Medicolegal Issues

Mentored Implementation


 

When Kendall Rogers, MD, signed up for his first mentored implementation project, he remembers being skeptical. After all, it seemed too good to be true. “I wanted to ask, ‘What’s the catch? Are you trying to get us to adopt a certain practice?’ ” says Dr. Rogers, a hospitalist at the University of New Mexico Health Science Center School of Medicine in Albuquerque.

Now, after participating in SHM’s Venous Thromboembolism (VTE) Prevention Collaborative and later mentoring other hospitalists in SHM’s Glycemic Control Mentored Implemen-tation (GCMI) program, he understands the motivation.

“Mentored implementation is unique in that it accomplishes two goals,” he says. “It improves the nuts and bolts of a project, and it also creates new hospitalist leaders and quality-improvement [QI] experts.”

Prior to his work in the VTE Prevention Collaborative, Dr. Rogers had little exposure to QI programs. He has since implemented a VTE prevention program at his hospital, and his mentorship of hospitalists in the GCMI program is helping to create custom programs to optimize glycemic control protocols. He also is a faculty member for SHM’s QI and patient-safety pre-course and is leading SHM training sessions on VTE prevention.

Public Service Involvement Made Easy

SHM’s public advocacy gives hospitalists a voice

For hospitalists and others following the public debate over healthcare reform, it can be difficult to keep all the facts straight. More to the point, hospital-based care is a major issue in many healthcare reform proposals.

Hospitalists have two options for learning more and getting involved. They can spend hours watching or listening to congressional subcommittees, dedicate entire days to reviewing thousands of pages of legislation, or keep tabs on never-ending commentary from media. Or they can spend a few minutes surfing the “Advocacy” section of SHM’s Web site.

“SHM’s Public Policy Committee has taken great steps to ensure that the best information for hospitalists is available online,” says Laura Allendorf, SHM’s senior advisor for advocacy and government affairs in Washington, D.C. “For those hospitalists who are actively interested in public policy, this has become a destination for information and action.”

In addition to providing timely bulletins on healthcare policy activity, the Advocacy section publishes the “Washington Update,” a monthly digest of SHM’s initiatives and hospitalist-related healthcare legislation and regulations.

For hospitalists ready to actively engage their lawmakers on the issues, the “Legislative Action Center” provides state-by-state contact information for legislators, enabling you to quickly e-mail your senator or representative in response to an SHM “alert” about pending issues on Capitol Hill and tips for outreach.

The Public Policy Committee also works to promote the interests of hospitalists and the patients they serve by reviewing proposed legislation and submitting comments on legislation to members of Congress. “Hospitalists are already on the front lines of delivering care,” Allendorf says. “It makes sense that they’re on the front lines in Washington, promoting the best care for hospitalized patients, too.”

The mentored implementation model, he says, is an effective way to get over many of the daunting roadblocks that can stand in the way of a hospitalist-led QI program. “Many people need that spark,” Dr. Rogers says. “This is a highly effective way to be that spark. I’ve seen too many people get disillusioned and frustrated with quality-improvement programs and give up. In these programs, the mentor can help identify and address roadblocks.”

What is Mentored Implementation?

In theory, mentored implementation is a unique and simple approach to both education and QI in healthcare. At its core, mentored implementation is the pairing of a program participant with a subject-matter expert who already has been involved in similar programs and will help the participant implement a QI program of their own.

The concept is new to QI initiatives. Although SHM has embraced the idea, mentored implementation programs first started at the Center to Advance Palliative Care in New York City, says Kathleen Kerr, SHM’s program manager for mentored implementation programs and senior research analyst in the Department of Medicine at the University of California at San Francisco. The model is an alternative to more traditional educational approaches that rely exclusively on lectures or educational sessions.

“You could sit in a session and it’s very valuable, but also very different from actually doing it,” Kerr says. “It’s hard to process so much information in a session. You don’t understand the complexity of something like gathering data until you’re actually doing it. The mentor can tailor what they’re teaching to the exact stage of the project.”

In practice, the most effective mentored implementation projects create multiple layers of support for both the mentor and the participant. SHM’s mentored implementation programs include online resource rooms on the topic (e.g., glycemic control or hospital discharge) and collaboration between participants. Rather than being just repositories of information on the subject, SHM’s resource rooms are roadmaps for new programs.

“SHM’s resource rooms define an intervention that can be implemented,” says Geri Barnes, SHM’s senior director of education and meetings.

Those resources, plus ongoing guidance from mentors, help hospitalists implement QI programs at their hospitals. Many hospitalists are early in their careers and benefit from all of the resources available. The energy that early-career hospitalists bring to QI is one of the key components the program harnesses, Kerr says.

“Junior staff are really motivated to do things in their scope, but there aren’t really a lot of mid-career local mentors” who can provide the guidance they need, Kerr says.

Training Days

Given SHM’s focus on QI and the relative youth of both HM as a specialty and hospitalists in relation to their peers, the mentored implementation model seems particularly suited to hospitalists. Launched in 2007, the VTE Prevention Collaborative was SHM’s first mentored implementation program. It was designed to help hospitalists create custom programs to prevent VTE. The collaborative included mentors, an online resource room, and on-site consultations with experts.

Many people get disillusioned and frustrated with quality-improvement programs and give up. In these programs, the mentor can help identify and address roadblocks.

—Kendall Rogers, MD, University of New Mexico Health Science Center School of Medicine, Albuquerque

SHM created Project BOOST (Better Outcomes for Older adults through Safe Transitions) in 2008. Project BOOST began with six pilot sites and has now expanded to 30 sites. Each hospital site can participate in daylong training sessions and yearlong mentorships. Sites also receive the Project BOOST implementation guide from SHM’s resource room. Since it was posted in July 2008, more than 250 hospitals have downloaded the guide.

In 2009, SHM and hospitalists are teaming up in 30 different sites across the country to improve early detection and treatment of hyperglycemia in hospitalized patients through the Glycemic Control Mentored Implementation program. Each participant in the two-year program receives a toolkit, access to Web-based resources, and is assigned a mentor to guide implementation.

How To Get Involved

MI 2.0

Despite early successes with SHM’s mentored implementation programs, those closest to them acknowledge there is room for improvement. Among a host of factors is the success of the next generation of programs, which will hinge on the idea’s scalability.

“We’re looking at testing models where we have a one-to-one mentoring program, compared to a one-to-five mentoring program,” says Jane Kelly-Cummings, RN, CPHQ, SHM’s senior director of quality initiatives.

Kerr also sees opportunities to expand the scope without sacrificing the customized approach. “We are looking for ways to expand the reach of each individual effort. Right now, customization means that mentored implementation is more like building a Ferrari than a Ford,” she says. “We need to do some ‘train the trainer’ models and explore ways to reach more hospitals simultaneously.”

For Dr. Rogers, his experience with mentored implementation and QI has strengthened his resolve to help hospitalists get it right.

“We have a lot to learn to do this effectively. We have 5,000 hospitals out there and hospitalists are naturally looked at as leaders within the institution,” he says. “The failure of one hospitalist quality-improvement program affects all of us, so success is key. This is one of the most effective tools for doing it.”­ TH

Brandon Shank is a freelance writer based in Philadelphia.

Hospital Care Collaborative: HM joins partnership aimed at better patient care

While collaboration between hospitalists is important, so is collaboration between specialists on the hospital floor.

Hospital Care Collaborative Member Organizations

  • American Association of Critical Care Nurses (AACN)
  • American Association of Respiratory Care (AARC)
  • American Society of Health-System Pharmacists (ASHP)
  • Case Manager Society of America (CMSA)
  • Society for Social Work Leadership in Health Care (SSWLHC)
  • Society of Hospital Medicine (SHM)

That’s the idea behind the new Hospital Care Collaborative (HCC), a group of six national medical organizations that, together, represent hundreds of thousands of healthcare professionals.

HCC member organizations represent a wide range of hospital-based specialties, from case managers to respiratory therapists.

“This is an important sea change in how healthcare is delivered at our nation’s hospitals,” says Scott Flanders, MD, FHM, president of SHM.

After meeting in Philadelphia in August, the HCC committed to 13 common principles for providing care in the hospital setting. The principles emphasize the need for collaboration and a focus on patient-centered care, accountability, and information sharing.

The HCC’s members are committed to identifying and disseminating best practices in multidisciplinary teamwork and expanding collaboration between each organization.

“Our patients will benefit when the entire healthcare team is mobilized to provide the best care we can all muster for their benefit,” Dr. Flanders says. “SHM is committed to working closely with our health professional allies—nursing, pharmacy, social work, case managers, and respiratory therapists—to make this happen.”

For more information, visit www.hospitalmedicine.org.

Letters

The Unique Potential of Hospitalists as Leaders in Healthcare Reform

The usual first response when a physician is asked, “Why do you practice medicine?” is “to help people.” This is especially true for younger practitioners. A frequent second response is “I like the independence.” As physicians, we enjoy being our own boss and calling the shots.

Chapter Updates

New Jersey

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The New Jersey chapter met Sept. 10 at Fiorino’s Restaurant in Summit. The meeting consisted of two discussions: the safe use of anticoagulation to reduce the likelihood of harm, and the current state of healthcare and how it will impact the hospitalist. There were 27 attendees from five HM groups in attendance.

Western Massachusetts

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The Western Massachusetts chapter met June 11 at Zen Restaurant in Northampton. The meeting included a dinner lecture by Richard Zuwallack, MD, FACCP, associate chief of pulmonary diseases at St. Francis Hospital in Hartford, Conn. His talk was titled “Optimizing the Management of COPD.” A discussion followed his presentation. Hospitalists from three local hospitals attended.

Therein rests the cultural healthcare quandary. Physicians need to accept the fact that standardization of medicine is going to happen, as it allows for improved efficiencies with a resultant decrease in healthcare expenditures. Yet the independent and entrepreneurial nature of physicians has caused them to resist the standardization of medicine for years. After all, while one fellow physician might treat a disease or perform a procedure differently than another, as long as it is efficacious, we all believe our peers should be able to practice the way they want.

Hospitalists are no different, as they are independent, too. They are simply working under the hospital umbrella. This relationship of working in hospitals positions HM practitioners, as a group, to be central players in the healthcare reform debate. This truly is a unique opportunity.

Looking demographically at the generational makeup of all physicians, we have four familiar groups represented: baby boomers, Gen X’ers, Gen Y’ers, and millennials. There are certain broad yet defining characteristics of these four generational groups. The baby boomers, being the offspring of the World War II generation, the generation that rebuilt the world and kept their “nose to the grindstone,” are defined by their work ethic. Simply put, boomers live to work. As children and students of the 1960s, they also value individuality.

Gen X’ers focus more on themselves, and often are referred to as the “me generation.” They expect to have a range of choices within their expression of individuality.

Gen Y’ers have a different work ethic, one their managers often find alarming. They are defined by the adage “work to live.” This dilemma, while difficult for their managers, allows Gen Y’ers to adapt to workplace practices, as their individuality is no longer of primary concern. After all, “it is only work.”

Millennials, having been brought up in the digital age, are bombarded with information and entertainment 24 hours a day. From birth on, they have heard that the future is uncertain. Demographically, they are more aligned with the work ethic of their great-grandparents, the World War II generation, and they are more willing to serve the common good. Thus, millennials, like Generation Y, are less individualistic and more willing to adapt to the work environment.

In considering hospitalists and their roles in the current healthcare debate and medical standards, this young specialty is uniquely poised to implement the upcoming standardizations required for three reasons. First, HM has an unusually large representation of Gen Y’ers and millennials—more than other medical specialties. These younger physicians, with their adaptability for the common good, are less resistant to the standardization of medicine.

Second, unlike most practitioners, hospitalists tend to practice in larger medical groups. Thus, they are familiar with standardization and the uniformity necessary for the group to practice effectively.

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Third, with the Centers for Medicare and Medicaid Services (CMS) adopting the experimental payment mechanism known as value-based purchasing, hospitals will insist on standardization to maximize reimbursement.

The benefits to HM practitioners are twofold. The hospitalist will share in reimbursement of pay-for-performance, thereby gaining a financial incentive for the greater efficiencies that standardization yields. This is evidenced by the trend that hospitalist contracts are increasingly based on pay-for-performance, rather than payment based on relative value units.

The second benefit, and perhaps the most important, is that the influence and power of hospitalists will greatly increase, particularly in formulating the standards of medical treatment, procedures, and, more importantly, QI and patient safety.

As the practice of HM matures from infancy into adolescence, recognizing the opportunity at hand and deciding how to proceed is paramount to its future position and existence.

Michael G. Cassatly, DMD

Certified business coach,

American Board of Oral and Maxillofacial Surgery diplomate

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