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The HM Wishlist


What’s on your wish list for 2008? For many hospitalists, the list is full of cultural changes they’d like to see sweep through their institutions, prying loose old, entrenched habits and replacing them with new, efficient methods and practices. They’re changes that would improve patient safety and care and create better working conditions for physicians.

Those ideas don’t have to remain wishes. We’ve compiled a list of some of the top changes hospitalists say they’d like to see in the coming year, including ideas for how to implement them and some success stories to prove change is possible. Of course, it’s not easy.

“We had to work, and we had to work hard,” says Dr. William Ford, MD, director of the hospitalist program at Temple University in Philadelphia. It took major collaboration and a lot of face-to-face talks to create the cultural shifts he wanted to see at Temple, which partnered with Cogent Healthcare in 2006. But the work paid off, winning support for an observation unit from key stakeholders, such as residency program leaders and nurses.

Dr. Ford’s experience might inspire hospitalists who wish to improve the following critical facets of how hospital medicine is done:

1) Integrate hospitalists into policy-making bodies of institutions. Hospitalists work right in the thick of things, yet don’t often have a voice in their institution’s strategic planning, says Alpesh Amin, MD, MBA, FACP, professor and chief, general internal medicine, executive director and founder of the hospitalist program at the University of California, Irvine. Bringing hospitalists onto major committees would benefit everyone, he says.

Hospitalists have a vested interest in their institutions and a deep knowledge of it. They should be involved in operations, business development, and growth, Dr. Amin notes. That can mean growing the surgical business, increasing referrals, or meeting joint commission goals and requirements of the Accreditation Council for Graduate Medical Education (ACGME).

“Many of the bylaws of an institution have been created 10, 20 years ago, when there wasn’t such a thing as hospitalists,” so they don’t automatically get a seat at the table, Dr. Amin says.

But that should change, he argues, because today hospitalists affect every part of an institution. Hospitalists should sit on medical executive committees and contribute to discussions about bylaws, planning, business strategy, and more.

“The hospitalist is integral to helping a hospital improve operations and patient safety,” Dr. Amin says. “Having a permanent seat on the medical executive committee seems like a natural role for the hospitalist director to have.”

2) Reduce paperwork. Mark Thoelke, MD, clinical director of the hospitalist program and associate professor of medicine at Washington University School of Medicine in St. Louis, would love to put down his pen.

“I’ve been doing this job for 15 years now,” he says. “When I started, there was one piece of paper I’d fill out for admissions. [Now] we have to fill out 15 separate pieces of paper when we admit a patient to the hospital.”

Worthwhile and well-meaning patient process improvement groups tend to generate more paperwork for physicians, he points out.

“Nobody seems to want to complain about this because you’re going to be perceived as someone who’s against patient safety,” Dr. Thoelke says. “I feel very strongly about providing excellent patient care. But it makes it harder for me to take care of patients if I’m concerned about filling out multiple pieces of paper.”

To combat the paper flood, his institution has been using Lean Six Sigma, a business improvement strategy that addresses speed and quality. Admission forms are now in a single large packet available in one spot. Dr. Thoelke would like to see even more improvements.

“The end result of any committee is a new piece of paper that the physician has to fill out,” Dr. Thoelke says. “The perception is, it’s just one piece of paper. But it adds up to an incredible amount of time.”

3) Eliminate 24-hour shifts. Chris Landrigan, MD, MPH, studies the relationship between workplace safety and patient care, particularly the long hours residents tend to work.

In general, residents’ shifts are restricted to no more than 24 consecutive hours, plus up to six hours for paperwork and arranging patient care, according to the ACGME. Residents are to have 10-hour rest periods between duty shifts, and can work no more than 80 hours a week, averaged over four weeks.

“There’s no question that traditional shifts of 24 or more hours endanger residents and their patients,” says Dr. Landrigan director of the Sleep and Patient Safety Program, Brigham and Women’s Hospital, and research and fellowship director, Inpatient Pediatrics Service, Children’s Hospital Boston. “Twenty-four hour shifts are associated with an increased rate of serious medical errors, and residents frequently crash their cars on the way home from working these marathon shifts. In the last few years, I know of eight residents at Children’s alone who have had post-call crashes on the way home from work.”

In accordance with ACGME standards limiting residents’ work hours, hospitalists can encourage a cultural shift that would improve workplace safety and patient care, he says. “Hospitalists in some cases are the residency directors, or some of the key teachers, and have a lot of influence there,” he says. “They’re in a position to begin to challenge the traditional model, just as they have in other ways.”

Dr. Landrigan acknowledges this massive change will be slow to catch on, but it’s already started. At Brigham and Women’s Hospital, 24-hour shifts for surgical residents have been eliminated on most rotations, he says, and a few programs in New York, Ohio, and elsewhere have done the same. “The department of surgery at Brigham and Women’s viewed the data themselves, and they felt that this was an important issue,” Dr. Landrigan says. He plans to study the impact of eliminating 24-hour shifts in the surgical intensive care units at Brigham and Women’s.

4) Include leadership training in medical school curriculum. “When you go to medical school, you [learn] to make a diagnosis and interact with a patient essentially on a one-on-one level,” says Eric Howell, MD, assistant professor of medicine, faculty leader, Helen B. Taussig College, Johns Hopkins University School of Medicine in Baltimore, and the chairman of SHM’s leadership committee.

“But in the hospital, that teaching is almost counterproductive,” he explains. There, the physician-patient relationship expands into one with multiple players. The physician leads a team with the patient at its center that can include case managers, nurses, administrative staff, ancillary staff, social workers, and others.

Physicians get no training in school about how to manage multidisciplinary teams, or how to create change where change is needed; instead, they learn on the job, Dr. Howell says. At a summit in Chicago this fall, the Leadership Committee discussed the possibility of providing scholarships for residents to attend SHM’s leadership academies.

“That got a lot of positive reviews, even unofficially,” Dr. Howell says. “The other thing we’re doing is we’re trying to get the word out that many hospitalists have the tools to lead teams, and to manage teams, to non-hospitalist groups,” such as hospital administrators and the American College of Healthcare Executives. “We’re trying to get the word out that there are physicians in hospitals available to lead.”

5) Make “hospitalist” a specialty. Dr. Ford would like to see “hospitalist” recognized as a medical sub-specialty in 2008. As specialists, hospitalists would have specific training requirements and other benefits, he says.

“Right now, we’re a big black box,” Dr. Ford says. “There are no clearly defined guidelines for what we can and can’t do.”

A formal credential for hospitalists is closer to reality. The American Board of Internal Medicine (ABIM) has officially approved the creation of a Focused Recognition for Hospital Medicine through its Maintenance of Certification (MOC) system. The ABIM’s formal proposal to the American Board of Medical Specialties (ABMS) is expected to be approved by September 2008. SHM began pursuing certification three years ago and intends to reach out to the pediatric and family medicine boards so certification can be available to all hospitalists.

The move would help make “hospitalist” a more recognizable term in the medical community and in the public arena, says Dr. Ford. “We’re not just your stereotypical general practice doctor. I think we’re more than that. I’d like to promote more of a global perspective of what hospitals are: We make the best use of resources as well as provide the most up-to-date care.”

6) Break down silos and collaborate more. “Medicine in general really is traditionally a siloed field, and at our institution there has been a lot of effort to break down those silos and work collaboratively,” Dr. Howell says.

In 1999 and 2000, the Johns Hopkins Bayview Medical Center, where Dr. Howell works, addressed a major patient throughput issue by bringing together two large groups for negotiation: the emergency department (ED) and the department of medicine. Together they reduced ED waiting time by 90 minutes, Dr. Howell says. The collaborative process received national recognition and resulted in joint publications. They did it again seven years later, this time bringing five large groups to the negotiating table and reducing the wait time even more.

“Each of those groups had to give up something,” such as control over the process, and they had to agree to greater transparency, Dr. Howell concedes. “But in return, they got a lot more.”

Bayview used collaboration again to tackle the issue of ambulance diversion, known as Red Alert, to dramatic effect. In fiscal year 2006, the campus had 2,025 Red Alert hours. The following year, it was 503. Fiscal year 2008 had, as of October, zero Red Alert hours.

“For years, we had been trying to solve the problems individually,” Dr. Howell says. “Imagine if everybody were approaching problems from the teamwork perspective right away. This is a cultural shift that’s going to have to change, and I think it’s going to take a long time. But for hospitalist medicine, these things are already happening.”

7) Improve staffing and retention rates. It almost doesn’t matter how sophisticated hospital culture is overall if the institution still battles one crucial weakness: burnout.

“There is a true burnout factor to hospitalists,” Dr. Amin says. “A lot of institutions are challenged with having the appropriate staffing of hospitalists. Part of that boils down to economics.”

Dr. Amin understands that bumping up staffing is tough to promote when the additions don’t correspond with increased revenue. An appropriate staffing model takes into account a number of variables, including patient load, vacation schedules, and non-clinical duties such as teaching, academics, research, administration, and quality-improvement efforts, he says.

Hiring hospitalists is not like hiring a new primary care doctor or another specialist who might attract new patients to the institution, he says. “A hospitalist program will have the same volume of patients that need to be covered regardless. If a hospitalist goes on vacation, one can’t close the hospital.”

Yet stop-gap measures, such as double shifts when someone’s on vacation, only work for so long, he points out. “You can’t continue to keep doing that as you’re being asked to see more and more patients, do more and more teaching, do more and more oversight, and still do it with the same number of people.”

Hospitalists’ great reputations for providing more efficient care and decreasing length of stay may convince institutions it’s worth it to change their staffing models and add more people. “Hospitals are running at capacity,” he says. “You still need quality.”

8) Improve communication: Pick up the phone. “One of the big things we’ve been working on is physician-to-physician communication,” Dr. Thoelke says. “That’s another problem area at many large academic institutions, and I think at most community institutions as well.”

Every consult should lead to a phone call, not just a note in a chart that another doctor might not see until the next day. It’s not only for courtesy’s sake: Dr. Thoelke believes that better, more direct communication will further decrease length of stay.

“You gather so much more information even in brief conversations from one doctor to another,” Dr. Thoelke says. “I object personally when I have a consultant schedule my patient for a test that they don’t make me aware of. I’m on the phone saying, ‘This is not appropriate.’ I’m the person who’s going to be dealing with the complications of this procedure. So I’m pushing back directly to physicians.”

He’s also working hand in hand with hospital administration to encourage a culture of communication.

A standardized hand-off of every patient, every time, would also help, says Dr. Landrigan.

“As it stands now, there’s a lot of looseness,” Dr. Landrigan says. Physicians sometimes assume that the next clinician can simply take over. “The reality is that when clinicians know the patients less well, care suffers.”

An SHM task force has created basic standards for hospitalists to use for hand-offs (The Hospitalist August 2007, p.18).

9) Meet face to face with all those involved when you want to make change. No matter what’s on your wish list for 2008, your chances of making it happen improve if you communicate directly, according to Dr. Ford.

“I would recommend this not just for hospital medicine, but for anything,” Dr. Ford says. “You really have to go and meet with people. You really have to communicate, and not just by e-mail. E-mail is a good way to set up times to meet.”

To build support for the changes he wanted to make at Temple when Cogent Healthcare began managing its hospitalist program, Ford brought everyone into the discussion, from medical department chairs to representatives from nursing, administration, the labs, and more. “All the key stakeholders,” he says.

Now, Temple’s overall culture focuses on the institution’s financial health as well as on patient health. It also has an observation unit run entirely by hospitalists, freeing residents to work on other cases and still comply with ACGME rules.

“We did get a lot of resistance,” Dr. Ford admits. “University faculty weren’t very receptive to having a non-university faction running this unit. We had to break down the stereotypes that we weren’t a for-profit monster. We had to gain the trust of the emergency department [and others] to allow us to take care of their patients.” TH

Liz Tascio is a journalist based in New York.

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