QI Initiatives

Empathy: ability to understand and share the feelings of another.

In today’s increasingly hyper-measured healthcare world, we are looking more and more at measures of patient outcomes. The Institute for Healthcare Improvement (IHI) touts the Triple Aim principle as the lens through which we should be approaching our work. The Triple Aim is the three-part goal and simultaneous focus of improving the health of the community and our patients, improving affordability of care, and finally and perhaps most elusively, improving the patient experience. Who wouldn’t want to hit on these admirable goals? How do we do it?

In approaching the health aspect of the Triple Aim, we, as hospitalists, have tried-and-true frameworks of process improvement. Clinical research and peer-reviewed publication advance the knowledge of what medicines and procedures can improve care. Although powerful and generally truthful, this system results in a slow diffusion of practice improvement, not to mention idiosyncratic and nonstandardized care. This has led to a new toolkit of improvement techniques: continuous quality improvement, Lean, and Six Sigma. We learn and adopt these and watch our scores go up at a steady pace.

Improving affordability has its challenges, some huge, like our basic cultural ethos that “more is better.” Yet affordability is still something we can grasp. It is rooted in systems we are all familiar with, from basic personal finance to resource allocation to generally accepted accounting principles. We all can grasp that the current system of pay for widgets is teetering at the edge, just waiting for a shove from CMS to send it to its doom. Once this happens, affordability likely will become something we can start to make serious headway against.

Improving the experience of patients and families is perhaps the toughest of the three and where I would like to focus.

Patients First

First, a question: Are experience scores reflective of the true experience of a patient?

Two weeks after discharge, when patients receive their HCAHPS questionnaire in the mail, do they remember the details of their stay? And who was their doctor anyway? The cardiologist who placed a stent? The on-call doctor? The hospitalist who visited them every morning? If all we focus on is the scores, and we lack faith that the scores represent the true experience of patients, then how can we ever truly create a more satisfying experience for our patients?

I believe that the answer lies with empathy. What’s unique about this part of the Triple Aim is that many of the answers are within us. Gaining empathy with our patients requires us to ask questions of them and also to ask questions of ourselves. It requires us to invoke ancient methods of learning and thinking, like walking in another’s shoes for a day or using the Golden Rule. Experience doesn’t lend itself to being taught by PowerPoint. It must be lived and channeled back and out through our emotional selves as empathy.

Using the wisdom of patients themselves is one way to understand their needs and develop the empathy to motivate us to change how we do things in health care. Many organizations around the country have used some form of patient focus group to help learn from patients. Park Nicollet, a large health system in Minnesota, has incorporated family councils in nearly every clinic and care area. They usually are patients or caregivers from the area, bound together by a common disease or location. They dedicate their time, often meeting monthly, to share their stories, give opinions on care processes, and even to shape the design of a care area. Currently, there are more than 100 patient councils in the system, and the number continues to grow.

Film, when done skillfully, is a powerful tool in helping us gain empathy. The Cleveland Clinic has produced an amazing short film called “Empathy: The Human Connection to Patient Care.” It follows patients, families, and staff through the care system. As the camera focuses on each person, floating text appears near them, explaining their situation, inner thoughts, or fears, all overlaid by an emotional piano score. Tears will flow. Understanding follows.

Jim Merlino, MD, Cleveland Clinic’s chief experience officer, explains, “We need to understand that being on the other side of health care is frightening, and our job, our responsibility as people responsible for other people, is to help ease that fear.” Cleveland Clinic has done a remarkable job in reminding us why we went in to health care.

Morgan Spurlock of “Super Size Me” fame produced a reality series called “30 Days.” In each episode, a participant spent 30 days in the shoes of another. In the “Life in a Wheelchair” episode, Super Bowl-winning football player Ray Crockett lives in a wheelchair for 30 days and explores what it is like going through recovery and the healthcare system. He meets several rehabbing paraplegics and quadriplegics and accompanies them through their daily lives at home and the hospital. Viewers gain empathy directly in seeing these patients struggle to get better and work with the healthcare system. We also gain empathy watching Crockett gain empathy. The combination is powerful.

In Patients’ Shoes

In addition to listening and observation, we can begin to literally walk in the shoes of our patients.

I recently attended IHI’s International Forum in London. The National Health Service (NHS) in England is using a new tool to help providers understand what it is like for geriatric patients who must navigate the healthcare system with diminished senses and capabilities. Providers put on an age-simulation suit (www.age-simulation-suit.com) that mimics the impairments of aging. Special goggles fog the vision and narrow the visual field. Head mobility is reduced so that it becomes difficult to see beyond the field cuts. Earmuffs reduce high-frequency hearing and the ability to understand speech clearly. The overall suit impedes motion and reduces strength. Thick gloves make it difficult to coordinate fine motions. Wearing this suit and trying to go through a hospital or clinic setting instantly makes the wearer gain empathy for our patients’ needs.

Most important, be a patient. SHM immediate past president Shaun Frost, MD, SFHM, whose personal mission during his tenure was to help the society understand patient experience, explained it best to me. “In one episode in the hospital with a family member, I learned more about patient experience than all the reading and self-educating I have been doing for the last year.”

I think any of us who have been a patient in the hospital, or accompanied a loved one, comes out frustrated that the healthcare system is so convoluted and lacking in clarity for patients. Then there is often a sense of renewal, hopefully,followed by evangelism to spread their newfound empathy to others in the system.

In our busy work lives as hospitalists, it isn’t easy turning our daily focus away from efficiency and productivity. Yet we must always remain mindful of that core idea every one of us wrote down as the heart of our personal statements on our applications to medical school. Do you remember writing something like this? “I want to help people and relieve suffering in their time of need.”

Empathy is the start of our work.

Dr. Kealey is medical director of hospital specialties at HealthPartners Medical Group in St. Paul, Minn. He is an SHM board member and SHM president-elect.

Empathy: ability to understand and share the feelings of another.

In today’s increasingly hyper-measured healthcare world, we are looking more and more at measures of patient outcomes. The Institute for Healthcare Improvement (IHI) touts the Triple Aim principle as the lens through which we should be approaching our work. The Triple Aim is the three-part goal and simultaneous focus of improving the health of the community and our patients, improving affordability of care, and finally and perhaps most elusively, improving the patient experience. Who wouldn’t want to hit on these admirable goals? How do we do it?

In approaching the health aspect of the Triple Aim, we, as hospitalists, have tried-and-true frameworks of process improvement. Clinical research and peer-reviewed publication advance the knowledge of what medicines and procedures can improve care. Although powerful and generally truthful, this system results in a slow diffusion of practice improvement, not to mention idiosyncratic and nonstandardized care. This has led to a new toolkit of improvement techniques: continuous quality improvement, Lean, and Six Sigma. We learn and adopt these and watch our scores go up at a steady pace.

Improving affordability has its challenges, some huge, like our basic cultural ethos that “more is better.” Yet affordability is still something we can grasp. It is rooted in systems we are all familiar with, from basic personal finance to resource allocation to generally accepted accounting principles. We all can grasp that the current system of pay for widgets is teetering at the edge, just waiting for a shove from CMS to send it to its doom. Once this happens, affordability likely will become something we can start to make serious headway against.

Improving the experience of patients and families is perhaps the toughest of the three and where I would like to focus.

Patients First

First, a question: Are experience scores reflective of the true experience of a patient?

Two weeks after discharge, when patients receive their HCAHPS questionnaire in the mail, do they remember the details of their stay? And who was their doctor anyway? The cardiologist who placed a stent? The on-call doctor? The hospitalist who visited them every morning? If all we focus on is the scores, and we lack faith that the scores represent the true experience of patients, then how can we ever truly create a more satisfying experience for our patients?

I believe that the answer lies with empathy. What’s unique about this part of the Triple Aim is that many of the answers are within us. Gaining empathy with our patients requires us to ask questions of them and also to ask questions of ourselves. It requires us to invoke ancient methods of learning and thinking, like walking in another’s shoes for a day or using the Golden Rule. Experience doesn’t lend itself to being taught by PowerPoint. It must be lived and channeled back and out through our emotional selves as empathy.

Using the wisdom of patients themselves is one way to understand their needs and develop the empathy to motivate us to change how we do things in health care. Many organizations around the country have used some form of patient focus group to help learn from patients. Park Nicollet, a large health system in Minnesota, has incorporated family councils in nearly every clinic and care area. They usually are patients or caregivers from the area, bound together by a common disease or location. They dedicate their time, often meeting monthly, to share their stories, give opinions on care processes, and even to shape the design of a care area. Currently, there are more than 100 patient councils in the system, and the number continues to grow.

Film, when done skillfully, is a powerful tool in helping us gain empathy. The Cleveland Clinic has produced an amazing short film called “Empathy: The Human Connection to Patient Care.” It follows patients, families, and staff through the care system. As the camera focuses on each person, floating text appears near them, explaining their situation, inner thoughts, or fears, all overlaid by an emotional piano score. Tears will flow. Understanding follows.

Jim Merlino, MD, Cleveland Clinic’s chief experience officer, explains, “We need to understand that being on the other side of health care is frightening, and our job, our responsibility as people responsible for other people, is to help ease that fear.” Cleveland Clinic has done a remarkable job in reminding us why we went in to health care.

Morgan Spurlock of “Super Size Me” fame produced a reality series called “30 Days.” In each episode, a participant spent 30 days in the shoes of another. In the “Life in a Wheelchair” episode, Super Bowl-winning football player Ray Crockett lives in a wheelchair for 30 days and explores what it is like going through recovery and the healthcare system. He meets several rehabbing paraplegics and quadriplegics and accompanies them through their daily lives at home and the hospital. Viewers gain empathy directly in seeing these patients struggle to get better and work with the healthcare system. We also gain empathy watching Crockett gain empathy. The combination is powerful.

In Patients’ Shoes

In addition to listening and observation, we can begin to literally walk in the shoes of our patients.

I recently attended IHI’s International Forum in London. The National Health Service (NHS) in England is using a new tool to help providers understand what it is like for geriatric patients who must navigate the healthcare system with diminished senses and capabilities. Providers put on an age-simulation suit (www.age-simulation-suit.com) that mimics the impairments of aging. Special goggles fog the vision and narrow the visual field. Head mobility is reduced so that it becomes difficult to see beyond the field cuts. Earmuffs reduce high-frequency hearing and the ability to understand speech clearly. The overall suit impedes motion and reduces strength. Thick gloves make it difficult to coordinate fine motions. Wearing this suit and trying to go through a hospital or clinic setting instantly makes the wearer gain empathy for our patients’ needs.

Most important, be a patient. SHM immediate past president Shaun Frost, MD, SFHM, whose personal mission during his tenure was to help the society understand patient experience, explained it best to me. “In one episode in the hospital with a family member, I learned more about patient experience than all the reading and self-educating I have been doing for the last year.”

I think any of us who have been a patient in the hospital, or accompanied a loved one, comes out frustrated that the healthcare system is so convoluted and lacking in clarity for patients. Then there is often a sense of renewal, hopefully,followed by evangelism to spread their newfound empathy to others in the system.

In our busy work lives as hospitalists, it isn’t easy turning our daily focus away from efficiency and productivity. Yet we must always remain mindful of that core idea every one of us wrote down as the heart of our personal statements on our applications to medical school. Do you remember writing something like this? “I want to help people and relieve suffering in their time of need.”

Empathy is the start of our work.

Dr. Kealey is medical director of hospital specialties at HealthPartners Medical Group in St. Paul, Minn. He is an SHM board member and SHM president-elect.

Empathy: ability to understand and share the feelings of another.

In today’s increasingly hyper-measured healthcare world, we are looking more and more at measures of patient outcomes. The Institute for Healthcare Improvement (IHI) touts the Triple Aim principle as the lens through which we should be approaching our work. The Triple Aim is the three-part goal and simultaneous focus of improving the health of the community and our patients, improving affordability of care, and finally and perhaps most elusively, improving the patient experience. Who wouldn’t want to hit on these admirable goals? How do we do it?

In approaching the health aspect of the Triple Aim, we, as hospitalists, have tried-and-true frameworks of process improvement. Clinical research and peer-reviewed publication advance the knowledge of what medicines and procedures can improve care. Although powerful and generally truthful, this system results in a slow diffusion of practice improvement, not to mention idiosyncratic and nonstandardized care. This has led to a new toolkit of improvement techniques: continuous quality improvement, Lean, and Six Sigma. We learn and adopt these and watch our scores go up at a steady pace.

Improving affordability has its challenges, some huge, like our basic cultural ethos that “more is better.” Yet affordability is still something we can grasp. It is rooted in systems we are all familiar with, from basic personal finance to resource allocation to generally accepted accounting principles. We all can grasp that the current system of pay for widgets is teetering at the edge, just waiting for a shove from CMS to send it to its doom. Once this happens, affordability likely will become something we can start to make serious headway against.

Improving the experience of patients and families is perhaps the toughest of the three and where I would like to focus.

Patients First

First, a question: Are experience scores reflective of the true experience of a patient?

Two weeks after discharge, when patients receive their HCAHPS questionnaire in the mail, do they remember the details of their stay? And who was their doctor anyway? The cardiologist who placed a stent? The on-call doctor? The hospitalist who visited them every morning? If all we focus on is the scores, and we lack faith that the scores represent the true experience of patients, then how can we ever truly create a more satisfying experience for our patients?

I believe that the answer lies with empathy. What’s unique about this part of the Triple Aim is that many of the answers are within us. Gaining empathy with our patients requires us to ask questions of them and also to ask questions of ourselves. It requires us to invoke ancient methods of learning and thinking, like walking in another’s shoes for a day or using the Golden Rule. Experience doesn’t lend itself to being taught by PowerPoint. It must be lived and channeled back and out through our emotional selves as empathy.

Using the wisdom of patients themselves is one way to understand their needs and develop the empathy to motivate us to change how we do things in health care. Many organizations around the country have used some form of patient focus group to help learn from patients. Park Nicollet, a large health system in Minnesota, has incorporated family councils in nearly every clinic and care area. They usually are patients or caregivers from the area, bound together by a common disease or location. They dedicate their time, often meeting monthly, to share their stories, give opinions on care processes, and even to shape the design of a care area. Currently, there are more than 100 patient councils in the system, and the number continues to grow.

Film, when done skillfully, is a powerful tool in helping us gain empathy. The Cleveland Clinic has produced an amazing short film called “Empathy: The Human Connection to Patient Care.” It follows patients, families, and staff through the care system. As the camera focuses on each person, floating text appears near them, explaining their situation, inner thoughts, or fears, all overlaid by an emotional piano score. Tears will flow. Understanding follows.

Jim Merlino, MD, Cleveland Clinic’s chief experience officer, explains, “We need to understand that being on the other side of health care is frightening, and our job, our responsibility as people responsible for other people, is to help ease that fear.” Cleveland Clinic has done a remarkable job in reminding us why we went in to health care.

Morgan Spurlock of “Super Size Me” fame produced a reality series called “30 Days.” In each episode, a participant spent 30 days in the shoes of another. In the “Life in a Wheelchair” episode, Super Bowl-winning football player Ray Crockett lives in a wheelchair for 30 days and explores what it is like going through recovery and the healthcare system. He meets several rehabbing paraplegics and quadriplegics and accompanies them through their daily lives at home and the hospital. Viewers gain empathy directly in seeing these patients struggle to get better and work with the healthcare system. We also gain empathy watching Crockett gain empathy. The combination is powerful.

In Patients’ Shoes

In addition to listening and observation, we can begin to literally walk in the shoes of our patients.

I recently attended IHI’s International Forum in London. The National Health Service (NHS) in England is using a new tool to help providers understand what it is like for geriatric patients who must navigate the healthcare system with diminished senses and capabilities. Providers put on an age-simulation suit (www.age-simulation-suit.com) that mimics the impairments of aging. Special goggles fog the vision and narrow the visual field. Head mobility is reduced so that it becomes difficult to see beyond the field cuts. Earmuffs reduce high-frequency hearing and the ability to understand speech clearly. The overall suit impedes motion and reduces strength. Thick gloves make it difficult to coordinate fine motions. Wearing this suit and trying to go through a hospital or clinic setting instantly makes the wearer gain empathy for our patients’ needs.

Most important, be a patient. SHM immediate past president Shaun Frost, MD, SFHM, whose personal mission during his tenure was to help the society understand patient experience, explained it best to me. “In one episode in the hospital with a family member, I learned more about patient experience than all the reading and self-educating I have been doing for the last year.”

I think any of us who have been a patient in the hospital, or accompanied a loved one, comes out frustrated that the healthcare system is so convoluted and lacking in clarity for patients. Then there is often a sense of renewal, hopefully,followed by evangelism to spread their newfound empathy to others in the system.

In our busy work lives as hospitalists, it isn’t easy turning our daily focus away from efficiency and productivity. Yet we must always remain mindful of that core idea every one of us wrote down as the heart of our personal statements on our applications to medical school. Do you remember writing something like this? “I want to help people and relieve suffering in their time of need.”

Empathy is the start of our work.

Dr. Kealey is medical director of hospital specialties at HealthPartners Medical Group in St. Paul, Minn. He is an SHM board member and SHM president-elect.

Two oral research poster presentations at HM13 explored malpractice concerns of hospitalists and the issue of defensive-medicine-related overutilization—popular topics considering how policymakers are attempting to bend the cost curve in the direction of greater efficiency and value.

Hospitalist Alan Kachalia, MD, JD, and colleagues at Brigham and Women’s Hospital in Boston conducted a randomized national survey of 1,020 hospitalists and analyzed their responses to common clinical scenarios. They found evidence of inappropriate overutilization and deviance from scientific evidence or recognized treatment guidelines, which the research team pegged to the practice of defensive medicine.

Dr. Kachalia’s presentation, “Overutilization and Defensive Medicine in U.S. Hospitals: A Randomized National Survey of Hospitalists,” was named best of the oral presentations in the research category.

“Our survey found substantial overutilization, frequently caused by defensive medicine,” in response to questions about practice patterns for two common clinical scenarios: preoperative evaluation and syncope, Dr. Kachalia said. Physicians who practiced at Veterans Affairs medical centers had less association with defensive medicine, while those who paid for their own liability insurance reported more. Overall, defensive medicine was reported for 37% of preoperative evaluations and 58% of the syncope scenarios.

More than 800 abstracts were submitted for HM13’s Research, Innovations, and Clinical Vignettes (RIV) competition. Nearly 600 were accepted, put on display at the annual meeting, and published online (www.shmabstracts.com). More than 100 abstracts were judged, with 15 of the Research and Innovations entries invited to make oral presentations of their projects. Three others gave “Best of RIV” plenary presentations at the conference.

The diversity and richness of HM13’s oral and poster presentations also will be highlighted in the Innovations department of The Hospitalist over the next year.

Asked to suggest policy responses to these findings, Dr. Kachalia said reform of the malpractice system is needed. “What a lot of us argue is that to get physicians to follow treatment guidelines, make them more clear and practical,” he said. “We’d also like to see safe harbors [from lawsuits] for following recognized guidelines.”

Adam Schaffer, MD, also a hospitalist at Brigham and Women’s Hospital in Boston, and colleagues reviewed a medical liability insurance carrier’s database of more than 30,000 closed claims for those in which a hospitalist was the attending of record. Dr. Schaffer’s retrospective, observational analysis, “Medical Malpractice: Causes and Outcomes of Claims Against Hospitalists,” of the claims database from 1997 to 2011 found 272 claims—almost 1%—for which the attending was a hospitalist.

“The claims rate was almost four times lower for hospitalists than for nonhospitalist internal-medicine physicians,” he said.

The average payment for claims against hospitalists also was smaller. He noted that the types of claims were similar and tended to fall in three general categories: errors in medical treatment, missed or delayed diagnoses, and medication-related errors (although claims also tended to have multiple contributing factors).

Research like Dr. Schaffer’s could help to inform patient-safety efforts and reduce legal malpractice risk, he said. If hospitalists have fewer malpractice claims, that information might also be used to argue for lower malpractice premium rates.

Larry Beresford is a freelance writer in Oakland, Calif.

Two oral research poster presentations at HM13 explored malpractice concerns of hospitalists and the issue of defensive-medicine-related overutilization—popular topics considering how policymakers are attempting to bend the cost curve in the direction of greater efficiency and value.

Hospitalist Alan Kachalia, MD, JD, and colleagues at Brigham and Women’s Hospital in Boston conducted a randomized national survey of 1,020 hospitalists and analyzed their responses to common clinical scenarios. They found evidence of inappropriate overutilization and deviance from scientific evidence or recognized treatment guidelines, which the research team pegged to the practice of defensive medicine.

Dr. Kachalia’s presentation, “Overutilization and Defensive Medicine in U.S. Hospitals: A Randomized National Survey of Hospitalists,” was named best of the oral presentations in the research category.

“Our survey found substantial overutilization, frequently caused by defensive medicine,” in response to questions about practice patterns for two common clinical scenarios: preoperative evaluation and syncope, Dr. Kachalia said. Physicians who practiced at Veterans Affairs medical centers had less association with defensive medicine, while those who paid for their own liability insurance reported more. Overall, defensive medicine was reported for 37% of preoperative evaluations and 58% of the syncope scenarios.

More than 800 abstracts were submitted for HM13’s Research, Innovations, and Clinical Vignettes (RIV) competition. Nearly 600 were accepted, put on display at the annual meeting, and published online (www.shmabstracts.com). More than 100 abstracts were judged, with 15 of the Research and Innovations entries invited to make oral presentations of their projects. Three others gave “Best of RIV” plenary presentations at the conference.

The diversity and richness of HM13’s oral and poster presentations also will be highlighted in the Innovations department of The Hospitalist over the next year.

Asked to suggest policy responses to these findings, Dr. Kachalia said reform of the malpractice system is needed. “What a lot of us argue is that to get physicians to follow treatment guidelines, make them more clear and practical,” he said. “We’d also like to see safe harbors [from lawsuits] for following recognized guidelines.”

Adam Schaffer, MD, also a hospitalist at Brigham and Women’s Hospital in Boston, and colleagues reviewed a medical liability insurance carrier’s database of more than 30,000 closed claims for those in which a hospitalist was the attending of record. Dr. Schaffer’s retrospective, observational analysis, “Medical Malpractice: Causes and Outcomes of Claims Against Hospitalists,” of the claims database from 1997 to 2011 found 272 claims—almost 1%—for which the attending was a hospitalist.

“The claims rate was almost four times lower for hospitalists than for nonhospitalist internal-medicine physicians,” he said.

The average payment for claims against hospitalists also was smaller. He noted that the types of claims were similar and tended to fall in three general categories: errors in medical treatment, missed or delayed diagnoses, and medication-related errors (although claims also tended to have multiple contributing factors).

Research like Dr. Schaffer’s could help to inform patient-safety efforts and reduce legal malpractice risk, he said. If hospitalists have fewer malpractice claims, that information might also be used to argue for lower malpractice premium rates.

Larry Beresford is a freelance writer in Oakland, Calif.

Two oral research poster presentations at HM13 explored malpractice concerns of hospitalists and the issue of defensive-medicine-related overutilization—popular topics considering how policymakers are attempting to bend the cost curve in the direction of greater efficiency and value.

Hospitalist Alan Kachalia, MD, JD, and colleagues at Brigham and Women’s Hospital in Boston conducted a randomized national survey of 1,020 hospitalists and analyzed their responses to common clinical scenarios. They found evidence of inappropriate overutilization and deviance from scientific evidence or recognized treatment guidelines, which the research team pegged to the practice of defensive medicine.

Dr. Kachalia’s presentation, “Overutilization and Defensive Medicine in U.S. Hospitals: A Randomized National Survey of Hospitalists,” was named best of the oral presentations in the research category.

“Our survey found substantial overutilization, frequently caused by defensive medicine,” in response to questions about practice patterns for two common clinical scenarios: preoperative evaluation and syncope, Dr. Kachalia said. Physicians who practiced at Veterans Affairs medical centers had less association with defensive medicine, while those who paid for their own liability insurance reported more. Overall, defensive medicine was reported for 37% of preoperative evaluations and 58% of the syncope scenarios.

More than 800 abstracts were submitted for HM13’s Research, Innovations, and Clinical Vignettes (RIV) competition. Nearly 600 were accepted, put on display at the annual meeting, and published online (www.shmabstracts.com). More than 100 abstracts were judged, with 15 of the Research and Innovations entries invited to make oral presentations of their projects. Three others gave “Best of RIV” plenary presentations at the conference.

The diversity and richness of HM13’s oral and poster presentations also will be highlighted in the Innovations department of The Hospitalist over the next year.

Asked to suggest policy responses to these findings, Dr. Kachalia said reform of the malpractice system is needed. “What a lot of us argue is that to get physicians to follow treatment guidelines, make them more clear and practical,” he said. “We’d also like to see safe harbors [from lawsuits] for following recognized guidelines.”

Adam Schaffer, MD, also a hospitalist at Brigham and Women’s Hospital in Boston, and colleagues reviewed a medical liability insurance carrier’s database of more than 30,000 closed claims for those in which a hospitalist was the attending of record. Dr. Schaffer’s retrospective, observational analysis, “Medical Malpractice: Causes and Outcomes of Claims Against Hospitalists,” of the claims database from 1997 to 2011 found 272 claims—almost 1%—for which the attending was a hospitalist.

“The claims rate was almost four times lower for hospitalists than for nonhospitalist internal-medicine physicians,” he said.

The average payment for claims against hospitalists also was smaller. He noted that the types of claims were similar and tended to fall in three general categories: errors in medical treatment, missed or delayed diagnoses, and medication-related errors (although claims also tended to have multiple contributing factors).

Research like Dr. Schaffer’s could help to inform patient-safety efforts and reduce legal malpractice risk, he said. If hospitalists have fewer malpractice claims, that information might also be used to argue for lower malpractice premium rates.

Larry Beresford is a freelance writer in Oakland, Calif.

One of the busiest times of HM13—and, come to think of it, every recent annual meeting—is the poster session for the Research, Innovations, and Clinical Vignettes (RIV) competition. This year, more than 800 abstracts were submitted and reviewed, with nearly 600 being accepted for presentation at HM13. That meant thousands of hospitalists thumbtacking posters to rows and rows of portable bulletin boards in the Gaylord National Resort & Convention Center’s massive exhibit hall.

With all those posters and accompanying oral presentations, it’s impossible for RIV judges to chat with everybody, so they choose finalists based on the abstracts, then listen to quick-hit summaries before choosing a winner on site. And meeting attendees are just as strapped for time, so they do the best they can to see as many posters as they can, taking time to network with old connections and make new ones.

So with all the limitations on how many people will interact with your poster, the small chance of winning Best in Show, and the hundreds of work hours that go into a poster presentation, why do it?

“To share is what I think is really important,” says Todd Hecht, MD, FACP, SFHM, associate professor of clinical medicine at the Perelman School of Medicine at the University of Pennsylvania in Philadelphia. “If you don’t let other people know what you’re doing, they can’t bring it to their institutions, nor can you learn from others and bring their innovations to your own hospital.”

Dr. Hecht, director of the Anticoagulation Management Center and Anticoagulation Management Program at the Hospital of the University of Pennsylvania, takes the poster sessions very seriously. This year, he entered a poster in both the Innovations and Vignette categories. His Innovations poster, “Impact of a Multidisciplinary Safety Checklist on the Rate of Preventable Hospital Complications and Standardization of Care,” was a finalist.

That meant that, at the very least, he’d be able to explain to at least two judges what motivated his research team’s project. And what was the inspiration? A 90-year-old male patient with metastatic melanoma who, in the fall of 2011, refused to take medication for VTE prophylaxis, as lesions on his skin made the process rather painful. After refusing the doses for a bit, though, the high-risk patient unsurprisingly developed a pulmonary embolism (PE).

The man survived the PE, but Dr. Hecht and his colleagues began to wonder how many patients refuse VTE prophylaxis. So they investigated, and it turned out that from December 2010 to February 2011, 26.4% of the prescribed doses of prophylaxis on the medicine floors they studied were missed. Moreover, nearly 80% of all missed doses on the medicine floors were due to patient refusal.

“It was astonishing to me that it was that high,” Dr. Hecht says. “If there were 1,000 doses in a month, 260 of them were not being given—and 205 of them were not given because they were refused.”

Checklist Integration

So Dr. Hecht and colleagues set out to create a checklist that could be used daily on multidisciplinary rounds to help reduce the risk of VTE. First question on the list: Has prophylaxis been ordered, and if so, is the patient refusing it? Knowing that patients are “refusing” medication can lead to discussions about why that is happening, which in turn can lead to ways to convince the patient that the preventative measure is a good idea.

Dr. Hecht says the team also realized a checklist creates the opportunity to improve other quality metrics, such as hospital-associated infections (HAIs). Two questions on the checklist ask whether indwelling urinary catheters (IUCs) and central venous catheters (CVCs) can be removed. Two questions ask if telemetry can be stopped and whether there are any pain-management concerns. A final query asks whether there are any nursing, social work, or discharge-related questions—a step that, according to Dr. Hecht, loops the entire multidisciplinary team into the care-plan discussion.

“An ongoing challenge is making sure it’s not just questions being asked and being answered by rote,” Dr. Hecht says. “Just pause and think for just a second for each question. You can get through the checklist in 10 seconds, but you can’t go through the checklist in two seconds.”

The project’s results are what made it a finalist. After the checklist intervention, the number of missed doses of VTE prophylaxis plummeted 59% to just 10.9% (P<0.001) from September to November 2012; the number of “patient refused” doses dropped to 6.3% (P<0.001).

Not only was Dr. Hecht caught off guard by his findings, but so were the judges who visited his poster—Mangla Gulati, MD, FHM, of the University of Maryland School of Medicine and Rachel George, MD, MBA, FHM, of Cogent HMG.

“I wonder if it’s like that in every hospital,” Dr. George says. “I’d like to know.”

The positive reaction and feedback to Dr. Hecht’s poster, however, was not enough to win the Innovations category. That honor went to “SEPTRIS: Improving Sepsis Recognition and Management Through a Mobile Educational Game,” which was developed by a team of researchers at Stanford University in Palo Alto, Calif. The video game

(http://med.stanford.edu/septris/)—a mashup of sepsis and the once-popular Tetris puzzle game—already has been played 17,000 times and is on its way to being shared in other languages.

“Win or lose, it doesn’t matter,” Dr. Hecht says. “The goal is to share your information with other people and learn from them.”

Peter Watson, MD, FACP, FHM, sees it the same way. That’s why this year he was both judge and judged. The division head of hospital medicine for Henry Ford Medical Group in Detroit was part of a group presenting “Feasibility and Efficacy of a Specialized Pilot Training Program to Enhance Inpatient Communication Skills of Hospitalists.” He was a judge for the Research portion of the contest. He says he’s hard-pressed to say which process he enjoyed more, but one trick of the poster trade he passes along is that “judging actually makes you a better presenter on the back end,” especially when it comes to describing in less than five minutes a poster whose work may date back 12 to 18 months.

“In your brain,” he says, “you have a Tolstoy novel of information, but you have to break that down into a paragraph of CliffsNotes, and actually convince the people that are judging you that you have a really cool project that either is going to have a big impact in the field or may lead to other big studies or is going to impress somebody so much that they’re going to go back to their institution and say, ‘Hey, I’m going to do that.’”

Dr. Watson also urges people not to be discouraged by not winning the poster contest. First, all of the accepted abstracts get published online (www.shmabstracts.com) by the Journal of Hospital Medicine, a high point for medical students, residents, and early-career physicians looking to make a mark. Second, presenting information of value to one’s peers is the definition of a specialty that prides itself on collaboration.

“To see a second-year medical student presenting all the way up to a very senior division chief and everything in between is a really good example for our profession,” he says. “That’s really the magic of this meeting.”

Richard Quinn is a freelance writer in New Jersey.

One of the busiest times of HM13—and, come to think of it, every recent annual meeting—is the poster session for the Research, Innovations, and Clinical Vignettes (RIV) competition. This year, more than 800 abstracts were submitted and reviewed, with nearly 600 being accepted for presentation at HM13. That meant thousands of hospitalists thumbtacking posters to rows and rows of portable bulletin boards in the Gaylord National Resort & Convention Center’s massive exhibit hall.

With all those posters and accompanying oral presentations, it’s impossible for RIV judges to chat with everybody, so they choose finalists based on the abstracts, then listen to quick-hit summaries before choosing a winner on site. And meeting attendees are just as strapped for time, so they do the best they can to see as many posters as they can, taking time to network with old connections and make new ones.

So with all the limitations on how many people will interact with your poster, the small chance of winning Best in Show, and the hundreds of work hours that go into a poster presentation, why do it?

“To share is what I think is really important,” says Todd Hecht, MD, FACP, SFHM, associate professor of clinical medicine at the Perelman School of Medicine at the University of Pennsylvania in Philadelphia. “If you don’t let other people know what you’re doing, they can’t bring it to their institutions, nor can you learn from others and bring their innovations to your own hospital.”

Dr. Hecht, director of the Anticoagulation Management Center and Anticoagulation Management Program at the Hospital of the University of Pennsylvania, takes the poster sessions very seriously. This year, he entered a poster in both the Innovations and Vignette categories. His Innovations poster, “Impact of a Multidisciplinary Safety Checklist on the Rate of Preventable Hospital Complications and Standardization of Care,” was a finalist.

That meant that, at the very least, he’d be able to explain to at least two judges what motivated his research team’s project. And what was the inspiration? A 90-year-old male patient with metastatic melanoma who, in the fall of 2011, refused to take medication for VTE prophylaxis, as lesions on his skin made the process rather painful. After refusing the doses for a bit, though, the high-risk patient unsurprisingly developed a pulmonary embolism (PE).

The man survived the PE, but Dr. Hecht and his colleagues began to wonder how many patients refuse VTE prophylaxis. So they investigated, and it turned out that from December 2010 to February 2011, 26.4% of the prescribed doses of prophylaxis on the medicine floors they studied were missed. Moreover, nearly 80% of all missed doses on the medicine floors were due to patient refusal.

“It was astonishing to me that it was that high,” Dr. Hecht says. “If there were 1,000 doses in a month, 260 of them were not being given—and 205 of them were not given because they were refused.”

Checklist Integration

So Dr. Hecht and colleagues set out to create a checklist that could be used daily on multidisciplinary rounds to help reduce the risk of VTE. First question on the list: Has prophylaxis been ordered, and if so, is the patient refusing it? Knowing that patients are “refusing” medication can lead to discussions about why that is happening, which in turn can lead to ways to convince the patient that the preventative measure is a good idea.

Dr. Hecht says the team also realized a checklist creates the opportunity to improve other quality metrics, such as hospital-associated infections (HAIs). Two questions on the checklist ask whether indwelling urinary catheters (IUCs) and central venous catheters (CVCs) can be removed. Two questions ask if telemetry can be stopped and whether there are any pain-management concerns. A final query asks whether there are any nursing, social work, or discharge-related questions—a step that, according to Dr. Hecht, loops the entire multidisciplinary team into the care-plan discussion.

“An ongoing challenge is making sure it’s not just questions being asked and being answered by rote,” Dr. Hecht says. “Just pause and think for just a second for each question. You can get through the checklist in 10 seconds, but you can’t go through the checklist in two seconds.”

The project’s results are what made it a finalist. After the checklist intervention, the number of missed doses of VTE prophylaxis plummeted 59% to just 10.9% (P<0.001) from September to November 2012; the number of “patient refused” doses dropped to 6.3% (P<0.001).

Not only was Dr. Hecht caught off guard by his findings, but so were the judges who visited his poster—Mangla Gulati, MD, FHM, of the University of Maryland School of Medicine and Rachel George, MD, MBA, FHM, of Cogent HMG.

“I wonder if it’s like that in every hospital,” Dr. George says. “I’d like to know.”

The positive reaction and feedback to Dr. Hecht’s poster, however, was not enough to win the Innovations category. That honor went to “SEPTRIS: Improving Sepsis Recognition and Management Through a Mobile Educational Game,” which was developed by a team of researchers at Stanford University in Palo Alto, Calif. The video game

(http://med.stanford.edu/septris/)—a mashup of sepsis and the once-popular Tetris puzzle game—already has been played 17,000 times and is on its way to being shared in other languages.

“Win or lose, it doesn’t matter,” Dr. Hecht says. “The goal is to share your information with other people and learn from them.”

Peter Watson, MD, FACP, FHM, sees it the same way. That’s why this year he was both judge and judged. The division head of hospital medicine for Henry Ford Medical Group in Detroit was part of a group presenting “Feasibility and Efficacy of a Specialized Pilot Training Program to Enhance Inpatient Communication Skills of Hospitalists.” He was a judge for the Research portion of the contest. He says he’s hard-pressed to say which process he enjoyed more, but one trick of the poster trade he passes along is that “judging actually makes you a better presenter on the back end,” especially when it comes to describing in less than five minutes a poster whose work may date back 12 to 18 months.

“In your brain,” he says, “you have a Tolstoy novel of information, but you have to break that down into a paragraph of CliffsNotes, and actually convince the people that are judging you that you have a really cool project that either is going to have a big impact in the field or may lead to other big studies or is going to impress somebody so much that they’re going to go back to their institution and say, ‘Hey, I’m going to do that.’”

Dr. Watson also urges people not to be discouraged by not winning the poster contest. First, all of the accepted abstracts get published online (www.shmabstracts.com) by the Journal of Hospital Medicine, a high point for medical students, residents, and early-career physicians looking to make a mark. Second, presenting information of value to one’s peers is the definition of a specialty that prides itself on collaboration.

“To see a second-year medical student presenting all the way up to a very senior division chief and everything in between is a really good example for our profession,” he says. “That’s really the magic of this meeting.”

Richard Quinn is a freelance writer in New Jersey.

One of the busiest times of HM13—and, come to think of it, every recent annual meeting—is the poster session for the Research, Innovations, and Clinical Vignettes (RIV) competition. This year, more than 800 abstracts were submitted and reviewed, with nearly 600 being accepted for presentation at HM13. That meant thousands of hospitalists thumbtacking posters to rows and rows of portable bulletin boards in the Gaylord National Resort & Convention Center’s massive exhibit hall.

With all those posters and accompanying oral presentations, it’s impossible for RIV judges to chat with everybody, so they choose finalists based on the abstracts, then listen to quick-hit summaries before choosing a winner on site. And meeting attendees are just as strapped for time, so they do the best they can to see as many posters as they can, taking time to network with old connections and make new ones.

So with all the limitations on how many people will interact with your poster, the small chance of winning Best in Show, and the hundreds of work hours that go into a poster presentation, why do it?

“To share is what I think is really important,” says Todd Hecht, MD, FACP, SFHM, associate professor of clinical medicine at the Perelman School of Medicine at the University of Pennsylvania in Philadelphia. “If you don’t let other people know what you’re doing, they can’t bring it to their institutions, nor can you learn from others and bring their innovations to your own hospital.”

Dr. Hecht, director of the Anticoagulation Management Center and Anticoagulation Management Program at the Hospital of the University of Pennsylvania, takes the poster sessions very seriously. This year, he entered a poster in both the Innovations and Vignette categories. His Innovations poster, “Impact of a Multidisciplinary Safety Checklist on the Rate of Preventable Hospital Complications and Standardization of Care,” was a finalist.

That meant that, at the very least, he’d be able to explain to at least two judges what motivated his research team’s project. And what was the inspiration? A 90-year-old male patient with metastatic melanoma who, in the fall of 2011, refused to take medication for VTE prophylaxis, as lesions on his skin made the process rather painful. After refusing the doses for a bit, though, the high-risk patient unsurprisingly developed a pulmonary embolism (PE).

The man survived the PE, but Dr. Hecht and his colleagues began to wonder how many patients refuse VTE prophylaxis. So they investigated, and it turned out that from December 2010 to February 2011, 26.4% of the prescribed doses of prophylaxis on the medicine floors they studied were missed. Moreover, nearly 80% of all missed doses on the medicine floors were due to patient refusal.

“It was astonishing to me that it was that high,” Dr. Hecht says. “If there were 1,000 doses in a month, 260 of them were not being given—and 205 of them were not given because they were refused.”

Checklist Integration

So Dr. Hecht and colleagues set out to create a checklist that could be used daily on multidisciplinary rounds to help reduce the risk of VTE. First question on the list: Has prophylaxis been ordered, and if so, is the patient refusing it? Knowing that patients are “refusing” medication can lead to discussions about why that is happening, which in turn can lead to ways to convince the patient that the preventative measure is a good idea.

Dr. Hecht says the team also realized a checklist creates the opportunity to improve other quality metrics, such as hospital-associated infections (HAIs). Two questions on the checklist ask whether indwelling urinary catheters (IUCs) and central venous catheters (CVCs) can be removed. Two questions ask if telemetry can be stopped and whether there are any pain-management concerns. A final query asks whether there are any nursing, social work, or discharge-related questions—a step that, according to Dr. Hecht, loops the entire multidisciplinary team into the care-plan discussion.

“An ongoing challenge is making sure it’s not just questions being asked and being answered by rote,” Dr. Hecht says. “Just pause and think for just a second for each question. You can get through the checklist in 10 seconds, but you can’t go through the checklist in two seconds.”

The project’s results are what made it a finalist. After the checklist intervention, the number of missed doses of VTE prophylaxis plummeted 59% to just 10.9% (P<0.001) from September to November 2012; the number of “patient refused” doses dropped to 6.3% (P<0.001).

Not only was Dr. Hecht caught off guard by his findings, but so were the judges who visited his poster—Mangla Gulati, MD, FHM, of the University of Maryland School of Medicine and Rachel George, MD, MBA, FHM, of Cogent HMG.

“I wonder if it’s like that in every hospital,” Dr. George says. “I’d like to know.”

The positive reaction and feedback to Dr. Hecht’s poster, however, was not enough to win the Innovations category. That honor went to “SEPTRIS: Improving Sepsis Recognition and Management Through a Mobile Educational Game,” which was developed by a team of researchers at Stanford University in Palo Alto, Calif. The video game

(http://med.stanford.edu/septris/)—a mashup of sepsis and the once-popular Tetris puzzle game—already has been played 17,000 times and is on its way to being shared in other languages.

“Win or lose, it doesn’t matter,” Dr. Hecht says. “The goal is to share your information with other people and learn from them.”

Peter Watson, MD, FACP, FHM, sees it the same way. That’s why this year he was both judge and judged. The division head of hospital medicine for Henry Ford Medical Group in Detroit was part of a group presenting “Feasibility and Efficacy of a Specialized Pilot Training Program to Enhance Inpatient Communication Skills of Hospitalists.” He was a judge for the Research portion of the contest. He says he’s hard-pressed to say which process he enjoyed more, but one trick of the poster trade he passes along is that “judging actually makes you a better presenter on the back end,” especially when it comes to describing in less than five minutes a poster whose work may date back 12 to 18 months.

“In your brain,” he says, “you have a Tolstoy novel of information, but you have to break that down into a paragraph of CliffsNotes, and actually convince the people that are judging you that you have a really cool project that either is going to have a big impact in the field or may lead to other big studies or is going to impress somebody so much that they’re going to go back to their institution and say, ‘Hey, I’m going to do that.’”

Dr. Watson also urges people not to be discouraged by not winning the poster contest. First, all of the accepted abstracts get published online (www.shmabstracts.com) by the Journal of Hospital Medicine, a high point for medical students, residents, and early-career physicians looking to make a mark. Second, presenting information of value to one’s peers is the definition of a specialty that prides itself on collaboration.

“To see a second-year medical student presenting all the way up to a very senior division chief and everything in between is a really good example for our profession,” he says. “That’s really the magic of this meeting.”

Richard Quinn is a freelance writer in New Jersey.

Like a grinning child at a carnival, Iqbal M. Binoj, MD, steps right up and gives it a try—except instead of tossing rings, he’s gripping an intraosseous infusion drill.

A tutor shows him how the device, which looks remarkably like a glue gun, inserts into the bones of the shoulder or knee and drills down until it hits the marrow. He is guided on using a steady speed to maintain the integrity of the cavity. He’s also taught about the maneuver’s low complication rates and ability to expedite workups.

“I’ve seen it used before, but I never did it,” says Dr. Binoj, a hospitalist with Cogent HMG at Genesis Medical Center in Davenport, Iowa.

Well, he never did it before a hands-on pre-course at HM13 that focused on improving hospitalists’ proficiency at such procedures as lumbar punctures and ultrasound-guided vascular access. Quality improvement (QI) is always a focus of SHM’s annual meeting, but sometimes the science of improving care is viewed from up on high.

Not everything needs to be a national imitative, an institution-wide project, or even a unit-based intervention. Sometimes, it’s as simple as teaching a room full of hospitalists how to use an intraosseous infusion drill, says Michelle Fox, RN, BSN, senior director of clinical affairs with Vidacare, which manufactures the drill used in the demonstration.

“Hospitalists have an increasing role in doing these procedures, not only in the environment they predominantly support but in other areas of the hospital,” Fox says, adding that “the primary goal of this course is to give them the opportunity to perfect those skills.”

Hospitalist Bradley Rosen, MD, MBA, FHM, medical of the inpatient specialty program at Cedars-Sinai in Los Angeles, says the point of hands-on demonstrations is to translate QI to the bedside. Take ultrasound devices, he says. In the past few years, the technology has become less expensive, better in resolution, more common, and more portable. Hospitalists must ensure hands-on training that keeps pace with that technology.

“We actually want people to get gloves on, hands on, learn where they may have challenges in terms of their own dexterity or workflow, which hand is dominant, and how to visualize on the ultrasound machine a three-dimensional structure in 2D,” he says. “We don’t want people watching from the sidelines. ... We try to get people in it and engaged.”

And once hospitalists master procedures or diagnostic maneuvers, they invariably are sought out by other physicians to pass that knowledge on to others, Dr. Rosen says.

“In so doing, we get involved in larger quality initiatives and systemwide changes that can go top-down,” he adds, “but from our perspective, it starts with the individual practitioner. And I think SHM has always advocated and preached the importance of the individual hospitalist doing the best possible job for your patient, and the group, and the institution.”

Shared Excellence

What’s best for individual institutions moving forward is what worries SHM immediate past president Shaun Frost, MD, SFHM. He fears CMS’ Value-Based Payment Modifier (VBPM) program could have the unintended consequence of spurring some hospitals to hang on to innovative ideas in order to keep a competitive business advantage.

In health care, where quality and affordability have long been viewed as valuable for nonmonetary reasons, “the medical profession willingly shares new information” to improve patient care, Dr. Frost said in his farewell speech. But he is concerned that commodification—imbuing monetary value into something that previously had none—could change that dynamic, a situation he says is “ethically not acceptable.”

“When somebody builds a better mousetrap, it should be freely shared so that all patients have the opportunity to benefit,” Dr. Frost said. “The pursuit of economic competitive advantage should not prevent us from collaborating and sharing new ideas that hopefully make the health system better.”

Kendall Rogers, MD, FACP, SFHM, chief of the division of hospital medicine at the University of New Mexico Health Sciences Center in Albuquerque, N.M., says part of that improvement in quality and patient safety will come via hospitalists pushing for improvements to health information technology (HIT), particularly to maximize computerized physician order entry (CPOE) and order sets. He empathizes with those who complain about the operability of existing systems but urges physicians to stop complaining and take action.

“We need to stop accepting what our existing limitations are, and we need to be the innovators,” he says. “Many of us aren’t even thinking about, ‘What are the products we need?’ We’re just reacting to the products we currently have and stating how they don’t meet our needs.”

He suggests people communally report safety or troubleshooting issues, in part via Hospital Medicine Exchange (HMX), an online community SHM launched last year to discuss HM issues (www.hmxchange.org). He also wants hospitalists to push HIT vendors to provide improved functionality, and for institutions to provide necessary training.

“We just need to be vocal,” says Dr. Rogers, chair of SHM’s IT Executive Committee. “I do believe this is all leading us to a good place, but there’s a dip down before we have a swing up.”

Frustration Surge

In the long run, hospitalist Anuj Mehta, MD, medical director of the adult hospitalist program at Nyack Hospital in New York, agrees with Dr. Rogers. But as a provider seeing patients day after day, he says it’s often easier to not engage HIT than it is to slog through it.

“We try to work around the system, and sometimes it’s a much longer workaround,” he says. “So what happens is loss of productivity, greater length of stay, poor patient satisfaction, more screen time, and less bedside time.”

Dr. Mehta says frustration is building as society—outside of medicine—moves rapidly through such technology as smartphones, tablets, and other intuitive devices that make actions easier. He notes that his toddler daughter could learn how to navigate an iPad in a fraction of the time it takes him to complete an HIT training course.

“You cannot have physicians going through learning for four hours, learning a system to do step one before step two before step three,” he laments. “It should flow naturally. I don’t think the IT people have realized that as of yet.”

Richard Quinn is a freelance writer in New Jersey.

Like a grinning child at a carnival, Iqbal M. Binoj, MD, steps right up and gives it a try—except instead of tossing rings, he’s gripping an intraosseous infusion drill.

A tutor shows him how the device, which looks remarkably like a glue gun, inserts into the bones of the shoulder or knee and drills down until it hits the marrow. He is guided on using a steady speed to maintain the integrity of the cavity. He’s also taught about the maneuver’s low complication rates and ability to expedite workups.

“I’ve seen it used before, but I never did it,” says Dr. Binoj, a hospitalist with Cogent HMG at Genesis Medical Center in Davenport, Iowa.

Well, he never did it before a hands-on pre-course at HM13 that focused on improving hospitalists’ proficiency at such procedures as lumbar punctures and ultrasound-guided vascular access. Quality improvement (QI) is always a focus of SHM’s annual meeting, but sometimes the science of improving care is viewed from up on high.

Not everything needs to be a national imitative, an institution-wide project, or even a unit-based intervention. Sometimes, it’s as simple as teaching a room full of hospitalists how to use an intraosseous infusion drill, says Michelle Fox, RN, BSN, senior director of clinical affairs with Vidacare, which manufactures the drill used in the demonstration.

“Hospitalists have an increasing role in doing these procedures, not only in the environment they predominantly support but in other areas of the hospital,” Fox says, adding that “the primary goal of this course is to give them the opportunity to perfect those skills.”

Hospitalist Bradley Rosen, MD, MBA, FHM, medical of the inpatient specialty program at Cedars-Sinai in Los Angeles, says the point of hands-on demonstrations is to translate QI to the bedside. Take ultrasound devices, he says. In the past few years, the technology has become less expensive, better in resolution, more common, and more portable. Hospitalists must ensure hands-on training that keeps pace with that technology.

“We actually want people to get gloves on, hands on, learn where they may have challenges in terms of their own dexterity or workflow, which hand is dominant, and how to visualize on the ultrasound machine a three-dimensional structure in 2D,” he says. “We don’t want people watching from the sidelines. ... We try to get people in it and engaged.”

And once hospitalists master procedures or diagnostic maneuvers, they invariably are sought out by other physicians to pass that knowledge on to others, Dr. Rosen says.

“In so doing, we get involved in larger quality initiatives and systemwide changes that can go top-down,” he adds, “but from our perspective, it starts with the individual practitioner. And I think SHM has always advocated and preached the importance of the individual hospitalist doing the best possible job for your patient, and the group, and the institution.”

Shared Excellence

What’s best for individual institutions moving forward is what worries SHM immediate past president Shaun Frost, MD, SFHM. He fears CMS’ Value-Based Payment Modifier (VBPM) program could have the unintended consequence of spurring some hospitals to hang on to innovative ideas in order to keep a competitive business advantage.

In health care, where quality and affordability have long been viewed as valuable for nonmonetary reasons, “the medical profession willingly shares new information” to improve patient care, Dr. Frost said in his farewell speech. But he is concerned that commodification—imbuing monetary value into something that previously had none—could change that dynamic, a situation he says is “ethically not acceptable.”

“When somebody builds a better mousetrap, it should be freely shared so that all patients have the opportunity to benefit,” Dr. Frost said. “The pursuit of economic competitive advantage should not prevent us from collaborating and sharing new ideas that hopefully make the health system better.”

Kendall Rogers, MD, FACP, SFHM, chief of the division of hospital medicine at the University of New Mexico Health Sciences Center in Albuquerque, N.M., says part of that improvement in quality and patient safety will come via hospitalists pushing for improvements to health information technology (HIT), particularly to maximize computerized physician order entry (CPOE) and order sets. He empathizes with those who complain about the operability of existing systems but urges physicians to stop complaining and take action.

“We need to stop accepting what our existing limitations are, and we need to be the innovators,” he says. “Many of us aren’t even thinking about, ‘What are the products we need?’ We’re just reacting to the products we currently have and stating how they don’t meet our needs.”

He suggests people communally report safety or troubleshooting issues, in part via Hospital Medicine Exchange (HMX), an online community SHM launched last year to discuss HM issues (www.hmxchange.org). He also wants hospitalists to push HIT vendors to provide improved functionality, and for institutions to provide necessary training.

“We just need to be vocal,” says Dr. Rogers, chair of SHM’s IT Executive Committee. “I do believe this is all leading us to a good place, but there’s a dip down before we have a swing up.”

Frustration Surge

In the long run, hospitalist Anuj Mehta, MD, medical director of the adult hospitalist program at Nyack Hospital in New York, agrees with Dr. Rogers. But as a provider seeing patients day after day, he says it’s often easier to not engage HIT than it is to slog through it.

“We try to work around the system, and sometimes it’s a much longer workaround,” he says. “So what happens is loss of productivity, greater length of stay, poor patient satisfaction, more screen time, and less bedside time.”

Dr. Mehta says frustration is building as society—outside of medicine—moves rapidly through such technology as smartphones, tablets, and other intuitive devices that make actions easier. He notes that his toddler daughter could learn how to navigate an iPad in a fraction of the time it takes him to complete an HIT training course.

“You cannot have physicians going through learning for four hours, learning a system to do step one before step two before step three,” he laments. “It should flow naturally. I don’t think the IT people have realized that as of yet.”

Richard Quinn is a freelance writer in New Jersey.

Like a grinning child at a carnival, Iqbal M. Binoj, MD, steps right up and gives it a try—except instead of tossing rings, he’s gripping an intraosseous infusion drill.

A tutor shows him how the device, which looks remarkably like a glue gun, inserts into the bones of the shoulder or knee and drills down until it hits the marrow. He is guided on using a steady speed to maintain the integrity of the cavity. He’s also taught about the maneuver’s low complication rates and ability to expedite workups.

“I’ve seen it used before, but I never did it,” says Dr. Binoj, a hospitalist with Cogent HMG at Genesis Medical Center in Davenport, Iowa.

Well, he never did it before a hands-on pre-course at HM13 that focused on improving hospitalists’ proficiency at such procedures as lumbar punctures and ultrasound-guided vascular access. Quality improvement (QI) is always a focus of SHM’s annual meeting, but sometimes the science of improving care is viewed from up on high.

Not everything needs to be a national imitative, an institution-wide project, or even a unit-based intervention. Sometimes, it’s as simple as teaching a room full of hospitalists how to use an intraosseous infusion drill, says Michelle Fox, RN, BSN, senior director of clinical affairs with Vidacare, which manufactures the drill used in the demonstration.

“Hospitalists have an increasing role in doing these procedures, not only in the environment they predominantly support but in other areas of the hospital,” Fox says, adding that “the primary goal of this course is to give them the opportunity to perfect those skills.”

Hospitalist Bradley Rosen, MD, MBA, FHM, medical of the inpatient specialty program at Cedars-Sinai in Los Angeles, says the point of hands-on demonstrations is to translate QI to the bedside. Take ultrasound devices, he says. In the past few years, the technology has become less expensive, better in resolution, more common, and more portable. Hospitalists must ensure hands-on training that keeps pace with that technology.

“We actually want people to get gloves on, hands on, learn where they may have challenges in terms of their own dexterity or workflow, which hand is dominant, and how to visualize on the ultrasound machine a three-dimensional structure in 2D,” he says. “We don’t want people watching from the sidelines. ... We try to get people in it and engaged.”

And once hospitalists master procedures or diagnostic maneuvers, they invariably are sought out by other physicians to pass that knowledge on to others, Dr. Rosen says.

“In so doing, we get involved in larger quality initiatives and systemwide changes that can go top-down,” he adds, “but from our perspective, it starts with the individual practitioner. And I think SHM has always advocated and preached the importance of the individual hospitalist doing the best possible job for your patient, and the group, and the institution.”

Shared Excellence

What’s best for individual institutions moving forward is what worries SHM immediate past president Shaun Frost, MD, SFHM. He fears CMS’ Value-Based Payment Modifier (VBPM) program could have the unintended consequence of spurring some hospitals to hang on to innovative ideas in order to keep a competitive business advantage.

In health care, where quality and affordability have long been viewed as valuable for nonmonetary reasons, “the medical profession willingly shares new information” to improve patient care, Dr. Frost said in his farewell speech. But he is concerned that commodification—imbuing monetary value into something that previously had none—could change that dynamic, a situation he says is “ethically not acceptable.”

“When somebody builds a better mousetrap, it should be freely shared so that all patients have the opportunity to benefit,” Dr. Frost said. “The pursuit of economic competitive advantage should not prevent us from collaborating and sharing new ideas that hopefully make the health system better.”

Kendall Rogers, MD, FACP, SFHM, chief of the division of hospital medicine at the University of New Mexico Health Sciences Center in Albuquerque, N.M., says part of that improvement in quality and patient safety will come via hospitalists pushing for improvements to health information technology (HIT), particularly to maximize computerized physician order entry (CPOE) and order sets. He empathizes with those who complain about the operability of existing systems but urges physicians to stop complaining and take action.

“We need to stop accepting what our existing limitations are, and we need to be the innovators,” he says. “Many of us aren’t even thinking about, ‘What are the products we need?’ We’re just reacting to the products we currently have and stating how they don’t meet our needs.”

He suggests people communally report safety or troubleshooting issues, in part via Hospital Medicine Exchange (HMX), an online community SHM launched last year to discuss HM issues (www.hmxchange.org). He also wants hospitalists to push HIT vendors to provide improved functionality, and for institutions to provide necessary training.

“We just need to be vocal,” says Dr. Rogers, chair of SHM’s IT Executive Committee. “I do believe this is all leading us to a good place, but there’s a dip down before we have a swing up.”

Frustration Surge

In the long run, hospitalist Anuj Mehta, MD, medical director of the adult hospitalist program at Nyack Hospital in New York, agrees with Dr. Rogers. But as a provider seeing patients day after day, he says it’s often easier to not engage HIT than it is to slog through it.

“We try to work around the system, and sometimes it’s a much longer workaround,” he says. “So what happens is loss of productivity, greater length of stay, poor patient satisfaction, more screen time, and less bedside time.”

Dr. Mehta says frustration is building as society—outside of medicine—moves rapidly through such technology as smartphones, tablets, and other intuitive devices that make actions easier. He notes that his toddler daughter could learn how to navigate an iPad in a fraction of the time it takes him to complete an HIT training course.

“You cannot have physicians going through learning for four hours, learning a system to do step one before step two before step three,” he laments. “It should flow naturally. I don’t think the IT people have realized that as of yet.”

Richard Quinn is a freelance writer in New Jersey.

Dear Mark,

I am pleased and excited that you are willing to abandon your plan for being a vagabond and will give serious consideration to joining the faculty of the Department of Pediatrics to become a core member of a new [general pediatric inpatient] program that I believe has exciting potential.

So reads the first line of my very first job offer letter. Obviously, my chairman had a sense of humor. But he also was not off target, as before May 21 of my third year of residency, I had no meaningful work lined up. Dreams of locum tenens work in Hawaii or a California coastal town quickly disappeared as I received only offers for work in small-town Mississippi and Oklahoma. Eleven years later, I don’t think I could have planned a more fulfilling early career, particularly when the alternative might have been surfing on the Mississippi River.

I would like this opportunity, in my final column as The Hospitalist’s pediatric editor, to reflect on this odyssey from vagabond to hospitalist.

The Early Years

As a new attending, I was appropriately terrified of how much I didn’t know. I also had ambitious goals at first, wanting to emulate my two favorite role models from residency, Charles Ginsburg and Heinz Eichenwald. We might call them hospitalists now, but back then they were old-fashioned, generalist inpatient clinician-educators, even while chairing the department of pediatrics over their separate tenures. They were the smartest and wisest teachers that I have ever met. These early years were a pseudo-fellowship of sorts; under their tutelage, I soaked up more than I ever had during residency.

Despite all of this learning, I remained sheltered in my clinician-educator bubble. The path to excellence for me was defined through frequent trips to the library (where journals used to be stored) and trying to teach as well as my mentors did. I largely was ignorant of the national hospitalist movement, until the 2007 SHM annual meeting was held in my backyard in Dallas. Listening to Bob Wachter that year, and then Don Berwick the following year, I suddenly realized the tremendous and intertwined importance of the quality movement and hospitalists. We were going to fix medicine. OK, maybe not all of medicine, but it happened to be the perfect time for me to learn about our health-care crisis, quality, and the role of hospital medicine.

If my first five years were about clinical medicine, the next five years were all about lessons in leadership. I had a new role, directing 8 15 20 25 hospitalists—and now was accountable for the group’s results. I’ve often said that an explicit leadership role is like stepping behind a curtain, where your own previous n=1 perspective is now the challenge of herding a group of n=25. And let’s be clear that it’s one thing to manage the group and keep the ship afloat, but it’s entirely another thing to lead the group toward success.

A Path for Me

Although the cacophony of managing that many voices was deafening early on, I found solace in the lessons of quality improvement (QI), where no project lives without a team that is all going the same direction. Between the national opportunities for collaborative improvement and the day-to-day experiences within my group, I found two simple principles worked well: 1) engage the team and 2) deliver objective results.

And just as I had craved a clinical learning environment early on, I now found myself learning from local and national peers putting their leadership skills in action to produce quality outcomes. The beauty of collaborative teamwork is that it creates self-sustaining capacity for more positive results.

Looking forward, the opportunities seem limitless for pediatric hospital medicine. From the inherent fulfillment of our day-to-day bedside work to the explicit leadership that we offer the complex hospital system, our family of pediatric hospitalists has blazed career paths in all directions. We are program directors. We are directors of quality and safety. We are division directors and section chiefs. We are professors. We are fellowship-trained. We are CEOs, of entire hospitals and the CMO of CMS. There has never been a better time to be a pediatric hospitalist.

This rapid ascent has to be the fastest in the history of medicine and might surprise the unsuspecting, but these career paths really should have been expected. Residents and students still identify the most with their ward months—we always will be leaders in education. Hospitals and health-care systems recognize the value of hospitalists as systems improvers and will forever need enlightened physicians to guide safer, better care. But we also remain generalists, perched over the exact intersection of acute illness and health. From this vantage point, we have the perfect perspective from which to lead the transformation of our health-care system. I’m not sure there is a leadership position in health care that a hospitalist will not fill in the near future.

A New Frontier

With all of this opportunity before us, there exists an imperative for true leadership. And unlike all of our past requirements for achievement, relying on our quantitative abilities will no longer be enough. Rather, we will need to focus on the qualitative “soft” skills, whether you call this emotional intelligence, interpersonal communication, or behavioral economics. The creation of value-based, care-delivery systems requires high-functioning units. We will need to design and lead teams from the bedside to the boardroom.

In the coming years, this leadership imperative will only intensify, as we all will be pressured to do more with less. We will be asked to improve quality and decrease costs. We will need to broaden our focus to health in addition to acute illness. Doing more with less will require courage and leadership. If you look at our growth curve to date, we have an abundance of both.

Dr. Shen is medical director of hospital medicine at Dell Children's Medical Center in Austin, Texas. He served as The Hospitalist's pediatric editor since 2010 and this marks his last column in his role as editor. In his newfound spare time, he looks forward to defining value in health care.

Dear Mark,

I am pleased and excited that you are willing to abandon your plan for being a vagabond and will give serious consideration to joining the faculty of the Department of Pediatrics to become a core member of a new [general pediatric inpatient] program that I believe has exciting potential.

So reads the first line of my very first job offer letter. Obviously, my chairman had a sense of humor. But he also was not off target, as before May 21 of my third year of residency, I had no meaningful work lined up. Dreams of locum tenens work in Hawaii or a California coastal town quickly disappeared as I received only offers for work in small-town Mississippi and Oklahoma. Eleven years later, I don’t think I could have planned a more fulfilling early career, particularly when the alternative might have been surfing on the Mississippi River.

I would like this opportunity, in my final column as The Hospitalist’s pediatric editor, to reflect on this odyssey from vagabond to hospitalist.

The Early Years

As a new attending, I was appropriately terrified of how much I didn’t know. I also had ambitious goals at first, wanting to emulate my two favorite role models from residency, Charles Ginsburg and Heinz Eichenwald. We might call them hospitalists now, but back then they were old-fashioned, generalist inpatient clinician-educators, even while chairing the department of pediatrics over their separate tenures. They were the smartest and wisest teachers that I have ever met. These early years were a pseudo-fellowship of sorts; under their tutelage, I soaked up more than I ever had during residency.

Despite all of this learning, I remained sheltered in my clinician-educator bubble. The path to excellence for me was defined through frequent trips to the library (where journals used to be stored) and trying to teach as well as my mentors did. I largely was ignorant of the national hospitalist movement, until the 2007 SHM annual meeting was held in my backyard in Dallas. Listening to Bob Wachter that year, and then Don Berwick the following year, I suddenly realized the tremendous and intertwined importance of the quality movement and hospitalists. We were going to fix medicine. OK, maybe not all of medicine, but it happened to be the perfect time for me to learn about our health-care crisis, quality, and the role of hospital medicine.

If my first five years were about clinical medicine, the next five years were all about lessons in leadership. I had a new role, directing 8 15 20 25 hospitalists—and now was accountable for the group’s results. I’ve often said that an explicit leadership role is like stepping behind a curtain, where your own previous n=1 perspective is now the challenge of herding a group of n=25. And let’s be clear that it’s one thing to manage the group and keep the ship afloat, but it’s entirely another thing to lead the group toward success.

A Path for Me

Although the cacophony of managing that many voices was deafening early on, I found solace in the lessons of quality improvement (QI), where no project lives without a team that is all going the same direction. Between the national opportunities for collaborative improvement and the day-to-day experiences within my group, I found two simple principles worked well: 1) engage the team and 2) deliver objective results.

And just as I had craved a clinical learning environment early on, I now found myself learning from local and national peers putting their leadership skills in action to produce quality outcomes. The beauty of collaborative teamwork is that it creates self-sustaining capacity for more positive results.

Looking forward, the opportunities seem limitless for pediatric hospital medicine. From the inherent fulfillment of our day-to-day bedside work to the explicit leadership that we offer the complex hospital system, our family of pediatric hospitalists has blazed career paths in all directions. We are program directors. We are directors of quality and safety. We are division directors and section chiefs. We are professors. We are fellowship-trained. We are CEOs, of entire hospitals and the CMO of CMS. There has never been a better time to be a pediatric hospitalist.

This rapid ascent has to be the fastest in the history of medicine and might surprise the unsuspecting, but these career paths really should have been expected. Residents and students still identify the most with their ward months—we always will be leaders in education. Hospitals and health-care systems recognize the value of hospitalists as systems improvers and will forever need enlightened physicians to guide safer, better care. But we also remain generalists, perched over the exact intersection of acute illness and health. From this vantage point, we have the perfect perspective from which to lead the transformation of our health-care system. I’m not sure there is a leadership position in health care that a hospitalist will not fill in the near future.

A New Frontier

With all of this opportunity before us, there exists an imperative for true leadership. And unlike all of our past requirements for achievement, relying on our quantitative abilities will no longer be enough. Rather, we will need to focus on the qualitative “soft” skills, whether you call this emotional intelligence, interpersonal communication, or behavioral economics. The creation of value-based, care-delivery systems requires high-functioning units. We will need to design and lead teams from the bedside to the boardroom.

In the coming years, this leadership imperative will only intensify, as we all will be pressured to do more with less. We will be asked to improve quality and decrease costs. We will need to broaden our focus to health in addition to acute illness. Doing more with less will require courage and leadership. If you look at our growth curve to date, we have an abundance of both.

Dr. Shen is medical director of hospital medicine at Dell Children's Medical Center in Austin, Texas. He served as The Hospitalist's pediatric editor since 2010 and this marks his last column in his role as editor. In his newfound spare time, he looks forward to defining value in health care.

Dear Mark,

I am pleased and excited that you are willing to abandon your plan for being a vagabond and will give serious consideration to joining the faculty of the Department of Pediatrics to become a core member of a new [general pediatric inpatient] program that I believe has exciting potential.

So reads the first line of my very first job offer letter. Obviously, my chairman had a sense of humor. But he also was not off target, as before May 21 of my third year of residency, I had no meaningful work lined up. Dreams of locum tenens work in Hawaii or a California coastal town quickly disappeared as I received only offers for work in small-town Mississippi and Oklahoma. Eleven years later, I don’t think I could have planned a more fulfilling early career, particularly when the alternative might have been surfing on the Mississippi River.

I would like this opportunity, in my final column as The Hospitalist’s pediatric editor, to reflect on this odyssey from vagabond to hospitalist.

The Early Years

As a new attending, I was appropriately terrified of how much I didn’t know. I also had ambitious goals at first, wanting to emulate my two favorite role models from residency, Charles Ginsburg and Heinz Eichenwald. We might call them hospitalists now, but back then they were old-fashioned, generalist inpatient clinician-educators, even while chairing the department of pediatrics over their separate tenures. They were the smartest and wisest teachers that I have ever met. These early years were a pseudo-fellowship of sorts; under their tutelage, I soaked up more than I ever had during residency.

Despite all of this learning, I remained sheltered in my clinician-educator bubble. The path to excellence for me was defined through frequent trips to the library (where journals used to be stored) and trying to teach as well as my mentors did. I largely was ignorant of the national hospitalist movement, until the 2007 SHM annual meeting was held in my backyard in Dallas. Listening to Bob Wachter that year, and then Don Berwick the following year, I suddenly realized the tremendous and intertwined importance of the quality movement and hospitalists. We were going to fix medicine. OK, maybe not all of medicine, but it happened to be the perfect time for me to learn about our health-care crisis, quality, and the role of hospital medicine.

If my first five years were about clinical medicine, the next five years were all about lessons in leadership. I had a new role, directing 8 15 20 25 hospitalists—and now was accountable for the group’s results. I’ve often said that an explicit leadership role is like stepping behind a curtain, where your own previous n=1 perspective is now the challenge of herding a group of n=25. And let’s be clear that it’s one thing to manage the group and keep the ship afloat, but it’s entirely another thing to lead the group toward success.

A Path for Me

Although the cacophony of managing that many voices was deafening early on, I found solace in the lessons of quality improvement (QI), where no project lives without a team that is all going the same direction. Between the national opportunities for collaborative improvement and the day-to-day experiences within my group, I found two simple principles worked well: 1) engage the team and 2) deliver objective results.

And just as I had craved a clinical learning environment early on, I now found myself learning from local and national peers putting their leadership skills in action to produce quality outcomes. The beauty of collaborative teamwork is that it creates self-sustaining capacity for more positive results.

Looking forward, the opportunities seem limitless for pediatric hospital medicine. From the inherent fulfillment of our day-to-day bedside work to the explicit leadership that we offer the complex hospital system, our family of pediatric hospitalists has blazed career paths in all directions. We are program directors. We are directors of quality and safety. We are division directors and section chiefs. We are professors. We are fellowship-trained. We are CEOs, of entire hospitals and the CMO of CMS. There has never been a better time to be a pediatric hospitalist.

This rapid ascent has to be the fastest in the history of medicine and might surprise the unsuspecting, but these career paths really should have been expected. Residents and students still identify the most with their ward months—we always will be leaders in education. Hospitals and health-care systems recognize the value of hospitalists as systems improvers and will forever need enlightened physicians to guide safer, better care. But we also remain generalists, perched over the exact intersection of acute illness and health. From this vantage point, we have the perfect perspective from which to lead the transformation of our health-care system. I’m not sure there is a leadership position in health care that a hospitalist will not fill in the near future.

A New Frontier

With all of this opportunity before us, there exists an imperative for true leadership. And unlike all of our past requirements for achievement, relying on our quantitative abilities will no longer be enough. Rather, we will need to focus on the qualitative “soft” skills, whether you call this emotional intelligence, interpersonal communication, or behavioral economics. The creation of value-based, care-delivery systems requires high-functioning units. We will need to design and lead teams from the bedside to the boardroom.

In the coming years, this leadership imperative will only intensify, as we all will be pressured to do more with less. We will be asked to improve quality and decrease costs. We will need to broaden our focus to health in addition to acute illness. Doing more with less will require courage and leadership. If you look at our growth curve to date, we have an abundance of both.

Dr. Shen is medical director of hospital medicine at Dell Children's Medical Center in Austin, Texas. He served as The Hospitalist's pediatric editor since 2010 and this marks his last column in his role as editor. In his newfound spare time, he looks forward to defining value in health care.

To some HM13 attendees, the keynote speakers might have seemed to be talking about different things.

Patrick Conway, MD, MSc, FAAP, SFHM, chief medical officer and director of the Center for Clinical Standards and Quality at the Centers for Medicare & Medicaid Services (CMS), hinted at promising results from the first accountable-care organizations (ACOs) and noted a meaningful reduction in 30-day readmission rates for the first time in years.

David Feinberg, MD, MBA, president of UCLA Health System in Los Angeles, told hospitalists that unless they’re getting patient care right every time, they’re not getting it right enough. And nothing would make him happier than seeing fewer hospitalists at SHM’s annual meeting—because that would mean fewer hospitalized patients.

HM pioneer Bob Wachter, MD, MHM, said it’s time for hospitalists to link their quality-improvement (QI) efforts and safety acumen to projects focused on cutting costs and reducing waste in the health-care system.

So while each made their points in a different way, each plenary speaker left many meeting-goers with a similar thought: Hospitalists are positioned at the nexus of big-picture reform and day-to-day implementation. So if hospitalists as a specialty continue to embrace teamwork, evidence-based practice, quality, safety, and a sense that the patient comes first, they will cement themselves as leaders in the next iteration of health-care delivery.

“There is enormous change going on in the healthcare system,” says SHM CEO Larry Wellikson. “And we are right in the middle of this. We are essential. If we are bad, we are going to sink it. And if we’re great, we are going to take it to another level.”

Needle Movement

Dr. Conway said some of that progress already is evident. He disclosed that initial findings from the first data sets coming from the first ACOs are showing promising results, though he can’t go into detail until the information is publicly released. However, he did boast that after decades of Medicare readmission rates hovering around 19%, data from late 2012 and early 2013 show that figure has dropped to below 18%.

“That is a 1.5% to 2% shift in readmissions nationally,” he said. “It is a credit to the work you and others are doing in the field. That’s hundreds of thousands of Medicare beneficiaries that are not readmitted every year, that stay home healthy. … It’s a tremendous example of moving a national needle.”

He dismissed those who attribute the initial readmission progress solely to penalties instituted on readmissions, though he acknowledged that CMS is using both carrots and sticks to push change.

“It’s a combination of interventions,” he said.

And all of those initiatives must be aimed jointly at improving the patient experience, said Dr. Feinberg, a child psychiatrist by training whose mantra is “patient-centeredness.” Dr. Feinberg’s reputation is that of a physician-administrator who puts patients first. For example, even though his health system (www.uclahealth.org) is in the 99th percentile for patient satisfaction, he is unhappy. That’s because the top ranking means roughly 85 out of every 100 patients served are pretty happy with their experience.

“It means that we’re the cream of the crap,” he said. “Of the last 100 people we took care of, 15 of them—and, by definition, those 15 people are someone’s mom, someone’s brother, someone’s coworker—would not refer us to a friend, or rate us a 9 or 10. So, I think, while we’ve really moved the needle, we’re really not done until we get it right with every patient, every time.”

He added that those who argue against difficult or time-consuming innovations and improvements that better patient care are arguing against the moral high ground of how they would want a family member to be treated in the hospital.

“The pushback I hear is, ‘Some of this stuff is unpreventable,’” Dr. Feinberg said. “Well, maybe it’s unpreventable the way we’re doing it now. But maybe we need to think differently. Maybe it is unpreventable, but if this decreases the prevalence, or makes it better, then to me, it’s important to do.”

Dr. Feinberg, who took over as UCLA Health System’s president in 2011, says he still spends several hours every day talking to patients. For those who say there’s not enough time to stay connected to patients and that all the time spent making sure patients are happy takes away from other activities, he says they’re forgetting what brought them into medicine in the first place: healing. He blames the delivery system for stifling what he believes is a provider’s desire to help people.

“We haven’t allowed the culture to come out,” he said. “I think it’s there.”

Dr. Wachter has a similar faith in the hospitalist culture—although his is based in the pluripotent nature of the specialty. Hospitalists have worked hard to be viewed as “generalists, able to solve all kinds of problems,” and that means the specialty is poised to adapt and thrive.

“We will morph into what is needed,” said Dr. Wachter, a past president of SHM whose titles include chief of the division of hospital medicine at the University of California at San Francisco and chair of the American Board of Internal Medicine. “That will be all sorts of things: comanagement, dealing with the residency limits in teaching hospitals, systems improvement, cost reductions, transitions, working in skilled nursing facilities, all the specialty hospitalists.

“We will fill new niches,” he said.

What Dr. Wachter does not want to see is that the field grows “fat and happy,” as it is now firmly entrenched in the U.S. health-care delivery system. In fact, he urged hospitalists to welcome change, particularly initiatives that improve quality and safety, reduce costs and waste, and, ultimately, improve the patient experience.

But he cautioned against conceptually separating QI and cost reduction. Instead, they should be viewed as equally meaningful parts of his oft-quoted value equation, which, viewed from the health-care consumer’s point of view, is quality divided by cost.

“You can’t survive and thrive in a world with the kinds of pressures that we have to improve performance if you do business the same old way,” he added. “It’s no longer possible to achieve the things you need to achieve handling these as single projects. You need to transform the way you think about care.”

Richard Quinn is a freelance writer in New Jersey.

To some HM13 attendees, the keynote speakers might have seemed to be talking about different things.

Patrick Conway, MD, MSc, FAAP, SFHM, chief medical officer and director of the Center for Clinical Standards and Quality at the Centers for Medicare & Medicaid Services (CMS), hinted at promising results from the first accountable-care organizations (ACOs) and noted a meaningful reduction in 30-day readmission rates for the first time in years.

David Feinberg, MD, MBA, president of UCLA Health System in Los Angeles, told hospitalists that unless they’re getting patient care right every time, they’re not getting it right enough. And nothing would make him happier than seeing fewer hospitalists at SHM’s annual meeting—because that would mean fewer hospitalized patients.

HM pioneer Bob Wachter, MD, MHM, said it’s time for hospitalists to link their quality-improvement (QI) efforts and safety acumen to projects focused on cutting costs and reducing waste in the health-care system.

So while each made their points in a different way, each plenary speaker left many meeting-goers with a similar thought: Hospitalists are positioned at the nexus of big-picture reform and day-to-day implementation. So if hospitalists as a specialty continue to embrace teamwork, evidence-based practice, quality, safety, and a sense that the patient comes first, they will cement themselves as leaders in the next iteration of health-care delivery.

“There is enormous change going on in the healthcare system,” says SHM CEO Larry Wellikson. “And we are right in the middle of this. We are essential. If we are bad, we are going to sink it. And if we’re great, we are going to take it to another level.”

Needle Movement

Dr. Conway said some of that progress already is evident. He disclosed that initial findings from the first data sets coming from the first ACOs are showing promising results, though he can’t go into detail until the information is publicly released. However, he did boast that after decades of Medicare readmission rates hovering around 19%, data from late 2012 and early 2013 show that figure has dropped to below 18%.

“That is a 1.5% to 2% shift in readmissions nationally,” he said. “It is a credit to the work you and others are doing in the field. That’s hundreds of thousands of Medicare beneficiaries that are not readmitted every year, that stay home healthy. … It’s a tremendous example of moving a national needle.”

He dismissed those who attribute the initial readmission progress solely to penalties instituted on readmissions, though he acknowledged that CMS is using both carrots and sticks to push change.

“It’s a combination of interventions,” he said.

And all of those initiatives must be aimed jointly at improving the patient experience, said Dr. Feinberg, a child psychiatrist by training whose mantra is “patient-centeredness.” Dr. Feinberg’s reputation is that of a physician-administrator who puts patients first. For example, even though his health system (www.uclahealth.org) is in the 99th percentile for patient satisfaction, he is unhappy. That’s because the top ranking means roughly 85 out of every 100 patients served are pretty happy with their experience.

“It means that we’re the cream of the crap,” he said. “Of the last 100 people we took care of, 15 of them—and, by definition, those 15 people are someone’s mom, someone’s brother, someone’s coworker—would not refer us to a friend, or rate us a 9 or 10. So, I think, while we’ve really moved the needle, we’re really not done until we get it right with every patient, every time.”

He added that those who argue against difficult or time-consuming innovations and improvements that better patient care are arguing against the moral high ground of how they would want a family member to be treated in the hospital.

“The pushback I hear is, ‘Some of this stuff is unpreventable,’” Dr. Feinberg said. “Well, maybe it’s unpreventable the way we’re doing it now. But maybe we need to think differently. Maybe it is unpreventable, but if this decreases the prevalence, or makes it better, then to me, it’s important to do.”

Dr. Feinberg, who took over as UCLA Health System’s president in 2011, says he still spends several hours every day talking to patients. For those who say there’s not enough time to stay connected to patients and that all the time spent making sure patients are happy takes away from other activities, he says they’re forgetting what brought them into medicine in the first place: healing. He blames the delivery system for stifling what he believes is a provider’s desire to help people.

“We haven’t allowed the culture to come out,” he said. “I think it’s there.”

Dr. Wachter has a similar faith in the hospitalist culture—although his is based in the pluripotent nature of the specialty. Hospitalists have worked hard to be viewed as “generalists, able to solve all kinds of problems,” and that means the specialty is poised to adapt and thrive.

“We will morph into what is needed,” said Dr. Wachter, a past president of SHM whose titles include chief of the division of hospital medicine at the University of California at San Francisco and chair of the American Board of Internal Medicine. “That will be all sorts of things: comanagement, dealing with the residency limits in teaching hospitals, systems improvement, cost reductions, transitions, working in skilled nursing facilities, all the specialty hospitalists.

“We will fill new niches,” he said.

What Dr. Wachter does not want to see is that the field grows “fat and happy,” as it is now firmly entrenched in the U.S. health-care delivery system. In fact, he urged hospitalists to welcome change, particularly initiatives that improve quality and safety, reduce costs and waste, and, ultimately, improve the patient experience.

But he cautioned against conceptually separating QI and cost reduction. Instead, they should be viewed as equally meaningful parts of his oft-quoted value equation, which, viewed from the health-care consumer’s point of view, is quality divided by cost.

“You can’t survive and thrive in a world with the kinds of pressures that we have to improve performance if you do business the same old way,” he added. “It’s no longer possible to achieve the things you need to achieve handling these as single projects. You need to transform the way you think about care.”

Richard Quinn is a freelance writer in New Jersey.

To some HM13 attendees, the keynote speakers might have seemed to be talking about different things.

Patrick Conway, MD, MSc, FAAP, SFHM, chief medical officer and director of the Center for Clinical Standards and Quality at the Centers for Medicare & Medicaid Services (CMS), hinted at promising results from the first accountable-care organizations (ACOs) and noted a meaningful reduction in 30-day readmission rates for the first time in years.

David Feinberg, MD, MBA, president of UCLA Health System in Los Angeles, told hospitalists that unless they’re getting patient care right every time, they’re not getting it right enough. And nothing would make him happier than seeing fewer hospitalists at SHM’s annual meeting—because that would mean fewer hospitalized patients.

HM pioneer Bob Wachter, MD, MHM, said it’s time for hospitalists to link their quality-improvement (QI) efforts and safety acumen to projects focused on cutting costs and reducing waste in the health-care system.

So while each made their points in a different way, each plenary speaker left many meeting-goers with a similar thought: Hospitalists are positioned at the nexus of big-picture reform and day-to-day implementation. So if hospitalists as a specialty continue to embrace teamwork, evidence-based practice, quality, safety, and a sense that the patient comes first, they will cement themselves as leaders in the next iteration of health-care delivery.

“There is enormous change going on in the healthcare system,” says SHM CEO Larry Wellikson. “And we are right in the middle of this. We are essential. If we are bad, we are going to sink it. And if we’re great, we are going to take it to another level.”

Needle Movement

Dr. Conway said some of that progress already is evident. He disclosed that initial findings from the first data sets coming from the first ACOs are showing promising results, though he can’t go into detail until the information is publicly released. However, he did boast that after decades of Medicare readmission rates hovering around 19%, data from late 2012 and early 2013 show that figure has dropped to below 18%.

“That is a 1.5% to 2% shift in readmissions nationally,” he said. “It is a credit to the work you and others are doing in the field. That’s hundreds of thousands of Medicare beneficiaries that are not readmitted every year, that stay home healthy. … It’s a tremendous example of moving a national needle.”

He dismissed those who attribute the initial readmission progress solely to penalties instituted on readmissions, though he acknowledged that CMS is using both carrots and sticks to push change.

“It’s a combination of interventions,” he said.

And all of those initiatives must be aimed jointly at improving the patient experience, said Dr. Feinberg, a child psychiatrist by training whose mantra is “patient-centeredness.” Dr. Feinberg’s reputation is that of a physician-administrator who puts patients first. For example, even though his health system (www.uclahealth.org) is in the 99th percentile for patient satisfaction, he is unhappy. That’s because the top ranking means roughly 85 out of every 100 patients served are pretty happy with their experience.

“It means that we’re the cream of the crap,” he said. “Of the last 100 people we took care of, 15 of them—and, by definition, those 15 people are someone’s mom, someone’s brother, someone’s coworker—would not refer us to a friend, or rate us a 9 or 10. So, I think, while we’ve really moved the needle, we’re really not done until we get it right with every patient, every time.”

He added that those who argue against difficult or time-consuming innovations and improvements that better patient care are arguing against the moral high ground of how they would want a family member to be treated in the hospital.

“The pushback I hear is, ‘Some of this stuff is unpreventable,’” Dr. Feinberg said. “Well, maybe it’s unpreventable the way we’re doing it now. But maybe we need to think differently. Maybe it is unpreventable, but if this decreases the prevalence, or makes it better, then to me, it’s important to do.”

Dr. Feinberg, who took over as UCLA Health System’s president in 2011, says he still spends several hours every day talking to patients. For those who say there’s not enough time to stay connected to patients and that all the time spent making sure patients are happy takes away from other activities, he says they’re forgetting what brought them into medicine in the first place: healing. He blames the delivery system for stifling what he believes is a provider’s desire to help people.

“We haven’t allowed the culture to come out,” he said. “I think it’s there.”

Dr. Wachter has a similar faith in the hospitalist culture—although his is based in the pluripotent nature of the specialty. Hospitalists have worked hard to be viewed as “generalists, able to solve all kinds of problems,” and that means the specialty is poised to adapt and thrive.

“We will morph into what is needed,” said Dr. Wachter, a past president of SHM whose titles include chief of the division of hospital medicine at the University of California at San Francisco and chair of the American Board of Internal Medicine. “That will be all sorts of things: comanagement, dealing with the residency limits in teaching hospitals, systems improvement, cost reductions, transitions, working in skilled nursing facilities, all the specialty hospitalists.

“We will fill new niches,” he said.

What Dr. Wachter does not want to see is that the field grows “fat and happy,” as it is now firmly entrenched in the U.S. health-care delivery system. In fact, he urged hospitalists to welcome change, particularly initiatives that improve quality and safety, reduce costs and waste, and, ultimately, improve the patient experience.

But he cautioned against conceptually separating QI and cost reduction. Instead, they should be viewed as equally meaningful parts of his oft-quoted value equation, which, viewed from the health-care consumer’s point of view, is quality divided by cost.

“You can’t survive and thrive in a world with the kinds of pressures that we have to improve performance if you do business the same old way,” he added. “It’s no longer possible to achieve the things you need to achieve handling these as single projects. You need to transform the way you think about care.”

Richard Quinn is a freelance writer in New Jersey.

Curriculums using Lean quality-improvement (QI) principles and techniques are becoming entrenched in medical teaching programs across the country.

A curriculum based on Lean QI is teaching medical residents at Boston Medical Center techniques based on successes in manufacturing and service industries, according to Charlene Weigel, MD, who now works as a hospitalist at Mount Auburn Hospital in Cambridge, Mass. Residents also are learning about implementation of Lean principles at the medical center, Dr. Weigel and co-authors report in a study published in the American Journal of Medical Quality.¹

“In Week One, we gave an introduction to QI and explained what Lean means,” Dr. Weigel says. Three other interactive sessions explored such techniques as how to create process maps and root-cause analysis, and identifying steps that aren’t helpful. The 90 residents and eight Boston University School of Public Health students also created 17 group QI project plans. “The goal was for the QI classwork and ideas to become implemented in hospital QI projects, but logistically, we had to scale back expectations for that initial go-round,” Dr. Weigel says.

The medical center recently started a second cycle of the QI course, with students from the first cycle encouraged to continue their QI projects on their own. One group submitted its project as an Institute for Healthcare Improvement storyboard at a national meeting.

“The experience also exposed the residents to our interprofessional team structure, which reflects their future working relationships and professional roles in QI,” Dr. Weigel says.

Lean concepts also are the basis for the Perfecting Patient Care University (PPCU, www.prhi.org/perfecting-patient-care/what-is-ppc), a QI training program for health-care leaders and clinicians offered in a variety of formats by the Pittsburgh Regional Health Initiative, a regional health collaborative. An evaluation of outcomes at PPCU was published online in the American Journal of Medical Quality in April.² The same journal also describes the curriculum, program evaluation, and lessons learned by SHM’s Quality and Safety Educators Academy (http://sites.hospitalmedicine.org/qsea), which provides training in QI and patient safety for teaching faculty.³ The academy, a 2.5-day course, is co-sponsored by the Alliance for Academic Internal Medicine.

Larry Beresford is a freelance writer in San Francisco

References

1. Weigel C, Suen W, Gupta G. Using Lean methodology to teach quality improvement to internal medicine residents at a safety net hospital. Am J Med Qual. 2013 Feb 4 [Epub ahead of print].
2. Morganti KG, Lovejoy S, Beckjord EB, Haviland AM, Haas AC, Farley DO. A retrospective evaluation of the Perfecting Patient Care University training program for health care organizations. Am J Med Qual. 2013 Apr 9 [Epub ahead of print].
3. Myers JS, Tess A, Glasheen JJ, et al. The Quality and Safety Educators’ Academy: fulfilling an unmet need for faculty development. Am J Med Qual.  2013 Apr 11 [Epub ahead of print].
4. Dong XQ, Simon MA. Elder abuse as a risk factor for hospitalization in older persons. JAMA Intern Med. 2013 Apr 8:1-7. doi: 10.1001/jamainternmed.2013.238 [Epub ahead of print].
5. Cisco mConcierge. 90% American workers use their own smartphones for work. Cisco mConcierge website. Available at: http://www.ciscomcon.com/sw/swchannel/registration/internet/registrationcfm?SWAPPID=91&RegPageID=350200&SWTHEMEID=12949. Accessed

Curriculums using Lean quality-improvement (QI) principles and techniques are becoming entrenched in medical teaching programs across the country.

A curriculum based on Lean QI is teaching medical residents at Boston Medical Center techniques based on successes in manufacturing and service industries, according to Charlene Weigel, MD, who now works as a hospitalist at Mount Auburn Hospital in Cambridge, Mass. Residents also are learning about implementation of Lean principles at the medical center, Dr. Weigel and co-authors report in a study published in the American Journal of Medical Quality.¹

“In Week One, we gave an introduction to QI and explained what Lean means,” Dr. Weigel says. Three other interactive sessions explored such techniques as how to create process maps and root-cause analysis, and identifying steps that aren’t helpful. The 90 residents and eight Boston University School of Public Health students also created 17 group QI project plans. “The goal was for the QI classwork and ideas to become implemented in hospital QI projects, but logistically, we had to scale back expectations for that initial go-round,” Dr. Weigel says.

The medical center recently started a second cycle of the QI course, with students from the first cycle encouraged to continue their QI projects on their own. One group submitted its project as an Institute for Healthcare Improvement storyboard at a national meeting.

“The experience also exposed the residents to our interprofessional team structure, which reflects their future working relationships and professional roles in QI,” Dr. Weigel says.

Lean concepts also are the basis for the Perfecting Patient Care University (PPCU, www.prhi.org/perfecting-patient-care/what-is-ppc), a QI training program for health-care leaders and clinicians offered in a variety of formats by the Pittsburgh Regional Health Initiative, a regional health collaborative. An evaluation of outcomes at PPCU was published online in the American Journal of Medical Quality in April.² The same journal also describes the curriculum, program evaluation, and lessons learned by SHM’s Quality and Safety Educators Academy (http://sites.hospitalmedicine.org/qsea), which provides training in QI and patient safety for teaching faculty.³ The academy, a 2.5-day course, is co-sponsored by the Alliance for Academic Internal Medicine.

Larry Beresford is a freelance writer in San Francisco

References

1. Weigel C, Suen W, Gupta G. Using Lean methodology to teach quality improvement to internal medicine residents at a safety net hospital. Am J Med Qual. 2013 Feb 4 [Epub ahead of print].
2. Morganti KG, Lovejoy S, Beckjord EB, Haviland AM, Haas AC, Farley DO. A retrospective evaluation of the Perfecting Patient Care University training program for health care organizations. Am J Med Qual. 2013 Apr 9 [Epub ahead of print].
3. Myers JS, Tess A, Glasheen JJ, et al. The Quality and Safety Educators’ Academy: fulfilling an unmet need for faculty development. Am J Med Qual.  2013 Apr 11 [Epub ahead of print].
4. Dong XQ, Simon MA. Elder abuse as a risk factor for hospitalization in older persons. JAMA Intern Med. 2013 Apr 8:1-7. doi: 10.1001/jamainternmed.2013.238 [Epub ahead of print].
5. Cisco mConcierge. 90% American workers use their own smartphones for work. Cisco mConcierge website. Available at: http://www.ciscomcon.com/sw/swchannel/registration/internet/registrationcfm?SWAPPID=91&RegPageID=350200&SWTHEMEID=12949. Accessed

Curriculums using Lean quality-improvement (QI) principles and techniques are becoming entrenched in medical teaching programs across the country.

A curriculum based on Lean QI is teaching medical residents at Boston Medical Center techniques based on successes in manufacturing and service industries, according to Charlene Weigel, MD, who now works as a hospitalist at Mount Auburn Hospital in Cambridge, Mass. Residents also are learning about implementation of Lean principles at the medical center, Dr. Weigel and co-authors report in a study published in the American Journal of Medical Quality.¹

“In Week One, we gave an introduction to QI and explained what Lean means,” Dr. Weigel says. Three other interactive sessions explored such techniques as how to create process maps and root-cause analysis, and identifying steps that aren’t helpful. The 90 residents and eight Boston University School of Public Health students also created 17 group QI project plans. “The goal was for the QI classwork and ideas to become implemented in hospital QI projects, but logistically, we had to scale back expectations for that initial go-round,” Dr. Weigel says.

The medical center recently started a second cycle of the QI course, with students from the first cycle encouraged to continue their QI projects on their own. One group submitted its project as an Institute for Healthcare Improvement storyboard at a national meeting.

“The experience also exposed the residents to our interprofessional team structure, which reflects their future working relationships and professional roles in QI,” Dr. Weigel says.

Lean concepts also are the basis for the Perfecting Patient Care University (PPCU, www.prhi.org/perfecting-patient-care/what-is-ppc), a QI training program for health-care leaders and clinicians offered in a variety of formats by the Pittsburgh Regional Health Initiative, a regional health collaborative. An evaluation of outcomes at PPCU was published online in the American Journal of Medical Quality in April.² The same journal also describes the curriculum, program evaluation, and lessons learned by SHM’s Quality and Safety Educators Academy (http://sites.hospitalmedicine.org/qsea), which provides training in QI and patient safety for teaching faculty.³ The academy, a 2.5-day course, is co-sponsored by the Alliance for Academic Internal Medicine.

Larry Beresford is a freelance writer in San Francisco

References

1. Weigel C, Suen W, Gupta G. Using Lean methodology to teach quality improvement to internal medicine residents at a safety net hospital. Am J Med Qual. 2013 Feb 4 [Epub ahead of print].
2. Morganti KG, Lovejoy S, Beckjord EB, Haviland AM, Haas AC, Farley DO. A retrospective evaluation of the Perfecting Patient Care University training program for health care organizations. Am J Med Qual. 2013 Apr 9 [Epub ahead of print].
3. Myers JS, Tess A, Glasheen JJ, et al. The Quality and Safety Educators’ Academy: fulfilling an unmet need for faculty development. Am J Med Qual.  2013 Apr 11 [Epub ahead of print].
4. Dong XQ, Simon MA. Elder abuse as a risk factor for hospitalization in older persons. JAMA Intern Med. 2013 Apr 8:1-7. doi: 10.1001/jamainternmed.2013.238 [Epub ahead of print].
5. Cisco mConcierge. 90% American workers use their own smartphones for work. Cisco mConcierge website. Available at: http://www.ciscomcon.com/sw/swchannel/registration/internet/registrationcfm?SWAPPID=91&RegPageID=350200&SWTHEMEID=12949. Accessed

A veritable perfect storm of relationships brought hospitalist Jairy Hunter, MD, MBA, SFHM, to “Hospitalists on the Hill 2013,” a daylong advocacy affair that preceded HM13 last month.

First, Dr. Hunter was born and bred—and now lives—in South Carolina, a close-knit state where leaders across industries tend to run in the same circles, or at least have relatives who do. Second, Dr. Hunter’s father, Jairy Hunter Jr., is the longtime president of Charleston Southern University, where Sen. Tim Scott (R-S.C.) earned his undergraduate degree when it was still called Baptist College at Charleston. And three, Dr. Hunter is associate executive medical director of one of the state’s flagship health-care institutions, Medical University of South Carolina in Charleston.

So it was that SHM set Dr. Hunter up in meetings with the offices of Scott, Sen. Lindsey Graham (R-S.C.), and Rep. Jim Clyburn (D-S.C.), and—for the day at least—made Dr. Hunter the voice of hospital medicine.

“It was a little bit demystifying of an experience to be able to know there’s actually people you can talk to and you can develop a relationship with,” says Dr. Hunter, who also serves on Team Hospitalist. “I thought that was very rewarding.”

The connections made by Dr. Hunter are the point of the annual trek made by SHM leaders and members to lobby legislators and federal staffers “on the way policies affect your practice and your patients,” SHM says on its website (www.hospitalmedicine.org/advocacy). This year’s volunteer effort was by far the largest ever, says Public Policy Committee chair Ron Greeno, MD, FCCP, MHM. More than 150 hospitalists participated in training, 113 hospitalists visited Capitol Hill, and scores more had to be turned away. All told, hospitalists held 409 individual meetings with legislators and staff members.

“Quite frankly, if we’d have had the budget, we could have had another 100 to 150 people come,” Dr. Greeno says. “That’s how many people wanted to go.”

Dr. Greeno attributes the interest to two factors. One, having the annual meeting at the Gaylord National Resort & Convention Center, just outside Washington, D.C, makes the Hill trip a natural extension. Two, the current landscape of health-care reform has motivated many physicians to become more involved than they might otherwise be. One challenge of having so many first-timers making this year’s trip was making sure they were properly prepared. To hone the message, SHM gave the group a few hours of education by former legislative staffer Stephanie Vance of Advocacy Associates, a communications firm that helps organizations, such as medical societies, tailor their message to policymakers. Vance told hospitalists a personal visit with a constituent often becomes the most influential type of advocacy.

“That’s why it was easy to make an initial connection, because these staffers are from where I’m from, friends with people that I’m friends with,” Dr. Hunter says.

Unique Approach

SHM CEO Larry Wellikson, MD, SFHM, says the society tries to differentiate itself from other organizations through its grassroots approach to advocacy. More important, the society refrains from giving a long list of legislative requests that are self-serving.

“We’re someone they want to talk to because we’re not coming there to just say, ‘Here’s a power play for hospitalists,’” Dr. Wellikson says. “We come and try to provide solutions.”

To that end, this year’s lobbying effort was targeted to topics important both to HM and the health-care system:

• Repealing the sustainable growth rate (SGR) formula for Medicare payments, specifically via the proposed Medicare Physician Payment Innovation Act of 2013 (H.R. 574);
• Solving the quagmire of observation status time not counting toward the required three consecutive overnights as an inpatient needed to qualify for Medicare benefits at a skilled nursing facility, by supporting the Improving Access to Medicare Coverage Act of 2013 (H.R. 1179, S. 569); and
• Getting the federal government to commit to providing $434 million in funding for the Agency for Healthcare Research and Quality (AHRQ) in fiscal 2014.

“The message that we’re sending resonated with the people we met with on both sides of the aisle,” Dr. Greeno says. “The SGR, for instance, they know there needs to be a fix. We want to serve as a resource for them as they start to figure out the answer to the question: What are we going to replace it with?

“What we want to do is make everybody on the Hill understand that we can be relied upon as a resource when they’re looking for solutions,” he says.

Focused on Follow-Up

And that’s where rank-and-filers, such as Dr. Hunter, have to take charge. So for his Hill Day visits, he tried to stand out. Everyone he met with got a lapel pin in the shape of a South Carolina state flag, which has become a popular fashion statement in recent years. And Scott also got a pin from Charleston Southern University, his alma mater. The gestures were small, but they served as icebreakers and reminders that Dr. Hunter and the people he met are bound by service to the residents of the Palmetto State.

Dr. Hunter also hopes the small token will be that little extra that makes him memorable enough that the next time a Congressional staffer has an SGR question, they’ll ask him and not a doctor from another specialty.

“I’m interested to see how much feedback I get back from them,” he says. “I can feed them all day long, but I don’t want to be that crazy guy bugging them. If they respond back to me, I can hopefully make more inroads.”

He certainly would if Dr. Greeno gets his way. Moving forward, SHM hopes to be able to rely more on local advocates pushing for reform than just a once-a-year major event and formal positions drafted by SHM’s staffers or the Public Policy Committee. Dr. Greeno says the physicians who participated in this year’s Hill trip are likely to find they will be asked to be the first cohort of a grassroots initiative meant to deliver the society’s message more routinely.

“These are not easy things to change because there are not easy solutions,” Dr. Greeno adds. “If you have just one meeting on the Hill, you’ll have no impact at all. You have to follow up. You have to do it consistently. And you have to have a consistent message. And we will.”

Richard Quinn is a freelance writer in New Jersey.

A veritable perfect storm of relationships brought hospitalist Jairy Hunter, MD, MBA, SFHM, to “Hospitalists on the Hill 2013,” a daylong advocacy affair that preceded HM13 last month.

First, Dr. Hunter was born and bred—and now lives—in South Carolina, a close-knit state where leaders across industries tend to run in the same circles, or at least have relatives who do. Second, Dr. Hunter’s father, Jairy Hunter Jr., is the longtime president of Charleston Southern University, where Sen. Tim Scott (R-S.C.) earned his undergraduate degree when it was still called Baptist College at Charleston. And three, Dr. Hunter is associate executive medical director of one of the state’s flagship health-care institutions, Medical University of South Carolina in Charleston.

So it was that SHM set Dr. Hunter up in meetings with the offices of Scott, Sen. Lindsey Graham (R-S.C.), and Rep. Jim Clyburn (D-S.C.), and—for the day at least—made Dr. Hunter the voice of hospital medicine.

“It was a little bit demystifying of an experience to be able to know there’s actually people you can talk to and you can develop a relationship with,” says Dr. Hunter, who also serves on Team Hospitalist. “I thought that was very rewarding.”

The connections made by Dr. Hunter are the point of the annual trek made by SHM leaders and members to lobby legislators and federal staffers “on the way policies affect your practice and your patients,” SHM says on its website (www.hospitalmedicine.org/advocacy). This year’s volunteer effort was by far the largest ever, says Public Policy Committee chair Ron Greeno, MD, FCCP, MHM. More than 150 hospitalists participated in training, 113 hospitalists visited Capitol Hill, and scores more had to be turned away. All told, hospitalists held 409 individual meetings with legislators and staff members.

“Quite frankly, if we’d have had the budget, we could have had another 100 to 150 people come,” Dr. Greeno says. “That’s how many people wanted to go.”

Dr. Greeno attributes the interest to two factors. One, having the annual meeting at the Gaylord National Resort & Convention Center, just outside Washington, D.C, makes the Hill trip a natural extension. Two, the current landscape of health-care reform has motivated many physicians to become more involved than they might otherwise be. One challenge of having so many first-timers making this year’s trip was making sure they were properly prepared. To hone the message, SHM gave the group a few hours of education by former legislative staffer Stephanie Vance of Advocacy Associates, a communications firm that helps organizations, such as medical societies, tailor their message to policymakers. Vance told hospitalists a personal visit with a constituent often becomes the most influential type of advocacy.

“That’s why it was easy to make an initial connection, because these staffers are from where I’m from, friends with people that I’m friends with,” Dr. Hunter says.

Unique Approach

SHM CEO Larry Wellikson, MD, SFHM, says the society tries to differentiate itself from other organizations through its grassroots approach to advocacy. More important, the society refrains from giving a long list of legislative requests that are self-serving.

“We’re someone they want to talk to because we’re not coming there to just say, ‘Here’s a power play for hospitalists,’” Dr. Wellikson says. “We come and try to provide solutions.”

To that end, this year’s lobbying effort was targeted to topics important both to HM and the health-care system:

• Repealing the sustainable growth rate (SGR) formula for Medicare payments, specifically via the proposed Medicare Physician Payment Innovation Act of 2013 (H.R. 574);
• Solving the quagmire of observation status time not counting toward the required three consecutive overnights as an inpatient needed to qualify for Medicare benefits at a skilled nursing facility, by supporting the Improving Access to Medicare Coverage Act of 2013 (H.R. 1179, S. 569); and
• Getting the federal government to commit to providing $434 million in funding for the Agency for Healthcare Research and Quality (AHRQ) in fiscal 2014.

“The message that we’re sending resonated with the people we met with on both sides of the aisle,” Dr. Greeno says. “The SGR, for instance, they know there needs to be a fix. We want to serve as a resource for them as they start to figure out the answer to the question: What are we going to replace it with?

“What we want to do is make everybody on the Hill understand that we can be relied upon as a resource when they’re looking for solutions,” he says.

Focused on Follow-Up

And that’s where rank-and-filers, such as Dr. Hunter, have to take charge. So for his Hill Day visits, he tried to stand out. Everyone he met with got a lapel pin in the shape of a South Carolina state flag, which has become a popular fashion statement in recent years. And Scott also got a pin from Charleston Southern University, his alma mater. The gestures were small, but they served as icebreakers and reminders that Dr. Hunter and the people he met are bound by service to the residents of the Palmetto State.

Dr. Hunter also hopes the small token will be that little extra that makes him memorable enough that the next time a Congressional staffer has an SGR question, they’ll ask him and not a doctor from another specialty.

“I’m interested to see how much feedback I get back from them,” he says. “I can feed them all day long, but I don’t want to be that crazy guy bugging them. If they respond back to me, I can hopefully make more inroads.”

He certainly would if Dr. Greeno gets his way. Moving forward, SHM hopes to be able to rely more on local advocates pushing for reform than just a once-a-year major event and formal positions drafted by SHM’s staffers or the Public Policy Committee. Dr. Greeno says the physicians who participated in this year’s Hill trip are likely to find they will be asked to be the first cohort of a grassroots initiative meant to deliver the society’s message more routinely.

“These are not easy things to change because there are not easy solutions,” Dr. Greeno adds. “If you have just one meeting on the Hill, you’ll have no impact at all. You have to follow up. You have to do it consistently. And you have to have a consistent message. And we will.”

Richard Quinn is a freelance writer in New Jersey.

A veritable perfect storm of relationships brought hospitalist Jairy Hunter, MD, MBA, SFHM, to “Hospitalists on the Hill 2013,” a daylong advocacy affair that preceded HM13 last month.

First, Dr. Hunter was born and bred—and now lives—in South Carolina, a close-knit state where leaders across industries tend to run in the same circles, or at least have relatives who do. Second, Dr. Hunter’s father, Jairy Hunter Jr., is the longtime president of Charleston Southern University, where Sen. Tim Scott (R-S.C.) earned his undergraduate degree when it was still called Baptist College at Charleston. And three, Dr. Hunter is associate executive medical director of one of the state’s flagship health-care institutions, Medical University of South Carolina in Charleston.

So it was that SHM set Dr. Hunter up in meetings with the offices of Scott, Sen. Lindsey Graham (R-S.C.), and Rep. Jim Clyburn (D-S.C.), and—for the day at least—made Dr. Hunter the voice of hospital medicine.

“It was a little bit demystifying of an experience to be able to know there’s actually people you can talk to and you can develop a relationship with,” says Dr. Hunter, who also serves on Team Hospitalist. “I thought that was very rewarding.”

The connections made by Dr. Hunter are the point of the annual trek made by SHM leaders and members to lobby legislators and federal staffers “on the way policies affect your practice and your patients,” SHM says on its website (www.hospitalmedicine.org/advocacy). This year’s volunteer effort was by far the largest ever, says Public Policy Committee chair Ron Greeno, MD, FCCP, MHM. More than 150 hospitalists participated in training, 113 hospitalists visited Capitol Hill, and scores more had to be turned away. All told, hospitalists held 409 individual meetings with legislators and staff members.

“Quite frankly, if we’d have had the budget, we could have had another 100 to 150 people come,” Dr. Greeno says. “That’s how many people wanted to go.”

Dr. Greeno attributes the interest to two factors. One, having the annual meeting at the Gaylord National Resort & Convention Center, just outside Washington, D.C, makes the Hill trip a natural extension. Two, the current landscape of health-care reform has motivated many physicians to become more involved than they might otherwise be. One challenge of having so many first-timers making this year’s trip was making sure they were properly prepared. To hone the message, SHM gave the group a few hours of education by former legislative staffer Stephanie Vance of Advocacy Associates, a communications firm that helps organizations, such as medical societies, tailor their message to policymakers. Vance told hospitalists a personal visit with a constituent often becomes the most influential type of advocacy.

“That’s why it was easy to make an initial connection, because these staffers are from where I’m from, friends with people that I’m friends with,” Dr. Hunter says.

Unique Approach

SHM CEO Larry Wellikson, MD, SFHM, says the society tries to differentiate itself from other organizations through its grassroots approach to advocacy. More important, the society refrains from giving a long list of legislative requests that are self-serving.

“We’re someone they want to talk to because we’re not coming there to just say, ‘Here’s a power play for hospitalists,’” Dr. Wellikson says. “We come and try to provide solutions.”

To that end, this year’s lobbying effort was targeted to topics important both to HM and the health-care system:

• Repealing the sustainable growth rate (SGR) formula for Medicare payments, specifically via the proposed Medicare Physician Payment Innovation Act of 2013 (H.R. 574);
• Solving the quagmire of observation status time not counting toward the required three consecutive overnights as an inpatient needed to qualify for Medicare benefits at a skilled nursing facility, by supporting the Improving Access to Medicare Coverage Act of 2013 (H.R. 1179, S. 569); and
• Getting the federal government to commit to providing $434 million in funding for the Agency for Healthcare Research and Quality (AHRQ) in fiscal 2014.

“The message that we’re sending resonated with the people we met with on both sides of the aisle,” Dr. Greeno says. “The SGR, for instance, they know there needs to be a fix. We want to serve as a resource for them as they start to figure out the answer to the question: What are we going to replace it with?

“What we want to do is make everybody on the Hill understand that we can be relied upon as a resource when they’re looking for solutions,” he says.

Focused on Follow-Up

And that’s where rank-and-filers, such as Dr. Hunter, have to take charge. So for his Hill Day visits, he tried to stand out. Everyone he met with got a lapel pin in the shape of a South Carolina state flag, which has become a popular fashion statement in recent years. And Scott also got a pin from Charleston Southern University, his alma mater. The gestures were small, but they served as icebreakers and reminders that Dr. Hunter and the people he met are bound by service to the residents of the Palmetto State.

Dr. Hunter also hopes the small token will be that little extra that makes him memorable enough that the next time a Congressional staffer has an SGR question, they’ll ask him and not a doctor from another specialty.

“I’m interested to see how much feedback I get back from them,” he says. “I can feed them all day long, but I don’t want to be that crazy guy bugging them. If they respond back to me, I can hopefully make more inroads.”

He certainly would if Dr. Greeno gets his way. Moving forward, SHM hopes to be able to rely more on local advocates pushing for reform than just a once-a-year major event and formal positions drafted by SHM’s staffers or the Public Policy Committee. Dr. Greeno says the physicians who participated in this year’s Hill trip are likely to find they will be asked to be the first cohort of a grassroots initiative meant to deliver the society’s message more routinely.

“These are not easy things to change because there are not easy solutions,” Dr. Greeno adds. “If you have just one meeting on the Hill, you’ll have no impact at all. You have to follow up. You have to do it consistently. And you have to have a consistent message. And we will.”

Richard Quinn is a freelance writer in New Jersey.

Alarms about our nation’s health-care costs have been sounding for well over a decade. According to the Centers for Medicare & Medicaid Services (CMS), spending on U.S. health care doubled between 1999 and 2011, climbing to $2.7 trillion from $1.3 trillion, and now represents 17.9% of the United States’ GDP.¹

“The medical care system is bankrupting the country,” Paul B. Ginsburg, PhD, president of the Center for Studying Health System Change (HSC), based in Washington, D.C., says bluntly. A four-decade-long upward spending trend is “unsustainable,” he wrote in the New England Journal of Medicine with Chapin White, PhD, a senior health researcher at HSC.²

Recent reports suggest that rising premiums and out-of-pocket costs are rendering the price of health care untenable for the average consumer. A 2011 RAND Corp. study found that, for the average American family, the rate of increased costs for health care had outpaced growth in earnings from 1999 to 2009.³ And last year, for the first time, the cost of health care for a typical American family of four surpassed $20,000, the annual Milliman Medical Index reported.⁴

Should hospitalists be concerned, professionally and personally, about these trends? Absolutely, say hospitalist leaders who spoke with The Hospitalist. HM clinicians have much to contribute at both the macro level (addressing systemic causes of overutilization through quality improvement and other initiatives) and at the micro level, by understanding their personal contributions and by engaging patients and their families in shared decision-making.

But getting at and addressing the root causes of rising health-care costs, according to health-care policy analysts and veteran hospitalists, will require major shifts in thinking and processes.

Contributors to Rising Costs

It’s difficult to pinpoint the root causes of the recent surge in health-care costs. Victor Fuchs, emeritus professor of economics and health research and policy at Stanford University, points to the U.S.’ high administrative costs and complicated billing systems.⁵ A fragmented, nontransparent system for negotiating fees between insurers and providers also plays a role, as demonstrated in a Consumer Reports investigation into geographic variations in costs for common tests and procedures. A complete blood count might be as low as $15 or as high as $105; a colonoscopy ranges from $800 to $3,160.⁶

Bradley Flansbaum, DO, MPH, SFHM, an SHM Public Policy Committee member and AMA delegate, says rising costs are a provider-specific issue. He challenges colleagues to take an honest look at their own practice patterns to assess whether they’re contributing to overuse of resources (see “A Lesson in Change,”).

“The culture of practice has developed so that this is not going to change overnight,” says Dr. Flansbaum, director of hospitalist services at Lenox Hill Hospital in New York City. That’s because many physicians fail to view their own decisions as a problem. For example, says Dr. Flansbaum, “an oncologist may not identify a third round of chemotherapy as an embodiment of the problem, or a gastroenterologist might not embody the colonoscopy at Year Four instead of Year Five as the problem. We must come to grips with the usual mindset, look in the mirror, and admit, ‘Maybe we are part of the problem.’”

The culture of practice has developed so that this is not going to change overnight. An oncologist may not identify a third round of chemotherapy as an embodiment of the problem. We must come to grips with the usual mindset, look in the mirror, and admit, 'Maybe we are part of the problem.'

—Bradley Flansbaum, DO, MPH, SFHM

Potential Solutions

Hospitalists, intensivists, and ED clinicians are tasked with finding a balance between being prudent stewards of resources and staying within a comfort zone that promotes patient safety. SHM supports the goals of the ABIM Foundation’s Choosing Wisely campaign, which aims to reduce waste by curtailing duplicative and unnecessary care (see “Better Choices, Better Care,” March 2013). Also included in the campaign (www.ChoosingWisely.org) are the American College of Physicians’ recommendations against low-value testing (e.g. obtaining imaging studies in patients with nonspecific low back pain).

“Those recommendations are not going to solve our health spending problem,” says White, “but they are part of a broader move to give permission to clinicians, based on evidence, to follow more conservative practice patterns.”

Still, counters David I. Auerbach, PhD, a health economist at RAND in Boston and author of the RAND study, “there’s another value to these tests that the cost-effectiveness equations do not always consider, which is, they can bring peace of mind. We’re trying to nudge patients down the pathway that we think is best for them without rationing care. That’s a delicate balance.”

Dr. Flansbaum says SHM’s Public Policy Committee has discussed a variety of issues related to rising costs, although the group has not directly tackled advice in the form of a white paper. He suggests some ways that hospitalists can address cost savings:

• Involve patients in shared decision-making, and discuss the evidence against unnecessary testing;
• Utilize generic medications on discharge, when available, especially if patients are uninsured or have limited drug coverage with their insurance plans;
• Use palliative care whenever appropriate; and
• Adhere to transitional-care standards.

On the macro level, HM has “always been the specialty invited to champion the important discussion relating to resource utilization, and the evidence-based medicine driving that resource utilization,” says Christopher Frost, MD, FHM, medical director of hospital medicine at the Hospital Corporation of America (HCA) in Nashville, Tenn. He points to SHM’s leadership with Project BOOST (www.hospitalmedicine.org/boost) as one example of addressing the utilization of resources in caring for older adults (see “Resources for Improving Transitions in Care,”).

What else can hospitalists do? Going forward, says Dan Fuller, president and co-founder of IN Compass Health in Alpharetta, Ga., it might be a good idea for the SHM Practice Analysis Committee, of which he’s a member, to look at its possible role in the issue.

We need the time to make these calls [to PCPs], to sit down with families. This adds value to our health system and to society at large.

—Dr. Frederickson

Embrace Reality

Whatever the downstream developments around the Affordable Care Act, Dr. Ginsburg is “confident” that Medicare policies will continue in a direction of reduced reimbursements. Thomas Frederickson, MD, FACP, FHM, MBA, medical director of the hospital medicine service at Alegent Health in Omaha, Neb., agrees with such an assessment. He also believes that hospitalists are in a prime position to improve care delivery at less cost. To do so, though, requires deliberate partnership-building with outpatient providers to better bridge the transitions of care.

At his institution, Dr. Frederickson says, hospitalists invite themselves to primary-care physicians’ (PCP) meetings. This facilitates rapport so that calls to PCPs at discharge not only communicate essential clinical information, but also build confidence in the hospitalists’ care of their patients. As hospitalists demonstrate value, they must intentionally put metrics in place so that administrators appreciate the need to keep the census at a certain level, Dr. Frederickson says.

“We need the time to make these calls, to sit down with families,” he says. “This adds value to our health system and to society at large.”

SHM does a good job, says Dr. Frost, of being part of the conversation as the hospital C-suite focuses more on episodes of care.

“The intensity of that discussion is getting dialed up and will be driven more by government and the payors,” he adds. The challenge going forward will be to bridge those arenas just outside the acute episode of care, where hospitalists have ownership of processes, to those where they do not have as much control. If payors apply broader definitions to the episode of care, Dr. Frost says, hospitalists might be “invited to play an increasing role, that of ‘transitionist.’”

And in that context, he says, hospitalists need to look at length of stay with a new lens.

Partnership-building will become more important as the definition of “episode of care” expands beyond the hospital stay to the post-acute setting.

“Including post-acute care in the episode of care is a core aspect of the whole” value-based purchasing approach, Dr. Ginsburg says. “Hospitals [and hospitalists] will be wise to opt for the model with the greatest potential to reduce costs, particularly costs incurred by other providers.”

Gretchen Henkel is a freelance writer in California.

References

1. Centers for Medicare & Medicaid Services. National health expenditures 2011 highlights. Centers for Medicare & Medicaid Services website. Available at: http://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/NationalHealthExpendData/Downloads/highlights.pdf. Accessed May 6, 2013. costs how much? Consumer Reports website. Available at: http://www.consumerreports.org/cro/magazine/ 2012/07/that-ct-scan-costs-how-much/index.htm. Accessed Aug. 2, 2012.
2. White C, Ginsburg PB. Slower growth in Medicare spending—is this the new normal? N Engl J Med. 2012;366(12):1073-1075.
3. Auerbach DI, Kellermann AL. A decade of health care cost growth has wiped out real income gains for an average US family. Health Aff (Millwood). 2011;30(9):1630-1636.
4. Milliman Inc. 2012 Milliman Medical Index. Milliman Inc. website. Available at: http://publications.milliman.com/periodicals/mmi/pdfs/milliman-medical-index-2012.pdf. Accessed Aug. 1, 2012.
5. Kolata G. Knotty challenges in health care costs. The New York Times website. Available at: http://www.nytimes.com/2012/03/06/health/policy/an-interview-with-victor-fuchs-on-health-care-costs.html. Accessed March 8, 2012.
6. Consumer Reports. That CT scan costs how much? Consumer Reports website. Available at: http://www.consumerreports.org/cro/magazine/ 2012/07/that-ct-scan-costs-how-much/index.htm.

Alarms about our nation’s health-care costs have been sounding for well over a decade. According to the Centers for Medicare & Medicaid Services (CMS), spending on U.S. health care doubled between 1999 and 2011, climbing to $2.7 trillion from $1.3 trillion, and now represents 17.9% of the United States’ GDP.¹

“The medical care system is bankrupting the country,” Paul B. Ginsburg, PhD, president of the Center for Studying Health System Change (HSC), based in Washington, D.C., says bluntly. A four-decade-long upward spending trend is “unsustainable,” he wrote in the New England Journal of Medicine with Chapin White, PhD, a senior health researcher at HSC.²

Recent reports suggest that rising premiums and out-of-pocket costs are rendering the price of health care untenable for the average consumer. A 2011 RAND Corp. study found that, for the average American family, the rate of increased costs for health care had outpaced growth in earnings from 1999 to 2009.³ And last year, for the first time, the cost of health care for a typical American family of four surpassed $20,000, the annual Milliman Medical Index reported.⁴

Should hospitalists be concerned, professionally and personally, about these trends? Absolutely, say hospitalist leaders who spoke with The Hospitalist. HM clinicians have much to contribute at both the macro level (addressing systemic causes of overutilization through quality improvement and other initiatives) and at the micro level, by understanding their personal contributions and by engaging patients and their families in shared decision-making.

But getting at and addressing the root causes of rising health-care costs, according to health-care policy analysts and veteran hospitalists, will require major shifts in thinking and processes.

Contributors to Rising Costs

It’s difficult to pinpoint the root causes of the recent surge in health-care costs. Victor Fuchs, emeritus professor of economics and health research and policy at Stanford University, points to the U.S.’ high administrative costs and complicated billing systems.⁵ A fragmented, nontransparent system for negotiating fees between insurers and providers also plays a role, as demonstrated in a Consumer Reports investigation into geographic variations in costs for common tests and procedures. A complete blood count might be as low as $15 or as high as $105; a colonoscopy ranges from $800 to $3,160.⁶

Bradley Flansbaum, DO, MPH, SFHM, an SHM Public Policy Committee member and AMA delegate, says rising costs are a provider-specific issue. He challenges colleagues to take an honest look at their own practice patterns to assess whether they’re contributing to overuse of resources (see “A Lesson in Change,”).

“The culture of practice has developed so that this is not going to change overnight,” says Dr. Flansbaum, director of hospitalist services at Lenox Hill Hospital in New York City. That’s because many physicians fail to view their own decisions as a problem. For example, says Dr. Flansbaum, “an oncologist may not identify a third round of chemotherapy as an embodiment of the problem, or a gastroenterologist might not embody the colonoscopy at Year Four instead of Year Five as the problem. We must come to grips with the usual mindset, look in the mirror, and admit, ‘Maybe we are part of the problem.’”

The culture of practice has developed so that this is not going to change overnight. An oncologist may not identify a third round of chemotherapy as an embodiment of the problem. We must come to grips with the usual mindset, look in the mirror, and admit, 'Maybe we are part of the problem.'

—Bradley Flansbaum, DO, MPH, SFHM

Potential Solutions

Hospitalists, intensivists, and ED clinicians are tasked with finding a balance between being prudent stewards of resources and staying within a comfort zone that promotes patient safety. SHM supports the goals of the ABIM Foundation’s Choosing Wisely campaign, which aims to reduce waste by curtailing duplicative and unnecessary care (see “Better Choices, Better Care,” March 2013). Also included in the campaign (www.ChoosingWisely.org) are the American College of Physicians’ recommendations against low-value testing (e.g. obtaining imaging studies in patients with nonspecific low back pain).

“Those recommendations are not going to solve our health spending problem,” says White, “but they are part of a broader move to give permission to clinicians, based on evidence, to follow more conservative practice patterns.”

Still, counters David I. Auerbach, PhD, a health economist at RAND in Boston and author of the RAND study, “there’s another value to these tests that the cost-effectiveness equations do not always consider, which is, they can bring peace of mind. We’re trying to nudge patients down the pathway that we think is best for them without rationing care. That’s a delicate balance.”

Dr. Flansbaum says SHM’s Public Policy Committee has discussed a variety of issues related to rising costs, although the group has not directly tackled advice in the form of a white paper. He suggests some ways that hospitalists can address cost savings:

• Involve patients in shared decision-making, and discuss the evidence against unnecessary testing;
• Utilize generic medications on discharge, when available, especially if patients are uninsured or have limited drug coverage with their insurance plans;
• Use palliative care whenever appropriate; and
• Adhere to transitional-care standards.

On the macro level, HM has “always been the specialty invited to champion the important discussion relating to resource utilization, and the evidence-based medicine driving that resource utilization,” says Christopher Frost, MD, FHM, medical director of hospital medicine at the Hospital Corporation of America (HCA) in Nashville, Tenn. He points to SHM’s leadership with Project BOOST (www.hospitalmedicine.org/boost) as one example of addressing the utilization of resources in caring for older adults (see “Resources for Improving Transitions in Care,”).

What else can hospitalists do? Going forward, says Dan Fuller, president and co-founder of IN Compass Health in Alpharetta, Ga., it might be a good idea for the SHM Practice Analysis Committee, of which he’s a member, to look at its possible role in the issue.

We need the time to make these calls [to PCPs], to sit down with families. This adds value to our health system and to society at large.

—Dr. Frederickson

Embrace Reality

Whatever the downstream developments around the Affordable Care Act, Dr. Ginsburg is “confident” that Medicare policies will continue in a direction of reduced reimbursements. Thomas Frederickson, MD, FACP, FHM, MBA, medical director of the hospital medicine service at Alegent Health in Omaha, Neb., agrees with such an assessment. He also believes that hospitalists are in a prime position to improve care delivery at less cost. To do so, though, requires deliberate partnership-building with outpatient providers to better bridge the transitions of care.

At his institution, Dr. Frederickson says, hospitalists invite themselves to primary-care physicians’ (PCP) meetings. This facilitates rapport so that calls to PCPs at discharge not only communicate essential clinical information, but also build confidence in the hospitalists’ care of their patients. As hospitalists demonstrate value, they must intentionally put metrics in place so that administrators appreciate the need to keep the census at a certain level, Dr. Frederickson says.

“We need the time to make these calls, to sit down with families,” he says. “This adds value to our health system and to society at large.”

SHM does a good job, says Dr. Frost, of being part of the conversation as the hospital C-suite focuses more on episodes of care.

“The intensity of that discussion is getting dialed up and will be driven more by government and the payors,” he adds. The challenge going forward will be to bridge those arenas just outside the acute episode of care, where hospitalists have ownership of processes, to those where they do not have as much control. If payors apply broader definitions to the episode of care, Dr. Frost says, hospitalists might be “invited to play an increasing role, that of ‘transitionist.’”

And in that context, he says, hospitalists need to look at length of stay with a new lens.

Partnership-building will become more important as the definition of “episode of care” expands beyond the hospital stay to the post-acute setting.

“Including post-acute care in the episode of care is a core aspect of the whole” value-based purchasing approach, Dr. Ginsburg says. “Hospitals [and hospitalists] will be wise to opt for the model with the greatest potential to reduce costs, particularly costs incurred by other providers.”

Gretchen Henkel is a freelance writer in California.

References

1. Centers for Medicare & Medicaid Services. National health expenditures 2011 highlights. Centers for Medicare & Medicaid Services website. Available at: http://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/NationalHealthExpendData/Downloads/highlights.pdf. Accessed May 6, 2013. costs how much? Consumer Reports website. Available at: http://www.consumerreports.org/cro/magazine/ 2012/07/that-ct-scan-costs-how-much/index.htm. Accessed Aug. 2, 2012.
2. White C, Ginsburg PB. Slower growth in Medicare spending—is this the new normal? N Engl J Med. 2012;366(12):1073-1075.
3. Auerbach DI, Kellermann AL. A decade of health care cost growth has wiped out real income gains for an average US family. Health Aff (Millwood). 2011;30(9):1630-1636.
4. Milliman Inc. 2012 Milliman Medical Index. Milliman Inc. website. Available at: http://publications.milliman.com/periodicals/mmi/pdfs/milliman-medical-index-2012.pdf. Accessed Aug. 1, 2012.
5. Kolata G. Knotty challenges in health care costs. The New York Times website. Available at: http://www.nytimes.com/2012/03/06/health/policy/an-interview-with-victor-fuchs-on-health-care-costs.html. Accessed March 8, 2012.
6. Consumer Reports. That CT scan costs how much? Consumer Reports website. Available at: http://www.consumerreports.org/cro/magazine/ 2012/07/that-ct-scan-costs-how-much/index.htm.

Alarms about our nation’s health-care costs have been sounding for well over a decade. According to the Centers for Medicare & Medicaid Services (CMS), spending on U.S. health care doubled between 1999 and 2011, climbing to $2.7 trillion from $1.3 trillion, and now represents 17.9% of the United States’ GDP.¹

“The medical care system is bankrupting the country,” Paul B. Ginsburg, PhD, president of the Center for Studying Health System Change (HSC), based in Washington, D.C., says bluntly. A four-decade-long upward spending trend is “unsustainable,” he wrote in the New England Journal of Medicine with Chapin White, PhD, a senior health researcher at HSC.²

Recent reports suggest that rising premiums and out-of-pocket costs are rendering the price of health care untenable for the average consumer. A 2011 RAND Corp. study found that, for the average American family, the rate of increased costs for health care had outpaced growth in earnings from 1999 to 2009.³ And last year, for the first time, the cost of health care for a typical American family of four surpassed $20,000, the annual Milliman Medical Index reported.⁴

Should hospitalists be concerned, professionally and personally, about these trends? Absolutely, say hospitalist leaders who spoke with The Hospitalist. HM clinicians have much to contribute at both the macro level (addressing systemic causes of overutilization through quality improvement and other initiatives) and at the micro level, by understanding their personal contributions and by engaging patients and their families in shared decision-making.

But getting at and addressing the root causes of rising health-care costs, according to health-care policy analysts and veteran hospitalists, will require major shifts in thinking and processes.

Contributors to Rising Costs

It’s difficult to pinpoint the root causes of the recent surge in health-care costs. Victor Fuchs, emeritus professor of economics and health research and policy at Stanford University, points to the U.S.’ high administrative costs and complicated billing systems.⁵ A fragmented, nontransparent system for negotiating fees between insurers and providers also plays a role, as demonstrated in a Consumer Reports investigation into geographic variations in costs for common tests and procedures. A complete blood count might be as low as $15 or as high as $105; a colonoscopy ranges from $800 to $3,160.⁶

Bradley Flansbaum, DO, MPH, SFHM, an SHM Public Policy Committee member and AMA delegate, says rising costs are a provider-specific issue. He challenges colleagues to take an honest look at their own practice patterns to assess whether they’re contributing to overuse of resources (see “A Lesson in Change,”).

“The culture of practice has developed so that this is not going to change overnight,” says Dr. Flansbaum, director of hospitalist services at Lenox Hill Hospital in New York City. That’s because many physicians fail to view their own decisions as a problem. For example, says Dr. Flansbaum, “an oncologist may not identify a third round of chemotherapy as an embodiment of the problem, or a gastroenterologist might not embody the colonoscopy at Year Four instead of Year Five as the problem. We must come to grips with the usual mindset, look in the mirror, and admit, ‘Maybe we are part of the problem.’”

The culture of practice has developed so that this is not going to change overnight. An oncologist may not identify a third round of chemotherapy as an embodiment of the problem. We must come to grips with the usual mindset, look in the mirror, and admit, 'Maybe we are part of the problem.'

—Bradley Flansbaum, DO, MPH, SFHM

Potential Solutions

Hospitalists, intensivists, and ED clinicians are tasked with finding a balance between being prudent stewards of resources and staying within a comfort zone that promotes patient safety. SHM supports the goals of the ABIM Foundation’s Choosing Wisely campaign, which aims to reduce waste by curtailing duplicative and unnecessary care (see “Better Choices, Better Care,” March 2013). Also included in the campaign (www.ChoosingWisely.org) are the American College of Physicians’ recommendations against low-value testing (e.g. obtaining imaging studies in patients with nonspecific low back pain).

“Those recommendations are not going to solve our health spending problem,” says White, “but they are part of a broader move to give permission to clinicians, based on evidence, to follow more conservative practice patterns.”

Still, counters David I. Auerbach, PhD, a health economist at RAND in Boston and author of the RAND study, “there’s another value to these tests that the cost-effectiveness equations do not always consider, which is, they can bring peace of mind. We’re trying to nudge patients down the pathway that we think is best for them without rationing care. That’s a delicate balance.”

Dr. Flansbaum says SHM’s Public Policy Committee has discussed a variety of issues related to rising costs, although the group has not directly tackled advice in the form of a white paper. He suggests some ways that hospitalists can address cost savings:

• Involve patients in shared decision-making, and discuss the evidence against unnecessary testing;
• Utilize generic medications on discharge, when available, especially if patients are uninsured or have limited drug coverage with their insurance plans;
• Use palliative care whenever appropriate; and
• Adhere to transitional-care standards.

On the macro level, HM has “always been the specialty invited to champion the important discussion relating to resource utilization, and the evidence-based medicine driving that resource utilization,” says Christopher Frost, MD, FHM, medical director of hospital medicine at the Hospital Corporation of America (HCA) in Nashville, Tenn. He points to SHM’s leadership with Project BOOST (www.hospitalmedicine.org/boost) as one example of addressing the utilization of resources in caring for older adults (see “Resources for Improving Transitions in Care,”).

What else can hospitalists do? Going forward, says Dan Fuller, president and co-founder of IN Compass Health in Alpharetta, Ga., it might be a good idea for the SHM Practice Analysis Committee, of which he’s a member, to look at its possible role in the issue.

We need the time to make these calls [to PCPs], to sit down with families. This adds value to our health system and to society at large.

—Dr. Frederickson

Embrace Reality

Whatever the downstream developments around the Affordable Care Act, Dr. Ginsburg is “confident” that Medicare policies will continue in a direction of reduced reimbursements. Thomas Frederickson, MD, FACP, FHM, MBA, medical director of the hospital medicine service at Alegent Health in Omaha, Neb., agrees with such an assessment. He also believes that hospitalists are in a prime position to improve care delivery at less cost. To do so, though, requires deliberate partnership-building with outpatient providers to better bridge the transitions of care.

At his institution, Dr. Frederickson says, hospitalists invite themselves to primary-care physicians’ (PCP) meetings. This facilitates rapport so that calls to PCPs at discharge not only communicate essential clinical information, but also build confidence in the hospitalists’ care of their patients. As hospitalists demonstrate value, they must intentionally put metrics in place so that administrators appreciate the need to keep the census at a certain level, Dr. Frederickson says.

“We need the time to make these calls, to sit down with families,” he says. “This adds value to our health system and to society at large.”

SHM does a good job, says Dr. Frost, of being part of the conversation as the hospital C-suite focuses more on episodes of care.

“The intensity of that discussion is getting dialed up and will be driven more by government and the payors,” he adds. The challenge going forward will be to bridge those arenas just outside the acute episode of care, where hospitalists have ownership of processes, to those where they do not have as much control. If payors apply broader definitions to the episode of care, Dr. Frost says, hospitalists might be “invited to play an increasing role, that of ‘transitionist.’”

And in that context, he says, hospitalists need to look at length of stay with a new lens.

Partnership-building will become more important as the definition of “episode of care” expands beyond the hospital stay to the post-acute setting.

“Including post-acute care in the episode of care is a core aspect of the whole” value-based purchasing approach, Dr. Ginsburg says. “Hospitals [and hospitalists] will be wise to opt for the model with the greatest potential to reduce costs, particularly costs incurred by other providers.”

Gretchen Henkel is a freelance writer in California.

References

1. Centers for Medicare & Medicaid Services. National health expenditures 2011 highlights. Centers for Medicare & Medicaid Services website. Available at: http://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/NationalHealthExpendData/Downloads/highlights.pdf. Accessed May 6, 2013. costs how much? Consumer Reports website. Available at: http://www.consumerreports.org/cro/magazine/ 2012/07/that-ct-scan-costs-how-much/index.htm. Accessed Aug. 2, 2012.
2. White C, Ginsburg PB. Slower growth in Medicare spending—is this the new normal? N Engl J Med. 2012;366(12):1073-1075.
3. Auerbach DI, Kellermann AL. A decade of health care cost growth has wiped out real income gains for an average US family. Health Aff (Millwood). 2011;30(9):1630-1636.
4. Milliman Inc. 2012 Milliman Medical Index. Milliman Inc. website. Available at: http://publications.milliman.com/periodicals/mmi/pdfs/milliman-medical-index-2012.pdf. Accessed Aug. 1, 2012.
5. Kolata G. Knotty challenges in health care costs. The New York Times website. Available at: http://www.nytimes.com/2012/03/06/health/policy/an-interview-with-victor-fuchs-on-health-care-costs.html. Accessed March 8, 2012.
6. Consumer Reports. That CT scan costs how much? Consumer Reports website. Available at: http://www.consumerreports.org/cro/magazine/ 2012/07/that-ct-scan-costs-how-much/index.htm.

I read the article “Call for Transparency in Health-Care Performance Results to Impact Hospitalists” (January 2013, p. 47) by Shaun Frost, MD, SFHM, president of the Society of Hospital Medicine, with interest. I’d like to clarify a key point about Physician Compare. In the article, the statement that the Physician Compare website (www.medicare.gov/find-a-doctor) provides performance information on individual doctors is inaccurate.

The Affordable Care Act (ACA) states that the Centers for Medicare & Medicaid Services (CMS) must have a plan in place by Jan. 1, 2013, to include quality-of-care information on the site. To meet that requirement, CMS has established a plan that initiates a phased approach to public reporting. The 2012 Physician Fee Schedule (PFS) Final Rule was the first step in that phased approach. This rule established that the first measures to be reported on the site would be group-level measures for data collected no sooner than program year 2012. A second critical step is the 2013 PFS Proposed Rule, which outlines a longer-term public reporting plan. According to this plan, we expect the first set of group-level quality measure data to be included on the site in calendar year 2014. We are targeting publishing individual-level quality measures no sooner than 2015 reflecting data collected in program year 2014, if technically feasible.

As you may be aware, Physician Compare is undergoing a redesign to significantly improve the underlying database and thus the information on Physician Compare, as well as the ease of use and functionality of the site. We’ll be unveiling the redesigned site soon. We welcome your feedback and look forward to maintaining a dialogue with you as Physician Compare continues to evolve.

Rashaan Byers, MPH, social science research analyst, Centers forMedicare & Medicaid Services, Center for Clinical Standards & Quality, Quality Measurement & Health Assessment Group

Dr. Frost responds:

I thank Mr. Byers for his clarification regarding the current content on the CMS Physician Compare website, and agree that at the present time the website does not report individual physician clinical performance data.

Physician Compare, however, does currently report if an individual physician participated in the CMS Physician Quality Reporting System (PQRS) by stating “this professional chose to take part in Medicare’s PQRS, and reported quality information satisfactorily for the year 2010.” For those physicians who did not participate in PQRS, their personal website pages do not make reference to the PQRS program.

As the intent of transparency is to educate consumers to make informed choices about where to seek health care, care providers should know that their participation in PQRS is currently publically reported. It is, therefore, possible that patient decisions about whom to seek care from may be influenced by this.

As acknowledged in my January 2013 column in The Hospitalist, Physician Compare currently reports very little information. We should expect this to change, however, as Medicare moves forward with developing a plan to publically report valid and reliable individual physician performance metrics. CMS’ clarification of the timeline by which we can expect to see more detailed information is thus greatly appreciated.

The take-home message for hospitalists is that public reporting of care provider performance will become increasingly comprehensive and transparent in the future. As pointed out, CMS’ present plan targets the publication of individual, physician-level quality measures as soon as 2015, which will reflect actual performance during program year 2014. The measurement period is thus less than one year away, so it behooves us all to focus ever more intently on delivering high-value healthcare.

Shaun Frost, MD, SFHM, past president, SHM

I read the article “Call for Transparency in Health-Care Performance Results to Impact Hospitalists” (January 2013, p. 47) by Shaun Frost, MD, SFHM, president of the Society of Hospital Medicine, with interest. I’d like to clarify a key point about Physician Compare. In the article, the statement that the Physician Compare website (www.medicare.gov/find-a-doctor) provides performance information on individual doctors is inaccurate.

The Affordable Care Act (ACA) states that the Centers for Medicare & Medicaid Services (CMS) must have a plan in place by Jan. 1, 2013, to include quality-of-care information on the site. To meet that requirement, CMS has established a plan that initiates a phased approach to public reporting. The 2012 Physician Fee Schedule (PFS) Final Rule was the first step in that phased approach. This rule established that the first measures to be reported on the site would be group-level measures for data collected no sooner than program year 2012. A second critical step is the 2013 PFS Proposed Rule, which outlines a longer-term public reporting plan. According to this plan, we expect the first set of group-level quality measure data to be included on the site in calendar year 2014. We are targeting publishing individual-level quality measures no sooner than 2015 reflecting data collected in program year 2014, if technically feasible.

As you may be aware, Physician Compare is undergoing a redesign to significantly improve the underlying database and thus the information on Physician Compare, as well as the ease of use and functionality of the site. We’ll be unveiling the redesigned site soon. We welcome your feedback and look forward to maintaining a dialogue with you as Physician Compare continues to evolve.

Rashaan Byers, MPH, social science research analyst, Centers forMedicare & Medicaid Services, Center for Clinical Standards & Quality, Quality Measurement & Health Assessment Group

Dr. Frost responds:

I thank Mr. Byers for his clarification regarding the current content on the CMS Physician Compare website, and agree that at the present time the website does not report individual physician clinical performance data.

Physician Compare, however, does currently report if an individual physician participated in the CMS Physician Quality Reporting System (PQRS) by stating “this professional chose to take part in Medicare’s PQRS, and reported quality information satisfactorily for the year 2010.” For those physicians who did not participate in PQRS, their personal website pages do not make reference to the PQRS program.

As the intent of transparency is to educate consumers to make informed choices about where to seek health care, care providers should know that their participation in PQRS is currently publically reported. It is, therefore, possible that patient decisions about whom to seek care from may be influenced by this.

As acknowledged in my January 2013 column in The Hospitalist, Physician Compare currently reports very little information. We should expect this to change, however, as Medicare moves forward with developing a plan to publically report valid and reliable individual physician performance metrics. CMS’ clarification of the timeline by which we can expect to see more detailed information is thus greatly appreciated.

The take-home message for hospitalists is that public reporting of care provider performance will become increasingly comprehensive and transparent in the future. As pointed out, CMS’ present plan targets the publication of individual, physician-level quality measures as soon as 2015, which will reflect actual performance during program year 2014. The measurement period is thus less than one year away, so it behooves us all to focus ever more intently on delivering high-value healthcare.

Shaun Frost, MD, SFHM, past president, SHM

I read the article “Call for Transparency in Health-Care Performance Results to Impact Hospitalists” (January 2013, p. 47) by Shaun Frost, MD, SFHM, president of the Society of Hospital Medicine, with interest. I’d like to clarify a key point about Physician Compare. In the article, the statement that the Physician Compare website (www.medicare.gov/find-a-doctor) provides performance information on individual doctors is inaccurate.

The Affordable Care Act (ACA) states that the Centers for Medicare & Medicaid Services (CMS) must have a plan in place by Jan. 1, 2013, to include quality-of-care information on the site. To meet that requirement, CMS has established a plan that initiates a phased approach to public reporting. The 2012 Physician Fee Schedule (PFS) Final Rule was the first step in that phased approach. This rule established that the first measures to be reported on the site would be group-level measures for data collected no sooner than program year 2012. A second critical step is the 2013 PFS Proposed Rule, which outlines a longer-term public reporting plan. According to this plan, we expect the first set of group-level quality measure data to be included on the site in calendar year 2014. We are targeting publishing individual-level quality measures no sooner than 2015 reflecting data collected in program year 2014, if technically feasible.

As you may be aware, Physician Compare is undergoing a redesign to significantly improve the underlying database and thus the information on Physician Compare, as well as the ease of use and functionality of the site. We’ll be unveiling the redesigned site soon. We welcome your feedback and look forward to maintaining a dialogue with you as Physician Compare continues to evolve.

Rashaan Byers, MPH, social science research analyst, Centers forMedicare & Medicaid Services, Center for Clinical Standards & Quality, Quality Measurement & Health Assessment Group

Dr. Frost responds:

I thank Mr. Byers for his clarification regarding the current content on the CMS Physician Compare website, and agree that at the present time the website does not report individual physician clinical performance data.

Physician Compare, however, does currently report if an individual physician participated in the CMS Physician Quality Reporting System (PQRS) by stating “this professional chose to take part in Medicare’s PQRS, and reported quality information satisfactorily for the year 2010.” For those physicians who did not participate in PQRS, their personal website pages do not make reference to the PQRS program.

As the intent of transparency is to educate consumers to make informed choices about where to seek health care, care providers should know that their participation in PQRS is currently publically reported. It is, therefore, possible that patient decisions about whom to seek care from may be influenced by this.

As acknowledged in my January 2013 column in The Hospitalist, Physician Compare currently reports very little information. We should expect this to change, however, as Medicare moves forward with developing a plan to publically report valid and reliable individual physician performance metrics. CMS’ clarification of the timeline by which we can expect to see more detailed information is thus greatly appreciated.

The take-home message for hospitalists is that public reporting of care provider performance will become increasingly comprehensive and transparent in the future. As pointed out, CMS’ present plan targets the publication of individual, physician-level quality measures as soon as 2015, which will reflect actual performance during program year 2014. The measurement period is thus less than one year away, so it behooves us all to focus ever more intently on delivering high-value healthcare.

Shaun Frost, MD, SFHM, past president, SHM