It’s little wonder we haven’t moved the quality needle much. Viewed through this lens, the fact that we have accomplished even modest improvements is impressive.
Second, we need to do a better job of measuring our benefit. Mortality and readmission are important outcomes, and we should always aim to improve these quality indicators. However, they’re both downstream markers that are easy to measure but difficult to budge.
We must acknowledge, however, that we haven’t done a good job of measuring our effect on the value-added aspects of hospital medicine: nursing happiness, hospital leadership, team work, staff education, patient satisfaction, protocol development, and our willingness to take on work others are not keen to do, such as unassigned emergency department call.
How do we put a price on the value of being available for a patient in extremis, a nurse with a question, a committee chairpersonship? How do we measure the downstream benefit of offloading our surgical and medical subspecialty colleagues so they can perform more procedures while we care for their recently proceduralized patients?
This is difficult material to measure, especially in a scientific manner. In this regard, it is incumbent on local leaders to ensure these data are collected and available for presentation to those who subsidize our practices.
Short of this, groups are exposed to a serious threat from a hospital chief financial officer armed with a directive to cut costs and the Dec. 20 edition of The Wall Street Journal.
Hospital medicine is a work in progress. We need to do a better job of measuring our value-added benefits. However, we should strive to exceed what is acceptable. While it is reasonable to accept little documented improvement in quality indicators today, it should not be acceptable in the near future.
The field will need to move toward improving, documenting, and rewarding improvements in clinical outcomes. This means elemental change toward developing practice standards and models of care for common disease states, standardizing care throughout the hospital and actively engaging in improving quality at every turn.
Hospitalists will need to agree to be measured, participate in measurement, and be held accountable for achieving quality benchmarks.
This transformation necessitates that hospitalist educators (both residency and post-residency) better prepare hospitalists to lead change in areas of quality improvement.
These educators must impart the basic tenets of change management, process improvement, and patient safety.
These changes will take provider time—time that will need to be supported by hospitals and group leaders in the form of accepting less revenue per provider, which will in turn require inspired leadership to negotiate this time and build a new sustainable business model centered around quality.
As the field matures it is becoming clearer that our business can no longer be predicated on cost savings and efficiency alone.
While we need to be ever mindful of these metrics, we need to evolve beyond this model to one with quality at its core.
We should expect and reward superior patient outcomes at the expense of quantity. Anything short of this squanders one of the purest opportunities to positively affect the U.S. healthcare system for generations to come. TH
Dr. Glasheen is associate professor of medicine at the University of Colorado Denver, where he serves as director of the Hospital Medicine Program and the Hospitalist Training Program, and as associate program director of the Internal Medicine Residency Program.
- Levitz J. Hospitalists are seen as help. The Wall Street Journal. Dec. 20, 2007:D7.
- Lindenauer PK, Rothberg MB, Pekow PS, Kenwood C, Benjamin EM, Auerbach AD et al. Outcomes of care by hospitalists, general internists, and family physicians. N Engl J Med. 2007 Dec 20; 357(25):2589-2600.
- Auerbach AD, Rasic MA, Sehgal N, Ide B, Stone B, Maselli Jet al. Opportunity missed: medical consultation, resource use, and quality of care of patients undergoing major surgery. Arch Intern Med. 2007 Nov. 26;167(21): 2338-2344.