QI Initiatives

Robert Wood Johnson University Hospital in Hamilton, N.J., has partnered with Jewish Family and Children’s Services of Greater Mercer County to support care transitions for 350 chronically ill older patients. Patients will receive a transitions coach following hospital discharge for education, support, and encouragement to keep appointments with their physicians. This “coach” will develop a plan of care for the patient, making one hospital visit, one home visit, and three phone calls, says Joyce Schwarz, the hospital’s vice president of quality and the project’s director.

The hospital received a $300,000 grant under the New Jersey Health Initiative from the Robert Wood Johnson Foundation to use an evidence-based intervention to improve care transitions and reduce readmissions, acting as a bridge between hospital personnel and community physicians.

Robert Wood Johnson University Hospital in Hamilton, N.J., has partnered with Jewish Family and Children’s Services of Greater Mercer County to support care transitions for 350 chronically ill older patients. Patients will receive a transitions coach following hospital discharge for education, support, and encouragement to keep appointments with their physicians. This “coach” will develop a plan of care for the patient, making one hospital visit, one home visit, and three phone calls, says Joyce Schwarz, the hospital’s vice president of quality and the project’s director.

The hospital received a $300,000 grant under the New Jersey Health Initiative from the Robert Wood Johnson Foundation to use an evidence-based intervention to improve care transitions and reduce readmissions, acting as a bridge between hospital personnel and community physicians.

Robert Wood Johnson University Hospital in Hamilton, N.J., has partnered with Jewish Family and Children’s Services of Greater Mercer County to support care transitions for 350 chronically ill older patients. Patients will receive a transitions coach following hospital discharge for education, support, and encouragement to keep appointments with their physicians. This “coach” will develop a plan of care for the patient, making one hospital visit, one home visit, and three phone calls, says Joyce Schwarz, the hospital’s vice president of quality and the project’s director.

The hospital received a $300,000 grant under the New Jersey Health Initiative from the Robert Wood Johnson Foundation to use an evidence-based intervention to improve care transitions and reduce readmissions, acting as a bridge between hospital personnel and community physicians.

PRO

Observational, database studies provide a powerful QI supplement

The proposed rules by the Centers for Medicare & Medicaid Services (CMS), which will allow access to patient-protected Medicare data, will provide for greater transparency and for data that could be utilized toward comparative-effectiveness research (CER). Thus, these rules have the potential to improve the quality of healthcare and impact patient safety.

The Institute of Medicine in December 1999 issued its now-famous article “To Err is Human,” which reported that medical errors cause up to 98,000 deaths and more than 1 million injuries each year in the U.S.⁶ However, the evidence shows minimal impact on improving patient safety in the past 10 years.

A retrospective study of 10 North Carolina hospitals reported in the New England Journal of Medicine by Landrigan and colleagues found that harms resulting from medical care remained extremely common, with little evidence for improvement.⁷ It also is estimated that it takes 17 years on average for clinical research to become incorporated into the majority of clinical practices.⁸ Although the randomized control trial (RCT) is unquestionably the best research tool to explore simple components of clinical care (i.e. tests, drugs, and procedures), its translation into daily clinical practice remains difficult.

Improving the process of care leading to quality remains an extremely difficult proposition based on such sociological issues as resistance to change, the need for interdisciplinary teamwork, level of support staff, economic factors, information retrieval inadequacies, and, most important, the complexity of patients with multiple comorbidities that do not fit the parameters of the RCT.

Don Berwick, MD, the lead author in the landmark IOM report and currently CMS administrator, has stated “in such complex terrain, the RCT is an impoverished way to learn.”⁹ Factors that cause this chasm include:¹⁰

• Too narrowly focused RCT;
• More required resources, including financial and personnel support with RCT, compared with usually clinical practices;
• Lack of collaboration between academic medical center researchers and community clinicians; and
• Lack of expertise and experience to undertake quality improvement in healthcare.

CER has received a $1.1 billion investment with the passage of the American Recovery and Reinvestment Act to provide evidence on the effectiveness, benefits, and harms of various treatment options.¹¹ As part of this research to improve IOM’s goals to improve healthcare, better evidence is desperately needed to cross the translational gap between clinical research and the bedside.¹² Observational outcome studies based on registries or databases derived primarily from clinical care can provide a powerful supplement to quality improvement.¹³

Thus, the ability to combine Medicare claims with other data through the Availability of Medicare Data for Performance Measurement would supply a wealth of information to potentially impact quality. As a cautionary note, safeguards such as provider review and appeal, monitoring the validity of the information, and only using the data for quality improvement are vital.

Dr. Holder is medical director of hospitalist services and chief medical information officer at Decatur (Ill.) Memorial Hospital. He is a member of Team Hospitalist.

CON

Unanswered questions, risks make CMS plan a bad idea

On June 8, the Centers for Medicare & Medicaid Services (CMS) proposed a rule to allow “qualified entities” access to patient-protected Medicare data for provider performance publication. CMS allowed 60 days for public comment and a start date of Jan. 1, 2012. But this controversial rule appeared with short notice, little discussion, and abbreviated opportunity for comment.

CMS maintains this rule will result in higher quality and more cost-effective care. Considering the present volume of data published on multiple performance parameters for both hospitals and providers, it would seem prudent to have solid data for efficacy prior to implementing more required reporting and costs to the industry.^1,2,3

Physicians and hospitals will have 30 days to review and verify three years of CMS claims data before it is released. The burden and cost of review will be borne by the private practices involved.¹ This process will impose added administrative costs, and it is unlikely three years of data can be carefully reviewed in just 30 days. If practitioners find the review too cumbersome and expensive, which is likely, they will forgo review, putting the accuracy of the data in question.

Quality data already is published for both physicians and hospitals. Is there evidence this process will significantly increase transparency? Adding more layers of administrative work for both CMS and caregivers—higher overhead without defined benefit—seems an ill-conceived idea. From an evidence-based-practice standpoint, where is the evidence that this rule will improve “quality” and make care “cost-effective”? Have the risks (added bureaucracy, increased overhead, questionable data) and benefits (added transparency) been evaluated?

Additionally, it is unclear who will be monitoring the quality of the data published and who will provide oversight for the “entities” to ensure these data are fairly and accurately presented. Who will pay for this oversight, and what recourse will be afforded physicians and hospitals that feel they have been wronged?^4,5

The “qualified entities” will pay CMS to cover their cost of providing data, raising concerns that this practice could evolve into patient-data “purchasing.” Although it is likely the selected entities will be industry leaders (or at least initially) with the capability to protect data, is this not another opportunity for misuse or corruption in the system?

Other issues not clearly addressed include the nature of the patient-protected information and who will interpret this data in a clinical context. How will these data be adjusted for patient comorbidities and case mix, or will the data be published without regard to these important confounders?^1,3

Publishing clinical data for quality assurance and feedback purposes is essential for quality care. Transparency has increased consumer confidence in the healthcare system and, indeed, has increased the healthcare system’s responsiveness to quality concerns. Granting the benefits of transparency, published data must be precise, accurate, and managed with good oversight in order to ensure the process does not target providers or skew results. Another program, especially one being fast-tracked and making once-protected patient information available to unspecified entities, raises many questions. Who will be watching these agencies for a clear interpretation? Is this yet another layer of CMS bureaucracy? In an era of evidence-based medicine, where is the evidence that this program will improve the system for the better?

Dr. Brezina is a hospitalist at Durham Regional Hospital in North Carolina.

References

1. Under the magnifying glass (again): CMS proposes new access to Medicare data for public provider performance reports. Bass, Berry and Sims website. Available at: http://www.bassberry.com/communicationscenter/newsletters/. Accessed Aug. 31, 2011.
2. Controversial rule to allow access to Medicare data. Modern Health website. Available at: http://www.modernHealthcare.com. Accessed Aug. 31, 2011.
3. Physician report cards must give correct grades. American Medical News website. Available at: http://www.ama-assn.org/amednews/2011/09/05/edsa0905.htm. Accessed Sept. 12, 2011.
4. OIG identifies huge lapses in hospital security, shifts its focus from CMS to OCR. Atlantic Information Services Inc. website. Available at: http://www.AISHealth.com. Accessed Sept. 12, 2011.
5. Berry M. Insurers mishandle 1 in 5 claims, AMA finds. American Medical News website. Available at: http://www.ama-assn.org/amednews/2011/07/04/prl20704.htm. Accessed Sept. 12, 2011.
6. Kohn LT, Corrigan JM, Donaldson MS, eds. To error is human: building a safer health system. Washington: National Academies Press; 1999.
7. Landrigan CP, Parry GJ, Bones CB, Hackbarth AD, Goldmann DA, Sharek PJ. Temporal trends in rates of patient harm resulting from medical care. N Engl J Med. 2010;363(22):2124-2134.
8. Institute of Medicine. Crossing the quality chasm: a new health system for the 21st century. Washington: National Academy Press; 2001:13.
9. Berwick DM. The science of improvement. JAMA. 2008;299(10):1182-1184.
10. Ting HH, Shojania KG, Montori VM, Bradley EH. Quality improvement science and action. Circulation. 2009;119:1962-1974.
11. Committee on Comparative Research Prioritization. Institute of Medicine Initial National Priorities for Comparative Effectiveness Research. Washington: National Academy Press; 2009.
12. Sullivan P, Goldman D. The promise of comparative effectiveness research. JAMA. 2011;305(4):400-401.
13. Washington AE, Lipstein SH. The patient-centered outcomes research institute: promoting better information, decisions and health. Sept. 28, 2011; DOI: 10.10.1056/NEJMp1109407.

PRO

Observational, database studies provide a powerful QI supplement

The proposed rules by the Centers for Medicare & Medicaid Services (CMS), which will allow access to patient-protected Medicare data, will provide for greater transparency and for data that could be utilized toward comparative-effectiveness research (CER). Thus, these rules have the potential to improve the quality of healthcare and impact patient safety.

The Institute of Medicine in December 1999 issued its now-famous article “To Err is Human,” which reported that medical errors cause up to 98,000 deaths and more than 1 million injuries each year in the U.S.⁶ However, the evidence shows minimal impact on improving patient safety in the past 10 years.

A retrospective study of 10 North Carolina hospitals reported in the New England Journal of Medicine by Landrigan and colleagues found that harms resulting from medical care remained extremely common, with little evidence for improvement.⁷ It also is estimated that it takes 17 years on average for clinical research to become incorporated into the majority of clinical practices.⁸ Although the randomized control trial (RCT) is unquestionably the best research tool to explore simple components of clinical care (i.e. tests, drugs, and procedures), its translation into daily clinical practice remains difficult.

Improving the process of care leading to quality remains an extremely difficult proposition based on such sociological issues as resistance to change, the need for interdisciplinary teamwork, level of support staff, economic factors, information retrieval inadequacies, and, most important, the complexity of patients with multiple comorbidities that do not fit the parameters of the RCT.

Don Berwick, MD, the lead author in the landmark IOM report and currently CMS administrator, has stated “in such complex terrain, the RCT is an impoverished way to learn.”⁹ Factors that cause this chasm include:¹⁰

• Too narrowly focused RCT;
• More required resources, including financial and personnel support with RCT, compared with usually clinical practices;
• Lack of collaboration between academic medical center researchers and community clinicians; and
• Lack of expertise and experience to undertake quality improvement in healthcare.

CER has received a $1.1 billion investment with the passage of the American Recovery and Reinvestment Act to provide evidence on the effectiveness, benefits, and harms of various treatment options.¹¹ As part of this research to improve IOM’s goals to improve healthcare, better evidence is desperately needed to cross the translational gap between clinical research and the bedside.¹² Observational outcome studies based on registries or databases derived primarily from clinical care can provide a powerful supplement to quality improvement.¹³

Thus, the ability to combine Medicare claims with other data through the Availability of Medicare Data for Performance Measurement would supply a wealth of information to potentially impact quality. As a cautionary note, safeguards such as provider review and appeal, monitoring the validity of the information, and only using the data for quality improvement are vital.

Dr. Holder is medical director of hospitalist services and chief medical information officer at Decatur (Ill.) Memorial Hospital. He is a member of Team Hospitalist.

CON

Unanswered questions, risks make CMS plan a bad idea

On June 8, the Centers for Medicare & Medicaid Services (CMS) proposed a rule to allow “qualified entities” access to patient-protected Medicare data for provider performance publication. CMS allowed 60 days for public comment and a start date of Jan. 1, 2012. But this controversial rule appeared with short notice, little discussion, and abbreviated opportunity for comment.

CMS maintains this rule will result in higher quality and more cost-effective care. Considering the present volume of data published on multiple performance parameters for both hospitals and providers, it would seem prudent to have solid data for efficacy prior to implementing more required reporting and costs to the industry.^1,2,3

Physicians and hospitals will have 30 days to review and verify three years of CMS claims data before it is released. The burden and cost of review will be borne by the private practices involved.¹ This process will impose added administrative costs, and it is unlikely three years of data can be carefully reviewed in just 30 days. If practitioners find the review too cumbersome and expensive, which is likely, they will forgo review, putting the accuracy of the data in question.

Quality data already is published for both physicians and hospitals. Is there evidence this process will significantly increase transparency? Adding more layers of administrative work for both CMS and caregivers—higher overhead without defined benefit—seems an ill-conceived idea. From an evidence-based-practice standpoint, where is the evidence that this rule will improve “quality” and make care “cost-effective”? Have the risks (added bureaucracy, increased overhead, questionable data) and benefits (added transparency) been evaluated?

Additionally, it is unclear who will be monitoring the quality of the data published and who will provide oversight for the “entities” to ensure these data are fairly and accurately presented. Who will pay for this oversight, and what recourse will be afforded physicians and hospitals that feel they have been wronged?^4,5

The “qualified entities” will pay CMS to cover their cost of providing data, raising concerns that this practice could evolve into patient-data “purchasing.” Although it is likely the selected entities will be industry leaders (or at least initially) with the capability to protect data, is this not another opportunity for misuse or corruption in the system?

Other issues not clearly addressed include the nature of the patient-protected information and who will interpret this data in a clinical context. How will these data be adjusted for patient comorbidities and case mix, or will the data be published without regard to these important confounders?^1,3

Publishing clinical data for quality assurance and feedback purposes is essential for quality care. Transparency has increased consumer confidence in the healthcare system and, indeed, has increased the healthcare system’s responsiveness to quality concerns. Granting the benefits of transparency, published data must be precise, accurate, and managed with good oversight in order to ensure the process does not target providers or skew results. Another program, especially one being fast-tracked and making once-protected patient information available to unspecified entities, raises many questions. Who will be watching these agencies for a clear interpretation? Is this yet another layer of CMS bureaucracy? In an era of evidence-based medicine, where is the evidence that this program will improve the system for the better?

Dr. Brezina is a hospitalist at Durham Regional Hospital in North Carolina.

References

1. Under the magnifying glass (again): CMS proposes new access to Medicare data for public provider performance reports. Bass, Berry and Sims website. Available at: http://www.bassberry.com/communicationscenter/newsletters/. Accessed Aug. 31, 2011.
2. Controversial rule to allow access to Medicare data. Modern Health website. Available at: http://www.modernHealthcare.com. Accessed Aug. 31, 2011.
3. Physician report cards must give correct grades. American Medical News website. Available at: http://www.ama-assn.org/amednews/2011/09/05/edsa0905.htm. Accessed Sept. 12, 2011.
4. OIG identifies huge lapses in hospital security, shifts its focus from CMS to OCR. Atlantic Information Services Inc. website. Available at: http://www.AISHealth.com. Accessed Sept. 12, 2011.
5. Berry M. Insurers mishandle 1 in 5 claims, AMA finds. American Medical News website. Available at: http://www.ama-assn.org/amednews/2011/07/04/prl20704.htm. Accessed Sept. 12, 2011.
6. Kohn LT, Corrigan JM, Donaldson MS, eds. To error is human: building a safer health system. Washington: National Academies Press; 1999.
7. Landrigan CP, Parry GJ, Bones CB, Hackbarth AD, Goldmann DA, Sharek PJ. Temporal trends in rates of patient harm resulting from medical care. N Engl J Med. 2010;363(22):2124-2134.
8. Institute of Medicine. Crossing the quality chasm: a new health system for the 21st century. Washington: National Academy Press; 2001:13.
9. Berwick DM. The science of improvement. JAMA. 2008;299(10):1182-1184.
10. Ting HH, Shojania KG, Montori VM, Bradley EH. Quality improvement science and action. Circulation. 2009;119:1962-1974.
11. Committee on Comparative Research Prioritization. Institute of Medicine Initial National Priorities for Comparative Effectiveness Research. Washington: National Academy Press; 2009.
12. Sullivan P, Goldman D. The promise of comparative effectiveness research. JAMA. 2011;305(4):400-401.
13. Washington AE, Lipstein SH. The patient-centered outcomes research institute: promoting better information, decisions and health. Sept. 28, 2011; DOI: 10.10.1056/NEJMp1109407.

PRO

Observational, database studies provide a powerful QI supplement

The proposed rules by the Centers for Medicare & Medicaid Services (CMS), which will allow access to patient-protected Medicare data, will provide for greater transparency and for data that could be utilized toward comparative-effectiveness research (CER). Thus, these rules have the potential to improve the quality of healthcare and impact patient safety.

The Institute of Medicine in December 1999 issued its now-famous article “To Err is Human,” which reported that medical errors cause up to 98,000 deaths and more than 1 million injuries each year in the U.S.⁶ However, the evidence shows minimal impact on improving patient safety in the past 10 years.

A retrospective study of 10 North Carolina hospitals reported in the New England Journal of Medicine by Landrigan and colleagues found that harms resulting from medical care remained extremely common, with little evidence for improvement.⁷ It also is estimated that it takes 17 years on average for clinical research to become incorporated into the majority of clinical practices.⁸ Although the randomized control trial (RCT) is unquestionably the best research tool to explore simple components of clinical care (i.e. tests, drugs, and procedures), its translation into daily clinical practice remains difficult.

Improving the process of care leading to quality remains an extremely difficult proposition based on such sociological issues as resistance to change, the need for interdisciplinary teamwork, level of support staff, economic factors, information retrieval inadequacies, and, most important, the complexity of patients with multiple comorbidities that do not fit the parameters of the RCT.

Don Berwick, MD, the lead author in the landmark IOM report and currently CMS administrator, has stated “in such complex terrain, the RCT is an impoverished way to learn.”⁹ Factors that cause this chasm include:¹⁰

• Too narrowly focused RCT;
• More required resources, including financial and personnel support with RCT, compared with usually clinical practices;
• Lack of collaboration between academic medical center researchers and community clinicians; and
• Lack of expertise and experience to undertake quality improvement in healthcare.

CER has received a $1.1 billion investment with the passage of the American Recovery and Reinvestment Act to provide evidence on the effectiveness, benefits, and harms of various treatment options.¹¹ As part of this research to improve IOM’s goals to improve healthcare, better evidence is desperately needed to cross the translational gap between clinical research and the bedside.¹² Observational outcome studies based on registries or databases derived primarily from clinical care can provide a powerful supplement to quality improvement.¹³

Thus, the ability to combine Medicare claims with other data through the Availability of Medicare Data for Performance Measurement would supply a wealth of information to potentially impact quality. As a cautionary note, safeguards such as provider review and appeal, monitoring the validity of the information, and only using the data for quality improvement are vital.

Dr. Holder is medical director of hospitalist services and chief medical information officer at Decatur (Ill.) Memorial Hospital. He is a member of Team Hospitalist.

CON

Unanswered questions, risks make CMS plan a bad idea

On June 8, the Centers for Medicare & Medicaid Services (CMS) proposed a rule to allow “qualified entities” access to patient-protected Medicare data for provider performance publication. CMS allowed 60 days for public comment and a start date of Jan. 1, 2012. But this controversial rule appeared with short notice, little discussion, and abbreviated opportunity for comment.

CMS maintains this rule will result in higher quality and more cost-effective care. Considering the present volume of data published on multiple performance parameters for both hospitals and providers, it would seem prudent to have solid data for efficacy prior to implementing more required reporting and costs to the industry.^1,2,3

Physicians and hospitals will have 30 days to review and verify three years of CMS claims data before it is released. The burden and cost of review will be borne by the private practices involved.¹ This process will impose added administrative costs, and it is unlikely three years of data can be carefully reviewed in just 30 days. If practitioners find the review too cumbersome and expensive, which is likely, they will forgo review, putting the accuracy of the data in question.

Quality data already is published for both physicians and hospitals. Is there evidence this process will significantly increase transparency? Adding more layers of administrative work for both CMS and caregivers—higher overhead without defined benefit—seems an ill-conceived idea. From an evidence-based-practice standpoint, where is the evidence that this rule will improve “quality” and make care “cost-effective”? Have the risks (added bureaucracy, increased overhead, questionable data) and benefits (added transparency) been evaluated?

Additionally, it is unclear who will be monitoring the quality of the data published and who will provide oversight for the “entities” to ensure these data are fairly and accurately presented. Who will pay for this oversight, and what recourse will be afforded physicians and hospitals that feel they have been wronged?^4,5

The “qualified entities” will pay CMS to cover their cost of providing data, raising concerns that this practice could evolve into patient-data “purchasing.” Although it is likely the selected entities will be industry leaders (or at least initially) with the capability to protect data, is this not another opportunity for misuse or corruption in the system?

Other issues not clearly addressed include the nature of the patient-protected information and who will interpret this data in a clinical context. How will these data be adjusted for patient comorbidities and case mix, or will the data be published without regard to these important confounders?^1,3

Publishing clinical data for quality assurance and feedback purposes is essential for quality care. Transparency has increased consumer confidence in the healthcare system and, indeed, has increased the healthcare system’s responsiveness to quality concerns. Granting the benefits of transparency, published data must be precise, accurate, and managed with good oversight in order to ensure the process does not target providers or skew results. Another program, especially one being fast-tracked and making once-protected patient information available to unspecified entities, raises many questions. Who will be watching these agencies for a clear interpretation? Is this yet another layer of CMS bureaucracy? In an era of evidence-based medicine, where is the evidence that this program will improve the system for the better?

Dr. Brezina is a hospitalist at Durham Regional Hospital in North Carolina.

References

1. Under the magnifying glass (again): CMS proposes new access to Medicare data for public provider performance reports. Bass, Berry and Sims website. Available at: http://www.bassberry.com/communicationscenter/newsletters/. Accessed Aug. 31, 2011.
2. Controversial rule to allow access to Medicare data. Modern Health website. Available at: http://www.modernHealthcare.com. Accessed Aug. 31, 2011.
3. Physician report cards must give correct grades. American Medical News website. Available at: http://www.ama-assn.org/amednews/2011/09/05/edsa0905.htm. Accessed Sept. 12, 2011.
4. OIG identifies huge lapses in hospital security, shifts its focus from CMS to OCR. Atlantic Information Services Inc. website. Available at: http://www.AISHealth.com. Accessed Sept. 12, 2011.
5. Berry M. Insurers mishandle 1 in 5 claims, AMA finds. American Medical News website. Available at: http://www.ama-assn.org/amednews/2011/07/04/prl20704.htm. Accessed Sept. 12, 2011.
6. Kohn LT, Corrigan JM, Donaldson MS, eds. To error is human: building a safer health system. Washington: National Academies Press; 1999.
7. Landrigan CP, Parry GJ, Bones CB, Hackbarth AD, Goldmann DA, Sharek PJ. Temporal trends in rates of patient harm resulting from medical care. N Engl J Med. 2010;363(22):2124-2134.
8. Institute of Medicine. Crossing the quality chasm: a new health system for the 21st century. Washington: National Academy Press; 2001:13.
9. Berwick DM. The science of improvement. JAMA. 2008;299(10):1182-1184.
10. Ting HH, Shojania KG, Montori VM, Bradley EH. Quality improvement science and action. Circulation. 2009;119:1962-1974.
11. Committee on Comparative Research Prioritization. Institute of Medicine Initial National Priorities for Comparative Effectiveness Research. Washington: National Academy Press; 2009.
12. Sullivan P, Goldman D. The promise of comparative effectiveness research. JAMA. 2011;305(4):400-401.
13. Washington AE, Lipstein SH. The patient-centered outcomes research institute: promoting better information, decisions and health. Sept. 28, 2011; DOI: 10.10.1056/NEJMp1109407.

A new study evaluating outcomes for hospitals participating in the American Heart Association’s Get with the Guidelines program found no correlation between high performance on adhering to measures and care standards for acute myocardial infarction and for heart failure despite overlap between the sets of care processes (J Am Coll Cardio. 2011;58:637-644).

A total of 400,000 heart patients were studied, and 283 participating hospitals were stratified into thirds based on their adherence to core quality measures for each disease, with the upper third labeled superior in performance. Lead author Tracy Wang, MD, MHS, MSc, of the Duke Clinical Research Institute in Durham, N.C., and colleagues found that superior performance for only one of the two diseases led to such end-result outcomes as in-hospital mortality that were no better than for hospitals that were not high performers for either condition. But hospitals with superior performance for both conditions had lower in-hospital mortality rates.

“Perhaps quality is more than just following checklists,” Dr. Wang says. “There’s something special about these high-performing hospitals across the board, with better QI, perhaps a little more investment in infrastructure for quality.”

This result, Dr. Wang says, should give ammunition for hospitalists and other physicians to go to their hospital administrators to request more investment in quality improvement overall, not just for specific conditions.

A new study evaluating outcomes for hospitals participating in the American Heart Association’s Get with the Guidelines program found no correlation between high performance on adhering to measures and care standards for acute myocardial infarction and for heart failure despite overlap between the sets of care processes (J Am Coll Cardio. 2011;58:637-644).

A total of 400,000 heart patients were studied, and 283 participating hospitals were stratified into thirds based on their adherence to core quality measures for each disease, with the upper third labeled superior in performance. Lead author Tracy Wang, MD, MHS, MSc, of the Duke Clinical Research Institute in Durham, N.C., and colleagues found that superior performance for only one of the two diseases led to such end-result outcomes as in-hospital mortality that were no better than for hospitals that were not high performers for either condition. But hospitals with superior performance for both conditions had lower in-hospital mortality rates.

“Perhaps quality is more than just following checklists,” Dr. Wang says. “There’s something special about these high-performing hospitals across the board, with better QI, perhaps a little more investment in infrastructure for quality.”

This result, Dr. Wang says, should give ammunition for hospitalists and other physicians to go to their hospital administrators to request more investment in quality improvement overall, not just for specific conditions.

A new study evaluating outcomes for hospitals participating in the American Heart Association’s Get with the Guidelines program found no correlation between high performance on adhering to measures and care standards for acute myocardial infarction and for heart failure despite overlap between the sets of care processes (J Am Coll Cardio. 2011;58:637-644).

A total of 400,000 heart patients were studied, and 283 participating hospitals were stratified into thirds based on their adherence to core quality measures for each disease, with the upper third labeled superior in performance. Lead author Tracy Wang, MD, MHS, MSc, of the Duke Clinical Research Institute in Durham, N.C., and colleagues found that superior performance for only one of the two diseases led to such end-result outcomes as in-hospital mortality that were no better than for hospitals that were not high performers for either condition. But hospitals with superior performance for both conditions had lower in-hospital mortality rates.

“Perhaps quality is more than just following checklists,” Dr. Wang says. “There’s something special about these high-performing hospitals across the board, with better QI, perhaps a little more investment in infrastructure for quality.”

This result, Dr. Wang says, should give ammunition for hospitalists and other physicians to go to their hospital administrators to request more investment in quality improvement overall, not just for specific conditions.

A new Joint Commission program offering advanced certification for hospital-based palliative-care services is accepting applications and conducting daylong surveys through the end of this month. As with the Joint Commission’s reviews of other specialty services (e.g. primary stroke centers), certification is narrower in scope, with service-specific evaluation of care and outcomes, than a full accreditation survey—which is an organizationwide evaluation of core processes and functions.

Advanced certification in palliative care is voluntary for the steadily growing number of acute-care hospitals offering palliative-care services (1,568, according to the latest count by the American Hospital Association), but the hospital seeking it must be accredited by the Joint Commission.1 Certification is intended for formal, defined, inpatient palliative care, whether dedicated units or consultation services, with the ability to direct clinical management of patients.

The core palliative-care team includes “licensed independent practitioners” (typically physicians), registered nurses, chaplains, and social workers.2 The service should follow palliative-care guidelines and evidence-based practice, and it must collect quality data on four performance measures—two of them clinical—and use these data to improve performance.

According to Michelle Sacco, the Joint Commission’s executive director for palliative care, evidence-based practice includes ensuring appropriate transitions to other community resources, such as hospices. She thinks the program is perfect for hospitalists, as HM increasingly is participating in palliative care in their hospitals. “This is also an opportunity to change the mindset that palliative care is for the end-stage only,” Sacco says.

Two-year certification costs $9,655, including the onsite review. For more information, visit the Joint Commission website (www.jointcommission.org/certification) or the Center to Advance Palliative Care’s site (www.capc.org).

References

1. Palliative care in hospitals continues rapid growth for 10th straight year, according to latest analysis. Center to Advance Palliative Care website. Available at: www.capc.org/news-and-events/releases/07-14-11. Accessed Aug. 30, 2011.
2. The National Consensus Project’s Clinical Practice Guidelines for Quality Palliative Care. The National Consensus Project website. Available at: www.nationalconsensusproject.org/. Accessed Aug. 31, 2011.

A new Joint Commission program offering advanced certification for hospital-based palliative-care services is accepting applications and conducting daylong surveys through the end of this month. As with the Joint Commission’s reviews of other specialty services (e.g. primary stroke centers), certification is narrower in scope, with service-specific evaluation of care and outcomes, than a full accreditation survey—which is an organizationwide evaluation of core processes and functions.

Advanced certification in palliative care is voluntary for the steadily growing number of acute-care hospitals offering palliative-care services (1,568, according to the latest count by the American Hospital Association), but the hospital seeking it must be accredited by the Joint Commission.1 Certification is intended for formal, defined, inpatient palliative care, whether dedicated units or consultation services, with the ability to direct clinical management of patients.

The core palliative-care team includes “licensed independent practitioners” (typically physicians), registered nurses, chaplains, and social workers.2 The service should follow palliative-care guidelines and evidence-based practice, and it must collect quality data on four performance measures—two of them clinical—and use these data to improve performance.

According to Michelle Sacco, the Joint Commission’s executive director for palliative care, evidence-based practice includes ensuring appropriate transitions to other community resources, such as hospices. She thinks the program is perfect for hospitalists, as HM increasingly is participating in palliative care in their hospitals. “This is also an opportunity to change the mindset that palliative care is for the end-stage only,” Sacco says.

Two-year certification costs $9,655, including the onsite review. For more information, visit the Joint Commission website (www.jointcommission.org/certification) or the Center to Advance Palliative Care’s site (www.capc.org).

References

1. Palliative care in hospitals continues rapid growth for 10th straight year, according to latest analysis. Center to Advance Palliative Care website. Available at: www.capc.org/news-and-events/releases/07-14-11. Accessed Aug. 30, 2011.
2. The National Consensus Project’s Clinical Practice Guidelines for Quality Palliative Care. The National Consensus Project website. Available at: www.nationalconsensusproject.org/. Accessed Aug. 31, 2011.

A new Joint Commission program offering advanced certification for hospital-based palliative-care services is accepting applications and conducting daylong surveys through the end of this month. As with the Joint Commission’s reviews of other specialty services (e.g. primary stroke centers), certification is narrower in scope, with service-specific evaluation of care and outcomes, than a full accreditation survey—which is an organizationwide evaluation of core processes and functions.

Advanced certification in palliative care is voluntary for the steadily growing number of acute-care hospitals offering palliative-care services (1,568, according to the latest count by the American Hospital Association), but the hospital seeking it must be accredited by the Joint Commission.1 Certification is intended for formal, defined, inpatient palliative care, whether dedicated units or consultation services, with the ability to direct clinical management of patients.

The core palliative-care team includes “licensed independent practitioners” (typically physicians), registered nurses, chaplains, and social workers.2 The service should follow palliative-care guidelines and evidence-based practice, and it must collect quality data on four performance measures—two of them clinical—and use these data to improve performance.

According to Michelle Sacco, the Joint Commission’s executive director for palliative care, evidence-based practice includes ensuring appropriate transitions to other community resources, such as hospices. She thinks the program is perfect for hospitalists, as HM increasingly is participating in palliative care in their hospitals. “This is also an opportunity to change the mindset that palliative care is for the end-stage only,” Sacco says.

Two-year certification costs $9,655, including the onsite review. For more information, visit the Joint Commission website (www.jointcommission.org/certification) or the Center to Advance Palliative Care’s site (www.capc.org).

References

1. Palliative care in hospitals continues rapid growth for 10th straight year, according to latest analysis. Center to Advance Palliative Care website. Available at: www.capc.org/news-and-events/releases/07-14-11. Accessed Aug. 30, 2011.
2. The National Consensus Project’s Clinical Practice Guidelines for Quality Palliative Care. The National Consensus Project website. Available at: www.nationalconsensusproject.org/. Accessed Aug. 31, 2011.

At first glance, the deck might seem hopelessly stacked against hospitalists with regard to patient satisfaction. HM practitioners lack the long-term relationship with patients that many primary-care physicians (PCPs) have established. Unlike surgeons and other specialists, they tend to care for those patients—more complicated, lacking a regular doctor, or admitted through the ED, for example—who are more inclined to rate their hospital stay unfavorably.¹ They may not even be accurately remembered by patients who encounter multiple doctors during the course of their hospitalization.² And hospital information systems can misidentify the treating physician, while the actual surveys used to gauge hospitalists have been imperfect at best.³

And yet, the hospitalist model has evolved substantially on the question of how it can impact patient perceptions of care.

Initially, hospitalist champions adopted a largely defensive posture: The model would not negatively impact patient satisfaction as it delivered on efficiency—and later on quality. The healthcare system, however, is beginning to recognize the hospitalist as part of a care “team” whose patient-centered approach might pay big dividends in the inpatient experience and, eventually, on satisfaction scores.

“I think the next phase, which is a focus on the hospitalist as a team member and team builder, is going to be key,” says William Southern, MD, MPH, SFHM, chief of the division of hospital medicine at Montefiore Medical Center in Bronx, N.Y.

Recent studies suggest that hospitalists are helping to design and test new tools that will not only improve satisfaction, but also more fairly assess the impact of individual doctors. As the maturation process continues, experts say, hospitalists have an opportunity to influence both provider-based interventions and more programmatic decision-making that can have far-reaching effects. Certainly, the hand dealt to hospitalists is looking more favorable even as the ante has been raised with Medicare programs like value-based purchasing, and its pot of money tied to patient perceptions of care.

So how have hospitalists played their cards so far?

A Look at the Evidence

In its early years, the HM model faced a persistent criticism: Replacing traditional caregivers with these new inpatient providers in the name of efficiency would increase handoffs and, therefore, discontinuities of care delivered by a succession of unfamiliar faces. If patients didn’t see their PCP in the hospital, the thinking went, they might be more disgruntled at being tended to by hospitalists, leading to lower satisfaction scores.⁴

A particularly heated exchange played out in 1999 in the New England Journal of Medicine. Farris A. Manian, MD, MPH, of Infectious Disease Consultants in St. Louis wrote in one letter, “I am particularly concerned about what impressionable house-staff members will learn from hospitalists who place an inordinate emphasis on cost rather than the quality of patient care or teaching.”⁵

A few subsequent studies, however, hinted that such concerns might be overstated. A 2000 analysis in the American Journal of Medicine that examined North Mississippi Health Services in Tupelo, for instance, found that care administered by hospitalists led to a shorter length of stay and lower costs than care delivered by internists. Importantly, the study found that patient satisfaction was similar for both models, while quality metrics were likewise equal or even tilted slightly toward hospitalists.⁶

In their influential 2002 review of a profession that was only a half-decade old, Robert Wachter, MD, MHM, and Lee Goldman, MD, MPH, FACP from the University of California at San Francisco reinforced the message that HM wouldn’t lead to unhappy patients. “Empirical research supports the premise that hospitalists improve inpatient efficiency without harmful effects on quality or patient satisfaction,” they asserted.⁷

Among pediatric patients, a 2005 review found that “none of the four studies that evaluated patient satisfaction found statistically significant differences in satisfaction with inpatient care. However, two of the three evaluations that did assess parents’ satisfaction with care provided to their children found that parents were more satisfied with some aspects of care provided by hospitalists.”⁸

I think it’s really important to say, “I know you don’t know me, but here’s the upside.” And my experience is that patients easily understand that tradeoff and are very positive.

—William Southern, MD, chief, division of hospital medicine, Montefiore Medical Center, Bronx, N.Y.

Similar findings were popping up around the country: Replacing an internal medicine residency program with a physician assistant/hospitalist model at Brooklyn, N.Y.’s Coney Island Hospital did not adversely impact patient satisfaction, while it significantly improved mortality.⁹ Brigham & Women’s Hospital in Boston likewise reported no change in patient satisfaction in a study comparing a physician assistant/hospitalist service with traditional house staff services.¹⁰

The shift toward a more proactive position on patient satisfaction is exemplified within a 2008 white paper, “Hospitalists Meeting the Challenge of Patient Satisfaction,” written by a group of 19 private-practice HM experts known as The Phoenix Group.3 The paper acknowledged the flaws and limitations of existing survey methodologies, including Medicare’s Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) scores. Even so, the authors urged practice groups to adopt a team-oriented approach to communicate to hospital administrations “the belief that hospitalists are in the best position to improve survey scores overall for the facility.”

Listen to Diane Sliwka

Carle Foundation Hospital in Urbana, Ill., is now publicly advertising its HM service’s contribution to high patient satisfaction scores on its website, and underscoring the hospitalists’ consistency, accessibility, and communication skills. “The hospital is never without a hospitalist, and our nurses know that they can rely on them,” says Lynn Barnes, vice president of hospital operations. “They’re available, they’re within a few minutes away, and patients’ needs get met very efficiently and rapidly.”

As a result, she says, their presence can lead to higher scores in patients’ perceptions of communication.

Hospitalists also have been central to several safety initiatives at Carle. Napoleon Knight, MD, medical director of hospital medicine and associate vice president for quality, says the HM team has helped address undiagnosed sleep apnea and implement rapid responses, such as “Code Speed.” Caregivers or family members can use the code to immediately call for help if they detect a downturn in a patient’s condition.

The ongoing initiatives, Dr. Knight and Barnes say, are helping the hospital improve how patients and their loved ones perceive care as Carle adapts to a rapidly shifting healthcare landscape. “With all of the changes that seem to be coming from the external environment weekly, we want to work collaboratively to make sure we’re connected and aligned and communicating in an ongoing fashion so we can react to all of these changes,” Dr. Knight says.

Continued below...

A Hopeful Trend

So far, evidence that the HM model is more broadly raising patient satisfaction scores is largely anecdotal. But a few analyses suggest the trend is moving in the right direction. A recent study in the American Journal of Medical Quality, for instance, concludes that facilities with hospitalists might have an advantage in patient satisfaction with nursing and such personal issues as privacy, emotional needs, and response to complaints.¹¹ The study also posits that teaching facilities employing hospitalists could see benefits in overall satisfaction, while large facilities with hospitalists might see gains in satisfaction with admissions, nursing, and tests and treatments.

Brad Fulton, PhD, a researcher at South Bend, Ind.-based healthcare consulting firm Press Ganey and the study’s lead author, says the 30,000-foot view of patient satisfaction at the facility level can get foggy in a hurry due to differences in the kind and size of hospitalist programs. “And despite all of that fog, we’re still able to see through that and find something,” he says.

One limitation is that the study findings could also reflect differences in the culture of facilities that choose to add hospitalists. That caveat means it might not be possible to completely untangle the effect of an HM group on inpatient care from the larger, hospitalwide values that have allowed the group to set up shop. The wrinkle brings its own fascinating questions, according to Fulton. For example, is that kind of culture necessary for hospitalists to function as well as they do?

The hospital is never without a hospitalist, and our nurses know that they can rely on them. They’re available, they’re within a few minutes away, and patients’ needs get met very efficiently and rapidly.

—Lynn Barnes, vice president of hospital operations, Carle Foundation Hospital, Urbana, Ill.

Such considerations will become more important as the healthcare system places additional emphasis on patient satisfaction, as Medicare’s value-based purchasing program is doing through its HCAHPS scores. With all the changes, success or failure on the patient experience front is going to carry “not just a reputational import, but also a financial impact,” says Ethan Cumbler, MD, FACP, director of Acute Care for the Elderly (ACE) Service at the University of Colorado Denver.

So how can HM fairly and accurately assess its own practitioners? “I think one starts by trying to apply some of the rigor that we have learned from our experience as hospitalists in quality improvement to the more warm and fuzzy field of patient experience,” Dr. Cumbler says. Many hospitals employ surveys supplied by consultants like Press Ganey to track the global patient satisfaction for their institution, he says.

“But for an individual hospitalist or hospitalist group, that kind of tool often lacks both the specificity and the timeliness necessary to make good decisions about impact of interventions on patient satisfaction,” he says.

Mark Williams, MD, FACP, FHM, professor and chief of the division of hospital medicine at Northwestern University’s Feinberg School of Medicine in Chicago, agrees that such imprecision could lead to unfair assessments. “You can imagine a scenario where a patient actually liked their hospitalist very much,” he says, “but when they got the survey, they said [their stay] was terrible and the reasons being because maybe the nurse call button was not answered and the food was terrible and medications were given to them incorrectly, or it was noisy at night so they couldn’t sleep.”

A recent study by Dr. Williams and his colleagues, in which they employed a new assessment method called the Communication Assessment Tool (CAT), confirmed the group’s suspicions: “that the results from the Press Ganey didn’t match up with the CAT, which was a direct assessment of the patient’s perception of the hospitalist’s communication skills,” he says.¹²

The validated tool, he adds, provides directed feedback to the physician based on the percentage of patients rating that provider as excellent, instead of on the average total score. Hospitalists have felt vindicated by the results. “They were very nervous because the hospital talked about basing an incentive off of the Press Ganey scores, and we said, ‘You can’t do that,’ because we didn’t feel they were accurate, and this study proved that,” Dr. Williams explains.

Fortunately, the message has reached researchers and consultants alike, and better tools are starting to reach hospitals around the country. At HM11 in May, Press Ganey unveiled a new survey designed to help patients assess the care delivered by two hospitalists, the average for inpatient stays. The item set is specific to HM functions, and includes the photo and name of each hospitalist, which Fulton says should improve the validity and accuracy of the data.

“The early response looks really good,” Fulton says, though it’s too early to say whether the tool, called Hospitalist Insight, will live up to its billing. If it proves its mettle, Fulton says, the survey could be used to reward top-performing hospitalists, and the growing dataset could allow hospitals to compare themselves with appropriate peer groups for fairer comparisons.

Meanwhile, researchers are testing out checklists to score hospitalist etiquette, and tracking and paging systems to help ensure continuity of care. They have found increased patient satisfaction when doctors engage in verbal communication during a discharge, in interdisciplinary team rounding, and in efforts to address religious and spiritual concerns.

Since 2000, when Montefiore’s hospitalist program began, Dr. Southern says the hospital has explained to patients the tradeoff accompanying the HM model. “I say something like this to every patient: ‘I know I’m not the doctor that you know, and you’re just meeting me. The downside is that you haven’t met me before and I’m a new face, but the upside is that if you need me during the day, I’m here all the time, I’m not someplace else. And so if you need something, I can be here quickly.’ ”

Being very explicit about that tradeoff, he says, has made patients very comfortable with the model of care, especially during a crisis moment in their lives. “I think it’s really important to say, ‘I know you don’t know me, but here’s the upside.’ And my experience is that patients easily understand that tradeoff and are very positive,” Dr. Southern says.

The Verdict

Available evidence suggests that practitioners of the HM model have pivoted from defending against early criticism that they may harm patient satisfaction to pitching themselves as team leaders who can boost facilitywide perceptions of care. So far, too little research has been conducted to suggest whether that optimism is fully warranted, but early signs look promising.

At facilities like Chicago’s Northwestern Memorial Hospital, medical floors staffed by hospitalists are beginning to beat out surgical floors for the traveling patient satisfaction award. And experts like Dr. Cumbler are pondering how ongoing initiatives to boost scores can follow in the footsteps of efficiency and quality-raising efforts by making the transition from focusing on individual doctors to adopting a more programmatic approach. “What’s happening to that patient during the 23 hours and 45 minutes of their hospital day that you are not sitting by the bedside? And what influence should a hospitalist have in affecting that other 23 hours and 45 minutes?” he says.

Handoffs, discharges, communication with PCPs, and other potential weak points in maintaining high levels of patient satisfaction, Dr. Cumbler says, all are amenable to systems-based improvement. “As hospitalists, we are in a unique position to influence not only our one-one-one interaction with the patient, but also to influence that system of care in a way that patients will notice in a real and tangible way,” he says. “I think we’ve recognized for some time that a healthy heart but a miserable patient is not a healthy person.”

Teaching Hospitals Gain Ground in Patient Satisfaction

Listen to Diane Sliwka

One widely accepted truism about teaching facilities is that they’re known to have lower patient satisfaction scores than nonteaching hospitals. Brad Fulton, researcher for South Bend, Ind.-based consultant firm Press Ganey, attributes the difference in part to the fact that many doctors at teaching facilities must divide their time among patient care, education, and research. Such hospitals also tend to have some of the more medically difficult patients, he says, some of who may be more apt to feel like they’re on display with the abundance of students and residents.

In one of his recent studies, however, teaching facilities with hospitalists scored higher on patient satisfaction than nonteaching facilities or teaching facilities that lacked hospitalists. One potential follow-up question could have broad implications: “What is it about having hospitalists in teaching facilities that works so well in terms of patient satisfaction?” Can that be replicated elsewhere, he wonders? And is there an essential element that could be applied to nonteaching facilities?

A separate study also defied expectations by finding that teaching bedside procedures to inexperienced residents can be reassuring to patients, if done correctly. In a teaching model instituted at the University of California San Francisco, an experienced hospitalist with extra training supervises a novice during bedside procedures such as lumbar punctures and paracentesis. Study coauthor Diane Sliwka, MD, associate clinical professor of medicine and a hospitalist, says the feedback so far suggests that the model can improve safety, boost education, and deliver a positive patient experience.

Patients may be hesitant about having trainees do procedures, she says, but surveys suggest those patients are reassured when they know an expert is in the room and watching. They also want to hear what will happen next to counteract the anxiety of feeling pain or encountering something unexpected.

As the study suggested, what patients may find to be the most difficult or nerve-wracking can be quite different from what doctors expect. “You would think it was actually the procedure that was most painful part, but actually that was after we had given lidocaine,” Dr. Sliwka says. Patients repeatedly reacted to the doctors using a plastic pen cap to imprint the site where they would insert a needle. “Over and over we would hear people say, ‘That is actually the most painful part and you didn’t warn me about that,’ ” she recalls. “And we didn’t warn people about that because we didn’t think it was a big deal.”

Procedures can take longer with trainees, another tradeoff that can leading to lower satisfaction scores. But what the study also showed is that in academic settings, involving residents doesn’t harm the overall patient experience and can in fact improve it. “Anecdotally, what we hear from patients a lot is, ‘Oh, I had this procedure done before and it went horribly.’ They would tell stories of previous bad experiences, and then really be thankful for the experience that they had in our setting,” Dr. Sliwka says.

The extended face-to-face time can yield another positive effect. Dr. Sliwka found that hospitalists and residents often learned medical and historical information about the patient that the primary care team hadn’t yet had an opportunity to glean. “Patients just start to tell you about their families, their lives, their medical problems, their experiences,” she says, a product of building more rapport with them. “We would often find ourselves telling the primary medical team, ‘By the way, we found this out and you should probably know it: the patient is very concerned about this that’s been going on,’ and the patient hasn’t had a chance to tell the team because there isn’t that kind of time.”

Even without the specific model, Dr. Sliwka says, several principles can be applied to daily interactions. Framing things appropriately, she says, helps patients gain confidence in the doctors and allows them to safely conduct bedside teaching and openly discuss procedures. Even correcting mistakes can be a positive experience. “That actually makes the patient feel more confident in you than less confident,” Dr. Sliwka says.

Ultimately, the teaching experience can help residents broaden their thinking about patient satisfaction. “I think when trainees are starting, their real focus is, ‘How do I deal with this correctly?’ ” Dr. Sliwka says. “It takes a level of comfort with the basic skills to then go beyond that and start thinking about, ‘How is the patient perceiving this?’”

Bryn Nelson is a freelance medical journalist based in Seattle.

References

1. Williams M, Flanders SA, Whitcomb WF. Comprehensive hospital medicine: an evidence based approach. Elsevier;2007:971-976.
2. Arora V, Gangireddy S, Mehrotra A, Ginde R, Tormey M, Meltzer D. Ability of hospitalized patients to identify their in-hospital physicians. Arch Intern Med. 2009;169(2):199-201.
3. Singer AS, et al. Hospitalists meeting the challenge of patient satisfaction. The Phoenix Group. 2008;1-5.
4. Manian FA. Whither continuity of care? N Engl J Med. 1999;340:1362-1363.
5. Correspondence. Whither continuity of care? N Engl J Med. 1999;341:850-852.
6. Davis KM, Koch KE, Harvey JK, et al. Effects of hospitalists on cost, outcomes, and patient satisfaction in a rural health system. Amer J Med. 2000;108(8):621-626.
7. Wachter RM, Goldman L. The hospitalist movement 5 years later. JAMA. 2002;287(4):487-494.
8. Coffman J, Rundall TG. The impact of hospitalists on the cost and quality of inpatient care in the United States (a research synthesis). Med Care Res Rev. 2005;62:379–406.
9. Dhuper S, Choksi S. Replacing an academic internal medicine residency program with a physician assistant-hospitalist model: a comparative analysis study. Am J Med Qual. 2009;24(2):132-139.
10. Roy CL, Liang CL, Lund M, et al. Implementation of a physician assistant/hospitalist service in an academic medical center: impact on efficiency and patient outcomes. J Hosp Med. 2008;3(5):361-368.
11. Fulton BR, Drevs KE, Ayala LJ, Malott DL Jr. Patient satisfaction with hospitalists: facility-level analyses. Am J Med Qual. 2011;26(2):95-102.
12. Ferranti DE, Makoul G, Forth VE, Rauworth J, Lee J, Williams MV. Assessing patient perceptions of hospitalist communication skills using the Communication Assessment Tool (CAT). J Hosp Med. 2010;5(9):522-527.

At first glance, the deck might seem hopelessly stacked against hospitalists with regard to patient satisfaction. HM practitioners lack the long-term relationship with patients that many primary-care physicians (PCPs) have established. Unlike surgeons and other specialists, they tend to care for those patients—more complicated, lacking a regular doctor, or admitted through the ED, for example—who are more inclined to rate their hospital stay unfavorably.¹ They may not even be accurately remembered by patients who encounter multiple doctors during the course of their hospitalization.² And hospital information systems can misidentify the treating physician, while the actual surveys used to gauge hospitalists have been imperfect at best.³

And yet, the hospitalist model has evolved substantially on the question of how it can impact patient perceptions of care.

Initially, hospitalist champions adopted a largely defensive posture: The model would not negatively impact patient satisfaction as it delivered on efficiency—and later on quality. The healthcare system, however, is beginning to recognize the hospitalist as part of a care “team” whose patient-centered approach might pay big dividends in the inpatient experience and, eventually, on satisfaction scores.

“I think the next phase, which is a focus on the hospitalist as a team member and team builder, is going to be key,” says William Southern, MD, MPH, SFHM, chief of the division of hospital medicine at Montefiore Medical Center in Bronx, N.Y.

Recent studies suggest that hospitalists are helping to design and test new tools that will not only improve satisfaction, but also more fairly assess the impact of individual doctors. As the maturation process continues, experts say, hospitalists have an opportunity to influence both provider-based interventions and more programmatic decision-making that can have far-reaching effects. Certainly, the hand dealt to hospitalists is looking more favorable even as the ante has been raised with Medicare programs like value-based purchasing, and its pot of money tied to patient perceptions of care.

So how have hospitalists played their cards so far?

A Look at the Evidence

In its early years, the HM model faced a persistent criticism: Replacing traditional caregivers with these new inpatient providers in the name of efficiency would increase handoffs and, therefore, discontinuities of care delivered by a succession of unfamiliar faces. If patients didn’t see their PCP in the hospital, the thinking went, they might be more disgruntled at being tended to by hospitalists, leading to lower satisfaction scores.⁴

A particularly heated exchange played out in 1999 in the New England Journal of Medicine. Farris A. Manian, MD, MPH, of Infectious Disease Consultants in St. Louis wrote in one letter, “I am particularly concerned about what impressionable house-staff members will learn from hospitalists who place an inordinate emphasis on cost rather than the quality of patient care or teaching.”⁵

A few subsequent studies, however, hinted that such concerns might be overstated. A 2000 analysis in the American Journal of Medicine that examined North Mississippi Health Services in Tupelo, for instance, found that care administered by hospitalists led to a shorter length of stay and lower costs than care delivered by internists. Importantly, the study found that patient satisfaction was similar for both models, while quality metrics were likewise equal or even tilted slightly toward hospitalists.⁶

In their influential 2002 review of a profession that was only a half-decade old, Robert Wachter, MD, MHM, and Lee Goldman, MD, MPH, FACP from the University of California at San Francisco reinforced the message that HM wouldn’t lead to unhappy patients. “Empirical research supports the premise that hospitalists improve inpatient efficiency without harmful effects on quality or patient satisfaction,” they asserted.⁷

Among pediatric patients, a 2005 review found that “none of the four studies that evaluated patient satisfaction found statistically significant differences in satisfaction with inpatient care. However, two of the three evaluations that did assess parents’ satisfaction with care provided to their children found that parents were more satisfied with some aspects of care provided by hospitalists.”⁸

I think it’s really important to say, “I know you don’t know me, but here’s the upside.” And my experience is that patients easily understand that tradeoff and are very positive.

—William Southern, MD, chief, division of hospital medicine, Montefiore Medical Center, Bronx, N.Y.

Similar findings were popping up around the country: Replacing an internal medicine residency program with a physician assistant/hospitalist model at Brooklyn, N.Y.’s Coney Island Hospital did not adversely impact patient satisfaction, while it significantly improved mortality.⁹ Brigham & Women’s Hospital in Boston likewise reported no change in patient satisfaction in a study comparing a physician assistant/hospitalist service with traditional house staff services.¹⁰

The shift toward a more proactive position on patient satisfaction is exemplified within a 2008 white paper, “Hospitalists Meeting the Challenge of Patient Satisfaction,” written by a group of 19 private-practice HM experts known as The Phoenix Group.3 The paper acknowledged the flaws and limitations of existing survey methodologies, including Medicare’s Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) scores. Even so, the authors urged practice groups to adopt a team-oriented approach to communicate to hospital administrations “the belief that hospitalists are in the best position to improve survey scores overall for the facility.”

Listen to Diane Sliwka

Carle Foundation Hospital in Urbana, Ill., is now publicly advertising its HM service’s contribution to high patient satisfaction scores on its website, and underscoring the hospitalists’ consistency, accessibility, and communication skills. “The hospital is never without a hospitalist, and our nurses know that they can rely on them,” says Lynn Barnes, vice president of hospital operations. “They’re available, they’re within a few minutes away, and patients’ needs get met very efficiently and rapidly.”

As a result, she says, their presence can lead to higher scores in patients’ perceptions of communication.

Hospitalists also have been central to several safety initiatives at Carle. Napoleon Knight, MD, medical director of hospital medicine and associate vice president for quality, says the HM team has helped address undiagnosed sleep apnea and implement rapid responses, such as “Code Speed.” Caregivers or family members can use the code to immediately call for help if they detect a downturn in a patient’s condition.

The ongoing initiatives, Dr. Knight and Barnes say, are helping the hospital improve how patients and their loved ones perceive care as Carle adapts to a rapidly shifting healthcare landscape. “With all of the changes that seem to be coming from the external environment weekly, we want to work collaboratively to make sure we’re connected and aligned and communicating in an ongoing fashion so we can react to all of these changes,” Dr. Knight says.

Continued below...

A Hopeful Trend

So far, evidence that the HM model is more broadly raising patient satisfaction scores is largely anecdotal. But a few analyses suggest the trend is moving in the right direction. A recent study in the American Journal of Medical Quality, for instance, concludes that facilities with hospitalists might have an advantage in patient satisfaction with nursing and such personal issues as privacy, emotional needs, and response to complaints.¹¹ The study also posits that teaching facilities employing hospitalists could see benefits in overall satisfaction, while large facilities with hospitalists might see gains in satisfaction with admissions, nursing, and tests and treatments.

Brad Fulton, PhD, a researcher at South Bend, Ind.-based healthcare consulting firm Press Ganey and the study’s lead author, says the 30,000-foot view of patient satisfaction at the facility level can get foggy in a hurry due to differences in the kind and size of hospitalist programs. “And despite all of that fog, we’re still able to see through that and find something,” he says.

One limitation is that the study findings could also reflect differences in the culture of facilities that choose to add hospitalists. That caveat means it might not be possible to completely untangle the effect of an HM group on inpatient care from the larger, hospitalwide values that have allowed the group to set up shop. The wrinkle brings its own fascinating questions, according to Fulton. For example, is that kind of culture necessary for hospitalists to function as well as they do?

The hospital is never without a hospitalist, and our nurses know that they can rely on them. They’re available, they’re within a few minutes away, and patients’ needs get met very efficiently and rapidly.

—Lynn Barnes, vice president of hospital operations, Carle Foundation Hospital, Urbana, Ill.

Such considerations will become more important as the healthcare system places additional emphasis on patient satisfaction, as Medicare’s value-based purchasing program is doing through its HCAHPS scores. With all the changes, success or failure on the patient experience front is going to carry “not just a reputational import, but also a financial impact,” says Ethan Cumbler, MD, FACP, director of Acute Care for the Elderly (ACE) Service at the University of Colorado Denver.

So how can HM fairly and accurately assess its own practitioners? “I think one starts by trying to apply some of the rigor that we have learned from our experience as hospitalists in quality improvement to the more warm and fuzzy field of patient experience,” Dr. Cumbler says. Many hospitals employ surveys supplied by consultants like Press Ganey to track the global patient satisfaction for their institution, he says.

“But for an individual hospitalist or hospitalist group, that kind of tool often lacks both the specificity and the timeliness necessary to make good decisions about impact of interventions on patient satisfaction,” he says.

Mark Williams, MD, FACP, FHM, professor and chief of the division of hospital medicine at Northwestern University’s Feinberg School of Medicine in Chicago, agrees that such imprecision could lead to unfair assessments. “You can imagine a scenario where a patient actually liked their hospitalist very much,” he says, “but when they got the survey, they said [their stay] was terrible and the reasons being because maybe the nurse call button was not answered and the food was terrible and medications were given to them incorrectly, or it was noisy at night so they couldn’t sleep.”

A recent study by Dr. Williams and his colleagues, in which they employed a new assessment method called the Communication Assessment Tool (CAT), confirmed the group’s suspicions: “that the results from the Press Ganey didn’t match up with the CAT, which was a direct assessment of the patient’s perception of the hospitalist’s communication skills,” he says.¹²

The validated tool, he adds, provides directed feedback to the physician based on the percentage of patients rating that provider as excellent, instead of on the average total score. Hospitalists have felt vindicated by the results. “They were very nervous because the hospital talked about basing an incentive off of the Press Ganey scores, and we said, ‘You can’t do that,’ because we didn’t feel they were accurate, and this study proved that,” Dr. Williams explains.

Fortunately, the message has reached researchers and consultants alike, and better tools are starting to reach hospitals around the country. At HM11 in May, Press Ganey unveiled a new survey designed to help patients assess the care delivered by two hospitalists, the average for inpatient stays. The item set is specific to HM functions, and includes the photo and name of each hospitalist, which Fulton says should improve the validity and accuracy of the data.

“The early response looks really good,” Fulton says, though it’s too early to say whether the tool, called Hospitalist Insight, will live up to its billing. If it proves its mettle, Fulton says, the survey could be used to reward top-performing hospitalists, and the growing dataset could allow hospitals to compare themselves with appropriate peer groups for fairer comparisons.

Meanwhile, researchers are testing out checklists to score hospitalist etiquette, and tracking and paging systems to help ensure continuity of care. They have found increased patient satisfaction when doctors engage in verbal communication during a discharge, in interdisciplinary team rounding, and in efforts to address religious and spiritual concerns.

Since 2000, when Montefiore’s hospitalist program began, Dr. Southern says the hospital has explained to patients the tradeoff accompanying the HM model. “I say something like this to every patient: ‘I know I’m not the doctor that you know, and you’re just meeting me. The downside is that you haven’t met me before and I’m a new face, but the upside is that if you need me during the day, I’m here all the time, I’m not someplace else. And so if you need something, I can be here quickly.’ ”

Being very explicit about that tradeoff, he says, has made patients very comfortable with the model of care, especially during a crisis moment in their lives. “I think it’s really important to say, ‘I know you don’t know me, but here’s the upside.’ And my experience is that patients easily understand that tradeoff and are very positive,” Dr. Southern says.

The Verdict

Available evidence suggests that practitioners of the HM model have pivoted from defending against early criticism that they may harm patient satisfaction to pitching themselves as team leaders who can boost facilitywide perceptions of care. So far, too little research has been conducted to suggest whether that optimism is fully warranted, but early signs look promising.

At facilities like Chicago’s Northwestern Memorial Hospital, medical floors staffed by hospitalists are beginning to beat out surgical floors for the traveling patient satisfaction award. And experts like Dr. Cumbler are pondering how ongoing initiatives to boost scores can follow in the footsteps of efficiency and quality-raising efforts by making the transition from focusing on individual doctors to adopting a more programmatic approach. “What’s happening to that patient during the 23 hours and 45 minutes of their hospital day that you are not sitting by the bedside? And what influence should a hospitalist have in affecting that other 23 hours and 45 minutes?” he says.

Handoffs, discharges, communication with PCPs, and other potential weak points in maintaining high levels of patient satisfaction, Dr. Cumbler says, all are amenable to systems-based improvement. “As hospitalists, we are in a unique position to influence not only our one-one-one interaction with the patient, but also to influence that system of care in a way that patients will notice in a real and tangible way,” he says. “I think we’ve recognized for some time that a healthy heart but a miserable patient is not a healthy person.”

Teaching Hospitals Gain Ground in Patient Satisfaction

Listen to Diane Sliwka

One widely accepted truism about teaching facilities is that they’re known to have lower patient satisfaction scores than nonteaching hospitals. Brad Fulton, researcher for South Bend, Ind.-based consultant firm Press Ganey, attributes the difference in part to the fact that many doctors at teaching facilities must divide their time among patient care, education, and research. Such hospitals also tend to have some of the more medically difficult patients, he says, some of who may be more apt to feel like they’re on display with the abundance of students and residents.

In one of his recent studies, however, teaching facilities with hospitalists scored higher on patient satisfaction than nonteaching facilities or teaching facilities that lacked hospitalists. One potential follow-up question could have broad implications: “What is it about having hospitalists in teaching facilities that works so well in terms of patient satisfaction?” Can that be replicated elsewhere, he wonders? And is there an essential element that could be applied to nonteaching facilities?

A separate study also defied expectations by finding that teaching bedside procedures to inexperienced residents can be reassuring to patients, if done correctly. In a teaching model instituted at the University of California San Francisco, an experienced hospitalist with extra training supervises a novice during bedside procedures such as lumbar punctures and paracentesis. Study coauthor Diane Sliwka, MD, associate clinical professor of medicine and a hospitalist, says the feedback so far suggests that the model can improve safety, boost education, and deliver a positive patient experience.

Patients may be hesitant about having trainees do procedures, she says, but surveys suggest those patients are reassured when they know an expert is in the room and watching. They also want to hear what will happen next to counteract the anxiety of feeling pain or encountering something unexpected.

As the study suggested, what patients may find to be the most difficult or nerve-wracking can be quite different from what doctors expect. “You would think it was actually the procedure that was most painful part, but actually that was after we had given lidocaine,” Dr. Sliwka says. Patients repeatedly reacted to the doctors using a plastic pen cap to imprint the site where they would insert a needle. “Over and over we would hear people say, ‘That is actually the most painful part and you didn’t warn me about that,’ ” she recalls. “And we didn’t warn people about that because we didn’t think it was a big deal.”

Procedures can take longer with trainees, another tradeoff that can leading to lower satisfaction scores. But what the study also showed is that in academic settings, involving residents doesn’t harm the overall patient experience and can in fact improve it. “Anecdotally, what we hear from patients a lot is, ‘Oh, I had this procedure done before and it went horribly.’ They would tell stories of previous bad experiences, and then really be thankful for the experience that they had in our setting,” Dr. Sliwka says.

The extended face-to-face time can yield another positive effect. Dr. Sliwka found that hospitalists and residents often learned medical and historical information about the patient that the primary care team hadn’t yet had an opportunity to glean. “Patients just start to tell you about their families, their lives, their medical problems, their experiences,” she says, a product of building more rapport with them. “We would often find ourselves telling the primary medical team, ‘By the way, we found this out and you should probably know it: the patient is very concerned about this that’s been going on,’ and the patient hasn’t had a chance to tell the team because there isn’t that kind of time.”

Even without the specific model, Dr. Sliwka says, several principles can be applied to daily interactions. Framing things appropriately, she says, helps patients gain confidence in the doctors and allows them to safely conduct bedside teaching and openly discuss procedures. Even correcting mistakes can be a positive experience. “That actually makes the patient feel more confident in you than less confident,” Dr. Sliwka says.

Ultimately, the teaching experience can help residents broaden their thinking about patient satisfaction. “I think when trainees are starting, their real focus is, ‘How do I deal with this correctly?’ ” Dr. Sliwka says. “It takes a level of comfort with the basic skills to then go beyond that and start thinking about, ‘How is the patient perceiving this?’”

Bryn Nelson is a freelance medical journalist based in Seattle.

References

1. Williams M, Flanders SA, Whitcomb WF. Comprehensive hospital medicine: an evidence based approach. Elsevier;2007:971-976.
2. Arora V, Gangireddy S, Mehrotra A, Ginde R, Tormey M, Meltzer D. Ability of hospitalized patients to identify their in-hospital physicians. Arch Intern Med. 2009;169(2):199-201.
3. Singer AS, et al. Hospitalists meeting the challenge of patient satisfaction. The Phoenix Group. 2008;1-5.
4. Manian FA. Whither continuity of care? N Engl J Med. 1999;340:1362-1363.
5. Correspondence. Whither continuity of care? N Engl J Med. 1999;341:850-852.
6. Davis KM, Koch KE, Harvey JK, et al. Effects of hospitalists on cost, outcomes, and patient satisfaction in a rural health system. Amer J Med. 2000;108(8):621-626.
7. Wachter RM, Goldman L. The hospitalist movement 5 years later. JAMA. 2002;287(4):487-494.
8. Coffman J, Rundall TG. The impact of hospitalists on the cost and quality of inpatient care in the United States (a research synthesis). Med Care Res Rev. 2005;62:379–406.
9. Dhuper S, Choksi S. Replacing an academic internal medicine residency program with a physician assistant-hospitalist model: a comparative analysis study. Am J Med Qual. 2009;24(2):132-139.
10. Roy CL, Liang CL, Lund M, et al. Implementation of a physician assistant/hospitalist service in an academic medical center: impact on efficiency and patient outcomes. J Hosp Med. 2008;3(5):361-368.
11. Fulton BR, Drevs KE, Ayala LJ, Malott DL Jr. Patient satisfaction with hospitalists: facility-level analyses. Am J Med Qual. 2011;26(2):95-102.
12. Ferranti DE, Makoul G, Forth VE, Rauworth J, Lee J, Williams MV. Assessing patient perceptions of hospitalist communication skills using the Communication Assessment Tool (CAT). J Hosp Med. 2010;5(9):522-527.

At first glance, the deck might seem hopelessly stacked against hospitalists with regard to patient satisfaction. HM practitioners lack the long-term relationship with patients that many primary-care physicians (PCPs) have established. Unlike surgeons and other specialists, they tend to care for those patients—more complicated, lacking a regular doctor, or admitted through the ED, for example—who are more inclined to rate their hospital stay unfavorably.¹ They may not even be accurately remembered by patients who encounter multiple doctors during the course of their hospitalization.² And hospital information systems can misidentify the treating physician, while the actual surveys used to gauge hospitalists have been imperfect at best.³

And yet, the hospitalist model has evolved substantially on the question of how it can impact patient perceptions of care.

Initially, hospitalist champions adopted a largely defensive posture: The model would not negatively impact patient satisfaction as it delivered on efficiency—and later on quality. The healthcare system, however, is beginning to recognize the hospitalist as part of a care “team” whose patient-centered approach might pay big dividends in the inpatient experience and, eventually, on satisfaction scores.

“I think the next phase, which is a focus on the hospitalist as a team member and team builder, is going to be key,” says William Southern, MD, MPH, SFHM, chief of the division of hospital medicine at Montefiore Medical Center in Bronx, N.Y.

Recent studies suggest that hospitalists are helping to design and test new tools that will not only improve satisfaction, but also more fairly assess the impact of individual doctors. As the maturation process continues, experts say, hospitalists have an opportunity to influence both provider-based interventions and more programmatic decision-making that can have far-reaching effects. Certainly, the hand dealt to hospitalists is looking more favorable even as the ante has been raised with Medicare programs like value-based purchasing, and its pot of money tied to patient perceptions of care.

So how have hospitalists played their cards so far?

A Look at the Evidence

In its early years, the HM model faced a persistent criticism: Replacing traditional caregivers with these new inpatient providers in the name of efficiency would increase handoffs and, therefore, discontinuities of care delivered by a succession of unfamiliar faces. If patients didn’t see their PCP in the hospital, the thinking went, they might be more disgruntled at being tended to by hospitalists, leading to lower satisfaction scores.⁴

A particularly heated exchange played out in 1999 in the New England Journal of Medicine. Farris A. Manian, MD, MPH, of Infectious Disease Consultants in St. Louis wrote in one letter, “I am particularly concerned about what impressionable house-staff members will learn from hospitalists who place an inordinate emphasis on cost rather than the quality of patient care or teaching.”⁵

A few subsequent studies, however, hinted that such concerns might be overstated. A 2000 analysis in the American Journal of Medicine that examined North Mississippi Health Services in Tupelo, for instance, found that care administered by hospitalists led to a shorter length of stay and lower costs than care delivered by internists. Importantly, the study found that patient satisfaction was similar for both models, while quality metrics were likewise equal or even tilted slightly toward hospitalists.⁶

In their influential 2002 review of a profession that was only a half-decade old, Robert Wachter, MD, MHM, and Lee Goldman, MD, MPH, FACP from the University of California at San Francisco reinforced the message that HM wouldn’t lead to unhappy patients. “Empirical research supports the premise that hospitalists improve inpatient efficiency without harmful effects on quality or patient satisfaction,” they asserted.⁷

Among pediatric patients, a 2005 review found that “none of the four studies that evaluated patient satisfaction found statistically significant differences in satisfaction with inpatient care. However, two of the three evaluations that did assess parents’ satisfaction with care provided to their children found that parents were more satisfied with some aspects of care provided by hospitalists.”⁸

I think it’s really important to say, “I know you don’t know me, but here’s the upside.” And my experience is that patients easily understand that tradeoff and are very positive.

—William Southern, MD, chief, division of hospital medicine, Montefiore Medical Center, Bronx, N.Y.

Similar findings were popping up around the country: Replacing an internal medicine residency program with a physician assistant/hospitalist model at Brooklyn, N.Y.’s Coney Island Hospital did not adversely impact patient satisfaction, while it significantly improved mortality.⁹ Brigham & Women’s Hospital in Boston likewise reported no change in patient satisfaction in a study comparing a physician assistant/hospitalist service with traditional house staff services.¹⁰

The shift toward a more proactive position on patient satisfaction is exemplified within a 2008 white paper, “Hospitalists Meeting the Challenge of Patient Satisfaction,” written by a group of 19 private-practice HM experts known as The Phoenix Group.3 The paper acknowledged the flaws and limitations of existing survey methodologies, including Medicare’s Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) scores. Even so, the authors urged practice groups to adopt a team-oriented approach to communicate to hospital administrations “the belief that hospitalists are in the best position to improve survey scores overall for the facility.”

Listen to Diane Sliwka

Carle Foundation Hospital in Urbana, Ill., is now publicly advertising its HM service’s contribution to high patient satisfaction scores on its website, and underscoring the hospitalists’ consistency, accessibility, and communication skills. “The hospital is never without a hospitalist, and our nurses know that they can rely on them,” says Lynn Barnes, vice president of hospital operations. “They’re available, they’re within a few minutes away, and patients’ needs get met very efficiently and rapidly.”

As a result, she says, their presence can lead to higher scores in patients’ perceptions of communication.

Hospitalists also have been central to several safety initiatives at Carle. Napoleon Knight, MD, medical director of hospital medicine and associate vice president for quality, says the HM team has helped address undiagnosed sleep apnea and implement rapid responses, such as “Code Speed.” Caregivers or family members can use the code to immediately call for help if they detect a downturn in a patient’s condition.

The ongoing initiatives, Dr. Knight and Barnes say, are helping the hospital improve how patients and their loved ones perceive care as Carle adapts to a rapidly shifting healthcare landscape. “With all of the changes that seem to be coming from the external environment weekly, we want to work collaboratively to make sure we’re connected and aligned and communicating in an ongoing fashion so we can react to all of these changes,” Dr. Knight says.

Continued below...

A Hopeful Trend

So far, evidence that the HM model is more broadly raising patient satisfaction scores is largely anecdotal. But a few analyses suggest the trend is moving in the right direction. A recent study in the American Journal of Medical Quality, for instance, concludes that facilities with hospitalists might have an advantage in patient satisfaction with nursing and such personal issues as privacy, emotional needs, and response to complaints.¹¹ The study also posits that teaching facilities employing hospitalists could see benefits in overall satisfaction, while large facilities with hospitalists might see gains in satisfaction with admissions, nursing, and tests and treatments.

Brad Fulton, PhD, a researcher at South Bend, Ind.-based healthcare consulting firm Press Ganey and the study’s lead author, says the 30,000-foot view of patient satisfaction at the facility level can get foggy in a hurry due to differences in the kind and size of hospitalist programs. “And despite all of that fog, we’re still able to see through that and find something,” he says.

One limitation is that the study findings could also reflect differences in the culture of facilities that choose to add hospitalists. That caveat means it might not be possible to completely untangle the effect of an HM group on inpatient care from the larger, hospitalwide values that have allowed the group to set up shop. The wrinkle brings its own fascinating questions, according to Fulton. For example, is that kind of culture necessary for hospitalists to function as well as they do?

The hospital is never without a hospitalist, and our nurses know that they can rely on them. They’re available, they’re within a few minutes away, and patients’ needs get met very efficiently and rapidly.

—Lynn Barnes, vice president of hospital operations, Carle Foundation Hospital, Urbana, Ill.

Such considerations will become more important as the healthcare system places additional emphasis on patient satisfaction, as Medicare’s value-based purchasing program is doing through its HCAHPS scores. With all the changes, success or failure on the patient experience front is going to carry “not just a reputational import, but also a financial impact,” says Ethan Cumbler, MD, FACP, director of Acute Care for the Elderly (ACE) Service at the University of Colorado Denver.

So how can HM fairly and accurately assess its own practitioners? “I think one starts by trying to apply some of the rigor that we have learned from our experience as hospitalists in quality improvement to the more warm and fuzzy field of patient experience,” Dr. Cumbler says. Many hospitals employ surveys supplied by consultants like Press Ganey to track the global patient satisfaction for their institution, he says.

“But for an individual hospitalist or hospitalist group, that kind of tool often lacks both the specificity and the timeliness necessary to make good decisions about impact of interventions on patient satisfaction,” he says.

Mark Williams, MD, FACP, FHM, professor and chief of the division of hospital medicine at Northwestern University’s Feinberg School of Medicine in Chicago, agrees that such imprecision could lead to unfair assessments. “You can imagine a scenario where a patient actually liked their hospitalist very much,” he says, “but when they got the survey, they said [their stay] was terrible and the reasons being because maybe the nurse call button was not answered and the food was terrible and medications were given to them incorrectly, or it was noisy at night so they couldn’t sleep.”

A recent study by Dr. Williams and his colleagues, in which they employed a new assessment method called the Communication Assessment Tool (CAT), confirmed the group’s suspicions: “that the results from the Press Ganey didn’t match up with the CAT, which was a direct assessment of the patient’s perception of the hospitalist’s communication skills,” he says.¹²

The validated tool, he adds, provides directed feedback to the physician based on the percentage of patients rating that provider as excellent, instead of on the average total score. Hospitalists have felt vindicated by the results. “They were very nervous because the hospital talked about basing an incentive off of the Press Ganey scores, and we said, ‘You can’t do that,’ because we didn’t feel they were accurate, and this study proved that,” Dr. Williams explains.

Fortunately, the message has reached researchers and consultants alike, and better tools are starting to reach hospitals around the country. At HM11 in May, Press Ganey unveiled a new survey designed to help patients assess the care delivered by two hospitalists, the average for inpatient stays. The item set is specific to HM functions, and includes the photo and name of each hospitalist, which Fulton says should improve the validity and accuracy of the data.

“The early response looks really good,” Fulton says, though it’s too early to say whether the tool, called Hospitalist Insight, will live up to its billing. If it proves its mettle, Fulton says, the survey could be used to reward top-performing hospitalists, and the growing dataset could allow hospitals to compare themselves with appropriate peer groups for fairer comparisons.

Meanwhile, researchers are testing out checklists to score hospitalist etiquette, and tracking and paging systems to help ensure continuity of care. They have found increased patient satisfaction when doctors engage in verbal communication during a discharge, in interdisciplinary team rounding, and in efforts to address religious and spiritual concerns.

Since 2000, when Montefiore’s hospitalist program began, Dr. Southern says the hospital has explained to patients the tradeoff accompanying the HM model. “I say something like this to every patient: ‘I know I’m not the doctor that you know, and you’re just meeting me. The downside is that you haven’t met me before and I’m a new face, but the upside is that if you need me during the day, I’m here all the time, I’m not someplace else. And so if you need something, I can be here quickly.’ ”

Being very explicit about that tradeoff, he says, has made patients very comfortable with the model of care, especially during a crisis moment in their lives. “I think it’s really important to say, ‘I know you don’t know me, but here’s the upside.’ And my experience is that patients easily understand that tradeoff and are very positive,” Dr. Southern says.

The Verdict

Available evidence suggests that practitioners of the HM model have pivoted from defending against early criticism that they may harm patient satisfaction to pitching themselves as team leaders who can boost facilitywide perceptions of care. So far, too little research has been conducted to suggest whether that optimism is fully warranted, but early signs look promising.

At facilities like Chicago’s Northwestern Memorial Hospital, medical floors staffed by hospitalists are beginning to beat out surgical floors for the traveling patient satisfaction award. And experts like Dr. Cumbler are pondering how ongoing initiatives to boost scores can follow in the footsteps of efficiency and quality-raising efforts by making the transition from focusing on individual doctors to adopting a more programmatic approach. “What’s happening to that patient during the 23 hours and 45 minutes of their hospital day that you are not sitting by the bedside? And what influence should a hospitalist have in affecting that other 23 hours and 45 minutes?” he says.

Handoffs, discharges, communication with PCPs, and other potential weak points in maintaining high levels of patient satisfaction, Dr. Cumbler says, all are amenable to systems-based improvement. “As hospitalists, we are in a unique position to influence not only our one-one-one interaction with the patient, but also to influence that system of care in a way that patients will notice in a real and tangible way,” he says. “I think we’ve recognized for some time that a healthy heart but a miserable patient is not a healthy person.”

Teaching Hospitals Gain Ground in Patient Satisfaction

Listen to Diane Sliwka

One widely accepted truism about teaching facilities is that they’re known to have lower patient satisfaction scores than nonteaching hospitals. Brad Fulton, researcher for South Bend, Ind.-based consultant firm Press Ganey, attributes the difference in part to the fact that many doctors at teaching facilities must divide their time among patient care, education, and research. Such hospitals also tend to have some of the more medically difficult patients, he says, some of who may be more apt to feel like they’re on display with the abundance of students and residents.

In one of his recent studies, however, teaching facilities with hospitalists scored higher on patient satisfaction than nonteaching facilities or teaching facilities that lacked hospitalists. One potential follow-up question could have broad implications: “What is it about having hospitalists in teaching facilities that works so well in terms of patient satisfaction?” Can that be replicated elsewhere, he wonders? And is there an essential element that could be applied to nonteaching facilities?

A separate study also defied expectations by finding that teaching bedside procedures to inexperienced residents can be reassuring to patients, if done correctly. In a teaching model instituted at the University of California San Francisco, an experienced hospitalist with extra training supervises a novice during bedside procedures such as lumbar punctures and paracentesis. Study coauthor Diane Sliwka, MD, associate clinical professor of medicine and a hospitalist, says the feedback so far suggests that the model can improve safety, boost education, and deliver a positive patient experience.

Patients may be hesitant about having trainees do procedures, she says, but surveys suggest those patients are reassured when they know an expert is in the room and watching. They also want to hear what will happen next to counteract the anxiety of feeling pain or encountering something unexpected.

As the study suggested, what patients may find to be the most difficult or nerve-wracking can be quite different from what doctors expect. “You would think it was actually the procedure that was most painful part, but actually that was after we had given lidocaine,” Dr. Sliwka says. Patients repeatedly reacted to the doctors using a plastic pen cap to imprint the site where they would insert a needle. “Over and over we would hear people say, ‘That is actually the most painful part and you didn’t warn me about that,’ ” she recalls. “And we didn’t warn people about that because we didn’t think it was a big deal.”

Procedures can take longer with trainees, another tradeoff that can leading to lower satisfaction scores. But what the study also showed is that in academic settings, involving residents doesn’t harm the overall patient experience and can in fact improve it. “Anecdotally, what we hear from patients a lot is, ‘Oh, I had this procedure done before and it went horribly.’ They would tell stories of previous bad experiences, and then really be thankful for the experience that they had in our setting,” Dr. Sliwka says.

The extended face-to-face time can yield another positive effect. Dr. Sliwka found that hospitalists and residents often learned medical and historical information about the patient that the primary care team hadn’t yet had an opportunity to glean. “Patients just start to tell you about their families, their lives, their medical problems, their experiences,” she says, a product of building more rapport with them. “We would often find ourselves telling the primary medical team, ‘By the way, we found this out and you should probably know it: the patient is very concerned about this that’s been going on,’ and the patient hasn’t had a chance to tell the team because there isn’t that kind of time.”

Even without the specific model, Dr. Sliwka says, several principles can be applied to daily interactions. Framing things appropriately, she says, helps patients gain confidence in the doctors and allows them to safely conduct bedside teaching and openly discuss procedures. Even correcting mistakes can be a positive experience. “That actually makes the patient feel more confident in you than less confident,” Dr. Sliwka says.

Ultimately, the teaching experience can help residents broaden their thinking about patient satisfaction. “I think when trainees are starting, their real focus is, ‘How do I deal with this correctly?’ ” Dr. Sliwka says. “It takes a level of comfort with the basic skills to then go beyond that and start thinking about, ‘How is the patient perceiving this?’”

Bryn Nelson is a freelance medical journalist based in Seattle.

References

1. Williams M, Flanders SA, Whitcomb WF. Comprehensive hospital medicine: an evidence based approach. Elsevier;2007:971-976.
2. Arora V, Gangireddy S, Mehrotra A, Ginde R, Tormey M, Meltzer D. Ability of hospitalized patients to identify their in-hospital physicians. Arch Intern Med. 2009;169(2):199-201.
3. Singer AS, et al. Hospitalists meeting the challenge of patient satisfaction. The Phoenix Group. 2008;1-5.
4. Manian FA. Whither continuity of care? N Engl J Med. 1999;340:1362-1363.
5. Correspondence. Whither continuity of care? N Engl J Med. 1999;341:850-852.
6. Davis KM, Koch KE, Harvey JK, et al. Effects of hospitalists on cost, outcomes, and patient satisfaction in a rural health system. Amer J Med. 2000;108(8):621-626.
7. Wachter RM, Goldman L. The hospitalist movement 5 years later. JAMA. 2002;287(4):487-494.
8. Coffman J, Rundall TG. The impact of hospitalists on the cost and quality of inpatient care in the United States (a research synthesis). Med Care Res Rev. 2005;62:379–406.
9. Dhuper S, Choksi S. Replacing an academic internal medicine residency program with a physician assistant-hospitalist model: a comparative analysis study. Am J Med Qual. 2009;24(2):132-139.
10. Roy CL, Liang CL, Lund M, et al. Implementation of a physician assistant/hospitalist service in an academic medical center: impact on efficiency and patient outcomes. J Hosp Med. 2008;3(5):361-368.
11. Fulton BR, Drevs KE, Ayala LJ, Malott DL Jr. Patient satisfaction with hospitalists: facility-level analyses. Am J Med Qual. 2011;26(2):95-102.
12. Ferranti DE, Makoul G, Forth VE, Rauworth J, Lee J, Williams MV. Assessing patient perceptions of hospitalist communication skills using the Communication Assessment Tool (CAT). J Hosp Med. 2010;5(9):522-527.

For those who say they would pay $50 more per patient if the quality is better, here’s the problem: Show me the data that say hospitalist care is higher-quality.

I suspect most of you have reviewed the study or at least heard about it. Bob Wachter, MD, MHM, blogged about the study. An article about the study appeared in American Medical Association News. Even National Public Radio ran a piece about the study on their show “Morning Edition.”

I am, of course, referring to the study by Kuo and Goodwin, which was published in the Annals of Internal Medicine in early August.¹

In this study, the authors looked at a sample of patients (5%) with primary-care physicians (PCPs) enrolled in Medicare who were cared for by their PCP or a hospitalist during a period from 2001 to 2006. The authors stated their underlying hypotheses as:

• Hospitalist care would be associated with costs shifting from the hospital to the post-hospital setting;
• Hospitalist care would be associated with a decrease in discharges directly to home; and
• Discontinuities of care associated with hospitalist care would lead to a greater rate of visits to the emergency room and readmissions to the hospital, resulting in increased Medicare costs.

Did the authors say hospitalist care cost more? They can’t possibly be correct, can they? Don’t all the hospitalist studies show that hospitalists provide the same quality of care as primary-care doctors, except the costs are lower and the hospital length of stay (LOS) is shorter when hospitalists care for patients?

The point here is that these investigators look at the care not only during a patient’s hospital stay, but also for 30 days after discharge. This is something that had not been done previously—at least not on this scale.

Focus on Facts

And what did the authors find? Patients cared for by hospitalists, as compared to their PCPs, had a shorter LOS and lower in-hospital costs, but these patients also were less likely to be discharged directly to home, less likely to see their PCPs post-discharge, and had more hospital readmissions, ED visits, and nursing home visits after discharge.

Since its release two months ago, I have heard a lot of discussion about the study. Here are a few of the comments I’ve heard:

• “This was an observational study. You can’t possibly remove all confounders in an observational study.”
• “The authors looked at a time period early in the hospitalist movement. If they did the study today, the results would be different.”
• “The additional costs hospitalists incurred were only $50 per patient. Wouldn’t you pay $50 more if the care was better?”
• “This is why hospitals hired hospitalists. They save money for the hospitals. What did they expect to find?”

I agree that observational studies have limitations (even the authors acknowledged this), but this doesn’t mean results from observational studies are invalid. Some of us don’t want to hear this, but this actually was a pretty well-done study with a robust statistical analysis. We should recognize the study has limitations and think about the results.

Kuo and Goodwin looked at data during a period of time early in the hospitalist movement; the results could be different if the study were to be repeated today. But we don’t know what the data would be today. I suppose the data could be better, worse, or about the same. The fact of the matter is that HM leaders—and most of the rest of us—knew that transitions of care, under the hospitalist model, were a potential weakness. How many times have you heard Win Whitcomb, MD, MHM, and John Nelson, MD, MHM, talk about the potential “voltage drop” with handoffs?

The good news is that leaders in our field have done something about this. Project BOOST (Better Outcomes for Older Adults through Safer Transitions) is a program SHM has helped implement at dozens of hospitals across the country to address the issue of unnecessary hospital readmissions (www.hospitalmedicine. org/boost). Improving transitions of care and preventing unnecessary readmissions should be on the minds of all hospitalists. If your program and your hospital have not yet taken steps to address this issue, please let this be your wake-up call.

Show Me the Money

For those who say they would pay $50 more per patient if the quality is better, here’s the problem: Show me the data that say hospitalist care is higher-quality. I agree with you that it is hard to look at costs without looking at quality. Therein lies the basis for our nation’s move toward value-based purchasing of healthcare (see “Value-Based Purchasing Raises the Stakes,” May 2011).

When I hear hospitalists explain why the role of hospitalists was developed, the explanation often involves some discussion of cost and LOS reduction. Don’t get me wrong; it’s not that I believe HM has focused too much attention on cost reduction. I believe we have not focused enough on improving quality. This should not be surprising. Moving the bar on cost reduction is a lot easier than moving the bar on quality and patient safety. The first step toward improvement is an understanding of what you are doing currently. If your hospitalist group has not implemented a program to help its hospitalists measure the quality of care being provided, again, this is your wake-up call.

Last, but not least, for those of you who are not “surprised” by the results because of the belief that hospitalists were created to help the hospital save money and nothing more, I could not disagree with you more. I look at the roles that hospitalists have taken on in our nation’s hospitals, and I am incredibly proud to call myself a hospitalist.

Hospitalists are providing timely care when patients need it. Hospitalists are caring for patients without PCPs. Not only do hospitalists allow PCPs to provide more care in their outpatient clinics, but hospitalists also are caring for patients in ICUs in many places where there are not enough doctors sufficiently trained in critical care.

Rather than acting as an indictment on HM, I believe the Annals article makes a comment on the misalignment of incentives in our healthcare system.

It is 2011, not 1996; HM is here to stay. Most acute-care hospitals in America could not function without hospitalists. I applaud Kuo and Goodwin for doing the research and publishing their results. Let this be an opportunity for hospitalists around the country to think about how to implement systems to improve transitions of care and the quality of care we provide.

Dr. Li is president of SHM.

Reference

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

For those who say they would pay $50 more per patient if the quality is better, here’s the problem: Show me the data that say hospitalist care is higher-quality.

I suspect most of you have reviewed the study or at least heard about it. Bob Wachter, MD, MHM, blogged about the study. An article about the study appeared in American Medical Association News. Even National Public Radio ran a piece about the study on their show “Morning Edition.”

I am, of course, referring to the study by Kuo and Goodwin, which was published in the Annals of Internal Medicine in early August.¹

In this study, the authors looked at a sample of patients (5%) with primary-care physicians (PCPs) enrolled in Medicare who were cared for by their PCP or a hospitalist during a period from 2001 to 2006. The authors stated their underlying hypotheses as:

• Hospitalist care would be associated with costs shifting from the hospital to the post-hospital setting;
• Hospitalist care would be associated with a decrease in discharges directly to home; and
• Discontinuities of care associated with hospitalist care would lead to a greater rate of visits to the emergency room and readmissions to the hospital, resulting in increased Medicare costs.

Did the authors say hospitalist care cost more? They can’t possibly be correct, can they? Don’t all the hospitalist studies show that hospitalists provide the same quality of care as primary-care doctors, except the costs are lower and the hospital length of stay (LOS) is shorter when hospitalists care for patients?

The point here is that these investigators look at the care not only during a patient’s hospital stay, but also for 30 days after discharge. This is something that had not been done previously—at least not on this scale.

Focus on Facts

And what did the authors find? Patients cared for by hospitalists, as compared to their PCPs, had a shorter LOS and lower in-hospital costs, but these patients also were less likely to be discharged directly to home, less likely to see their PCPs post-discharge, and had more hospital readmissions, ED visits, and nursing home visits after discharge.

Since its release two months ago, I have heard a lot of discussion about the study. Here are a few of the comments I’ve heard:

• “This was an observational study. You can’t possibly remove all confounders in an observational study.”
• “The authors looked at a time period early in the hospitalist movement. If they did the study today, the results would be different.”
• “The additional costs hospitalists incurred were only $50 per patient. Wouldn’t you pay $50 more if the care was better?”
• “This is why hospitals hired hospitalists. They save money for the hospitals. What did they expect to find?”

I agree that observational studies have limitations (even the authors acknowledged this), but this doesn’t mean results from observational studies are invalid. Some of us don’t want to hear this, but this actually was a pretty well-done study with a robust statistical analysis. We should recognize the study has limitations and think about the results.

Kuo and Goodwin looked at data during a period of time early in the hospitalist movement; the results could be different if the study were to be repeated today. But we don’t know what the data would be today. I suppose the data could be better, worse, or about the same. The fact of the matter is that HM leaders—and most of the rest of us—knew that transitions of care, under the hospitalist model, were a potential weakness. How many times have you heard Win Whitcomb, MD, MHM, and John Nelson, MD, MHM, talk about the potential “voltage drop” with handoffs?

The good news is that leaders in our field have done something about this. Project BOOST (Better Outcomes for Older Adults through Safer Transitions) is a program SHM has helped implement at dozens of hospitals across the country to address the issue of unnecessary hospital readmissions (www.hospitalmedicine. org/boost). Improving transitions of care and preventing unnecessary readmissions should be on the minds of all hospitalists. If your program and your hospital have not yet taken steps to address this issue, please let this be your wake-up call.

Show Me the Money

For those who say they would pay $50 more per patient if the quality is better, here’s the problem: Show me the data that say hospitalist care is higher-quality. I agree with you that it is hard to look at costs without looking at quality. Therein lies the basis for our nation’s move toward value-based purchasing of healthcare (see “Value-Based Purchasing Raises the Stakes,” May 2011).

When I hear hospitalists explain why the role of hospitalists was developed, the explanation often involves some discussion of cost and LOS reduction. Don’t get me wrong; it’s not that I believe HM has focused too much attention on cost reduction. I believe we have not focused enough on improving quality. This should not be surprising. Moving the bar on cost reduction is a lot easier than moving the bar on quality and patient safety. The first step toward improvement is an understanding of what you are doing currently. If your hospitalist group has not implemented a program to help its hospitalists measure the quality of care being provided, again, this is your wake-up call.

Last, but not least, for those of you who are not “surprised” by the results because of the belief that hospitalists were created to help the hospital save money and nothing more, I could not disagree with you more. I look at the roles that hospitalists have taken on in our nation’s hospitals, and I am incredibly proud to call myself a hospitalist.

Hospitalists are providing timely care when patients need it. Hospitalists are caring for patients without PCPs. Not only do hospitalists allow PCPs to provide more care in their outpatient clinics, but hospitalists also are caring for patients in ICUs in many places where there are not enough doctors sufficiently trained in critical care.

Rather than acting as an indictment on HM, I believe the Annals article makes a comment on the misalignment of incentives in our healthcare system.

It is 2011, not 1996; HM is here to stay. Most acute-care hospitals in America could not function without hospitalists. I applaud Kuo and Goodwin for doing the research and publishing their results. Let this be an opportunity for hospitalists around the country to think about how to implement systems to improve transitions of care and the quality of care we provide.

Dr. Li is president of SHM.

Reference

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

For those who say they would pay $50 more per patient if the quality is better, here’s the problem: Show me the data that say hospitalist care is higher-quality.

I suspect most of you have reviewed the study or at least heard about it. Bob Wachter, MD, MHM, blogged about the study. An article about the study appeared in American Medical Association News. Even National Public Radio ran a piece about the study on their show “Morning Edition.”

I am, of course, referring to the study by Kuo and Goodwin, which was published in the Annals of Internal Medicine in early August.¹

In this study, the authors looked at a sample of patients (5%) with primary-care physicians (PCPs) enrolled in Medicare who were cared for by their PCP or a hospitalist during a period from 2001 to 2006. The authors stated their underlying hypotheses as:

• Hospitalist care would be associated with costs shifting from the hospital to the post-hospital setting;
• Hospitalist care would be associated with a decrease in discharges directly to home; and
• Discontinuities of care associated with hospitalist care would lead to a greater rate of visits to the emergency room and readmissions to the hospital, resulting in increased Medicare costs.

Did the authors say hospitalist care cost more? They can’t possibly be correct, can they? Don’t all the hospitalist studies show that hospitalists provide the same quality of care as primary-care doctors, except the costs are lower and the hospital length of stay (LOS) is shorter when hospitalists care for patients?

The point here is that these investigators look at the care not only during a patient’s hospital stay, but also for 30 days after discharge. This is something that had not been done previously—at least not on this scale.

Focus on Facts

And what did the authors find? Patients cared for by hospitalists, as compared to their PCPs, had a shorter LOS and lower in-hospital costs, but these patients also were less likely to be discharged directly to home, less likely to see their PCPs post-discharge, and had more hospital readmissions, ED visits, and nursing home visits after discharge.

Since its release two months ago, I have heard a lot of discussion about the study. Here are a few of the comments I’ve heard:

• “This was an observational study. You can’t possibly remove all confounders in an observational study.”
• “The authors looked at a time period early in the hospitalist movement. If they did the study today, the results would be different.”
• “The additional costs hospitalists incurred were only $50 per patient. Wouldn’t you pay $50 more if the care was better?”
• “This is why hospitals hired hospitalists. They save money for the hospitals. What did they expect to find?”

I agree that observational studies have limitations (even the authors acknowledged this), but this doesn’t mean results from observational studies are invalid. Some of us don’t want to hear this, but this actually was a pretty well-done study with a robust statistical analysis. We should recognize the study has limitations and think about the results.

Kuo and Goodwin looked at data during a period of time early in the hospitalist movement; the results could be different if the study were to be repeated today. But we don’t know what the data would be today. I suppose the data could be better, worse, or about the same. The fact of the matter is that HM leaders—and most of the rest of us—knew that transitions of care, under the hospitalist model, were a potential weakness. How many times have you heard Win Whitcomb, MD, MHM, and John Nelson, MD, MHM, talk about the potential “voltage drop” with handoffs?

The good news is that leaders in our field have done something about this. Project BOOST (Better Outcomes for Older Adults through Safer Transitions) is a program SHM has helped implement at dozens of hospitals across the country to address the issue of unnecessary hospital readmissions (www.hospitalmedicine. org/boost). Improving transitions of care and preventing unnecessary readmissions should be on the minds of all hospitalists. If your program and your hospital have not yet taken steps to address this issue, please let this be your wake-up call.

Show Me the Money

For those who say they would pay $50 more per patient if the quality is better, here’s the problem: Show me the data that say hospitalist care is higher-quality. I agree with you that it is hard to look at costs without looking at quality. Therein lies the basis for our nation’s move toward value-based purchasing of healthcare (see “Value-Based Purchasing Raises the Stakes,” May 2011).

When I hear hospitalists explain why the role of hospitalists was developed, the explanation often involves some discussion of cost and LOS reduction. Don’t get me wrong; it’s not that I believe HM has focused too much attention on cost reduction. I believe we have not focused enough on improving quality. This should not be surprising. Moving the bar on cost reduction is a lot easier than moving the bar on quality and patient safety. The first step toward improvement is an understanding of what you are doing currently. If your hospitalist group has not implemented a program to help its hospitalists measure the quality of care being provided, again, this is your wake-up call.

Last, but not least, for those of you who are not “surprised” by the results because of the belief that hospitalists were created to help the hospital save money and nothing more, I could not disagree with you more. I look at the roles that hospitalists have taken on in our nation’s hospitals, and I am incredibly proud to call myself a hospitalist.

Hospitalists are providing timely care when patients need it. Hospitalists are caring for patients without PCPs. Not only do hospitalists allow PCPs to provide more care in their outpatient clinics, but hospitalists also are caring for patients in ICUs in many places where there are not enough doctors sufficiently trained in critical care.

Rather than acting as an indictment on HM, I believe the Annals article makes a comment on the misalignment of incentives in our healthcare system.

It is 2011, not 1996; HM is here to stay. Most acute-care hospitals in America could not function without hospitalists. I applaud Kuo and Goodwin for doing the research and publishing their results. Let this be an opportunity for hospitalists around the country to think about how to implement systems to improve transitions of care and the quality of care we provide.

Dr. Li is president of SHM.

Reference

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

In a bit of counterintuition, an empty discharge lounge might be the most successful kind.

Christine Collins, executive director of patient access services at Brigham and Women’s Hospital in Boston, says that the lounge should be a service for discharged patients who have completed medical treatment, but who for some reason remain unable to leave the institution. Such cases can include waiting on a prescription from the pharmacy, or simply waiting on a relative or friend to arrive with transportation.

She does not view Brigham’s discharge lounge, a room with lounge chairs and light meals that is staffed by a registered nurse, as the answer to the throughput conundrum hospitals across the country face each and every day. So when the lounge is empty, it means patients have been discharged without any hang-ups.

“It’s not a patient-care area,” Collins says. “They’re people that should be home.”

Some view discharge lounges as a potential aid in smoothing out the discharge process. In theory, patients ready to be medically discharged but unable to leave the hospital have a place to go. But keeping the patients in the building, and under the eye of a nurse, could create liability issues, says Ken Simone, DO, SFHM, president of Hospitalist and Practice Solutions in Veazie, Maine, and a member of Team Hospitalist. Dr. Simone also wonders how the lounge concept impacts patient satisfaction, as some could view it negatively if they’re told they have to sit in what could be construed as a back-end waiting room.

“People need to assess what they’re doing it for and is it really accomplishing what they want it to accomplish,” Collins says.

Discharge lounges “can’t be another nursing unit because a patient is supposed to be discharged. ... Whether you have a discharge lounge or not, you need to improve your systems so that the patients leave when they leave.”

Richard Quinn is a freelance writer based in New Jersey.

In a bit of counterintuition, an empty discharge lounge might be the most successful kind.

Christine Collins, executive director of patient access services at Brigham and Women’s Hospital in Boston, says that the lounge should be a service for discharged patients who have completed medical treatment, but who for some reason remain unable to leave the institution. Such cases can include waiting on a prescription from the pharmacy, or simply waiting on a relative or friend to arrive with transportation.

She does not view Brigham’s discharge lounge, a room with lounge chairs and light meals that is staffed by a registered nurse, as the answer to the throughput conundrum hospitals across the country face each and every day. So when the lounge is empty, it means patients have been discharged without any hang-ups.

“It’s not a patient-care area,” Collins says. “They’re people that should be home.”

Some view discharge lounges as a potential aid in smoothing out the discharge process. In theory, patients ready to be medically discharged but unable to leave the hospital have a place to go. But keeping the patients in the building, and under the eye of a nurse, could create liability issues, says Ken Simone, DO, SFHM, president of Hospitalist and Practice Solutions in Veazie, Maine, and a member of Team Hospitalist. Dr. Simone also wonders how the lounge concept impacts patient satisfaction, as some could view it negatively if they’re told they have to sit in what could be construed as a back-end waiting room.

“People need to assess what they’re doing it for and is it really accomplishing what they want it to accomplish,” Collins says.

Discharge lounges “can’t be another nursing unit because a patient is supposed to be discharged. ... Whether you have a discharge lounge or not, you need to improve your systems so that the patients leave when they leave.”

Richard Quinn is a freelance writer based in New Jersey.

In a bit of counterintuition, an empty discharge lounge might be the most successful kind.

Christine Collins, executive director of patient access services at Brigham and Women’s Hospital in Boston, says that the lounge should be a service for discharged patients who have completed medical treatment, but who for some reason remain unable to leave the institution. Such cases can include waiting on a prescription from the pharmacy, or simply waiting on a relative or friend to arrive with transportation.

She does not view Brigham’s discharge lounge, a room with lounge chairs and light meals that is staffed by a registered nurse, as the answer to the throughput conundrum hospitals across the country face each and every day. So when the lounge is empty, it means patients have been discharged without any hang-ups.

“It’s not a patient-care area,” Collins says. “They’re people that should be home.”

Some view discharge lounges as a potential aid in smoothing out the discharge process. In theory, patients ready to be medically discharged but unable to leave the hospital have a place to go. But keeping the patients in the building, and under the eye of a nurse, could create liability issues, says Ken Simone, DO, SFHM, president of Hospitalist and Practice Solutions in Veazie, Maine, and a member of Team Hospitalist. Dr. Simone also wonders how the lounge concept impacts patient satisfaction, as some could view it negatively if they’re told they have to sit in what could be construed as a back-end waiting room.

“People need to assess what they’re doing it for and is it really accomplishing what they want it to accomplish,” Collins says.

Discharge lounges “can’t be another nursing unit because a patient is supposed to be discharged. ... Whether you have a discharge lounge or not, you need to improve your systems so that the patients leave when they leave.”

Richard Quinn is a freelance writer based in New Jersey.

Click here to listen to ENA President AnnMarie Papa.

Click here to listen to Dr. Simone.

Click here to listen to ENA President AnnMarie Papa.

Click here to listen to Dr. Simone.

Click here to listen to ENA President AnnMarie Papa.

Click here to listen to Dr. Simone.

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

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

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

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

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

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

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

No. 1: Take Your Time

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

No. 2: Identify Your Passion

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

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

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

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

No. 3: Stay in Your Own Orbit

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

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

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

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

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

No. 4: Master the Network

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

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

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

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

No. 5: Take Calculated Risks

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

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

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

No. 6: Ready For Change

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

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

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

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

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

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

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

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

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

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

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

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

No. 1: Take Your Time

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

No. 2: Identify Your Passion

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

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

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

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

No. 3: Stay in Your Own Orbit

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

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

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

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

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

No. 4: Master the Network

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

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

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

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

No. 5: Take Calculated Risks

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

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

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

No. 6: Ready For Change

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

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

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

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

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

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

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

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

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

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

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

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

No. 1: Take Your Time

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

No. 2: Identify Your Passion

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

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

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

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

No. 3: Stay in Your Own Orbit

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

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

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

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

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

No. 4: Master the Network

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

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

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

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

No. 5: Take Calculated Risks

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

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

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

No. 6: Ready For Change

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Brendon Shank is associate vice president of communications at SHM.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Brendon Shank is associate vice president of communications at SHM.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Brendon Shank is associate vice president of communications at SHM.