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Patient-Centered, Measurable-Quality, True Teamwork


I have mentioned in previous columns and often in public speeches that hospitalists will actively create and implement the hospital of the future. This is not an idle promise but an inevitability, and SHM is working actively with other key players to make this happen.

This new era will have as its hallmark 3 essential features:

  • Care will be patient-centered;
  • Quality standards will be met, measured, and documented; and
  • Hospital care will be delivered by empowered teams of health professionals.

If you think this is already the standard of care, you either practice in a utopian hospital that I am not aware of or your definitions are different than mine. Let me walk you through what I foresee.

“Hospitalists will be both the measured and the measurers [of quality].”

Patient-Centered Care

Today’s hospitals are set up, for the most part, to accommodate the physician rather than the patient. We live in an on-demand world where the “consumers” expect to have as much information as they want and to have it when they want it. When a patient at your hospital has a test performed, does someone stop by within the hour with the results and an explanation of what the results mean to the patient? When the patient first arrives, does someone on the healthcare team sit down and ask the patient what his or her expectations are for this hospitalization (e.g., cure, diagnosis, pain relief, a good death)? Does the patient have immediate access to caregivers (e.g., cell phone or pager numbers) and has he or she been genuinely told to “call me if I can help”? Do patients even know when their doctor will be back to see them?

Do their doctors talk to them in terms meant for the patient and not for grand rounds? Do they use words like “blood clot” rather than “deep vein thrombosis”? Do they understand that health literacy is a major problem for many of our patients?

If patients have a hospitalist as their care manager and if this hospitalist works in a state-of-the-art hospital medicine group, then maybe this is already happening. But hospitalists will need to make this happen, if this is ever to be a universal focus of our hospital care.

Quality Is Job 1

For the 30 years I have been a physician we have “talked” about quality. Any quality we have in our system is largely a function of the altruism and hard work of the healthcare professionals and advances in science. It certainly is not baked into the culture, the data collection, or the compensation structure. Today doctors are paid for doing more, not for doing better. In fact, there is almost no incentive for even knowing how good a job you do. Has anyone ever been denied payment or denied the ability to manage diabetes because they have never checked a glycohemoglobin?

This will change, and hospitalists need to be at the center of this revolution. There are forces amassing that may nudge this movement forward. Leapfrog and other forces in the business community are demanding that something happen, and soon. The National Quality Forum (NQF) is trying to set and enforce standards. There are rumblings of pay for performance (P4P), although I think this will translate more into paying less for poor performance. JCAHO, IHI, AHRQ, and so many others have projects centered around patient safety and quality improvement that just from sheer effort alone things will change.

At the same time, patients seem to have noticed all this commotion and wonder why all of a sudden there are so many concerns about both the safety of their hospital and the quality they receive in it. This is definitely on the radar screen.

Hospitalists will be both the measured and the measurers. We will need to work with others to decide what data will help tell us how well we are doing, what changes in the systems need to be installed to improve quality, and how to harness all the resources available to be better tomorrow than we are today.

True Teamwork

And this leads me to the third leg of this triad. Hospitalists and other physicians can’t do this alone, and we can’t do this under the old model where the doctor has the steering wheel and everyone else waits to see where the ship is going. This may evolve into more of an orchestra, where the physician is the conductor and others are the virtuoso musicians.

Current legal limitations aside, we markedly underutilize the perspective and expertise of nurses, pharmacists, social workers, therapists, and case managers. These other team members often know important information about our patients and about the hospital and available resources. If we had a seamless way to incorporate this knowledge base, patients would get better care, the entire team would feel empowered, and job satisfaction would improve for everyone.

Critical-Care Collaborative

For the past year, senior leaders from SHM have met with senior leaders from the American College of Chest Physicians (ACCP), the American Association of Critical Care Nurses (AACN), the American Society of Health System Pharmacists (ASHP), and representatives of respiratory therapy to examine our current management of acutely ill patients in the hospital and to develop plans to move to a new health system that is patient centered and team driven. AACN has started giving out Beacon Awards to hospital units that demonstrate these values. SHM will partner with ASHP in 2005 on joint research of teams of hospitalists and pharmacists. The Collaborative will look at any examples of collaborative efforts that are in place and working today.

Those of you who think this is pie in the sky should look back at some history. About 15 to 20 years ago, about 10 physicians got together and decided to make California smoke free. Our goal was to remove cigarettes from restaurants, businesses, and the work place by 2000. The doubters said we were up against a multibillion dollar industry and trying to outlaw an addictive substance. Today about the only public place you can still smoke a cigarette in California is out in front of a hospital.

Grand goals can happen when motivated people are willing to make them a priority. Making the patient the focus of health care, creating an environment where teams can flourish, and raising expectations for delivering a quality experience in every hospital will happen in my lifetime. And hospitalists (along with other key stakeholders) will be at the center of this effort. This is the right commitment at the right time. SHM will do our share, and we hope each of you will make this one of your core professional values.

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