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The Front Line of Change


We are in the midst of a true evolution of how hospitals will approach creating a culture of quality. The drivers for process improvement and management of resources have traditionally been more concerned with full occupancy and risk management, but now many external forces are raising quality improvement as a potential core competency for our nation’s hospitals.

With the push of the Institute for Healthcare Improvement (IHI), Leapfrog, and even Medicare, hospitals now must grapple with a culture change—one in which measurement and reporting of outcomes and processes will become, if not truly job one, at least in the top five. The fact that a hospital’s revenue stream through pay-for-performance (P4P) bonuses and its reputation by public reporting are at stake only serve to create a real immediacy in the coming years.

A recent SHM survey of the leaders of hospital medicine groups (HMGs) has shown that, once again, hospitalists find themselves right smack in the middle of quality improvement.

Survey Says

More than 41% of hospitalist leaders report that their HMG has a quality incentive program. This is even more prevalent at hospitals participating in P4P programs, where 60% of HMGs have quality incentives to align priorities. It is a hallmark of hospitalist groups to place a particular emphasis on the process and system improvement necessary for true measurable quality improvement. Many times, this improvement takes time away from direct and billable patient care.

Pointing to the relatively early stage in the adoption of P4P, this same survey reported that only 29% of HMGs were working in hospitals that participated in P4P programs, while 56% report their hospital did not have any P4P programs in place.

As we enter 2007, it is clear that while a small percentage of hospitals have embraced P4P the majority of hospitals are—at best—on the sidelines or still in planning mode. But those who are active in P4P have engaged their hospitalists to help them meet their goals. And everything that is coming out in the literature commonly read by the hospital C-suite promotes the promise of more reimbursement from the insurance industry and Medicare, leading to the conclusion that P4P and rewarding performance will increase in the near term.

Hospitalists are on the front line of change. Our patients, our institutions, our fellow physicians, and the other members of the healthcare team want and need a better system.

What Can SHM Do for You?

Positioning hospitalists to play a key role in quality improvement, SHM has launched a number of initiatives and partnerships to provide hospitalists with the tools they need to help their hospitals to succeed.

As a framework of tools, SHM has now built six Web-based Quality Improvement Resource Rooms in VTE, Heart Failure, Stroke, Glycemic Control, Care Transitions in the Elderly, and Antibiotic Resistance. These practical tools and references are now available on the SHM Web site ( as are, in many cases, a comprehensive workbook that helps hospitalists to be the leaders of quality improvement change at their hospitals.

SHM realizes that, while this approach may work for the savvy, experienced quality improvement (QI) implementer, most young hospitalist leaders need a more personal, hands-on approach. With this in mind, SHM has launched its Mentored QI Implementation project. Centered around VTE prevention and supported by funding from Sanofi-Aventis, two senior hospitalist mentors will each work with 15 HMG leaders to take them step by step through the process of implementing a quality improvement process in 2007 and 2008.

To take this hands-on, supportive approach to the next level SHM (with support from a Kettering Foundation grant) will add the capability for on-site consultation—sort of a QI SWAT team that can show up at your hospital and work shoulder to shoulder with hospitalists and other members of the healthcare team to develop and implement processes that will improve patient care.

To further educate and energize hospitalist leaders who have been charged with leading this change, SHM developed the Leadership Academy. To date more than 400 hospitalist leaders have been trained in sold-out small-group sessions during the past two years. The most recent academy was held last month in Orlando, Fla.

SHM provides additional training for those who will implement quality improvement at the Quality Training precourse at the SHM Annual Meeting. In the precourse up to 100 change leaders get hands-on direction, tools, and tricks of the trade to allow them to succeed in their local efforts. The next Quality Training Precourse will be held in small group sessions on May 23, 2007, in Dallas.

The SHM Annual Meeting has consistently been a venue that allows hospitalists to hear from national thought leaders in the quality revolution. In 2006, hospitalists heard from Carolyn Clancy, MD, CEO of the Agency for Healthcare Research and Quality, and Jack Rowe, MD, CEO of Aetna Insurance Company.

At this year’s meeting Jonathan Perlin, MD, PhD, who led the cutting edge QI efforts at Veterans Affairs and who is now bringing innovation to HCA (Nashville, Tenn.), the nation’s largest hospital company, will share his ideas with us. In addition, hospitalists will hear from David Brailer, MD, PhD, President George W. Bush’s first appointee to head up national efforts for health information technology. In addition, SHM’s Bob Wachter, MD, a nationally recognized leader in QI and patient safety, will share his perspectives on hospital medicine. With Drs. Perlin, Brailer, and Wachter, SHM continues its tradition of placing innovations that are changing healthcare for the better front and center at our annual meeting.

As for the future, SHM has submitted a multi-year grant application to the Hartford Foundation (Conn.) to expand our efforts—specifically in developing implementation strategies to improve the care processes and outcomes for the senior population.

One of the key areas that emerged from SHM’s work with the Hartford Foundation is the importance of improving the transitions of care and better coordinating healthcare from the patient’s point of view. This has led SHM to partner with several national organizations to make sense of what has been a squishy subject. SHM is working closely with the American Board of Internal Medicine (ABIM) Foundation on its Stepping Up to the Plate consortium, a group of specialty physicians focusing on best practice strategies in patient-centered transitions, hand-offs, and information transfer.

In addition, SHM is working with the American College of Physicians, the AHRQ, the ABIM, the American Geriatrics Society (AGS), and the Society of General Internal Medicine to hold a National Consensus Conference in 2007 to establish policy on transitions of care. The conference will involve a broad range of stakeholders and may very well lead to the establishment of performance standards that can be applied directly to patient care.

Also SHM has been working with the Case Management Society of America to bring together the broader healthcare team on its National Transitions of Care Coalition (NTOCC) project. NTOCC includes pharmacists (American Society of Health-System Pharmacists), the C-suite (American College of Healthcare Executives), social workers (National Association of Social Workers), geriatricians (the AGS), the Joint Commission on Accreditation of Healthcare Organizations, and others. NTOCC plans to develop clear tools, guidelines, and pathways for consistent communication among patients, providers, and payers throughout the care continuum, and to look at aligning incentives for use of these tools and resources.

SHM has also worked with recognized leaders in action-oriented campaigns in QI, including the IHI—first on its “100,000 Lives Campaign,” and more recently on its “5 Million Lives Campaign.” In fact, leadership from only one medical professional society—SHM—was on the stage with Don Berwick for IHI’s national announcement at the December 2006 IHI national meeting in Orlando.

Hospitalists Lead the Charge

It is clear that our nation’s hospitals will be incentivized and mandated to create processes and produce outcomes based on national performance standards and data. This will require a re-engineering of the hospitals and their medical staffs. Hospitalists will be charged (as part of their job description) to be physician leaders in making this happen. Unfortunately, their training in medical school or residency has not provided them with all the skills in QI measurement or implementation that they will need. That is where SHM comes in.

Whether developing tools and workbooks or developing educational and implementation strategies, SHM will be innovative and on the cutting edge. Just as importantly, SHM will be on the lookout for like-minded organizations to partner with to raise the visibility and necessity of QI. We will not shy away from helping to set performance standards just because they may create initial discomfort with some of our members. We will not back off from developing creative strategies to push QI down to more than 4,000 acute care hospitals just because it is difficult and at times daunting.

Hospitalists are on the front line of change. Our patients, our institutions, our fellow physicians, and the other members of the healthcare team want and need a better system. There is no standing still. There is no turning back. The time is now. It is our turn, and hospitalists, with SHM’s help, are ready to step up and make it happen. TH

Dr. Wellikson has been CEO of SHM since 2000.

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