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Remains of the Day


 

It seems like yesterday that I began the journey of being SHM’s president. And now I find myself in the “remains of the day,” reflecting upon what was accomplished, and what remains to be done. Here, then, in the twilight of my day as president, are a few reflections from the most recent chapter in HM before I say goodbye.

The Organizational Chassis

This was the year that the contracts for both the CEO and our journal editor came due. I am pleased to have re-signed our CEO to a three-year contract, ensuring continued leadership of our initiatives during a time in which we cannot pause. I am also pleased that the search committee, with great diligence, has arrived upon a candidate who I am sure will continue the imprimatur of excellence that has defined the Journal of Hospital Medicine during Mark Williams’ tenure. In concert with this appointment is a new contract with JHM’s publisher, Wiley-Blackwell, the terms of which will ensure the continued and expanding impact that the journal has upon HM practice.

I am also pleased with SHM’s huge step forward with respect to the policies and procedures regarding transparency and its external relationships with industry. My column in the December 2010 issue (see “The Story of Us,” p. 43) outlines the progress; the accompanying letter to the editor outlines what remains to be done. The policy revisions are a remarkable step forward in ensuring the integrity of the organization, but I do agree we can do more.

Membership

SHM’s membership now exceeds 12,000, an impressive accomplishment eclipsed only by 88% membership retention. SHM, like no other organization, has built an infrastructure of empowerment, particularly with respect to advancing the goals of quality and patient safety, and people are voting with their feet by joining and sustaining membership with the organization.

Equally impressive is the organization’s ability to maintain the “big tent” as a part of this membership growth. I am pleased with the board’s decision to pass by-laws reforms to ensure that any unique constituency, with sufficient size, would have a provision for placing a representative on the Board of Directors. But even so, the seams of the “big tent” will be increasingly stressed as we continue to grow. Making the adaptations necessary to maintain this “big tent” must remain a priority for the organization.

To address this challenge, three new committees were established within the “membership cluster” this year. The Young Physicians Task Force was divided into two new committees: one committee (Pipeline) was moved to the academic cluster to focus upon our relationships with the educational infrastructure (medical schools and residency training programs) and ensure that hospitalists of the future are better prepared to assume the role, particularly with respect to advancing quality and patient safety.

HM’s persistent challenge is the harsh reality that not all hospitalists engage in quality and patient safety. To this end, I am pleased that SHM’s quality database, SQUINT, has come to fruition. While nascent in its development, this Web-based platform will enable those who have enacted quality initiatives to upload their project to a searchable database.

The second committee from this division, Early Career Hospitalists, remained within membership to ensure that the unique needs of the hospitalist in their first five years of practice were being addressed. My vision from the outset was that there would come a day that a “virtual mentor system” would be in place for the young SHM member, and based upon the work of this committee, I believe the foundation has been laid to realize this dream sooner than you might think.

Does SHM’s leadership reflect the gender, race, religion, ethnicity, and sexual-preference diversity of the 30,000-plus hospitalists practicing in the U.S.? I don’t know the answer, but I suspect that whatever measure of diversity we have reflected in our organizational leadership, it could be better. I am very pleased with the initiation of the Diversity Task Force, which will ensure that SHM is developing leaders from these constituencies within its committees such that, in the coming years, there is meaningful integration of these diversities into the SHM leadership.

If SHM is to fulfill its destiny of changing American healthcare, it will do so only as a part of collaboration with other national organizations and entities. What comes next is too big for one physician organization to enact alone. One such organization is the Veterans Administration healthcare system, and I am pleased that we have started this journey by establishing the VA Affairs Committee. I look forward to seeing what will come of SHM’s collaboration with the VA. I believe that in 10 years’ time, both entities will count themselves fortunate for having engaged in this collaborative journey together.

Academics

From the outset, SHM’s attention to academics was about the pipeline, for despite our diverse practice patterns, we all share one common denominator in that we are where we are today as a product of our training. Much has been said about whether there will be a sufficient number of students and residents entering the practice of HM. But the question is about quality, not quantity. For HM to be sustainable, the best and brightest of our medical students and residents must select HM as a lifelong career, not as a year between residency and subspecialty fellowship. Career decisions are based upon mentors and role models, and the only solution is to ensure that our students and residents are regularly interacting with hospitalists as role models in their medical schools and residencies.

This was the second year for the Academic Hospitalist Academy: an initiative critical to ensuring that the hospitalists with whom our students and residents interact have the educational and leadership skills to be effective as role models. The work by the Academic Practice and Promotion Committee will soon yield a position paper that will establish the benchmarks for hospitalist promotions, empowering chairs and promotion committees to sustain hospitalists within the academic infrastructure. This is the second year of funding young investigators in HM, and SHM’s inclusion in the GEMSTAR program will enable further funding to ensure that the specialty is creating new knowledge.

And, as noted above, the new Pipeline Committee already has been effective in establishing a relationship with the Alliance for Academic Internal Medicine (professors, clerkship directors, residency directors). The collaborative venture, the Quality and Safety Educators Academy (QSEA), will come to fruition early in 2012, further integrating hospitalists as mentors in the educational infrastructure.

And even as you read this, I will be representing SHM in a joint collaborative with AAIM, ABIM, SGIM, and ACP regarding the “milestones project” as a new model of establishing resident competency, ensuring that the knowledge and skills requisite for being a hospitalist will be acquired in residency training in years to come.

Practice Management

After 48 trips over the course of the year, I can tell you that despite how far we have come as a profession, there remains remarkable heterogeneity as to how hospitalist groups are structured. And yet there are common principles that underlie the high-performing teams, principles captured in the work of the Practice Management and Practice Analysis committees. This valuable SHM service as the clearinghouse of best practices must continue to grow.

My guess as to what comes next in the practice of HM is the progressive blurring of the artificial barriers among the ED, the wards, and the ICU. The reality is that hospitalists are increasingly involved in all three domains, providing emergency and critical care as much as they are standard ward management. I am pleased that we are now engaged in discussions with the American College of Emergency Physicians and the Society for Critical Care Medicine, looking for potential areas of collaboration in building the hospital of the future.

Quality and Patient Safety

In the past year, SHM’s mentored-implementation initiatives have continued to expand, now improving more than 100 clinical sites. In their own right, these initiatives are impressive. But the most impressive element is the philosophy that one cookie-cutter strategy is unlikely to work for all systems. Tailoring the strategy to the unique features of the system, under the guidance of a mentor/coach, is the brilliance that has defined SHM’s efforts. Further, it espouses the greater philosophical principle that we are our brother’s keepers.

For meaningful healthcare reform to come to fruition, quality improvement in isolation (i.e. a few ACOs here or there) will be insufficient, a point I made at the White House briefing on healthcare reform. It is the role of a physician society such as SHM to bring together the community of all hospital systems, removed from the mindset of competition, to ensure that what meaningful improvements are made in one system are replicated in others.

SHM has made the jump to the next level in advancing quality by securing resources for a full-time physician quality leader within the organization. The announcement of who this leader will be will follow shortly, though I am pleased that SHM’s commitment to quality and patient safety continues to expand.

But with quality today addressed, what do we do about tomorrow? How do we ensure that those physicians who will follow us (i.e. our current medical students and residents) are better prepared to enact meaningful quality and patient safety as a part of their careers? I am pleased with the work enacted by the Quality Education Committee, establishing a Web-based portal that will serve as the foundation for teaching medical students and residents the essential principles of quality and patient safety.

But meaningful learning requires a “coach,” an educator trained in the principles of teaching and applying these critical skills. To meet this need, SHM has joined forces with the Alliance for Academic Internal Medicine (AAIM) to develop a Quality and Safety Educators Academy, which will take place early in 2012. This academy will train hospitalists interested in teaching quality and patient safety to medical students and residents, using the product developed by the QIE committee as its substrate. The ancillary benefit, of course, is the integration of more hospitalists into the educational infrastructure, exposing students and residents to their potential mentors such that HM becomes a valued career in their minds.

Of all of the decisions made in the past year, there is none wiser than to have invested in our advocacy infrastructure.

HM’s persistent challenge is the harsh reality that not all hospitalists engage in quality and patient safety. To this end, I am pleased that SHM’s quality database, SQUINT, has come to fruition. While nascent in its development, this Web-based platform will enable those who have enacted quality initiatives to upload their project to a searchable database, further enabling other hospitalists interested in starting a QI project to quickly search for projects that are similar to their hospital’s size, structure, and needs.

As the format for SQUINT will replicate the structure of ABIM’s Practice Improvement Module format, it will provide the added service of empowering hospitalists engaged in Maintenance of Certification (MOC) in Focused Practice in Hospital Medicine. And vice versa, it will enable all who have completed ABIM PIMs to post their QI projects on SQUINT, further leveraging the size and depth of the SQUINT database.

Education

October 2010 marked the first MOC examination with the Focused Practice in Hospital Medicine designation. I am pleased that SHM has not yielded in its efforts to ensure that MOC in HM is not just a piece of paper, but also a tangible process that leverages improved performance on the part of the hospitalist. To assist hospitalists in meeting these requirements, SHM has worked on three medical knowledge modules this year, one that already qualifies for MOC credit and two more expected to be available by this time next year.

The consistent quality of SHM’s educational programming has continued throughout the year. Undoubtedly, many of you will be reading this en route to another exceptional annual meeting in Dallas. Though you will not see this at HM11, the foundation plan for a completely electronic meeting, enabling real-time dialogue between speakers and audience members (via smartphones, etc.), has been set in motion. The fully electronic annual meeting is not far away.

Advocacy

Heading into this past year, the board made the decision to double the resources for the advocacy cluster. SHM has become a major voice in the conversation of healthcare reform, and the advocacy leadership of the organization has been invited to weigh in on all components of the Patient Protection and Affordable Care Act.

From bundling to ACOs, from value-based purchasing to readmissions, I am proud of the message espoused by SHM’s advocacy leadership (www.hospital medicine.org/advocacy). Proud, because the modus operandi that has gained us great credibility among legislators has continued: a message that advocates for the needs of the hospitalist but never at the expense of what is best for the patient.

Of all of the decisions made in the past year, there is none wiser than to have invested in our advocacy infrastructure. The conversation in which we are now involved transcends what is best for the hospitalist—it is a conversation about changing a decades-old healthcare system to something better. And the complexities of this conversation require erudite and wise thought leaders, people who care about the right things.

Going forward, the road will be no less challenging. Walking the line of preserving our specialty while doing what is best for the patient must remain our priority.

A year ago today, I set forth 10 goals:

  • Ensure a solid leadership base for the years to come;
  • Move the organization to an even higher level of integrity and transparency;
  • Augment the “pipeline” of the profession, ensuring that those who come next will be better prepared than we were;
  • Augment the infrastructure to advance diversity within the organization;
  • Ensure that the philosophy of the “big tent” vision is sustained;
  • Ensure that our advocacy efforts are about doing the right thing: providing the safest and highest-quality care for all patients;
  • Establish relationships with other organizations;
  • Establish an infrastructure that enables all hospitalists to participate in quality and patient-safety initiatives;
  • Further establish HM as its own specialty, a specialty known for being the vanguard of quality and patient safety; and
  • Ensure that the leaders of the organization who follow me inherit an organization that is better than when I found it.

Only time will tell whether I was successful in meeting these goals, but to the extent we succeeded, I give full credit to the SHM staff, leadership, and member volunteers who made it happen. To the extent that we fell short, I take full responsibility.

It has been an honor to be your president. As with all things in life, success or failure is measured in 10 minutes—those solitary 10 minutes each night before you fall asleep. For it is in those 10 minutes that you find yourself utterly and completely alone with your life; what you said, and what you meant to say; what you did, and what you didn’t do. Despite the ups and downs of the year, I’ve never once begrudged those 10 minutes, for I have nothing but pride in my heart as I think about you and SHM, an organization and a community that is, and will continue to be, one that cares about the right things in life.

So this is me signing off. I look forward to serving HM in whatever way I can as the years transpire.

For now, I look forward to president-elect Joseph Ming Wah Li, MD, SFHM, FACP, continuing this journey. And so should you. I am confident that even better days are soon to come under his leadership. TH

Dr. Wiese is president of SHM.

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