Community hospitals offer multiple opportunities for hospitalists to become involved in both quality assurance and quality improvement. To help steer the right approach and avoid possible missteps, it’s important to acknowledge the differences between the community and academic settings, according to two medical directors with whom we spoke.
For example, in the rural, 47-bed Riverside Tappahannock Hospital where Randy Ferrance, DC, MD, SFHM, is medical director for hospital-based quality, cost effectiveness is king.
“We live on a thin margin, and being sure we provide cost-effective care is the difference between having adequate nursing and not,” he says. It’s a critical difference from academic institutions, he notes, where “there is protected time to do QI, research, and administrative tasks.”
Dr. Ferrance advises those interested in tackling quality projects to “make sure that the project is tied to quality measures and that you’re being cognizant of the cost impact.”
Although much of the work around quality assurance and quality improvement in the community hospital setting is being tackled by nonphysician administrative partners, “those people are usually more than happy to develop a physician partner,” says Colleen A. McCoy, MD, PhD, medical director for hospital medicine at Williamsport (Pa.) Regional Medical Center, a part of the Susquehanna Health System.
“The idea is to look for quality projects where there is a quantifiable financial payoff to the hospital,” she says. That could be a Centers for Medicare and Medicaid Services (CMS) core measure or helping to rewrite an order set for new inpatient guidelines on stroke, as Dr. McCoy did at her hospital.
First Order of Business
Dr. McCoy has been actively engaged in quality initiatives since she joined Williams-port in 2012. She cautions new hospitalists to spend the first six months at their new job developing a reputation for clinical excellence and attention to detail.
“Having a reputation that is respected clinically opens many doors,” she says. As generalists, hospitalists interact with a wider variety of staff than specialists. This leads to broad early exposure to a diverse group of decision makers in your institution. “As a hospitalist, you can get a lot of credibility in your organization much sooner than, for example, a young cardiologist or a young gastroenterologist,” she notes.
It is also important for new hospitalists to be mindful of their position in the organization and to watch how their institutions work and operate, so that when they propose a project they are not doing so from a critical standpoint.
“Unrequested input is often seen as criticism,” she says.
Dr. Ferrance agrees. “It’s always a good idea to make sure we focus on processes and not on people in the process.”
Meeting the Mark
“If you want to leapfrog into doing things quickly, you have to be very savvy about the cost impact of your quality improvement,” continues Dr. McCoy. She and Dr. Ferrance advise those just getting started to consider tackling core measures that are reported to CMS or to identify other quality improvement projects that can be financially quantified.
Early on at Riverside Tappahannock Hospital, Dr. Ferrance participated in root cause analyses and developed (at that time) paper-based standard order sets with quality measures attached to them.
Because of her attention to detail during her orientation at Williamsport, Dr. McCoy, who had been a clinical instructor at Emory University and worked for Kaiser Permanente, quickly spotted some necessary omissions regarding DVT prophylaxis. She helped rewrite the ICU admission order sets, inserting a query for DVT prophylaxis. That one intervention helped to increase compliance on a CMS core measure.
Assess Advancement Ops
Is your community hospital open to QI projects? Dr. McCoy says candidates should ask direct questions during job interviews to assess a prospective employer’s approach to quality. She suggests two fair questions:
- Is it possible, within my first two years here as a junior staff member, to participate in a QI project?
- If I were successful in that venture, is this organization open and able to give me more opportunities in that field?
It is key for the medical director to know who in the administrative organization of the hospital would really appreciate a physician partner or physician champion for new projects. If young hospitalists are interested in such projects, they should make that known to their medical directors.
“Having the senior person in your group make a connection with your [administrative] partner is how things get done in the community medical center,” Dr. McCoy says.
Dr. Ferrance’s HM group comprises four physicians and one nurse practitioner, so “there are plenty of QI projects to go around.”
“I would be more than happy to give them [junior staff hospitalists] any QI project they are interested in taking on,” he adds. “With medicine evolving as it does, we need to revisit processes every two to three years.” For example, drug shortages and cost increases often necessitate formulary cutbacks and the need for a change in administration protocols.
When selecting a QI project, it pays to stay ahead of the game, Dr. McCoy says. She encourages hospitalists to be aware of the next core measures and volunteer to help develop guidelines. She helped create a new protocol for inpatient tissue plasminogen activator (tPa) evaluation for acute stroke, which was a recent recommendation for stroke center certification. This approach was key in helping Williamsport retain its accreditation as a stroke center. The hospital has garnered multiple accolades from the Joint Commission, U.S. News and World Report, and other reporting agencies.
“The community setting is a much smaller world than academia,” she says. But smaller can be good for one’s career advancement. “If you hit a project out of the park and it makes your hospital look better, you can very quickly get a promotion or an increase in other opportunities. These types of projects may lead to the hospital asking, ‘Have you thought about being director of the hospital medicine group or taking a leadership role in hospital operations?’”
Gretchen Henkel is a freelance writer in California.