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Specially-Trained Hospitalists Spearhead SHM’s Quality Improvement Programs
When SHM received the Joint Commission’s John M. Eisenberg Patient Safety and Quality Award for 2011 for innovation in patient safety and quality at the national level, the award represented national recognition for the society’s three major hospital quality improvement initiatives. Moreover, it highlighted the integral role mentors play in each of the programs, helping physicians and hospitals make accelerated progress on important patient safety and quality issues.
Mentored implementation assigns a physician expert to train, guide, and work with the participating facilities’ hospitalist-led, multidisciplinary team through the life cycle of a QI initiative. The three programs focus on VTE prevention, glycemic control, and transitions of care. The first hospital cohort for VTE prevention—the VTE Prevention Collaborative—was in 2007. The care transitions program, known as Project BOOST, started in 2008. The Glycemic Control Mentored Implementation (GCMI) Program began in 2009. A fourth SHM mentored implementation program is MARQUIS, the Multi-Center Medication Reconciliation Quality Improvement Study.
In basic terms, mentoring is “coaching from a physician who has expertise both in the clinical subject matter and in implementing the processes and tools of quality improvement—usually because they’ve done it themselves,” says Gregory Maynard, MD, MSc, SFHM, senior vice president of SHM’s Center for Hospital Innovation and Improvement and a co-founder of two of its mentored implementation programs.
Mentors typically are paired with one or two participating hospitals for 12 to 18 months, conducting monthly conference calls with the team, sharing tools and resources from SHM’s online library, and offering advice on how to navigate the treacherous currents of culture change within a hospital. BOOST mentors also make in-person site visits. They are well versed in protocol and order set design and quality measurement strategies, and they know how to engage frontline professionals and institutional leadership, Dr. Maynard says.
Some mentors have received formal QI training, and many have attended Mentor University, a 1-1/2 day intensive training course offered by SHM that reinforces the nuances of coaching, the contents of SHM’s quality toolkits, and ideas for overcoming common barriers to improvement. SHM’s mentor support provides continuous professional development for the mentors, pairing new mentors with senior mentors to coach them in the process and hosting an online community with other mentors.
“What’s telling to me is that many of the people who have been mentored by SHM’s programs in one topic go on to become mentors in another topic, taking those portable skills and principles and applying them in other quality areas,” Dr. Maynard says. “We’re fostering leadership and quality improvement skills among hospitalists; that’s really one of our main goals. People learn the skill and then spread it within their system.”
Mark Williams, MD, FACP, MHM, Project BOOST principal investigator and a veteran SHM mentor, says that just providing educational materials to health professionals often isn’t enough for them to overcome the barriers to change.
“I’ve seen many large-scale quality projects that didn’t work, as they were simply disseminating information, content, or knowledge,” he says. Mentored implementation as practiced by SHM is “a model for disseminating quality improvement nationally,” he adds. “Pretty much any quality improvement project can be done this way.”
Key to the mentored implementation program’s success is the personalized approach and customized solutions.
“You directly meet with the team in their own setting and begin to see what’s going on,” Dr. Williams says. “You also meet with the hospital’s senior leadership. That’s when you start to see change.”
The Hospitalist connected with eight SHM mentors. The following are snapshots of their work in the mentorship program and some of the lessons they taught—and learned—from the program.
Christine Lum Lung, MD, SFHM
Title: Medical director, Northern Colorado Hospitalists, Fort Collins
Program: VTE Prevention Collaborative
Background: As a practicing hospitalist and medical director of the HM group for a two-hospital system, Dr. Lum Lung chaired its quality committee for VTE protocol development. “It was obvious at our hospitals that we needed to do better at VTE prevention,” she explains.
Dr. Lum Lung’s team received VTE mentorship from Dr. Maynard, who later asked her to become a VTE mentor. She also attended all three levels of SHM’s Leadership Academy and has since become a mentor for the new HP3 (Hospitalist Program Peak Performance) mentored implementation program, a one-year collaboration among SHM, Northwestern University, Blue Cross/Blue Shield of Illinois, and the Illinois Hospital Association that is designed to help hospitalist groups optimize their programs and build healthy group culture.
Teachable moment: The essential qualities of a good mentee, Dr. Lum Lung says, are drive and dedication. “You believe strongly about it, so you can sell it to others. You also need a thick skin to face the adversities that come up. When my mentor gave me tasks and deadlines, I met those deadlines.”
Success story: “I’ve been impressed with how hard groups and individuals can work.” Most of the teams she has worked with were facing significant external stressors—starting a new program, moving into a new hospital, rolling out a new EHR, becoming part of a growing medical group. “Yet each of them has been incredibly engaged in the process and dedicated to completing their projects.”
Lessons learned: “That we all have something to learn from each other. While I am officially the mentor, I have learned a lot about processes, teamwork, and flow issues from the sites that could potentially be incorporated in our program.”
Advice: Working on a project as a team can be very powerful, she says. Even seemingly ‘small’ projects have allowed teams to learn how to work better together on day-to-day issues. With the victory of a small project behind them, they make lists of the next thing that they want to tackle.
“Our profession is constantly changing. We need to be thinking ahead for how we will face those challenges,” Dr. Lum Lung says. “A team that works well together will have an advantage in this new environment. Even if you have people who are new to quality improvement, their participation can still be important.”
Jordan Messler, MD, SFHM
Title: Medical director, Morton Plant Hospitalists, Clearwater, Fla.
Program: GCMI; Project BOOST
Background: Dr. Messler’s interest in QI led him to work with colleagues in SHM who are national leaders in quality. “A couple of years ago, I enrolled in Emory’s Quality Academy, a sister course to Intermountain Health’s course on quality. Then I enrolled our hospital in both the GCMI Program and Project BOOST. My mentors for those programs were terrific guides, which led to my interest in seeing their side of the program as a mentor myself.”
Teachable moment: One program had difficulty implementing a VTE prevention tool and couldn’t get nursing support as it had expected, largely due to lack of nursing engagement on the project team, he says. “We started talking about the history of the projects, and prior interventions. In addition, we talked to the different disciplines separately. It seems there used to be an excellent system where nursing helped out on the project team for risk assessment.”
As VTE prevention became more of a priority, some physicians separately created a new tool to replace the nursing tool without involving the whole team. “And they couldn’t understand why nursing wasn’t buying into the new process.”
Success story: There are similar themes to success and failure. Sites that have strong administrative support (i.e., C-suite representation on the QI team), that have “accountability structure and stick to the basics of QI, with clear goals, ability to gather and report data, and use of a QI model [such as PDSA or Six Sigma] are the ones that succeed,” Dr. Messler says. “And the reverse is consistently true. Sustainable QI needs to be multidisciplinary, involving every voice, considering prior interventions and understanding of the culture.”
Lessons learned: “As mentors, we all continue to say we learn as much or more from these sites as they, hopefully, are learning from us. This collaboration and sharing of ideas has been instrumental to the success of the program.”
Advice: Get started today, and don’t give up. Follow the road map of QI projects, gather support, and get started. You will learn as much from your failures as your successes.
Dr. Messler says hospitals are looking for physician leaders to improve quality, and hospitalists are perfectly positioned to be those QI leaders. These big projects can last for years, so quality teams and hospitals need to be prepared to take the long view.
—Jennifer Quartarolo, MD, SFHM
Stephanie Rennke, MD
Title: Associate clinical professor of medicine, co-director of faculty development, division of hospital medicine, University of California San Francisco Medical Center.
Program: Project BOOST
Background: “When I started as a hospitalist right out of residency, QI had not been part of my training. But I noticed that quality was at the forefront of the academic interests of all the hospitalists at UCSF. I was personally interested in transitions of care. I still do home visits after hours for at-risk patients when they leave the hospital.”
Dr. Rennke started in QI as a member of UCSF’s BOOST team in 2008. “I worked with other faculty in the division who had previous experience in quality improvement and transitions in care. One of the co-principal investigators for BOOST, Dr. Arpana Vidyarthi, suggested that it would be a really rewarding experience to mentor—and it was.”
Teachable moment: “I’ve been so impressed by the diversity of what’s out there. No hospitalist program or hospital is the same. There is no one-size-fits-all for quality improvement or transitions of care, so it is incredibly important that the mentor takes the time to get to know both the team and the hospital.”
Success story: “During a site visit, I had an opportunity to watch one of the nurses, who had received training from a competency-based Teach Back program, practice Teach Back with a patient at the bedside,” Dr. Rennke says. “I was doing a tour of the floor and went into the room of a patient about to be discharged. A young float nurse, not long out of school, sat down with the patient and went through the medications and discharge plan using Teach Back. It didn’t take more time, but the time was spent more constructively, with interaction back and forth. I remember that ‘aha’ moment for the patient and the look in her eyes. For me, as a mentor, it was exciting to think that something I had tried to bring to them had been incorporated by the site and was really working.”
Lessons learned: “I have learned that, while at a large institution like UCSF we tend to work in silos, smaller sites are often more integrated with the various disciplines. You can walk down the hall to the clinical pharmacist or have lunch with the charge nurse. So I’ve tried to bring back home a commitment to really get to know professional colleagues and have them feel that I’m interested in their perspectives.”
Advice: “Work in teams. You cannot do this alone. Include frontline staff. And don’t forget to advertise to others that the program exists. Get the word out—let people know.”
Jennifer Quartarolo, MD, SFHM
Title: Medical director, clinical resource management; associate clinical professor, division of hospital medicine, University of California San Diego Health System
Program: Project BOOST
Background: Dr. Quartarolo has 11 years of clinical experience as an academic hospitalist at two different medical centers, and she completed a training program in healthcare delivery and improvement through the Institute for Health Care Delivery Research in Salt Lake City, Utah. “At my own institution, I had been involved in multiple QI projects,” she says. “Since joining the faculty, I worked with our care transitions team for five years before becoming a mentor. We incorporated many elements from Project BOOST as we worked to improve our care transitions process,” which led to an invitation to be a mentor.
Teachable moment: “I had one site that I worked with that had a great new form they had developed to incorporate into their transition process; however, when they decided to implement the form, they got a lot of pushback from nursing,” she says. “Then they realized that they had not involved any frontline nurses in their planning. This example points out how important it is to have all the key players involved on your team, as improving transitions of care is a complex process requiring multidisciplinary collaboration.”
Success story: Dr. Quartarolo says she has worked with several hospitals that have seen significant improvement in their readmission rates after participating in Project BOOST and implementing its tools.
Lessons learned: “I am constantly impressed by the innovative ideas that teams come up with to deal with the challenges that their hospitals face,” she says. Every hospital is unique and needs to do self-evaluation before deciding what to focus on. “I have also worked with many sites that have challenges getting physicians engaged in their efforts, particularly if they do not have a hospitalist program.”
Advice: “We are in a unique role as hospitalists to identify systems issues and improve quality of care in the inpatient setting, and this is particularly useful in improving care transitions and decreasing readmissions rates.”
Rich Balaban, MD
Title: Medical director, Hospital-to-Home Community Collaboration Program, Cambridge Health Alliance; assistant professor of medicine, Harvard Medical School, Boston
Program: Project BOOST
Background: Dr. Balaban has worked clinically in both the inpatient setting as a hospitalist and the outpatient setting as a primary care doctor. “I have seen hospital discharges as both a receiver and a sender, so [I] have been able to appreciate the challenges facing doctors, nurses, case managers, and patients involved in the care transition process,” he says.
Dr. Balaban also conducted a randomized controlled trial that demonstrated the benefits of engaging nurses at a patient’s primary care site to make outreach phone calls immediately after hospital discharge. Dr. Williams asked him to present on the study.
“It was a great opportunity for me to share the results of our work and for Mark to see my presentation skills,” he says. “When I asked if there were opportunities to get more involved in care transitions work, he invited me to consider becoming a BOOST mentor.”
Teachable moment: “Wearing my primary care hat, I believe that while it is very important to structure an effective discharge for the patient while in the hospital, success or failure ultimately is determined by what happens in the outpatient setting,” Dr. Balaban says. Even if a ‘perfect discharge’ occurs in the hospital, it can all quickly unravel once the patient arrives at home.
Success story: “At several sites, I have encouraged the inpatient care team to invite the outpatient care team to become part of the care transitions team. This has frequently brought an important viewpoint and voice to the care transitions table. While hospitalists have initiated the discussion about care transitions, they need an effective outpatient partner to create a truly effective process.”
Lessons learned: “I have learned to hold judgment until seeing with my own eyes,” Dr. Balaban says. “One of the first sites I visited had developed a post-discharge clinic, which they were excited to show me. From my point of view, I thought that after discharge, patient care should be assumed by the primary care office as soon as possible, and a post-discharge clinic would only delay that process.
“To my great surprise, their post-discharge clinic provided an ideal bridge between the hospital and primary care. The post-discharge clinic really worked and provided patients with a wonderful resource. … I’ve learned that there are many ways to solve problems, often based on the available resources at a specific site.”
Advice: In order to best understand the challenges of hospital discharge, it is critical that you understand what happens to patients after they leave the hospital. Make a home visit to a recently discharged patient to really understand the challenges that patients face when they return home.
Amitkumar R. Patel, MD, MBA, FACP, SFHM
Title: Clinical instructor in hospital medicine, Feinberg School of Medicine, Northwestern University, Chicago
Program: Project BOOST; also working with critical access hospitals in Illinois through PREP (Preventing Readmissions through Effective Partnerships)
Background: Although he now works in an urban teaching hospital, Dr. Patel also did private practice as a community hospitalist and has pursued formal healthcare management-focused training.
“I became a mentor because my experience and interest in quality improvement fit well with Project BOOST,” he says. “I enjoy coaching teams as they face challenges in quality improvement, especially in relation to readmissions reduction. My work with critical access hospitals is the result of my first year as a mentor with the PREP collaborative in Illinois.”
PREP, a collaborative initiative of SHM and the Illinois Hospital Association that is funded by Blue Cross/Blue Shield of Illinois, aims to help hospitals focus on quality initiatives, including BOOST.
Teachable moment/success story: One of Dr. Patel’s BOOST sites believed the team included all appropriate personnel to obtain discharge appointments prior to patients’ discharges. But as they began to work through the process of making sure each appointment was appropriately documented, the various team members assigned to this process could not consistently complete the task within their workflow.
The pilot unit secretaries were not part of the BOOST team initially but saw that they could fulfill this role quickly and easily. They knew who to call at the physicians’ offices to avoid getting stuck in the phone menu trees, and they used this knowledge to reach the schedulers directly. The BOOST team quickly realized the unit secretaries were the most appropriate personnel to capture this information and work with the patients or their families/caregivers to obtain the most convenient appointments. This role was added to the team, and the unit secretaries took ownership of this process. Other teams may also want to look beyond the customary team members to roles that may not be thought of as quality team members.
Lessons learned: “The biggest take-away for me involves the unique culture that exists in many of our urban and rural communities,” he says. Every BOOST site implements the project’s elements in its own unique way, and what works well in one location may not fit the needs of another. The role of the mentor is to balance the need for community-specific advice with unique attributes of the facility and the elements of Project BOOST. “Often, we use our mentor calls to brainstorm solutions, and the teams are teaching me what will work best in their environment.”
Advice: “Responsibility for hospital change management should not be abdicated to administrators or quality improvement staff members,” he says. “QI is not a sometime thing for some staff; it’s an all-the-time process for every staff member, including physicians, to participate in and actively manage.”
—Christopher Kim, MD, MBA, SFHM
Cheryl O’Malley, MD, FHM
Title: Internal medicine residency program director, Banner Good Samaritan Medical Center, Phoenix
Program: GCMI
Background: Banner Good Samaritan has participated in the BOOST, VTE, and GCMI programs. Dr. O’Malley brought her experience from developing, implementing, and leading local glycemic control efforts to mentoring others.
“When I first started working on our hospital’s process, I had so many questions and asked one of my mentors from residency, Dr. Greg Maynard,” she says. “He helped me to see that people around the country were asking the same questions and invited me to join SHM’s glycemic control work group. When the GCMI program started, I was asked to be a mentor.”
Teachable moment: “When I was a new attending on the wards after residency, my patients would ask me why their blood sugars were so much better controlled at home than in the hospital. Usually, the answer was that they were put on a sliding scale when they came into the hospital,” she says, noting that what was done at home wasn’t going to work in the hospital. Patients needed a different regimen—a more proactive approach than just the customary sliding scale.
“I started to learn more about basal rates, nutrition, and correction insulin regimens in the hospital, but I realized that to really have adequate safety and direction for the nursing staff, it would require a formal order set and systematic approach,” she says.
Success story: “One of my sites invited me to come and present grand rounds at the hospital, and the local physician team leader invited the whole quality team to her home. It was a very exciting team and had achieved a lot. Fifteen or 20 of us spent the evening talking about the project but also just enjoying the collegiality,” Dr. O’Malley says. “Even though we had never seen one another, I instantly knew everyone by voice from spending so much time on the phone. And we knew a lot about one another’s personal lives and careers.”
Lessons learned: “Hearing a program describe what they are doing and knowing that they were far ahead of my own hospital in many ways but still being able to provide an insight or a perspective to help them achieve their own next steps. Everyone has something to learn from another hospital or another discipline. We can all leverage our experiences to improve patient care.”
Advice: “Be patient. This is a really long process of constant improvements. I have been working on glycemic control for 10 years now and still feel like we have many opportunities to further improve.”
Christopher Kim, MD, MBA, SFHM
Title: Clinical associate professor of internal medicine and assistant professor of pediatrics, University of Michigan Health System, Ann Arbor
Program: Project BOOST; Michigan Transitions of Care Collaborative (M-TC2)
Background: Dr. Kim brings clinical, quality improvement, leadership, collaborative learning, and discussion facilitation skills to his work as program director of M-TC2 and as mentor to the sites he works with.
The collaborative is part of a set of state collaborative quality initiatives funded by Blue Cross Blue Shield of Michigan. One of those initiatives is focused on improving care transitions between the hospital setting and ambulatory care providers, using Project BOOST tools—expanded to integrate more closely with primary care providers, physician organizations, and ambulatory care. The eight Michigan-based mentors for M-TC2 have all attended SHM’s Mentor University.
Teachable moment: There are local challenges and there are general challenges—those that are commonly shared by most hospitals, Dr. Kim explains. Both need to be overcome when working on an improvement project such as transitions of care. The local hospitalist brings expertise about the former—which are often more difficult to understand and overcome. The mentor brings knowledge and experience of the universal challenges, as well as the benefit of having seen or heard about what other programs have done. Together, they can work to help the organization become better equipped to improve the initiative at hand.
Success story: “One hospital in the collaborative realized that it could roll out the Teach Back concept to both nurses and physicians,” he says. They started to teach residents how to interact with patients and began using this approach in physician-nurse teams. Subsequently, the team shared with the collaborative how physicians have embraced the concept.
Lessons learned: Every site has its successes and challenges, he says. Sharing both sides of the story can only advance the mission of the collaborative, as each organization learns from the successes and failures of the others.
Mentored implementation really does what it’s intended to do—helping to support the sites and keeping an organization on track and accountable for the work it does, because someone external to the organization is working with it and providing information about what other sites are doing.
Advice: Talk with different disciplines and find out how much they long to work with other care providers, and then have discussions about how to make interdisciplinary practice happen. “At our collaborative meetings over time, many of the 24 participating sites have shared their progress—the good things and the struggles,” Dr. Kim says.
Larry Beresford is a freelance writer in Alameda, Calif.
When SHM received the Joint Commission’s John M. Eisenberg Patient Safety and Quality Award for 2011 for innovation in patient safety and quality at the national level, the award represented national recognition for the society’s three major hospital quality improvement initiatives. Moreover, it highlighted the integral role mentors play in each of the programs, helping physicians and hospitals make accelerated progress on important patient safety and quality issues.
Mentored implementation assigns a physician expert to train, guide, and work with the participating facilities’ hospitalist-led, multidisciplinary team through the life cycle of a QI initiative. The three programs focus on VTE prevention, glycemic control, and transitions of care. The first hospital cohort for VTE prevention—the VTE Prevention Collaborative—was in 2007. The care transitions program, known as Project BOOST, started in 2008. The Glycemic Control Mentored Implementation (GCMI) Program began in 2009. A fourth SHM mentored implementation program is MARQUIS, the Multi-Center Medication Reconciliation Quality Improvement Study.
In basic terms, mentoring is “coaching from a physician who has expertise both in the clinical subject matter and in implementing the processes and tools of quality improvement—usually because they’ve done it themselves,” says Gregory Maynard, MD, MSc, SFHM, senior vice president of SHM’s Center for Hospital Innovation and Improvement and a co-founder of two of its mentored implementation programs.
Mentors typically are paired with one or two participating hospitals for 12 to 18 months, conducting monthly conference calls with the team, sharing tools and resources from SHM’s online library, and offering advice on how to navigate the treacherous currents of culture change within a hospital. BOOST mentors also make in-person site visits. They are well versed in protocol and order set design and quality measurement strategies, and they know how to engage frontline professionals and institutional leadership, Dr. Maynard says.
Some mentors have received formal QI training, and many have attended Mentor University, a 1-1/2 day intensive training course offered by SHM that reinforces the nuances of coaching, the contents of SHM’s quality toolkits, and ideas for overcoming common barriers to improvement. SHM’s mentor support provides continuous professional development for the mentors, pairing new mentors with senior mentors to coach them in the process and hosting an online community with other mentors.
“What’s telling to me is that many of the people who have been mentored by SHM’s programs in one topic go on to become mentors in another topic, taking those portable skills and principles and applying them in other quality areas,” Dr. Maynard says. “We’re fostering leadership and quality improvement skills among hospitalists; that’s really one of our main goals. People learn the skill and then spread it within their system.”
Mark Williams, MD, FACP, MHM, Project BOOST principal investigator and a veteran SHM mentor, says that just providing educational materials to health professionals often isn’t enough for them to overcome the barriers to change.
“I’ve seen many large-scale quality projects that didn’t work, as they were simply disseminating information, content, or knowledge,” he says. Mentored implementation as practiced by SHM is “a model for disseminating quality improvement nationally,” he adds. “Pretty much any quality improvement project can be done this way.”
Key to the mentored implementation program’s success is the personalized approach and customized solutions.
“You directly meet with the team in their own setting and begin to see what’s going on,” Dr. Williams says. “You also meet with the hospital’s senior leadership. That’s when you start to see change.”
The Hospitalist connected with eight SHM mentors. The following are snapshots of their work in the mentorship program and some of the lessons they taught—and learned—from the program.
Christine Lum Lung, MD, SFHM
Title: Medical director, Northern Colorado Hospitalists, Fort Collins
Program: VTE Prevention Collaborative
Background: As a practicing hospitalist and medical director of the HM group for a two-hospital system, Dr. Lum Lung chaired its quality committee for VTE protocol development. “It was obvious at our hospitals that we needed to do better at VTE prevention,” she explains.
Dr. Lum Lung’s team received VTE mentorship from Dr. Maynard, who later asked her to become a VTE mentor. She also attended all three levels of SHM’s Leadership Academy and has since become a mentor for the new HP3 (Hospitalist Program Peak Performance) mentored implementation program, a one-year collaboration among SHM, Northwestern University, Blue Cross/Blue Shield of Illinois, and the Illinois Hospital Association that is designed to help hospitalist groups optimize their programs and build healthy group culture.
Teachable moment: The essential qualities of a good mentee, Dr. Lum Lung says, are drive and dedication. “You believe strongly about it, so you can sell it to others. You also need a thick skin to face the adversities that come up. When my mentor gave me tasks and deadlines, I met those deadlines.”
Success story: “I’ve been impressed with how hard groups and individuals can work.” Most of the teams she has worked with were facing significant external stressors—starting a new program, moving into a new hospital, rolling out a new EHR, becoming part of a growing medical group. “Yet each of them has been incredibly engaged in the process and dedicated to completing their projects.”
Lessons learned: “That we all have something to learn from each other. While I am officially the mentor, I have learned a lot about processes, teamwork, and flow issues from the sites that could potentially be incorporated in our program.”
Advice: Working on a project as a team can be very powerful, she says. Even seemingly ‘small’ projects have allowed teams to learn how to work better together on day-to-day issues. With the victory of a small project behind them, they make lists of the next thing that they want to tackle.
“Our profession is constantly changing. We need to be thinking ahead for how we will face those challenges,” Dr. Lum Lung says. “A team that works well together will have an advantage in this new environment. Even if you have people who are new to quality improvement, their participation can still be important.”
Jordan Messler, MD, SFHM
Title: Medical director, Morton Plant Hospitalists, Clearwater, Fla.
Program: GCMI; Project BOOST
Background: Dr. Messler’s interest in QI led him to work with colleagues in SHM who are national leaders in quality. “A couple of years ago, I enrolled in Emory’s Quality Academy, a sister course to Intermountain Health’s course on quality. Then I enrolled our hospital in both the GCMI Program and Project BOOST. My mentors for those programs were terrific guides, which led to my interest in seeing their side of the program as a mentor myself.”
Teachable moment: One program had difficulty implementing a VTE prevention tool and couldn’t get nursing support as it had expected, largely due to lack of nursing engagement on the project team, he says. “We started talking about the history of the projects, and prior interventions. In addition, we talked to the different disciplines separately. It seems there used to be an excellent system where nursing helped out on the project team for risk assessment.”
As VTE prevention became more of a priority, some physicians separately created a new tool to replace the nursing tool without involving the whole team. “And they couldn’t understand why nursing wasn’t buying into the new process.”
Success story: There are similar themes to success and failure. Sites that have strong administrative support (i.e., C-suite representation on the QI team), that have “accountability structure and stick to the basics of QI, with clear goals, ability to gather and report data, and use of a QI model [such as PDSA or Six Sigma] are the ones that succeed,” Dr. Messler says. “And the reverse is consistently true. Sustainable QI needs to be multidisciplinary, involving every voice, considering prior interventions and understanding of the culture.”
Lessons learned: “As mentors, we all continue to say we learn as much or more from these sites as they, hopefully, are learning from us. This collaboration and sharing of ideas has been instrumental to the success of the program.”
Advice: Get started today, and don’t give up. Follow the road map of QI projects, gather support, and get started. You will learn as much from your failures as your successes.
Dr. Messler says hospitals are looking for physician leaders to improve quality, and hospitalists are perfectly positioned to be those QI leaders. These big projects can last for years, so quality teams and hospitals need to be prepared to take the long view.
—Jennifer Quartarolo, MD, SFHM
Stephanie Rennke, MD
Title: Associate clinical professor of medicine, co-director of faculty development, division of hospital medicine, University of California San Francisco Medical Center.
Program: Project BOOST
Background: “When I started as a hospitalist right out of residency, QI had not been part of my training. But I noticed that quality was at the forefront of the academic interests of all the hospitalists at UCSF. I was personally interested in transitions of care. I still do home visits after hours for at-risk patients when they leave the hospital.”
Dr. Rennke started in QI as a member of UCSF’s BOOST team in 2008. “I worked with other faculty in the division who had previous experience in quality improvement and transitions in care. One of the co-principal investigators for BOOST, Dr. Arpana Vidyarthi, suggested that it would be a really rewarding experience to mentor—and it was.”
Teachable moment: “I’ve been so impressed by the diversity of what’s out there. No hospitalist program or hospital is the same. There is no one-size-fits-all for quality improvement or transitions of care, so it is incredibly important that the mentor takes the time to get to know both the team and the hospital.”
Success story: “During a site visit, I had an opportunity to watch one of the nurses, who had received training from a competency-based Teach Back program, practice Teach Back with a patient at the bedside,” Dr. Rennke says. “I was doing a tour of the floor and went into the room of a patient about to be discharged. A young float nurse, not long out of school, sat down with the patient and went through the medications and discharge plan using Teach Back. It didn’t take more time, but the time was spent more constructively, with interaction back and forth. I remember that ‘aha’ moment for the patient and the look in her eyes. For me, as a mentor, it was exciting to think that something I had tried to bring to them had been incorporated by the site and was really working.”
Lessons learned: “I have learned that, while at a large institution like UCSF we tend to work in silos, smaller sites are often more integrated with the various disciplines. You can walk down the hall to the clinical pharmacist or have lunch with the charge nurse. So I’ve tried to bring back home a commitment to really get to know professional colleagues and have them feel that I’m interested in their perspectives.”
Advice: “Work in teams. You cannot do this alone. Include frontline staff. And don’t forget to advertise to others that the program exists. Get the word out—let people know.”
Jennifer Quartarolo, MD, SFHM
Title: Medical director, clinical resource management; associate clinical professor, division of hospital medicine, University of California San Diego Health System
Program: Project BOOST
Background: Dr. Quartarolo has 11 years of clinical experience as an academic hospitalist at two different medical centers, and she completed a training program in healthcare delivery and improvement through the Institute for Health Care Delivery Research in Salt Lake City, Utah. “At my own institution, I had been involved in multiple QI projects,” she says. “Since joining the faculty, I worked with our care transitions team for five years before becoming a mentor. We incorporated many elements from Project BOOST as we worked to improve our care transitions process,” which led to an invitation to be a mentor.
Teachable moment: “I had one site that I worked with that had a great new form they had developed to incorporate into their transition process; however, when they decided to implement the form, they got a lot of pushback from nursing,” she says. “Then they realized that they had not involved any frontline nurses in their planning. This example points out how important it is to have all the key players involved on your team, as improving transitions of care is a complex process requiring multidisciplinary collaboration.”
Success story: Dr. Quartarolo says she has worked with several hospitals that have seen significant improvement in their readmission rates after participating in Project BOOST and implementing its tools.
Lessons learned: “I am constantly impressed by the innovative ideas that teams come up with to deal with the challenges that their hospitals face,” she says. Every hospital is unique and needs to do self-evaluation before deciding what to focus on. “I have also worked with many sites that have challenges getting physicians engaged in their efforts, particularly if they do not have a hospitalist program.”
Advice: “We are in a unique role as hospitalists to identify systems issues and improve quality of care in the inpatient setting, and this is particularly useful in improving care transitions and decreasing readmissions rates.”
Rich Balaban, MD
Title: Medical director, Hospital-to-Home Community Collaboration Program, Cambridge Health Alliance; assistant professor of medicine, Harvard Medical School, Boston
Program: Project BOOST
Background: Dr. Balaban has worked clinically in both the inpatient setting as a hospitalist and the outpatient setting as a primary care doctor. “I have seen hospital discharges as both a receiver and a sender, so [I] have been able to appreciate the challenges facing doctors, nurses, case managers, and patients involved in the care transition process,” he says.
Dr. Balaban also conducted a randomized controlled trial that demonstrated the benefits of engaging nurses at a patient’s primary care site to make outreach phone calls immediately after hospital discharge. Dr. Williams asked him to present on the study.
“It was a great opportunity for me to share the results of our work and for Mark to see my presentation skills,” he says. “When I asked if there were opportunities to get more involved in care transitions work, he invited me to consider becoming a BOOST mentor.”
Teachable moment: “Wearing my primary care hat, I believe that while it is very important to structure an effective discharge for the patient while in the hospital, success or failure ultimately is determined by what happens in the outpatient setting,” Dr. Balaban says. Even if a ‘perfect discharge’ occurs in the hospital, it can all quickly unravel once the patient arrives at home.
Success story: “At several sites, I have encouraged the inpatient care team to invite the outpatient care team to become part of the care transitions team. This has frequently brought an important viewpoint and voice to the care transitions table. While hospitalists have initiated the discussion about care transitions, they need an effective outpatient partner to create a truly effective process.”
Lessons learned: “I have learned to hold judgment until seeing with my own eyes,” Dr. Balaban says. “One of the first sites I visited had developed a post-discharge clinic, which they were excited to show me. From my point of view, I thought that after discharge, patient care should be assumed by the primary care office as soon as possible, and a post-discharge clinic would only delay that process.
“To my great surprise, their post-discharge clinic provided an ideal bridge between the hospital and primary care. The post-discharge clinic really worked and provided patients with a wonderful resource. … I’ve learned that there are many ways to solve problems, often based on the available resources at a specific site.”
Advice: In order to best understand the challenges of hospital discharge, it is critical that you understand what happens to patients after they leave the hospital. Make a home visit to a recently discharged patient to really understand the challenges that patients face when they return home.
Amitkumar R. Patel, MD, MBA, FACP, SFHM
Title: Clinical instructor in hospital medicine, Feinberg School of Medicine, Northwestern University, Chicago
Program: Project BOOST; also working with critical access hospitals in Illinois through PREP (Preventing Readmissions through Effective Partnerships)
Background: Although he now works in an urban teaching hospital, Dr. Patel also did private practice as a community hospitalist and has pursued formal healthcare management-focused training.
“I became a mentor because my experience and interest in quality improvement fit well with Project BOOST,” he says. “I enjoy coaching teams as they face challenges in quality improvement, especially in relation to readmissions reduction. My work with critical access hospitals is the result of my first year as a mentor with the PREP collaborative in Illinois.”
PREP, a collaborative initiative of SHM and the Illinois Hospital Association that is funded by Blue Cross/Blue Shield of Illinois, aims to help hospitals focus on quality initiatives, including BOOST.
Teachable moment/success story: One of Dr. Patel’s BOOST sites believed the team included all appropriate personnel to obtain discharge appointments prior to patients’ discharges. But as they began to work through the process of making sure each appointment was appropriately documented, the various team members assigned to this process could not consistently complete the task within their workflow.
The pilot unit secretaries were not part of the BOOST team initially but saw that they could fulfill this role quickly and easily. They knew who to call at the physicians’ offices to avoid getting stuck in the phone menu trees, and they used this knowledge to reach the schedulers directly. The BOOST team quickly realized the unit secretaries were the most appropriate personnel to capture this information and work with the patients or their families/caregivers to obtain the most convenient appointments. This role was added to the team, and the unit secretaries took ownership of this process. Other teams may also want to look beyond the customary team members to roles that may not be thought of as quality team members.
Lessons learned: “The biggest take-away for me involves the unique culture that exists in many of our urban and rural communities,” he says. Every BOOST site implements the project’s elements in its own unique way, and what works well in one location may not fit the needs of another. The role of the mentor is to balance the need for community-specific advice with unique attributes of the facility and the elements of Project BOOST. “Often, we use our mentor calls to brainstorm solutions, and the teams are teaching me what will work best in their environment.”
Advice: “Responsibility for hospital change management should not be abdicated to administrators or quality improvement staff members,” he says. “QI is not a sometime thing for some staff; it’s an all-the-time process for every staff member, including physicians, to participate in and actively manage.”
—Christopher Kim, MD, MBA, SFHM
Cheryl O’Malley, MD, FHM
Title: Internal medicine residency program director, Banner Good Samaritan Medical Center, Phoenix
Program: GCMI
Background: Banner Good Samaritan has participated in the BOOST, VTE, and GCMI programs. Dr. O’Malley brought her experience from developing, implementing, and leading local glycemic control efforts to mentoring others.
“When I first started working on our hospital’s process, I had so many questions and asked one of my mentors from residency, Dr. Greg Maynard,” she says. “He helped me to see that people around the country were asking the same questions and invited me to join SHM’s glycemic control work group. When the GCMI program started, I was asked to be a mentor.”
Teachable moment: “When I was a new attending on the wards after residency, my patients would ask me why their blood sugars were so much better controlled at home than in the hospital. Usually, the answer was that they were put on a sliding scale when they came into the hospital,” she says, noting that what was done at home wasn’t going to work in the hospital. Patients needed a different regimen—a more proactive approach than just the customary sliding scale.
“I started to learn more about basal rates, nutrition, and correction insulin regimens in the hospital, but I realized that to really have adequate safety and direction for the nursing staff, it would require a formal order set and systematic approach,” she says.
Success story: “One of my sites invited me to come and present grand rounds at the hospital, and the local physician team leader invited the whole quality team to her home. It was a very exciting team and had achieved a lot. Fifteen or 20 of us spent the evening talking about the project but also just enjoying the collegiality,” Dr. O’Malley says. “Even though we had never seen one another, I instantly knew everyone by voice from spending so much time on the phone. And we knew a lot about one another’s personal lives and careers.”
Lessons learned: “Hearing a program describe what they are doing and knowing that they were far ahead of my own hospital in many ways but still being able to provide an insight or a perspective to help them achieve their own next steps. Everyone has something to learn from another hospital or another discipline. We can all leverage our experiences to improve patient care.”
Advice: “Be patient. This is a really long process of constant improvements. I have been working on glycemic control for 10 years now and still feel like we have many opportunities to further improve.”
Christopher Kim, MD, MBA, SFHM
Title: Clinical associate professor of internal medicine and assistant professor of pediatrics, University of Michigan Health System, Ann Arbor
Program: Project BOOST; Michigan Transitions of Care Collaborative (M-TC2)
Background: Dr. Kim brings clinical, quality improvement, leadership, collaborative learning, and discussion facilitation skills to his work as program director of M-TC2 and as mentor to the sites he works with.
The collaborative is part of a set of state collaborative quality initiatives funded by Blue Cross Blue Shield of Michigan. One of those initiatives is focused on improving care transitions between the hospital setting and ambulatory care providers, using Project BOOST tools—expanded to integrate more closely with primary care providers, physician organizations, and ambulatory care. The eight Michigan-based mentors for M-TC2 have all attended SHM’s Mentor University.
Teachable moment: There are local challenges and there are general challenges—those that are commonly shared by most hospitals, Dr. Kim explains. Both need to be overcome when working on an improvement project such as transitions of care. The local hospitalist brings expertise about the former—which are often more difficult to understand and overcome. The mentor brings knowledge and experience of the universal challenges, as well as the benefit of having seen or heard about what other programs have done. Together, they can work to help the organization become better equipped to improve the initiative at hand.
Success story: “One hospital in the collaborative realized that it could roll out the Teach Back concept to both nurses and physicians,” he says. They started to teach residents how to interact with patients and began using this approach in physician-nurse teams. Subsequently, the team shared with the collaborative how physicians have embraced the concept.
Lessons learned: Every site has its successes and challenges, he says. Sharing both sides of the story can only advance the mission of the collaborative, as each organization learns from the successes and failures of the others.
Mentored implementation really does what it’s intended to do—helping to support the sites and keeping an organization on track and accountable for the work it does, because someone external to the organization is working with it and providing information about what other sites are doing.
Advice: Talk with different disciplines and find out how much they long to work with other care providers, and then have discussions about how to make interdisciplinary practice happen. “At our collaborative meetings over time, many of the 24 participating sites have shared their progress—the good things and the struggles,” Dr. Kim says.
Larry Beresford is a freelance writer in Alameda, Calif.
When SHM received the Joint Commission’s John M. Eisenberg Patient Safety and Quality Award for 2011 for innovation in patient safety and quality at the national level, the award represented national recognition for the society’s three major hospital quality improvement initiatives. Moreover, it highlighted the integral role mentors play in each of the programs, helping physicians and hospitals make accelerated progress on important patient safety and quality issues.
Mentored implementation assigns a physician expert to train, guide, and work with the participating facilities’ hospitalist-led, multidisciplinary team through the life cycle of a QI initiative. The three programs focus on VTE prevention, glycemic control, and transitions of care. The first hospital cohort for VTE prevention—the VTE Prevention Collaborative—was in 2007. The care transitions program, known as Project BOOST, started in 2008. The Glycemic Control Mentored Implementation (GCMI) Program began in 2009. A fourth SHM mentored implementation program is MARQUIS, the Multi-Center Medication Reconciliation Quality Improvement Study.
In basic terms, mentoring is “coaching from a physician who has expertise both in the clinical subject matter and in implementing the processes and tools of quality improvement—usually because they’ve done it themselves,” says Gregory Maynard, MD, MSc, SFHM, senior vice president of SHM’s Center for Hospital Innovation and Improvement and a co-founder of two of its mentored implementation programs.
Mentors typically are paired with one or two participating hospitals for 12 to 18 months, conducting monthly conference calls with the team, sharing tools and resources from SHM’s online library, and offering advice on how to navigate the treacherous currents of culture change within a hospital. BOOST mentors also make in-person site visits. They are well versed in protocol and order set design and quality measurement strategies, and they know how to engage frontline professionals and institutional leadership, Dr. Maynard says.
Some mentors have received formal QI training, and many have attended Mentor University, a 1-1/2 day intensive training course offered by SHM that reinforces the nuances of coaching, the contents of SHM’s quality toolkits, and ideas for overcoming common barriers to improvement. SHM’s mentor support provides continuous professional development for the mentors, pairing new mentors with senior mentors to coach them in the process and hosting an online community with other mentors.
“What’s telling to me is that many of the people who have been mentored by SHM’s programs in one topic go on to become mentors in another topic, taking those portable skills and principles and applying them in other quality areas,” Dr. Maynard says. “We’re fostering leadership and quality improvement skills among hospitalists; that’s really one of our main goals. People learn the skill and then spread it within their system.”
Mark Williams, MD, FACP, MHM, Project BOOST principal investigator and a veteran SHM mentor, says that just providing educational materials to health professionals often isn’t enough for them to overcome the barriers to change.
“I’ve seen many large-scale quality projects that didn’t work, as they were simply disseminating information, content, or knowledge,” he says. Mentored implementation as practiced by SHM is “a model for disseminating quality improvement nationally,” he adds. “Pretty much any quality improvement project can be done this way.”
Key to the mentored implementation program’s success is the personalized approach and customized solutions.
“You directly meet with the team in their own setting and begin to see what’s going on,” Dr. Williams says. “You also meet with the hospital’s senior leadership. That’s when you start to see change.”
The Hospitalist connected with eight SHM mentors. The following are snapshots of their work in the mentorship program and some of the lessons they taught—and learned—from the program.
Christine Lum Lung, MD, SFHM
Title: Medical director, Northern Colorado Hospitalists, Fort Collins
Program: VTE Prevention Collaborative
Background: As a practicing hospitalist and medical director of the HM group for a two-hospital system, Dr. Lum Lung chaired its quality committee for VTE protocol development. “It was obvious at our hospitals that we needed to do better at VTE prevention,” she explains.
Dr. Lum Lung’s team received VTE mentorship from Dr. Maynard, who later asked her to become a VTE mentor. She also attended all three levels of SHM’s Leadership Academy and has since become a mentor for the new HP3 (Hospitalist Program Peak Performance) mentored implementation program, a one-year collaboration among SHM, Northwestern University, Blue Cross/Blue Shield of Illinois, and the Illinois Hospital Association that is designed to help hospitalist groups optimize their programs and build healthy group culture.
Teachable moment: The essential qualities of a good mentee, Dr. Lum Lung says, are drive and dedication. “You believe strongly about it, so you can sell it to others. You also need a thick skin to face the adversities that come up. When my mentor gave me tasks and deadlines, I met those deadlines.”
Success story: “I’ve been impressed with how hard groups and individuals can work.” Most of the teams she has worked with were facing significant external stressors—starting a new program, moving into a new hospital, rolling out a new EHR, becoming part of a growing medical group. “Yet each of them has been incredibly engaged in the process and dedicated to completing their projects.”
Lessons learned: “That we all have something to learn from each other. While I am officially the mentor, I have learned a lot about processes, teamwork, and flow issues from the sites that could potentially be incorporated in our program.”
Advice: Working on a project as a team can be very powerful, she says. Even seemingly ‘small’ projects have allowed teams to learn how to work better together on day-to-day issues. With the victory of a small project behind them, they make lists of the next thing that they want to tackle.
“Our profession is constantly changing. We need to be thinking ahead for how we will face those challenges,” Dr. Lum Lung says. “A team that works well together will have an advantage in this new environment. Even if you have people who are new to quality improvement, their participation can still be important.”
Jordan Messler, MD, SFHM
Title: Medical director, Morton Plant Hospitalists, Clearwater, Fla.
Program: GCMI; Project BOOST
Background: Dr. Messler’s interest in QI led him to work with colleagues in SHM who are national leaders in quality. “A couple of years ago, I enrolled in Emory’s Quality Academy, a sister course to Intermountain Health’s course on quality. Then I enrolled our hospital in both the GCMI Program and Project BOOST. My mentors for those programs were terrific guides, which led to my interest in seeing their side of the program as a mentor myself.”
Teachable moment: One program had difficulty implementing a VTE prevention tool and couldn’t get nursing support as it had expected, largely due to lack of nursing engagement on the project team, he says. “We started talking about the history of the projects, and prior interventions. In addition, we talked to the different disciplines separately. It seems there used to be an excellent system where nursing helped out on the project team for risk assessment.”
As VTE prevention became more of a priority, some physicians separately created a new tool to replace the nursing tool without involving the whole team. “And they couldn’t understand why nursing wasn’t buying into the new process.”
Success story: There are similar themes to success and failure. Sites that have strong administrative support (i.e., C-suite representation on the QI team), that have “accountability structure and stick to the basics of QI, with clear goals, ability to gather and report data, and use of a QI model [such as PDSA or Six Sigma] are the ones that succeed,” Dr. Messler says. “And the reverse is consistently true. Sustainable QI needs to be multidisciplinary, involving every voice, considering prior interventions and understanding of the culture.”
Lessons learned: “As mentors, we all continue to say we learn as much or more from these sites as they, hopefully, are learning from us. This collaboration and sharing of ideas has been instrumental to the success of the program.”
Advice: Get started today, and don’t give up. Follow the road map of QI projects, gather support, and get started. You will learn as much from your failures as your successes.
Dr. Messler says hospitals are looking for physician leaders to improve quality, and hospitalists are perfectly positioned to be those QI leaders. These big projects can last for years, so quality teams and hospitals need to be prepared to take the long view.
—Jennifer Quartarolo, MD, SFHM
Stephanie Rennke, MD
Title: Associate clinical professor of medicine, co-director of faculty development, division of hospital medicine, University of California San Francisco Medical Center.
Program: Project BOOST
Background: “When I started as a hospitalist right out of residency, QI had not been part of my training. But I noticed that quality was at the forefront of the academic interests of all the hospitalists at UCSF. I was personally interested in transitions of care. I still do home visits after hours for at-risk patients when they leave the hospital.”
Dr. Rennke started in QI as a member of UCSF’s BOOST team in 2008. “I worked with other faculty in the division who had previous experience in quality improvement and transitions in care. One of the co-principal investigators for BOOST, Dr. Arpana Vidyarthi, suggested that it would be a really rewarding experience to mentor—and it was.”
Teachable moment: “I’ve been so impressed by the diversity of what’s out there. No hospitalist program or hospital is the same. There is no one-size-fits-all for quality improvement or transitions of care, so it is incredibly important that the mentor takes the time to get to know both the team and the hospital.”
Success story: “During a site visit, I had an opportunity to watch one of the nurses, who had received training from a competency-based Teach Back program, practice Teach Back with a patient at the bedside,” Dr. Rennke says. “I was doing a tour of the floor and went into the room of a patient about to be discharged. A young float nurse, not long out of school, sat down with the patient and went through the medications and discharge plan using Teach Back. It didn’t take more time, but the time was spent more constructively, with interaction back and forth. I remember that ‘aha’ moment for the patient and the look in her eyes. For me, as a mentor, it was exciting to think that something I had tried to bring to them had been incorporated by the site and was really working.”
Lessons learned: “I have learned that, while at a large institution like UCSF we tend to work in silos, smaller sites are often more integrated with the various disciplines. You can walk down the hall to the clinical pharmacist or have lunch with the charge nurse. So I’ve tried to bring back home a commitment to really get to know professional colleagues and have them feel that I’m interested in their perspectives.”
Advice: “Work in teams. You cannot do this alone. Include frontline staff. And don’t forget to advertise to others that the program exists. Get the word out—let people know.”
Jennifer Quartarolo, MD, SFHM
Title: Medical director, clinical resource management; associate clinical professor, division of hospital medicine, University of California San Diego Health System
Program: Project BOOST
Background: Dr. Quartarolo has 11 years of clinical experience as an academic hospitalist at two different medical centers, and she completed a training program in healthcare delivery and improvement through the Institute for Health Care Delivery Research in Salt Lake City, Utah. “At my own institution, I had been involved in multiple QI projects,” she says. “Since joining the faculty, I worked with our care transitions team for five years before becoming a mentor. We incorporated many elements from Project BOOST as we worked to improve our care transitions process,” which led to an invitation to be a mentor.
Teachable moment: “I had one site that I worked with that had a great new form they had developed to incorporate into their transition process; however, when they decided to implement the form, they got a lot of pushback from nursing,” she says. “Then they realized that they had not involved any frontline nurses in their planning. This example points out how important it is to have all the key players involved on your team, as improving transitions of care is a complex process requiring multidisciplinary collaboration.”
Success story: Dr. Quartarolo says she has worked with several hospitals that have seen significant improvement in their readmission rates after participating in Project BOOST and implementing its tools.
Lessons learned: “I am constantly impressed by the innovative ideas that teams come up with to deal with the challenges that their hospitals face,” she says. Every hospital is unique and needs to do self-evaluation before deciding what to focus on. “I have also worked with many sites that have challenges getting physicians engaged in their efforts, particularly if they do not have a hospitalist program.”
Advice: “We are in a unique role as hospitalists to identify systems issues and improve quality of care in the inpatient setting, and this is particularly useful in improving care transitions and decreasing readmissions rates.”
Rich Balaban, MD
Title: Medical director, Hospital-to-Home Community Collaboration Program, Cambridge Health Alliance; assistant professor of medicine, Harvard Medical School, Boston
Program: Project BOOST
Background: Dr. Balaban has worked clinically in both the inpatient setting as a hospitalist and the outpatient setting as a primary care doctor. “I have seen hospital discharges as both a receiver and a sender, so [I] have been able to appreciate the challenges facing doctors, nurses, case managers, and patients involved in the care transition process,” he says.
Dr. Balaban also conducted a randomized controlled trial that demonstrated the benefits of engaging nurses at a patient’s primary care site to make outreach phone calls immediately after hospital discharge. Dr. Williams asked him to present on the study.
“It was a great opportunity for me to share the results of our work and for Mark to see my presentation skills,” he says. “When I asked if there were opportunities to get more involved in care transitions work, he invited me to consider becoming a BOOST mentor.”
Teachable moment: “Wearing my primary care hat, I believe that while it is very important to structure an effective discharge for the patient while in the hospital, success or failure ultimately is determined by what happens in the outpatient setting,” Dr. Balaban says. Even if a ‘perfect discharge’ occurs in the hospital, it can all quickly unravel once the patient arrives at home.
Success story: “At several sites, I have encouraged the inpatient care team to invite the outpatient care team to become part of the care transitions team. This has frequently brought an important viewpoint and voice to the care transitions table. While hospitalists have initiated the discussion about care transitions, they need an effective outpatient partner to create a truly effective process.”
Lessons learned: “I have learned to hold judgment until seeing with my own eyes,” Dr. Balaban says. “One of the first sites I visited had developed a post-discharge clinic, which they were excited to show me. From my point of view, I thought that after discharge, patient care should be assumed by the primary care office as soon as possible, and a post-discharge clinic would only delay that process.
“To my great surprise, their post-discharge clinic provided an ideal bridge between the hospital and primary care. The post-discharge clinic really worked and provided patients with a wonderful resource. … I’ve learned that there are many ways to solve problems, often based on the available resources at a specific site.”
Advice: In order to best understand the challenges of hospital discharge, it is critical that you understand what happens to patients after they leave the hospital. Make a home visit to a recently discharged patient to really understand the challenges that patients face when they return home.
Amitkumar R. Patel, MD, MBA, FACP, SFHM
Title: Clinical instructor in hospital medicine, Feinberg School of Medicine, Northwestern University, Chicago
Program: Project BOOST; also working with critical access hospitals in Illinois through PREP (Preventing Readmissions through Effective Partnerships)
Background: Although he now works in an urban teaching hospital, Dr. Patel also did private practice as a community hospitalist and has pursued formal healthcare management-focused training.
“I became a mentor because my experience and interest in quality improvement fit well with Project BOOST,” he says. “I enjoy coaching teams as they face challenges in quality improvement, especially in relation to readmissions reduction. My work with critical access hospitals is the result of my first year as a mentor with the PREP collaborative in Illinois.”
PREP, a collaborative initiative of SHM and the Illinois Hospital Association that is funded by Blue Cross/Blue Shield of Illinois, aims to help hospitals focus on quality initiatives, including BOOST.
Teachable moment/success story: One of Dr. Patel’s BOOST sites believed the team included all appropriate personnel to obtain discharge appointments prior to patients’ discharges. But as they began to work through the process of making sure each appointment was appropriately documented, the various team members assigned to this process could not consistently complete the task within their workflow.
The pilot unit secretaries were not part of the BOOST team initially but saw that they could fulfill this role quickly and easily. They knew who to call at the physicians’ offices to avoid getting stuck in the phone menu trees, and they used this knowledge to reach the schedulers directly. The BOOST team quickly realized the unit secretaries were the most appropriate personnel to capture this information and work with the patients or their families/caregivers to obtain the most convenient appointments. This role was added to the team, and the unit secretaries took ownership of this process. Other teams may also want to look beyond the customary team members to roles that may not be thought of as quality team members.
Lessons learned: “The biggest take-away for me involves the unique culture that exists in many of our urban and rural communities,” he says. Every BOOST site implements the project’s elements in its own unique way, and what works well in one location may not fit the needs of another. The role of the mentor is to balance the need for community-specific advice with unique attributes of the facility and the elements of Project BOOST. “Often, we use our mentor calls to brainstorm solutions, and the teams are teaching me what will work best in their environment.”
Advice: “Responsibility for hospital change management should not be abdicated to administrators or quality improvement staff members,” he says. “QI is not a sometime thing for some staff; it’s an all-the-time process for every staff member, including physicians, to participate in and actively manage.”
—Christopher Kim, MD, MBA, SFHM
Cheryl O’Malley, MD, FHM
Title: Internal medicine residency program director, Banner Good Samaritan Medical Center, Phoenix
Program: GCMI
Background: Banner Good Samaritan has participated in the BOOST, VTE, and GCMI programs. Dr. O’Malley brought her experience from developing, implementing, and leading local glycemic control efforts to mentoring others.
“When I first started working on our hospital’s process, I had so many questions and asked one of my mentors from residency, Dr. Greg Maynard,” she says. “He helped me to see that people around the country were asking the same questions and invited me to join SHM’s glycemic control work group. When the GCMI program started, I was asked to be a mentor.”
Teachable moment: “When I was a new attending on the wards after residency, my patients would ask me why their blood sugars were so much better controlled at home than in the hospital. Usually, the answer was that they were put on a sliding scale when they came into the hospital,” she says, noting that what was done at home wasn’t going to work in the hospital. Patients needed a different regimen—a more proactive approach than just the customary sliding scale.
“I started to learn more about basal rates, nutrition, and correction insulin regimens in the hospital, but I realized that to really have adequate safety and direction for the nursing staff, it would require a formal order set and systematic approach,” she says.
Success story: “One of my sites invited me to come and present grand rounds at the hospital, and the local physician team leader invited the whole quality team to her home. It was a very exciting team and had achieved a lot. Fifteen or 20 of us spent the evening talking about the project but also just enjoying the collegiality,” Dr. O’Malley says. “Even though we had never seen one another, I instantly knew everyone by voice from spending so much time on the phone. And we knew a lot about one another’s personal lives and careers.”
Lessons learned: “Hearing a program describe what they are doing and knowing that they were far ahead of my own hospital in many ways but still being able to provide an insight or a perspective to help them achieve their own next steps. Everyone has something to learn from another hospital or another discipline. We can all leverage our experiences to improve patient care.”
Advice: “Be patient. This is a really long process of constant improvements. I have been working on glycemic control for 10 years now and still feel like we have many opportunities to further improve.”
Christopher Kim, MD, MBA, SFHM
Title: Clinical associate professor of internal medicine and assistant professor of pediatrics, University of Michigan Health System, Ann Arbor
Program: Project BOOST; Michigan Transitions of Care Collaborative (M-TC2)
Background: Dr. Kim brings clinical, quality improvement, leadership, collaborative learning, and discussion facilitation skills to his work as program director of M-TC2 and as mentor to the sites he works with.
The collaborative is part of a set of state collaborative quality initiatives funded by Blue Cross Blue Shield of Michigan. One of those initiatives is focused on improving care transitions between the hospital setting and ambulatory care providers, using Project BOOST tools—expanded to integrate more closely with primary care providers, physician organizations, and ambulatory care. The eight Michigan-based mentors for M-TC2 have all attended SHM’s Mentor University.
Teachable moment: There are local challenges and there are general challenges—those that are commonly shared by most hospitals, Dr. Kim explains. Both need to be overcome when working on an improvement project such as transitions of care. The local hospitalist brings expertise about the former—which are often more difficult to understand and overcome. The mentor brings knowledge and experience of the universal challenges, as well as the benefit of having seen or heard about what other programs have done. Together, they can work to help the organization become better equipped to improve the initiative at hand.
Success story: “One hospital in the collaborative realized that it could roll out the Teach Back concept to both nurses and physicians,” he says. They started to teach residents how to interact with patients and began using this approach in physician-nurse teams. Subsequently, the team shared with the collaborative how physicians have embraced the concept.
Lessons learned: Every site has its successes and challenges, he says. Sharing both sides of the story can only advance the mission of the collaborative, as each organization learns from the successes and failures of the others.
Mentored implementation really does what it’s intended to do—helping to support the sites and keeping an organization on track and accountable for the work it does, because someone external to the organization is working with it and providing information about what other sites are doing.
Advice: Talk with different disciplines and find out how much they long to work with other care providers, and then have discussions about how to make interdisciplinary practice happen. “At our collaborative meetings over time, many of the 24 participating sites have shared their progress—the good things and the struggles,” Dr. Kim says.
Larry Beresford is a freelance writer in Alameda, Calif.
LISTEN NOW: Mark Williams, MD, MHM, Discusses SHM's Mentored Implementation Programs
Click here to listen to excerpts of our interview with Dr. Williams
Click here to listen to excerpts of our interview with Dr. Williams
Click here to listen to excerpts of our interview with Dr. Williams
Hospital Patient Safety, Quality Movement Helped Propel Hospitalists
Hippocrates, Epidemics.“The Physician must be able to do good or to do no harm.”
This is part three of my ongoing series on the journey of hospital medicine and how we are poised for greater things yet. In part one, “Tinder and Spark,” macro changes in the American healthcare landscape pressured primary care physicians to get creative with new ways to practice, the most prominent result being the creation of hospitalist practices. Wachter and Goldman provided the spark that gave the field its name and cohesiveness. In part two, “Fuel,” the Baby Boomers shaped the field, setting the stage for the Generation X physicians who fueled HM’s early growth.
But the field might have stagnated there, the fire attenuated, if not for the rise of something new, something that stoked our growth to new heights.
Orlando, Fla., December 2006.
SHM President-Elect Rusty Holman, MD, MHM, was on stage representing hospitalists at the annual Institute for Healthcare Improvement (IHI) National Forum in front of more than 5,000 enthusiastic attendees representing every discipline of clinical care from hundreds of healthcare organizations across the country and internationally. This was a special event. Two years earlier, IHI President Don Berwick, MD, MPP, had launched an audacious campaign, called the 100,000 Lives Campaign, that aimed to prevent the deaths of 100,000 patients in our nation’s hospitals in the following 18 months, not by utilizing some great new technological advance but by changing the culture around safety and quality in our nation’s hospitals and enacting proven safety methods and processes.1 Out of this plan came widespread use of terms and programs that weren’t widely adopted then but are familiar to all of us now: rapid response teams, medicine reconciliation, surgical site infection prevention, and ventilator-acquired pneumonia.
That program estimated that it saved 122,000 lives.1
IHI was looking to build on the safety and quality infrastructure that had been built up to make the 100,000 Lives Campaign a success and to launch an even bigger program. The 5 Million Lives Campaign’s goal was to reduce incidents of harm in five million patients over the next two years. For this campaign, IHI understood that success could only be achieved with partners. SHM and the field of hospital medicine, which had grown in size and influence, was seen as a critical and influential partner in achieving the goal of reducing harm in our nation’s hospitals. Thus, Dr. Holman was standing on that stage for SHM at the launch of the biggest safety and quality initiative in our nation’s history. SHM was among seven partner organizations, including the American Nurses Association, the Centers for Medicare and Medicaid Services (CMS), the American Heart Association, and the CDC. SHM was the only medical society represented. Pretty heady stuff for a field barely 10 years old. How did we get there? For that story, we need to go back a few years.
In 1984, Libby Zion, an 18-year-old college student, died from serotonin syndrome. A contributing factor was felt to be overworked residents not getting enough sleep. In his landmark 1990 article, “Human Factors in Hazardous Situations,” James Reason, PhD, introduced the world to some key concepts: active versus latent errors and the Swiss cheese model of errors.2 These concepts influence our thinking to this day. In 1994, Betsy Lehman, a health reporter for the Boston Globe, died from a massive chemotherapy overdose. That same year Lucian Leape, MD, a Harvard pediatric surgeon, published his influential article in JAMA, “Errors in Medicine,” which called for a systems approach to improving patient safety.3
These key moments in safety and quality, all of which occurred in the years leading up to hospitalists gaining their identity, were but a prelude to the widespread patient safety and quality movement. Like our own social movement, “Patient Safety and Quality” was born with an influential publication. This was the 1999 release of the Institute of Medicine’s “To Err is Human,” a report that reiterated claims that up to 98,000 U.S. patients per year were dying from medical errors.4 It also supported Dr. Leape’s earlier work calling for systems changes. In 2001, the Institute of Medicine published a second report, “Crossing the Quality Chasm: A New Health System for the 21st Century,” which introduced the six aims for healthcare improvement: safe, timely, effective, efficient, equitable, and patient-centered.5
Before 1999, hospitalists were just getting their feet on the ground. Groups were experimenting with practice models and recruiting young talent, mostly with a pitch for a new way to practice with freedom to design their day and often an interesting work schedule.
After the publication of “To Err is Human” in 1999, changes in patient safety and quality began to accelerate. Taking one of the recommendations from “To Err is Human,” which suggested that employers should use their market power to improve quality and safety, the Leapfrog Group, a consortium of large employers, organized in 2000. Leapfrog began rewarding and recognizing hospitals that put accepted safety measures in place.6 Suddenly, hospital CEOs began to see tangible rewards for improving quality in their hospitals.
Here is where the hospitalist movement and the patient safety and quality movement began to intersect.
Shift to Quality and Safety
In 2001, the same year “Crossing the Quality Chasm” was published, Congress created the Center for Quality Improvement and Patient Safety within the Agency for Healthcare Research and Quality. Significant funding was suddenly available for quality and safety research, and a more organized reporting mechanism for quality would soon be available.
In 2002, the Joint Commission released its first set of National Patient Safety Goals. There were seven, and key goals for hospitalists included improving the effectiveness of communication among caregivers, reducing the risk of healthcare-acquired infections, and reconciling medications.
And, lastly, as if that weren’t enough activity in the patient safety and quality world, the Joint Commission and CMS released in 2003 the first joint, aligned set of core measures, with which we are all now very familiar, around acute myocardial infarction, congestive heart failure, and pneumonia.
Hospital executives were trying to get a handle on the meaning of this flurry of activity for their hospitals. It certainly meant new regulatory requirements. It probably meant greater visibility to the public around what happened behind the walls of their facilities. No doubt dollars on the line wouldn’t be too far behind. They needed help, and they needed it fast.
No longer were hospitalists a small group of young docs roaming the halls; now, instead of just taking care of one patient at a time, they were reaching the threshold of size—and even status in some organizations—where they could leverage their working knowledge of the system and presence on site to affect the various facets of quality now being measured and incented. Additionally, as the information technology (IT) revolution rolled out, hospitalists, mostly tech-savvy Gen X’ers, looked to ease the transition into the new world of EHRs, which promised to serve as a new base for improving quality.
As the C-suite continued making value calculations in their heads, they saw that, in addition to helping them manage the many facets of the transition of primary care and specialty teaching attendings out of the hospital, hospitalists could now be a powerful weapon in helping them stay competitive in the looming patient safety and quality revolution. They pulled out their checkbooks.
When SHM first started gathering data to explore this gap, we discovered that in 2003 the reported median support per FTE of an adult hospitalist in this country was $60,000.7 With an estimated 11,000 hospitalists in the country at that time, C-suite funders paid out over $600 million to help overcome the deficit between hospitalist professional billings and salary and benefits. By the time SHM partnered with IHI on the 5 Million Lives Campaign in 2006, the figure stood at well over $2 billion. The 2011 SHM/Medical Group Management Association survey data showed $139,090 support per FTE. With 31,000 U.S. hospitalists estimated at the time, that figure had doubled to over $4 billion in just five years’ time.
The new generation of doctors had come along in the late 1990s looking for a practice that fit their wants and needs. HM gave them what they were looking for: autonomy, the promise of work-life balance, and the ability to help patients in their most vulnerable time. The traditional E&M [evaluation and management]-based funding mechanisms simply weren’t designed to account for physicians who spend all of their time doing the critical cognitive and coordinating clinical work. To account for this, hospitals and medical groups, seeing the value to their organizations in this new specialty, anteed up to cover the difference. That gave us a great beginning.
But it was the convergence of the early hospitalist movement and the emergent patient safety and quality movement that created a synergy that propelled both movements forward. Boosted by the influx of funding directly and indirectly related to patient safety and quality, hospitalists grew in number from an estimated 5,000 physicians at the 1999 publication of “To Err is Human” to north of 40,000 today.
The synergy was evident when SHM President-Elect Dr. Holman, representing our fledgling specialty and society, faced that cheering throng in Orlando alongside Dr. Don Berwick, the face of the patient safety and quality movement.
But that’s not quite the end of the story.
To get us up to the present and on to our bright future, there will be a few more additions to the quality story and an all-new generation arriving on the scene to shake things up.
Dr. Kealey is SHM president and medical director of hospital specialties at HealthPartners Medical Group in St. Paul, Minn.
References
- Institute for Healthcare Improvement. Overview of the 100,000 Lives Campaign. Available at: http://www.ihi.org/Engage/Initiatives/Completed/5MillionLivesCampaign/Documents/Overview%20of%20the%20100K%20Campaign.pdf. Accessed July 6, 2014.
- Broadbent DE, Reason J, Baddeley A, eds. Human Factors in Hazardous Situations: Proceedings of a Royal Society Discussion Meeting Held on 28 and 29 June 1989. Gloucestershire, England: Clarendon Press; 1990:475-484.
- Leape LL. Error in medicine JAMA.1994;272(23):1851-1857.
- Institute of Medicine. Kohn LT, Corrigan JM, Donaldson MS, eds. To Err Is Human: Building a Safer Health System. Washington, D.C.: The National Academy Press; 2000.
- Institute of Medicine. Committee on Quality of Healthcare in America. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, D.C.: The National Academy Press; 2001.
- The Leapfrog Group. About Leapfrog. Available at: http://www.leapfroggroup.org/about_leapfrog. Accessed July 6, 2014.
- Society of Hospital Medicine. SHM’s State of Hospital Medicine Surveys 2003-2012. Available at: www.hospitalmedicine.org/survey. Accessed July 3, 2014.
Hippocrates, Epidemics.“The Physician must be able to do good or to do no harm.”
This is part three of my ongoing series on the journey of hospital medicine and how we are poised for greater things yet. In part one, “Tinder and Spark,” macro changes in the American healthcare landscape pressured primary care physicians to get creative with new ways to practice, the most prominent result being the creation of hospitalist practices. Wachter and Goldman provided the spark that gave the field its name and cohesiveness. In part two, “Fuel,” the Baby Boomers shaped the field, setting the stage for the Generation X physicians who fueled HM’s early growth.
But the field might have stagnated there, the fire attenuated, if not for the rise of something new, something that stoked our growth to new heights.
Orlando, Fla., December 2006.
SHM President-Elect Rusty Holman, MD, MHM, was on stage representing hospitalists at the annual Institute for Healthcare Improvement (IHI) National Forum in front of more than 5,000 enthusiastic attendees representing every discipline of clinical care from hundreds of healthcare organizations across the country and internationally. This was a special event. Two years earlier, IHI President Don Berwick, MD, MPP, had launched an audacious campaign, called the 100,000 Lives Campaign, that aimed to prevent the deaths of 100,000 patients in our nation’s hospitals in the following 18 months, not by utilizing some great new technological advance but by changing the culture around safety and quality in our nation’s hospitals and enacting proven safety methods and processes.1 Out of this plan came widespread use of terms and programs that weren’t widely adopted then but are familiar to all of us now: rapid response teams, medicine reconciliation, surgical site infection prevention, and ventilator-acquired pneumonia.
That program estimated that it saved 122,000 lives.1
IHI was looking to build on the safety and quality infrastructure that had been built up to make the 100,000 Lives Campaign a success and to launch an even bigger program. The 5 Million Lives Campaign’s goal was to reduce incidents of harm in five million patients over the next two years. For this campaign, IHI understood that success could only be achieved with partners. SHM and the field of hospital medicine, which had grown in size and influence, was seen as a critical and influential partner in achieving the goal of reducing harm in our nation’s hospitals. Thus, Dr. Holman was standing on that stage for SHM at the launch of the biggest safety and quality initiative in our nation’s history. SHM was among seven partner organizations, including the American Nurses Association, the Centers for Medicare and Medicaid Services (CMS), the American Heart Association, and the CDC. SHM was the only medical society represented. Pretty heady stuff for a field barely 10 years old. How did we get there? For that story, we need to go back a few years.
In 1984, Libby Zion, an 18-year-old college student, died from serotonin syndrome. A contributing factor was felt to be overworked residents not getting enough sleep. In his landmark 1990 article, “Human Factors in Hazardous Situations,” James Reason, PhD, introduced the world to some key concepts: active versus latent errors and the Swiss cheese model of errors.2 These concepts influence our thinking to this day. In 1994, Betsy Lehman, a health reporter for the Boston Globe, died from a massive chemotherapy overdose. That same year Lucian Leape, MD, a Harvard pediatric surgeon, published his influential article in JAMA, “Errors in Medicine,” which called for a systems approach to improving patient safety.3
These key moments in safety and quality, all of which occurred in the years leading up to hospitalists gaining their identity, were but a prelude to the widespread patient safety and quality movement. Like our own social movement, “Patient Safety and Quality” was born with an influential publication. This was the 1999 release of the Institute of Medicine’s “To Err is Human,” a report that reiterated claims that up to 98,000 U.S. patients per year were dying from medical errors.4 It also supported Dr. Leape’s earlier work calling for systems changes. In 2001, the Institute of Medicine published a second report, “Crossing the Quality Chasm: A New Health System for the 21st Century,” which introduced the six aims for healthcare improvement: safe, timely, effective, efficient, equitable, and patient-centered.5
Before 1999, hospitalists were just getting their feet on the ground. Groups were experimenting with practice models and recruiting young talent, mostly with a pitch for a new way to practice with freedom to design their day and often an interesting work schedule.
After the publication of “To Err is Human” in 1999, changes in patient safety and quality began to accelerate. Taking one of the recommendations from “To Err is Human,” which suggested that employers should use their market power to improve quality and safety, the Leapfrog Group, a consortium of large employers, organized in 2000. Leapfrog began rewarding and recognizing hospitals that put accepted safety measures in place.6 Suddenly, hospital CEOs began to see tangible rewards for improving quality in their hospitals.
Here is where the hospitalist movement and the patient safety and quality movement began to intersect.
Shift to Quality and Safety
In 2001, the same year “Crossing the Quality Chasm” was published, Congress created the Center for Quality Improvement and Patient Safety within the Agency for Healthcare Research and Quality. Significant funding was suddenly available for quality and safety research, and a more organized reporting mechanism for quality would soon be available.
In 2002, the Joint Commission released its first set of National Patient Safety Goals. There were seven, and key goals for hospitalists included improving the effectiveness of communication among caregivers, reducing the risk of healthcare-acquired infections, and reconciling medications.
And, lastly, as if that weren’t enough activity in the patient safety and quality world, the Joint Commission and CMS released in 2003 the first joint, aligned set of core measures, with which we are all now very familiar, around acute myocardial infarction, congestive heart failure, and pneumonia.
Hospital executives were trying to get a handle on the meaning of this flurry of activity for their hospitals. It certainly meant new regulatory requirements. It probably meant greater visibility to the public around what happened behind the walls of their facilities. No doubt dollars on the line wouldn’t be too far behind. They needed help, and they needed it fast.
No longer were hospitalists a small group of young docs roaming the halls; now, instead of just taking care of one patient at a time, they were reaching the threshold of size—and even status in some organizations—where they could leverage their working knowledge of the system and presence on site to affect the various facets of quality now being measured and incented. Additionally, as the information technology (IT) revolution rolled out, hospitalists, mostly tech-savvy Gen X’ers, looked to ease the transition into the new world of EHRs, which promised to serve as a new base for improving quality.
As the C-suite continued making value calculations in their heads, they saw that, in addition to helping them manage the many facets of the transition of primary care and specialty teaching attendings out of the hospital, hospitalists could now be a powerful weapon in helping them stay competitive in the looming patient safety and quality revolution. They pulled out their checkbooks.
When SHM first started gathering data to explore this gap, we discovered that in 2003 the reported median support per FTE of an adult hospitalist in this country was $60,000.7 With an estimated 11,000 hospitalists in the country at that time, C-suite funders paid out over $600 million to help overcome the deficit between hospitalist professional billings and salary and benefits. By the time SHM partnered with IHI on the 5 Million Lives Campaign in 2006, the figure stood at well over $2 billion. The 2011 SHM/Medical Group Management Association survey data showed $139,090 support per FTE. With 31,000 U.S. hospitalists estimated at the time, that figure had doubled to over $4 billion in just five years’ time.
The new generation of doctors had come along in the late 1990s looking for a practice that fit their wants and needs. HM gave them what they were looking for: autonomy, the promise of work-life balance, and the ability to help patients in their most vulnerable time. The traditional E&M [evaluation and management]-based funding mechanisms simply weren’t designed to account for physicians who spend all of their time doing the critical cognitive and coordinating clinical work. To account for this, hospitals and medical groups, seeing the value to their organizations in this new specialty, anteed up to cover the difference. That gave us a great beginning.
But it was the convergence of the early hospitalist movement and the emergent patient safety and quality movement that created a synergy that propelled both movements forward. Boosted by the influx of funding directly and indirectly related to patient safety and quality, hospitalists grew in number from an estimated 5,000 physicians at the 1999 publication of “To Err is Human” to north of 40,000 today.
The synergy was evident when SHM President-Elect Dr. Holman, representing our fledgling specialty and society, faced that cheering throng in Orlando alongside Dr. Don Berwick, the face of the patient safety and quality movement.
But that’s not quite the end of the story.
To get us up to the present and on to our bright future, there will be a few more additions to the quality story and an all-new generation arriving on the scene to shake things up.
Dr. Kealey is SHM president and medical director of hospital specialties at HealthPartners Medical Group in St. Paul, Minn.
References
- Institute for Healthcare Improvement. Overview of the 100,000 Lives Campaign. Available at: http://www.ihi.org/Engage/Initiatives/Completed/5MillionLivesCampaign/Documents/Overview%20of%20the%20100K%20Campaign.pdf. Accessed July 6, 2014.
- Broadbent DE, Reason J, Baddeley A, eds. Human Factors in Hazardous Situations: Proceedings of a Royal Society Discussion Meeting Held on 28 and 29 June 1989. Gloucestershire, England: Clarendon Press; 1990:475-484.
- Leape LL. Error in medicine JAMA.1994;272(23):1851-1857.
- Institute of Medicine. Kohn LT, Corrigan JM, Donaldson MS, eds. To Err Is Human: Building a Safer Health System. Washington, D.C.: The National Academy Press; 2000.
- Institute of Medicine. Committee on Quality of Healthcare in America. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, D.C.: The National Academy Press; 2001.
- The Leapfrog Group. About Leapfrog. Available at: http://www.leapfroggroup.org/about_leapfrog. Accessed July 6, 2014.
- Society of Hospital Medicine. SHM’s State of Hospital Medicine Surveys 2003-2012. Available at: www.hospitalmedicine.org/survey. Accessed July 3, 2014.
Hippocrates, Epidemics.“The Physician must be able to do good or to do no harm.”
This is part three of my ongoing series on the journey of hospital medicine and how we are poised for greater things yet. In part one, “Tinder and Spark,” macro changes in the American healthcare landscape pressured primary care physicians to get creative with new ways to practice, the most prominent result being the creation of hospitalist practices. Wachter and Goldman provided the spark that gave the field its name and cohesiveness. In part two, “Fuel,” the Baby Boomers shaped the field, setting the stage for the Generation X physicians who fueled HM’s early growth.
But the field might have stagnated there, the fire attenuated, if not for the rise of something new, something that stoked our growth to new heights.
Orlando, Fla., December 2006.
SHM President-Elect Rusty Holman, MD, MHM, was on stage representing hospitalists at the annual Institute for Healthcare Improvement (IHI) National Forum in front of more than 5,000 enthusiastic attendees representing every discipline of clinical care from hundreds of healthcare organizations across the country and internationally. This was a special event. Two years earlier, IHI President Don Berwick, MD, MPP, had launched an audacious campaign, called the 100,000 Lives Campaign, that aimed to prevent the deaths of 100,000 patients in our nation’s hospitals in the following 18 months, not by utilizing some great new technological advance but by changing the culture around safety and quality in our nation’s hospitals and enacting proven safety methods and processes.1 Out of this plan came widespread use of terms and programs that weren’t widely adopted then but are familiar to all of us now: rapid response teams, medicine reconciliation, surgical site infection prevention, and ventilator-acquired pneumonia.
That program estimated that it saved 122,000 lives.1
IHI was looking to build on the safety and quality infrastructure that had been built up to make the 100,000 Lives Campaign a success and to launch an even bigger program. The 5 Million Lives Campaign’s goal was to reduce incidents of harm in five million patients over the next two years. For this campaign, IHI understood that success could only be achieved with partners. SHM and the field of hospital medicine, which had grown in size and influence, was seen as a critical and influential partner in achieving the goal of reducing harm in our nation’s hospitals. Thus, Dr. Holman was standing on that stage for SHM at the launch of the biggest safety and quality initiative in our nation’s history. SHM was among seven partner organizations, including the American Nurses Association, the Centers for Medicare and Medicaid Services (CMS), the American Heart Association, and the CDC. SHM was the only medical society represented. Pretty heady stuff for a field barely 10 years old. How did we get there? For that story, we need to go back a few years.
In 1984, Libby Zion, an 18-year-old college student, died from serotonin syndrome. A contributing factor was felt to be overworked residents not getting enough sleep. In his landmark 1990 article, “Human Factors in Hazardous Situations,” James Reason, PhD, introduced the world to some key concepts: active versus latent errors and the Swiss cheese model of errors.2 These concepts influence our thinking to this day. In 1994, Betsy Lehman, a health reporter for the Boston Globe, died from a massive chemotherapy overdose. That same year Lucian Leape, MD, a Harvard pediatric surgeon, published his influential article in JAMA, “Errors in Medicine,” which called for a systems approach to improving patient safety.3
These key moments in safety and quality, all of which occurred in the years leading up to hospitalists gaining their identity, were but a prelude to the widespread patient safety and quality movement. Like our own social movement, “Patient Safety and Quality” was born with an influential publication. This was the 1999 release of the Institute of Medicine’s “To Err is Human,” a report that reiterated claims that up to 98,000 U.S. patients per year were dying from medical errors.4 It also supported Dr. Leape’s earlier work calling for systems changes. In 2001, the Institute of Medicine published a second report, “Crossing the Quality Chasm: A New Health System for the 21st Century,” which introduced the six aims for healthcare improvement: safe, timely, effective, efficient, equitable, and patient-centered.5
Before 1999, hospitalists were just getting their feet on the ground. Groups were experimenting with practice models and recruiting young talent, mostly with a pitch for a new way to practice with freedom to design their day and often an interesting work schedule.
After the publication of “To Err is Human” in 1999, changes in patient safety and quality began to accelerate. Taking one of the recommendations from “To Err is Human,” which suggested that employers should use their market power to improve quality and safety, the Leapfrog Group, a consortium of large employers, organized in 2000. Leapfrog began rewarding and recognizing hospitals that put accepted safety measures in place.6 Suddenly, hospital CEOs began to see tangible rewards for improving quality in their hospitals.
Here is where the hospitalist movement and the patient safety and quality movement began to intersect.
Shift to Quality and Safety
In 2001, the same year “Crossing the Quality Chasm” was published, Congress created the Center for Quality Improvement and Patient Safety within the Agency for Healthcare Research and Quality. Significant funding was suddenly available for quality and safety research, and a more organized reporting mechanism for quality would soon be available.
In 2002, the Joint Commission released its first set of National Patient Safety Goals. There were seven, and key goals for hospitalists included improving the effectiveness of communication among caregivers, reducing the risk of healthcare-acquired infections, and reconciling medications.
And, lastly, as if that weren’t enough activity in the patient safety and quality world, the Joint Commission and CMS released in 2003 the first joint, aligned set of core measures, with which we are all now very familiar, around acute myocardial infarction, congestive heart failure, and pneumonia.
Hospital executives were trying to get a handle on the meaning of this flurry of activity for their hospitals. It certainly meant new regulatory requirements. It probably meant greater visibility to the public around what happened behind the walls of their facilities. No doubt dollars on the line wouldn’t be too far behind. They needed help, and they needed it fast.
No longer were hospitalists a small group of young docs roaming the halls; now, instead of just taking care of one patient at a time, they were reaching the threshold of size—and even status in some organizations—where they could leverage their working knowledge of the system and presence on site to affect the various facets of quality now being measured and incented. Additionally, as the information technology (IT) revolution rolled out, hospitalists, mostly tech-savvy Gen X’ers, looked to ease the transition into the new world of EHRs, which promised to serve as a new base for improving quality.
As the C-suite continued making value calculations in their heads, they saw that, in addition to helping them manage the many facets of the transition of primary care and specialty teaching attendings out of the hospital, hospitalists could now be a powerful weapon in helping them stay competitive in the looming patient safety and quality revolution. They pulled out their checkbooks.
When SHM first started gathering data to explore this gap, we discovered that in 2003 the reported median support per FTE of an adult hospitalist in this country was $60,000.7 With an estimated 11,000 hospitalists in the country at that time, C-suite funders paid out over $600 million to help overcome the deficit between hospitalist professional billings and salary and benefits. By the time SHM partnered with IHI on the 5 Million Lives Campaign in 2006, the figure stood at well over $2 billion. The 2011 SHM/Medical Group Management Association survey data showed $139,090 support per FTE. With 31,000 U.S. hospitalists estimated at the time, that figure had doubled to over $4 billion in just five years’ time.
The new generation of doctors had come along in the late 1990s looking for a practice that fit their wants and needs. HM gave them what they were looking for: autonomy, the promise of work-life balance, and the ability to help patients in their most vulnerable time. The traditional E&M [evaluation and management]-based funding mechanisms simply weren’t designed to account for physicians who spend all of their time doing the critical cognitive and coordinating clinical work. To account for this, hospitals and medical groups, seeing the value to their organizations in this new specialty, anteed up to cover the difference. That gave us a great beginning.
But it was the convergence of the early hospitalist movement and the emergent patient safety and quality movement that created a synergy that propelled both movements forward. Boosted by the influx of funding directly and indirectly related to patient safety and quality, hospitalists grew in number from an estimated 5,000 physicians at the 1999 publication of “To Err is Human” to north of 40,000 today.
The synergy was evident when SHM President-Elect Dr. Holman, representing our fledgling specialty and society, faced that cheering throng in Orlando alongside Dr. Don Berwick, the face of the patient safety and quality movement.
But that’s not quite the end of the story.
To get us up to the present and on to our bright future, there will be a few more additions to the quality story and an all-new generation arriving on the scene to shake things up.
Dr. Kealey is SHM president and medical director of hospital specialties at HealthPartners Medical Group in St. Paul, Minn.
References
- Institute for Healthcare Improvement. Overview of the 100,000 Lives Campaign. Available at: http://www.ihi.org/Engage/Initiatives/Completed/5MillionLivesCampaign/Documents/Overview%20of%20the%20100K%20Campaign.pdf. Accessed July 6, 2014.
- Broadbent DE, Reason J, Baddeley A, eds. Human Factors in Hazardous Situations: Proceedings of a Royal Society Discussion Meeting Held on 28 and 29 June 1989. Gloucestershire, England: Clarendon Press; 1990:475-484.
- Leape LL. Error in medicine JAMA.1994;272(23):1851-1857.
- Institute of Medicine. Kohn LT, Corrigan JM, Donaldson MS, eds. To Err Is Human: Building a Safer Health System. Washington, D.C.: The National Academy Press; 2000.
- Institute of Medicine. Committee on Quality of Healthcare in America. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, D.C.: The National Academy Press; 2001.
- The Leapfrog Group. About Leapfrog. Available at: http://www.leapfroggroup.org/about_leapfrog. Accessed July 6, 2014.
- Society of Hospital Medicine. SHM’s State of Hospital Medicine Surveys 2003-2012. Available at: www.hospitalmedicine.org/survey. Accessed July 3, 2014.
Society of Hospital Medicine’s Project BOOST Pays Off
–Manasi Kekan, MD, MS, FACP, medical director for Houston Methodist Hospital
Financial pressures to reduce 30-day hospital readmissions and improve discharge processes continue to grow. The Centers for Medicare and Medicaid Services started by penalizing hospitals for up to 1% of their Medicare reimbursement via the Hospital Readmissions Reduction Program. By 2015, the program will penalize hospitals up to 3%.
This is no longer news to the hospital C-suite. A 2013 survey reported that 85% of hospital leaders had addressed the readmissions penalty in their business plan (http://content.hcpro.com/pdf/content/296905.pdf); however, the same survey revealed that only 62% of hospital leaders reported changes to clinical protocols and practices during acute care, and even fewer were providing care navigators or coaches for high-risk patients.
That’s where hospitalists can help. Through SHM’s Project BOOST, hospitalists and hospital-based care teams improve transition from hospital to home. Project BOOST also helps hospitals identify high-risk patients and target risk-specific interventions, a critical part of reducing readmissions.
Beyond the immediate financial implications, implementing programs like Project BOOST to reduce readmissions can position hospitals as leaders for better healthcare in their communities.
“I recommend Project BOOST enthusiastically and unequivocally,” says Manasi Kekan, MD, MS, FACP, medical director for Houston Methodist Hospital. “If implemented efficiently, it could result in a ‘win-win’ situation for patients, the hospital, and the healthcare providers.”
SHM is accepting applications for the 2014 Project BOOST cohort through August 30. For details and application, visit www.hospitalmedicine.org/boost.
–Manasi Kekan, MD, MS, FACP, medical director for Houston Methodist Hospital
Financial pressures to reduce 30-day hospital readmissions and improve discharge processes continue to grow. The Centers for Medicare and Medicaid Services started by penalizing hospitals for up to 1% of their Medicare reimbursement via the Hospital Readmissions Reduction Program. By 2015, the program will penalize hospitals up to 3%.
This is no longer news to the hospital C-suite. A 2013 survey reported that 85% of hospital leaders had addressed the readmissions penalty in their business plan (http://content.hcpro.com/pdf/content/296905.pdf); however, the same survey revealed that only 62% of hospital leaders reported changes to clinical protocols and practices during acute care, and even fewer were providing care navigators or coaches for high-risk patients.
That’s where hospitalists can help. Through SHM’s Project BOOST, hospitalists and hospital-based care teams improve transition from hospital to home. Project BOOST also helps hospitals identify high-risk patients and target risk-specific interventions, a critical part of reducing readmissions.
Beyond the immediate financial implications, implementing programs like Project BOOST to reduce readmissions can position hospitals as leaders for better healthcare in their communities.
“I recommend Project BOOST enthusiastically and unequivocally,” says Manasi Kekan, MD, MS, FACP, medical director for Houston Methodist Hospital. “If implemented efficiently, it could result in a ‘win-win’ situation for patients, the hospital, and the healthcare providers.”
SHM is accepting applications for the 2014 Project BOOST cohort through August 30. For details and application, visit www.hospitalmedicine.org/boost.
–Manasi Kekan, MD, MS, FACP, medical director for Houston Methodist Hospital
Financial pressures to reduce 30-day hospital readmissions and improve discharge processes continue to grow. The Centers for Medicare and Medicaid Services started by penalizing hospitals for up to 1% of their Medicare reimbursement via the Hospital Readmissions Reduction Program. By 2015, the program will penalize hospitals up to 3%.
This is no longer news to the hospital C-suite. A 2013 survey reported that 85% of hospital leaders had addressed the readmissions penalty in their business plan (http://content.hcpro.com/pdf/content/296905.pdf); however, the same survey revealed that only 62% of hospital leaders reported changes to clinical protocols and practices during acute care, and even fewer were providing care navigators or coaches for high-risk patients.
That’s where hospitalists can help. Through SHM’s Project BOOST, hospitalists and hospital-based care teams improve transition from hospital to home. Project BOOST also helps hospitals identify high-risk patients and target risk-specific interventions, a critical part of reducing readmissions.
Beyond the immediate financial implications, implementing programs like Project BOOST to reduce readmissions can position hospitals as leaders for better healthcare in their communities.
“I recommend Project BOOST enthusiastically and unequivocally,” says Manasi Kekan, MD, MS, FACP, medical director for Houston Methodist Hospital. “If implemented efficiently, it could result in a ‘win-win’ situation for patients, the hospital, and the healthcare providers.”
SHM is accepting applications for the 2014 Project BOOST cohort through August 30. For details and application, visit www.hospitalmedicine.org/boost.
Choosing Wisely Case Competition Deadline Is September 9
Are you helping your hospital choose wisely? You could receive thousands of dollars in return for your good work in providing high-value care to hospitalized patients through SHM’s Choosing Wisely case study competition.
SHM will be awarding a total of $20,000 to hospitalists who submit winning case studies illustrating their implementation of the Choosing Wisely principles published by SHM in 2013. Grand prize winners for both adult and pediatric HM will receive $4,000 each, and three honorable mention winners in both categories will each receive $2,000.
But don’t wait long. The deadline for submissions is September 9. For information and submission forms, visit www.hospitalmedicine.org/choosingwisely.
Are you helping your hospital choose wisely? You could receive thousands of dollars in return for your good work in providing high-value care to hospitalized patients through SHM’s Choosing Wisely case study competition.
SHM will be awarding a total of $20,000 to hospitalists who submit winning case studies illustrating their implementation of the Choosing Wisely principles published by SHM in 2013. Grand prize winners for both adult and pediatric HM will receive $4,000 each, and three honorable mention winners in both categories will each receive $2,000.
But don’t wait long. The deadline for submissions is September 9. For information and submission forms, visit www.hospitalmedicine.org/choosingwisely.
Are you helping your hospital choose wisely? You could receive thousands of dollars in return for your good work in providing high-value care to hospitalized patients through SHM’s Choosing Wisely case study competition.
SHM will be awarding a total of $20,000 to hospitalists who submit winning case studies illustrating their implementation of the Choosing Wisely principles published by SHM in 2013. Grand prize winners for both adult and pediatric HM will receive $4,000 each, and three honorable mention winners in both categories will each receive $2,000.
But don’t wait long. The deadline for submissions is September 9. For information and submission forms, visit www.hospitalmedicine.org/choosingwisely.
Quality Improvement, Patient Safety Top Hospitalists’ Priority Lists at HM14
LAS VEGAS—Hospitalist Ijeoma “Carol” Nwelue, MD, has been more focused on patient readmissions over the past year at her practice in Lansing, Mich. So when the directors at Sparrow Hospitalists told her she had a meeting a few weeks after HM14 to discuss different risk assessment tools that might be used to pre-identify patients at high risk for readmission, she wasn’t nervous.
Instead, she prepped at SHM’s annual meeting at Mandalay Bay Resort and Casino—a veritable three-day crash course in the latest and greatest approaches to preventing readmissions.
“It’s very helpful,” she says. “It helps to see things that I haven’t thought about in our practice that other people are looking into.”
Quality improvement (QI) and patient safety are at the core of what hospitalists do, and the HM14 organizers understand that. From multiple pre-courses on the topics trending today to a dedicated educational track of breakout sessions and expert speakers to hundreds of posters identifying HM-specific QI projects, SHM’s annual meeting is a veritable QI opportunity of its own.
Take the annual pre-course, “ABIM Maintenance of Certification Facilitated Modules.” One attendee told presenter Read Pierce, MD, director of quality improvement and clinical innovation for the hospitalist group at the University of Colorado Denver, that before the session in Las Vegas he had always had “the sense that quality and safety is soft science or fuzzy stuff around the edges, and if you were a smart clinician, that was good enough.”
After some time in the session, Dr. Pierce recounts, the man “realized it’s not just enough to have great intellectual horsepower. You have to have some approach for dealing with these complex systems. And I think that’s the really fun thing....It’s not just about the discreet concepts; it’s about understanding the environment in which we practice, the importance of engaging systems and of using the tools of quality and safety to augment what physicians have always been good at doing.”
John Coppes, MD, FHM, a hospitalist at Mount Nittany Medical Center in State College, Pa., says quality and patient safety are the “most important things that we do.”
“It’s our responsibility to our patients to do the best job we can,” he notes. “It’s our responsibility to society to do it as efficiently as we can.”
Veteran meeting faculty John Bulger, DO, MBA, FACP, SFHM, hospitalist and chief quality officer at Geisinger Health System in Pennsylvania, agrees completely and is one of HM’s biggest proponents of the American Board of Internal Medicine (ABIM) Foundation’s Choosing Wisely (www.hospitalmedicine.org/choosingwisely) campaign. The national initiative, aimed at educating physicians—and patients—about wasteful medical tests, procedures, and treatments, launched in 2012, but SHM joined the chorus as a strategic partner last year.
“Choosing Wisely is about bending the cost curve,” Dr. Bulger says.
He added that although standardization of care is necessary for Choosing Wisely to work, homogeneity doesn’t mean everybody does everything exactly the same way. It means ensuring that hospitalists adopt “agreed upon best practices” before local variations are added. He compared it to a cookbook of apple pie recipes. All apple pies contain apples and crust, but the tasty treats are tailored differently from there.
“When you come up with guidelines in your hospital, that’s what you’re doing,” Dr. Bulger says. “You’re writing the cookbook and coming up with what works at your hospital. It might not work at [my hospital] at all, but I can look at it and learn.”
In the long-term, SHM hopes to create resources beyond the recommendations themselves—perhaps including a mentored implementation program akin to Project BOOST or pre-packaged order sets and checklists. Whatever the society does, it needs to engage the younger generation of physicians to ensure that quality and safety stay a priority for them, says Darlene Tad-y, MD, chair of SHM’s Physicians in Training Committee.
An assistant professor of medicine and a hospitalist at the University of Colorado Denver, Dr. Tad-y says that getting residents and students involved in quality and safety measures is critical for HM’s future.
“Especially since we want to have hospital medicine be at the forefront,” she explains. “It’s vital for us to have our students and residents taking the lead.”
Younger physicians already see the role quality and safety take in day-to-day practice. So, for them, according to Dr. Tad-y, a focus on making sure patient care is delivered better and more safely isn’t a renewed effort—it’s what they’re taught from the beginning.
“They haven’t been trained in the old way yet,” she says. “They still have an open mind. They see that things can change and things can be better. We don’t have to change old habits. We are just evolving good new habits for them.”
One new perspective was a first-time pre-course, “Cardiology: What Hospitalists Need to Know as Front-Line Providers.” The eight-hour seminar was led by cardiologist Matthews Chacko, MD, of Johns Hopkins Hospital in Baltimore, who says the time is right for quality-focused hospitalists to devote a full-day pre-course to cardiology.
“Cardiovascular disease is the most common reason we die,” he says. “It’s something hospital-based practitioners see often. Providing a comprehensive, yet simplified, overview of the way to manage some of these diseases with talks given by some of the leading experts in the field seemed very appropriate for this meeting.”
The sheer scale of QI initiatives can be daunting, says Michelle Mourad, MD, director of quality and safety at the University of California at San Francisco (UCSF) School of Medicine. She urges her peers to take the proverbial step back, identify a single issue—sepsis mortality or hand hygiene, for example—and then focus on understanding that issue intimately. That way, a hospitalist or HM group can convince other physicians that there is a problem and that it’s worth the work to fix it. Once that’s done, a hospitalist can launch a QI project that devises a measurement strategy to see if change is occurring.
And, while sustaining that change beyond the initial start-up can be difficult, Dr. Mourad believes success breeds success.
“When you work hard at a quality gap that’s in your organization, [when you] actually see the care you provide get better—not just for the patient in front of you, but for all the patients in your organization—it’s extremely powerful and motivating,” she says. “It changes the culture in your institution and convinces other people that they can do the same.”
LAS VEGAS—Hospitalist Ijeoma “Carol” Nwelue, MD, has been more focused on patient readmissions over the past year at her practice in Lansing, Mich. So when the directors at Sparrow Hospitalists told her she had a meeting a few weeks after HM14 to discuss different risk assessment tools that might be used to pre-identify patients at high risk for readmission, she wasn’t nervous.
Instead, she prepped at SHM’s annual meeting at Mandalay Bay Resort and Casino—a veritable three-day crash course in the latest and greatest approaches to preventing readmissions.
“It’s very helpful,” she says. “It helps to see things that I haven’t thought about in our practice that other people are looking into.”
Quality improvement (QI) and patient safety are at the core of what hospitalists do, and the HM14 organizers understand that. From multiple pre-courses on the topics trending today to a dedicated educational track of breakout sessions and expert speakers to hundreds of posters identifying HM-specific QI projects, SHM’s annual meeting is a veritable QI opportunity of its own.
Take the annual pre-course, “ABIM Maintenance of Certification Facilitated Modules.” One attendee told presenter Read Pierce, MD, director of quality improvement and clinical innovation for the hospitalist group at the University of Colorado Denver, that before the session in Las Vegas he had always had “the sense that quality and safety is soft science or fuzzy stuff around the edges, and if you were a smart clinician, that was good enough.”
After some time in the session, Dr. Pierce recounts, the man “realized it’s not just enough to have great intellectual horsepower. You have to have some approach for dealing with these complex systems. And I think that’s the really fun thing....It’s not just about the discreet concepts; it’s about understanding the environment in which we practice, the importance of engaging systems and of using the tools of quality and safety to augment what physicians have always been good at doing.”
John Coppes, MD, FHM, a hospitalist at Mount Nittany Medical Center in State College, Pa., says quality and patient safety are the “most important things that we do.”
“It’s our responsibility to our patients to do the best job we can,” he notes. “It’s our responsibility to society to do it as efficiently as we can.”
Veteran meeting faculty John Bulger, DO, MBA, FACP, SFHM, hospitalist and chief quality officer at Geisinger Health System in Pennsylvania, agrees completely and is one of HM’s biggest proponents of the American Board of Internal Medicine (ABIM) Foundation’s Choosing Wisely (www.hospitalmedicine.org/choosingwisely) campaign. The national initiative, aimed at educating physicians—and patients—about wasteful medical tests, procedures, and treatments, launched in 2012, but SHM joined the chorus as a strategic partner last year.
“Choosing Wisely is about bending the cost curve,” Dr. Bulger says.
He added that although standardization of care is necessary for Choosing Wisely to work, homogeneity doesn’t mean everybody does everything exactly the same way. It means ensuring that hospitalists adopt “agreed upon best practices” before local variations are added. He compared it to a cookbook of apple pie recipes. All apple pies contain apples and crust, but the tasty treats are tailored differently from there.
“When you come up with guidelines in your hospital, that’s what you’re doing,” Dr. Bulger says. “You’re writing the cookbook and coming up with what works at your hospital. It might not work at [my hospital] at all, but I can look at it and learn.”
In the long-term, SHM hopes to create resources beyond the recommendations themselves—perhaps including a mentored implementation program akin to Project BOOST or pre-packaged order sets and checklists. Whatever the society does, it needs to engage the younger generation of physicians to ensure that quality and safety stay a priority for them, says Darlene Tad-y, MD, chair of SHM’s Physicians in Training Committee.
An assistant professor of medicine and a hospitalist at the University of Colorado Denver, Dr. Tad-y says that getting residents and students involved in quality and safety measures is critical for HM’s future.
“Especially since we want to have hospital medicine be at the forefront,” she explains. “It’s vital for us to have our students and residents taking the lead.”
Younger physicians already see the role quality and safety take in day-to-day practice. So, for them, according to Dr. Tad-y, a focus on making sure patient care is delivered better and more safely isn’t a renewed effort—it’s what they’re taught from the beginning.
“They haven’t been trained in the old way yet,” she says. “They still have an open mind. They see that things can change and things can be better. We don’t have to change old habits. We are just evolving good new habits for them.”
One new perspective was a first-time pre-course, “Cardiology: What Hospitalists Need to Know as Front-Line Providers.” The eight-hour seminar was led by cardiologist Matthews Chacko, MD, of Johns Hopkins Hospital in Baltimore, who says the time is right for quality-focused hospitalists to devote a full-day pre-course to cardiology.
“Cardiovascular disease is the most common reason we die,” he says. “It’s something hospital-based practitioners see often. Providing a comprehensive, yet simplified, overview of the way to manage some of these diseases with talks given by some of the leading experts in the field seemed very appropriate for this meeting.”
The sheer scale of QI initiatives can be daunting, says Michelle Mourad, MD, director of quality and safety at the University of California at San Francisco (UCSF) School of Medicine. She urges her peers to take the proverbial step back, identify a single issue—sepsis mortality or hand hygiene, for example—and then focus on understanding that issue intimately. That way, a hospitalist or HM group can convince other physicians that there is a problem and that it’s worth the work to fix it. Once that’s done, a hospitalist can launch a QI project that devises a measurement strategy to see if change is occurring.
And, while sustaining that change beyond the initial start-up can be difficult, Dr. Mourad believes success breeds success.
“When you work hard at a quality gap that’s in your organization, [when you] actually see the care you provide get better—not just for the patient in front of you, but for all the patients in your organization—it’s extremely powerful and motivating,” she says. “It changes the culture in your institution and convinces other people that they can do the same.”
LAS VEGAS—Hospitalist Ijeoma “Carol” Nwelue, MD, has been more focused on patient readmissions over the past year at her practice in Lansing, Mich. So when the directors at Sparrow Hospitalists told her she had a meeting a few weeks after HM14 to discuss different risk assessment tools that might be used to pre-identify patients at high risk for readmission, she wasn’t nervous.
Instead, she prepped at SHM’s annual meeting at Mandalay Bay Resort and Casino—a veritable three-day crash course in the latest and greatest approaches to preventing readmissions.
“It’s very helpful,” she says. “It helps to see things that I haven’t thought about in our practice that other people are looking into.”
Quality improvement (QI) and patient safety are at the core of what hospitalists do, and the HM14 organizers understand that. From multiple pre-courses on the topics trending today to a dedicated educational track of breakout sessions and expert speakers to hundreds of posters identifying HM-specific QI projects, SHM’s annual meeting is a veritable QI opportunity of its own.
Take the annual pre-course, “ABIM Maintenance of Certification Facilitated Modules.” One attendee told presenter Read Pierce, MD, director of quality improvement and clinical innovation for the hospitalist group at the University of Colorado Denver, that before the session in Las Vegas he had always had “the sense that quality and safety is soft science or fuzzy stuff around the edges, and if you were a smart clinician, that was good enough.”
After some time in the session, Dr. Pierce recounts, the man “realized it’s not just enough to have great intellectual horsepower. You have to have some approach for dealing with these complex systems. And I think that’s the really fun thing....It’s not just about the discreet concepts; it’s about understanding the environment in which we practice, the importance of engaging systems and of using the tools of quality and safety to augment what physicians have always been good at doing.”
John Coppes, MD, FHM, a hospitalist at Mount Nittany Medical Center in State College, Pa., says quality and patient safety are the “most important things that we do.”
“It’s our responsibility to our patients to do the best job we can,” he notes. “It’s our responsibility to society to do it as efficiently as we can.”
Veteran meeting faculty John Bulger, DO, MBA, FACP, SFHM, hospitalist and chief quality officer at Geisinger Health System in Pennsylvania, agrees completely and is one of HM’s biggest proponents of the American Board of Internal Medicine (ABIM) Foundation’s Choosing Wisely (www.hospitalmedicine.org/choosingwisely) campaign. The national initiative, aimed at educating physicians—and patients—about wasteful medical tests, procedures, and treatments, launched in 2012, but SHM joined the chorus as a strategic partner last year.
“Choosing Wisely is about bending the cost curve,” Dr. Bulger says.
He added that although standardization of care is necessary for Choosing Wisely to work, homogeneity doesn’t mean everybody does everything exactly the same way. It means ensuring that hospitalists adopt “agreed upon best practices” before local variations are added. He compared it to a cookbook of apple pie recipes. All apple pies contain apples and crust, but the tasty treats are tailored differently from there.
“When you come up with guidelines in your hospital, that’s what you’re doing,” Dr. Bulger says. “You’re writing the cookbook and coming up with what works at your hospital. It might not work at [my hospital] at all, but I can look at it and learn.”
In the long-term, SHM hopes to create resources beyond the recommendations themselves—perhaps including a mentored implementation program akin to Project BOOST or pre-packaged order sets and checklists. Whatever the society does, it needs to engage the younger generation of physicians to ensure that quality and safety stay a priority for them, says Darlene Tad-y, MD, chair of SHM’s Physicians in Training Committee.
An assistant professor of medicine and a hospitalist at the University of Colorado Denver, Dr. Tad-y says that getting residents and students involved in quality and safety measures is critical for HM’s future.
“Especially since we want to have hospital medicine be at the forefront,” she explains. “It’s vital for us to have our students and residents taking the lead.”
Younger physicians already see the role quality and safety take in day-to-day practice. So, for them, according to Dr. Tad-y, a focus on making sure patient care is delivered better and more safely isn’t a renewed effort—it’s what they’re taught from the beginning.
“They haven’t been trained in the old way yet,” she says. “They still have an open mind. They see that things can change and things can be better. We don’t have to change old habits. We are just evolving good new habits for them.”
One new perspective was a first-time pre-course, “Cardiology: What Hospitalists Need to Know as Front-Line Providers.” The eight-hour seminar was led by cardiologist Matthews Chacko, MD, of Johns Hopkins Hospital in Baltimore, who says the time is right for quality-focused hospitalists to devote a full-day pre-course to cardiology.
“Cardiovascular disease is the most common reason we die,” he says. “It’s something hospital-based practitioners see often. Providing a comprehensive, yet simplified, overview of the way to manage some of these diseases with talks given by some of the leading experts in the field seemed very appropriate for this meeting.”
The sheer scale of QI initiatives can be daunting, says Michelle Mourad, MD, director of quality and safety at the University of California at San Francisco (UCSF) School of Medicine. She urges her peers to take the proverbial step back, identify a single issue—sepsis mortality or hand hygiene, for example—and then focus on understanding that issue intimately. That way, a hospitalist or HM group can convince other physicians that there is a problem and that it’s worth the work to fix it. Once that’s done, a hospitalist can launch a QI project that devises a measurement strategy to see if change is occurring.
And, while sustaining that change beyond the initial start-up can be difficult, Dr. Mourad believes success breeds success.
“When you work hard at a quality gap that’s in your organization, [when you] actually see the care you provide get better—not just for the patient in front of you, but for all the patients in your organization—it’s extremely powerful and motivating,” she says. “It changes the culture in your institution and convinces other people that they can do the same.”
Tips for Submitting Applications to Society of Hospital Medicine's Project BOOST
Many potential Project BOOST candidate sites apply, but not all are accepted into the program. What makes for a successful application? Ask one of the founding members of Project BOOST and a current mentor, Dr. Jeffrey Greenwald.
- A strong letter of support. Qualified candidates can demonstrate that the hospital’s leadership is already behind their interest to reduce readmission rates through a program like Project BOOST.
- Demonstrate the existing support of the team. Good applications show that it’s not just a good idea to a few people. Good Project BOOST candidates can illustrate that their hospital has an “institutional prioritization for transitions of care.”
- An honest assessment on organizing change. Project BOOST has helped high-performing sites and beginners alike, but a thoughtful assessment of your site’s prior experience in organizing change and process improvement helps program leaders better understand your needs.
Apply Now Project BOOST is accepting applications now through August 30. Visit www.hospitalmedicine.org/projectboost.
Many potential Project BOOST candidate sites apply, but not all are accepted into the program. What makes for a successful application? Ask one of the founding members of Project BOOST and a current mentor, Dr. Jeffrey Greenwald.
- A strong letter of support. Qualified candidates can demonstrate that the hospital’s leadership is already behind their interest to reduce readmission rates through a program like Project BOOST.
- Demonstrate the existing support of the team. Good applications show that it’s not just a good idea to a few people. Good Project BOOST candidates can illustrate that their hospital has an “institutional prioritization for transitions of care.”
- An honest assessment on organizing change. Project BOOST has helped high-performing sites and beginners alike, but a thoughtful assessment of your site’s prior experience in organizing change and process improvement helps program leaders better understand your needs.
Apply Now Project BOOST is accepting applications now through August 30. Visit www.hospitalmedicine.org/projectboost.
Many potential Project BOOST candidate sites apply, but not all are accepted into the program. What makes for a successful application? Ask one of the founding members of Project BOOST and a current mentor, Dr. Jeffrey Greenwald.
- A strong letter of support. Qualified candidates can demonstrate that the hospital’s leadership is already behind their interest to reduce readmission rates through a program like Project BOOST.
- Demonstrate the existing support of the team. Good applications show that it’s not just a good idea to a few people. Good Project BOOST candidates can illustrate that their hospital has an “institutional prioritization for transitions of care.”
- An honest assessment on organizing change. Project BOOST has helped high-performing sites and beginners alike, but a thoughtful assessment of your site’s prior experience in organizing change and process improvement helps program leaders better understand your needs.
Apply Now Project BOOST is accepting applications now through August 30. Visit www.hospitalmedicine.org/projectboost.
Houston-Based Hospital Reduces Readmissions with Society of Hospital Medicine's Project BOOST
Change doesn’t always come easily to hospitals, but once a catalyst comes along, one positive change can set the stage for the next one—and the one after that. At least that’s the lesson from Houston Methodist Hospital (HMH) and their work with SHM’s Project BOOST, a yearlong, mentored implementation program designed to help hospitals nationwide reduce readmission rates.
As the saying goes, every journey begins with a single step. For hospitals ready to start their journey to reduce readmissions rates and tackle other quality improvement challenges, the first step is the application to Project BOOST, which is due at the end of August. Details on the application and fees are available at www.hospitalmedicine.org/boost.
At Houston Methodist Hospital—a hospital U.S. News & World Report ranked one of “America’s Best Hospitals” in a dozen specialties and designated as a magnet hospital for excellence in nursing—taking that first step toward reducing readmissions by applying to Project BOOST has been well worth it.
“I recommend Project BOOST enthusiastically and unequivocally. If implemented efficiently, it could result in a ‘win-win’ situation for patients, the hospital, and the healthcare providers,” says Manasi Kekan, MD, MS, FACP, who serves as HMH’s medical director. “As a hospitalist, at times, I have found it challenging to ration my times between patient contact and documentation to meet the goals set by the healthcare industry. Being involved in BOOST and watching tangible improvements for my patients has provided me with immense personal and professional gratification!”
In fact, Dr. Kekan and her team have been so pleased with the results, both quantitative and qualitative, from their participation in Project BOOST that they enrolled twice: first in 2012 and again in 2013. She cites the program’s adaptability “that would help us develop a higher quality discharge process for our patients.”
Like many fruitful journeys, though, this one did not find Dr. Kekan and the caregivers at HMH alone: They had a guide who made all the difference.
Change implementation can be difficult, says Houston Methodist’s Janice Finder, RN, MSN. “Everyone knows how they want to design the house, so to speak,” she says, “but if you have someone who has done it before and can lead and direct, it goes much smoother.”
That was the true value of their Project BOOST mentor, Jeffrey Greenwald, MD, SFHM, one of the founding developers of Project BOOST.
“Dr. Greenwald gave us great mentorship and guidance,” Finder says. “The guidance about leadership is essential. If you do not have full support and a person who has ‘been there, done that,’ it is hard to envision.”
From his perspective, Dr. Greenwald saw that HMH had many of the critical elements in place to be successful.
“They had a good set of experiences already. They had the will and leadership and skill on the ground in process improvement,” he says, calling HMH an “incredibly well-oiled machine” with buy-in from the kind of inter-professional team that can make Project BOOST a success.
Overall, Dr. Greenwald calls HMH a “good example of a hospital that has married Project BOOST with the hospital’s existing priorities.”
Other Project BOOST sites start at different levels, in terms of basic interventions and process improvement, Dr. Greenwald explains. Many are able to address more advanced challenges, like how to implement change across broader areas in the hospital, working with leadership, addressing political issues, and improving waning interest in groups.
Dr. Greenwald’s interest in mentorship of Project BOOST sites stems from his own experiences early on—and the need for mentors in quality improvement projects.
“I wish I would have had someone like that when I got started,” says Dr. Greenwald, who tries to fill that role for others now. “Hopefully, each group moves down the path of making sure they have the right stakeholders, the right communications styles and skills in how to look at data and work with front-end staff.”
While Project BOOST focuses teams on reducing readmissions rates, Dr. Kekan has found that the skills learned from Project BOOST have created a blueprint that is applicable to many other team-based challenges in the hospital.
“We describe BOOST as a patient-centric quality initiative that mainly helps improve care transitions and encourages patients to stay informed about their health, which, in turn, helps reduce readmissions,” she says. “BOOST can be used as a framework to enhance other disease-specific discharge initiatives, like CHF [congestive heart failure] and delirium.”
Still, the core elements of reducing readmission rates and making a qualitative impact on her, her team, and the hospital resonate the most with Dr. Kekan.
“Providing a good transition plan to our patients provides satisfaction like none other.”
Brendon Shank is SHM’s associate vice president of communications.
Change doesn’t always come easily to hospitals, but once a catalyst comes along, one positive change can set the stage for the next one—and the one after that. At least that’s the lesson from Houston Methodist Hospital (HMH) and their work with SHM’s Project BOOST, a yearlong, mentored implementation program designed to help hospitals nationwide reduce readmission rates.
As the saying goes, every journey begins with a single step. For hospitals ready to start their journey to reduce readmissions rates and tackle other quality improvement challenges, the first step is the application to Project BOOST, which is due at the end of August. Details on the application and fees are available at www.hospitalmedicine.org/boost.
At Houston Methodist Hospital—a hospital U.S. News & World Report ranked one of “America’s Best Hospitals” in a dozen specialties and designated as a magnet hospital for excellence in nursing—taking that first step toward reducing readmissions by applying to Project BOOST has been well worth it.
“I recommend Project BOOST enthusiastically and unequivocally. If implemented efficiently, it could result in a ‘win-win’ situation for patients, the hospital, and the healthcare providers,” says Manasi Kekan, MD, MS, FACP, who serves as HMH’s medical director. “As a hospitalist, at times, I have found it challenging to ration my times between patient contact and documentation to meet the goals set by the healthcare industry. Being involved in BOOST and watching tangible improvements for my patients has provided me with immense personal and professional gratification!”
In fact, Dr. Kekan and her team have been so pleased with the results, both quantitative and qualitative, from their participation in Project BOOST that they enrolled twice: first in 2012 and again in 2013. She cites the program’s adaptability “that would help us develop a higher quality discharge process for our patients.”
Like many fruitful journeys, though, this one did not find Dr. Kekan and the caregivers at HMH alone: They had a guide who made all the difference.
Change implementation can be difficult, says Houston Methodist’s Janice Finder, RN, MSN. “Everyone knows how they want to design the house, so to speak,” she says, “but if you have someone who has done it before and can lead and direct, it goes much smoother.”
That was the true value of their Project BOOST mentor, Jeffrey Greenwald, MD, SFHM, one of the founding developers of Project BOOST.
“Dr. Greenwald gave us great mentorship and guidance,” Finder says. “The guidance about leadership is essential. If you do not have full support and a person who has ‘been there, done that,’ it is hard to envision.”
From his perspective, Dr. Greenwald saw that HMH had many of the critical elements in place to be successful.
“They had a good set of experiences already. They had the will and leadership and skill on the ground in process improvement,” he says, calling HMH an “incredibly well-oiled machine” with buy-in from the kind of inter-professional team that can make Project BOOST a success.
Overall, Dr. Greenwald calls HMH a “good example of a hospital that has married Project BOOST with the hospital’s existing priorities.”
Other Project BOOST sites start at different levels, in terms of basic interventions and process improvement, Dr. Greenwald explains. Many are able to address more advanced challenges, like how to implement change across broader areas in the hospital, working with leadership, addressing political issues, and improving waning interest in groups.
Dr. Greenwald’s interest in mentorship of Project BOOST sites stems from his own experiences early on—and the need for mentors in quality improvement projects.
“I wish I would have had someone like that when I got started,” says Dr. Greenwald, who tries to fill that role for others now. “Hopefully, each group moves down the path of making sure they have the right stakeholders, the right communications styles and skills in how to look at data and work with front-end staff.”
While Project BOOST focuses teams on reducing readmissions rates, Dr. Kekan has found that the skills learned from Project BOOST have created a blueprint that is applicable to many other team-based challenges in the hospital.
“We describe BOOST as a patient-centric quality initiative that mainly helps improve care transitions and encourages patients to stay informed about their health, which, in turn, helps reduce readmissions,” she says. “BOOST can be used as a framework to enhance other disease-specific discharge initiatives, like CHF [congestive heart failure] and delirium.”
Still, the core elements of reducing readmission rates and making a qualitative impact on her, her team, and the hospital resonate the most with Dr. Kekan.
“Providing a good transition plan to our patients provides satisfaction like none other.”
Brendon Shank is SHM’s associate vice president of communications.
Change doesn’t always come easily to hospitals, but once a catalyst comes along, one positive change can set the stage for the next one—and the one after that. At least that’s the lesson from Houston Methodist Hospital (HMH) and their work with SHM’s Project BOOST, a yearlong, mentored implementation program designed to help hospitals nationwide reduce readmission rates.
As the saying goes, every journey begins with a single step. For hospitals ready to start their journey to reduce readmissions rates and tackle other quality improvement challenges, the first step is the application to Project BOOST, which is due at the end of August. Details on the application and fees are available at www.hospitalmedicine.org/boost.
At Houston Methodist Hospital—a hospital U.S. News & World Report ranked one of “America’s Best Hospitals” in a dozen specialties and designated as a magnet hospital for excellence in nursing—taking that first step toward reducing readmissions by applying to Project BOOST has been well worth it.
“I recommend Project BOOST enthusiastically and unequivocally. If implemented efficiently, it could result in a ‘win-win’ situation for patients, the hospital, and the healthcare providers,” says Manasi Kekan, MD, MS, FACP, who serves as HMH’s medical director. “As a hospitalist, at times, I have found it challenging to ration my times between patient contact and documentation to meet the goals set by the healthcare industry. Being involved in BOOST and watching tangible improvements for my patients has provided me with immense personal and professional gratification!”
In fact, Dr. Kekan and her team have been so pleased with the results, both quantitative and qualitative, from their participation in Project BOOST that they enrolled twice: first in 2012 and again in 2013. She cites the program’s adaptability “that would help us develop a higher quality discharge process for our patients.”
Like many fruitful journeys, though, this one did not find Dr. Kekan and the caregivers at HMH alone: They had a guide who made all the difference.
Change implementation can be difficult, says Houston Methodist’s Janice Finder, RN, MSN. “Everyone knows how they want to design the house, so to speak,” she says, “but if you have someone who has done it before and can lead and direct, it goes much smoother.”
That was the true value of their Project BOOST mentor, Jeffrey Greenwald, MD, SFHM, one of the founding developers of Project BOOST.
“Dr. Greenwald gave us great mentorship and guidance,” Finder says. “The guidance about leadership is essential. If you do not have full support and a person who has ‘been there, done that,’ it is hard to envision.”
From his perspective, Dr. Greenwald saw that HMH had many of the critical elements in place to be successful.
“They had a good set of experiences already. They had the will and leadership and skill on the ground in process improvement,” he says, calling HMH an “incredibly well-oiled machine” with buy-in from the kind of inter-professional team that can make Project BOOST a success.
Overall, Dr. Greenwald calls HMH a “good example of a hospital that has married Project BOOST with the hospital’s existing priorities.”
Other Project BOOST sites start at different levels, in terms of basic interventions and process improvement, Dr. Greenwald explains. Many are able to address more advanced challenges, like how to implement change across broader areas in the hospital, working with leadership, addressing political issues, and improving waning interest in groups.
Dr. Greenwald’s interest in mentorship of Project BOOST sites stems from his own experiences early on—and the need for mentors in quality improvement projects.
“I wish I would have had someone like that when I got started,” says Dr. Greenwald, who tries to fill that role for others now. “Hopefully, each group moves down the path of making sure they have the right stakeholders, the right communications styles and skills in how to look at data and work with front-end staff.”
While Project BOOST focuses teams on reducing readmissions rates, Dr. Kekan has found that the skills learned from Project BOOST have created a blueprint that is applicable to many other team-based challenges in the hospital.
“We describe BOOST as a patient-centric quality initiative that mainly helps improve care transitions and encourages patients to stay informed about their health, which, in turn, helps reduce readmissions,” she says. “BOOST can be used as a framework to enhance other disease-specific discharge initiatives, like CHF [congestive heart failure] and delirium.”
Still, the core elements of reducing readmission rates and making a qualitative impact on her, her team, and the hospital resonate the most with Dr. Kekan.
“Providing a good transition plan to our patients provides satisfaction like none other.”
Brendon Shank is SHM’s associate vice president of communications.
Federal Grant Extends Anti-Infection Initiative
The American Hospital Association’s Health Research and Educational Trust (HRET) recently obtained a grant from the federal Agency for Healthcare Research and Quality to expand CUSP, the Comprehensive Unit-based Safety Program for reducing catheter-associated urinary tract infections (CAUTI) and other healthcare-associated infections, to nursing homes and skilled nursing facilities nationwide.
CUSP has posted a 40% reduction in central line-associated bloodstream infections (CLABSI) in 1,000 participating hospitals by providing education and support and an evidence-based protocol. The grant will be administered by HRET in partnership with others, including the University of Michigan Health System, the Association for Professionals in Infection Control and Epidemiology, and SHM.
Meanwhile, a study published in the American Journal of Infection Control found that rates of catheter-associated urinary tract infections in adult patients given urinary catheter placements dropped nationwide to 5.3% in 2010 from 9.4% in 2001.3 The retrospective analysis of data from the National Hospital Discharge Survey found that CAUTI-related mortality and associated length of hospital stay also declined during the same period.
Larry Beresford is a freelance writer in Alameda, Calif.
The American Hospital Association’s Health Research and Educational Trust (HRET) recently obtained a grant from the federal Agency for Healthcare Research and Quality to expand CUSP, the Comprehensive Unit-based Safety Program for reducing catheter-associated urinary tract infections (CAUTI) and other healthcare-associated infections, to nursing homes and skilled nursing facilities nationwide.
CUSP has posted a 40% reduction in central line-associated bloodstream infections (CLABSI) in 1,000 participating hospitals by providing education and support and an evidence-based protocol. The grant will be administered by HRET in partnership with others, including the University of Michigan Health System, the Association for Professionals in Infection Control and Epidemiology, and SHM.
Meanwhile, a study published in the American Journal of Infection Control found that rates of catheter-associated urinary tract infections in adult patients given urinary catheter placements dropped nationwide to 5.3% in 2010 from 9.4% in 2001.3 The retrospective analysis of data from the National Hospital Discharge Survey found that CAUTI-related mortality and associated length of hospital stay also declined during the same period.
Larry Beresford is a freelance writer in Alameda, Calif.
The American Hospital Association’s Health Research and Educational Trust (HRET) recently obtained a grant from the federal Agency for Healthcare Research and Quality to expand CUSP, the Comprehensive Unit-based Safety Program for reducing catheter-associated urinary tract infections (CAUTI) and other healthcare-associated infections, to nursing homes and skilled nursing facilities nationwide.
CUSP has posted a 40% reduction in central line-associated bloodstream infections (CLABSI) in 1,000 participating hospitals by providing education and support and an evidence-based protocol. The grant will be administered by HRET in partnership with others, including the University of Michigan Health System, the Association for Professionals in Infection Control and Epidemiology, and SHM.
Meanwhile, a study published in the American Journal of Infection Control found that rates of catheter-associated urinary tract infections in adult patients given urinary catheter placements dropped nationwide to 5.3% in 2010 from 9.4% in 2001.3 The retrospective analysis of data from the National Hospital Discharge Survey found that CAUTI-related mortality and associated length of hospital stay also declined during the same period.
Larry Beresford is a freelance writer in Alameda, Calif.
SHM’s Online Community Easy to Access, Use
HMX in 3 Minutes or Less
More than 2,500 hospitalists have logged into HMX to share their experiences and ask questions on a wide variety of topics, from HM group practice management to clinical details about glycemic control.
New communities are being added regularly, so be sure to set up your account, sign up for customizable e-mail notifications, and check back regularly to follow your favorite discussions.
Have a question or idea for other hospitalists? Share it today.
Here’s how to get started. All you need are your SHM login credentials.
- Go to www.hmxchange.org.
- In the top right-hand corner, click the link that reads, “Login to see members only content.”
- Enter your SHM login credentials and click login.
- Now you’re logged in. On the right-hand side, you will find a box with a list of the various communities. Click on the community you would like to view and/or post in.
- Click the “Discussions” tab and, on the right, click the square button that says “+ Post New Message.”
- Compose your message with subject and body (and you can include an attachment if you want).
- Click “Send.”
Hospitalists can now follow their favorite discussions on the go with the Member Centric app for HMX.
- Go to your preferred app store and download “MemberCentric.”
- Search for “Society of Hospital Medicine” in the list of organizations.
- Log in with your SHM/HMX username and password.
- Get access to your discussions, contacts, private message inbox, and events calendar.
HMX in 3 Minutes or Less
More than 2,500 hospitalists have logged into HMX to share their experiences and ask questions on a wide variety of topics, from HM group practice management to clinical details about glycemic control.
New communities are being added regularly, so be sure to set up your account, sign up for customizable e-mail notifications, and check back regularly to follow your favorite discussions.
Have a question or idea for other hospitalists? Share it today.
Here’s how to get started. All you need are your SHM login credentials.
- Go to www.hmxchange.org.
- In the top right-hand corner, click the link that reads, “Login to see members only content.”
- Enter your SHM login credentials and click login.
- Now you’re logged in. On the right-hand side, you will find a box with a list of the various communities. Click on the community you would like to view and/or post in.
- Click the “Discussions” tab and, on the right, click the square button that says “+ Post New Message.”
- Compose your message with subject and body (and you can include an attachment if you want).
- Click “Send.”
Hospitalists can now follow their favorite discussions on the go with the Member Centric app for HMX.
- Go to your preferred app store and download “MemberCentric.”
- Search for “Society of Hospital Medicine” in the list of organizations.
- Log in with your SHM/HMX username and password.
- Get access to your discussions, contacts, private message inbox, and events calendar.
HMX in 3 Minutes or Less
More than 2,500 hospitalists have logged into HMX to share their experiences and ask questions on a wide variety of topics, from HM group practice management to clinical details about glycemic control.
New communities are being added regularly, so be sure to set up your account, sign up for customizable e-mail notifications, and check back regularly to follow your favorite discussions.
Have a question or idea for other hospitalists? Share it today.
Here’s how to get started. All you need are your SHM login credentials.
- Go to www.hmxchange.org.
- In the top right-hand corner, click the link that reads, “Login to see members only content.”
- Enter your SHM login credentials and click login.
- Now you’re logged in. On the right-hand side, you will find a box with a list of the various communities. Click on the community you would like to view and/or post in.
- Click the “Discussions” tab and, on the right, click the square button that says “+ Post New Message.”
- Compose your message with subject and body (and you can include an attachment if you want).
- Click “Send.”
Hospitalists can now follow their favorite discussions on the go with the Member Centric app for HMX.
- Go to your preferred app store and download “MemberCentric.”
- Search for “Society of Hospital Medicine” in the list of organizations.
- Log in with your SHM/HMX username and password.
- Get access to your discussions, contacts, private message inbox, and events calendar.