Daniel D. Dressler, MD, MSc

A 34‐year‐old man was admitted for evaluation of elevated blood glucose despite extremely high subcutaneous (SQ) insulin requirements. He had a 12‐year history of Type 2 diabetes mellitus (T2DM) without episodes of ketoacidosis, managed initially with oral medications (metformin with various sulfonylureas and thiazolidinediones). Three months prior to admission, he was transitioned to SQ insulin and thereafter his requirements escalated rapidly. By the time of his admission, his blood glucose measurements were consistently above 300 mg/dL despite injecting more than 4100 units of insulin daily. His regimen included 300 units of insulin glargine (Lantus) 2 times per day (BID) and 1.75 mL of Humilin U‐500 Insulin (875 units) 4 times per day (QID). Past medical history included metabolic syndrome, nonalcoholic steatohepatitis, and diabetic neuropathy. Physical exam was remarkable for centripetal obesity (body mass index [BMI] = 38.9 kg/m²), acanthosis nigricans, and necrobiosis lipoidica diabeticorum (NLD) (Figure 1).

Figure 1

We undertook an investigation to characterize this extreme insulin resistance. After 24 hours without insulin supplementation, and 12 hours of nothing by mouth (NPO), his blood glucose level was 280 mg/dL and his serum insulin was 133.5 IU/mL. We injected 12 units of insulin Aspart and subsequently measured his serum glucose and insulin once more. His blood glucose level had risen to 289 mg/dL and his serum insulin fell to 110.7 IU/mL. We then transitioned the patient to intravenous (IV) insulin. After a series of boluses totaling 400 units, his blood glucose normalized (90 mg/dL) and was maintained in normal range on a rate of 48 units per hour. Over 24 hours, we had infused over 1400 units.

During this time, we also drew several labs. Serum antiinsulin antibodies were undetectable (ARUP Laboratories, Salt Lake City, UT). A full rheumatologic workup was negative for systemic lupus erythematosus (SLE), rheumatoid factor, Sjgren's syndrome (SS)‐A and SS‐B. Androgen levels were normal, as were 24‐hour urine collections for cortisol and metanephrines. The patient was discharged on a regimen of U‐500 without glargine.

By 5 months after discharge, his blood glucose remained uncontrolled despite increasing doses of U‐500 (with or without metformin and thiazolidinediones). The patient was offered a gastric bypass operation. Now, 4 months postoperative, his blood glucose is controlled, no greater than 90 mg/dL in the morning and 125 mg/dL in the evening. He is off insulin, taking 30 mg pioglitazone (Actos) daily and 500 mg metformin 3 times per day (TID).

Discussion

Extreme insulin resistance (EIR), defined by daily insulin requirements in excess of 200 U, is a rare and frustrating condition.1 Rarer still is extreme subcutaneous insulin resistance (ESIR). A systematic Medline review revealed only 29 reported cases of ESIR, all of which involved patients that maintained IV sensitivity to insulin. Classic diagnostic criteria for ESIR include preserved sensitivity to IV insulin, failure to increase serum insulin with subcutaneous injection, and insulin degrading activity of subcutaneous tissue.2, 3 However, there are, at present, no laboratory tests that can test the final criterion. Indeed, very few of the published reports of ESIR satisfy it, with most studies considering as diagnostic of ESIR the constellation of EIR with failure to raise serum insulin after injection and preserved intravenous insulin sensitivity.

As was evident in the high doses of IV insulin required for blood glucose normalization, our patient also had a proven receptor‐level peripheral resistance. Beyond the common, multifactorial insulin resistance of T2DM, the published reports of patients with extreme peripheral resistance are of 2 types: (A) genetic (eg, Leprechaunism) and (B) acquired autoimmune (Table 1).4 This patient fits neither category. Patients with Type A are very sick, with a syndromic disease that sharply curtails their life expectancy. Patients with Type B acquire antibodies directed against their insulin receptors and are almost invariably elderly African‐American women with severe rheumatological disease, namely SLE. We could not test our patient for an insulin‐receptor antibody secondary to prohibitive cost. This is probably moot, given that his autoimmune workup was negative and, as above, patients with such antibodies are vastly different compared to our patients.

Based on SQ insulin requirements, our patient had EIR. As his insulin levels failed to rise following an insulin injection, his EIR is thus subcutaneous in nature. However, among patients with this condition his failure to respond to IV insulin is unique. He does not fit criteria for types A or B insulin resistance; his condition is likely also due to an extreme version of the more common, multifactorial peripheral insulin resistance. This is supported by his successful response to the gastric bypass operation.5

The standard treatments for ESIR include: (1) concentrated regular insulin (U‐500) and (2) implantable intraperitoneal delivery; our patient received the former.6 U‐500 use in EIR has been shown to be more cost‐effective.1 Several reports have suggested success with protease inhibitors (aprotinin, nafamostat ointment), plasmapheresis, and intravenous immunoglobulin for extreme SQ resistance. Our case also represents the first treated successfully with a gastric bypass operation.

CONCLUSIONS

EIR can present a significant challenge for both the patient and hospitalist. The approach to this condition should begin with the determination of 24‐hour IV insulin requirement utilizing an insulin drip; serum insulin antibody evaluation; and endocrinology consultation. Our case also highlights a few important points about the broader management of diabetes mellitus. First, there are dermatological manifestations of diabetes that serve as potential markers for disease (namely acanthosis nigricans and NLD). Second, for patients with extreme insulin requirements, an extensive workup should be initiated and the patient should be transitioned to a concentrated regular insulin or intraperitoneal delivery. Third, our experience suggests a role for other measures such as gastric bypass that ought to be studied further.

A 34‐year‐old man was admitted for evaluation of elevated blood glucose despite extremely high subcutaneous (SQ) insulin requirements. He had a 12‐year history of Type 2 diabetes mellitus (T2DM) without episodes of ketoacidosis, managed initially with oral medications (metformin with various sulfonylureas and thiazolidinediones). Three months prior to admission, he was transitioned to SQ insulin and thereafter his requirements escalated rapidly. By the time of his admission, his blood glucose measurements were consistently above 300 mg/dL despite injecting more than 4100 units of insulin daily. His regimen included 300 units of insulin glargine (Lantus) 2 times per day (BID) and 1.75 mL of Humilin U‐500 Insulin (875 units) 4 times per day (QID). Past medical history included metabolic syndrome, nonalcoholic steatohepatitis, and diabetic neuropathy. Physical exam was remarkable for centripetal obesity (body mass index [BMI] = 38.9 kg/m²), acanthosis nigricans, and necrobiosis lipoidica diabeticorum (NLD) (Figure 1).

Figure 1

We undertook an investigation to characterize this extreme insulin resistance. After 24 hours without insulin supplementation, and 12 hours of nothing by mouth (NPO), his blood glucose level was 280 mg/dL and his serum insulin was 133.5 IU/mL. We injected 12 units of insulin Aspart and subsequently measured his serum glucose and insulin once more. His blood glucose level had risen to 289 mg/dL and his serum insulin fell to 110.7 IU/mL. We then transitioned the patient to intravenous (IV) insulin. After a series of boluses totaling 400 units, his blood glucose normalized (90 mg/dL) and was maintained in normal range on a rate of 48 units per hour. Over 24 hours, we had infused over 1400 units.

During this time, we also drew several labs. Serum antiinsulin antibodies were undetectable (ARUP Laboratories, Salt Lake City, UT). A full rheumatologic workup was negative for systemic lupus erythematosus (SLE), rheumatoid factor, Sjgren's syndrome (SS)‐A and SS‐B. Androgen levels were normal, as were 24‐hour urine collections for cortisol and metanephrines. The patient was discharged on a regimen of U‐500 without glargine.

By 5 months after discharge, his blood glucose remained uncontrolled despite increasing doses of U‐500 (with or without metformin and thiazolidinediones). The patient was offered a gastric bypass operation. Now, 4 months postoperative, his blood glucose is controlled, no greater than 90 mg/dL in the morning and 125 mg/dL in the evening. He is off insulin, taking 30 mg pioglitazone (Actos) daily and 500 mg metformin 3 times per day (TID).

Discussion

Extreme insulin resistance (EIR), defined by daily insulin requirements in excess of 200 U, is a rare and frustrating condition.1 Rarer still is extreme subcutaneous insulin resistance (ESIR). A systematic Medline review revealed only 29 reported cases of ESIR, all of which involved patients that maintained IV sensitivity to insulin. Classic diagnostic criteria for ESIR include preserved sensitivity to IV insulin, failure to increase serum insulin with subcutaneous injection, and insulin degrading activity of subcutaneous tissue.2, 3 However, there are, at present, no laboratory tests that can test the final criterion. Indeed, very few of the published reports of ESIR satisfy it, with most studies considering as diagnostic of ESIR the constellation of EIR with failure to raise serum insulin after injection and preserved intravenous insulin sensitivity.

As was evident in the high doses of IV insulin required for blood glucose normalization, our patient also had a proven receptor‐level peripheral resistance. Beyond the common, multifactorial insulin resistance of T2DM, the published reports of patients with extreme peripheral resistance are of 2 types: (A) genetic (eg, Leprechaunism) and (B) acquired autoimmune (Table 1).4 This patient fits neither category. Patients with Type A are very sick, with a syndromic disease that sharply curtails their life expectancy. Patients with Type B acquire antibodies directed against their insulin receptors and are almost invariably elderly African‐American women with severe rheumatological disease, namely SLE. We could not test our patient for an insulin‐receptor antibody secondary to prohibitive cost. This is probably moot, given that his autoimmune workup was negative and, as above, patients with such antibodies are vastly different compared to our patients.

Based on SQ insulin requirements, our patient had EIR. As his insulin levels failed to rise following an insulin injection, his EIR is thus subcutaneous in nature. However, among patients with this condition his failure to respond to IV insulin is unique. He does not fit criteria for types A or B insulin resistance; his condition is likely also due to an extreme version of the more common, multifactorial peripheral insulin resistance. This is supported by his successful response to the gastric bypass operation.5

The standard treatments for ESIR include: (1) concentrated regular insulin (U‐500) and (2) implantable intraperitoneal delivery; our patient received the former.6 U‐500 use in EIR has been shown to be more cost‐effective.1 Several reports have suggested success with protease inhibitors (aprotinin, nafamostat ointment), plasmapheresis, and intravenous immunoglobulin for extreme SQ resistance. Our case also represents the first treated successfully with a gastric bypass operation.

CONCLUSIONS

EIR can present a significant challenge for both the patient and hospitalist. The approach to this condition should begin with the determination of 24‐hour IV insulin requirement utilizing an insulin drip; serum insulin antibody evaluation; and endocrinology consultation. Our case also highlights a few important points about the broader management of diabetes mellitus. First, there are dermatological manifestations of diabetes that serve as potential markers for disease (namely acanthosis nigricans and NLD). Second, for patients with extreme insulin requirements, an extensive workup should be initiated and the patient should be transitioned to a concentrated regular insulin or intraperitoneal delivery. Third, our experience suggests a role for other measures such as gastric bypass that ought to be studied further.

A 34‐year‐old man was admitted for evaluation of elevated blood glucose despite extremely high subcutaneous (SQ) insulin requirements. He had a 12‐year history of Type 2 diabetes mellitus (T2DM) without episodes of ketoacidosis, managed initially with oral medications (metformin with various sulfonylureas and thiazolidinediones). Three months prior to admission, he was transitioned to SQ insulin and thereafter his requirements escalated rapidly. By the time of his admission, his blood glucose measurements were consistently above 300 mg/dL despite injecting more than 4100 units of insulin daily. His regimen included 300 units of insulin glargine (Lantus) 2 times per day (BID) and 1.75 mL of Humilin U‐500 Insulin (875 units) 4 times per day (QID). Past medical history included metabolic syndrome, nonalcoholic steatohepatitis, and diabetic neuropathy. Physical exam was remarkable for centripetal obesity (body mass index [BMI] = 38.9 kg/m²), acanthosis nigricans, and necrobiosis lipoidica diabeticorum (NLD) (Figure 1).

Figure 1

We undertook an investigation to characterize this extreme insulin resistance. After 24 hours without insulin supplementation, and 12 hours of nothing by mouth (NPO), his blood glucose level was 280 mg/dL and his serum insulin was 133.5 IU/mL. We injected 12 units of insulin Aspart and subsequently measured his serum glucose and insulin once more. His blood glucose level had risen to 289 mg/dL and his serum insulin fell to 110.7 IU/mL. We then transitioned the patient to intravenous (IV) insulin. After a series of boluses totaling 400 units, his blood glucose normalized (90 mg/dL) and was maintained in normal range on a rate of 48 units per hour. Over 24 hours, we had infused over 1400 units.

During this time, we also drew several labs. Serum antiinsulin antibodies were undetectable (ARUP Laboratories, Salt Lake City, UT). A full rheumatologic workup was negative for systemic lupus erythematosus (SLE), rheumatoid factor, Sjgren's syndrome (SS)‐A and SS‐B. Androgen levels were normal, as were 24‐hour urine collections for cortisol and metanephrines. The patient was discharged on a regimen of U‐500 without glargine.

By 5 months after discharge, his blood glucose remained uncontrolled despite increasing doses of U‐500 (with or without metformin and thiazolidinediones). The patient was offered a gastric bypass operation. Now, 4 months postoperative, his blood glucose is controlled, no greater than 90 mg/dL in the morning and 125 mg/dL in the evening. He is off insulin, taking 30 mg pioglitazone (Actos) daily and 500 mg metformin 3 times per day (TID).

Discussion

Extreme insulin resistance (EIR), defined by daily insulin requirements in excess of 200 U, is a rare and frustrating condition.1 Rarer still is extreme subcutaneous insulin resistance (ESIR). A systematic Medline review revealed only 29 reported cases of ESIR, all of which involved patients that maintained IV sensitivity to insulin. Classic diagnostic criteria for ESIR include preserved sensitivity to IV insulin, failure to increase serum insulin with subcutaneous injection, and insulin degrading activity of subcutaneous tissue.2, 3 However, there are, at present, no laboratory tests that can test the final criterion. Indeed, very few of the published reports of ESIR satisfy it, with most studies considering as diagnostic of ESIR the constellation of EIR with failure to raise serum insulin after injection and preserved intravenous insulin sensitivity.

As was evident in the high doses of IV insulin required for blood glucose normalization, our patient also had a proven receptor‐level peripheral resistance. Beyond the common, multifactorial insulin resistance of T2DM, the published reports of patients with extreme peripheral resistance are of 2 types: (A) genetic (eg, Leprechaunism) and (B) acquired autoimmune (Table 1).4 This patient fits neither category. Patients with Type A are very sick, with a syndromic disease that sharply curtails their life expectancy. Patients with Type B acquire antibodies directed against their insulin receptors and are almost invariably elderly African‐American women with severe rheumatological disease, namely SLE. We could not test our patient for an insulin‐receptor antibody secondary to prohibitive cost. This is probably moot, given that his autoimmune workup was negative and, as above, patients with such antibodies are vastly different compared to our patients.

Based on SQ insulin requirements, our patient had EIR. As his insulin levels failed to rise following an insulin injection, his EIR is thus subcutaneous in nature. However, among patients with this condition his failure to respond to IV insulin is unique. He does not fit criteria for types A or B insulin resistance; his condition is likely also due to an extreme version of the more common, multifactorial peripheral insulin resistance. This is supported by his successful response to the gastric bypass operation.5

The standard treatments for ESIR include: (1) concentrated regular insulin (U‐500) and (2) implantable intraperitoneal delivery; our patient received the former.6 U‐500 use in EIR has been shown to be more cost‐effective.1 Several reports have suggested success with protease inhibitors (aprotinin, nafamostat ointment), plasmapheresis, and intravenous immunoglobulin for extreme SQ resistance. Our case also represents the first treated successfully with a gastric bypass operation.

CONCLUSIONS

EIR can present a significant challenge for both the patient and hospitalist. The approach to this condition should begin with the determination of 24‐hour IV insulin requirement utilizing an insulin drip; serum insulin antibody evaluation; and endocrinology consultation. Our case also highlights a few important points about the broader management of diabetes mellitus. First, there are dermatological manifestations of diabetes that serve as potential markers for disease (namely acanthosis nigricans and NLD). Second, for patients with extreme insulin requirements, an extensive workup should be initiated and the patient should be transitioned to a concentrated regular insulin or intraperitoneal delivery. Third, our experience suggests a role for other measures such as gastric bypass that ought to be studied further.

Handoffs during hospitalization from one provider to another represent critical transition points in patient care.1 In‐hospital handoffs are a frequent occurrence, with 1 teaching hospital reporting 4000 handoffs daily for a total of 1.6 million per year.2

Incomplete or poor‐quality handoffs have been implicated as a source of adverse events and near misses in hospitalized patients.35 Standardizing the handoff process may improve patient safety during care transitions.6 In 2006, the Joint Commission issued a National Patient Safety Goal that requires care providers to adopt a standardized approach for handoff communications, including an opportunity to ask and respond to questions about a patient's care.7 The reductions in resident work hours by the Accreditation Council for Graduate Medical Education (ACGME) has also resulted in a greater number and greater scrutiny of handoffs in teaching hospitals.8, 9

In response to these issues, and because handoffs are a core competency for hospitalists, the Society of Hospital Medicine (SHM)convened a task force.10 Our goal was to develop a set of recommendations for handoffs that would be applicable in both community and academic settings; among physicians (hospitalists, internists, subspecialists, residents), nurse practitioners, and physicians assistants; and across roles including serving as the primary provider of hospital care, comanager, or consultant. This work focuses on handoffs that occur at shift change and service change.11 Shift changes are transitions of care between an outgoing provider and an incoming provider that occur at the end of the outgoing provider's continuous on‐duty period. Service changesa special type of shift changeare transitions of care between an outgoing provider and an incoming provider that occur when an outgoing provider is leaving a rotation or period of consecutive daily care for patients on the same service.

For this initiative, transfers of care in which the patient is moving from one patient area to another (eg, Emergency Department to inpatient floor, or floor to intensive care unit [ICU]) were excluded since they likely require unique consideration given their cross‐disciplinary and multispecialty nature. Likewise, transitions of care at hospital admission and discharge were also excluded because recommendations for discharge are already summarized in 2 complementary reports.12, 13

To develop recommendations for handoffs at routine shift change and service changes, the Handoff Task Force performed a systematic review of the literature to develop initial recommendations, obtained feedback from hospital‐based clinicians in addition to a panel of handoff experts, and finalized handoff recommendations, as well as a proposed research agenda, for the SHM.

Methods

The SHM Healthcare Quality and Patient Safety (HQPS) Committee convened the Handoff Task Force, which was comprised of 6 geographically diverse, predominantly academic hospitalists with backgrounds in education, patient safety, health communication, evidence‐based medicine, and handoffs. The Task Force then engaged a panel of 4 content experts selected for their work on handoffs in the fields of nursing, information technology, human factors engineering, and hospital medicine. Similar to clinical guideline development by professional societies, the Task Force used a combination of evidence‐based review and expert opinions to propose recommendations.

Results

Literature Review

Of the 374 articles identified by the electronic search of PubMed and the AHRQ Patient Safety Network, 109 were retrieved for detailed review, and 10 of these met the criteria for inclusion (Figure 1). Of these studies, 3 were derived from nursing literature and the remaining were tests of technology solutions or structured templates (Table 1).1618, 20, 22, 3842 No studies examined hospitalist handoffs. All eligible studies concerned shift change. There were no studies of service change. Only 1 study was a randomized controlled trial; the rest were pre‐post studies with historical controls or a controlled simulation. All reports were single‐site studies. Most outcomes were staff‐related or system‐related, with only 2 studies using patient outcomes.

Table 1.Characteristics of Studies Included in Review

Author (Year)	Study Design	Intervention	Setting and Study Population	Target	Outcomes
Abbreviations: IM, internal medicine; IS, ; UW, University of Washington.
Nursing
Kelly22 (2005)	Pre‐post	Change to walk‐round handover (at bedside) from baseline (control)	12‐bed rehab unit with 18 nurses and 10 patients	Staff, patient	11/18 nurses felt more or much more informed and involved; 8/10 patients felt more involved
Pothier et al.20 (2005)	Controlled simulation	Compared pure verbal to verbal with note‐taking to verbal plus typed content	Handover of 12 simulated patients over 5 cycles	System (data loss)	Minimal data loss with typed content, compared to 31% data retained with note‐taking, and no data retained with verbal only
Wallum38 (1995)	Pre‐post	Change from oral handover (baseline) to written template read with exchange	20 nurses in a geriatric dementia ward	Staff	83% of nurses felt care plans followed better; 88% knew care plans better
Technology or structured template
Cheah et al.39 (2005)	Pre‐post	Electronic template with free‐text entry compared to baseline	14 UK Surgery residents	Staff	100% (14) of residents rated electronic system as desirable, but 7 (50%) reported that information was not updated
Lee et al.40 (1996)	Pre‐post	Standardized signout card for interns to transmit information during handoffs compared to handwritten (baseline)	Inpatient cardiology service at IM residency program in Minnesota with 19 new interns over a 3‐month period	Staff	Intervention interns (n = 10) reported poor sign‐out less often than controls (n = 9) [intervention 8 nights (5.8%) vs. control 17 nights (14.9%); P = 0.016]
Kannry and Moore18 (1999)	Pre‐post	Compared web‐based signout program to usual system (baseline)	An academic teaching hospital in New York (34 patients admitted in 1997; 40 patients admitted in 1998)	System	Improved provider identification (86% web signout vs. 57% hospital census)
Petersen et al.17 (1998)	Pre‐post	4 months of computerized signouts compared to baseline period (control)	3747 patients admitted to the medical service at an academic teaching hospital	Patient	Preventable adverse events (ADE) decreased (1.7% to 1.2%, P < 0.10); risk of cross‐cover physician for ADE eliminated
Ram and Block41 (1993)	Pre‐post	Compared handwritten (baseline) to computer‐generated	Family medicine residents at 2 academic teaching hospitals [Buffalo (n = 16) and Pittsburgh (n = 16)]	Staff	Higher satisfaction after electronic signout, but complaints with burden of data entry and need to keep information updated
Van Eaton et al.42 (2004)	Pre‐post	Use of UW Cores links sign‐out to list for rounds and IS data	28 surgical and medical residents at 2 teaching hospitals	System	At 6 months, 66% of patients entered in system (adoption)
Van Eaton et al.16 (2005)	Prospective, randomized, crossover study.	Compared UW Cores* integrated system compared to usual system	14 inpatient resident teams (6 surgery, 8 IM) at 2 teaching hospitals for 5 months	Staff, system	50% reduction in the perceived time spent copying data [from 24% to 12% (P < 0.0001)] and number of patients missed on rounds (2.5 vs. 5 patients/team/month, P = 0.0001); improved signout quality (69.6% agree or strongly agree); and improved continuity of care (66.1% agree or strongly agree)

Figure 1

Overall, the literature presented supports the use of a verbal handoff supplemented with written documentation in a structured format or technology solution. The 2 most rigorous studies were led by Van Eaton et al.16 and Petersen et al.17 and focused on evaluating technology solutions. Van Eaton et al.16 performed a randomized controlled trial of a locally created rounding template with 161 surgical residents. This template downloads certain information (lab values and recent vital signs) from the hospital system into a sign‐out sheet and allows residents to enter notes about diagnoses, allergies, medications and to‐do items. When implemented, the investigators found the number of patients missed on rounds decreased by 50%. Residents reported an increase of 40% in the amount of time available to pre‐round, due largely to not having to copy data such as vital signs. They reported a decrease in rounding time by 3 hours per week, and this was perceived as helping them meet the ACGME 80 hours work rules. Lastly, the residents reported a higher quality of sign‐outs from their peers and perceived an overall improvement in continuity of care. Petersen and colleagues implemented a computerized sign‐out (auto‐imported medications, name, room number) in an internal medicine residency to improve continuity of care during cross‐coverage and decrease adverse events.17 Prior to the intervention, the frequency of preventable adverse events was 1.7% and it was significantly associated with cross‐coverage. Preventable adverse events were identified using a confidential self‐report system that was also validated by clinician review. After the intervention, the frequency of preventable adverse events dropped to 1.2% (P < 0.1), and cross‐coverage was no longer associated with preventable adverse events. In other studies, technological solutions also improved provider identification and staff communication.18, 19 Together, these technology‐based intervention studies suggest that a computerized sign‐out with auto‐imported fields has the ability to improve physician efficiency and also improve inpatient care (reduction in number of patients missed on rounds, decrease in preventable adverse events).

Studies from nursing demonstrated that supplementing a verbal exchange with written information improved transfer of information, compared to verbal exchange alone.20 One of these studies rated the transfer of information using videotaped simulated handoff cases.21 Last, 1 nursing study that more directly involved patients in the handoff process resulted in improved nursing knowledge and greater patient empowerment (Table 1).22

White papers or consensus statements originated from international and national consortia in patient safety including the Australian Council for Safety and Quality in Healthcare,23 the Junior Doctors Committee of the British Medical Association,24 University Health Consortium,25 the Department of Defense Patient Safety Program,26 and The Joint Commission.27 Several common themes were prevalent in all white papers. First, there exists a need to train new personnel on how to perform an effective handoff. Second, efforts should be undertaken to ensure adequate time for handoffs and reduce interruptions during handoffs. Third, several of the papers supported verbal exchange that facilitates interactive questioning, focuses on ill patients, and delineates actions to be taken. Lastly, content should be updated to ensure transfer of the latest clinical information.

Final Handoff Recommendations

The final handoff recommendations are shown in Figure 2. The recommendations were designed to be consistent with the overall finding of the literature review, which supports the use of a verbal handoff supplemented with written documentation or a technological solution in a structured format. With the exception of 1 recommendation that is specific to service changes, all recommendations are designed to refer to shift changes and service changes. One overarching recommendation refers to the need for a formally recognized handoff plan at a shift change or change of service. The remaining 12 recommendations are divided into 4 that refer to hospitalist groups or programs, 3 that refer to verbal exchange, and 5 that refer to content exchange. The distinction is an important one because program‐level recommendations require organizational support and buy‐in to promote clinician participation and adherence. The 4 program recommendations also form the necessary framework for the remaining recommendations. For example, the second program recommendation describes the need for a standardized template or technology solution for accessing and recording patient information during the handoff. After a program adopts such a mechanism for exchanging patient information, the specific details for use and maintenance are outlined in greater detail in content exchange recommendations.

Figure 2

Because of the limited trials of handoff strategies, none of the recommendations are supported with level of evidence A (multiple numerous randomized controlled trials). In fact, with the exception of using a template or technology solution which was supported with level of evidence B, all handoff recommendations were supported with C level of evidence. The recommendations, however, were rated as Class I (effective) because there were no conflicting expert opinions or studies (Figure 2).

Discussion

In summary, our review of the literature supports the use of face‐to‐face verbal handoffs that are aided by the use of structured template to guide exchange of information. Furthermore, the development of these recommendations is the first effort of its kind for hospitalist handoffs and a movement towards standardizing the handoff process. While these recommendations are meant to provide structure to the hospitalist handoff process, the use and implementation by individual hospitalist programs may require more specific detail than these recommendations provide. Local modifications can allow for improved acceptance and adoption by practicing hospitalists. These recommendations can also help guide teaching efforts for academic hospitalists who are responsible for supervising residents.

The limitations of these recommendations related to lack of evidence in this field. Studies suffered from small size, poor description of methods, and a paucity of controlled interventions. The described technology solutions are not standardized or commercially available. Only 1 study included patient outcomes.28 There are no multicenter studies, studies of hospitalist handoffs, or studies to guide inclusion of specific content. Randomized controlled trials, interrupted time series analyses, and other rigorous study designs are needed in both teaching and non‐teaching settings to evaluate these recommendations and other approaches to improving handoffs. Ideally, these studies would occur through multicenter collaboratives and with human factors researchers familiar with mixed methods approaches to evaluate how and why interventions work.29 Efforts should focus on developing surrogate measures that are sensitive to handoff quality and related to important patient outcomes. The results of future studies should be used to refine the present recommendations. Locating new literature could be facilitated through the introduction of Medical Subject Heading for the term handoff by the National Library of Medicine. After completing this systematic review and developing the handoff recommendations described here, a few other noteworthy articles have been published on this topic, to which we refer interested readers. Several of these studies demonstrate that standardizing content and process during medical or surgical intern sign‐out improves resident confidence with handoffs,30 resident perceptions of accuracy and completeness of signout,31 and perceptions of patient safety.32 Another prospective audiotape study of 12 days of resident signout of clinical information demonstrated that poor quality oral sign‐outs was associated with an increased risk of post‐call resident reported signout‐related problems.5 Lastly, 1 nursing study demonstrated improved staff reports of safety, efficiency, and teamwork after a change from verbal reporting in an isolated room to bedside handover.33 Overall, these additional studies continue to support the current recommendations presented in this paper and do not significantly impact the conclusions of our literature review.

While lacking specific content domain recommendations, this report can be used as a starting point to guide development of self and peer assessment of hospitalist handoff quality. Development and validation of such assessments is especially important and can be incorporated into efforts to certify hospitalists through the recently approved certificate of focused practice in hospital medicine by the American Board of Internal Medicine (ABIM). Initiatives by several related organizations may help guide these effortsThe Joint Commission, the ABIM's Stepping Up to the Plate (SUTTP) Alliance, the Institute for Healthcare Improvement, the Information Transfer and Communication Practices (ITCP) Project for surgical care transitions, and the Hospital at Night (H@N) Program sponsored by the United Kingdom's National Health Service.3437 Professional medical organizations can also serve as powerful mediators of change in this area, not only by raising the visibility of handoffs, but also by mobilizing research funding. Patients and their caregivers may also play an important role in increasing awareness and education in this area. Future efforts should target handoffs not addressed in this initiative, such as transfers from emergency departments to inpatient care units, or between ICUs and the medical floor.

Conclusion

With the growth of hospital medicine and the increased acuity of inpatients, improving handoffs becomes an important part of ensuring patient safety. The goal of the SHM Handoffs Task Force was to begin to standardize handoffs at change of shift and change of servicea fundamental activity of hospitalists. These recommendations build on the limited literature in surgery, nursing, and medical informatics and provide a starting point for promoting safe and seamless in‐hospital handoffs for practitioners of Hospital Medicine.

Handoffs during hospitalization from one provider to another represent critical transition points in patient care.1 In‐hospital handoffs are a frequent occurrence, with 1 teaching hospital reporting 4000 handoffs daily for a total of 1.6 million per year.2

Incomplete or poor‐quality handoffs have been implicated as a source of adverse events and near misses in hospitalized patients.35 Standardizing the handoff process may improve patient safety during care transitions.6 In 2006, the Joint Commission issued a National Patient Safety Goal that requires care providers to adopt a standardized approach for handoff communications, including an opportunity to ask and respond to questions about a patient's care.7 The reductions in resident work hours by the Accreditation Council for Graduate Medical Education (ACGME) has also resulted in a greater number and greater scrutiny of handoffs in teaching hospitals.8, 9

In response to these issues, and because handoffs are a core competency for hospitalists, the Society of Hospital Medicine (SHM)convened a task force.10 Our goal was to develop a set of recommendations for handoffs that would be applicable in both community and academic settings; among physicians (hospitalists, internists, subspecialists, residents), nurse practitioners, and physicians assistants; and across roles including serving as the primary provider of hospital care, comanager, or consultant. This work focuses on handoffs that occur at shift change and service change.11 Shift changes are transitions of care between an outgoing provider and an incoming provider that occur at the end of the outgoing provider's continuous on‐duty period. Service changesa special type of shift changeare transitions of care between an outgoing provider and an incoming provider that occur when an outgoing provider is leaving a rotation or period of consecutive daily care for patients on the same service.

For this initiative, transfers of care in which the patient is moving from one patient area to another (eg, Emergency Department to inpatient floor, or floor to intensive care unit [ICU]) were excluded since they likely require unique consideration given their cross‐disciplinary and multispecialty nature. Likewise, transitions of care at hospital admission and discharge were also excluded because recommendations for discharge are already summarized in 2 complementary reports.12, 13

To develop recommendations for handoffs at routine shift change and service changes, the Handoff Task Force performed a systematic review of the literature to develop initial recommendations, obtained feedback from hospital‐based clinicians in addition to a panel of handoff experts, and finalized handoff recommendations, as well as a proposed research agenda, for the SHM.

Methods

The SHM Healthcare Quality and Patient Safety (HQPS) Committee convened the Handoff Task Force, which was comprised of 6 geographically diverse, predominantly academic hospitalists with backgrounds in education, patient safety, health communication, evidence‐based medicine, and handoffs. The Task Force then engaged a panel of 4 content experts selected for their work on handoffs in the fields of nursing, information technology, human factors engineering, and hospital medicine. Similar to clinical guideline development by professional societies, the Task Force used a combination of evidence‐based review and expert opinions to propose recommendations.

Results

Literature Review

Of the 374 articles identified by the electronic search of PubMed and the AHRQ Patient Safety Network, 109 were retrieved for detailed review, and 10 of these met the criteria for inclusion (Figure 1). Of these studies, 3 were derived from nursing literature and the remaining were tests of technology solutions or structured templates (Table 1).1618, 20, 22, 3842 No studies examined hospitalist handoffs. All eligible studies concerned shift change. There were no studies of service change. Only 1 study was a randomized controlled trial; the rest were pre‐post studies with historical controls or a controlled simulation. All reports were single‐site studies. Most outcomes were staff‐related or system‐related, with only 2 studies using patient outcomes.

Table 1.Characteristics of Studies Included in Review

Author (Year)	Study Design	Intervention	Setting and Study Population	Target	Outcomes
Abbreviations: IM, internal medicine; IS, ; UW, University of Washington.
Nursing
Kelly22 (2005)	Pre‐post	Change to walk‐round handover (at bedside) from baseline (control)	12‐bed rehab unit with 18 nurses and 10 patients	Staff, patient	11/18 nurses felt more or much more informed and involved; 8/10 patients felt more involved
Pothier et al.20 (2005)	Controlled simulation	Compared pure verbal to verbal with note‐taking to verbal plus typed content	Handover of 12 simulated patients over 5 cycles	System (data loss)	Minimal data loss with typed content, compared to 31% data retained with note‐taking, and no data retained with verbal only
Wallum38 (1995)	Pre‐post	Change from oral handover (baseline) to written template read with exchange	20 nurses in a geriatric dementia ward	Staff	83% of nurses felt care plans followed better; 88% knew care plans better
Technology or structured template
Cheah et al.39 (2005)	Pre‐post	Electronic template with free‐text entry compared to baseline	14 UK Surgery residents	Staff	100% (14) of residents rated electronic system as desirable, but 7 (50%) reported that information was not updated
Lee et al.40 (1996)	Pre‐post	Standardized signout card for interns to transmit information during handoffs compared to handwritten (baseline)	Inpatient cardiology service at IM residency program in Minnesota with 19 new interns over a 3‐month period	Staff	Intervention interns (n = 10) reported poor sign‐out less often than controls (n = 9) [intervention 8 nights (5.8%) vs. control 17 nights (14.9%); P = 0.016]
Kannry and Moore18 (1999)	Pre‐post	Compared web‐based signout program to usual system (baseline)	An academic teaching hospital in New York (34 patients admitted in 1997; 40 patients admitted in 1998)	System	Improved provider identification (86% web signout vs. 57% hospital census)
Petersen et al.17 (1998)	Pre‐post	4 months of computerized signouts compared to baseline period (control)	3747 patients admitted to the medical service at an academic teaching hospital	Patient	Preventable adverse events (ADE) decreased (1.7% to 1.2%, P < 0.10); risk of cross‐cover physician for ADE eliminated
Ram and Block41 (1993)	Pre‐post	Compared handwritten (baseline) to computer‐generated	Family medicine residents at 2 academic teaching hospitals [Buffalo (n = 16) and Pittsburgh (n = 16)]	Staff	Higher satisfaction after electronic signout, but complaints with burden of data entry and need to keep information updated
Van Eaton et al.42 (2004)	Pre‐post	Use of UW Cores links sign‐out to list for rounds and IS data	28 surgical and medical residents at 2 teaching hospitals	System	At 6 months, 66% of patients entered in system (adoption)
Van Eaton et al.16 (2005)	Prospective, randomized, crossover study.	Compared UW Cores* integrated system compared to usual system	14 inpatient resident teams (6 surgery, 8 IM) at 2 teaching hospitals for 5 months	Staff, system	50% reduction in the perceived time spent copying data [from 24% to 12% (P < 0.0001)] and number of patients missed on rounds (2.5 vs. 5 patients/team/month, P = 0.0001); improved signout quality (69.6% agree or strongly agree); and improved continuity of care (66.1% agree or strongly agree)

Figure 1

Overall, the literature presented supports the use of a verbal handoff supplemented with written documentation in a structured format or technology solution. The 2 most rigorous studies were led by Van Eaton et al.16 and Petersen et al.17 and focused on evaluating technology solutions. Van Eaton et al.16 performed a randomized controlled trial of a locally created rounding template with 161 surgical residents. This template downloads certain information (lab values and recent vital signs) from the hospital system into a sign‐out sheet and allows residents to enter notes about diagnoses, allergies, medications and to‐do items. When implemented, the investigators found the number of patients missed on rounds decreased by 50%. Residents reported an increase of 40% in the amount of time available to pre‐round, due largely to not having to copy data such as vital signs. They reported a decrease in rounding time by 3 hours per week, and this was perceived as helping them meet the ACGME 80 hours work rules. Lastly, the residents reported a higher quality of sign‐outs from their peers and perceived an overall improvement in continuity of care. Petersen and colleagues implemented a computerized sign‐out (auto‐imported medications, name, room number) in an internal medicine residency to improve continuity of care during cross‐coverage and decrease adverse events.17 Prior to the intervention, the frequency of preventable adverse events was 1.7% and it was significantly associated with cross‐coverage. Preventable adverse events were identified using a confidential self‐report system that was also validated by clinician review. After the intervention, the frequency of preventable adverse events dropped to 1.2% (P < 0.1), and cross‐coverage was no longer associated with preventable adverse events. In other studies, technological solutions also improved provider identification and staff communication.18, 19 Together, these technology‐based intervention studies suggest that a computerized sign‐out with auto‐imported fields has the ability to improve physician efficiency and also improve inpatient care (reduction in number of patients missed on rounds, decrease in preventable adverse events).

Studies from nursing demonstrated that supplementing a verbal exchange with written information improved transfer of information, compared to verbal exchange alone.20 One of these studies rated the transfer of information using videotaped simulated handoff cases.21 Last, 1 nursing study that more directly involved patients in the handoff process resulted in improved nursing knowledge and greater patient empowerment (Table 1).22

White papers or consensus statements originated from international and national consortia in patient safety including the Australian Council for Safety and Quality in Healthcare,23 the Junior Doctors Committee of the British Medical Association,24 University Health Consortium,25 the Department of Defense Patient Safety Program,26 and The Joint Commission.27 Several common themes were prevalent in all white papers. First, there exists a need to train new personnel on how to perform an effective handoff. Second, efforts should be undertaken to ensure adequate time for handoffs and reduce interruptions during handoffs. Third, several of the papers supported verbal exchange that facilitates interactive questioning, focuses on ill patients, and delineates actions to be taken. Lastly, content should be updated to ensure transfer of the latest clinical information.

Final Handoff Recommendations

The final handoff recommendations are shown in Figure 2. The recommendations were designed to be consistent with the overall finding of the literature review, which supports the use of a verbal handoff supplemented with written documentation or a technological solution in a structured format. With the exception of 1 recommendation that is specific to service changes, all recommendations are designed to refer to shift changes and service changes. One overarching recommendation refers to the need for a formally recognized handoff plan at a shift change or change of service. The remaining 12 recommendations are divided into 4 that refer to hospitalist groups or programs, 3 that refer to verbal exchange, and 5 that refer to content exchange. The distinction is an important one because program‐level recommendations require organizational support and buy‐in to promote clinician participation and adherence. The 4 program recommendations also form the necessary framework for the remaining recommendations. For example, the second program recommendation describes the need for a standardized template or technology solution for accessing and recording patient information during the handoff. After a program adopts such a mechanism for exchanging patient information, the specific details for use and maintenance are outlined in greater detail in content exchange recommendations.

Figure 2

Because of the limited trials of handoff strategies, none of the recommendations are supported with level of evidence A (multiple numerous randomized controlled trials). In fact, with the exception of using a template or technology solution which was supported with level of evidence B, all handoff recommendations were supported with C level of evidence. The recommendations, however, were rated as Class I (effective) because there were no conflicting expert opinions or studies (Figure 2).

Discussion

In summary, our review of the literature supports the use of face‐to‐face verbal handoffs that are aided by the use of structured template to guide exchange of information. Furthermore, the development of these recommendations is the first effort of its kind for hospitalist handoffs and a movement towards standardizing the handoff process. While these recommendations are meant to provide structure to the hospitalist handoff process, the use and implementation by individual hospitalist programs may require more specific detail than these recommendations provide. Local modifications can allow for improved acceptance and adoption by practicing hospitalists. These recommendations can also help guide teaching efforts for academic hospitalists who are responsible for supervising residents.

The limitations of these recommendations related to lack of evidence in this field. Studies suffered from small size, poor description of methods, and a paucity of controlled interventions. The described technology solutions are not standardized or commercially available. Only 1 study included patient outcomes.28 There are no multicenter studies, studies of hospitalist handoffs, or studies to guide inclusion of specific content. Randomized controlled trials, interrupted time series analyses, and other rigorous study designs are needed in both teaching and non‐teaching settings to evaluate these recommendations and other approaches to improving handoffs. Ideally, these studies would occur through multicenter collaboratives and with human factors researchers familiar with mixed methods approaches to evaluate how and why interventions work.29 Efforts should focus on developing surrogate measures that are sensitive to handoff quality and related to important patient outcomes. The results of future studies should be used to refine the present recommendations. Locating new literature could be facilitated through the introduction of Medical Subject Heading for the term handoff by the National Library of Medicine. After completing this systematic review and developing the handoff recommendations described here, a few other noteworthy articles have been published on this topic, to which we refer interested readers. Several of these studies demonstrate that standardizing content and process during medical or surgical intern sign‐out improves resident confidence with handoffs,30 resident perceptions of accuracy and completeness of signout,31 and perceptions of patient safety.32 Another prospective audiotape study of 12 days of resident signout of clinical information demonstrated that poor quality oral sign‐outs was associated with an increased risk of post‐call resident reported signout‐related problems.5 Lastly, 1 nursing study demonstrated improved staff reports of safety, efficiency, and teamwork after a change from verbal reporting in an isolated room to bedside handover.33 Overall, these additional studies continue to support the current recommendations presented in this paper and do not significantly impact the conclusions of our literature review.

While lacking specific content domain recommendations, this report can be used as a starting point to guide development of self and peer assessment of hospitalist handoff quality. Development and validation of such assessments is especially important and can be incorporated into efforts to certify hospitalists through the recently approved certificate of focused practice in hospital medicine by the American Board of Internal Medicine (ABIM). Initiatives by several related organizations may help guide these effortsThe Joint Commission, the ABIM's Stepping Up to the Plate (SUTTP) Alliance, the Institute for Healthcare Improvement, the Information Transfer and Communication Practices (ITCP) Project for surgical care transitions, and the Hospital at Night (H@N) Program sponsored by the United Kingdom's National Health Service.3437 Professional medical organizations can also serve as powerful mediators of change in this area, not only by raising the visibility of handoffs, but also by mobilizing research funding. Patients and their caregivers may also play an important role in increasing awareness and education in this area. Future efforts should target handoffs not addressed in this initiative, such as transfers from emergency departments to inpatient care units, or between ICUs and the medical floor.

Conclusion

With the growth of hospital medicine and the increased acuity of inpatients, improving handoffs becomes an important part of ensuring patient safety. The goal of the SHM Handoffs Task Force was to begin to standardize handoffs at change of shift and change of servicea fundamental activity of hospitalists. These recommendations build on the limited literature in surgery, nursing, and medical informatics and provide a starting point for promoting safe and seamless in‐hospital handoffs for practitioners of Hospital Medicine.

Handoffs during hospitalization from one provider to another represent critical transition points in patient care.1 In‐hospital handoffs are a frequent occurrence, with 1 teaching hospital reporting 4000 handoffs daily for a total of 1.6 million per year.2

Incomplete or poor‐quality handoffs have been implicated as a source of adverse events and near misses in hospitalized patients.35 Standardizing the handoff process may improve patient safety during care transitions.6 In 2006, the Joint Commission issued a National Patient Safety Goal that requires care providers to adopt a standardized approach for handoff communications, including an opportunity to ask and respond to questions about a patient's care.7 The reductions in resident work hours by the Accreditation Council for Graduate Medical Education (ACGME) has also resulted in a greater number and greater scrutiny of handoffs in teaching hospitals.8, 9

In response to these issues, and because handoffs are a core competency for hospitalists, the Society of Hospital Medicine (SHM)convened a task force.10 Our goal was to develop a set of recommendations for handoffs that would be applicable in both community and academic settings; among physicians (hospitalists, internists, subspecialists, residents), nurse practitioners, and physicians assistants; and across roles including serving as the primary provider of hospital care, comanager, or consultant. This work focuses on handoffs that occur at shift change and service change.11 Shift changes are transitions of care between an outgoing provider and an incoming provider that occur at the end of the outgoing provider's continuous on‐duty period. Service changesa special type of shift changeare transitions of care between an outgoing provider and an incoming provider that occur when an outgoing provider is leaving a rotation or period of consecutive daily care for patients on the same service.

For this initiative, transfers of care in which the patient is moving from one patient area to another (eg, Emergency Department to inpatient floor, or floor to intensive care unit [ICU]) were excluded since they likely require unique consideration given their cross‐disciplinary and multispecialty nature. Likewise, transitions of care at hospital admission and discharge were also excluded because recommendations for discharge are already summarized in 2 complementary reports.12, 13

To develop recommendations for handoffs at routine shift change and service changes, the Handoff Task Force performed a systematic review of the literature to develop initial recommendations, obtained feedback from hospital‐based clinicians in addition to a panel of handoff experts, and finalized handoff recommendations, as well as a proposed research agenda, for the SHM.

Methods

The SHM Healthcare Quality and Patient Safety (HQPS) Committee convened the Handoff Task Force, which was comprised of 6 geographically diverse, predominantly academic hospitalists with backgrounds in education, patient safety, health communication, evidence‐based medicine, and handoffs. The Task Force then engaged a panel of 4 content experts selected for their work on handoffs in the fields of nursing, information technology, human factors engineering, and hospital medicine. Similar to clinical guideline development by professional societies, the Task Force used a combination of evidence‐based review and expert opinions to propose recommendations.

Results

Literature Review

Of the 374 articles identified by the electronic search of PubMed and the AHRQ Patient Safety Network, 109 were retrieved for detailed review, and 10 of these met the criteria for inclusion (Figure 1). Of these studies, 3 were derived from nursing literature and the remaining were tests of technology solutions or structured templates (Table 1).1618, 20, 22, 3842 No studies examined hospitalist handoffs. All eligible studies concerned shift change. There were no studies of service change. Only 1 study was a randomized controlled trial; the rest were pre‐post studies with historical controls or a controlled simulation. All reports were single‐site studies. Most outcomes were staff‐related or system‐related, with only 2 studies using patient outcomes.

Table 1.Characteristics of Studies Included in Review

Author (Year)	Study Design	Intervention	Setting and Study Population	Target	Outcomes
Abbreviations: IM, internal medicine; IS, ; UW, University of Washington.
Nursing
Kelly22 (2005)	Pre‐post	Change to walk‐round handover (at bedside) from baseline (control)	12‐bed rehab unit with 18 nurses and 10 patients	Staff, patient	11/18 nurses felt more or much more informed and involved; 8/10 patients felt more involved
Pothier et al.20 (2005)	Controlled simulation	Compared pure verbal to verbal with note‐taking to verbal plus typed content	Handover of 12 simulated patients over 5 cycles	System (data loss)	Minimal data loss with typed content, compared to 31% data retained with note‐taking, and no data retained with verbal only
Wallum38 (1995)	Pre‐post	Change from oral handover (baseline) to written template read with exchange	20 nurses in a geriatric dementia ward	Staff	83% of nurses felt care plans followed better; 88% knew care plans better
Technology or structured template
Cheah et al.39 (2005)	Pre‐post	Electronic template with free‐text entry compared to baseline	14 UK Surgery residents	Staff	100% (14) of residents rated electronic system as desirable, but 7 (50%) reported that information was not updated
Lee et al.40 (1996)	Pre‐post	Standardized signout card for interns to transmit information during handoffs compared to handwritten (baseline)	Inpatient cardiology service at IM residency program in Minnesota with 19 new interns over a 3‐month period	Staff	Intervention interns (n = 10) reported poor sign‐out less often than controls (n = 9) [intervention 8 nights (5.8%) vs. control 17 nights (14.9%); P = 0.016]
Kannry and Moore18 (1999)	Pre‐post	Compared web‐based signout program to usual system (baseline)	An academic teaching hospital in New York (34 patients admitted in 1997; 40 patients admitted in 1998)	System	Improved provider identification (86% web signout vs. 57% hospital census)
Petersen et al.17 (1998)	Pre‐post	4 months of computerized signouts compared to baseline period (control)	3747 patients admitted to the medical service at an academic teaching hospital	Patient	Preventable adverse events (ADE) decreased (1.7% to 1.2%, P < 0.10); risk of cross‐cover physician for ADE eliminated
Ram and Block41 (1993)	Pre‐post	Compared handwritten (baseline) to computer‐generated	Family medicine residents at 2 academic teaching hospitals [Buffalo (n = 16) and Pittsburgh (n = 16)]	Staff	Higher satisfaction after electronic signout, but complaints with burden of data entry and need to keep information updated
Van Eaton et al.42 (2004)	Pre‐post	Use of UW Cores links sign‐out to list for rounds and IS data	28 surgical and medical residents at 2 teaching hospitals	System	At 6 months, 66% of patients entered in system (adoption)
Van Eaton et al.16 (2005)	Prospective, randomized, crossover study.	Compared UW Cores* integrated system compared to usual system	14 inpatient resident teams (6 surgery, 8 IM) at 2 teaching hospitals for 5 months	Staff, system	50% reduction in the perceived time spent copying data [from 24% to 12% (P < 0.0001)] and number of patients missed on rounds (2.5 vs. 5 patients/team/month, P = 0.0001); improved signout quality (69.6% agree or strongly agree); and improved continuity of care (66.1% agree or strongly agree)

Figure 1

Overall, the literature presented supports the use of a verbal handoff supplemented with written documentation in a structured format or technology solution. The 2 most rigorous studies were led by Van Eaton et al.16 and Petersen et al.17 and focused on evaluating technology solutions. Van Eaton et al.16 performed a randomized controlled trial of a locally created rounding template with 161 surgical residents. This template downloads certain information (lab values and recent vital signs) from the hospital system into a sign‐out sheet and allows residents to enter notes about diagnoses, allergies, medications and to‐do items. When implemented, the investigators found the number of patients missed on rounds decreased by 50%. Residents reported an increase of 40% in the amount of time available to pre‐round, due largely to not having to copy data such as vital signs. They reported a decrease in rounding time by 3 hours per week, and this was perceived as helping them meet the ACGME 80 hours work rules. Lastly, the residents reported a higher quality of sign‐outs from their peers and perceived an overall improvement in continuity of care. Petersen and colleagues implemented a computerized sign‐out (auto‐imported medications, name, room number) in an internal medicine residency to improve continuity of care during cross‐coverage and decrease adverse events.17 Prior to the intervention, the frequency of preventable adverse events was 1.7% and it was significantly associated with cross‐coverage. Preventable adverse events were identified using a confidential self‐report system that was also validated by clinician review. After the intervention, the frequency of preventable adverse events dropped to 1.2% (P < 0.1), and cross‐coverage was no longer associated with preventable adverse events. In other studies, technological solutions also improved provider identification and staff communication.18, 19 Together, these technology‐based intervention studies suggest that a computerized sign‐out with auto‐imported fields has the ability to improve physician efficiency and also improve inpatient care (reduction in number of patients missed on rounds, decrease in preventable adverse events).

Studies from nursing demonstrated that supplementing a verbal exchange with written information improved transfer of information, compared to verbal exchange alone.20 One of these studies rated the transfer of information using videotaped simulated handoff cases.21 Last, 1 nursing study that more directly involved patients in the handoff process resulted in improved nursing knowledge and greater patient empowerment (Table 1).22

White papers or consensus statements originated from international and national consortia in patient safety including the Australian Council for Safety and Quality in Healthcare,23 the Junior Doctors Committee of the British Medical Association,24 University Health Consortium,25 the Department of Defense Patient Safety Program,26 and The Joint Commission.27 Several common themes were prevalent in all white papers. First, there exists a need to train new personnel on how to perform an effective handoff. Second, efforts should be undertaken to ensure adequate time for handoffs and reduce interruptions during handoffs. Third, several of the papers supported verbal exchange that facilitates interactive questioning, focuses on ill patients, and delineates actions to be taken. Lastly, content should be updated to ensure transfer of the latest clinical information.

Final Handoff Recommendations

The final handoff recommendations are shown in Figure 2. The recommendations were designed to be consistent with the overall finding of the literature review, which supports the use of a verbal handoff supplemented with written documentation or a technological solution in a structured format. With the exception of 1 recommendation that is specific to service changes, all recommendations are designed to refer to shift changes and service changes. One overarching recommendation refers to the need for a formally recognized handoff plan at a shift change or change of service. The remaining 12 recommendations are divided into 4 that refer to hospitalist groups or programs, 3 that refer to verbal exchange, and 5 that refer to content exchange. The distinction is an important one because program‐level recommendations require organizational support and buy‐in to promote clinician participation and adherence. The 4 program recommendations also form the necessary framework for the remaining recommendations. For example, the second program recommendation describes the need for a standardized template or technology solution for accessing and recording patient information during the handoff. After a program adopts such a mechanism for exchanging patient information, the specific details for use and maintenance are outlined in greater detail in content exchange recommendations.

Figure 2

Because of the limited trials of handoff strategies, none of the recommendations are supported with level of evidence A (multiple numerous randomized controlled trials). In fact, with the exception of using a template or technology solution which was supported with level of evidence B, all handoff recommendations were supported with C level of evidence. The recommendations, however, were rated as Class I (effective) because there were no conflicting expert opinions or studies (Figure 2).

Discussion

In summary, our review of the literature supports the use of face‐to‐face verbal handoffs that are aided by the use of structured template to guide exchange of information. Furthermore, the development of these recommendations is the first effort of its kind for hospitalist handoffs and a movement towards standardizing the handoff process. While these recommendations are meant to provide structure to the hospitalist handoff process, the use and implementation by individual hospitalist programs may require more specific detail than these recommendations provide. Local modifications can allow for improved acceptance and adoption by practicing hospitalists. These recommendations can also help guide teaching efforts for academic hospitalists who are responsible for supervising residents.

The limitations of these recommendations related to lack of evidence in this field. Studies suffered from small size, poor description of methods, and a paucity of controlled interventions. The described technology solutions are not standardized or commercially available. Only 1 study included patient outcomes.28 There are no multicenter studies, studies of hospitalist handoffs, or studies to guide inclusion of specific content. Randomized controlled trials, interrupted time series analyses, and other rigorous study designs are needed in both teaching and non‐teaching settings to evaluate these recommendations and other approaches to improving handoffs. Ideally, these studies would occur through multicenter collaboratives and with human factors researchers familiar with mixed methods approaches to evaluate how and why interventions work.29 Efforts should focus on developing surrogate measures that are sensitive to handoff quality and related to important patient outcomes. The results of future studies should be used to refine the present recommendations. Locating new literature could be facilitated through the introduction of Medical Subject Heading for the term handoff by the National Library of Medicine. After completing this systematic review and developing the handoff recommendations described here, a few other noteworthy articles have been published on this topic, to which we refer interested readers. Several of these studies demonstrate that standardizing content and process during medical or surgical intern sign‐out improves resident confidence with handoffs,30 resident perceptions of accuracy and completeness of signout,31 and perceptions of patient safety.32 Another prospective audiotape study of 12 days of resident signout of clinical information demonstrated that poor quality oral sign‐outs was associated with an increased risk of post‐call resident reported signout‐related problems.5 Lastly, 1 nursing study demonstrated improved staff reports of safety, efficiency, and teamwork after a change from verbal reporting in an isolated room to bedside handover.33 Overall, these additional studies continue to support the current recommendations presented in this paper and do not significantly impact the conclusions of our literature review.

While lacking specific content domain recommendations, this report can be used as a starting point to guide development of self and peer assessment of hospitalist handoff quality. Development and validation of such assessments is especially important and can be incorporated into efforts to certify hospitalists through the recently approved certificate of focused practice in hospital medicine by the American Board of Internal Medicine (ABIM). Initiatives by several related organizations may help guide these effortsThe Joint Commission, the ABIM's Stepping Up to the Plate (SUTTP) Alliance, the Institute for Healthcare Improvement, the Information Transfer and Communication Practices (ITCP) Project for surgical care transitions, and the Hospital at Night (H@N) Program sponsored by the United Kingdom's National Health Service.3437 Professional medical organizations can also serve as powerful mediators of change in this area, not only by raising the visibility of handoffs, but also by mobilizing research funding. Patients and their caregivers may also play an important role in increasing awareness and education in this area. Future efforts should target handoffs not addressed in this initiative, such as transfers from emergency departments to inpatient care units, or between ICUs and the medical floor.

Conclusion

With the growth of hospital medicine and the increased acuity of inpatients, improving handoffs becomes an important part of ensuring patient safety. The goal of the SHM Handoffs Task Force was to begin to standardize handoffs at change of shift and change of servicea fundamental activity of hospitalists. These recommendations build on the limited literature in surgery, nursing, and medical informatics and provide a starting point for promoting safe and seamless in‐hospital handoffs for practitioners of Hospital Medicine.

The seminal article that coined the term hospitalist, in 1996, attributed the role of the hospitalist to enhancing throughput and cost reduction, primarily through reduction in length of stay, accomplished by having a dedicated clinician on site in the hospital.1 Since that time the role of the hospitalist has evolved to address the needs of multiple stakeholders at a time when traditional residency programs in inpatient adult medicine do not adequately train physicians to become effective agents of change in complex and potentially unsafe hospital systems. Continuing the trend of pediatrics, obstetrics, gynecology, and geriatrics, hospitalists have emerged as a distinct group of physicians who fill a needed clinical niche and are demonstrating the benefits of bringing a unique role and skill sets to the general hospital ward.2

The eligibility requirements for certification by the American Board of Internal Medicine specify that the discipline must 1) have a distinct and unique body of knowledge, 2) have clinical applicability sufficient to support a distinct clinical practice, 3) generate new information and research, 4) require a minimum training period of 12 months, and 5) have a substantial number of trainees and training programs nationwide.3 The Society of Hospital Medicine (SHM), the national professional organization of hospitalists, commissioned a task force to develop The Core Competencies in Hospital Medicine: A Framework for Curriculum Development (referred to from here on as the Core Competencies) to standardize the expectations of practicing hospitalists, serve as a foundation for curricula and other professional development experiences, prioritize educational scholarship and research strategies, and assess the adequacy and improvement opportunities for current training and accreditation of hospital medicine physicians.4 The preceding companion article The Core Competencies in Hospital Medicine: Development and Methodology, describes in detail the rationale for the development of the Core Competencies and the methods by which the document was created.5

PURPOSE

The purpose of this article is to illustrate how curriculum developers can apply the Core Competencies in Hospital Medicine to educate trainees and faculty, to prioritize educational scholarship and research strategies, and thus to improve the care of our patients.

TARGET AUDIENCE

The Core Competencies specifically targets directors of continuing medical education (CME), hospitalist programs and fellowships, residency programs, and medical school internal medicine clerkships. It is also intended for health educators, hospital administrators, potential employers, policy makers, and agencies funding quality‐improvement initiatives in the hospital setting. For residency program directors and clerkship directors, the chapters can guide in the development of curricula for inpatient medicine rotations or in meeting the Accreditation Council on Graduate Medical Education's Outcomes Project. For directors developing medical education curricula, The Core Competencies in Hospital Medicine can serve as a template for CME. For hospitalists, hospital administrators, and potential employers, the Core Competencies can be used to as the starting point in local program development and as a resource for refining the skills of all hospitalists, even very experienced practicing clinicians.

DEFINITION OF CORE COMPETENCIES IN HOSPITAL MEDICINE

The Core Competencies in Hospital Medicine provides a framework for curricular development based on a shared understanding of the essential knowledge, skills, and attitudes expected of physicians working as hospitalists. The development process will be ongoing, with revisions reflecting the evolving specialty of hospital medicine, the needs of practicing hospitalists, and feedback from users of the Core Competencies.

PROBLEM IDENTIFICATION AND GENERAL NEEDS ASSESSMENT

Delivery of health care has large gaps compared to ideal performance. Since the publication by the Institute of Medicine of To Err Is Human, in 1999, multiple agencies including the American Hospital Association, the National Quality Forum, and the U.S. Agency for Health Care Research and Quality (AHRQ) have reported on the incidence of medical errors in U.S. hospitals.6, 7 Recognizing that medical errors represent a major health concern in the United States, the Joint Commission on the Accreditation of Health Care Organizations (JCAHO) now requires patient safety initiatives for hospital accreditation.8 Problem‐based learning and improvement and systems based practice are now required competencies in medical residency curricula by the Accreditation Council for Graduate Medical Education (ACGME) and these requirements have led to the development of continuous quality techniques for preventing errors and a variety of patient safety initiatives.9

In 2002 the SHM recognized the need for identifying a distinct set of competencies in hospital medicine. The published competencies highlight the current gap in training of hospitalists and the imperative for revising curricula relating to inpatient care, hospital systems, and teaching.4 With adequate training and preparation, hospitalists can take the lead in implementing systems for best practices from admission through discharge and care transition, and they can direct the development of a safer, more patient‐centered, and cost‐efficient culture.

By defining the role of the hospitalist, the Core Competencies reflects the view of the SHM about what is possible but does not suggest how a training program might be modified to achieve desired outcomes or provide any content, resources, or teaching strategies. It will be up to curriculum developers to determine the scope of cognitive, psychomotor, and affective objectives that targeted learnershospitalists, residents, and other members of the multidisciplinary teamshould be required to acquire through lectures, discussions, syllabus material, clinical experience, and other venues. We agree with a broader definition of the term curriculum for graduate medical education, one that goes beyond curriculum as a plan and takes into account the learners' experiences, both planned and unplanned in the hospital setting.10 In contrast to the technologic theory of curriculum, in which lists of knowledge and skills represent final destinations, in the experiential model of curriculum, the lists provide only points of departure.11 The goal of the Core Competencies is to facilitate curriculum development using complex teaching environments as building blocks through which learning can occur.

CORE COMPETENCIES FOR HOSPITALISTS: OVERVIEW

The Core Competencies in Hospital Medicine is the first published competency‐based framework for professional development of hospitalists and provides the basis for accreditation in hospital medicine.12 The Core Competencies is organized into three sectionsClinical Conditions, Procedures, and Healthcare Systems. The supplement intentionally does not focus on content; rather, specific competencies describe unambiguous, measurable learning objectives. Each chapter can be used as a stand‐alone chapter to develop training and curricula for a particular topic area. Each chapter divides competencies into three domains of educational outcomes: cognitive (knowledge), affective (attitudes), and psychomotor (skills). Each domain has defined levels of proficiency going from knowledge, the lowest level, to evaluation, the highest.12, 13 A specific level of proficiency is articulated in the competencies through careful selection of corresponding action verbs, which clearly indicate how mastery could be assessed (see Table 1).

In addition to specific competencies in these commonly accepted learning domains, the Clinical Conditions and Procedure sections of the Core Competencies articulate the proficiencies that hospitalists should possess in systems organization and improvement. The clinical topics were selected to set expectations of leading or participating in system improvements specific to a clinical area and to prevent predictable complications of acute illness. Competencies in the Systems Organization and Improvement section indicate mastery of multiple competencies across categories. The Core Competencies describes how the hospitalist approach facilitates coordination among all participants within the hospital system (clinical and nonclinical) and effects system changes that improve patient care processes. At the same time, the statements indicate a range of involvement from participation to leadership. For example, lead, coordination or participate in acknowledges the unique needs of different practice settings and suggests a potential professional evolution. The Systems Organization and Improvement competencies of each clinical and procedure chapter strive to capture the essence of hospitalists whose goals are to improve patient outcomes for a specific population of patients. Hospitalists do not solely focus on the care of the patient with x disease, but rather develop systems to provide the best and most efficient care for all patients with x disease, successfully transitioning these patients to outpatient care and avoiding readmission.

The third section of chapters in the Core Competencies, Healthcare Systems, distinguishes a hospitalist from others working in the inpatient setting whether practicing at academic medical centers, community hospitals, teaching hospitals, managed‐care settings, or for‐profit settings. The Healthcare Systems section identifies the integral components of the successful practice of hospital medicine and mastery of multiple competencies. This section highlights how hospitalists can facilitate coordination among all care providers within the hospital and with outpatient care providers. Hospitalists can effect system changes that improve complex care processes. It is likely that additional work experience and training beyond residency are required to attain global proficiency in the care of hospital medicine patients.

HOW TO USE THE CORE COMPETENCIES TO DEVELOP A CURRICULUM

The whole document, three sections and 51 chapters, develops expectations about the role of the hospitalist. Proficiency can be acquired through multiple means and should match the needs of the targeted learners in order to develop and maintain the necessary level of performance within the discipline of hospital medicine. Specific cases that hospitalists may encounter in their daily practice are used to illustrate how the Core Competencies can be applied to curriculum development.

The cases will employ the following six‐step approach described in Curriculum Development in Medical Education14:

• 1

  A problem and a need for improvement (the actual case and quality gap)

• 2

  Needs assessment of targeted learners (hospitalists, clinicians‐in‐training)

• 3

  Goals and specific measurable objectives (with competencies bridging the gap between traditional roles and setting expectations about the hospitalist role)

• 4

  Educational strategies (with competencies providing structure and guidance to educational efforts)

• 5

  Implementation (applying competencies to a variety of training opportunities and curricula)

• 6

  Evaluation and feedback (ongoing nationally, regionally, locally).

Like any quality‐improvement educational initiative, subsequent steps in curriculum development for hospitalists should include, after evaluation and feedback, dissemination of core competencies and promotion of rigorous ongoing evaluation and adaptation as needs and expectations evolve.

The first case example, failure to prevent and diagnose pulmonary embolism (see Table 2), illustrates quality issues relating to prevention of predictable complications of illness, clinical problem solving in complex conditions of uncertainty, repetitive and nondiagnostic testing, and triage of a critically ill patient between services. The Core Competencies sets expectations about the ideal role of the hospitalist that might lead to improved outcomes.

Using this case example, the Evidence‐Based Medicine (EBM) chapter establishes explicit expectations for hospitalists in clinical problem solving, including 1) explaining how the tests help to verify a suspected diagnosis, 2) describing the human factor in test interpretation (e.g., technical limitations of the most recent multi‐detector‐row spiral CT), and 3) explaining how timing relative to the onset of symptoms affects test results. Rather than an overreliance on technology, leading to repeating the chest CT with PE protocol and subsequent excessive nondiagnostic testing, the hospitalist would use knowledge of pretest probability and test characteristics to determine the best diagnostic strategy. The hospitalist approach to patient care, articulated in the affective (attitudes) domains of each chapter, integrates the application of EBM principles to clinical problem solving with deliberation of cost effectiveness and efficiency.

Continuing with this case example, the Team Approach and Communication chapters establish explicit expectations for practicing hospitalists who would take the extra steps to communicate with multiple members of the care team. Knowledgeable about the hospital, the hospitalist would review the chest CT with a radiologist skilled in chest interpretation and specifically query about the significance of an enlarged right atrium and right ventricle in the setting of a high pretest clinical probability of PE. Together the radiologist and hospitalist would consider a different imaging modality if the patient flunked the chest CT when the pretest probability was high. Rather than simply deferring to the medical specialist who is consulting, the hospitalist would be expected to improve the efficiency of care and reduce cost by only ordering tests that would change clinical management, perhaps with improved outcomes.

The Hospitalist as Teacher chapter provides a frameworkcore competencies for impromptu learningbased on the patient encounter. Members of the multidisciplinary care team can be exposed to explicit clinical decision making, an approach made possible by hospitalists on site, who can provide teaching moments in real time when decisions have to be made and educational feedback is needed. Teaching expectations for hospitalists include unambiguous clinical problem solving at the bedside and possibly directing the education of residents, physician assistants, and nurses on how to initiate a quality improvement (QI) project in a hospital setting.

The Quality Improvement and Venous Thromboembolism chapters clarify the role of the hospitalist, who should direct therapy against predictable complications of serious illness, critically review prophylaxis, provide hospital‐specific data to clinicians, identify and lower barriers to prevention, devise strategies to bridge the gap between knowledge and practice, develop automated reminder systems, and participate in clinical research.

The SHM has used the Core Competencies to develop educational resources to better meet the needs of the healthcare system. Although patient safety initiatives are mandated by JCAHO for hospital accreditation and AHRQ has identified areas for safety improvement that lists venous thromboembolism (VTE) prevention as the number one priority, VTE prophylaxis is still underutilized in the United States. Although some mechanisms are in place to educate residents and hospitalists about how to manage a specific disease, traditional medical education does not focus on teaching students and residents how to manage complex patients with multiple comorbidities, to prevent predictable complications of illness, and to examine and improve care processes.15, 16 When it comes to leading quality improvement (QI), individual feedback and traditional curricula, which may include didactic lectures on the pathophysiology of VTE and morbidity and mortality conferences, have not demonstrated improved outcomes.17

The SHM QI Web‐based resource rooms offer support to any QI effort and raise collective awareness of a performance gap.18 Each resource room will describe the evidence‐based practices that should be put into effect and will leverage experience with the disease as well as with the improvement process. The underlying goal of the resource rooms is to enhance the ability of hospitalists to actually improve inpatient outcomes through self‐directed learning (see Fig. 1).

Figure 1

Hospitalists, residency directors, and directors of hospitalist fellowships and continuing education can use The Core Competencies in Hospital Medicine to develop curricula for their local hospitalist service and request that invited speakers develop learning objectives and content based on core competencies rather than giving a prepared lecture on a specific clinical condition. This case of PE illustrates that risk assessment, prophylaxis, EBM clinical problem solving, and QI are core topics that should be emphasized in the training of hospitalists and physicians in training.0

The second case example, the hand‐off (see Table 3), illustrates quality issues related to transfer of care from one physician to another. In this example, if the patient with moderate pleural effusion had been signed out, an earlier thoracentesis to drain a presumptive parapneumonic infection might have relieved this patient's shortness of breath and saved her from undergoing a subsequent VATS procedure. This case also demonstrates the importance of correlating imaging abnormalities with a patient's clinical presentation rather than using the traditional approach of just ruling out potential diagnoses to determine the cause of a problem. This case highlights elements of the process and system of care that can be modified to improve patient outcomes. Being proficient in transferring care of patients can save the hospitalist from error and prevent adverse events.

The Team Approach chapter establishes the need to acquire proficiencies not ordinarily obtained during residency in order to lead a multidisciplinary care team. This role requires a level of functioning beyond that of simply being the attending of record. The hospitalist must be able to synthesize information rather than simply defer to the consultant. Competencies specified in the Diagnostic Decision‐Making chapter can be used to identify the educational needs of hospitalists, who are expected to minimize diagnostic errors by knowing when to ask for help and where to get it, recognizing common diseases with uncommon presentations, and generating a broad differential diagnosis where there is uncertainty. The Patient Handoff chapter defines the proficiencies hospitalists need to facilitate the safe transfer of patients to other physicians on their service.0

The third case example, which expands the responsibilities of hospitalist to include meeting important needs in the hospital (see Table 4), illustrates that hospitalist services cannot succeed by offering all things to all people, a distraction that that keeps the members of these services from concentrating on their goals. Always saying yes to whoever asks for help is a band‐aid, a short‐term fix that impedes the effort and creativity required for durable long‐term solutions to problems.

The Core Competencies sets expectations about the roles of hospitalists, who serve as well‐informed clinicians and clinical opinion leaders; effective educators, mentors, and role models; empathetic and timely communicators; efficient caregivers; and creative problem solvers arriving at durable, longer‐term solutions. The competencies demonstrate the knowledge, skills, and attitudes required to be effective agents of change. Changing business as usual almost always requires significant improvements in the underlying system, however uncomfortable. The Leadership chapter articulates competencies that hospitalists need in order to define their roles within the hospital, promote group cohesiveness, expand their practices intelligently, and anticipate and respond to change. This chapter details the proficiencies that hospitalists need in order to develop personal, team, and program goals and to identify and resolve conflicts using specific negotiation techniques. The Business Practices chapter articulates the fundamental skills needed to enhance program development and growth. Hospitalists can use the Core Competencies to identify educational needs and develop curricula to enhance their leadership and business skill sets.0

Medical educators should examine the outcomes of current training practices and assess what modifications of objectives, content, and instructional strategies should be made to better prepare the current and next generations of physicians to practice hospital medicine and to improve the hospital setting. Given the scope of the field of hospital medicine, the Core Competencies should guide: 1) what to teach and how much to teach; 2) how to teach and assess trainees, and how to assess and compare faculty development programs; 3) how to design systems for improving quality of care and assuring patient safety; and 4) how to establish priorities for hospital medicine research.

TRANSLATING A SET OF COMPETENCIES INTO CURRICULA: POTENTIAL BENEFITS

The Core Competencies in Hospital Medicine transcends hospital type, size, and setting and standardizes what the expectations for and proficiencies of a practicing hospitalist should be. By defining the role of the hospitalist, the Core Competencies serves as a resource for refining inpatient skills and assists in program development at the local, regional, and national levels. In addition, by using the Core Competencies as the standard and framework for the development of preparatory curricula, hospital administrators and other employers can rely on hospitalists having had a common preparation.

The medical profession is constantly evolving. Internal medicine curricula address the challenges hospital medicine physicians faced yesterday but could improve the training and preparation of physicians to serve in their new and emerging roles as leaders of multidisciplinary healthcare teams working to improve patient outcomes and the system of inpatient care. Hospital medicine no longer represents a group of physicians merely supporting other specialists and primary care physicians; it is itself a specialty, composed of physicians leading, directing, and improving inpatient care. The competencies presented in The Core Competencies in Hospital Medicine: A Framework for Curriculum Development, by the Society of Hospital Medicine, should spark debate about the adequacy and appropriateness of current training and certification expectations and serve as a foundation for the development of curricula to improve hospital medicine education.

The seminal article that coined the term hospitalist, in 1996, attributed the role of the hospitalist to enhancing throughput and cost reduction, primarily through reduction in length of stay, accomplished by having a dedicated clinician on site in the hospital.1 Since that time the role of the hospitalist has evolved to address the needs of multiple stakeholders at a time when traditional residency programs in inpatient adult medicine do not adequately train physicians to become effective agents of change in complex and potentially unsafe hospital systems. Continuing the trend of pediatrics, obstetrics, gynecology, and geriatrics, hospitalists have emerged as a distinct group of physicians who fill a needed clinical niche and are demonstrating the benefits of bringing a unique role and skill sets to the general hospital ward.2

The eligibility requirements for certification by the American Board of Internal Medicine specify that the discipline must 1) have a distinct and unique body of knowledge, 2) have clinical applicability sufficient to support a distinct clinical practice, 3) generate new information and research, 4) require a minimum training period of 12 months, and 5) have a substantial number of trainees and training programs nationwide.3 The Society of Hospital Medicine (SHM), the national professional organization of hospitalists, commissioned a task force to develop The Core Competencies in Hospital Medicine: A Framework for Curriculum Development (referred to from here on as the Core Competencies) to standardize the expectations of practicing hospitalists, serve as a foundation for curricula and other professional development experiences, prioritize educational scholarship and research strategies, and assess the adequacy and improvement opportunities for current training and accreditation of hospital medicine physicians.4 The preceding companion article The Core Competencies in Hospital Medicine: Development and Methodology, describes in detail the rationale for the development of the Core Competencies and the methods by which the document was created.5

PURPOSE

The purpose of this article is to illustrate how curriculum developers can apply the Core Competencies in Hospital Medicine to educate trainees and faculty, to prioritize educational scholarship and research strategies, and thus to improve the care of our patients.

TARGET AUDIENCE

The Core Competencies specifically targets directors of continuing medical education (CME), hospitalist programs and fellowships, residency programs, and medical school internal medicine clerkships. It is also intended for health educators, hospital administrators, potential employers, policy makers, and agencies funding quality‐improvement initiatives in the hospital setting. For residency program directors and clerkship directors, the chapters can guide in the development of curricula for inpatient medicine rotations or in meeting the Accreditation Council on Graduate Medical Education's Outcomes Project. For directors developing medical education curricula, The Core Competencies in Hospital Medicine can serve as a template for CME. For hospitalists, hospital administrators, and potential employers, the Core Competencies can be used to as the starting point in local program development and as a resource for refining the skills of all hospitalists, even very experienced practicing clinicians.

DEFINITION OF CORE COMPETENCIES IN HOSPITAL MEDICINE

The Core Competencies in Hospital Medicine provides a framework for curricular development based on a shared understanding of the essential knowledge, skills, and attitudes expected of physicians working as hospitalists. The development process will be ongoing, with revisions reflecting the evolving specialty of hospital medicine, the needs of practicing hospitalists, and feedback from users of the Core Competencies.

PROBLEM IDENTIFICATION AND GENERAL NEEDS ASSESSMENT

Delivery of health care has large gaps compared to ideal performance. Since the publication by the Institute of Medicine of To Err Is Human, in 1999, multiple agencies including the American Hospital Association, the National Quality Forum, and the U.S. Agency for Health Care Research and Quality (AHRQ) have reported on the incidence of medical errors in U.S. hospitals.6, 7 Recognizing that medical errors represent a major health concern in the United States, the Joint Commission on the Accreditation of Health Care Organizations (JCAHO) now requires patient safety initiatives for hospital accreditation.8 Problem‐based learning and improvement and systems based practice are now required competencies in medical residency curricula by the Accreditation Council for Graduate Medical Education (ACGME) and these requirements have led to the development of continuous quality techniques for preventing errors and a variety of patient safety initiatives.9

In 2002 the SHM recognized the need for identifying a distinct set of competencies in hospital medicine. The published competencies highlight the current gap in training of hospitalists and the imperative for revising curricula relating to inpatient care, hospital systems, and teaching.4 With adequate training and preparation, hospitalists can take the lead in implementing systems for best practices from admission through discharge and care transition, and they can direct the development of a safer, more patient‐centered, and cost‐efficient culture.

By defining the role of the hospitalist, the Core Competencies reflects the view of the SHM about what is possible but does not suggest how a training program might be modified to achieve desired outcomes or provide any content, resources, or teaching strategies. It will be up to curriculum developers to determine the scope of cognitive, psychomotor, and affective objectives that targeted learnershospitalists, residents, and other members of the multidisciplinary teamshould be required to acquire through lectures, discussions, syllabus material, clinical experience, and other venues. We agree with a broader definition of the term curriculum for graduate medical education, one that goes beyond curriculum as a plan and takes into account the learners' experiences, both planned and unplanned in the hospital setting.10 In contrast to the technologic theory of curriculum, in which lists of knowledge and skills represent final destinations, in the experiential model of curriculum, the lists provide only points of departure.11 The goal of the Core Competencies is to facilitate curriculum development using complex teaching environments as building blocks through which learning can occur.

CORE COMPETENCIES FOR HOSPITALISTS: OVERVIEW

The Core Competencies in Hospital Medicine is the first published competency‐based framework for professional development of hospitalists and provides the basis for accreditation in hospital medicine.12 The Core Competencies is organized into three sectionsClinical Conditions, Procedures, and Healthcare Systems. The supplement intentionally does not focus on content; rather, specific competencies describe unambiguous, measurable learning objectives. Each chapter can be used as a stand‐alone chapter to develop training and curricula for a particular topic area. Each chapter divides competencies into three domains of educational outcomes: cognitive (knowledge), affective (attitudes), and psychomotor (skills). Each domain has defined levels of proficiency going from knowledge, the lowest level, to evaluation, the highest.12, 13 A specific level of proficiency is articulated in the competencies through careful selection of corresponding action verbs, which clearly indicate how mastery could be assessed (see Table 1).

In addition to specific competencies in these commonly accepted learning domains, the Clinical Conditions and Procedure sections of the Core Competencies articulate the proficiencies that hospitalists should possess in systems organization and improvement. The clinical topics were selected to set expectations of leading or participating in system improvements specific to a clinical area and to prevent predictable complications of acute illness. Competencies in the Systems Organization and Improvement section indicate mastery of multiple competencies across categories. The Core Competencies describes how the hospitalist approach facilitates coordination among all participants within the hospital system (clinical and nonclinical) and effects system changes that improve patient care processes. At the same time, the statements indicate a range of involvement from participation to leadership. For example, lead, coordination or participate in acknowledges the unique needs of different practice settings and suggests a potential professional evolution. The Systems Organization and Improvement competencies of each clinical and procedure chapter strive to capture the essence of hospitalists whose goals are to improve patient outcomes for a specific population of patients. Hospitalists do not solely focus on the care of the patient with x disease, but rather develop systems to provide the best and most efficient care for all patients with x disease, successfully transitioning these patients to outpatient care and avoiding readmission.

The third section of chapters in the Core Competencies, Healthcare Systems, distinguishes a hospitalist from others working in the inpatient setting whether practicing at academic medical centers, community hospitals, teaching hospitals, managed‐care settings, or for‐profit settings. The Healthcare Systems section identifies the integral components of the successful practice of hospital medicine and mastery of multiple competencies. This section highlights how hospitalists can facilitate coordination among all care providers within the hospital and with outpatient care providers. Hospitalists can effect system changes that improve complex care processes. It is likely that additional work experience and training beyond residency are required to attain global proficiency in the care of hospital medicine patients.

HOW TO USE THE CORE COMPETENCIES TO DEVELOP A CURRICULUM

The whole document, three sections and 51 chapters, develops expectations about the role of the hospitalist. Proficiency can be acquired through multiple means and should match the needs of the targeted learners in order to develop and maintain the necessary level of performance within the discipline of hospital medicine. Specific cases that hospitalists may encounter in their daily practice are used to illustrate how the Core Competencies can be applied to curriculum development.

The cases will employ the following six‐step approach described in Curriculum Development in Medical Education14:

• 1

  A problem and a need for improvement (the actual case and quality gap)

• 2

  Needs assessment of targeted learners (hospitalists, clinicians‐in‐training)

• 3

  Goals and specific measurable objectives (with competencies bridging the gap between traditional roles and setting expectations about the hospitalist role)

• 4

  Educational strategies (with competencies providing structure and guidance to educational efforts)

• 5

  Implementation (applying competencies to a variety of training opportunities and curricula)

• 6

  Evaluation and feedback (ongoing nationally, regionally, locally).

Like any quality‐improvement educational initiative, subsequent steps in curriculum development for hospitalists should include, after evaluation and feedback, dissemination of core competencies and promotion of rigorous ongoing evaluation and adaptation as needs and expectations evolve.

The first case example, failure to prevent and diagnose pulmonary embolism (see Table 2), illustrates quality issues relating to prevention of predictable complications of illness, clinical problem solving in complex conditions of uncertainty, repetitive and nondiagnostic testing, and triage of a critically ill patient between services. The Core Competencies sets expectations about the ideal role of the hospitalist that might lead to improved outcomes.

Using this case example, the Evidence‐Based Medicine (EBM) chapter establishes explicit expectations for hospitalists in clinical problem solving, including 1) explaining how the tests help to verify a suspected diagnosis, 2) describing the human factor in test interpretation (e.g., technical limitations of the most recent multi‐detector‐row spiral CT), and 3) explaining how timing relative to the onset of symptoms affects test results. Rather than an overreliance on technology, leading to repeating the chest CT with PE protocol and subsequent excessive nondiagnostic testing, the hospitalist would use knowledge of pretest probability and test characteristics to determine the best diagnostic strategy. The hospitalist approach to patient care, articulated in the affective (attitudes) domains of each chapter, integrates the application of EBM principles to clinical problem solving with deliberation of cost effectiveness and efficiency.

Continuing with this case example, the Team Approach and Communication chapters establish explicit expectations for practicing hospitalists who would take the extra steps to communicate with multiple members of the care team. Knowledgeable about the hospital, the hospitalist would review the chest CT with a radiologist skilled in chest interpretation and specifically query about the significance of an enlarged right atrium and right ventricle in the setting of a high pretest clinical probability of PE. Together the radiologist and hospitalist would consider a different imaging modality if the patient flunked the chest CT when the pretest probability was high. Rather than simply deferring to the medical specialist who is consulting, the hospitalist would be expected to improve the efficiency of care and reduce cost by only ordering tests that would change clinical management, perhaps with improved outcomes.

The Hospitalist as Teacher chapter provides a frameworkcore competencies for impromptu learningbased on the patient encounter. Members of the multidisciplinary care team can be exposed to explicit clinical decision making, an approach made possible by hospitalists on site, who can provide teaching moments in real time when decisions have to be made and educational feedback is needed. Teaching expectations for hospitalists include unambiguous clinical problem solving at the bedside and possibly directing the education of residents, physician assistants, and nurses on how to initiate a quality improvement (QI) project in a hospital setting.

The Quality Improvement and Venous Thromboembolism chapters clarify the role of the hospitalist, who should direct therapy against predictable complications of serious illness, critically review prophylaxis, provide hospital‐specific data to clinicians, identify and lower barriers to prevention, devise strategies to bridge the gap between knowledge and practice, develop automated reminder systems, and participate in clinical research.

The SHM has used the Core Competencies to develop educational resources to better meet the needs of the healthcare system. Although patient safety initiatives are mandated by JCAHO for hospital accreditation and AHRQ has identified areas for safety improvement that lists venous thromboembolism (VTE) prevention as the number one priority, VTE prophylaxis is still underutilized in the United States. Although some mechanisms are in place to educate residents and hospitalists about how to manage a specific disease, traditional medical education does not focus on teaching students and residents how to manage complex patients with multiple comorbidities, to prevent predictable complications of illness, and to examine and improve care processes.15, 16 When it comes to leading quality improvement (QI), individual feedback and traditional curricula, which may include didactic lectures on the pathophysiology of VTE and morbidity and mortality conferences, have not demonstrated improved outcomes.17

The SHM QI Web‐based resource rooms offer support to any QI effort and raise collective awareness of a performance gap.18 Each resource room will describe the evidence‐based practices that should be put into effect and will leverage experience with the disease as well as with the improvement process. The underlying goal of the resource rooms is to enhance the ability of hospitalists to actually improve inpatient outcomes through self‐directed learning (see Fig. 1).

Figure 1

Hospitalists, residency directors, and directors of hospitalist fellowships and continuing education can use The Core Competencies in Hospital Medicine to develop curricula for their local hospitalist service and request that invited speakers develop learning objectives and content based on core competencies rather than giving a prepared lecture on a specific clinical condition. This case of PE illustrates that risk assessment, prophylaxis, EBM clinical problem solving, and QI are core topics that should be emphasized in the training of hospitalists and physicians in training.0

The second case example, the hand‐off (see Table 3), illustrates quality issues related to transfer of care from one physician to another. In this example, if the patient with moderate pleural effusion had been signed out, an earlier thoracentesis to drain a presumptive parapneumonic infection might have relieved this patient's shortness of breath and saved her from undergoing a subsequent VATS procedure. This case also demonstrates the importance of correlating imaging abnormalities with a patient's clinical presentation rather than using the traditional approach of just ruling out potential diagnoses to determine the cause of a problem. This case highlights elements of the process and system of care that can be modified to improve patient outcomes. Being proficient in transferring care of patients can save the hospitalist from error and prevent adverse events.

The Team Approach chapter establishes the need to acquire proficiencies not ordinarily obtained during residency in order to lead a multidisciplinary care team. This role requires a level of functioning beyond that of simply being the attending of record. The hospitalist must be able to synthesize information rather than simply defer to the consultant. Competencies specified in the Diagnostic Decision‐Making chapter can be used to identify the educational needs of hospitalists, who are expected to minimize diagnostic errors by knowing when to ask for help and where to get it, recognizing common diseases with uncommon presentations, and generating a broad differential diagnosis where there is uncertainty. The Patient Handoff chapter defines the proficiencies hospitalists need to facilitate the safe transfer of patients to other physicians on their service.0

The third case example, which expands the responsibilities of hospitalist to include meeting important needs in the hospital (see Table 4), illustrates that hospitalist services cannot succeed by offering all things to all people, a distraction that that keeps the members of these services from concentrating on their goals. Always saying yes to whoever asks for help is a band‐aid, a short‐term fix that impedes the effort and creativity required for durable long‐term solutions to problems.

The Core Competencies sets expectations about the roles of hospitalists, who serve as well‐informed clinicians and clinical opinion leaders; effective educators, mentors, and role models; empathetic and timely communicators; efficient caregivers; and creative problem solvers arriving at durable, longer‐term solutions. The competencies demonstrate the knowledge, skills, and attitudes required to be effective agents of change. Changing business as usual almost always requires significant improvements in the underlying system, however uncomfortable. The Leadership chapter articulates competencies that hospitalists need in order to define their roles within the hospital, promote group cohesiveness, expand their practices intelligently, and anticipate and respond to change. This chapter details the proficiencies that hospitalists need in order to develop personal, team, and program goals and to identify and resolve conflicts using specific negotiation techniques. The Business Practices chapter articulates the fundamental skills needed to enhance program development and growth. Hospitalists can use the Core Competencies to identify educational needs and develop curricula to enhance their leadership and business skill sets.0

Medical educators should examine the outcomes of current training practices and assess what modifications of objectives, content, and instructional strategies should be made to better prepare the current and next generations of physicians to practice hospital medicine and to improve the hospital setting. Given the scope of the field of hospital medicine, the Core Competencies should guide: 1) what to teach and how much to teach; 2) how to teach and assess trainees, and how to assess and compare faculty development programs; 3) how to design systems for improving quality of care and assuring patient safety; and 4) how to establish priorities for hospital medicine research.

TRANSLATING A SET OF COMPETENCIES INTO CURRICULA: POTENTIAL BENEFITS

The Core Competencies in Hospital Medicine transcends hospital type, size, and setting and standardizes what the expectations for and proficiencies of a practicing hospitalist should be. By defining the role of the hospitalist, the Core Competencies serves as a resource for refining inpatient skills and assists in program development at the local, regional, and national levels. In addition, by using the Core Competencies as the standard and framework for the development of preparatory curricula, hospital administrators and other employers can rely on hospitalists having had a common preparation.

The medical profession is constantly evolving. Internal medicine curricula address the challenges hospital medicine physicians faced yesterday but could improve the training and preparation of physicians to serve in their new and emerging roles as leaders of multidisciplinary healthcare teams working to improve patient outcomes and the system of inpatient care. Hospital medicine no longer represents a group of physicians merely supporting other specialists and primary care physicians; it is itself a specialty, composed of physicians leading, directing, and improving inpatient care. The competencies presented in The Core Competencies in Hospital Medicine: A Framework for Curriculum Development, by the Society of Hospital Medicine, should spark debate about the adequacy and appropriateness of current training and certification expectations and serve as a foundation for the development of curricula to improve hospital medicine education.

The seminal article that coined the term hospitalist, in 1996, attributed the role of the hospitalist to enhancing throughput and cost reduction, primarily through reduction in length of stay, accomplished by having a dedicated clinician on site in the hospital.1 Since that time the role of the hospitalist has evolved to address the needs of multiple stakeholders at a time when traditional residency programs in inpatient adult medicine do not adequately train physicians to become effective agents of change in complex and potentially unsafe hospital systems. Continuing the trend of pediatrics, obstetrics, gynecology, and geriatrics, hospitalists have emerged as a distinct group of physicians who fill a needed clinical niche and are demonstrating the benefits of bringing a unique role and skill sets to the general hospital ward.2

The eligibility requirements for certification by the American Board of Internal Medicine specify that the discipline must 1) have a distinct and unique body of knowledge, 2) have clinical applicability sufficient to support a distinct clinical practice, 3) generate new information and research, 4) require a minimum training period of 12 months, and 5) have a substantial number of trainees and training programs nationwide.3 The Society of Hospital Medicine (SHM), the national professional organization of hospitalists, commissioned a task force to develop The Core Competencies in Hospital Medicine: A Framework for Curriculum Development (referred to from here on as the Core Competencies) to standardize the expectations of practicing hospitalists, serve as a foundation for curricula and other professional development experiences, prioritize educational scholarship and research strategies, and assess the adequacy and improvement opportunities for current training and accreditation of hospital medicine physicians.4 The preceding companion article The Core Competencies in Hospital Medicine: Development and Methodology, describes in detail the rationale for the development of the Core Competencies and the methods by which the document was created.5

PURPOSE

The purpose of this article is to illustrate how curriculum developers can apply the Core Competencies in Hospital Medicine to educate trainees and faculty, to prioritize educational scholarship and research strategies, and thus to improve the care of our patients.

TARGET AUDIENCE

The Core Competencies specifically targets directors of continuing medical education (CME), hospitalist programs and fellowships, residency programs, and medical school internal medicine clerkships. It is also intended for health educators, hospital administrators, potential employers, policy makers, and agencies funding quality‐improvement initiatives in the hospital setting. For residency program directors and clerkship directors, the chapters can guide in the development of curricula for inpatient medicine rotations or in meeting the Accreditation Council on Graduate Medical Education's Outcomes Project. For directors developing medical education curricula, The Core Competencies in Hospital Medicine can serve as a template for CME. For hospitalists, hospital administrators, and potential employers, the Core Competencies can be used to as the starting point in local program development and as a resource for refining the skills of all hospitalists, even very experienced practicing clinicians.

DEFINITION OF CORE COMPETENCIES IN HOSPITAL MEDICINE

The Core Competencies in Hospital Medicine provides a framework for curricular development based on a shared understanding of the essential knowledge, skills, and attitudes expected of physicians working as hospitalists. The development process will be ongoing, with revisions reflecting the evolving specialty of hospital medicine, the needs of practicing hospitalists, and feedback from users of the Core Competencies.

PROBLEM IDENTIFICATION AND GENERAL NEEDS ASSESSMENT

Delivery of health care has large gaps compared to ideal performance. Since the publication by the Institute of Medicine of To Err Is Human, in 1999, multiple agencies including the American Hospital Association, the National Quality Forum, and the U.S. Agency for Health Care Research and Quality (AHRQ) have reported on the incidence of medical errors in U.S. hospitals.6, 7 Recognizing that medical errors represent a major health concern in the United States, the Joint Commission on the Accreditation of Health Care Organizations (JCAHO) now requires patient safety initiatives for hospital accreditation.8 Problem‐based learning and improvement and systems based practice are now required competencies in medical residency curricula by the Accreditation Council for Graduate Medical Education (ACGME) and these requirements have led to the development of continuous quality techniques for preventing errors and a variety of patient safety initiatives.9

In 2002 the SHM recognized the need for identifying a distinct set of competencies in hospital medicine. The published competencies highlight the current gap in training of hospitalists and the imperative for revising curricula relating to inpatient care, hospital systems, and teaching.4 With adequate training and preparation, hospitalists can take the lead in implementing systems for best practices from admission through discharge and care transition, and they can direct the development of a safer, more patient‐centered, and cost‐efficient culture.

By defining the role of the hospitalist, the Core Competencies reflects the view of the SHM about what is possible but does not suggest how a training program might be modified to achieve desired outcomes or provide any content, resources, or teaching strategies. It will be up to curriculum developers to determine the scope of cognitive, psychomotor, and affective objectives that targeted learnershospitalists, residents, and other members of the multidisciplinary teamshould be required to acquire through lectures, discussions, syllabus material, clinical experience, and other venues. We agree with a broader definition of the term curriculum for graduate medical education, one that goes beyond curriculum as a plan and takes into account the learners' experiences, both planned and unplanned in the hospital setting.10 In contrast to the technologic theory of curriculum, in which lists of knowledge and skills represent final destinations, in the experiential model of curriculum, the lists provide only points of departure.11 The goal of the Core Competencies is to facilitate curriculum development using complex teaching environments as building blocks through which learning can occur.

CORE COMPETENCIES FOR HOSPITALISTS: OVERVIEW

The Core Competencies in Hospital Medicine is the first published competency‐based framework for professional development of hospitalists and provides the basis for accreditation in hospital medicine.12 The Core Competencies is organized into three sectionsClinical Conditions, Procedures, and Healthcare Systems. The supplement intentionally does not focus on content; rather, specific competencies describe unambiguous, measurable learning objectives. Each chapter can be used as a stand‐alone chapter to develop training and curricula for a particular topic area. Each chapter divides competencies into three domains of educational outcomes: cognitive (knowledge), affective (attitudes), and psychomotor (skills). Each domain has defined levels of proficiency going from knowledge, the lowest level, to evaluation, the highest.12, 13 A specific level of proficiency is articulated in the competencies through careful selection of corresponding action verbs, which clearly indicate how mastery could be assessed (see Table 1).

In addition to specific competencies in these commonly accepted learning domains, the Clinical Conditions and Procedure sections of the Core Competencies articulate the proficiencies that hospitalists should possess in systems organization and improvement. The clinical topics were selected to set expectations of leading or participating in system improvements specific to a clinical area and to prevent predictable complications of acute illness. Competencies in the Systems Organization and Improvement section indicate mastery of multiple competencies across categories. The Core Competencies describes how the hospitalist approach facilitates coordination among all participants within the hospital system (clinical and nonclinical) and effects system changes that improve patient care processes. At the same time, the statements indicate a range of involvement from participation to leadership. For example, lead, coordination or participate in acknowledges the unique needs of different practice settings and suggests a potential professional evolution. The Systems Organization and Improvement competencies of each clinical and procedure chapter strive to capture the essence of hospitalists whose goals are to improve patient outcomes for a specific population of patients. Hospitalists do not solely focus on the care of the patient with x disease, but rather develop systems to provide the best and most efficient care for all patients with x disease, successfully transitioning these patients to outpatient care and avoiding readmission.

The third section of chapters in the Core Competencies, Healthcare Systems, distinguishes a hospitalist from others working in the inpatient setting whether practicing at academic medical centers, community hospitals, teaching hospitals, managed‐care settings, or for‐profit settings. The Healthcare Systems section identifies the integral components of the successful practice of hospital medicine and mastery of multiple competencies. This section highlights how hospitalists can facilitate coordination among all care providers within the hospital and with outpatient care providers. Hospitalists can effect system changes that improve complex care processes. It is likely that additional work experience and training beyond residency are required to attain global proficiency in the care of hospital medicine patients.

HOW TO USE THE CORE COMPETENCIES TO DEVELOP A CURRICULUM

The whole document, three sections and 51 chapters, develops expectations about the role of the hospitalist. Proficiency can be acquired through multiple means and should match the needs of the targeted learners in order to develop and maintain the necessary level of performance within the discipline of hospital medicine. Specific cases that hospitalists may encounter in their daily practice are used to illustrate how the Core Competencies can be applied to curriculum development.

The cases will employ the following six‐step approach described in Curriculum Development in Medical Education14:

• 1

  A problem and a need for improvement (the actual case and quality gap)

• 2

  Needs assessment of targeted learners (hospitalists, clinicians‐in‐training)

• 3

  Goals and specific measurable objectives (with competencies bridging the gap between traditional roles and setting expectations about the hospitalist role)

• 4

  Educational strategies (with competencies providing structure and guidance to educational efforts)

• 5

  Implementation (applying competencies to a variety of training opportunities and curricula)

• 6

  Evaluation and feedback (ongoing nationally, regionally, locally).

Like any quality‐improvement educational initiative, subsequent steps in curriculum development for hospitalists should include, after evaluation and feedback, dissemination of core competencies and promotion of rigorous ongoing evaluation and adaptation as needs and expectations evolve.

The first case example, failure to prevent and diagnose pulmonary embolism (see Table 2), illustrates quality issues relating to prevention of predictable complications of illness, clinical problem solving in complex conditions of uncertainty, repetitive and nondiagnostic testing, and triage of a critically ill patient between services. The Core Competencies sets expectations about the ideal role of the hospitalist that might lead to improved outcomes.

Using this case example, the Evidence‐Based Medicine (EBM) chapter establishes explicit expectations for hospitalists in clinical problem solving, including 1) explaining how the tests help to verify a suspected diagnosis, 2) describing the human factor in test interpretation (e.g., technical limitations of the most recent multi‐detector‐row spiral CT), and 3) explaining how timing relative to the onset of symptoms affects test results. Rather than an overreliance on technology, leading to repeating the chest CT with PE protocol and subsequent excessive nondiagnostic testing, the hospitalist would use knowledge of pretest probability and test characteristics to determine the best diagnostic strategy. The hospitalist approach to patient care, articulated in the affective (attitudes) domains of each chapter, integrates the application of EBM principles to clinical problem solving with deliberation of cost effectiveness and efficiency.

Continuing with this case example, the Team Approach and Communication chapters establish explicit expectations for practicing hospitalists who would take the extra steps to communicate with multiple members of the care team. Knowledgeable about the hospital, the hospitalist would review the chest CT with a radiologist skilled in chest interpretation and specifically query about the significance of an enlarged right atrium and right ventricle in the setting of a high pretest clinical probability of PE. Together the radiologist and hospitalist would consider a different imaging modality if the patient flunked the chest CT when the pretest probability was high. Rather than simply deferring to the medical specialist who is consulting, the hospitalist would be expected to improve the efficiency of care and reduce cost by only ordering tests that would change clinical management, perhaps with improved outcomes.

The Hospitalist as Teacher chapter provides a frameworkcore competencies for impromptu learningbased on the patient encounter. Members of the multidisciplinary care team can be exposed to explicit clinical decision making, an approach made possible by hospitalists on site, who can provide teaching moments in real time when decisions have to be made and educational feedback is needed. Teaching expectations for hospitalists include unambiguous clinical problem solving at the bedside and possibly directing the education of residents, physician assistants, and nurses on how to initiate a quality improvement (QI) project in a hospital setting.

The Quality Improvement and Venous Thromboembolism chapters clarify the role of the hospitalist, who should direct therapy against predictable complications of serious illness, critically review prophylaxis, provide hospital‐specific data to clinicians, identify and lower barriers to prevention, devise strategies to bridge the gap between knowledge and practice, develop automated reminder systems, and participate in clinical research.

The SHM has used the Core Competencies to develop educational resources to better meet the needs of the healthcare system. Although patient safety initiatives are mandated by JCAHO for hospital accreditation and AHRQ has identified areas for safety improvement that lists venous thromboembolism (VTE) prevention as the number one priority, VTE prophylaxis is still underutilized in the United States. Although some mechanisms are in place to educate residents and hospitalists about how to manage a specific disease, traditional medical education does not focus on teaching students and residents how to manage complex patients with multiple comorbidities, to prevent predictable complications of illness, and to examine and improve care processes.15, 16 When it comes to leading quality improvement (QI), individual feedback and traditional curricula, which may include didactic lectures on the pathophysiology of VTE and morbidity and mortality conferences, have not demonstrated improved outcomes.17

The SHM QI Web‐based resource rooms offer support to any QI effort and raise collective awareness of a performance gap.18 Each resource room will describe the evidence‐based practices that should be put into effect and will leverage experience with the disease as well as with the improvement process. The underlying goal of the resource rooms is to enhance the ability of hospitalists to actually improve inpatient outcomes through self‐directed learning (see Fig. 1).

Figure 1

Hospitalists, residency directors, and directors of hospitalist fellowships and continuing education can use The Core Competencies in Hospital Medicine to develop curricula for their local hospitalist service and request that invited speakers develop learning objectives and content based on core competencies rather than giving a prepared lecture on a specific clinical condition. This case of PE illustrates that risk assessment, prophylaxis, EBM clinical problem solving, and QI are core topics that should be emphasized in the training of hospitalists and physicians in training.0

The second case example, the hand‐off (see Table 3), illustrates quality issues related to transfer of care from one physician to another. In this example, if the patient with moderate pleural effusion had been signed out, an earlier thoracentesis to drain a presumptive parapneumonic infection might have relieved this patient's shortness of breath and saved her from undergoing a subsequent VATS procedure. This case also demonstrates the importance of correlating imaging abnormalities with a patient's clinical presentation rather than using the traditional approach of just ruling out potential diagnoses to determine the cause of a problem. This case highlights elements of the process and system of care that can be modified to improve patient outcomes. Being proficient in transferring care of patients can save the hospitalist from error and prevent adverse events.

The Team Approach chapter establishes the need to acquire proficiencies not ordinarily obtained during residency in order to lead a multidisciplinary care team. This role requires a level of functioning beyond that of simply being the attending of record. The hospitalist must be able to synthesize information rather than simply defer to the consultant. Competencies specified in the Diagnostic Decision‐Making chapter can be used to identify the educational needs of hospitalists, who are expected to minimize diagnostic errors by knowing when to ask for help and where to get it, recognizing common diseases with uncommon presentations, and generating a broad differential diagnosis where there is uncertainty. The Patient Handoff chapter defines the proficiencies hospitalists need to facilitate the safe transfer of patients to other physicians on their service.0

The third case example, which expands the responsibilities of hospitalist to include meeting important needs in the hospital (see Table 4), illustrates that hospitalist services cannot succeed by offering all things to all people, a distraction that that keeps the members of these services from concentrating on their goals. Always saying yes to whoever asks for help is a band‐aid, a short‐term fix that impedes the effort and creativity required for durable long‐term solutions to problems.

The Core Competencies sets expectations about the roles of hospitalists, who serve as well‐informed clinicians and clinical opinion leaders; effective educators, mentors, and role models; empathetic and timely communicators; efficient caregivers; and creative problem solvers arriving at durable, longer‐term solutions. The competencies demonstrate the knowledge, skills, and attitudes required to be effective agents of change. Changing business as usual almost always requires significant improvements in the underlying system, however uncomfortable. The Leadership chapter articulates competencies that hospitalists need in order to define their roles within the hospital, promote group cohesiveness, expand their practices intelligently, and anticipate and respond to change. This chapter details the proficiencies that hospitalists need in order to develop personal, team, and program goals and to identify and resolve conflicts using specific negotiation techniques. The Business Practices chapter articulates the fundamental skills needed to enhance program development and growth. Hospitalists can use the Core Competencies to identify educational needs and develop curricula to enhance their leadership and business skill sets.0

Medical educators should examine the outcomes of current training practices and assess what modifications of objectives, content, and instructional strategies should be made to better prepare the current and next generations of physicians to practice hospital medicine and to improve the hospital setting. Given the scope of the field of hospital medicine, the Core Competencies should guide: 1) what to teach and how much to teach; 2) how to teach and assess trainees, and how to assess and compare faculty development programs; 3) how to design systems for improving quality of care and assuring patient safety; and 4) how to establish priorities for hospital medicine research.

TRANSLATING A SET OF COMPETENCIES INTO CURRICULA: POTENTIAL BENEFITS

The Core Competencies in Hospital Medicine transcends hospital type, size, and setting and standardizes what the expectations for and proficiencies of a practicing hospitalist should be. By defining the role of the hospitalist, the Core Competencies serves as a resource for refining inpatient skills and assists in program development at the local, regional, and national levels. In addition, by using the Core Competencies as the standard and framework for the development of preparatory curricula, hospital administrators and other employers can rely on hospitalists having had a common preparation.

The medical profession is constantly evolving. Internal medicine curricula address the challenges hospital medicine physicians faced yesterday but could improve the training and preparation of physicians to serve in their new and emerging roles as leaders of multidisciplinary healthcare teams working to improve patient outcomes and the system of inpatient care. Hospital medicine no longer represents a group of physicians merely supporting other specialists and primary care physicians; it is itself a specialty, composed of physicians leading, directing, and improving inpatient care. The competencies presented in The Core Competencies in Hospital Medicine: A Framework for Curriculum Development, by the Society of Hospital Medicine, should spark debate about the adequacy and appropriateness of current training and certification expectations and serve as a foundation for the development of curricula to improve hospital medicine education.

Identification of the core competencies of a medical specialty provides the necessary framework for that specialty to develop, refine itself, and evolve. It also provides a structure from which training, testing, and curricula can be developed and effectively utilized. For nearly a decade, since the coining of the term hospitalist,1 the field of hospital medicine has been emerging as the next generation of site‐defined specialties, after emergency medicine and critical care medicine. The Core Competencies in Hospital Medicine: A Framework for Curriculum Development (referred to as the Core Competencies from this point on) introduces the expectations of hospitalists, helps to define their role, and suggests how knowledge, skill, and attitude acquisition might be evaluated. Furthermore, this document provides an initial structural framework from which curricula in adult hospital medicine may be developed.

The Core Competencies document, produced by the Society of Hospital Medicine (SHM) and published as a supplement to the first issue of the Journal of Hospital Medicine,2 is meant to serve as a framework for educators at all levels of medical education to develop curricula, training, and evaluations for students, clinicians‐in‐training, and practicing hospitalists. The Core Competencies document is not meant to contain a complete compilation of inpatient clinical topics or to re‐create what many residency training programs in adult inpatient care already provide. It should not limit and does not define every aspect of hospitalist practice. It includes the most common and fundamental elements of inpatient care without exhaustively listing every clinical entity that may be encountered by a hospitalist. Some of the more common clinical topics encountered by inpatient physicians are included, with an emphasis on subject areas that stress a systems‐based approach to health care, which is central to the practice of hospital medicine. This initial version of the Core Competencies document also focuses on potential areas of deficiency in the training of physicians to become hospitalists. It provides developers of curricula and content with a standardized set of measurable learning objectives, while allowing them the flexibility needed to address specific contexts and incorporate advances in medicine.

The SHM, the sole professional organization representing inpatient physicians, defines hospitalists as physicians whose primary professional focus is the general medical care of hospitalized patients. Their activities include patient care, teaching, research, and leadership related to Hospital Medicine.3 An estimated 12,000 hospitalists are currently practicing in the United States, with a projected workforce need of an estimated 20,00030,000 practicing hospitalists in the United States in the next 510 years.4 Various factors have contributed to the rapid growth and expansion of hospital medicine, including factors related to care efficiency, care quality, and inpatient teaching.512 The pressures that have contributed to the development of and evolution toward the hospitalist model of care over the past decade are facilitating the transformation from a traditional model of inpatient care to the care of inpatients by hospitalist physicians dedicated primarily to the inpatient setting. As a result of this growth in hospital medicine, the SHM realized that core competencies were needed to help define the field.

The purpose of this article is to describe the developmental process and content structure of the Core Competencies document. It delineates the process from initial needs assessment to topic list development to chapter production to internal and external review and revisions of individual chapters and the complete document. The supplement to this first issue of the Journal of Hospital Medicine contains 1) the Core Competencies,2 2) a reprint of this article, and 3) a reprint of the article by McKean et al. in this issue detailing how to use the Core Competencies,13 with examples and suggestions related to curriculum development. The authors propose that this combined compilation may spur curriculum development in hospital medicine that will help to define the field and set expectations for practice.

PROCESS AND TIMELINE

Education Summit

Early in the growth of hospital medicine, the Society of Hospital Medicine identified a need to better define a common educational and practice framework for hospitalist physicians. Such a framework could help to define hospitalists as a distinct group of practicing physicians with common goals and a common set of competencies. The importance of identifying and delineating the common knowledge, skills, and attitudes of hospitalists was paramount. Figure 1 shows the details of the 4‐year process of developing the Core Competencies.

Figure 1

In 2002, the SHM drew together educational leaders in hospital medicine in its first educational summit. One of the primary charges that the SHM received from this summit was to develop the needed core curriculum in hospital medicine. After the summit, the SHM's Education Committee formed the Core Curriculum Task Force (CCTF), composed of approximately 15 member hospitalists, with representation from university and community hospitals, teaching and nonteaching programs, and for‐profit and not‐for‐profit settings from various geographic regions of the country. The selection process ensured that the task force was representative of practicing hospitalists and SHM membership throughout the United States.

CHAPTER CONTENT DESCRIPTION

As previously delineated, the Core Competencies document has three sections: Clinical Conditions, Procedures, and Healthcare Systems. The chapters in the entire compendium and within each section have been designed to stand alone and to be used either individually or collectively to assist with curriculum development in hospital medicine. However, each chapter should be used in the context of the entire document because a particular issue may only be touched on in one chapter but may be more elaborately detailed in another. For example, all clinical conditions chapters include a competency on the issue of care transitions, but the specific competencies for care transitions are presented in a separate Transitions of Care chapter.

All chapters in each section begin with an introduction that provides brief background information and establishes the relevance of the topic to practicing hospitalists. Each chapter then utilizes the educational theory of learning domains. The learning domains include the cognitive domain (knowledge), the psychomotor domain (skills), and the affective domain (attitudes). The companion article How to Use The Core Competencies in Hospital Medicine: A Framework for Curriculum Development13 describes in detail the educational theory guiding the development of the Core Competencies document and suggested methods for applying it to the development and revision of curricula and other training activities.

The task force further decided that each chapter in the Clinical Conditions and Procedures sections should include a subsection dedicated to system organization and improvement, an added domain that requires integration of knowledge, skills, and attitudes and the involvement of other medical services and disciplines for optimal patient care. The editorial board believed that system organization and improvement was already an intrinsic feature embedded in the chapters of the Healthcare Systems section. Therefore, this subsection was not included in those chapters.

Hospitalists subscribe to a systems organizational approach to clinical management and processes of care within the hospital. This systems approach, more than any level of knowledge or skill, is required to effectively and efficiently practice in the hospital setting. Practicing with a systems approach, with the interest of improving processes of care, is embedded throughout the Core Competencies document and is a practice method that all hospitalists may strive to achieve as they develop and improve their inpatient care. The competencies within the Systems Organization and Improvement section may contain a range of competency expectation (eg, lead, coordinate, or participate in) to acknowledge their uniqueness and variation according to practice settings and locally instituted responsibilities.

Each competency within a chapter details a level of proficiency, providing guidance on learning activities and potential evaluation strategies. Several overarching themes are followed in the chapters that help to define hospitalists as physicians who specialize in the care of hospitalized patients. First, hospitalists strive to support and adhere to a multidisciplinary approach for the patients under their care. Such an approach involves active interaction with and integration of other hospital medical staff (eg, nursing, rehabilitation therapies, social services) and of specialty medical or surgical services when indicated. Recognizing that hospitalists vary in experience and mastery of their field, the task force and editorial board believed that, at minimum, hospitalists would participate in multidisciplinary teams for improvement of the care and process related to the clinical conditions within their organization. However, they might also lead and/or coordinate teams in such efforts. Therefore, most chapters contain competencies that expect hospitalists to lead, coordinate, or participate in multidisciplinary teams or initiatives that will facilitate optimal care within their organization.

Second, because hospital medicine centers around the quality of inpatient care, participation in quality improvement (QI) initiatives, focusing on improving processes or systems of care in a local institution or organization, may be common in hospitalist practices. The level of involvement and role in QI initiatives may vary according to the particular system, the resources available, and a hospitalist's experience. Finally, because hospitalist care intrinsically involves an increase in the number of care transitions and handoffs, hospitalists need to remain sensitive to and focused on the care transitions that occur with their patients. Such transitions may occur as patients enter the hospital, move from one location to another within the hospital, or leave the hospital. This vulnerable time for patients requires hospitalists to be vigilant in their communication effortswith patients, with medical staff, and with outpatient clinicians.

Each competency was crafted to indicate the relevant concept, the level of proficiency expected, and a way to evaluate mastery. The teaching processes and learning experiences that must take place to achieve competency are left for curriculum developers and instructors to design. These core competencies represent an initial step in curriculum development, creating an identity and core set of expectations for hospitalists that we believe will lead to progress and maturity within the field.

SUMMARY AND FUTURE DIRECTIONS

The practice of hospital medicine requires proficiency of interrelated aspects of practiceclinical, procedural, and system‐based competencies. For practicing hospitalists, the Core Competencies document may serve as a resource to refine skills and assist in program development at individual institutions, both regionally and nationally. For residency program directors and clerkship directors, the Core Competencies document can function as a guide for developing the curriculum of inpatient medicine rotations or for meeting the requirements of the Outcomes Project of the Accreditation Council on Graduate Medical Education's. Last, for those developing continuing medical education programs, the Core Competencies document or individual chapters or topics within it may serve as an outline around which specific or broad‐based programs can be developed. Although the development of such curricula and the recipients of them should be evaluated, the actual evaluation is left to the curriculum developers.

Hospitalists are invested in making hospitals run better. They are positioned to take leadership roles in addressing quality, efficiency, and cost interests in both community and academic hospital settings. Their goals include improving care processes, hospital work life, and the setting in which they practice. The key core competencies described in this compendium define hospitalists as agents of change 1) to develop and implement systems to enable best practices to occur from admission through discharge, and 2) to promote the development of a safer culture within the hospital.

Hospital medicine remains an evolving specialty. Although great care was taken to construct these competencies so they would retain their relevance over time, SHM, the Core Curriculum Task Force, and the editorial board recognize the need for their continual reevaluation and modification in the context of advances and changes in the practice of hospital medicine. Our intent is that these competencies be a common reference and foundation for the creation of hospital medicine curricula and serve to standardize and improve training practices.

Identification of the core competencies of a medical specialty provides the necessary framework for that specialty to develop, refine itself, and evolve. It also provides a structure from which training, testing, and curricula can be developed and effectively utilized. For nearly a decade, since the coining of the term hospitalist,1 the field of hospital medicine has been emerging as the next generation of site‐defined specialties, after emergency medicine and critical care medicine. The Core Competencies in Hospital Medicine: A Framework for Curriculum Development (referred to as the Core Competencies from this point on) introduces the expectations of hospitalists, helps to define their role, and suggests how knowledge, skill, and attitude acquisition might be evaluated. Furthermore, this document provides an initial structural framework from which curricula in adult hospital medicine may be developed.

The Core Competencies document, produced by the Society of Hospital Medicine (SHM) and published as a supplement to the first issue of the Journal of Hospital Medicine,2 is meant to serve as a framework for educators at all levels of medical education to develop curricula, training, and evaluations for students, clinicians‐in‐training, and practicing hospitalists. The Core Competencies document is not meant to contain a complete compilation of inpatient clinical topics or to re‐create what many residency training programs in adult inpatient care already provide. It should not limit and does not define every aspect of hospitalist practice. It includes the most common and fundamental elements of inpatient care without exhaustively listing every clinical entity that may be encountered by a hospitalist. Some of the more common clinical topics encountered by inpatient physicians are included, with an emphasis on subject areas that stress a systems‐based approach to health care, which is central to the practice of hospital medicine. This initial version of the Core Competencies document also focuses on potential areas of deficiency in the training of physicians to become hospitalists. It provides developers of curricula and content with a standardized set of measurable learning objectives, while allowing them the flexibility needed to address specific contexts and incorporate advances in medicine.

The SHM, the sole professional organization representing inpatient physicians, defines hospitalists as physicians whose primary professional focus is the general medical care of hospitalized patients. Their activities include patient care, teaching, research, and leadership related to Hospital Medicine.3 An estimated 12,000 hospitalists are currently practicing in the United States, with a projected workforce need of an estimated 20,00030,000 practicing hospitalists in the United States in the next 510 years.4 Various factors have contributed to the rapid growth and expansion of hospital medicine, including factors related to care efficiency, care quality, and inpatient teaching.512 The pressures that have contributed to the development of and evolution toward the hospitalist model of care over the past decade are facilitating the transformation from a traditional model of inpatient care to the care of inpatients by hospitalist physicians dedicated primarily to the inpatient setting. As a result of this growth in hospital medicine, the SHM realized that core competencies were needed to help define the field.

The purpose of this article is to describe the developmental process and content structure of the Core Competencies document. It delineates the process from initial needs assessment to topic list development to chapter production to internal and external review and revisions of individual chapters and the complete document. The supplement to this first issue of the Journal of Hospital Medicine contains 1) the Core Competencies,2 2) a reprint of this article, and 3) a reprint of the article by McKean et al. in this issue detailing how to use the Core Competencies,13 with examples and suggestions related to curriculum development. The authors propose that this combined compilation may spur curriculum development in hospital medicine that will help to define the field and set expectations for practice.

PROCESS AND TIMELINE

Education Summit

Early in the growth of hospital medicine, the Society of Hospital Medicine identified a need to better define a common educational and practice framework for hospitalist physicians. Such a framework could help to define hospitalists as a distinct group of practicing physicians with common goals and a common set of competencies. The importance of identifying and delineating the common knowledge, skills, and attitudes of hospitalists was paramount. Figure 1 shows the details of the 4‐year process of developing the Core Competencies.

Figure 1

In 2002, the SHM drew together educational leaders in hospital medicine in its first educational summit. One of the primary charges that the SHM received from this summit was to develop the needed core curriculum in hospital medicine. After the summit, the SHM's Education Committee formed the Core Curriculum Task Force (CCTF), composed of approximately 15 member hospitalists, with representation from university and community hospitals, teaching and nonteaching programs, and for‐profit and not‐for‐profit settings from various geographic regions of the country. The selection process ensured that the task force was representative of practicing hospitalists and SHM membership throughout the United States.

CHAPTER CONTENT DESCRIPTION

As previously delineated, the Core Competencies document has three sections: Clinical Conditions, Procedures, and Healthcare Systems. The chapters in the entire compendium and within each section have been designed to stand alone and to be used either individually or collectively to assist with curriculum development in hospital medicine. However, each chapter should be used in the context of the entire document because a particular issue may only be touched on in one chapter but may be more elaborately detailed in another. For example, all clinical conditions chapters include a competency on the issue of care transitions, but the specific competencies for care transitions are presented in a separate Transitions of Care chapter.

All chapters in each section begin with an introduction that provides brief background information and establishes the relevance of the topic to practicing hospitalists. Each chapter then utilizes the educational theory of learning domains. The learning domains include the cognitive domain (knowledge), the psychomotor domain (skills), and the affective domain (attitudes). The companion article How to Use The Core Competencies in Hospital Medicine: A Framework for Curriculum Development13 describes in detail the educational theory guiding the development of the Core Competencies document and suggested methods for applying it to the development and revision of curricula and other training activities.

The task force further decided that each chapter in the Clinical Conditions and Procedures sections should include a subsection dedicated to system organization and improvement, an added domain that requires integration of knowledge, skills, and attitudes and the involvement of other medical services and disciplines for optimal patient care. The editorial board believed that system organization and improvement was already an intrinsic feature embedded in the chapters of the Healthcare Systems section. Therefore, this subsection was not included in those chapters.

Hospitalists subscribe to a systems organizational approach to clinical management and processes of care within the hospital. This systems approach, more than any level of knowledge or skill, is required to effectively and efficiently practice in the hospital setting. Practicing with a systems approach, with the interest of improving processes of care, is embedded throughout the Core Competencies document and is a practice method that all hospitalists may strive to achieve as they develop and improve their inpatient care. The competencies within the Systems Organization and Improvement section may contain a range of competency expectation (eg, lead, coordinate, or participate in) to acknowledge their uniqueness and variation according to practice settings and locally instituted responsibilities.

Each competency within a chapter details a level of proficiency, providing guidance on learning activities and potential evaluation strategies. Several overarching themes are followed in the chapters that help to define hospitalists as physicians who specialize in the care of hospitalized patients. First, hospitalists strive to support and adhere to a multidisciplinary approach for the patients under their care. Such an approach involves active interaction with and integration of other hospital medical staff (eg, nursing, rehabilitation therapies, social services) and of specialty medical or surgical services when indicated. Recognizing that hospitalists vary in experience and mastery of their field, the task force and editorial board believed that, at minimum, hospitalists would participate in multidisciplinary teams for improvement of the care and process related to the clinical conditions within their organization. However, they might also lead and/or coordinate teams in such efforts. Therefore, most chapters contain competencies that expect hospitalists to lead, coordinate, or participate in multidisciplinary teams or initiatives that will facilitate optimal care within their organization.

Second, because hospital medicine centers around the quality of inpatient care, participation in quality improvement (QI) initiatives, focusing on improving processes or systems of care in a local institution or organization, may be common in hospitalist practices. The level of involvement and role in QI initiatives may vary according to the particular system, the resources available, and a hospitalist's experience. Finally, because hospitalist care intrinsically involves an increase in the number of care transitions and handoffs, hospitalists need to remain sensitive to and focused on the care transitions that occur with their patients. Such transitions may occur as patients enter the hospital, move from one location to another within the hospital, or leave the hospital. This vulnerable time for patients requires hospitalists to be vigilant in their communication effortswith patients, with medical staff, and with outpatient clinicians.

Each competency was crafted to indicate the relevant concept, the level of proficiency expected, and a way to evaluate mastery. The teaching processes and learning experiences that must take place to achieve competency are left for curriculum developers and instructors to design. These core competencies represent an initial step in curriculum development, creating an identity and core set of expectations for hospitalists that we believe will lead to progress and maturity within the field.

SUMMARY AND FUTURE DIRECTIONS

The practice of hospital medicine requires proficiency of interrelated aspects of practiceclinical, procedural, and system‐based competencies. For practicing hospitalists, the Core Competencies document may serve as a resource to refine skills and assist in program development at individual institutions, both regionally and nationally. For residency program directors and clerkship directors, the Core Competencies document can function as a guide for developing the curriculum of inpatient medicine rotations or for meeting the requirements of the Outcomes Project of the Accreditation Council on Graduate Medical Education's. Last, for those developing continuing medical education programs, the Core Competencies document or individual chapters or topics within it may serve as an outline around which specific or broad‐based programs can be developed. Although the development of such curricula and the recipients of them should be evaluated, the actual evaluation is left to the curriculum developers.

Hospitalists are invested in making hospitals run better. They are positioned to take leadership roles in addressing quality, efficiency, and cost interests in both community and academic hospital settings. Their goals include improving care processes, hospital work life, and the setting in which they practice. The key core competencies described in this compendium define hospitalists as agents of change 1) to develop and implement systems to enable best practices to occur from admission through discharge, and 2) to promote the development of a safer culture within the hospital.

Hospital medicine remains an evolving specialty. Although great care was taken to construct these competencies so they would retain their relevance over time, SHM, the Core Curriculum Task Force, and the editorial board recognize the need for their continual reevaluation and modification in the context of advances and changes in the practice of hospital medicine. Our intent is that these competencies be a common reference and foundation for the creation of hospital medicine curricula and serve to standardize and improve training practices.

Identification of the core competencies of a medical specialty provides the necessary framework for that specialty to develop, refine itself, and evolve. It also provides a structure from which training, testing, and curricula can be developed and effectively utilized. For nearly a decade, since the coining of the term hospitalist,1 the field of hospital medicine has been emerging as the next generation of site‐defined specialties, after emergency medicine and critical care medicine. The Core Competencies in Hospital Medicine: A Framework for Curriculum Development (referred to as the Core Competencies from this point on) introduces the expectations of hospitalists, helps to define their role, and suggests how knowledge, skill, and attitude acquisition might be evaluated. Furthermore, this document provides an initial structural framework from which curricula in adult hospital medicine may be developed.

The Core Competencies document, produced by the Society of Hospital Medicine (SHM) and published as a supplement to the first issue of the Journal of Hospital Medicine,2 is meant to serve as a framework for educators at all levels of medical education to develop curricula, training, and evaluations for students, clinicians‐in‐training, and practicing hospitalists. The Core Competencies document is not meant to contain a complete compilation of inpatient clinical topics or to re‐create what many residency training programs in adult inpatient care already provide. It should not limit and does not define every aspect of hospitalist practice. It includes the most common and fundamental elements of inpatient care without exhaustively listing every clinical entity that may be encountered by a hospitalist. Some of the more common clinical topics encountered by inpatient physicians are included, with an emphasis on subject areas that stress a systems‐based approach to health care, which is central to the practice of hospital medicine. This initial version of the Core Competencies document also focuses on potential areas of deficiency in the training of physicians to become hospitalists. It provides developers of curricula and content with a standardized set of measurable learning objectives, while allowing them the flexibility needed to address specific contexts and incorporate advances in medicine.

The SHM, the sole professional organization representing inpatient physicians, defines hospitalists as physicians whose primary professional focus is the general medical care of hospitalized patients. Their activities include patient care, teaching, research, and leadership related to Hospital Medicine.3 An estimated 12,000 hospitalists are currently practicing in the United States, with a projected workforce need of an estimated 20,00030,000 practicing hospitalists in the United States in the next 510 years.4 Various factors have contributed to the rapid growth and expansion of hospital medicine, including factors related to care efficiency, care quality, and inpatient teaching.512 The pressures that have contributed to the development of and evolution toward the hospitalist model of care over the past decade are facilitating the transformation from a traditional model of inpatient care to the care of inpatients by hospitalist physicians dedicated primarily to the inpatient setting. As a result of this growth in hospital medicine, the SHM realized that core competencies were needed to help define the field.

The purpose of this article is to describe the developmental process and content structure of the Core Competencies document. It delineates the process from initial needs assessment to topic list development to chapter production to internal and external review and revisions of individual chapters and the complete document. The supplement to this first issue of the Journal of Hospital Medicine contains 1) the Core Competencies,2 2) a reprint of this article, and 3) a reprint of the article by McKean et al. in this issue detailing how to use the Core Competencies,13 with examples and suggestions related to curriculum development. The authors propose that this combined compilation may spur curriculum development in hospital medicine that will help to define the field and set expectations for practice.

PROCESS AND TIMELINE

Education Summit

Early in the growth of hospital medicine, the Society of Hospital Medicine identified a need to better define a common educational and practice framework for hospitalist physicians. Such a framework could help to define hospitalists as a distinct group of practicing physicians with common goals and a common set of competencies. The importance of identifying and delineating the common knowledge, skills, and attitudes of hospitalists was paramount. Figure 1 shows the details of the 4‐year process of developing the Core Competencies.

Figure 1

In 2002, the SHM drew together educational leaders in hospital medicine in its first educational summit. One of the primary charges that the SHM received from this summit was to develop the needed core curriculum in hospital medicine. After the summit, the SHM's Education Committee formed the Core Curriculum Task Force (CCTF), composed of approximately 15 member hospitalists, with representation from university and community hospitals, teaching and nonteaching programs, and for‐profit and not‐for‐profit settings from various geographic regions of the country. The selection process ensured that the task force was representative of practicing hospitalists and SHM membership throughout the United States.

CHAPTER CONTENT DESCRIPTION

As previously delineated, the Core Competencies document has three sections: Clinical Conditions, Procedures, and Healthcare Systems. The chapters in the entire compendium and within each section have been designed to stand alone and to be used either individually or collectively to assist with curriculum development in hospital medicine. However, each chapter should be used in the context of the entire document because a particular issue may only be touched on in one chapter but may be more elaborately detailed in another. For example, all clinical conditions chapters include a competency on the issue of care transitions, but the specific competencies for care transitions are presented in a separate Transitions of Care chapter.

All chapters in each section begin with an introduction that provides brief background information and establishes the relevance of the topic to practicing hospitalists. Each chapter then utilizes the educational theory of learning domains. The learning domains include the cognitive domain (knowledge), the psychomotor domain (skills), and the affective domain (attitudes). The companion article How to Use The Core Competencies in Hospital Medicine: A Framework for Curriculum Development13 describes in detail the educational theory guiding the development of the Core Competencies document and suggested methods for applying it to the development and revision of curricula and other training activities.

The task force further decided that each chapter in the Clinical Conditions and Procedures sections should include a subsection dedicated to system organization and improvement, an added domain that requires integration of knowledge, skills, and attitudes and the involvement of other medical services and disciplines for optimal patient care. The editorial board believed that system organization and improvement was already an intrinsic feature embedded in the chapters of the Healthcare Systems section. Therefore, this subsection was not included in those chapters.

Hospitalists subscribe to a systems organizational approach to clinical management and processes of care within the hospital. This systems approach, more than any level of knowledge or skill, is required to effectively and efficiently practice in the hospital setting. Practicing with a systems approach, with the interest of improving processes of care, is embedded throughout the Core Competencies document and is a practice method that all hospitalists may strive to achieve as they develop and improve their inpatient care. The competencies within the Systems Organization and Improvement section may contain a range of competency expectation (eg, lead, coordinate, or participate in) to acknowledge their uniqueness and variation according to practice settings and locally instituted responsibilities.

Each competency within a chapter details a level of proficiency, providing guidance on learning activities and potential evaluation strategies. Several overarching themes are followed in the chapters that help to define hospitalists as physicians who specialize in the care of hospitalized patients. First, hospitalists strive to support and adhere to a multidisciplinary approach for the patients under their care. Such an approach involves active interaction with and integration of other hospital medical staff (eg, nursing, rehabilitation therapies, social services) and of specialty medical or surgical services when indicated. Recognizing that hospitalists vary in experience and mastery of their field, the task force and editorial board believed that, at minimum, hospitalists would participate in multidisciplinary teams for improvement of the care and process related to the clinical conditions within their organization. However, they might also lead and/or coordinate teams in such efforts. Therefore, most chapters contain competencies that expect hospitalists to lead, coordinate, or participate in multidisciplinary teams or initiatives that will facilitate optimal care within their organization.

Second, because hospital medicine centers around the quality of inpatient care, participation in quality improvement (QI) initiatives, focusing on improving processes or systems of care in a local institution or organization, may be common in hospitalist practices. The level of involvement and role in QI initiatives may vary according to the particular system, the resources available, and a hospitalist's experience. Finally, because hospitalist care intrinsically involves an increase in the number of care transitions and handoffs, hospitalists need to remain sensitive to and focused on the care transitions that occur with their patients. Such transitions may occur as patients enter the hospital, move from one location to another within the hospital, or leave the hospital. This vulnerable time for patients requires hospitalists to be vigilant in their communication effortswith patients, with medical staff, and with outpatient clinicians.

Each competency was crafted to indicate the relevant concept, the level of proficiency expected, and a way to evaluate mastery. The teaching processes and learning experiences that must take place to achieve competency are left for curriculum developers and instructors to design. These core competencies represent an initial step in curriculum development, creating an identity and core set of expectations for hospitalists that we believe will lead to progress and maturity within the field.

SUMMARY AND FUTURE DIRECTIONS

The practice of hospital medicine requires proficiency of interrelated aspects of practiceclinical, procedural, and system‐based competencies. For practicing hospitalists, the Core Competencies document may serve as a resource to refine skills and assist in program development at individual institutions, both regionally and nationally. For residency program directors and clerkship directors, the Core Competencies document can function as a guide for developing the curriculum of inpatient medicine rotations or for meeting the requirements of the Outcomes Project of the Accreditation Council on Graduate Medical Education's. Last, for those developing continuing medical education programs, the Core Competencies document or individual chapters or topics within it may serve as an outline around which specific or broad‐based programs can be developed. Although the development of such curricula and the recipients of them should be evaluated, the actual evaluation is left to the curriculum developers.

Hospitalists are invested in making hospitals run better. They are positioned to take leadership roles in addressing quality, efficiency, and cost interests in both community and academic hospital settings. Their goals include improving care processes, hospital work life, and the setting in which they practice. The key core competencies described in this compendium define hospitalists as agents of change 1) to develop and implement systems to enable best practices to occur from admission through discharge, and 2) to promote the development of a safer culture within the hospital.

Hospital medicine remains an evolving specialty. Although great care was taken to construct these competencies so they would retain their relevance over time, SHM, the Core Curriculum Task Force, and the editorial board recognize the need for their continual reevaluation and modification in the context of advances and changes in the practice of hospital medicine. Our intent is that these competencies be a common reference and foundation for the creation of hospital medicine curricula and serve to standardize and improve training practices.

The seminal article that coined the term hospitalist, in 1996, attributed the role of the hospitalist to enhancing throughput and cost reduction, primarily through reduction in length of stay, accomplished by having a dedicated clinician on site in the hospital.1 Since that time the role of the hospitalist has evolved to address the needs of multiple stakeholders at a time when traditional residency programs in inpatient adult medicine do not adequately train physicians to become effective agents of change in complex and potentially unsafe hospital systems. Continuing the trend of pediatrics, obstetrics, gynecology, and geriatrics, hospitalists have emerged as a distinct group of physicians who fill a needed clinical niche and are demonstrating the benefits of bringing a unique role and skill sets to the general hospital ward.2

The eligibility requirements for certification by the American Board of Internal Medicine specify that the discipline must 1) have a distinct and unique body of knowledge, 2) have clinical applicability sufficient to support a distinct clinical practice, 3) generate new information and research, 4) require a minimum training period of 12 months, and 5) have a substantial number of trainees and training programs nationwide.3 The Society of Hospital Medicine (SHM), the national professional organization of hospitalists, commissioned a task force to develop The Core Competencies in Hospital Medicine: A Framework for Curriculum Development (referred to from here on as the Core Competencies) to standardize the expectations of practicing hospitalists, serve as a foundation for curricula and other professional development experiences, prioritize educational scholarship and research strategies, and assess the adequacy and improvement opportunities for current training and accreditation of hospital medicine physicians.4 The preceding companion article The Core Competencies in Hospital Medicine: Development and Methodology, describes in detail the rationale for the development of the Core Competencies and the methods by which the document was created.5

PURPOSE

The purpose of this article is to illustrate how curriculum developers can apply the Core Competencies in Hospital Medicine to educate trainees and faculty, to prioritize educational scholarship and research strategies, and thus to improve the care of our patients.

TARGET AUDIENCE

The Core Competencies specifically targets directors of continuing medical education (CME), hospitalist programs and fellowships, residency programs, and medical school internal medicine clerkships. It is also intended for health educators, hospital administrators, potential employers, policy makers, and agencies funding quality‐improvement initiatives in the hospital setting. For residency program directors and clerkship directors, the chapters can guide in the development of curricula for inpatient medicine rotations or in meeting the Accreditation Council on Graduate Medical Education's Outcomes Project. For directors developing medical education curricula, The Core Competencies in Hospital Medicine can serve as a template for CME. For hospitalists, hospital administrators, and potential employers, the Core Competencies can be used to as the starting point in local program development and as a resource for refining the skills of all hospitalists, even very experienced practicing clinicians.

DEFINITION OF CORE COMPETENCIES IN HOSPITAL MEDICINE

The Core Competencies in Hospital Medicine provides a framework for curricular development based on a shared understanding of the essential knowledge, skills, and attitudes expected of physicians working as hospitalists. The development process will be ongoing, with revisions reflecting the evolving specialty of hospital medicine, the needs of practicing hospitalists, and feedback from users of the Core Competencies.

PROBLEM IDENTIFICATION AND GENERAL NEEDS ASSESSMENT

Delivery of health care has large gaps compared to ideal performance. Since the publication by the Institute of Medicine of To Err Is Human, in 1999, multiple agencies including the American Hospital Association, the National Quality Forum, and the U.S. Agency for Health Care Research and Quality (AHRQ) have reported on the incidence of medical errors in U.S. hospitals.6, 7 Recognizing that medical errors represent a major health concern in the United States, the Joint Commission on the Accreditation of Health Care Organizations (JCAHO) now requires patient safety initiatives for hospital accreditation.8 Problem‐based learning and improvement and systems based practice are now required competencies in medical residency curricula by the Accreditation Council for Graduate Medical Education (ACGME) and these requirements have led to the development of continuous quality techniques for preventing errors and a variety of patient safety initiatives.9

In 2002 the SHM recognized the need for identifying a distinct set of competencies in hospital medicine. The published competencies highlight the current gap in training of hospitalists and the imperative for revising curricula relating to inpatient care, hospital systems, and teaching.4 With adequate training and preparation, hospitalists can take the lead in implementing systems for best practices from admission through discharge and care transition, and they can direct the development of a safer, more patient‐centered, and cost‐efficient culture.

By defining the role of the hospitalist, the Core Competencies reflects the view of the SHM about what is possible but does not suggest how a training program might be modified to achieve desired outcomes or provide any content, resources, or teaching strategies. It will be up to curriculum developers to determine the scope of cognitive, psychomotor, and affective objectives that targeted learnershospitalists, residents, and other members of the multidisciplinary teamshould be required to acquire through lectures, discussions, syllabus material, clinical experience, and other venues. We agree with a broader definition of the term curriculum for graduate medical education, one that goes beyond curriculum as a plan and takes into account the learners' experiences, both planned and unplanned in the hospital setting.10 In contrast to the technologic theory of curriculum, in which lists of knowledge and skills represent final destinations, in the experiential model of curriculum, the lists provide only points of departure.11 The goal of the Core Competencies is to facilitate curriculum development using complex teaching environments as building blocks through which learning can occur.

CORE COMPETENCIES FOR HOSPITALISTS: OVERVIEW

The Core Competencies in Hospital Medicine is the first published competency‐based framework for professional development of hospitalists and provides the basis for accreditation in hospital medicine.12 The Core Competencies is organized into three sectionsClinical Conditions, Procedures, and Healthcare Systems. The supplement intentionally does not focus on content; rather, specific competencies describe unambiguous, measurable learning objectives. Each chapter can be used as a stand‐alone chapter to develop training and curricula for a particular topic area. Each chapter divides competencies into three domains of educational outcomes: cognitive (knowledge), affective (attitudes), and psychomotor (skills). Each domain has defined levels of proficiency going from knowledge, the lowest level, to evaluation, the highest.12, 13 A specific level of proficiency is articulated in the competencies through careful selection of corresponding action verbs, which clearly indicate how mastery could be assessed (see Table 1).

In addition to specific competencies in these commonly accepted learning domains, the Clinical Conditions and Procedure sections of the Core Competencies articulate the proficiencies that hospitalists should possess in systems organization and improvement. The clinical topics were selected to set expectations of leading or participating in system improvements specific to a clinical area and to prevent predictable complications of acute illness. Competencies in the Systems Organization and Improvement section indicate mastery of multiple competencies across categories. The Core Competencies describes how the hospitalist approach facilitates coordination among all participants within the hospital system (clinical and nonclinical) and effects system changes that improve patient care processes. At the same time, the statements indicate a range of involvement from participation to leadership. For example, lead, coordination or participate in acknowledges the unique needs of different practice settings and suggests a potential professional evolution. The Systems Organization and Improvement competencies of each clinical and procedure chapter strive to capture the essence of hospitalists whose goals are to improve patient outcomes for a specific population of patients. Hospitalists do not solely focus on the care of the patient with x disease, but rather develop systems to provide the best and most efficient care for all patients with x disease, successfully transitioning these patients to outpatient care and avoiding readmission.

The third section of chapters in the Core Competencies, Healthcare Systems, distinguishes a hospitalist from others working in the inpatient setting whether practicing at academic medical centers, community hospitals, teaching hospitals, managed‐care settings, or for‐profit settings. The Healthcare Systems section identifies the integral components of the successful practice of hospital medicine and mastery of multiple competencies. This section highlights how hospitalists can facilitate coordination among all care providers within the hospital and with outpatient care providers. Hospitalists can effect system changes that improve complex care processes. It is likely that additional work experience and training beyond residency are required to attain global proficiency in the care of hospital medicine patients.

HOW TO USE THE CORE COMPETENCIES TO DEVELOP A CURRICULUM

The whole document, three sections and 51 chapters, develops expectations about the role of the hospitalist. Proficiency can be acquired through multiple means and should match the needs of the targeted learners in order to develop and maintain the necessary level of performance within the discipline of hospital medicine. Specific cases that hospitalists may encounter in their daily practice are used to illustrate how the Core Competencies can be applied to curriculum development.

The cases will employ the following six‐step approach described in Curriculum Development in Medical Education14:

• 1

  A problem and a need for improvement (the actual case and quality gap)

• 2

  Needs assessment of targeted learners (hospitalists, clinicians‐in‐training)

• 3

  Goals and specific measurable objectives (with competencies bridging the gap between traditional roles and setting expectations about the hospitalist role)

• 4

  Educational strategies (with competencies providing structure and guidance to educational efforts)

• 5

  Implementation (applying competencies to a variety of training opportunities and curricula)

• 6

  Evaluation and feedback (ongoing nationally, regionally, locally).

Like any quality‐improvement educational initiative, subsequent steps in curriculum development for hospitalists should include, after evaluation and feedback, dissemination of core competencies and promotion of rigorous ongoing evaluation and adaptation as needs and expectations evolve.

The first case example, failure to prevent and diagnose pulmonary embolism (see Table 2), illustrates quality issues relating to prevention of predictable complications of illness, clinical problem solving in complex conditions of uncertainty, repetitive and nondiagnostic testing, and triage of a critically ill patient between services. The Core Competencies sets expectations about the ideal role of the hospitalist that might lead to improved outcomes.

Using this case example, the Evidence‐Based Medicine (EBM) chapter establishes explicit expectations for hospitalists in clinical problem solving, including 1) explaining how the tests help to verify a suspected diagnosis, 2) describing the human factor in test interpretation (e.g., technical limitations of the most recent multi‐detector‐row spiral CT), and 3) explaining how timing relative to the onset of symptoms affects test results. Rather than an overreliance on technology, leading to repeating the chest CT with PE protocol and subsequent excessive nondiagnostic testing, the hospitalist would use knowledge of pretest probability and test characteristics to determine the best diagnostic strategy. The hospitalist approach to patient care, articulated in the affective (attitudes) domains of each chapter, integrates the application of EBM principles to clinical problem solving with deliberation of cost effectiveness and efficiency.

Continuing with this case example, the Team Approach and Communication chapters establish explicit expectations for practicing hospitalists who would take the extra steps to communicate with multiple members of the care team. Knowledgeable about the hospital, the hospitalist would review the chest CT with a radiologist skilled in chest interpretation and specifically query about the significance of an enlarged right atrium and right ventricle in the setting of a high pretest clinical probability of PE. Together the radiologist and hospitalist would consider a different imaging modality if the patient flunked the chest CT when the pretest probability was high. Rather than simply deferring to the medical specialist who is consulting, the hospitalist would be expected to improve the efficiency of care and reduce cost by only ordering tests that would change clinical management, perhaps with improved outcomes.

The Hospitalist as Teacher chapter provides a frameworkcore competencies for impromptu learningbased on the patient encounter. Members of the multidisciplinary care team can be exposed to explicit clinical decision making, an approach made possible by hospitalists on site, who can provide teaching moments in real time when decisions have to be made and educational feedback is needed. Teaching expectations for hospitalists include unambiguous clinical problem solving at the bedside and possibly directing the education of residents, physician assistants, and nurses on how to initiate a quality improvement (QI) project in a hospital setting.

The Quality Improvement and Venous Thromboembolism chapters clarify the role of the hospitalist, who should direct therapy against predictable complications of serious illness, critically review prophylaxis, provide hospital‐specific data to clinicians, identify and lower barriers to prevention, devise strategies to bridge the gap between knowledge and practice, develop automated reminder systems, and participate in clinical research.

The SHM has used the Core Competencies to develop educational resources to better meet the needs of the healthcare system. Although patient safety initiatives are mandated by JCAHO for hospital accreditation and AHRQ has identified areas for safety improvement that lists venous thromboembolism (VTE) prevention as the number one priority, VTE prophylaxis is still underutilized in the United States. Although some mechanisms are in place to educate residents and hospitalists about how to manage a specific disease, traditional medical education does not focus on teaching students and residents how to manage complex patients with multiple comorbidities, to prevent predictable complications of illness, and to examine and improve care processes.15, 16 When it comes to leading quality improvement (QI), individual feedback and traditional curricula, which may include didactic lectures on the pathophysiology of VTE and morbidity and mortality conferences, have not demonstrated improved outcomes.17

The SHM QI Web‐based resource rooms offer support to any QI effort and raise collective awareness of a performance gap.18 Each resource room will describe the evidence‐based practices that should be put into effect and will leverage experience with the disease as well as with the improvement process. The underlying goal of the resource rooms is to enhance the ability of hospitalists to actually improve inpatient outcomes through self‐directed learning (see Fig. 1).

Figure 1

Hospitalists, residency directors, and directors of hospitalist fellowships and continuing education can use The Core Competencies in Hospital Medicine to develop curricula for their local hospitalist service and request that invited speakers develop learning objectives and content based on core competencies rather than giving a prepared lecture on a specific clinical condition. This case of PE illustrates that risk assessment, prophylaxis, EBM clinical problem solving, and QI are core topics that should be emphasized in the training of hospitalists and physicians in training.0

The second case example, the hand‐off (see Table 3), illustrates quality issues related to transfer of care from one physician to another. In this example, if the patient with moderate pleural effusion had been signed out, an earlier thoracentesis to drain a presumptive parapneumonic infection might have relieved this patient's shortness of breath and saved her from undergoing a subsequent VATS procedure. This case also demonstrates the importance of correlating imaging abnormalities with a patient's clinical presentation rather than using the traditional approach of just ruling out potential diagnoses to determine the cause of a problem. This case highlights elements of the process and system of care that can be modified to improve patient outcomes. Being proficient in transferring care of patients can save the hospitalist from error and prevent adverse events.

The Team Approach chapter establishes the need to acquire proficiencies not ordinarily obtained during residency in order to lead a multidisciplinary care team. This role requires a level of functioning beyond that of simply being the attending of record. The hospitalist must be able to synthesize information rather than simply defer to the consultant. Competencies specified in the Diagnostic Decision‐Making chapter can be used to identify the educational needs of hospitalists, who are expected to minimize diagnostic errors by knowing when to ask for help and where to get it, recognizing common diseases with uncommon presentations, and generating a broad differential diagnosis where there is uncertainty. The Patient Handoff chapter defines the proficiencies hospitalists need to facilitate the safe transfer of patients to other physicians on their service.0

The third case example, which expands the responsibilities of hospitalist to include meeting important needs in the hospital (see Table 4), illustrates that hospitalist services cannot succeed by offering all things to all people, a distraction that that keeps the members of these services from concentrating on their goals. Always saying yes to whoever asks for help is a band‐aid, a short‐term fix that impedes the effort and creativity required for durable long‐term solutions to problems.

The Core Competencies sets expectations about the roles of hospitalists, who serve as well‐informed clinicians and clinical opinion leaders; effective educators, mentors, and role models; empathetic and timely communicators; efficient caregivers; and creative problem solvers arriving at durable, longer‐term solutions. The competencies demonstrate the knowledge, skills, and attitudes required to be effective agents of change. Changing business as usual almost always requires significant improvements in the underlying system, however uncomfortable. The Leadership chapter articulates competencies that hospitalists need in order to define their roles within the hospital, promote group cohesiveness, expand their practices intelligently, and anticipate and respond to change. This chapter details the proficiencies that hospitalists need in order to develop personal, team, and program goals and to identify and resolve conflicts using specific negotiation techniques. The Business Practices chapter articulates the fundamental skills needed to enhance program development and growth. Hospitalists can use the Core Competencies to identify educational needs and develop curricula to enhance their leadership and business skill sets.0

Medical educators should examine the outcomes of current training practices and assess what modifications of objectives, content, and instructional strategies should be made to better prepare the current and next generations of physicians to practice hospital medicine and to improve the hospital setting. Given the scope of the field of hospital medicine, the Core Competencies should guide: 1) what to teach and how much to teach; 2) how to teach and assess trainees, and how to assess and compare faculty development programs; 3) how to design systems for improving quality of care and assuring patient safety; and 4) how to establish priorities for hospital medicine research.

TRANSLATING A SET OF COMPETENCIES INTO CURRICULA: POTENTIAL BENEFITS

The Core Competencies in Hospital Medicine transcends hospital type, size, and setting and standardizes what the expectations for and proficiencies of a practicing hospitalist should be. By defining the role of the hospitalist, the Core Competencies serves as a resource for refining inpatient skills and assists in program development at the local, regional, and national levels. In addition, by using the Core Competencies as the standard and framework for the development of preparatory curricula, hospital administrators and other employers can rely on hospitalists having had a common preparation.

The medical profession is constantly evolving. Internal medicine curricula address the challenges hospital medicine physicians faced yesterday but could improve the training and preparation of physicians to serve in their new and emerging roles as leaders of multidisciplinary healthcare teams working to improve patient outcomes and the system of inpatient care. Hospital medicine no longer represents a group of physicians merely supporting other specialists and primary care physicians; it is itself a specialty, composed of physicians leading, directing, and improving inpatient care. The competencies presented in The Core Competencies in Hospital Medicine: A Framework for Curriculum Development, by the Society of Hospital Medicine, should spark debate about the adequacy and appropriateness of current training and certification expectations and serve as a foundation for the development of curricula to improve hospital medicine education.

The seminal article that coined the term hospitalist, in 1996, attributed the role of the hospitalist to enhancing throughput and cost reduction, primarily through reduction in length of stay, accomplished by having a dedicated clinician on site in the hospital.1 Since that time the role of the hospitalist has evolved to address the needs of multiple stakeholders at a time when traditional residency programs in inpatient adult medicine do not adequately train physicians to become effective agents of change in complex and potentially unsafe hospital systems. Continuing the trend of pediatrics, obstetrics, gynecology, and geriatrics, hospitalists have emerged as a distinct group of physicians who fill a needed clinical niche and are demonstrating the benefits of bringing a unique role and skill sets to the general hospital ward.2

The eligibility requirements for certification by the American Board of Internal Medicine specify that the discipline must 1) have a distinct and unique body of knowledge, 2) have clinical applicability sufficient to support a distinct clinical practice, 3) generate new information and research, 4) require a minimum training period of 12 months, and 5) have a substantial number of trainees and training programs nationwide.3 The Society of Hospital Medicine (SHM), the national professional organization of hospitalists, commissioned a task force to develop The Core Competencies in Hospital Medicine: A Framework for Curriculum Development (referred to from here on as the Core Competencies) to standardize the expectations of practicing hospitalists, serve as a foundation for curricula and other professional development experiences, prioritize educational scholarship and research strategies, and assess the adequacy and improvement opportunities for current training and accreditation of hospital medicine physicians.4 The preceding companion article The Core Competencies in Hospital Medicine: Development and Methodology, describes in detail the rationale for the development of the Core Competencies and the methods by which the document was created.5

PURPOSE

The purpose of this article is to illustrate how curriculum developers can apply the Core Competencies in Hospital Medicine to educate trainees and faculty, to prioritize educational scholarship and research strategies, and thus to improve the care of our patients.

TARGET AUDIENCE

The Core Competencies specifically targets directors of continuing medical education (CME), hospitalist programs and fellowships, residency programs, and medical school internal medicine clerkships. It is also intended for health educators, hospital administrators, potential employers, policy makers, and agencies funding quality‐improvement initiatives in the hospital setting. For residency program directors and clerkship directors, the chapters can guide in the development of curricula for inpatient medicine rotations or in meeting the Accreditation Council on Graduate Medical Education's Outcomes Project. For directors developing medical education curricula, The Core Competencies in Hospital Medicine can serve as a template for CME. For hospitalists, hospital administrators, and potential employers, the Core Competencies can be used to as the starting point in local program development and as a resource for refining the skills of all hospitalists, even very experienced practicing clinicians.

DEFINITION OF CORE COMPETENCIES IN HOSPITAL MEDICINE

The Core Competencies in Hospital Medicine provides a framework for curricular development based on a shared understanding of the essential knowledge, skills, and attitudes expected of physicians working as hospitalists. The development process will be ongoing, with revisions reflecting the evolving specialty of hospital medicine, the needs of practicing hospitalists, and feedback from users of the Core Competencies.

PROBLEM IDENTIFICATION AND GENERAL NEEDS ASSESSMENT

Delivery of health care has large gaps compared to ideal performance. Since the publication by the Institute of Medicine of To Err Is Human, in 1999, multiple agencies including the American Hospital Association, the National Quality Forum, and the U.S. Agency for Health Care Research and Quality (AHRQ) have reported on the incidence of medical errors in U.S. hospitals.6, 7 Recognizing that medical errors represent a major health concern in the United States, the Joint Commission on the Accreditation of Health Care Organizations (JCAHO) now requires patient safety initiatives for hospital accreditation.8 Problem‐based learning and improvement and systems based practice are now required competencies in medical residency curricula by the Accreditation Council for Graduate Medical Education (ACGME) and these requirements have led to the development of continuous quality techniques for preventing errors and a variety of patient safety initiatives.9

In 2002 the SHM recognized the need for identifying a distinct set of competencies in hospital medicine. The published competencies highlight the current gap in training of hospitalists and the imperative for revising curricula relating to inpatient care, hospital systems, and teaching.4 With adequate training and preparation, hospitalists can take the lead in implementing systems for best practices from admission through discharge and care transition, and they can direct the development of a safer, more patient‐centered, and cost‐efficient culture.

By defining the role of the hospitalist, the Core Competencies reflects the view of the SHM about what is possible but does not suggest how a training program might be modified to achieve desired outcomes or provide any content, resources, or teaching strategies. It will be up to curriculum developers to determine the scope of cognitive, psychomotor, and affective objectives that targeted learnershospitalists, residents, and other members of the multidisciplinary teamshould be required to acquire through lectures, discussions, syllabus material, clinical experience, and other venues. We agree with a broader definition of the term curriculum for graduate medical education, one that goes beyond curriculum as a plan and takes into account the learners' experiences, both planned and unplanned in the hospital setting.10 In contrast to the technologic theory of curriculum, in which lists of knowledge and skills represent final destinations, in the experiential model of curriculum, the lists provide only points of departure.11 The goal of the Core Competencies is to facilitate curriculum development using complex teaching environments as building blocks through which learning can occur.

CORE COMPETENCIES FOR HOSPITALISTS: OVERVIEW

The Core Competencies in Hospital Medicine is the first published competency‐based framework for professional development of hospitalists and provides the basis for accreditation in hospital medicine.12 The Core Competencies is organized into three sectionsClinical Conditions, Procedures, and Healthcare Systems. The supplement intentionally does not focus on content; rather, specific competencies describe unambiguous, measurable learning objectives. Each chapter can be used as a stand‐alone chapter to develop training and curricula for a particular topic area. Each chapter divides competencies into three domains of educational outcomes: cognitive (knowledge), affective (attitudes), and psychomotor (skills). Each domain has defined levels of proficiency going from knowledge, the lowest level, to evaluation, the highest.12, 13 A specific level of proficiency is articulated in the competencies through careful selection of corresponding action verbs, which clearly indicate how mastery could be assessed (see Table 1).

In addition to specific competencies in these commonly accepted learning domains, the Clinical Conditions and Procedure sections of the Core Competencies articulate the proficiencies that hospitalists should possess in systems organization and improvement. The clinical topics were selected to set expectations of leading or participating in system improvements specific to a clinical area and to prevent predictable complications of acute illness. Competencies in the Systems Organization and Improvement section indicate mastery of multiple competencies across categories. The Core Competencies describes how the hospitalist approach facilitates coordination among all participants within the hospital system (clinical and nonclinical) and effects system changes that improve patient care processes. At the same time, the statements indicate a range of involvement from participation to leadership. For example, lead, coordination or participate in acknowledges the unique needs of different practice settings and suggests a potential professional evolution. The Systems Organization and Improvement competencies of each clinical and procedure chapter strive to capture the essence of hospitalists whose goals are to improve patient outcomes for a specific population of patients. Hospitalists do not solely focus on the care of the patient with x disease, but rather develop systems to provide the best and most efficient care for all patients with x disease, successfully transitioning these patients to outpatient care and avoiding readmission.

The third section of chapters in the Core Competencies, Healthcare Systems, distinguishes a hospitalist from others working in the inpatient setting whether practicing at academic medical centers, community hospitals, teaching hospitals, managed‐care settings, or for‐profit settings. The Healthcare Systems section identifies the integral components of the successful practice of hospital medicine and mastery of multiple competencies. This section highlights how hospitalists can facilitate coordination among all care providers within the hospital and with outpatient care providers. Hospitalists can effect system changes that improve complex care processes. It is likely that additional work experience and training beyond residency are required to attain global proficiency in the care of hospital medicine patients.

HOW TO USE THE CORE COMPETENCIES TO DEVELOP A CURRICULUM

The whole document, three sections and 51 chapters, develops expectations about the role of the hospitalist. Proficiency can be acquired through multiple means and should match the needs of the targeted learners in order to develop and maintain the necessary level of performance within the discipline of hospital medicine. Specific cases that hospitalists may encounter in their daily practice are used to illustrate how the Core Competencies can be applied to curriculum development.

The cases will employ the following six‐step approach described in Curriculum Development in Medical Education14:

• 1

  A problem and a need for improvement (the actual case and quality gap)

• 2

  Needs assessment of targeted learners (hospitalists, clinicians‐in‐training)

• 3

  Goals and specific measurable objectives (with competencies bridging the gap between traditional roles and setting expectations about the hospitalist role)

• 4

  Educational strategies (with competencies providing structure and guidance to educational efforts)

• 5

  Implementation (applying competencies to a variety of training opportunities and curricula)

• 6

  Evaluation and feedback (ongoing nationally, regionally, locally).

Like any quality‐improvement educational initiative, subsequent steps in curriculum development for hospitalists should include, after evaluation and feedback, dissemination of core competencies and promotion of rigorous ongoing evaluation and adaptation as needs and expectations evolve.

The first case example, failure to prevent and diagnose pulmonary embolism (see Table 2), illustrates quality issues relating to prevention of predictable complications of illness, clinical problem solving in complex conditions of uncertainty, repetitive and nondiagnostic testing, and triage of a critically ill patient between services. The Core Competencies sets expectations about the ideal role of the hospitalist that might lead to improved outcomes.

Using this case example, the Evidence‐Based Medicine (EBM) chapter establishes explicit expectations for hospitalists in clinical problem solving, including 1) explaining how the tests help to verify a suspected diagnosis, 2) describing the human factor in test interpretation (e.g., technical limitations of the most recent multi‐detector‐row spiral CT), and 3) explaining how timing relative to the onset of symptoms affects test results. Rather than an overreliance on technology, leading to repeating the chest CT with PE protocol and subsequent excessive nondiagnostic testing, the hospitalist would use knowledge of pretest probability and test characteristics to determine the best diagnostic strategy. The hospitalist approach to patient care, articulated in the affective (attitudes) domains of each chapter, integrates the application of EBM principles to clinical problem solving with deliberation of cost effectiveness and efficiency.

Continuing with this case example, the Team Approach and Communication chapters establish explicit expectations for practicing hospitalists who would take the extra steps to communicate with multiple members of the care team. Knowledgeable about the hospital, the hospitalist would review the chest CT with a radiologist skilled in chest interpretation and specifically query about the significance of an enlarged right atrium and right ventricle in the setting of a high pretest clinical probability of PE. Together the radiologist and hospitalist would consider a different imaging modality if the patient flunked the chest CT when the pretest probability was high. Rather than simply deferring to the medical specialist who is consulting, the hospitalist would be expected to improve the efficiency of care and reduce cost by only ordering tests that would change clinical management, perhaps with improved outcomes.

The Hospitalist as Teacher chapter provides a frameworkcore competencies for impromptu learningbased on the patient encounter. Members of the multidisciplinary care team can be exposed to explicit clinical decision making, an approach made possible by hospitalists on site, who can provide teaching moments in real time when decisions have to be made and educational feedback is needed. Teaching expectations for hospitalists include unambiguous clinical problem solving at the bedside and possibly directing the education of residents, physician assistants, and nurses on how to initiate a quality improvement (QI) project in a hospital setting.

The Quality Improvement and Venous Thromboembolism chapters clarify the role of the hospitalist, who should direct therapy against predictable complications of serious illness, critically review prophylaxis, provide hospital‐specific data to clinicians, identify and lower barriers to prevention, devise strategies to bridge the gap between knowledge and practice, develop automated reminder systems, and participate in clinical research.

The SHM has used the Core Competencies to develop educational resources to better meet the needs of the healthcare system. Although patient safety initiatives are mandated by JCAHO for hospital accreditation and AHRQ has identified areas for safety improvement that lists venous thromboembolism (VTE) prevention as the number one priority, VTE prophylaxis is still underutilized in the United States. Although some mechanisms are in place to educate residents and hospitalists about how to manage a specific disease, traditional medical education does not focus on teaching students and residents how to manage complex patients with multiple comorbidities, to prevent predictable complications of illness, and to examine and improve care processes.15, 16 When it comes to leading quality improvement (QI), individual feedback and traditional curricula, which may include didactic lectures on the pathophysiology of VTE and morbidity and mortality conferences, have not demonstrated improved outcomes.17

The SHM QI Web‐based resource rooms offer support to any QI effort and raise collective awareness of a performance gap.18 Each resource room will describe the evidence‐based practices that should be put into effect and will leverage experience with the disease as well as with the improvement process. The underlying goal of the resource rooms is to enhance the ability of hospitalists to actually improve inpatient outcomes through self‐directed learning (see Fig. 1).

Figure 1

Hospitalists, residency directors, and directors of hospitalist fellowships and continuing education can use The Core Competencies in Hospital Medicine to develop curricula for their local hospitalist service and request that invited speakers develop learning objectives and content based on core competencies rather than giving a prepared lecture on a specific clinical condition. This case of PE illustrates that risk assessment, prophylaxis, EBM clinical problem solving, and QI are core topics that should be emphasized in the training of hospitalists and physicians in training.0

The second case example, the hand‐off (see Table 3), illustrates quality issues related to transfer of care from one physician to another. In this example, if the patient with moderate pleural effusion had been signed out, an earlier thoracentesis to drain a presumptive parapneumonic infection might have relieved this patient's shortness of breath and saved her from undergoing a subsequent VATS procedure. This case also demonstrates the importance of correlating imaging abnormalities with a patient's clinical presentation rather than using the traditional approach of just ruling out potential diagnoses to determine the cause of a problem. This case highlights elements of the process and system of care that can be modified to improve patient outcomes. Being proficient in transferring care of patients can save the hospitalist from error and prevent adverse events.