The vision of a re-engineered hospital with patient-centered care, delivered by a fully empowered team of professionals, which is data driven with clear quality measurements, where better performance is rewarded by better compensation is coming to a hospital near you during your professional career. And SHM and hospitalists are at the center of this revolution in the care of the acutely ill patient.
Hospitals are complex organizations with many moving parts and many unique constituencies often with different and, at times, competing definitions of success. What is clear is that even though many people have been talking about rewarding quality or making the hospital work for the patient, the current system is primarily physician centered and driven by increasing units of activity rather than how well a job is done. If we had the ideal system the patient would be able to demand that the physician appear when he wanted him to and we would be paying more for the best quality of care.
In order to change this complex system many institutions will need to be overhauled. The physical plant of the hospital may need to change from the noisy centralized nurses’ station where the health professionals congregate to a place designed to have data and nurses and doctors at the bedside. This would be the first concrete step to get the important members of the team (physicians, nurses, pharmacists, therapists) closer to the patient and closer to each other. The next step is to figure out how best to use everyone’s knowledge and perspective of the patient to provide more efficient and more effective care. SHM is working with Robert Wood Johnson Foundation and others on this initiative.
We will need to shift the data we collect from being mostly about getting paid to more about measuring how good a job we are doing. And while we are at it, it would be good if we could agree on what should be measured and if we could create a constant format so we can compare performance between institutions and groups. It would also be nice if physicians would agree to even be measured, and even better if physicians would be active participants in validating and responding to the data.
Then we would need to get the payers, the businesses and the insurers, and the government to care enough about quality to put their money where their measurements are and start paying for better performance rather than for more units of service (e.g., more visits, procedures, or surgeries, no matter the indications or the outcomes).
Before you start thinking this is the raving of someone who wants manna from heaven, let me point out what is happening right now in 2005.
SHM has partnered with the Critical Care Institute of the American College of Chest Physicians (ACCP), the American Association of Critical Care Nurses (AACCN), the American Society of Health System Pharmacists (ASHP), and others to form a Critical Care Collaborative. Together these organizations represent over 100,000 healthcare professionals and through their leadership will work towards designing a more patient-focused approach that relies on communication and cooperation from the entire team responsible for delivering patient care. The goal will be to design and test models of care, as well as to increase recognition and awareness of existing models by tapping into the resources of the participating organizations. Efforts will be directed at all elements of the system including the point of care, support systems (IT), administration, payers, and regulatory bodies.
SHM is also actively participating in quality and team-based initiatives with the endocrine societies and the cardiology communities. This will lead to a new way of managing care in diabetes, heart failure, coronary artery disease, and deep vein thrombosis and pulmonary embolism.
On a national level President Bush has appointed David Brailler as the “health IT czar” with the charge to expand and integrate the information capabilities in health care. This coupled with the work being done at the National Quality Forum by Ken Kizer and others will lead to practical front line applications of standards of care and the ability to measure our performance in the reality of today’s hospital.
And even the payers are getting into the mix. The new buzz words are “pay for performance” and it is all the rage. CMS and others are well into beta test programs to see just how this would play out. Peer pressure and restriction of privileges have been the only concrete drivers to improve quality in the past. The prospect that demonstrable, measurable better care will translate into more compensation or greater market share is being tested in today’s hospital.
This is not a pipe dream or a Ralph Waldo Emerson essay. These initiatives are being driven by capable action oriented leaders who have a history of making change happen. And hospitalists, who for the most part are in the beginning of a 20 to 30-year professional career, are primed to play significant roles in this changing dynamic.
In the most basic way, today’s 12,000 hospitalists and the next 20,000 who will join us in the coming years must be much more than just willing participants to make this fly. Sure hospitalists will be the effector arm of health system change in their hospitals, but hospitalists must have
the skills and the vision to help shape this better day in health care. Hospitalists need to embrace the patient-centered, performance-driven acute care system. Hospitalists need to demand care delivered by teams and have the leadership skills to help these teams manage and lead change.
This wasn’t taught in medical school or residency, but that doesn’t matter. Hospital medicine as a new specialty has arrived coincident to (or by design at) a special moment in health care. Our patients have expectations of excellent care. There are plenty of resources available to do the best job. We just aren’t organized to be the best that we can be. But this will all be sorted out in the coming years. It is an exciting time to be a health professional, and hospitalists are at the center. And SHM has the vision and will have the programs to help our hospitalists be an important part in creating this new era of health care.