Medicolegal Issues

PSTF Monitors Quality


In spring 2006 SHM leadership agreed that there was a need to develop a coordinated approach to working with external organizations in the performance and standards quality arena, while collaborating with public policy and educational efforts in this area. To this end, I was hired as the SHM Senior Advisor for Quality Standards and Compliance. At around the same time, leaders from the Public Policy Committee (PPC) and Health Quality Patient Safety (HQPS) Committee joined to form a Performance and Standards Task Force (PSTF).

Purpose of the Task Force

Chaired by Patrick Torcson, MD, the PSTF works with staff to monitor the performance and quality landscape at national organizations charged with the measure development and consensus-building processes, as well as to outreach and develop liaison relationships with other professional medical societies and organizations. Ultimately, the task force wants to create a performance framework unique to and reflective of hospitalists.

Since its inception in the late spring, the PSTF has had several meetings to discuss which organizations SHM should engage with and at what level. In several cases, task force members agreed that an official member liaison should be appointed to serve as SHM’s representative to a particular organization. This serves the purpose of having a clinical expert resource available to staff with regard to the particular activities of each organization, as well as to create a consistent and reliable “SHM face” for a particular organization.

Performance Measures

SHM joined the AMA Physician Consortium for Performance Improvement (PCPI), which works with medical specialty organizations to develop physician-level performance measures. As a new member of the PCPI, SHM submitted feedback during the public comment period on perioperative care measures, the development of which was led by the American College of Surgeons, along with input from other medical specialties. SHM also participated in two expert workgroups this past summer, one on emergency medicine, focusing on treating MI and pneumonia, and another on geriatrics, which focused on falls, urinary incontinence, advanced-care planning as part of end-of-life care, and medication reconciliation as part of care coordination. Both the geriatrics and the emergency medicine measures have been released for public comment. At least through 2006, the PCPI is focusing on measures that fall under the Centers for Medicare and Medicaid Services (CMS) contract and will be included in the Physician Voluntary Reporting Program (PVRP).

The PSTF is actively recruiting leaders to participate in expert workgroups that were convened in November for both outpatient parenteral antimicrobial therapy and anesthesiology topics: perioperative normothermia and critical care. The task force will continue to evaluate the PCPI workgroups to determine which ones it should appoint members to participate in, depending on the topic area.

SHM has also become an organizational member of the National Quality Forum (NQF), a nonprofit organization that Congress, in early July, charged with endorsing consensus-based national standards for measurement and public reporting of healthcare performance data. At around the same time, NQF was seeking nominations for members of the steering committee and technical advisory panels that will oversee the work on the development of new consensus standards for hospital care. This project, sponsored by the Agency for Healthcare Research and Quality (AHRQ), will address patient safety, pediatrics, and inpatient care. The Society hopes to be fully engaged in this initiative.

In mid-October, NQF will hold its 7th Annual Meeting, a National Policy Conference on Quality, at the Grand Hyatt in Washington, D.C. This meeting will feature plenary sessions that focus on issues at the forefront of policy discussions, including incentivizing healthcare quality improvement, the role of policymakers, ways to lead professional and trade associations in improving healthcare quality, and efforts presently underway in the federal government to foster healthcare improvements. Mark Williams, MD, editor in chief of the Journal of Hospital Medicine and SHM member, will attend the policy conference as the SHM representative.

Quality Care Liaisons

In addition to fostering liaisons with organizations like PCPI and NQF, the PSTF has discussed the importance of exploring relationships with other groups, including CMS, the American College of Physicians (ACP), the Ambulatory Quality Care Alliance (AQA), and others engaged in the quality care arena.

In late spring 2006 several SHM members and staff met with CMS to discuss its PVRP in relation to hospitalists. While SHM has endorsed the PVRP, recommending that hospitalists register their intent to report and begin reporting on relevant performance measures to the extent practicable, it is clear that the 16 measures used in the PVRP have limited relevance for hospitalists because most measures used for internal medicine deal with services provided in the ambulatory setting.

Specifically, only two of the 16 measures apply to services billed by hospitalists and those only on a limited basis: aspirin on arrival for myocardial infarction and beta-blocker on arrival for MI have G-codes that can be used with the evaluation and management codes appropriate for hospitalists. In its follow-up letter to CMS staff thanking them for their time, SHM leadership also included recommendations that would expand the current number of PVRP measures that hospitalists could report on from two measures to seven.

SHM has also shared the above quality and performance improvement agenda with the staff of the ACP as well as their quality subcommittee, who have found it to be “well-reasoned and straightforward.” We anticipate having more in-depth discussions with the ACP as our quality agenda evolves.

In August, the Ambulatory Care Quality Alliance (AQA) and the Hospital Quality Alliance (HQA) joined forces to form a Quality Steering Committee in order to better coordinate the promotion of quality measurement, transparency, and improvement in care across hospital and ambulatory care settings. The PSTF is currently pursuing participation in one of the new AQA/HQA workgroups created by the steering committee, which would focus on harmonization of measures across settings.

SHM staff have also reached out to the Society of Critical Care Medicine, the Joint Commission on Accreditation of Healthcare Organizations, and the American Hospital Association to ascertain what these groups are doing in terms of quality and measure development, as well as to see how to align our efforts more closely.

In its work with all of these groups, the task force endeavors to ensure the development of performance measures that more accurately reflect services provided by hospitalists.

2007 Goals

The HQPS has developed a mechanism whereby they review measures proposed by a variety of organizations in order to evaluate which measures are relevant to individual clinicians as compared with institutional measures. It is PSTF’s goal (in conjunction with the HQPS, the PPC, and others) to recommend to the SHM board of directors which physician-level disease-specific measures are relevant to individual hospitalists and to identify where the gaps are. It hopes then to influence the scope of development of care coordination and other hospital-level measures that are in the pipeline, whether working through groups like the PCPI by taking the lead on an expert workgroup, by using the NQF consensus-building process, or by forming other key partnerships with groups like those noted above. It is likely that this work will be accomplished by some combination of these strategies.

Stay tuned for next month’s “SHM Behind the Scenes” by SHM Senior Vice President Joe Miller.

Epstein is the senior advisor for Standards and Compliance at SHM.

SHM Chapter Updates


On September 6, the Chicago chapter held a meeting at the Carnivale Restaurant and elected new officers. Tarek Karaman, MD, who will serve as president, announced plans for the next year and thanked the existing officers. This was followed by a lecture on MRSA infections. The evening was sponsored by Cubist Pharmaceuticals.

Pacific Northwest

The Pacific Northwest Chapter of SHM met Wednesday, September 20, at the Columbia Tower in Seattle. The chapter’s meeting was an open forum panel discussion in which attendees submitted questions. The panel consisted of representatives from four different hospital medicine groups. More than 40 attendees represented six HMGs. The Pacific Northwest Chapter’s September event was supported by Ortho-McNeil and Schering-Plough.

San Diego

San Diego’s most recent chapter dinner was held on September 14 at Roy’s in La Jolla. A presentation by Alpesh Amin, MD, of the University of California at Irvine, entitled “The Burden of MRSA in the Hospital Setting,” stimulated a lot of discussion and debate regarding the rapid expansion of MRSA in the U.S. and possible ways to control and contain it. Continuing Medical Education credit was provided to all attendees by RXperience through the University of Kentucky (Lexington).


The quarterly meeting of the Atlanta SHM Chapter took place on September 20 at Maggiano's Little Italy Restaurant in Buckhead. The keynote speaker was Michael Heisler, MD, MPH, associate professor of medicine, Emory University School of Medicine, and medical director, Hospital Medicine Service, Emory Eastside Medical Center, Atlanta. Attendees found Dr. Heisler's presentation, “Medical Emergency Team/Rapid Response Team: Pre-empted Strike: Saving Lives, One at a Time” concise, evidence-based, and tailored to everyday practice.

The keynote presentation was followed by a panel discussion. The panel included Martin Austin, MD, medical director, Hospital Medicine Service, Gwinnett Medical Center, Atlanta, and Cathy Wood, RN, director, Medical and Surgical Nursing Services, Emory Healthcare, Atlanta. Val Apokov, MD, medical director, Hospital Medicine Service, Emory Crawford Long Hospital, Atlanta, provided the introduction and discussion moderation.

Attendees represented many major medical centers in the metropolitan Atlanta area, including Emory Eastside Medical Center, Emory University Hospital, Emory Crawford Long Hospital, Children's Healthcare of Atlanta, Piedmont Hospital, Gwinnett Medical Center, and DeKalb Medical Center. The meeting was supported by Sanofi-Aventis.

2005-2006 Survey Factoid

Use of PAs and NPs in hospital medicine groups

  • Thirty percent of all hospital medicine groups (HMGs) employ nurse practitioners (NPs) and physician assistants (PAs).
  • Those groups, on average, have 11.2 physicians and 2.8 NPs/PAs. The 70% of groups without NPs/PAs average 7.9 physicians per group.
  • The following types of groups are more likely to employ NPs/PAs: academic programs, groups in the eastern U.S., and groups more than 5 years old.
  • The frequency with which NPs/PAs perform certain functions in HMGs is summarized in this table:

NP/PA Function - % of HMGs

  • Round daily on hospitalized patients - 83%
  • Write prescriptions for patients - 82%
  • Perform H & Ps upon admission - 77%
  • Act as initial responder (consults, admits) - 66%
  • Participate in discharge planning - 66%
  • Order specialty consultations - 53%
  • Assist in teaching students - 33%
  • Night or weekend call - 30%
  • Post discharge follow-up calls - 20%
  • Emergency response; Code Blue - 14%
  • Perform invasive procedures - 11%

Source: SHM’s 2005-2006 “Biannual State of the Hospital Medicine Movement” survey.

Conference Review

Kaiser Permanente Hospital Medicine Conference

On September 7-8 the 8th National Kaiser Permanente Hospital Medicine Conference took place at the Paradise Point Resort & Spa in San Diego. The conference offered participants a maximum of 14 AMA Physician’s Recognition Award (PRA) Category 1 credits. SHM representatives were present at the event to answer any questions about membership and to increase support and awareness for the hospital medicine movement. Conference attendees were given pertinent materials on the movement and copies of SHM educational supplements.

Throughout the conference, SHM held a drawing for a $100 gift certificate to the newly launched SHM Store (; click “SHM Store”). The store is the place to order everything SHM, from meeting registration and membership to educational products and SHM logo apparel.

SHM would like to congratulate Lorraine A. Eubany, MD, the winner of the SHM Store drawing. Thank you, Dr. Eubany, for visiting with us at the Kaiser Conference in San Diego. TH

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