Government and Regulations

Healthcare = Team Sport


While most of the focus has been on D.C. and the trillions of dollars to be spent on healthcare reform, HM has grown substantially in the last decade without any significant payment reform or new regulation. This is all the more incredible because the rise of HM has involved two institutions not synonymous with accepting or adapting to change: physicians and hospitals.

In the coming years, hospitals face important challenges, including their fiscal survival, public trust, workforce shortages, difficulty deciding whether their physicians are partners or competitors, and figuring out what to do about all this patient safety and performance improvement hubbub.

Although 2010’s version of healthcare reform will be about increasing access (see “An Imperfect Solution,” January 2010, p. 44), there are still the seeds planted to address the next two pillars of reform: reducing cost and rewarding performance. Together, they create the value proposition in healthcare. All this will make the coming decade one in which the hospital as an institution will need to evolve and adapt if it is to survive.

The only way to meet all of the volume and performance demands is with process change. We need a different way to deliver care to hospitalized patients.

What is Quality?

As we enter a transitional phase, in some ways, we aren’t even clear on just what quality healthcare is:

  • Is quality defined as a payment issue? We see this in discussions of not paying for “never events” or denying payment for readmissions.
  • Is quality about being more satisfied? This is found in emphasis on the surveys of patient and family satisfaction that drive hospital CEO compensation and bonuses, as well as in efforts to improve staff retention or in recognition by business, insurers, and government.
  • Is quality just checking things off on a clipboard? We all see the endless list of quality measures and increasing documentation that providers have told their patients to stop smoking or get a flu shot, but is that really the quality we are seeking in healthcare?
  • Is quality just avoiding embarrassment? Is the best driver of performance improvement outraged hospital trustees wielding printouts comparing hospitals?

We do know that in some ways, the discussion at most of our hospitals has shifted from “Is quality important?” to “How do we do it?” And in this discussion, HM and SHM have taken a leading role in the “solutions” to the problem. Our innovative programs help reduce unnecessary DVTs, improve glycemic control, and refine the discharge process (see Project BOOST) for better patient/family satisfaction, reduced ED visits, and reduced readmissions.

New Ways to Deliver Care

The hospital of the future—I’m talking 2020—will not be defined by bricks and walls. The hospital stay will not end with a patient in a wheelchair being helped into their car. We already know that most patients don’t leave the hospital cured, but are discharged when they are not sick enough to need to stay recumbent in the most expensive hotel in the city. Often these patients are in midcourse of an acute illness, frequently imposed on top of chronic dysfunctions.

While the patient as the true “medical home” for their health and illness have always borne the potholes of slipped handoffs and information transfer deficits, hospitalists now have a clear view of the precarious nature of post-discharge care. Bundling and payment reform, designed to reward coordination of care and the reduction of readmissions to the ED, might be a revenue-driven boost to our ill-designed healthcare system, but the hospital, with the help of their hospitalists, can take the lead in fixing these problems. And we don’t have to wait for payment reform.

The good news is we aren’t alone in our efforts to change the culture, even the mission, of our hospitals. In a time of healthcarewide workforce shortages, there are increasing demands for direct inpatient care, coupled with the added time needed to document current performance and train and implement needed improvements. The only way to meet all of the volume and performance demands is with process change. We need a different way to deliver care to hospitalized patients.

All-Star Teams

High-performing organizations are composed of high-performance teams and a set of operating principles that create a widespread culture of motivated individuals who are focused on metrics, are execution-driven, and are committed to continual improvement and rapid adaptation.

The characteristics of high-performance teams are that they:

  • Self-correct and reallocate resources;
  • Have clear roles and responsibilities;
  • Have clear, valued, and shared visions;
  • Have strong team leadership;
  • Develop a strong sense of “collective” trust and confidence; and
  • Manage and optimize performance outcomes.

SHM has taken the lead at a national level in helping to organize the Hospital Care Collaborative (HCC), which is made up of CEOs and leaders in nursing, pharmacy, case management, social workers, and respiratory therapy. The HCC has published a set of “Common Principles” (see “Common Principles for the Hospital Care Collaborative”) and is planning to develop practical strategies for building high-performance teams at our nation’s hospitals.

SHM recently received support from Ortho-McNeil and has created a partnership with the American Hospital Association, American Organization of Nurse Executives, and American College of Physician Executives to develop principles and strategies to implement high-performance teams and to use this as a springboard to look at hospital care in the broadest sense (including transfers with medical home and accountable-care organizations). To start, SHM has convened a blue-ribbon group of hospital CMOs, CQOs, nursing executives, and other leaders in the hospital C-suite. Former SHM president Pat Cawley, MD, MBA, FHM, assistant professor and executive medical officer at the Medical University of South Carolina in Charleston, will chair this effort.

In these two initiatives, SHM and national hospital leaders are providing direction and innovation at two entry points—the C-suite and executive team—as well as on the front lines with the other healthcare professionals who care for our nation’s hospitalized patients.

More to Come

HM has had an interesting decade, growing to more than 30,000 hospitalists now practicing in 75% of our nation’s hospitals. We’ve taken on comanagement and are providing real success as change agents. But the decade to come will see the reinvention of our nation’s hospitals and distinct changes in workflow and responsibilities. We are moving from care based on the unit of the visit or the procedure to episodes of care. We are moving from a system that rewards just doing something to one that rewards doing the correct thing and doing it well. We are moving our hospitals from a swap meet where each physician has a booth and everyone supports those individual efforts to an institution with a culture that is patient-centered, based on quality measurement and performance, and provides care delivered by teams of health professionals working in concert.

This is a world that hospitalists can thrive in and, with your help and direction, SHM will provide the tools along the way. TH

Dr. Wellikson is CEO of SHM.

Common Principles for the Hospital Care Collaborative

The following HCC common principles were approved by SHM and five other medical professional associations in 2009:

  • The HCC believes healthcare is a “team sport” with respect and recognition for the knowledge, talent, and professionalism of all team members.
  • The HCC supports clear delineation of team roles and responsibilities with an emphasis on a collaborative and nonhierarchical model.
  • The HCC believes in patient-centered care, rather than provider-centered care, and that the healthcare team members should involve the patient/family/caregiver in developing care plans and goals of care.
  • The HCC believes collaboration of the healthcare team can lead to improved systems and processes that provide care more efficiently and result in better patient outcomes. Examples include strategies for implementation, improved workflow, and the utilization of evidence-based processes.
  • The HCC believes all members of the team within their licensure and scope of practice have a role to play in establishing organizational policy, and directing and evaluating clinical care.
  • The HCC believes in a system that involves many team members; all health professionals should work to create safe care transitions and handoffs within the hospitalization and post-hospitalization episodes of care.
  • The HCC believes all team members must be as proficient in communications skills as in clinical skills.
  • The HCC believes the appropriate capacity and staffing of the entire team is a requirement for providing the best care.
  • The HCC believes all team members are accountable for their individual performance as a healthcare provider, as well as the performance of the entire team. While this may be defined by statute or regulation, this also relies on the clinical judgment of each member of the team.
  • The HCC understands that in order to improve quality of care, standards and measurement of performance are important. The HCC believes that the measurement should be of the outcomes of the team rather than of any individual member of the team.
  • The HCC believes that in order to provide the best care possible, appropriate information must be readily available to all team members, at the right point of decision-making, and in a format that allows for ongoing updating and communication to the team.
  • The HCC believes the current undergraduate and postgraduate professional education of team members is inadequate to promote true team functions. The HCC calls on the training institutions for health professionals to adopt new curricula and experiential models that foster the competencies and the culture that support team-based care. The HCC also calls on professional associations to likewise function in a team-based manner and develop creative approaches to “teaching” the professionals they represent, as well as modeling for other healthcare professionals the skills to be a functioning member of a healthcare team. Professional associations should foster research that demonstrates the effectiveness of team-provided care.
  • The HCC recognizes that today’s hospital cultures do not foster true teams of healthcare professionals. The HCC calls on all stakeholders (e.g., payors, providers, administrators, patients) to work together to create a new hospital culture that nurtures and rewards high-performing teams.

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