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Innovations for the Hospital Medicine Adventure


 

Spring and summer are the seasons of hope and promise. A time when seedlings turn into harvests, when every baseball team has hope, when things seem fresh and new. Hospital medicine is a specialty of hope and promise, of better things in the future. Hospitalists have the potential to change the course of medical care in the acute setting. Right now there are glimmers of this promise turning into realities.

We are seeing centers of experimentation as healthcare institutions and their visionary leaders use their ideas and energies to pilot test what may eventually be common changes throughout the country.

First Hospital Medicine Unit Being Built

In Rockford, Ill., the first Hospital Medicine Unit in Illinois—and possibly the country—is under construction. With a heritage as one of the first hospital medicine groups in Illinois, Rockford Health System is no stranger to innovation. They are currently framing the physical plant for a 17-bed hospital medicine unit and putting this right next to an ICU.

This unit will incorporate many of the accoutrements central to the design elements from the Hospital of the Future project that SHM is involved in with JCAHO and the Robert Wood Johnson Foundation. This plays into the SHM vision of the hospital of the future as patient centered, built on measurable quality, and delivered by teams.

All the rooms will be private with a healing environment incorporating the values of aesthetics, including restful light and sound. The design is set to promote communication and contact between the healthcare team and the patients and their families.

This unit will enhance efficiencies and quality care by concentrating hospitalists’ patients on one dedicated unit. The intent is to use this physical environment to create and reinforce a stronger team approach among hospitalists, nurses, pharmacists, therapists, and the rest of the healthcare team. There will be an opportunity to pilot new technology and treatment protocols to find out what works and what doesn’t. There will also be an opportunity to increase patient and family satisfaction.

As Lars Armainsson, chairman of the Rockford Hospital Medicine Department, says, “We’re pioneers in the way that we are transforming the way care is delivered, using the most advanced and sophisticated practice model to accommodate the 21st century.”

SHM, the rest of hospital medicine, and the C-suite of other hospitals will be waiting to hear how the Rockford Hospital Medicine Unit plays out. We hope the lessons learned there will soon provide a beacon of clarity for others to follow.

In an era calling for evidence-based medicine, accountability, measured quality, teamwork, and a renewed emphasis on the patient, there are many stakeholders in healthcare rooting for (and even counting on) hospital medicine to turn promise into performance. We must not let the perfect be the enemy of the good.

Three-Year Hospital Medicine Residency Track

The crisis in internal medicine residency training and the poor results in the recent intern match have at least one internal medicine residency program taking extreme measures to redesign and remarket its program to today’s medical students.

A residency program director in the West has contacted SHM about the feasibility of creating the first internal medicine residency to train only future hospitalists. This program has experienced more than 75% of its recent graduates going into hospital medicine careers. The program leaders also believe that with a continually shrinking pool of applicants for all of internal medicine their resident recruitment would be enhanced if they marketed their residency as a dedicated training program for the future hospitalists; cardiologists and outpatient internists need not apply.

The program leaders envision basing the new internal medicine residency curriculum on the SHM Core Competencies in Hospital Medicine and meeting RRC requirements for 33% of the training being outpatient in focus by training the future hospitalists in working to help the emergency department physicians with decision making, opening an outpatient clinic for the first one to two post-discharge follow-up visits, and starting an IMPACT clinic (such as the one started by hospitalists at the Cleveland Clinic) to evaluate preoperative patients.

This new residency program would also promote training in systems approaches, epidemiology, quality improvement, information technology, team building, leadership, and management.

The hope is that by narrowing the focus, this residency can attract better applicants, focus the training on a specific type of future internist, and have their graduates viewed by hospitalist employers as very desirable candidates for future hospitalist jobs.

Obviously, this revolutionary approach is a delicate path to walk. Because this is an idea working its way through its home institution, I have agreed to be purposely vague about where this is being investigated for now. Like the executive leadership at Rockford Health System, if the leadership of this hospital and medical staff can be equally visionary, I expect they will be looking for SHM and everyone else to promote this unique internal medicine residency and get the word out.

Mentored Implementation for QI

Not to be left out, SHM is doing its part in creating innovations to move forward hospital medicine’s agenda of change.

SHM has recently obtained two years’ worth of support from The Sanofi-Aventis Group to create and implement a mentored process to develop the hospitalist leaders who will be trained to measure and improve the quality of care that their hospitals deliver—especially in DVT prevention and treatment. Once these skills are learned, we hope that the same precepts can be used for other disease states that hospitalists manage.

This approach is modeled on similar approaches that have been successful in extending the reach of palliative care training. SHM’s idea is to select 10 outstanding hospitalist leaders and train them to do two fundamental things:

  1. Use SHM QI tools to measure and improve quality at their institutions; and
  2. Be trained to mentor future hospitalist leaders.

SHM would then use these initial 10 mentors to train another 30 hospitalist leaders (three for each initial mentor) in QI and potentially as future mentors.

Using this initial two-year project as a learning guide for process improvement and to develop the first cadre of quality mentors, the next step might be to ask for support from a foundation such as Hartford Foundation or Robert Wood Johnson Foundation—or a governmental agency such as the Agency for Healthcare Quality and Research—for broader funding to expand this initiative to 100 or even 500 sites. The goal would be to create a framework that would develop a hospitalist leader trained to lead the quality initiatives at every hospital in the country.

There are other partnerships that SHM is exploring to make this a reality. Recently SHM senior staff and leadership traveled to Boston to meet with senior leadership at the Institute for Healthcare Improvement (IHI). During those meetings, IHI CEO Don Berwick called hospitalists the “army for quality improvement implementation in our nation’s hospitals.” Ambitious undertakings like SHM’s mentored implementation project will be needed to export the well-known and well-documented knowledge of quality improvement and translate this down to the bedside.

Hospital medicine today is much more potential than reality. The history of American innovation is littered with ideas that failed because of issues with scope, scalability, or poor timing. In an era calling for evidence-based medicine, accountability, measured quality, teamwork, and a renewed emphasis on the patient, there are many stakeholders in healthcare rooting for (and even counting on) hospital medicine to turn promise into performance. We must not let the perfect be the enemy of the good. The status quo is just not good enough, and we will need to be risk takers and adventuresome to achieve great things.

In his book Organizing Genius: The Secrets of Creative Collaboration, Warren Bennis explores the success of such diverse enterprises as the development by Apple of the Macintosh, the engineering mastery at Lockheed Martin’s Skunk Works of the stealth aircraft, the Manhattan Project that developed the nuclear bomb, and Disney’s creation of animated feature films (e.g., “Snow White”) and found that an adventurous spirit was critical element. Adventure was defined as “risk, jeopardy, a daring feat, encountering a hazardous enterprise.”

Hospital medicine is on no less of an adventure. The prize at the end of the journey is better healthcare for our communities. Hospitalists are the soldiers in this battle. Whether you are the general or the foot soldier, we must all help prevail. SHM will be there to do its part. TH

Dr. Wellikson has been CEO of SHM since 2000.

LETTERS

Correction

In the April 2006 issue we inadvertently misspelled Norma Melgoza’s name in “Start Me Up,” p. 1. It was listed as “Malgoza” instead of “Melgoza.” We apologize for the error.

Praise for Families Article

Thanks to Gretchen Henkel for her timely and thorough article on dealing with the families of hospitalized patients (“The Challenge of Family,” April 2006, p. 23). This is an overlooked and under-appreciated aspect of communication. Involvement of family members is a dimension that defines “Patient Centered Care.”1 The expectations of family members related to decision-making and treatment plans must be met to achieve satisfactory service outcomes including patient satisfaction.

From a risk management standpoint, poor communication is cited as a frequent cause for plaintiff malpractice concerns. Often family members bring lawsuits on behalf of deceased or disabled patients.

Practical communication tools include proactive phone calls to family members not present at the usual rounding times, or an extra bedside visit when they are available. These types of services offer more than patients and families expect and can result in high levels of patient satisfaction.2

Patrick J. Torcson, MD, MMM, FACP

Director of Hospital Medicine

St. Tammany Parish

Hospital, Covington, La.

  1. Gerteis M, Edgman-Levitan S, Daley J, et al. Through the Patient’s Eyes. San Francisco: Jossey-Bass; 1993.
  2. Torcson PJ. Patient satisfaction: the hospitalist’s role. The Hospitalist. 2005; July/Aug:27-30.

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