Speakers at HM13 Stress Overarching Reform, Day-to-Day Implementation


Dr. Feinberg wonders why patient care isn't done right every time.

What Can Hospitalists Do?

Given the popularity of checklists at the poster sessions of SHM’s annual meeting, it was fitting that CMS’ Patrick Conway, MD, SFHM, gave hospitalists a take-home list of what they can do to further push QI, safety initiatives, and cost reductions in their home institutions.

  • Eliminate patient harm.
  • Focus on the patients.
  • Engage in alternative contracts that move from fee-for-service to ones tied to better outcomes at lower costs.
  • Invest in infrastructure.
  • Test models that provide more coordinated care for patients with multiple chronic conditions.
  • Research comparative effectiveness and implementation science.
  • Advocate at the local, state, and national levels.
  • Relentlessly pursue better outcomes.

To some HM13 attendees, the keynote speakers might have seemed to be talking about different things.

Patrick Conway, MD, MSc, FAAP, SFHM, chief medical officer and director of the Center for Clinical Standards and Quality at the Centers for Medicare & Medicaid Services (CMS), hinted at promising results from the first accountable-care organizations (ACOs) and noted a meaningful reduction in 30-day readmission rates for the first time in years.

David Feinberg, MD, MBA, president of UCLA Health System in Los Angeles, told hospitalists that unless they’re getting patient care right every time, they’re not getting it right enough. And nothing would make him happier than seeing fewer hospitalists at SHM’s annual meeting—because that would mean fewer hospitalized patients.

HM pioneer Bob Wachter, MD, MHM, said it’s time for hospitalists to link their quality-improvement (QI) efforts and safety acumen to projects focused on cutting costs and reducing waste in the health-care system.

So while each made their points in a different way, each plenary speaker left many meeting-goers with a similar thought: Hospitalists are positioned at the nexus of big-picture reform and day-to-day implementation. So if hospitalists as a specialty continue to embrace teamwork, evidence-based practice, quality, safety, and a sense that the patient comes first, they will cement themselves as leaders in the next iteration of health-care delivery.

“There is enormous change going on in the healthcare system,” says SHM CEO Larry Wellikson. “And we are right in the middle of this. We are essential. If we are bad, we are going to sink it. And if we’re great, we are going to take it to another level.”

Needle Movement

Dr. Conway said some of that progress already is evident. He disclosed that initial findings from the first data sets coming from the first ACOs are showing promising results, though he can’t go into detail until the information is publicly released. However, he did boast that after decades of Medicare readmission rates hovering around 19%, data from late 2012 and early 2013 show that figure has dropped to below 18%.

“That is a 1.5% to 2% shift in readmissions nationally,” he said. “It is a credit to the work you and others are doing in the field. That’s hundreds of thousands of Medicare beneficiaries that are not readmitted every year, that stay home healthy. … It’s a tremendous example of moving a national needle.”

He dismissed those who attribute the initial readmission progress solely to penalties instituted on readmissions, though he acknowledged that CMS is using both carrots and sticks to push change.

Dr. Wachter says HM will need to refocus QI efforts on cost, waste reduction.

Dr. Wachter says HM will need to refocus QI efforts on cost, waste reduction.

“It’s a combination of interventions,” he said.

And all of those initiatives must be aimed jointly at improving the patient experience, said Dr. Feinberg, a child psychiatrist by training whose mantra is “patient-centeredness.” Dr. Feinberg’s reputation is that of a physician-administrator who puts patients first. For example, even though his health system (www.uclahealth.org) is in the 99th percentile for patient satisfaction, he is unhappy. That’s because the top ranking means roughly 85 out of every 100 patients served are pretty happy with their experience.

“It means that we’re the cream of the crap,” he said. “Of the last 100 people we took care of, 15 of them—and, by definition, those 15 people are someone’s mom, someone’s brother, someone’s coworker—would not refer us to a friend, or rate us a 9 or 10. So, I think, while we’ve really moved the needle, we’re really not done until we get it right with every patient, every time.”

He added that those who argue against difficult or time-consuming innovations and improvements that better patient care are arguing against the moral high ground of how they would want a family member to be treated in the hospital.

“The pushback I hear is, ‘Some of this stuff is unpreventable,’” Dr. Feinberg said. “Well, maybe it’s unpreventable the way we’re doing it now. But maybe we need to think differently. Maybe it is unpreventable, but if this decreases the prevalence, or makes it better, then to me, it’s important to do.”

Dr. Feinberg, who took over as UCLA Health System’s president in 2011, says he still spends several hours every day talking to patients. For those who say there’s not enough time to stay connected to patients and that all the time spent making sure patients are happy takes away from other activities, he says they’re forgetting what brought them into medicine in the first place: healing. He blames the delivery system for stifling what he believes is a provider’s desire to help people.

“We haven’t allowed the culture to come out,” he said. “I think it’s there.”

SHM president Eric Howell

SHM president Eric Howell (right) makes his sister, Leslie Sutherland, the newest SHM member during his HM13 address.

Dr. Wachter has a similar faith in the hospitalist culture—although his is based in the pluripotent nature of the specialty. Hospitalists have worked hard to be viewed as “generalists, able to solve all kinds of problems,” and that means the specialty is poised to adapt and thrive.

“We will morph into what is needed,” said Dr. Wachter, a past president of SHM whose titles include chief of the division of hospital medicine at the University of California at San Francisco and chair of the American Board of Internal Medicine. “That will be all sorts of things: comanagement, dealing with the residency limits in teaching hospitals, systems improvement, cost reductions, transitions, working in skilled nursing facilities, all the specialty hospitalists.

“We will fill new niches,” he said.

Dr. Conway

Dr. Conway

What Dr. Wachter does not want to see is that the field grows “fat and happy,” as it is now firmly entrenched in the U.S. health-care delivery system. In fact, he urged hospitalists to welcome change, particularly initiatives that improve quality and safety, reduce costs and waste, and, ultimately, improve the patient experience.

But he cautioned against conceptually separating QI and cost reduction. Instead, they should be viewed as equally meaningful parts of his oft-quoted value equation, which, viewed from the health-care consumer’s point of view, is quality divided by cost.

“You can’t survive and thrive in a world with the kinds of pressures that we have to improve performance if you do business the same old way,” he added. “It’s no longer possible to achieve the things you need to achieve handling these as single projects. You need to transform the way you think about care.”

Richard Quinn is a freelance writer in New Jersey.

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