QI Initiatives

Laura Vento, MSN, RN, first took an interest in the teach-back process when her father had a liver transplant. Following a prolonged hospitalization, Vento’s dad was sent home with little understanding of how to take care of himself; most notably, he had no wound-care education. And when she reviewed his medications, Vento found serious discrepancies with his anti-rejection drug prescriptions.

Her mind was filled with questions: “What kind of transition of care was this? How well am I as a nurse preparing my patients for discharge?” says Vento, a clinical nurse leader on an acute-care medical unit at the University of California at San Diego (UCSD) Medical Center. “I have since learned that shocking numbers of [hospitalized] patients receive little or no education about how to care for themselves.”

About the same time as her dad’s recovery, Vento’s nurse manager heard about SHM’s Project BOOST. They applied for a grant to support training hospital staff in the teach-back system, an integral Project BOOST strategy for educating patients about their post-discharge care needs.

At UCSD, teach-back was incorporated into a larger process of improving care transitions and preventing avoidable readmissions. In addition to the new communication techniques, the process also includes risk assessment, post-discharge follow-up phone calls, and other strategies, supported by a hospitalwide, multidisciplinary education council.

Following a four-hour teach-back curriculum presented to nursing staff, “we did role modeling and role plays,” Vento says. “We followed up with a teach-back coach, me, going to patients’ bedsides with the nurses, because the workshop content alone was not enough without the patient interaction. We needed to verify the nurses’ competency.”

From its initial piloting on two units, teach-back is being hard-wired into UCSD’s electronic health record, with guides to ask for five basic teach-back checks: reason for admission, self-care needs, when to call a physician or 9ll, scheduled follow-up appointments, and changes to the medication list. The education council is now rolling out teach-back to nurses across the system. For her efforts in disseminating the strategy the past two years, Vento was named the UCSD health system’s Nurse of the Year for 2011.

And yet, despite this systemwide recognition, “the focus up to this point has mostly been on the nurses, who are responsible for the bulk of patient education,” says UCSD hospitalist and Project BOOST mentor Jennifer Quartarolo, MD, SFHM. “It’s probably been underutilized by other members of the care team.”

Despite competing demands on physicians’ time, Dr. Quartarolo says hospitalists need to improve their patient education skills. “Teach-back can help us effectively communicate the key teaching points that we’d like our hospitalized patients and their caregivers to take home with them,” she says.

Laura Vento, MSN, RN, first took an interest in the teach-back process when her father had a liver transplant. Following a prolonged hospitalization, Vento’s dad was sent home with little understanding of how to take care of himself; most notably, he had no wound-care education. And when she reviewed his medications, Vento found serious discrepancies with his anti-rejection drug prescriptions.

Her mind was filled with questions: “What kind of transition of care was this? How well am I as a nurse preparing my patients for discharge?” says Vento, a clinical nurse leader on an acute-care medical unit at the University of California at San Diego (UCSD) Medical Center. “I have since learned that shocking numbers of [hospitalized] patients receive little or no education about how to care for themselves.”

About the same time as her dad’s recovery, Vento’s nurse manager heard about SHM’s Project BOOST. They applied for a grant to support training hospital staff in the teach-back system, an integral Project BOOST strategy for educating patients about their post-discharge care needs.

At UCSD, teach-back was incorporated into a larger process of improving care transitions and preventing avoidable readmissions. In addition to the new communication techniques, the process also includes risk assessment, post-discharge follow-up phone calls, and other strategies, supported by a hospitalwide, multidisciplinary education council.

Following a four-hour teach-back curriculum presented to nursing staff, “we did role modeling and role plays,” Vento says. “We followed up with a teach-back coach, me, going to patients’ bedsides with the nurses, because the workshop content alone was not enough without the patient interaction. We needed to verify the nurses’ competency.”

From its initial piloting on two units, teach-back is being hard-wired into UCSD’s electronic health record, with guides to ask for five basic teach-back checks: reason for admission, self-care needs, when to call a physician or 9ll, scheduled follow-up appointments, and changes to the medication list. The education council is now rolling out teach-back to nurses across the system. For her efforts in disseminating the strategy the past two years, Vento was named the UCSD health system’s Nurse of the Year for 2011.

And yet, despite this systemwide recognition, “the focus up to this point has mostly been on the nurses, who are responsible for the bulk of patient education,” says UCSD hospitalist and Project BOOST mentor Jennifer Quartarolo, MD, SFHM. “It’s probably been underutilized by other members of the care team.”

Despite competing demands on physicians’ time, Dr. Quartarolo says hospitalists need to improve their patient education skills. “Teach-back can help us effectively communicate the key teaching points that we’d like our hospitalized patients and their caregivers to take home with them,” she says.

Laura Vento, MSN, RN, first took an interest in the teach-back process when her father had a liver transplant. Following a prolonged hospitalization, Vento’s dad was sent home with little understanding of how to take care of himself; most notably, he had no wound-care education. And when she reviewed his medications, Vento found serious discrepancies with his anti-rejection drug prescriptions.

Her mind was filled with questions: “What kind of transition of care was this? How well am I as a nurse preparing my patients for discharge?” says Vento, a clinical nurse leader on an acute-care medical unit at the University of California at San Diego (UCSD) Medical Center. “I have since learned that shocking numbers of [hospitalized] patients receive little or no education about how to care for themselves.”

About the same time as her dad’s recovery, Vento’s nurse manager heard about SHM’s Project BOOST. They applied for a grant to support training hospital staff in the teach-back system, an integral Project BOOST strategy for educating patients about their post-discharge care needs.

At UCSD, teach-back was incorporated into a larger process of improving care transitions and preventing avoidable readmissions. In addition to the new communication techniques, the process also includes risk assessment, post-discharge follow-up phone calls, and other strategies, supported by a hospitalwide, multidisciplinary education council.

Following a four-hour teach-back curriculum presented to nursing staff, “we did role modeling and role plays,” Vento says. “We followed up with a teach-back coach, me, going to patients’ bedsides with the nurses, because the workshop content alone was not enough without the patient interaction. We needed to verify the nurses’ competency.”

From its initial piloting on two units, teach-back is being hard-wired into UCSD’s electronic health record, with guides to ask for five basic teach-back checks: reason for admission, self-care needs, when to call a physician or 9ll, scheduled follow-up appointments, and changes to the medication list. The education council is now rolling out teach-back to nurses across the system. For her efforts in disseminating the strategy the past two years, Vento was named the UCSD health system’s Nurse of the Year for 2011.

And yet, despite this systemwide recognition, “the focus up to this point has mostly been on the nurses, who are responsible for the bulk of patient education,” says UCSD hospitalist and Project BOOST mentor Jennifer Quartarolo, MD, SFHM. “It’s probably been underutilized by other members of the care team.”

Despite competing demands on physicians’ time, Dr. Quartarolo says hospitalists need to improve their patient education skills. “Teach-back can help us effectively communicate the key teaching points that we’d like our hospitalized patients and their caregivers to take home with them,” she says.

Although a recently released study of Medicare data uncovers little progress in reducing hospital readmissions, and the Oct. 1 deadline to implement CMS’ Hospital Readmissions Reduction Program looms, Carolyn Clancy, MD, director of the Agency for Healthcare Research and Quality (AHRQ), says she's not worried about the ability of America’s hospitalists to rise to the occasion and get a handle on the problem.

Dr. Clancy recently wrote a commentary outlining the government's approach to controlling readmissions, stating that taking aim at readmissions is 1) an integral component of its value-based purchasing program and 2) is an opportunity for improving hospital quality and patient safety.

"Hospitalists are often on the receiving end of hospitalizations resulting from poor coordination of care. I think it would be very exciting to be part of the solution," Dr. Clancy says. She says she observed firsthand during a recent hospital stay how hospitalists helped her to think about how she should care for herself after returning home. But her father suffered a needless rehospitalization when important information (how much Coumadin to take) was miscommunicated in a post-discharge follow-up phone call, causing him to start bleeding.

"Hospitalists who want to embrace the challenge will find a phenomenal amount of information on Innovations Exchange, where people from all over America are sharing their clinical innovations."

Dr. Clancy says she hopes AHRQ-supported tools and studies "will make it easier for hospitals to do the right thing."

Although a recently released study of Medicare data uncovers little progress in reducing hospital readmissions, and the Oct. 1 deadline to implement CMS’ Hospital Readmissions Reduction Program looms, Carolyn Clancy, MD, director of the Agency for Healthcare Research and Quality (AHRQ), says she's not worried about the ability of America’s hospitalists to rise to the occasion and get a handle on the problem.

Dr. Clancy recently wrote a commentary outlining the government's approach to controlling readmissions, stating that taking aim at readmissions is 1) an integral component of its value-based purchasing program and 2) is an opportunity for improving hospital quality and patient safety.

"Hospitalists are often on the receiving end of hospitalizations resulting from poor coordination of care. I think it would be very exciting to be part of the solution," Dr. Clancy says. She says she observed firsthand during a recent hospital stay how hospitalists helped her to think about how she should care for herself after returning home. But her father suffered a needless rehospitalization when important information (how much Coumadin to take) was miscommunicated in a post-discharge follow-up phone call, causing him to start bleeding.

"Hospitalists who want to embrace the challenge will find a phenomenal amount of information on Innovations Exchange, where people from all over America are sharing their clinical innovations."

Dr. Clancy says she hopes AHRQ-supported tools and studies "will make it easier for hospitals to do the right thing."

Although a recently released study of Medicare data uncovers little progress in reducing hospital readmissions, and the Oct. 1 deadline to implement CMS’ Hospital Readmissions Reduction Program looms, Carolyn Clancy, MD, director of the Agency for Healthcare Research and Quality (AHRQ), says she's not worried about the ability of America’s hospitalists to rise to the occasion and get a handle on the problem.

Dr. Clancy recently wrote a commentary outlining the government's approach to controlling readmissions, stating that taking aim at readmissions is 1) an integral component of its value-based purchasing program and 2) is an opportunity for improving hospital quality and patient safety.

"Hospitalists are often on the receiving end of hospitalizations resulting from poor coordination of care. I think it would be very exciting to be part of the solution," Dr. Clancy says. She says she observed firsthand during a recent hospital stay how hospitalists helped her to think about how she should care for herself after returning home. But her father suffered a needless rehospitalization when important information (how much Coumadin to take) was miscommunicated in a post-discharge follow-up phone call, causing him to start bleeding.

"Hospitalists who want to embrace the challenge will find a phenomenal amount of information on Innovations Exchange, where people from all over America are sharing their clinical innovations."

Dr. Clancy says she hopes AHRQ-supported tools and studies "will make it easier for hospitals to do the right thing."

Just as the federal government is introducing several new programs to promote the recruitment, training, and placement of more primary-care providers, other efforts are being threatened with funding decreases or elimination.

One, the Children’s Hospitals Graduate Medical Education program, distributed $268 million in pediatric training funds to 55 freestanding children’s teaching hospitals in fiscal-year 2012. The program, however, was zeroed out in President Obama’s initial budget proposal last year, and the president’s fiscal-year 2013 budget proposal recommends slashing the program’s annual funding by two-thirds to $88 million.

Kathleen Klink, MD, director of the Division of Medicine and Dentistry in the federal Health Resources and Services Administration, also points to the Title VII Area Health Education Center program as an example of government-funded assistance. The competitive grant process supports innovation and access to care for vulnerable populations, in part by improving the primary-care workforce’s geographic and ethnic distribution. Some of the grantees introduce high school students to medical careers, while others recruit and train minorities or place providers in underserved communities, effectively targeting both ends of the pipeline.

Robert Phillips, MD, MSPH, director of the Washington, D.C.-based Robert Graham Center, a primary-care research center, has high regard for the Title VII program. But making an impact requires a long-term investment, he cautions. “In the states that do this well, like Arkansas and North Carolina, it pays off,” he says. “But they can’t prove it sufficiently to save their budget.” The federal program received $233 million in fiscal-year 2012. Under the president’s fiscal-year 2013 budget proposal, however, the funding is likewise eliminated.

Other programs have debuted in recent legislation. One program, introduced under the Affordable Care Act, provides $230 million over five years to expand residency training slots within ambulatory primary-care settings. Dr. Klink says the Teaching Health Center Graduate Medical Education program, as it is known, has so far supported 22 health centers and 150 enrolled residents. “It’s just the beginning,” she adds.

Another program, the Primary Care Residency Expansion, likewise initiated under the Affordable Care Act, will distribute $167 million to train an estimated 700 primary-care physicians (PCPs), 900 physician assistants, and 600 nurse practitioners and nurse midwives over five years. Glen Stream, president of the American Academy of Family Physicians, recently told The Washington Post, “It’s good, but it’s also a drop in the bucket.”

Bryn Nelson is a freelance medical writer in Seattle.

Just as the federal government is introducing several new programs to promote the recruitment, training, and placement of more primary-care providers, other efforts are being threatened with funding decreases or elimination.

One, the Children’s Hospitals Graduate Medical Education program, distributed $268 million in pediatric training funds to 55 freestanding children’s teaching hospitals in fiscal-year 2012. The program, however, was zeroed out in President Obama’s initial budget proposal last year, and the president’s fiscal-year 2013 budget proposal recommends slashing the program’s annual funding by two-thirds to $88 million.

Kathleen Klink, MD, director of the Division of Medicine and Dentistry in the federal Health Resources and Services Administration, also points to the Title VII Area Health Education Center program as an example of government-funded assistance. The competitive grant process supports innovation and access to care for vulnerable populations, in part by improving the primary-care workforce’s geographic and ethnic distribution. Some of the grantees introduce high school students to medical careers, while others recruit and train minorities or place providers in underserved communities, effectively targeting both ends of the pipeline.

Robert Phillips, MD, MSPH, director of the Washington, D.C.-based Robert Graham Center, a primary-care research center, has high regard for the Title VII program. But making an impact requires a long-term investment, he cautions. “In the states that do this well, like Arkansas and North Carolina, it pays off,” he says. “But they can’t prove it sufficiently to save their budget.” The federal program received $233 million in fiscal-year 2012. Under the president’s fiscal-year 2013 budget proposal, however, the funding is likewise eliminated.

Other programs have debuted in recent legislation. One program, introduced under the Affordable Care Act, provides $230 million over five years to expand residency training slots within ambulatory primary-care settings. Dr. Klink says the Teaching Health Center Graduate Medical Education program, as it is known, has so far supported 22 health centers and 150 enrolled residents. “It’s just the beginning,” she adds.

Another program, the Primary Care Residency Expansion, likewise initiated under the Affordable Care Act, will distribute $167 million to train an estimated 700 primary-care physicians (PCPs), 900 physician assistants, and 600 nurse practitioners and nurse midwives over five years. Glen Stream, president of the American Academy of Family Physicians, recently told The Washington Post, “It’s good, but it’s also a drop in the bucket.”

Bryn Nelson is a freelance medical writer in Seattle.

Just as the federal government is introducing several new programs to promote the recruitment, training, and placement of more primary-care providers, other efforts are being threatened with funding decreases or elimination.

One, the Children’s Hospitals Graduate Medical Education program, distributed $268 million in pediatric training funds to 55 freestanding children’s teaching hospitals in fiscal-year 2012. The program, however, was zeroed out in President Obama’s initial budget proposal last year, and the president’s fiscal-year 2013 budget proposal recommends slashing the program’s annual funding by two-thirds to $88 million.

Kathleen Klink, MD, director of the Division of Medicine and Dentistry in the federal Health Resources and Services Administration, also points to the Title VII Area Health Education Center program as an example of government-funded assistance. The competitive grant process supports innovation and access to care for vulnerable populations, in part by improving the primary-care workforce’s geographic and ethnic distribution. Some of the grantees introduce high school students to medical careers, while others recruit and train minorities or place providers in underserved communities, effectively targeting both ends of the pipeline.

Robert Phillips, MD, MSPH, director of the Washington, D.C.-based Robert Graham Center, a primary-care research center, has high regard for the Title VII program. But making an impact requires a long-term investment, he cautions. “In the states that do this well, like Arkansas and North Carolina, it pays off,” he says. “But they can’t prove it sufficiently to save their budget.” The federal program received $233 million in fiscal-year 2012. Under the president’s fiscal-year 2013 budget proposal, however, the funding is likewise eliminated.

Other programs have debuted in recent legislation. One program, introduced under the Affordable Care Act, provides $230 million over five years to expand residency training slots within ambulatory primary-care settings. Dr. Klink says the Teaching Health Center Graduate Medical Education program, as it is known, has so far supported 22 health centers and 150 enrolled residents. “It’s just the beginning,” she adds.

Another program, the Primary Care Residency Expansion, likewise initiated under the Affordable Care Act, will distribute $167 million to train an estimated 700 primary-care physicians (PCPs), 900 physician assistants, and 600 nurse practitioners and nurse midwives over five years. Glen Stream, president of the American Academy of Family Physicians, recently told The Washington Post, “It’s good, but it’s also a drop in the bucket.”

Bryn Nelson is a freelance medical writer in Seattle.

A paper published in the May/June issue of the Journal of Hospital Medicine shows that a collaborative approach to medication reconciliation ("med rec") appears to both prevent adverse drug events and pay for itself.

The paper, "Nurse-Pharmacist Collaboration on Medication Reconciliation Prevents Potential Harm," found that 225 of 500 surveyed patients had at least one unintended discrepancy in their house medication list (HML) on admission or discharge. And 162 of those patients had a discrepancy ranked on the upper end of the study's risk scale.

However, having nurses and pharmacists work together "allowed many discrepancies to be reconciled before causing harm," the study concluded.

"It absolutely supports the idea that we need to approach medicine as a team game," says hospitalist and lead author Lenny Feldman, MD, FACP, FAAP, SFHM, of John Hopkins School of Medicine in Baltimore. "We can't do this alone, and patients don't do better when we do this alone."

The study noted that it cost $113.64 to find one potentially harmful medication discrepancy. To offset those costs, an institution would have to prevent one discrepancy for every 290 patient encounters. The Johns Hopkins team averted 81 such events, but Dr. Feldman notes that without a control group, it’s difficult to say how many of those potential issues would have been caught at some other point in a patient's stay.

Still, he says, part of the value of a multidisciplinary approach to med rec is that it can help hospitalists improve patient care. By having nurses, physicians, and pharmacists working together, more potential adverse drug events could be prevented, Dr. Feldman says.

"That data-gathering is difficult and time-consuming, and it is not something hospitalists need do on their own," he adds.

A paper published in the May/June issue of the Journal of Hospital Medicine shows that a collaborative approach to medication reconciliation ("med rec") appears to both prevent adverse drug events and pay for itself.

The paper, "Nurse-Pharmacist Collaboration on Medication Reconciliation Prevents Potential Harm," found that 225 of 500 surveyed patients had at least one unintended discrepancy in their house medication list (HML) on admission or discharge. And 162 of those patients had a discrepancy ranked on the upper end of the study's risk scale.

However, having nurses and pharmacists work together "allowed many discrepancies to be reconciled before causing harm," the study concluded.

"It absolutely supports the idea that we need to approach medicine as a team game," says hospitalist and lead author Lenny Feldman, MD, FACP, FAAP, SFHM, of John Hopkins School of Medicine in Baltimore. "We can't do this alone, and patients don't do better when we do this alone."

The study noted that it cost $113.64 to find one potentially harmful medication discrepancy. To offset those costs, an institution would have to prevent one discrepancy for every 290 patient encounters. The Johns Hopkins team averted 81 such events, but Dr. Feldman notes that without a control group, it’s difficult to say how many of those potential issues would have been caught at some other point in a patient's stay.

Still, he says, part of the value of a multidisciplinary approach to med rec is that it can help hospitalists improve patient care. By having nurses, physicians, and pharmacists working together, more potential adverse drug events could be prevented, Dr. Feldman says.

"That data-gathering is difficult and time-consuming, and it is not something hospitalists need do on their own," he adds.

A paper published in the May/June issue of the Journal of Hospital Medicine shows that a collaborative approach to medication reconciliation ("med rec") appears to both prevent adverse drug events and pay for itself.

The paper, "Nurse-Pharmacist Collaboration on Medication Reconciliation Prevents Potential Harm," found that 225 of 500 surveyed patients had at least one unintended discrepancy in their house medication list (HML) on admission or discharge. And 162 of those patients had a discrepancy ranked on the upper end of the study's risk scale.

However, having nurses and pharmacists work together "allowed many discrepancies to be reconciled before causing harm," the study concluded.

"It absolutely supports the idea that we need to approach medicine as a team game," says hospitalist and lead author Lenny Feldman, MD, FACP, FAAP, SFHM, of John Hopkins School of Medicine in Baltimore. "We can't do this alone, and patients don't do better when we do this alone."

The study noted that it cost $113.64 to find one potentially harmful medication discrepancy. To offset those costs, an institution would have to prevent one discrepancy for every 290 patient encounters. The Johns Hopkins team averted 81 such events, but Dr. Feldman notes that without a control group, it’s difficult to say how many of those potential issues would have been caught at some other point in a patient's stay.

Still, he says, part of the value of a multidisciplinary approach to med rec is that it can help hospitalists improve patient care. By having nurses, physicians, and pharmacists working together, more potential adverse drug events could be prevented, Dr. Feldman says.

"That data-gathering is difficult and time-consuming, and it is not something hospitalists need do on their own," he adds.

At first blush, some hospitalists might see it as bad news that a recent report found a pharmacist-assisted medication reconciliation ("med rec") intervention did not significantly reduce clinically important medication errors after discharge. But a deeper reading of the study tells a different story, says a hospitalist who worked on the report.

"This is the latest in our growing understanding of the roles of certain interventions on transitions of care," says Jeffrey Schnipper, MD, MPH, FHM, director of clinical research and an associate physician in the general medicine division at Brigham and Women's Hospitalist Service in Boston, and co-author of the study "Effect of a Pharmacist Intervention on Clinically Important Medication Errors after Hospital Discharge." "What I don't want to have happen is for people to read this article ... and say, 'Oh, pharmacists don't make a difference.' They absolutely make a difference. This is a more nuanced issue of who do they have the biggest impact with, and 'On top of what other interventions are you doing this?'"

The researchers set out to determine whether a pharmacist-delivered intervention on patients with low health literacy (including a post-discharge telephone call) would lower adverse drug events and other clinically important medication errors. They concluded that it did not (unadjusted incidence rate ratio, 0.92 [95% CI, 0.77 to 1.10]).

Dr. Schnipper says the impact was likely muted because the patients studied had higher health-literacy levels than researchers expected. Also, because most follow-up phone calls occurred within a few days of discharge, the intervention failed to capture any events that happened in the 30 days after discharge.

He also notes that the institutions that participated in the study have already implemented multiple med-rec interventions over the past few years. Hospitals that have not focused intently on the issue could find much larger gains from implementing pharmacist-led programs.

"If you're a hospital that has not been fixated on improving medication safety and transitions of care, I think pharmacists are huge," Dr. Schnipper says. "The key, then, is to focus them on the highest-risk patients."

At first blush, some hospitalists might see it as bad news that a recent report found a pharmacist-assisted medication reconciliation ("med rec") intervention did not significantly reduce clinically important medication errors after discharge. But a deeper reading of the study tells a different story, says a hospitalist who worked on the report.

"This is the latest in our growing understanding of the roles of certain interventions on transitions of care," says Jeffrey Schnipper, MD, MPH, FHM, director of clinical research and an associate physician in the general medicine division at Brigham and Women's Hospitalist Service in Boston, and co-author of the study "Effect of a Pharmacist Intervention on Clinically Important Medication Errors after Hospital Discharge." "What I don't want to have happen is for people to read this article ... and say, 'Oh, pharmacists don't make a difference.' They absolutely make a difference. This is a more nuanced issue of who do they have the biggest impact with, and 'On top of what other interventions are you doing this?'"

The researchers set out to determine whether a pharmacist-delivered intervention on patients with low health literacy (including a post-discharge telephone call) would lower adverse drug events and other clinically important medication errors. They concluded that it did not (unadjusted incidence rate ratio, 0.92 [95% CI, 0.77 to 1.10]).

Dr. Schnipper says the impact was likely muted because the patients studied had higher health-literacy levels than researchers expected. Also, because most follow-up phone calls occurred within a few days of discharge, the intervention failed to capture any events that happened in the 30 days after discharge.

He also notes that the institutions that participated in the study have already implemented multiple med-rec interventions over the past few years. Hospitals that have not focused intently on the issue could find much larger gains from implementing pharmacist-led programs.

"If you're a hospital that has not been fixated on improving medication safety and transitions of care, I think pharmacists are huge," Dr. Schnipper says. "The key, then, is to focus them on the highest-risk patients."

At first blush, some hospitalists might see it as bad news that a recent report found a pharmacist-assisted medication reconciliation ("med rec") intervention did not significantly reduce clinically important medication errors after discharge. But a deeper reading of the study tells a different story, says a hospitalist who worked on the report.

"This is the latest in our growing understanding of the roles of certain interventions on transitions of care," says Jeffrey Schnipper, MD, MPH, FHM, director of clinical research and an associate physician in the general medicine division at Brigham and Women's Hospitalist Service in Boston, and co-author of the study "Effect of a Pharmacist Intervention on Clinically Important Medication Errors after Hospital Discharge." "What I don't want to have happen is for people to read this article ... and say, 'Oh, pharmacists don't make a difference.' They absolutely make a difference. This is a more nuanced issue of who do they have the biggest impact with, and 'On top of what other interventions are you doing this?'"

The researchers set out to determine whether a pharmacist-delivered intervention on patients with low health literacy (including a post-discharge telephone call) would lower adverse drug events and other clinically important medication errors. They concluded that it did not (unadjusted incidence rate ratio, 0.92 [95% CI, 0.77 to 1.10]).

Dr. Schnipper says the impact was likely muted because the patients studied had higher health-literacy levels than researchers expected. Also, because most follow-up phone calls occurred within a few days of discharge, the intervention failed to capture any events that happened in the 30 days after discharge.

He also notes that the institutions that participated in the study have already implemented multiple med-rec interventions over the past few years. Hospitals that have not focused intently on the issue could find much larger gains from implementing pharmacist-led programs.

"If you're a hospital that has not been fixated on improving medication safety and transitions of care, I think pharmacists are huge," Dr. Schnipper says. "The key, then, is to focus them on the highest-risk patients."

Although Medicare's looming financial penalties for hospitals with excessive readmissions might seem like a blunt weapon, private health plans often have the flexibility to negotiate with partnering hospitals around incentives for readmissions prevention.

"We have arrangements with private insurance companies where we put at risk future compensation, based on achieving negotiated readmissions results," says Mark Carley, vice president of managed care and network development for Centura Health, a 13-hospital system in Colorado.

Payors, including United Healthcare, have developed their own readmissions programs and reporting mechanisms, although each program’s incentives are a little different, Carley says. Target rates are negotiated based on each hospital's readmissions in the previous 12-month period and national averages. The plan can also provide helpful data on its beneficiaries and other forms of assistance, because it wants to see the hospital hit the target, he adds. "If the target has been set too high, they may be willing to renegotiate."

But the plan doesn't tell the hospital how to reach that target.

"Where the complexity comes in is how we as a system implement internal policies and procedures to improve our care coordination, discharge processes, follow-up, and communication with downstream providers," says Carley. Centura Health's approach to readmissions has included close study of past performance data in search of opportunities for improvement, fine-tuning of the discharge planning process, and follow-up phone calls to patients and providers.

"In addition, we are working with post-acute providers to provide smoother transitions in the discharge process," he says.

Although Medicare's looming financial penalties for hospitals with excessive readmissions might seem like a blunt weapon, private health plans often have the flexibility to negotiate with partnering hospitals around incentives for readmissions prevention.

"We have arrangements with private insurance companies where we put at risk future compensation, based on achieving negotiated readmissions results," says Mark Carley, vice president of managed care and network development for Centura Health, a 13-hospital system in Colorado.

Payors, including United Healthcare, have developed their own readmissions programs and reporting mechanisms, although each program’s incentives are a little different, Carley says. Target rates are negotiated based on each hospital's readmissions in the previous 12-month period and national averages. The plan can also provide helpful data on its beneficiaries and other forms of assistance, because it wants to see the hospital hit the target, he adds. "If the target has been set too high, they may be willing to renegotiate."

But the plan doesn't tell the hospital how to reach that target.

"Where the complexity comes in is how we as a system implement internal policies and procedures to improve our care coordination, discharge processes, follow-up, and communication with downstream providers," says Carley. Centura Health's approach to readmissions has included close study of past performance data in search of opportunities for improvement, fine-tuning of the discharge planning process, and follow-up phone calls to patients and providers.

"In addition, we are working with post-acute providers to provide smoother transitions in the discharge process," he says.

Although Medicare's looming financial penalties for hospitals with excessive readmissions might seem like a blunt weapon, private health plans often have the flexibility to negotiate with partnering hospitals around incentives for readmissions prevention.

"We have arrangements with private insurance companies where we put at risk future compensation, based on achieving negotiated readmissions results," says Mark Carley, vice president of managed care and network development for Centura Health, a 13-hospital system in Colorado.

Payors, including United Healthcare, have developed their own readmissions programs and reporting mechanisms, although each program’s incentives are a little different, Carley says. Target rates are negotiated based on each hospital's readmissions in the previous 12-month period and national averages. The plan can also provide helpful data on its beneficiaries and other forms of assistance, because it wants to see the hospital hit the target, he adds. "If the target has been set too high, they may be willing to renegotiate."

But the plan doesn't tell the hospital how to reach that target.

"Where the complexity comes in is how we as a system implement internal policies and procedures to improve our care coordination, discharge processes, follow-up, and communication with downstream providers," says Carley. Centura Health's approach to readmissions has included close study of past performance data in search of opportunities for improvement, fine-tuning of the discharge planning process, and follow-up phone calls to patients and providers.

"In addition, we are working with post-acute providers to provide smoother transitions in the discharge process," he says.

Clinical question: Can a quality-improvement (QI) collaborative decrease patient identification (ID) band errors?

Background: ID band errors often result in medication errors and unsafe care. Consequently, correct patient identification, through the use of at least two identifiers, has been an ongoing Joint Commission National Patient Safety Goal. Although individual sites have demonstrated improvement in accuracy of patient identification, there have not been reports of dissemination of successful practices.

Study design: Collaborative quality-improvement initiative.

Setting: Six hospitals.

Synopsis: ID band audits in 11,377 patients were performed in the learning collaborative’s six participating hospitals.

The audits were organized primarily around monthly conference calls. The hospital settings were diverse: community hospitals, hospitals within an academic medical center, and freestanding children’s hospitals. The aim of the collaborative was to reduce ID band errors by 50% within a one-year time frame across the collective sites.

Key interventions included transparent data collection and reporting; engagement of staff, families and leadership; voluntary event reporting; and auditing of failures. The mean combined ID band failure rate decreased to 4% from 22% within 13 months, representing a 77% relative reduction (P<0.001).

QI collaboratives are not designed to specifically result in generalizable knowledge, yet they might produce widespread improvement, as this effort demonstrates. The careful documentation of iterative factors implemented across sites in this initiative provides a blueprint for hospitals looking to replicate this success. Additionally, the interventions represent feasible and logical concepts within the basic constructs of improvement science methodology.

Bottom line: A QI collaborative might result in rapid and significant reductions in ID band errors.

Citation: Phillips SC, Saysana M, Worley S, Hain PD. Reduction in pediatric identification band errors: a quality collaborative. Pediatrics. 2012;129(6):e1587-e1593.

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

Clinical question: Can a quality-improvement (QI) collaborative decrease patient identification (ID) band errors?

Background: ID band errors often result in medication errors and unsafe care. Consequently, correct patient identification, through the use of at least two identifiers, has been an ongoing Joint Commission National Patient Safety Goal. Although individual sites have demonstrated improvement in accuracy of patient identification, there have not been reports of dissemination of successful practices.

Study design: Collaborative quality-improvement initiative.

Setting: Six hospitals.

Synopsis: ID band audits in 11,377 patients were performed in the learning collaborative’s six participating hospitals.

The audits were organized primarily around monthly conference calls. The hospital settings were diverse: community hospitals, hospitals within an academic medical center, and freestanding children’s hospitals. The aim of the collaborative was to reduce ID band errors by 50% within a one-year time frame across the collective sites.

Key interventions included transparent data collection and reporting; engagement of staff, families and leadership; voluntary event reporting; and auditing of failures. The mean combined ID band failure rate decreased to 4% from 22% within 13 months, representing a 77% relative reduction (P<0.001).

QI collaboratives are not designed to specifically result in generalizable knowledge, yet they might produce widespread improvement, as this effort demonstrates. The careful documentation of iterative factors implemented across sites in this initiative provides a blueprint for hospitals looking to replicate this success. Additionally, the interventions represent feasible and logical concepts within the basic constructs of improvement science methodology.

Bottom line: A QI collaborative might result in rapid and significant reductions in ID band errors.

Citation: Phillips SC, Saysana M, Worley S, Hain PD. Reduction in pediatric identification band errors: a quality collaborative. Pediatrics. 2012;129(6):e1587-e1593.

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

Clinical question: Can a quality-improvement (QI) collaborative decrease patient identification (ID) band errors?

Background: ID band errors often result in medication errors and unsafe care. Consequently, correct patient identification, through the use of at least two identifiers, has been an ongoing Joint Commission National Patient Safety Goal. Although individual sites have demonstrated improvement in accuracy of patient identification, there have not been reports of dissemination of successful practices.

Study design: Collaborative quality-improvement initiative.

Setting: Six hospitals.

Synopsis: ID band audits in 11,377 patients were performed in the learning collaborative’s six participating hospitals.

The audits were organized primarily around monthly conference calls. The hospital settings were diverse: community hospitals, hospitals within an academic medical center, and freestanding children’s hospitals. The aim of the collaborative was to reduce ID band errors by 50% within a one-year time frame across the collective sites.

Key interventions included transparent data collection and reporting; engagement of staff, families and leadership; voluntary event reporting; and auditing of failures. The mean combined ID band failure rate decreased to 4% from 22% within 13 months, representing a 77% relative reduction (P<0.001).

QI collaboratives are not designed to specifically result in generalizable knowledge, yet they might produce widespread improvement, as this effort demonstrates. The careful documentation of iterative factors implemented across sites in this initiative provides a blueprint for hospitals looking to replicate this success. Additionally, the interventions represent feasible and logical concepts within the basic constructs of improvement science methodology.

Bottom line: A QI collaborative might result in rapid and significant reductions in ID band errors.

Citation: Phillips SC, Saysana M, Worley S, Hain PD. Reduction in pediatric identification band errors: a quality collaborative. Pediatrics. 2012;129(6):e1587-e1593.

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

More than 100 hospitals across the country have used Project BOOST to reduce readmissions and improve their discharge processes. You and your hospital can be next by applying for Project BOOST. The deadline for the next national cohort of Project BOOST is Sept. 1.

To improve your chances of acceptance, start soon. In addition to an online form, the application requires a letter of support from an executive sponsor from each institution.

In October, accepted Project BOOST sites will receive:

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

To start the application process, visit www.hospitalmedicine.org/boost.

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

More than 100 hospitals across the country have used Project BOOST to reduce readmissions and improve their discharge processes. You and your hospital can be next by applying for Project BOOST. The deadline for the next national cohort of Project BOOST is Sept. 1.

To improve your chances of acceptance, start soon. In addition to an online form, the application requires a letter of support from an executive sponsor from each institution.

In October, accepted Project BOOST sites will receive:

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

To start the application process, visit www.hospitalmedicine.org/boost.

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

More than 100 hospitals across the country have used Project BOOST to reduce readmissions and improve their discharge processes. You and your hospital can be next by applying for Project BOOST. The deadline for the next national cohort of Project BOOST is Sept. 1.

To improve your chances of acceptance, start soon. In addition to an online form, the application requires a letter of support from an executive sponsor from each institution.

In October, accepted Project BOOST sites will receive:

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

To start the application process, visit www.hospitalmedicine.org/boost.

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

We need to be focused more on measures that encourage joint responsibility and cooperation among providers, and are important to patients across hospital, post-acute, and ambulatory settings.

—Thomas B. Valuck, MD, JD, senior vice president of strategic partnerships, National Quality Forum, former CMS adviser

No longer content to be a passive purchaser of healthcare services, the Centers for Medicare & Medicaid Services (CMS) is becoming a savvier shopper, holding providers increasingly accountable for the quality and efficiency of the care they deliver. With its value-based purchasing (VPB) program for hospitals already in place, now it’s the physicians’ turn.

CMS is marching toward a value-based payment modifier program that will adjust physician reimbursement based on the relative quality and efficiency of care that physicians provide to Medicare fee-for-service patients. The program will begin January 2015 and will extend to all physicians in 2017. Like the hospital VBP program, it will be budget-neutral—meaning that payment will increase for some physicians but decrease for others.

The coming months mark a pivotal period for physicians as CMS tweaks its accountability apparatus in ways that will determine how reimbursement will rise and fall, for whom, and for what.

Menu of Metrics

In crafting the payment modifier program, CMS can tap performance metrics from several of its existing programs, including the Physician Quality Reporting System (PQRS), the soon-to-be-expanded Physician Compare website (www.medicare.gov/find-a-doctor/provider-search.aspx), and the Physician Feedback Program.

“These agendas are part of a continuum, and of equal importance, in the evolution toward physician value-based purchasing,” says Patrick J. Torcson, MD, MMM, FACP, SFHM, chair of SHM’s Performance Measurement and Reporting Committee, and director of hospital medicine at St. Tammany Parish Hospital in Covington, La.

PQRS began as a voluntary “pay for reporting” system that gave physicians a modest financial bonus (currently 0.5% of allowable Medicare charges) for submitting quality data (left). The Affordable Care Act (ACA) has since authorized CMS to penalize physicians who do not participate—1.5% of allowable Medicare charges beginning in 2015, and 2% in 2016.

The Physician Compare website, launched at the end of 2010, currently contains such rudimentary information as education, gender, and whether a physician is enrolled in Medicare and satisfactorily reports data to the PQRS. But as of January, the site will begin reporting some PQRS data, as well as other metrics.

CMS’ Physician Feedback Program provides quality and cost information to physicians in an effort to encourage them to improve the care they provide and its efficiency. CMS recently combined the program with its value-based payment modifier program as it moves toward physician reimbursement that it says will reward “value rather than volume.” The program, currently being piloted in Iowa, Nebraska, Kansas, and Missouri, issues to physicians confidential quality and resource use reports (QRURs) that compare their performance to peer groups in similar specialties by tracking PQRS results, Healthcare Effectiveness Data and Information Set (HEDIS) measures, and per-capita cost data and preventable hospital admission rates for various medical conditions. CMS will roll out the program nationwide next year.

Metrics Lack Relevance

Developing performance measures that capture the most relevant activities of physicians across many different specialties with equal validity is notoriously difficult—something that CMS acknowledges.¹

Assigning the right patient to the right physician (i.e. figuring out who contributed what care, in what proportion, to which patient) also is fraught with complications, especially in the inpatient care setting, where a patient is likely to see many different physicians during a hospitalization.

SHM president Shaun Frost, MD, SFHM, highlighted these challenges in a letter sent in May to acting CMS administrator Marilyn B. Tavenner in which he pointed to dramatic data deficiencies in the initial round of QRURs sent to Physician Feedback Program participants that included hospitalists in Iowa, Nebraska, Kansas and Missouri. Because hospitalists were categorized as general internal-medicine physicians in the reports, their per-capita cost of care was dramatically higher (73% higher, in one case study) than the average cost of all internal-medicine physicians. No allowance was made for distinguishing the outpatient-oriented practice of a general internist from the inherently more expensive inpatient-focused hospitalist practice.

In the case study reviewed by SHM, the hospitalist’s patients saw, on average, 28 different physicians over the course of a year, during which the hospitalist contributed to the care of many patients but did not direct the care of any one of them—facts that clearly highlight the difficulty of assigning responsibility and accountability for a patient’s care when comparing physician performance.

“Based on the measurement used in the QRUR, it seems likely that a hospitalist would be severely disadvantaged with the introduction of a value-based modifier based on the present QRUR methodology,” Dr. Frost wrote.

SHM is similarly critical of the PQRS measures, which Dr. Torcson says lack relevance to hospitalist practices. “We want to be defined as HM physicians with our own unique measures of quality and cost,” he says. “Our results will look very different from those of an internist with a primarily outpatient practice.”

Dr. Torcson notes that SHM is an active participant in providing feedback during CMS rule proposals and has offered to work with the CMS on further refining the measures. For example, SHM proposed adding additional measures related to care transitions, given their particular relevance to hospitalist practices.

Rule-Changing Reform

The disruptive innovation of CMS’ healthcare reform agenda might wind up being a game-changer that dramatically affects the contours of all provider performance reporting and incentive systems, redefining the issues of physician accountability and patient assignment.

“We’re going to need to figure out how to restructure our measurement systems to match our evolving healthcare delivery and payment systems,” says Thomas B. Valuck, MD, JD, senior vice president of strategic partnerships for the National Quality Forum and former CMS adviser to the VBP program. Healthcare quality reporting should focus more on measures that cut across care contexts and assess whether the care provided truly made a difference for patients—metrics such as health improvement, return to functional status, level of patient involvement in the management of their care, provider team coordination, and other patient needs and preferences, Dr. Valuck believes.

“We need to be focused more on measures that encourage joint responsibility and cooperation among providers, and are important to patients across hospital, post-acute, and ambulatory settings, rather than those that are compartmentalized to one setting or relevant only to specific diseases or subspecialties,” Dr. Valuck says.

Such measure sets, while still retaining some disease- and physician-specific metrics, ideally would be complementary with families of related measures at the community, state, and national levels, Dr. Valuck says. “Such a multidimensional framework can begin to tell a meaningful story about what’s happening to the patient, and how well our system is delivering the right care,” he adds.

Dr. Torcson says HM has a pioneering role to play in this evolution, and he notes that SHM has proposed that CMS harmonize measures that align hospital-based physician activities (e.g. hospital medicine, emergency medicine, anesthesia, radiology) with hospital-level performance agendas so that physicians practicing together in the hospital setting can report on measures that are relevant to both.

Christopher Guadagnino is a freelance medical writer in Philadelphia.

Reference

1. Centers for Medicare & Medicaid Services. Physician Quality Reporting System Town Hall Meeting. Available at: http://www.usqualitymeasures.org/shared/content/C4M_PQRS_transcript.pdf. Accessed July 3, 2012.

We need to be focused more on measures that encourage joint responsibility and cooperation among providers, and are important to patients across hospital, post-acute, and ambulatory settings.

—Thomas B. Valuck, MD, JD, senior vice president of strategic partnerships, National Quality Forum, former CMS adviser

No longer content to be a passive purchaser of healthcare services, the Centers for Medicare & Medicaid Services (CMS) is becoming a savvier shopper, holding providers increasingly accountable for the quality and efficiency of the care they deliver. With its value-based purchasing (VPB) program for hospitals already in place, now it’s the physicians’ turn.

CMS is marching toward a value-based payment modifier program that will adjust physician reimbursement based on the relative quality and efficiency of care that physicians provide to Medicare fee-for-service patients. The program will begin January 2015 and will extend to all physicians in 2017. Like the hospital VBP program, it will be budget-neutral—meaning that payment will increase for some physicians but decrease for others.

The coming months mark a pivotal period for physicians as CMS tweaks its accountability apparatus in ways that will determine how reimbursement will rise and fall, for whom, and for what.

Menu of Metrics

In crafting the payment modifier program, CMS can tap performance metrics from several of its existing programs, including the Physician Quality Reporting System (PQRS), the soon-to-be-expanded Physician Compare website (www.medicare.gov/find-a-doctor/provider-search.aspx), and the Physician Feedback Program.

“These agendas are part of a continuum, and of equal importance, in the evolution toward physician value-based purchasing,” says Patrick J. Torcson, MD, MMM, FACP, SFHM, chair of SHM’s Performance Measurement and Reporting Committee, and director of hospital medicine at St. Tammany Parish Hospital in Covington, La.

PQRS began as a voluntary “pay for reporting” system that gave physicians a modest financial bonus (currently 0.5% of allowable Medicare charges) for submitting quality data (left). The Affordable Care Act (ACA) has since authorized CMS to penalize physicians who do not participate—1.5% of allowable Medicare charges beginning in 2015, and 2% in 2016.

The Physician Compare website, launched at the end of 2010, currently contains such rudimentary information as education, gender, and whether a physician is enrolled in Medicare and satisfactorily reports data to the PQRS. But as of January, the site will begin reporting some PQRS data, as well as other metrics.

CMS’ Physician Feedback Program provides quality and cost information to physicians in an effort to encourage them to improve the care they provide and its efficiency. CMS recently combined the program with its value-based payment modifier program as it moves toward physician reimbursement that it says will reward “value rather than volume.” The program, currently being piloted in Iowa, Nebraska, Kansas, and Missouri, issues to physicians confidential quality and resource use reports (QRURs) that compare their performance to peer groups in similar specialties by tracking PQRS results, Healthcare Effectiveness Data and Information Set (HEDIS) measures, and per-capita cost data and preventable hospital admission rates for various medical conditions. CMS will roll out the program nationwide next year.

Metrics Lack Relevance

Developing performance measures that capture the most relevant activities of physicians across many different specialties with equal validity is notoriously difficult—something that CMS acknowledges.¹

Assigning the right patient to the right physician (i.e. figuring out who contributed what care, in what proportion, to which patient) also is fraught with complications, especially in the inpatient care setting, where a patient is likely to see many different physicians during a hospitalization.

SHM president Shaun Frost, MD, SFHM, highlighted these challenges in a letter sent in May to acting CMS administrator Marilyn B. Tavenner in which he pointed to dramatic data deficiencies in the initial round of QRURs sent to Physician Feedback Program participants that included hospitalists in Iowa, Nebraska, Kansas and Missouri. Because hospitalists were categorized as general internal-medicine physicians in the reports, their per-capita cost of care was dramatically higher (73% higher, in one case study) than the average cost of all internal-medicine physicians. No allowance was made for distinguishing the outpatient-oriented practice of a general internist from the inherently more expensive inpatient-focused hospitalist practice.

In the case study reviewed by SHM, the hospitalist’s patients saw, on average, 28 different physicians over the course of a year, during which the hospitalist contributed to the care of many patients but did not direct the care of any one of them—facts that clearly highlight the difficulty of assigning responsibility and accountability for a patient’s care when comparing physician performance.

“Based on the measurement used in the QRUR, it seems likely that a hospitalist would be severely disadvantaged with the introduction of a value-based modifier based on the present QRUR methodology,” Dr. Frost wrote.

SHM is similarly critical of the PQRS measures, which Dr. Torcson says lack relevance to hospitalist practices. “We want to be defined as HM physicians with our own unique measures of quality and cost,” he says. “Our results will look very different from those of an internist with a primarily outpatient practice.”

Dr. Torcson notes that SHM is an active participant in providing feedback during CMS rule proposals and has offered to work with the CMS on further refining the measures. For example, SHM proposed adding additional measures related to care transitions, given their particular relevance to hospitalist practices.

Rule-Changing Reform

The disruptive innovation of CMS’ healthcare reform agenda might wind up being a game-changer that dramatically affects the contours of all provider performance reporting and incentive systems, redefining the issues of physician accountability and patient assignment.

“We’re going to need to figure out how to restructure our measurement systems to match our evolving healthcare delivery and payment systems,” says Thomas B. Valuck, MD, JD, senior vice president of strategic partnerships for the National Quality Forum and former CMS adviser to the VBP program. Healthcare quality reporting should focus more on measures that cut across care contexts and assess whether the care provided truly made a difference for patients—metrics such as health improvement, return to functional status, level of patient involvement in the management of their care, provider team coordination, and other patient needs and preferences, Dr. Valuck believes.

“We need to be focused more on measures that encourage joint responsibility and cooperation among providers, and are important to patients across hospital, post-acute, and ambulatory settings, rather than those that are compartmentalized to one setting or relevant only to specific diseases or subspecialties,” Dr. Valuck says.

Such measure sets, while still retaining some disease- and physician-specific metrics, ideally would be complementary with families of related measures at the community, state, and national levels, Dr. Valuck says. “Such a multidimensional framework can begin to tell a meaningful story about what’s happening to the patient, and how well our system is delivering the right care,” he adds.

Dr. Torcson says HM has a pioneering role to play in this evolution, and he notes that SHM has proposed that CMS harmonize measures that align hospital-based physician activities (e.g. hospital medicine, emergency medicine, anesthesia, radiology) with hospital-level performance agendas so that physicians practicing together in the hospital setting can report on measures that are relevant to both.

Christopher Guadagnino is a freelance medical writer in Philadelphia.

Reference

1. Centers for Medicare & Medicaid Services. Physician Quality Reporting System Town Hall Meeting. Available at: http://www.usqualitymeasures.org/shared/content/C4M_PQRS_transcript.pdf. Accessed July 3, 2012.

We need to be focused more on measures that encourage joint responsibility and cooperation among providers, and are important to patients across hospital, post-acute, and ambulatory settings.

—Thomas B. Valuck, MD, JD, senior vice president of strategic partnerships, National Quality Forum, former CMS adviser

No longer content to be a passive purchaser of healthcare services, the Centers for Medicare & Medicaid Services (CMS) is becoming a savvier shopper, holding providers increasingly accountable for the quality and efficiency of the care they deliver. With its value-based purchasing (VPB) program for hospitals already in place, now it’s the physicians’ turn.

CMS is marching toward a value-based payment modifier program that will adjust physician reimbursement based on the relative quality and efficiency of care that physicians provide to Medicare fee-for-service patients. The program will begin January 2015 and will extend to all physicians in 2017. Like the hospital VBP program, it will be budget-neutral—meaning that payment will increase for some physicians but decrease for others.

The coming months mark a pivotal period for physicians as CMS tweaks its accountability apparatus in ways that will determine how reimbursement will rise and fall, for whom, and for what.

Menu of Metrics

In crafting the payment modifier program, CMS can tap performance metrics from several of its existing programs, including the Physician Quality Reporting System (PQRS), the soon-to-be-expanded Physician Compare website (www.medicare.gov/find-a-doctor/provider-search.aspx), and the Physician Feedback Program.

“These agendas are part of a continuum, and of equal importance, in the evolution toward physician value-based purchasing,” says Patrick J. Torcson, MD, MMM, FACP, SFHM, chair of SHM’s Performance Measurement and Reporting Committee, and director of hospital medicine at St. Tammany Parish Hospital in Covington, La.

PQRS began as a voluntary “pay for reporting” system that gave physicians a modest financial bonus (currently 0.5% of allowable Medicare charges) for submitting quality data (left). The Affordable Care Act (ACA) has since authorized CMS to penalize physicians who do not participate—1.5% of allowable Medicare charges beginning in 2015, and 2% in 2016.

The Physician Compare website, launched at the end of 2010, currently contains such rudimentary information as education, gender, and whether a physician is enrolled in Medicare and satisfactorily reports data to the PQRS. But as of January, the site will begin reporting some PQRS data, as well as other metrics.

CMS’ Physician Feedback Program provides quality and cost information to physicians in an effort to encourage them to improve the care they provide and its efficiency. CMS recently combined the program with its value-based payment modifier program as it moves toward physician reimbursement that it says will reward “value rather than volume.” The program, currently being piloted in Iowa, Nebraska, Kansas, and Missouri, issues to physicians confidential quality and resource use reports (QRURs) that compare their performance to peer groups in similar specialties by tracking PQRS results, Healthcare Effectiveness Data and Information Set (HEDIS) measures, and per-capita cost data and preventable hospital admission rates for various medical conditions. CMS will roll out the program nationwide next year.

Metrics Lack Relevance

Developing performance measures that capture the most relevant activities of physicians across many different specialties with equal validity is notoriously difficult—something that CMS acknowledges.¹

Assigning the right patient to the right physician (i.e. figuring out who contributed what care, in what proportion, to which patient) also is fraught with complications, especially in the inpatient care setting, where a patient is likely to see many different physicians during a hospitalization.

SHM president Shaun Frost, MD, SFHM, highlighted these challenges in a letter sent in May to acting CMS administrator Marilyn B. Tavenner in which he pointed to dramatic data deficiencies in the initial round of QRURs sent to Physician Feedback Program participants that included hospitalists in Iowa, Nebraska, Kansas and Missouri. Because hospitalists were categorized as general internal-medicine physicians in the reports, their per-capita cost of care was dramatically higher (73% higher, in one case study) than the average cost of all internal-medicine physicians. No allowance was made for distinguishing the outpatient-oriented practice of a general internist from the inherently more expensive inpatient-focused hospitalist practice.

In the case study reviewed by SHM, the hospitalist’s patients saw, on average, 28 different physicians over the course of a year, during which the hospitalist contributed to the care of many patients but did not direct the care of any one of them—facts that clearly highlight the difficulty of assigning responsibility and accountability for a patient’s care when comparing physician performance.

“Based on the measurement used in the QRUR, it seems likely that a hospitalist would be severely disadvantaged with the introduction of a value-based modifier based on the present QRUR methodology,” Dr. Frost wrote.

SHM is similarly critical of the PQRS measures, which Dr. Torcson says lack relevance to hospitalist practices. “We want to be defined as HM physicians with our own unique measures of quality and cost,” he says. “Our results will look very different from those of an internist with a primarily outpatient practice.”

Dr. Torcson notes that SHM is an active participant in providing feedback during CMS rule proposals and has offered to work with the CMS on further refining the measures. For example, SHM proposed adding additional measures related to care transitions, given their particular relevance to hospitalist practices.

Rule-Changing Reform

The disruptive innovation of CMS’ healthcare reform agenda might wind up being a game-changer that dramatically affects the contours of all provider performance reporting and incentive systems, redefining the issues of physician accountability and patient assignment.

“We’re going to need to figure out how to restructure our measurement systems to match our evolving healthcare delivery and payment systems,” says Thomas B. Valuck, MD, JD, senior vice president of strategic partnerships for the National Quality Forum and former CMS adviser to the VBP program. Healthcare quality reporting should focus more on measures that cut across care contexts and assess whether the care provided truly made a difference for patients—metrics such as health improvement, return to functional status, level of patient involvement in the management of their care, provider team coordination, and other patient needs and preferences, Dr. Valuck believes.

“We need to be focused more on measures that encourage joint responsibility and cooperation among providers, and are important to patients across hospital, post-acute, and ambulatory settings, rather than those that are compartmentalized to one setting or relevant only to specific diseases or subspecialties,” Dr. Valuck says.

Such measure sets, while still retaining some disease- and physician-specific metrics, ideally would be complementary with families of related measures at the community, state, and national levels, Dr. Valuck says. “Such a multidimensional framework can begin to tell a meaningful story about what’s happening to the patient, and how well our system is delivering the right care,” he adds.

Dr. Torcson says HM has a pioneering role to play in this evolution, and he notes that SHM has proposed that CMS harmonize measures that align hospital-based physician activities (e.g. hospital medicine, emergency medicine, anesthesia, radiology) with hospital-level performance agendas so that physicians practicing together in the hospital setting can report on measures that are relevant to both.

Christopher Guadagnino is a freelance medical writer in Philadelphia.

Reference

1. Centers for Medicare & Medicaid Services. Physician Quality Reporting System Town Hall Meeting. Available at: http://www.usqualitymeasures.org/shared/content/C4M_PQRS_transcript.pdf. Accessed July 3, 2012.

The most recent report on hospital quality issued by independent healthcare rating company HealthGrades estimates that 254,000 safety incidents that occurred in U.S. hospitals from 2008 to 2010 could have been prevented, and that 56,367 hospitalized patients who died experienced one or more of those preventable events.¹

Drawing upon consumer-reported quality data in CMS’ Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey, HealthGrades concluded that 15% more patient safety incidents occurred at hospitals who ranked lowest (the bottom 10%) on the quality of their physician communication.

Reference

1. CPM Healthgrades. Patient safety and satisfaction: the state of American hospitals. CPM Healthgrades website. Available at: https://www.cpm.com/CPM/assets/File/HealthGradesPatientSafetySatisfactionReport2012.pdf. Accessed July 8, 2012.

The most recent report on hospital quality issued by independent healthcare rating company HealthGrades estimates that 254,000 safety incidents that occurred in U.S. hospitals from 2008 to 2010 could have been prevented, and that 56,367 hospitalized patients who died experienced one or more of those preventable events.¹

Drawing upon consumer-reported quality data in CMS’ Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey, HealthGrades concluded that 15% more patient safety incidents occurred at hospitals who ranked lowest (the bottom 10%) on the quality of their physician communication.

Reference

1. CPM Healthgrades. Patient safety and satisfaction: the state of American hospitals. CPM Healthgrades website. Available at: https://www.cpm.com/CPM/assets/File/HealthGradesPatientSafetySatisfactionReport2012.pdf. Accessed July 8, 2012.

The most recent report on hospital quality issued by independent healthcare rating company HealthGrades estimates that 254,000 safety incidents that occurred in U.S. hospitals from 2008 to 2010 could have been prevented, and that 56,367 hospitalized patients who died experienced one or more of those preventable events.¹

Drawing upon consumer-reported quality data in CMS’ Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey, HealthGrades concluded that 15% more patient safety incidents occurred at hospitals who ranked lowest (the bottom 10%) on the quality of their physician communication.

Reference

1. CPM Healthgrades. Patient safety and satisfaction: the state of American hospitals. CPM Healthgrades website. Available at: https://www.cpm.com/CPM/assets/File/HealthGradesPatientSafetySatisfactionReport2012.pdf. Accessed July 8, 2012.