The Society of Hospital Medicine asserts that one of the key principles of an effective hospital medicine group is demonstrating a commitment to continuous quality improvement (QI) and actively participating in initiatives directed at quality and patient safety.1 Large hospitalist groups expect their physicians to contribute to the QI initiatives of the hospitals they staff. But as any hospitalist practicing in a community setting can tell you, QI is much easier said than done.
Acknowledge, Overcome the Obstacles
One of the first hurdles hospitalists must overcome when initiating a QI program is finding the time in their schedule as well as obtaining the time commitment from group leadership and fellow clinicians.
“If a hospitalist has no dedicated time and is working clinically, it is difficult to find time to organize a study,” says Kenneth Epstein, MD, chief medical officer of Hospitalist Consultants, the hospitalist management division of ECI Healthcare Partners, in Traverse City, Mich.
However, many national hospitalist management groups, including ECI and IPC Healthcare of North Hollywood, Calif., expect their clinicians to be continuously engaged in QI projects relative to their facility.
Beyond time, an even tougher obstacle to surmount is a lack of training, according to Kerry Weiner, MD, IPC chief medical officer. He says that each of IPC’s clinical practice leaders must participate in a one-year training program that includes a QI project conducted within their facility and mentored by University of California, San Francisco faculty.
David Nash, MD, founding dean of Jefferson College of Population Health in Philadelphia, says The Joint Commission, as part of its accreditation process, requires hospitals to robustly review errors and “have a performance improvement system in place.” He believes the only way community hospitals can successfully undertake this effort is to make sure hospitalists have adequate training in quality and safety.
Training is available from SHM via its Quality and Safety Educators Academy as well as the American Association for Physician Leadership and the Institute for Healthcare Improvement. However, Dr. Nash recommends graduate-level programs in quality and safety available at several schools including Jefferson, Northwestern University in Chicago, and George Washington University in Washington, D.C.
Yet another hurdle is access to data. Many community hospitals have limited financial and human resources to collect accurate data to use for choosing an area to focus on and measuring improvement.
“Despite all the money invested in electronic medical records, finding timely and accurate data is still challenging,” says Jasen Gundersen, MD, president of Knoxville, Tenn.–based TeamHealth Acute Care Services. “The data may exist, but a community hospital may be limited when it comes to finding people to mine, configure, and analyze the data. Community hospitals tend to be focused on publically reported, whole-hospital data.
“If your project is not related to these metrics, you may have trouble getting quality department support.”
Dr. Weiner echoes that sentiment, noting most community hospitals “react to bad metrics, such as low HCAHPS scores. To get the most support possible,” he says, “design a QI program that people see as a genuine problem that needs to be fixed using their resources.”
Experience is another barrier to community-based QI projects. Dr. Gundersen believes that hospitalists who want to get involved in quality should first join a QI committee.
“One of the best ways to effect change in a hospital is to get to know the players—who’s who, who does what, and who is willing to help,” he says.
Arnu Mohan, MD, chief medical officer of hospital medicine at ApolloMD in Atlanta, agrees with gaining experience before setting out on your own.
“Joining a QI committee is almost never a bad idea,” Dr. Mohan says. “You’ll meet people who can support your work, get insight into the needs of the institution, be exposed to other work being done, and better understand the resources available.”
Choose Your Project Carefully
Dr. Gundersen recommends that before settling on a QI project, hospitalists should first consider what their career goals are.
“Ask yourself why you want to do it,” he says. “Do you have the ambition to become a medical director or chief quality officer? In that case, you need a few QI projects under your belt, and you want to choose a system-wide project. Or is there just something in your everyday life that frustrates you so much you must fix it?”
If the project that compels the clinician is not aligned with the needs of the hospital, “it is worthy of a discussion to make sure you are working on the right project,” he adds. “Is the hospitalist off base, or does the administration need to pay more attention to what is happening on the floor?”
A QI project has a greater chance at being successful if the participants have a high level of interest in the initiative and there is visible support from the administration: high-level people making public statements, making appearances at QI team meetings, and diverting resources such as information technology and process mapping support to sustain the project. This will only happen if community-based hospitalists are successful at selling their project to the C-suite.
“When you approach senior management, you have only 15 minutes to get their attention about your project,” Dr. Weiner says. “You need to show them that you are bringing part of the solution and your idea will affect their bottom line.”
Jeff Brady, MD, director of the Center for Quality Improvement and Patient Safety, says organization commitment is key to any patient safety initiative.
“In addition to the active engagement of leaders who focus on safety and quality, an organization’s culture is another factor that can either enable or thwart progress toward improving the care they deliver,” he says. “AHRQ [the Agency for Healthcare Research and Quality] developed a collection of instruments—AHRQ Surveys on Patient Safety Culture—to help organizations assess and better understand facilitators and barriers their organizations may encounter as they work to improve safety and quality.”2
Politics also can be a factor. Dr. Gundersen points out that smaller hospitals typically are used to “doing things one way.”
“They may not be receptive to changes a QI program would initiate,” he says. “You have to figure out a way to enlist people to move the project forward. Your ability to drive and influence change may be your most important quality as a physician leader.”
Dr. Mohan believes that the best approach is to find a mentor who has worked on QI initiatives before and can champion your efforts.
“You will need the support of the hospital to access required data, change processes, and implement new tools,” he says. “Many hospitals will have a chief medical officer, chief quality officer, or director of QI who can serve as an important ally to mobilize resources on your behalf.”
Go Beyond Hospital Medicine
Even with administrative support, it is better to assemble a team than attempt to go it alone. Successful QI projects, Dr. Mohan says, tend to be team efforts.
“Finding a community of people who will support your work is critical,” he adds. “A multidisciplinary team, including areas such as nursing, therapy, and administration, that engages people who will complement one another increases the likelihood of success.
“That said, multidisciplinary teams have their challenges. They can be unwieldy to lead and without clear roles and responsibilities. I would recommend a group of two to five people who are passionate about the issue you are trying to solve. And be clear from the beginning what each person’s role is within the group.”
Support can also be found in areas outside of the medical staff.
“Key people in other hospital departments can assist with supplying data, financial solutions, and institutional support,” Dr. Mohan says. “These people may be in various departments, such as quality improvement and case management.
“In the current era of value-based purchasing, where Medicare reimbursement is tied to quality metrics, it’s advantageous to show potential financial impact of the QI initiative on hospital revenue, so assistance by the CFO or others in finance may be helpful.”
Dr. Gundersen suggests hospitalists seek out a “lateral mentor,” someone in a department outside the medical staff who is looking for change and can offer resources.
“For example, physicians are looking for quality improvement, and those in the finance department are looking for good economic return. Physicians can explain medical reasons things need to be done, and the finance people can explain the impact of these choices,” he says. “Working together, they can improve both quality and the bottom line.”
Lateral mentoring also is an effective way to meet the challenge of obtaining accurate data, as it opens up the potential to mine data from various departments.
“At different institutions, data may reside in different departments,” Dr. Epstein says. “For example, patient satisfaction may reside with the CMO, core measures or readmissions may reside with the quality management department, and length of stay may be the purview of the finance department.”
Connections in other departments could be the source of your best data, according to Dr. Epstein.
Consider Incentives, Penalties
In addition to buy-in from administration and professionals in other departments, hospitalists also need the commitment of fellow clinicians. Dr. Weiner believes the only way to do this is through financial incentives.
“In a community setting, start with a meaningful reward for improvement. It must be enough that the hospitalist makes the QI project a priority,” he says.
Dr. Weiner also recommends a small penalty for non-participation.
“Most providers realize QI is just good practice, but for some individuals, you need a consequence. It must be part of the system so it isn’t personal,” Dr. Weiner says. “One way is to mandate that if you do not participate, not only do you not get any of the incentive pay, you might lose some of a productivity bonus. You need to be creative when thinking about how to promote QI.”
In the community hospital setting, Dr. Weiner says, practicality ultimately rules.
“The community hospital has real problems to deal with, so don’t make your project pie-in-the-sky,” he says. “Tie it to the bottom line of the hospital if you can. That’s where you start.” TH
Maybelle Cowan-Lincoln is a freelance writer in New Jersey.
- Cawley P, Deitelzweig S, Flores L. The key principles and characteristics of an effective hospital medicine group: as assessment guide for hospitals and hospitalists. J Hosp Med. 2014;9:123-128.
- Surveys on patient safety culture. AHRQ website. Accessed October 12, 2015.
- AHRQ Quality Indicators Toolkit for Hospitals: fact sheet. AHRQ website. Accessed October 10, 2015.
- Practice facilitation handbook. AHRQ website. Accessed on September 25, 2015.
- 5. SHM signature programs. SHM website. Accessed October 10, 2015.