergencies, a recent JCAHO examination of the issue reveals that there is no single model available today for surge facilities, but what is developing is a series of guidelines based on experience.2 Communities should study available examples of organizations that have faced with surge situations and then create contingency plans after assessing potential community needs and available resources.

While it is important for a hospital to take the initiative to consider surge capacity planning, no single hospital can by itself be expected to be able to address a large-scale emergency that sends large numbers of patients in search of healthcare. Securing temporary facilities, adequate staff, and critical supplies, equipment, and pharmaceuticals takes the concerted efforts of healthcare organizations, communities, and government agencies.

Hospitals must work with organizations such as hospital districts, state and county departments of health, the National Guard, various agencies charged with homeland security, medical schools, and so forth to plan for and operationalize surge capacity.

For example, the Commonwealth of Massachusetts maintains a statewide system to allocate surge capacity by identifying empty beds and distributing patients among existing hospitals.3 The very declaration of an emergency should automatically trigger government intervention necessary for surge capacity on the local, state, or federal level, as appropriate.

Components of Surge Facilities

Communities and healthcare planners preparing responses to a crisis must be innovative when considering how to accommodate a surge of patients. Surge facilities commonly fall into one of the following basic categories:

• Shuttered hospitals or closed wards;
• Facilities of opportunity, such as schools, hotels, conventions centers, and other types of buildings near a hospital that can easily be adapted during emergencies to treat unusually large numbers of patients;
• Mobile medical facilities; and
• Portable facilities.

Planning for locations is important, but it is important to remember that a surge facility is not so much a place as it is a capability. Wherever a surge facility is located, it must be equipped and staffed adequately. Beyond planning for the physical location of a surge facility, hospitals and communities must consider the other factors that will affect the ability to deliver care.

For example, will essential staff be available to treat patients? What might constitute essential staff? Surge capacity plans also must take into account the need to communicate with staff during times of crisis, transport staff, and make accommodations for staff who may be facing their own personal emergencies at home (i.e., damage to their homes or vehicles, concern for vulnerable family members, and so forth).

Creating plans to assist staff and their families during a crisis will ensure that vital members of the emergency response team are able and willing to perform their duties. The U.S. Department of Defense’s Modular Emergency Medical Stem can aid efforts to determine the number of staff necessary to effectively operate a surge facility. Other methods for securing the needed number of staff during an emergency include qualified volunteers from organizations such as the Medical Reserve Corps program, Civilian Emergency Response Teams, Disaster Medical Assistance Teams, health professional students, reserve military health providers, paramedics, and midwives. In addition, communities may consider training a pool of volunteers who could assist with surge healthcare needs by providing nonmedical support to healthcare providers.

Other critical considerations for hospitals and communities planning for surge capability include:

• Medical supplies and equipment: The Centers for Disease Control and Prevention (CDC) can provide necessary supplies through its Strategic National Stockpile program, but delivery may take days, as Hurricane Katrina demonstrated. Other potential sources of supplies, such as physician offices and medical supply houses, should be researched.
• Pharmaceuticals: Sufficient inventories to last for several days in the event of an emergency will help prevent problems, as will setting up contracts with pharmaceutical suppliers that take effect only during an emergency.
• Communication: The September 11 terrorist attacks and Hurricane Katrina demonstrated the fallibility of cellular phone and radio communications; multiple forms of communication (i.e., cellular, two-way radio, pagers, satellite, two-way phones, and so forth) are necessary to ensure that if one method fails, another is available.
• Data sharing: Hospitals must plan for how they will coordinate with local, state, and federal health agencies to conduct necessary work to care for patients.
• Sufficiency of care: During emergencies, surge facilities maybe able to treat each patient only until he or she can be transferred to an organization that provides an ideal level of care. Plans for surge capacity should take this possibility into consideration so agreements can be made in advance with other hospitals, while also ensuring that patients who need specific monitoring or ventilator assistance, for example, can be cared for until transferred.

Surge Facilities and the Joint Commission

The fact that surge facilities were forced to provide care for such an extended period of time following Hurricane Katrina has prompted the Joint Commission to consider establishing standards for this unique form of a healthcare organization. The standards might require surge facilities to comply with basic safety and quality expectations and help to ensure the public that care given at these temporary facilities is adequate. JCAHO is working on the standards with healthcare organizations that are developing plans for surge facilities so that any new requirements can be implemented quickly and with minimal cost.

Surge Facility, Emergency Management Resources

While healthcare leaders agree on the need for comprehensive emergency management plans, which include surge capacity, consensus on the necessary components and assigned accountabilities has been scarce. Hospitals have been left to use federal or state requirements, Joint Commission standards, and guidance from hospitals associations. The Joint Commission has worked over the past several years with experts in the public and private sectors to bring broader agreement and guidance on these issues.

Detailed information about what surge facilities are, the kind of planning that these alternate care sites require, how they can be set up, and who should be responsible for their establishment and operation is available through the JCAHO publication, Surge Hospitals: Providing Safe Care in Emergencies (available at www.jcaho.org/about+us/public+policy+initiatives/surge_hospital.htm). This Web-based publication describes the different types of surge facilities, such as shuttered hospitals, closed wards in existing hospitals, and mobile facilities, and the design considerations for each. It also explores the challenges of planning for, establishing, and operating surge facilities, such as obtaining sufficient staff, supplies and equipment, and providing safe care.

Lessons learned from healthcare organizations following Hurricanes Katrina and Rita along the Gulf Coast and into Texas are also included. These case studies specifically look at a surge facility established by the Harris County Hospital District at Reliant Arena in Houston, a surge facility at the Dallas Convention Center that treated more than 4,000 hurricane evacuees in during a single week, the Louisiana State University acute care facility mentioned earlier in this article, a field hospital set up in the site of a former retail store, and a healthcare shelter established in a Texas veterinary hospital to care for nursing home residents, pediatric burn patients, handicapped children, and home-health-care patients.

Beyond the very specific issue of surge facilities, JCAHO offers guidance on community-wide emergency management planning:

• Standing Together: An Emergency Planning Guide for America’s Communities provides detailed information about steps that communities must take to prepare for and successfully respond to major local and regional emergencies. The free planning guide, published in 2005, is the result of a two-year project that drew upon the expertise of front-line emergency responders, emergency preparedness planners, and public health and healthcare organization leaders. It’s available at www.jcaho.org/about+us/public+policy+initiatives/planning_guide.htm.
• Health Care at the Crossroads: Strategies for Creating and Sustaining Community-wide Emergency Preparedness Systems provides recommended strategies for developing community-wide preparedness. This free 2003 white paper is available at www.jcaho.org/about+us/public+policy+initiatives/emergency.htm.

Conclusion

The serious shortcomings of the nation’s emergency management planning capabilities were made evident by the events surrounding Hurricane Katrina. Hospitals, along with other types of healthcare facilities, must take an active role in all community-wide emergency planning activities to mitigate the effects on patient care. Communities and the healthcare organizations within them must plan to operate largely on their own for several days or even longer following a disaster. Surge facilities are a major component of these plans. Hospitals must prepare for the possibility that their buildings could be too damaged to function during, as well as after, a disaster.

Developing plans that allow for adequate patient care during emergencies requires hospitals and the communities that they serve to overcome barriers such as assigning responsibilities for planning, how to fund emergency readiness efforts, the specifics necessary to create effective planning and response processes, and how to coordinate with state and federal emergency management resources. This broad-based approach will help healthcare planners consider the challenges associated with major emergencies and develop appropriate plans to respond to such crises. TH

Cappiello is the vice president for Accreditation Field Operations at JCAHO. He is responsible for management of accreditation processes including survey functions, surveyor education, standards interpretation, staff education and training, and accreditation process improvement.

Contact the Joint Commission at www.jcaho.org or call (630) 792-5000.

References

1. Surge Hospitals: Providing Safe Care in Emergencies. Joint Commission Resources, Oakbrook Terrace, Ill., December 2005.
2. Surge Hospitals: Providing Safe Care in Emergencies. Joint Commission Resources, Oakbrook Terrace, Ill., December 2005.
3. Use of a Former (“Shuttered”) Hospital to Expand Surge Capacity. Available at www.ahrq.gov/research/shuttered/shuthosp1.htm. Last accessed March 2, 2006.

The devastation of American cities caused by Hurricane Katrina, combined with World Health Organization warnings about the possibility of an influenza pandemic and a continued heightened awareness of potential terrorist attacks, raise new concerns about the ability of the healthcare system to effectively respond to disasters. During crises, healthcare organizations must act quickly to meet the demands of their communities.

Makeshift—or “surge”—facilities provide care for the surging number of patients until normal operations can resume. These care sites can’t be thought of in traditional terms of brick-and-mortar hospitals. Instead, surge facilities protect brick-and-mortar facilities from a surge of patients who do not require acute intervention, or to protect brick-and-mortar facilities attempting to recover from damage.

Hurricane Katrina demonstrated, however, that even those communities with comprehensive plans for emergency response face considerable difficulties when major parts of infrastructure for medical care are significantly damaged. If almost all healthcare capabilities in a neighborhood, city, or even an entire region are damaged and the water supply, sewage system, and electricity are affected, how do communities cope with the surge? Such destruction also may force surge facilities to continue operations for weeks or months—instead of the hours or days that have typically been contemplated in the past.

The challenge for healthcare organizations is to work with local, state, and federal officials to develop comprehensive plans for meeting medical needs during community-wide emergencies. This article explores the obstacles and strategies to developing comprehensive, community-wide emergency plans, how healthcare and community leaders can understand the role of surge facilities, and how to establish these critical links to maintaining care. The goal of emergency planning is mitigation, preparedness, response, and recovery. Surge facilities may have a role in most of the components of emergency planning.

Planning for Emergencies

The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) and the federal government have long required thorough accreditation standards and Conditions of Participation, respectively, in order to help hospitals plan for emergencies. JCAHO, which has been actively involved in disaster preparedness for more than 30 years, increased its focus on emergency management in January 2001—nine months prior to the September 11 attacks on New York City and Washington, D.C. It has since worked even more closely with emergency management experts and healthcare organizations to make this issue a priority.

The resulting modified accreditation standards and overall guidelines developed by expert consensus reflect the need for hospitals and other healthcare organizations to be involved in community-wide planning, in addition to planning for an emergency at that particular institution.

Develop Emergency Management Plans

JCAHO’s Management of the Environment of Care (EC) standards call on hospitals to develop an emergency management plan that—among other requirements—ensures an effective response to emergencies through the implementation of the plan and execution of the plan by conducting emergency management drills. Hospitals also must participate with the community to establish priorities among potential emergencies, define the organization’s role in the community’s emergency management program, and link with the community’s command structure. (Note: EC.4.10, which addresses the entire topic of emergency management, also calls for hospitals to conduct a hazard-vulnerability analysis, which is discussed below.)

While recent national attention has focused on the emergencies created by Hurricane Katrina and the perceived lack of rapid federal response, JCAHO standards emphasize the need to consider a variety of natural or manmade events that suddenly or significantly disrupt the environment of care, disrupt care and treatment, and change or increase demands for the organization’s services.

Use an All-Hazards Approach

In order to plan for and respond to a variety of emergencies, hospitals must conduct a hazard vulnerability analysis (EC.4.10). This analysis is best done with community leadership to ensure that there is continuity at all levels of planning. This formal process for conducting a hazard vulnerability analysis has been a JCAHO requirement since 2001, although hospital standards previously had called for planning to address a variety of disasters.

The change in requirements simply provides a method—the hazard vulnerability analysis—for a hospital to focus attention on the disasters or catastrophes likely to have an effect on its operations. This analysis should be a dynamic document that is regularly reviewed and revised to reflect the latest information on the probability of events or threats and their effects.

By considering a complete list of potential hazards, hospital leaders can determine the effects that specific types of emergencies will have on their facility and the community. The hazard-vulnerabilities analysis also should take into account the fact that an emergency may have a cascading effect. Example: The hurricane in New Orleans did not initially cause as much damage as feared, but breaches in the levees from the hurricane’s rains caused massive flooding that resulted in nearly complete communications failures, loss of power, transportation breakdowns, and so forth.

After compiling as complete a list as possible of potential emergencies, hospital leaders [must work] with the community to prioritize the list considering likelihood and effect of such an occurrence. Then, the areas of vulnerability that most demand community and organizational attention can be addressed. Dealing with these issues requires hospitals to work with local and regional government agencies, emergency responders such as local fire and police departments, and other hospitals and healthcare organizations in the community.

By working together with other healthcare professionals and with community experts charged with responding to emergencies, hospitals can ensure that the full spectrum of likely emergencies and contingencies has been considered. The collaboration also allows the many organizations involved to understand their role in a larger crisis and anticipate how other partners will respond. An emergency affects the entire community, making it important for hospitals and other organizations to avoid “silo” approaches that leave each component of the community vulnerable if they are standing alone.

Surge Facilities

Recent experiences have shown that community-wide emergency management plans should include preparations to establish temporary healthcare facilities when a major disaster—or series of disasters as occurred in New Orleans—creates a surge of patients or cripples hospitals and forces patients and staff to evacuate. When an emergency occurs, the demands placed on a hospital escalate beyond the normal level of services required. Surge facilities provide care when permanent facilities exhaust their capacity or cannot operate because of damage or other conditions. Surge facilities also act as a buffer for lower acuity patients to protect the scarce resources of the operating hospital.

Some surges are such that a hospital can meet community needs within its own walls. For example, a hospital may be able to handle a commuter train accident that brings 30 injured patients through its doors. But, in many instances, economic factors operating over the past decade mean that hospitals are already operating at capacity and have little room for surge. Remember that “room” for surge is not just the number of beds, but the number of beds that can be adequately staffed and supplied. Where would patients already in an at-capacity organization go if a significant number of new patients—whether 30, 300, or 3,000—need treatment?

This scenario occurred during the aftermath of Hurricane Katrina when the Louisiana Department of Health and Hospitals (DHH) determined that it needed to establish an acute care surge facility at the Louisiana State University Pete Maravich Assembly Center in Baton Rouge because existing hospitals in the area would be inundated with patients.1

This recent example of coordination shows the imperative for hospitals and health officials to plan with community organizations to increase surge capacity at temporary locations. Off-site locations, which may be at facilities as diverse as civic centers, schools, or even veterinary hospitals, must be part of community-wide emergency management plans.

While there is general consensus about this idea and the need for a community-wide response plan to emergencies, a recent JCAHO examination of the issue reveals that there is no single model available today for surge facilities, but what is developing is a series of guidelines based on experience.2 Communities should study available examples of organizations that have faced with surge situations and then create contingency plans after assessing potential community needs and available resources.

While it is important for a hospital to take the initiative to consider surge capacity planning, no single hospital can by itself be expected to be able to address a large-scale emergency that sends large numbers of patients in search of healthcare. Securing temporary facilities, adequate staff, and critical supplies, equipment, and pharmaceuticals takes the concerted efforts of healthcare organizations, communities, and government agencies.

Hospitals must work with organizations such as hospital districts, state and county departments of health, the National Guard, various agencies charged with homeland security, medical schools, and so forth to plan for and operationalize surge capacity.

For example, the Commonwealth of Massachusetts maintains a statewide system to allocate surge capacity by identifying empty beds and distributing patients among existing hospitals.3 The very declaration of an emergency should automatically trigger government intervention necessary for surge capacity on the local, state, or federal level, as appropriate.

Components of Surge Facilities

Communities and healthcare planners preparing responses to a crisis must be innovative when considering how to accommodate a surge of patients. Surge facilities commonly fall into one of the following basic categories:

• Shuttered hospitals or closed wards;
• Facilities of opportunity, such as schools, hotels, conventions centers, and other types of buildings near a hospital that can easily be adapted during emergencies to treat unusually large numbers of patients;
• Mobile medical facilities; and
• Portable facilities.

Planning for locations is important, but it is important to remember that a surge facility is not so much a place as it is a capability. Wherever a surge facility is located, it must be equipped and staffed adequately. Beyond planning for the physical location of a surge facility, hospitals and communities must consider the other factors that will affect the ability to deliver care.

For example, will essential staff be available to treat patients? What might constitute essential staff? Surge capacity plans also must take into account the need to communicate with staff during times of crisis, transport staff, and make accommodations for staff who may be facing their own personal emergencies at home (i.e., damage to their homes or vehicles, concern for vulnerable family members, and so forth).

Creating plans to assist staff and their families during a crisis will ensure that vital members of the emergency response team are able and willing to perform their duties. The U.S. Department of Defense’s Modular Emergency Medical Stem can aid efforts to determine the number of staff necessary to effectively operate a surge facility. Other methods for securing the needed number of staff during an emergency include qualified volunteers from organizations such as the Medical Reserve Corps program, Civilian Emergency Response Teams, Disaster Medical Assistance Teams, health professional students, reserve military health providers, paramedics, and midwives. In addition, communities may consider training a pool of volunteers who could assist with surge healthcare needs by providing nonmedical support to healthcare providers.

Other critical considerations for hospitals and communities planning for surge capability include:

• Medical supplies and equipment: The Centers for Disease Control and Prevention (CDC) can provide necessary supplies through its Strategic National Stockpile program, but delivery may take days, as Hurricane Katrina demonstrated. Other potential sources of supplies, such as physician offices and medical supply houses, should be researched.
• Pharmaceuticals: Sufficient inventories to last for several days in the event of an emergency will help prevent problems, as will setting up contracts with pharmaceutical suppliers that take effect only during an emergency.
• Communication: The September 11 terrorist attacks and Hurricane Katrina demonstrated the fallibility of cellular phone and radio communications; multiple forms of communication (i.e., cellular, two-way radio, pagers, satellite, two-way phones, and so forth) are necessary to ensure that if one method fails, another is available.
• Data sharing: Hospitals must plan for how they will coordinate with local, state, and federal health agencies to conduct necessary work to care for patients.
• Sufficiency of care: During emergencies, surge facilities maybe able to treat each patient only until he or she can be transferred to an organization that provides an ideal level of care. Plans for surge capacity should take this possibility into consideration so agreements can be made in advance with other hospitals, while also ensuring that patients who need specific monitoring or ventilator assistance, for example, can be cared for until transferred.

Surge Facilities and the Joint Commission

The fact that surge facilities were forced to provide care for such an extended period of time following Hurricane Katrina has prompted the Joint Commission to consider establishing standards for this unique form of a healthcare organization. The standards might require surge facilities to comply with basic safety and quality expectations and help to ensure the public that care given at these temporary facilities is adequate. JCAHO is working on the standards with healthcare organizations that are developing plans for surge facilities so that any new requirements can be implemented quickly and with minimal cost.

Surge Facility, Emergency Management Resources

While healthcare leaders agree on the need for comprehensive emergency management plans, which include surge capacity, consensus on the necessary components and assigned accountabilities has been scarce. Hospitals have been left to use federal or state requirements, Joint Commission standards, and guidance from hospitals associations. The Joint Commission has worked over the past several years with experts in the public and private sectors to bring broader agreement and guidance on these issues.

Detailed information about what surge facilities are, the kind of planning that these alternate care sites require, how they can be set up, and who should be responsible for their establishment and operation is available through the JCAHO publication, Surge Hospitals: Providing Safe Care in Emergencies (available at www.jcaho.org/about+us/public+policy+initiatives/surge_hospital.htm). This Web-based publication describes the different types of surge facilities, such as shuttered hospitals, closed wards in existing hospitals, and mobile facilities, and the design considerations for each. It also explores the challenges of planning for, establishing, and operating surge facilities, such as obtaining sufficient staff, supplies and equipment, and providing safe care.

Lessons learned from healthcare organizations following Hurricanes Katrina and Rita along the Gulf Coast and into Texas are also included. These case studies specifically look at a surge facility established by the Harris County Hospital District at Reliant Arena in Houston, a surge facility at the Dallas Convention Center that treated more than 4,000 hurricane evacuees in during a single week, the Louisiana State University acute care facility mentioned earlier in this article, a field hospital set up in the site of a former retail store, and a healthcare shelter established in a Texas veterinary hospital to care for nursing home residents, pediatric burn patients, handicapped children, and home-health-care patients.

Beyond the very specific issue of surge facilities, JCAHO offers guidance on community-wide emergency management planning:

• Standing Together: An Emergency Planning Guide for America’s Communities provides detailed information about steps that communities must take to prepare for and successfully respond to major local and regional emergencies. The free planning guide, published in 2005, is the result of a two-year project that drew upon the expertise of front-line emergency responders, emergency preparedness planners, and public health and healthcare organization leaders. It’s available at www.jcaho.org/about+us/public+policy+initiatives/planning_guide.htm.
• Health Care at the Crossroads: Strategies for Creating and Sustaining Community-wide Emergency Preparedness Systems provides recommended strategies for developing community-wide preparedness. This free 2003 white paper is available at www.jcaho.org/about+us/public+policy+initiatives/emergency.htm.

Conclusion

The serious shortcomings of the nation’s emergency management planning capabilities were made evident by the events surrounding Hurricane Katrina. Hospitals, along with other types of healthcare facilities, must take an active role in all community-wide emergency planning activities to mitigate the effects on patient care. Communities and the healthcare organizations within them must plan to operate largely on their own for several days or even longer following a disaster. Surge facilities are a major component of these plans. Hospitals must prepare for the possibility that their buildings could be too damaged to function during, as well as after, a disaster.

Developing plans that allow for adequate patient care during emergencies requires hospitals and the communities that they serve to overcome barriers such as assigning responsibilities for planning, how to fund emergency readiness efforts, the specifics necessary to create effective planning and response processes, and how to coordinate with state and federal emergency management resources. This broad-based approach will help healthcare planners consider the challenges associated with major emergencies and develop appropriate plans to respond to such crises. TH

Cappiello is the vice president for Accreditation Field Operations at JCAHO. He is responsible for management of accreditation processes including survey functions, surveyor education, standards interpretation, staff education and training, and accreditation process improvement.

Contact the Joint Commission at www.jcaho.org or call (630) 792-5000.

References

1. Surge Hospitals: Providing Safe Care in Emergencies. Joint Commission Resources, Oakbrook Terrace, Ill., December 2005.
2. Surge Hospitals: Providing Safe Care in Emergencies. Joint Commission Resources, Oakbrook Terrace, Ill., December 2005.
3. Use of a Former (“Shuttered”) Hospital to Expand Surge Capacity. Available at www.ahrq.gov/research/shuttered/shuthosp1.htm. Last accessed March 2, 2006.

The devastation of American cities caused by Hurricane Katrina, combined with World Health Organization warnings about the possibility of an influenza pandemic and a continued heightened awareness of potential terrorist attacks, raise new concerns about the ability of the healthcare system to effectively respond to disasters. During crises, healthcare organizations must act quickly to meet the demands of their communities.

Makeshift—or “surge”—facilities provide care for the surging number of patients until normal operations can resume. These care sites can’t be thought of in traditional terms of brick-and-mortar hospitals. Instead, surge facilities protect brick-and-mortar facilities from a surge of patients who do not require acute intervention, or to protect brick-and-mortar facilities attempting to recover from damage.

Hurricane Katrina demonstrated, however, that even those communities with comprehensive plans for emergency response face considerable difficulties when major parts of infrastructure for medical care are significantly damaged. If almost all healthcare capabilities in a neighborhood, city, or even an entire region are damaged and the water supply, sewage system, and electricity are affected, how do communities cope with the surge? Such destruction also may force surge facilities to continue operations for weeks or months—instead of the hours or days that have typically been contemplated in the past.

The challenge for healthcare organizations is to work with local, state, and federal officials to develop comprehensive plans for meeting medical needs during community-wide emergencies. This article explores the obstacles and strategies to developing comprehensive, community-wide emergency plans, how healthcare and community leaders can understand the role of surge facilities, and how to establish these critical links to maintaining care. The goal of emergency planning is mitigation, preparedness, response, and recovery. Surge facilities may have a role in most of the components of emergency planning.

Planning for Emergencies

The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) and the federal government have long required thorough accreditation standards and Conditions of Participation, respectively, in order to help hospitals plan for emergencies. JCAHO, which has been actively involved in disaster preparedness for more than 30 years, increased its focus on emergency management in January 2001—nine months prior to the September 11 attacks on New York City and Washington, D.C. It has since worked even more closely with emergency management experts and healthcare organizations to make this issue a priority.

The resulting modified accreditation standards and overall guidelines developed by expert consensus reflect the need for hospitals and other healthcare organizations to be involved in community-wide planning, in addition to planning for an emergency at that particular institution.

Develop Emergency Management Plans

JCAHO’s Management of the Environment of Care (EC) standards call on hospitals to develop an emergency management plan that—among other requirements—ensures an effective response to emergencies through the implementation of the plan and execution of the plan by conducting emergency management drills. Hospitals also must participate with the community to establish priorities among potential emergencies, define the organization’s role in the community’s emergency management program, and link with the community’s command structure. (Note: EC.4.10, which addresses the entire topic of emergency management, also calls for hospitals to conduct a hazard-vulnerability analysis, which is discussed below.)

While recent national attention has focused on the emergencies created by Hurricane Katrina and the perceived lack of rapid federal response, JCAHO standards emphasize the need to consider a variety of natural or manmade events that suddenly or significantly disrupt the environment of care, disrupt care and treatment, and change or increase demands for the organization’s services.

Use an All-Hazards Approach

In order to plan for and respond to a variety of emergencies, hospitals must conduct a hazard vulnerability analysis (EC.4.10). This analysis is best done with community leadership to ensure that there is continuity at all levels of planning. This formal process for conducting a hazard vulnerability analysis has been a JCAHO requirement since 2001, although hospital standards previously had called for planning to address a variety of disasters.

The change in requirements simply provides a method—the hazard vulnerability analysis—for a hospital to focus attention on the disasters or catastrophes likely to have an effect on its operations. This analysis should be a dynamic document that is regularly reviewed and revised to reflect the latest information on the probability of events or threats and their effects.

By considering a complete list of potential hazards, hospital leaders can determine the effects that specific types of emergencies will have on their facility and the community. The hazard-vulnerabilities analysis also should take into account the fact that an emergency may have a cascading effect. Example: The hurricane in New Orleans did not initially cause as much damage as feared, but breaches in the levees from the hurricane’s rains caused massive flooding that resulted in nearly complete communications failures, loss of power, transportation breakdowns, and so forth.

After compiling as complete a list as possible of potential emergencies, hospital leaders [must work] with the community to prioritize the list considering likelihood and effect of such an occurrence. Then, the areas of vulnerability that most demand community and organizational attention can be addressed. Dealing with these issues requires hospitals to work with local and regional government agencies, emergency responders such as local fire and police departments, and other hospitals and healthcare organizations in the community.

By working together with other healthcare professionals and with community experts charged with responding to emergencies, hospitals can ensure that the full spectrum of likely emergencies and contingencies has been considered. The collaboration also allows the many organizations involved to understand their role in a larger crisis and anticipate how other partners will respond. An emergency affects the entire community, making it important for hospitals and other organizations to avoid “silo” approaches that leave each component of the community vulnerable if they are standing alone.

Surge Facilities

Recent experiences have shown that community-wide emergency management plans should include preparations to establish temporary healthcare facilities when a major disaster—or series of disasters as occurred in New Orleans—creates a surge of patients or cripples hospitals and forces patients and staff to evacuate. When an emergency occurs, the demands placed on a hospital escalate beyond the normal level of services required. Surge facilities provide care when permanent facilities exhaust their capacity or cannot operate because of damage or other conditions. Surge facilities also act as a buffer for lower acuity patients to protect the scarce resources of the operating hospital.

Some surges are such that a hospital can meet community needs within its own walls. For example, a hospital may be able to handle a commuter train accident that brings 30 injured patients through its doors. But, in many instances, economic factors operating over the past decade mean that hospitals are already operating at capacity and have little room for surge. Remember that “room” for surge is not just the number of beds, but the number of beds that can be adequately staffed and supplied. Where would patients already in an at-capacity organization go if a significant number of new patients—whether 30, 300, or 3,000—need treatment?

This scenario occurred during the aftermath of Hurricane Katrina when the Louisiana Department of Health and Hospitals (DHH) determined that it needed to establish an acute care surge facility at the Louisiana State University Pete Maravich Assembly Center in Baton Rouge because existing hospitals in the area would be inundated with patients.1

This recent example of coordination shows the imperative for hospitals and health officials to plan with community organizations to increase surge capacity at temporary locations. Off-site locations, which may be at facilities as diverse as civic centers, schools, or even veterinary hospitals, must be part of community-wide emergency management plans.

While there is general consensus about this idea and the need for a community-wide response plan to emergencies, a recent JCAHO examination of the issue reveals that there is no single model available today for surge facilities, but what is developing is a series of guidelines based on experience.2 Communities should study available examples of organizations that have faced with surge situations and then create contingency plans after assessing potential community needs and available resources.

While it is important for a hospital to take the initiative to consider surge capacity planning, no single hospital can by itself be expected to be able to address a large-scale emergency that sends large numbers of patients in search of healthcare. Securing temporary facilities, adequate staff, and critical supplies, equipment, and pharmaceuticals takes the concerted efforts of healthcare organizations, communities, and government agencies.

Hospitals must work with organizations such as hospital districts, state and county departments of health, the National Guard, various agencies charged with homeland security, medical schools, and so forth to plan for and operationalize surge capacity.

For example, the Commonwealth of Massachusetts maintains a statewide system to allocate surge capacity by identifying empty beds and distributing patients among existing hospitals.3 The very declaration of an emergency should automatically trigger government intervention necessary for surge capacity on the local, state, or federal level, as appropriate.

Components of Surge Facilities

Communities and healthcare planners preparing responses to a crisis must be innovative when considering how to accommodate a surge of patients. Surge facilities commonly fall into one of the following basic categories:

• Shuttered hospitals or closed wards;
• Facilities of opportunity, such as schools, hotels, conventions centers, and other types of buildings near a hospital that can easily be adapted during emergencies to treat unusually large numbers of patients;
• Mobile medical facilities; and
• Portable facilities.

Planning for locations is important, but it is important to remember that a surge facility is not so much a place as it is a capability. Wherever a surge facility is located, it must be equipped and staffed adequately. Beyond planning for the physical location of a surge facility, hospitals and communities must consider the other factors that will affect the ability to deliver care.

For example, will essential staff be available to treat patients? What might constitute essential staff? Surge capacity plans also must take into account the need to communicate with staff during times of crisis, transport staff, and make accommodations for staff who may be facing their own personal emergencies at home (i.e., damage to their homes or vehicles, concern for vulnerable family members, and so forth).

Creating plans to assist staff and their families during a crisis will ensure that vital members of the emergency response team are able and willing to perform their duties. The U.S. Department of Defense’s Modular Emergency Medical Stem can aid efforts to determine the number of staff necessary to effectively operate a surge facility. Other methods for securing the needed number of staff during an emergency include qualified volunteers from organizations such as the Medical Reserve Corps program, Civilian Emergency Response Teams, Disaster Medical Assistance Teams, health professional students, reserve military health providers, paramedics, and midwives. In addition, communities may consider training a pool of volunteers who could assist with surge healthcare needs by providing nonmedical support to healthcare providers.

Other critical considerations for hospitals and communities planning for surge capability include:

• Medical supplies and equipment: The Centers for Disease Control and Prevention (CDC) can provide necessary supplies through its Strategic National Stockpile program, but delivery may take days, as Hurricane Katrina demonstrated. Other potential sources of supplies, such as physician offices and medical supply houses, should be researched.
• Pharmaceuticals: Sufficient inventories to last for several days in the event of an emergency will help prevent problems, as will setting up contracts with pharmaceutical suppliers that take effect only during an emergency.
• Communication: The September 11 terrorist attacks and Hurricane Katrina demonstrated the fallibility of cellular phone and radio communications; multiple forms of communication (i.e., cellular, two-way radio, pagers, satellite, two-way phones, and so forth) are necessary to ensure that if one method fails, another is available.
• Data sharing: Hospitals must plan for how they will coordinate with local, state, and federal health agencies to conduct necessary work to care for patients.
• Sufficiency of care: During emergencies, surge facilities maybe able to treat each patient only until he or she can be transferred to an organization that provides an ideal level of care. Plans for surge capacity should take this possibility into consideration so agreements can be made in advance with other hospitals, while also ensuring that patients who need specific monitoring or ventilator assistance, for example, can be cared for until transferred.

Surge Facilities and the Joint Commission

The fact that surge facilities were forced to provide care for such an extended period of time following Hurricane Katrina has prompted the Joint Commission to consider establishing standards for this unique form of a healthcare organization. The standards might require surge facilities to comply with basic safety and quality expectations and help to ensure the public that care given at these temporary facilities is adequate. JCAHO is working on the standards with healthcare organizations that are developing plans for surge facilities so that any new requirements can be implemented quickly and with minimal cost.

Surge Facility, Emergency Management Resources

While healthcare leaders agree on the need for comprehensive emergency management plans, which include surge capacity, consensus on the necessary components and assigned accountabilities has been scarce. Hospitals have been left to use federal or state requirements, Joint Commission standards, and guidance from hospitals associations. The Joint Commission has worked over the past several years with experts in the public and private sectors to bring broader agreement and guidance on these issues.

Detailed information about what surge facilities are, the kind of planning that these alternate care sites require, how they can be set up, and who should be responsible for their establishment and operation is available through the JCAHO publication, Surge Hospitals: Providing Safe Care in Emergencies (available at www.jcaho.org/about+us/public+policy+initiatives/surge_hospital.htm). This Web-based publication describes the different types of surge facilities, such as shuttered hospitals, closed wards in existing hospitals, and mobile facilities, and the design considerations for each. It also explores the challenges of planning for, establishing, and operating surge facilities, such as obtaining sufficient staff, supplies and equipment, and providing safe care.

Lessons learned from healthcare organizations following Hurricanes Katrina and Rita along the Gulf Coast and into Texas are also included. These case studies specifically look at a surge facility established by the Harris County Hospital District at Reliant Arena in Houston, a surge facility at the Dallas Convention Center that treated more than 4,000 hurricane evacuees in during a single week, the Louisiana State University acute care facility mentioned earlier in this article, a field hospital set up in the site of a former retail store, and a healthcare shelter established in a Texas veterinary hospital to care for nursing home residents, pediatric burn patients, handicapped children, and home-health-care patients.

Beyond the very specific issue of surge facilities, JCAHO offers guidance on community-wide emergency management planning:

• Standing Together: An Emergency Planning Guide for America’s Communities provides detailed information about steps that communities must take to prepare for and successfully respond to major local and regional emergencies. The free planning guide, published in 2005, is the result of a two-year project that drew upon the expertise of front-line emergency responders, emergency preparedness planners, and public health and healthcare organization leaders. It’s available at www.jcaho.org/about+us/public+policy+initiatives/planning_guide.htm.
• Health Care at the Crossroads: Strategies for Creating and Sustaining Community-wide Emergency Preparedness Systems provides recommended strategies for developing community-wide preparedness. This free 2003 white paper is available at www.jcaho.org/about+us/public+policy+initiatives/emergency.htm.

Conclusion

The serious shortcomings of the nation’s emergency management planning capabilities were made evident by the events surrounding Hurricane Katrina. Hospitals, along with other types of healthcare facilities, must take an active role in all community-wide emergency planning activities to mitigate the effects on patient care. Communities and the healthcare organizations within them must plan to operate largely on their own for several days or even longer following a disaster. Surge facilities are a major component of these plans. Hospitals must prepare for the possibility that their buildings could be too damaged to function during, as well as after, a disaster.

Developing plans that allow for adequate patient care during emergencies requires hospitals and the communities that they serve to overcome barriers such as assigning responsibilities for planning, how to fund emergency readiness efforts, the specifics necessary to create effective planning and response processes, and how to coordinate with state and federal emergency management resources. This broad-based approach will help healthcare planners consider the challenges associated with major emergencies and develop appropriate plans to respond to such crises. TH

Cappiello is the vice president for Accreditation Field Operations at JCAHO. He is responsible for management of accreditation processes including survey functions, surveyor education, standards interpretation, staff education and training, and accreditation process improvement.

Contact the Joint Commission at www.jcaho.org or call (630) 792-5000.

References

1. Surge Hospitals: Providing Safe Care in Emergencies. Joint Commission Resources, Oakbrook Terrace, Ill., December 2005.
2. Surge Hospitals: Providing Safe Care in Emergencies. Joint Commission Resources, Oakbrook Terrace, Ill., December 2005.
3. Use of a Former (“Shuttered”) Hospital to Expand Surge Capacity. Available at www.ahrq.gov/research/shuttered/shuthosp1.htm. Last accessed March 2, 2006.

Supplement Editor:
Gary Francis, MD

Contents

Sodium and water retention in heart failure and diuretic therapy: Basic mechanisms
Domenic A. Sica, MD

Acute decompensated heart failure: The cardiorenal syndrome
Gary Francis, MD

New approaches to detect and manage edema and renal insufficiency in heart failure
W.H. Wilson Tang, MD

Vasopressin receptor antagonists: Mechanisms of action and potential effects in heart failure
Steven R. Goldsmith, MD

The clinical effects of vasopressin receptor antagonists in heart failure
Mihai Gheorghiade, MD

Panel discussion
Domenic A. Sica, MD; Gary Francis, MD; W.H. Wilson Tang, MD; Steven R. Goldsmith, MD; and Mihai Gheorghiade, MD

Supplement Editor:
Gary Francis, MD

Contents

Sodium and water retention in heart failure and diuretic therapy: Basic mechanisms
Domenic A. Sica, MD

Acute decompensated heart failure: The cardiorenal syndrome
Gary Francis, MD

New approaches to detect and manage edema and renal insufficiency in heart failure
W.H. Wilson Tang, MD

Vasopressin receptor antagonists: Mechanisms of action and potential effects in heart failure
Steven R. Goldsmith, MD

The clinical effects of vasopressin receptor antagonists in heart failure
Mihai Gheorghiade, MD

Panel discussion
Domenic A. Sica, MD; Gary Francis, MD; W.H. Wilson Tang, MD; Steven R. Goldsmith, MD; and Mihai Gheorghiade, MD

Supplement Editor:
Gary Francis, MD

Contents

Sodium and water retention in heart failure and diuretic therapy: Basic mechanisms
Domenic A. Sica, MD

Acute decompensated heart failure: The cardiorenal syndrome
Gary Francis, MD

New approaches to detect and manage edema and renal insufficiency in heart failure
W.H. Wilson Tang, MD

Vasopressin receptor antagonists: Mechanisms of action and potential effects in heart failure
Steven R. Goldsmith, MD

The clinical effects of vasopressin receptor antagonists in heart failure
Mihai Gheorghiade, MD

Panel discussion
Domenic A. Sica, MD; Gary Francis, MD; W.H. Wilson Tang, MD; Steven R. Goldsmith, MD; and Mihai Gheorghiade, MD