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Dr. Hospitalist

From: The Hospitalist, December 2007

Dr. Hospitalist

Measure Up

Question: I’m a new graduate who just took a job as a hospitalist. I’m hearing a lot about the importance of compliance with the “Core Measures.” Can you explain to me what they are and why these seem to be so important?
Measure for Measure,
Austin, Texas

Dr. Hospitalist responds: As a federal agency, the Center for Medicare and Medicaid Services (CMS) is the largest payer of healthcare in the country. In 2003, it required hospitals that receive CMS payments to report data on the quality of care Medicare recipients received for several inpatient diagnoses (myocardial infarction, heart failure, and community-acquired pneumonia).

CMS enacted this requirement because there was evidence to suggest hospitalized patients were not uniformly receiving evidence-based care.

For example, I am unaware of any healthcare providers who would question the routine use of aspirin in patients who present with acute myocardial infarction. Despite this widespread knowledge, CMS audits found this practice was not uniform among hospitals nationwide. More detailed analysis suggested this inconsistency was not usually because of ignorant providers but more often a lack of systems to ensure uniform care for all patients at all times.

Since 2003, CMS has expanded the number of Core Quality Measures hospitals must report. For example, the present quality measures for community-acquired pneumonia include:

  • Initial antibiotics within four hours of hospital presentation;
  • Oxygen assessment;
  • Blood culture before first antibiotic dose;
  • Appropriate initial antibiotic selection;
  • Smoking cessation counseling;
  • Influenza vaccination for inpatients from October through February; and
  • Pneumococcal vaccination for patients 65 and older.

This year, CMS raised the stakes by tying reimbursement to performance on these quality measures. I can assure you the few hospitals around the country that hadn’t addressed this issue have done so today. The risk of losing CMS funding is not an option for most hospitals. In many cases, the hospitals have turned to providers in location-based specialties (e.g., emergency department providers, hospitalists, and intensivists) as partners in the development, implementation, and enforcement of these quality measures. These providers are uniquely positioned to address performance on these quality measures.

Ask Dr. Hospitalist

Do you have a problem or concern that you’d like Dr. Hospitalist to address? E-mail your questions to drhospit@wiley.com.

Well Rounded

Question: Do you have any suggestions on how to improve communications between hospitalists and other inpatient providers like nurses and case managers?
Let’s Talk,
Madison, Wis.

Dr. Hospitalist responds: If your hospitalist program is not conducting multidisciplinary rounds, consider them.

The primary goal is interdisciplinary communication. Conduct these rounds at least once each morning, as early as possible after nursing shift change and hospitalist hand-off. Participants should include hospitalists, nurses, and case managers at a minimum. Some programs include other providers like nurses’ aides, pharmacists, physical/occupational therapists, social workers, and dietitians.

During rounds, the hospitalist leads a brief discussion about the plan of care for each patient, soliciting feedback from all participants. Discussions should last no longer than two-three minutes apiece and often are shorter. The occasional patient whose issues demand a longer discussion should be treated as an outlier and discussed at the end of rounds.

Nonphysician providers should solicit written physician orders during rounds. The team should consider barriers to discharge and identify ways to overcome those barriers. At the conclusion of rounds, each participant should leave with a clear understanding of each patient’s plan of care for that day and for the hospital stay. Hospitalists should leave rounds able to prioritize the order of patient care. They should see the sickest patients first, then potential early discharges, then everyone else.

Rounds can fail for several reasons. Watch for the signs and address them before the rounds spiral out of control:

  • Participants are late: It is vital to set the expectation that everyone will show up on time. Without that, the start time for rounds will drift from day to day and waste time;
  • Participants come unprepared: Taking part at rounds requires that the nurse leaves nursing hand-off with the necessary information to participate effectively. This is the same for the hospitalist with morning hand-off from the doctor who worked overnight. Without sufficient information, participants will find themselves with nothing to say—or worse, provide erroneous or useless information; or
  • Participants stray off the topic: It is easy to digress during group discussions. As the rounds leader, the hospitalist must keep discussion pertinent so rounds are not prolonged with unnecessary discussion. Think of rounds as an investment. We are asking busy providers to take 30 minutes out of their busy schedule to talk about patient care. A wise investment saves providers more time than they invested.

A primary benefit of rounds is as a forum for communication. All providers should try to funnel communication toward rounds rather than stopping the doctor or nurse throughout the day with questions and comments. Minimizing interruptions will foster more efficient care. Some hospitalist programs even huddle briefly in the afternoon to review plans discussed at morning rounds. TH


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