Jeff Wiese, MD, SFHM

Dr. Wiese

Dr. Wiese

In June 2010, the Accreditation Council for Graduate Medical Education (ACGME) announced new program requirements, calling for a further reduction in duty-hours for first-year residents, an increase in in-house supervision, and an augmented focus on transitions of care. Though not a major change in comparison to the first duty-hours regulations enacted in 2001, it has again raised the question of whether the 36 months of residency training is sufficient.

The fear, of course, is that with less time spent in training, graduating residents will be less competent upon graduation. The reality, however, is that few, if any, residents ever leave training fully competent. The days of “full mastery” of the profession upon graduation have long since passed.

Residency from its inception was not meant to be the end-all of establishing competence; it is three years of “setting the trajectory of the bow”: teaching residents methods of observation and problem-solving, establishing core competence in the fundamentals of the profession, ensuring that essential self-teaching and professionalism are acquired, and then “releasing the arrow,” such that he or she continues to learn and perform the art as part of their practice.

Pundits argue that the duty-hours restrictions lessen the time of ensuring the “accuracy” of the arrow’s aim. But this assumes that every hour of training is equivalent. As an attending physician who used to watch his residents fall asleep during post-call attending rounds (pre-duty-hours regulations), I can assure you that very little learning ever took place in the waning hours of a 36-hour shift (or at the end of a 100-hour week). What did take place were mistakes—mistakes that were subtly integrated into practice patterns.

Lengthening training time to compensate for training hours that were functionally meaningless outside of their service benefits, therefore, has no merit.

Even so, there is the financial question no one is prepared to answer: Who will pay for this additional training time? With federally funded positions capped in 1997, and with a financial climate leaning toward less, not more, compensation in GME funding, it seems unrealistic to think that there will be the 33% increase in GME funding necessary to support an extension in training. And to extend the financial theme, one wonders if the “best and brightest” medical students might cost-adjust their decision in favor of higher-paying professions as the length of training increases to a duration consistent with that required of ophthalmology, radiology, and dermatology.

I propose that instead of lengthening training, we think about the way in which we integrate newly practicing physicians into practice. Despite their innate abilities, these are not the same physicians as veteran hospitalists. Independent of the duty hours, we have to develop a better paradigm of assimilating newly practicing physicians into the profession, with a spectrum of greater supervision of new physicians, extending to greater autonomy as the physician demonstrates his or her skills and abilities in practice.

At the end of the day, with reference to training time, it’s not about quantity, it’s about quality. A fourth day in the hospital for a patient with pneumonia does not ensure better outcomes if the first three days were conducted properly; it just costs more money. As stewards of the profession, it is upon us to think of the way in which we supervise, teach, and empower our resident physicians. TH

Dr. Wiese is associate professor of medicine and residency program director at Tulane University Health Sciences Center in New Orleans, and president of SHM.

Dr. Wiese

Dr. Wiese

In June 2010, the Accreditation Council for Graduate Medical Education (ACGME) announced new program requirements, calling for a further reduction in duty-hours for first-year residents, an increase in in-house supervision, and an augmented focus on transitions of care. Though not a major change in comparison to the first duty-hours regulations enacted in 2001, it has again raised the question of whether the 36 months of residency training is sufficient.

The fear, of course, is that with less time spent in training, graduating residents will be less competent upon graduation. The reality, however, is that few, if any, residents ever leave training fully competent. The days of “full mastery” of the profession upon graduation have long since passed.

Residency from its inception was not meant to be the end-all of establishing competence; it is three years of “setting the trajectory of the bow”: teaching residents methods of observation and problem-solving, establishing core competence in the fundamentals of the profession, ensuring that essential self-teaching and professionalism are acquired, and then “releasing the arrow,” such that he or she continues to learn and perform the art as part of their practice.

Pundits argue that the duty-hours restrictions lessen the time of ensuring the “accuracy” of the arrow’s aim. But this assumes that every hour of training is equivalent. As an attending physician who used to watch his residents fall asleep during post-call attending rounds (pre-duty-hours regulations), I can assure you that very little learning ever took place in the waning hours of a 36-hour shift (or at the end of a 100-hour week). What did take place were mistakes—mistakes that were subtly integrated into practice patterns.

Lengthening training time to compensate for training hours that were functionally meaningless outside of their service benefits, therefore, has no merit.

Even so, there is the financial question no one is prepared to answer: Who will pay for this additional training time? With federally funded positions capped in 1997, and with a financial climate leaning toward less, not more, compensation in GME funding, it seems unrealistic to think that there will be the 33% increase in GME funding necessary to support an extension in training. And to extend the financial theme, one wonders if the “best and brightest” medical students might cost-adjust their decision in favor of higher-paying professions as the length of training increases to a duration consistent with that required of ophthalmology, radiology, and dermatology.

I propose that instead of lengthening training, we think about the way in which we integrate newly practicing physicians into practice. Despite their innate abilities, these are not the same physicians as veteran hospitalists. Independent of the duty hours, we have to develop a better paradigm of assimilating newly practicing physicians into the profession, with a spectrum of greater supervision of new physicians, extending to greater autonomy as the physician demonstrates his or her skills and abilities in practice.

At the end of the day, with reference to training time, it’s not about quantity, it’s about quality. A fourth day in the hospital for a patient with pneumonia does not ensure better outcomes if the first three days were conducted properly; it just costs more money. As stewards of the profession, it is upon us to think of the way in which we supervise, teach, and empower our resident physicians. TH

Dr. Wiese is associate professor of medicine and residency program director at Tulane University Health Sciences Center in New Orleans, and president of SHM.

Dr. Wiese

Dr. Wiese

In June 2010, the Accreditation Council for Graduate Medical Education (ACGME) announced new program requirements, calling for a further reduction in duty-hours for first-year residents, an increase in in-house supervision, and an augmented focus on transitions of care. Though not a major change in comparison to the first duty-hours regulations enacted in 2001, it has again raised the question of whether the 36 months of residency training is sufficient.

The fear, of course, is that with less time spent in training, graduating residents will be less competent upon graduation. The reality, however, is that few, if any, residents ever leave training fully competent. The days of “full mastery” of the profession upon graduation have long since passed.

Residency from its inception was not meant to be the end-all of establishing competence; it is three years of “setting the trajectory of the bow”: teaching residents methods of observation and problem-solving, establishing core competence in the fundamentals of the profession, ensuring that essential self-teaching and professionalism are acquired, and then “releasing the arrow,” such that he or she continues to learn and perform the art as part of their practice.

Pundits argue that the duty-hours restrictions lessen the time of ensuring the “accuracy” of the arrow’s aim. But this assumes that every hour of training is equivalent. As an attending physician who used to watch his residents fall asleep during post-call attending rounds (pre-duty-hours regulations), I can assure you that very little learning ever took place in the waning hours of a 36-hour shift (or at the end of a 100-hour week). What did take place were mistakes—mistakes that were subtly integrated into practice patterns.

Lengthening training time to compensate for training hours that were functionally meaningless outside of their service benefits, therefore, has no merit.

Even so, there is the financial question no one is prepared to answer: Who will pay for this additional training time? With federally funded positions capped in 1997, and with a financial climate leaning toward less, not more, compensation in GME funding, it seems unrealistic to think that there will be the 33% increase in GME funding necessary to support an extension in training. And to extend the financial theme, one wonders if the “best and brightest” medical students might cost-adjust their decision in favor of higher-paying professions as the length of training increases to a duration consistent with that required of ophthalmology, radiology, and dermatology.

I propose that instead of lengthening training, we think about the way in which we integrate newly practicing physicians into practice. Despite their innate abilities, these are not the same physicians as veteran hospitalists. Independent of the duty hours, we have to develop a better paradigm of assimilating newly practicing physicians into the profession, with a spectrum of greater supervision of new physicians, extending to greater autonomy as the physician demonstrates his or her skills and abilities in practice.

At the end of the day, with reference to training time, it’s not about quantity, it’s about quality. A fourth day in the hospital for a patient with pneumonia does not ensure better outcomes if the first three days were conducted properly; it just costs more money. As stewards of the profession, it is upon us to think of the way in which we supervise, teach, and empower our resident physicians. TH

Dr. Wiese is associate professor of medicine and residency program director at Tulane University Health Sciences Center in New Orleans, and president of SHM.

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

The Organizational Chassis

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

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

Membership

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

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

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

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

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

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

Academics

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

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

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

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

Practice Management

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

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

Quality and Patient Safety

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

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

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

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

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

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

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

Education

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

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

Advocacy

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

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

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

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

A year ago today, I set forth 10 goals:

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

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

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

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

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

Dr. Wiese is president of SHM.

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

The Organizational Chassis

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

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

Membership

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

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

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

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

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

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

Academics

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

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

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

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

Practice Management

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

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

Quality and Patient Safety

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

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

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

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

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

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

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

Education

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

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

Advocacy

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

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

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

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

A year ago today, I set forth 10 goals:

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

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

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

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

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

Dr. Wiese is president of SHM.

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

The Organizational Chassis

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

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

Membership

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

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

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

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

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

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

Academics

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

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

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

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

Practice Management

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

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

Quality and Patient Safety

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

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

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

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

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

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

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

Education

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

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

Advocacy

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

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

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

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

A year ago today, I set forth 10 goals:

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

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

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

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

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

Dr. Wiese is president of SHM.

In the December 2010 issue of The Hospitalist (p. 43), I started the discussion of “The Story of Us” by outlining three threats that could limit our effectiveness in realizing our vision of quality and patient safety. The story continues here, with four additional threats to the culture of quality that is our mutual dream.

Threat 4: Strategy Trumps Tactics and Execution

There is no shortage of “strategery” in the context of healthcare reform, and it is tempting to succumb to the idea that the correct strategy automatically translates into intended results. But anyone who has suffered through a high-school rendition of Hamlet knows that while Shakespeare’s words might be the same, it is hardly a Broadway performance. Put another way, what is written in the coach’s playbook is the first step; execution of the playbook is what wins or loses the game.

Chan et al’s article “Delayed Time to Defibrillation after In-Hospital Cardiac Arrest” makes this point.¹ I doubt there is any physician who does not know that defibrillation is indicated in a cardiac arrest, but as the article illustrates, it took more than two minutes for 30% of patients with in-hospital cardiac arrest to be defibrillated. The upshot: If you have a cardiac arrest, you might be safer in a casino than you are in a hospital.

Healthcare reform and the expanding literature in patient safety and quality bring us closer to having the strategy we need, but what lags is execution of that strategy. Tactics, not strategy, is our greatest deficiency now. And while strategy can be designed for virtually all hospitals, tactics rest with each individual hospital, as each individual hospital system is unique.

Enter again the importance of the hospitalist: the physician intimately aware of the intricacies of their hospital system. There are reasons that defibrillation might be delayed in an individual hospital; perhaps it’s the location of the code cart, perhaps it is how patients are determined to need telemetry monitoring, perhaps it is the line of communication between telemetry and the responsible physician. But whatever the reason, it is not likely to be the same for all hospitals.

And here is the new challenge for the hospitalist: Discover the unique systems deficits in your hospital that prevent the perfect strategy from translating into perfect results.

Threat 5: Focus on One Component at a Time

The essence of systems-level change is simple: In a system, changing one component has effects (good or bad) on other components of the system. Unfortunately, our healthcare systems continue to exist in silos, with few people in leadership positions who are empowered with a perspective of the system as a whole.

Case in point: the yin-yang of length of stay (LOS) and hospital readmissions. I doubt there is a hospitalist who has not heard the words “discharge by 11 a.m.,” in large part because of the hospital truism “every medicine bed is a wasted ortho bed.” Patients who leave by 11 a.m. open up more beds for patients coming out of the operating rooms, and that translates into more surgical procedures. But discharge by 11 a.m. is not as simple as it appears. A sound discharge decision that does not result in readmissions is predicated upon multiple components of the system: results from diagnostic testing have to be obtainable early, the physician must not be dual-tasked during the early hours (e.g. receiving patients from the ED or ICU, performing procedures, etc.), and communication with the family and PCP has to be established early.

The hospitalist thus finds herself stuck between the proverbial rock and a hard place: Discharge early (i.e. before you are ready to do so safely) but ensure that patients don’t come back. There is no easy answer to this potential dilemma, except to say that the solution rests with people who do have a systemwide perspective. To this end, it will be the hospitalist “on the ground,” familiar with the need to prevent readmissions but sensitive to the need to discharge early, who will have the unique insight to design solutions, for all elements of the hospital system, that ensure meeting both ends.

Threat 6: Ignoring the Adaptive Unconscious

Think about whether this has ever happened to you: You finish a busy day at work, with many thoughts still on your mind as you begin your car drive home. Thirty minutes later, you find yourself sitting in your car in your driveway, wondering, “Wow, how did I get home? I don’t remember that drive at all.” Such is the benefit of what Timothy Wilson in his book Strangers to Ourselves calls the “adaptive unconscious.” See it as the mind’s ability to go on “autopilot” to accomplish repetitive tasks without requiring conscious thought, freeing up the mind to devote mental energy to something else. It’s adaptive, of course, because without it, it would be impossible to do any physical activity (i.e. collecting your wallet and keys as you leave the house) while simultaneously doing another activity (i.e. talking on the cell phone as you leave the house). The danger, however, is that tasks that are performed by the adaptive unconscious autopilot are quite inaccessible to the conscious mind for inspection and improvement.

Now consider this example. Have you ever seen a patient in the ED, sat down at the nurses’ station with the chart (contemplating all that needs to happen for the patient’s care), only to look down a few minutes later to see a fully completed set of admission orders? And you say, “Wow, how did these orders get done? I don’t remember writing these at all. Well, thanks for that.”

The focus of the quality- and patient-safety movements has been on changing the physician’s “conscious mind” decisions. But the reality is that the vast majority of what we do in our daily lives is performed without conscious thought. You can’t begrudge it, because again, without it, you would be paralyzed. But it has profound implications for the goal of advancing quality and patient safety in our practice of medicine.

There are two points to make in the context of this discussion. First, the adaptive unconscious is not a magical gift; it develops as a product of our repetitive tasks. You can make that drive home, or write those admission orders, without conscious thought only because you have done it hundreds of times before. And here’s the implication: Much of the behavior that is not conducive to optimal patient safety is a product of what we have done for the past five years. And what we do now in changing physician behavior has implications not only for today, but also for what we will do five years from now.

With this in mind, the bad decisions that result in adverse events do not concern me as much as the bad decisions that do not result in adverse events. The adverse outcome has enough drama to immediately bring the decision into the realm of the conscious, making it accessible for the physician to change behavior. But a bad decision (call it a “near miss”) that does not result in an adverse outcome remains inaccessible to the conscious mind. And should the bad decision be repeated again and again, it would insidiously become integrated into the adaptive unconscious, forever coloring the physician’s delivery of care.

The scary part of the adaptive unconscious is that it is inaccessible to the conscious mind because it is unconscious. But there is a way to modify the adaptive unconscious: reflection. I am not advocating candles, incense, and Kenny G. But reflection on physician behavior has to occur, and it must be much more than just focusing upon the adverse events (which, by virtue of being adverse, are fully in the conscious mind). Reflection that meaningfully changes unconscious behavior has to be focused upon what seemingly didn’t happen. It is a step-by-step analysis of a physician’s performance in ordinary time.

Put another way, every quarterback in the NFL leaves the football game thinking about the interceptions thrown (the dramatic mistakes), but only by virtue of reviewing the game film does he become aware of the interceptions he almost threw. Unlike the NFL quarterback, the hospitalist does not have the luxury of reviewing game film, but the need for reflection on the “near miss” events is no less important.

This takes time, and it likely takes an element of external discipline that the ordinary physician cannot provide for himself. Time is addressed in the next threat, but see the summary of this discussion as simply this: In the face of the prevailing culture of peer review and RCAs, there has to be equal attention paid to finding time and structure to reviewing a physician’s performance in the absence of adverse events. Perhaps this is structured alone time; perhaps its structured time with other hospitalists as a group discussion—I don’t know. But some element of reflection in the absence of “what went wrong” has to occur, lest we find ourselves in 2020 repetitively responding to adverse events, wondering why in 10 years’ time, the number of adverse events has not appreciably diminished.

Threat 7: Failure to Optimize Efficiency

Our story began in 1999 with a focus on hospitalists improving efficiency. The second chapter of our story, of course, has been on improving quality and patient safety. Interesting, isn’t it, that we find ourselves where we began? For Chapter 3 begins again with a focus on improving efficiency, not for financial ends, but for the meaningful enactment of quality and patient safety. Two points make the case.

If I were reading the discussion above, and not writing it, I am sure I would have your same response: “Great, more things (reflection time) to do with a fixed amount of time, and no additional money. Thanks for another unfunded mandate.” The reality is that until we get to an ultimately inspired healthcare system, there is unlikely to be financial support, or a discounting of RVU expectations, to support reflection. So with a fixed amount of time, and increasing activities to fit into that time, there is only one answer: We must become more efficient.

Taiichi Ohno, Toyota’s chief engineer, described what are essentially the bones of “LEAN” in optimizing efficiency. The challenge before us, despite what we have already done, is to further eliminate the “Muda”: activity that does not add value. Not only will this save money, but it will also create the additional time necessary for reflection, which is in turn requisite for a meaningful culture of patient safety and quality.

But there is another reason, one that makes improved efficiency essential in advancing patient safety. In the early part of the century, Yerkes and Dodson published the performance vs. stress curve.² Like preload to the heart, the authors postulated that performance (on the Y axis) was related to stress (on the X axis) in a rainbow curve. With very little stress, there was very little performance. As stress increased, so did performance, at least to the inflection point on the rainbow curve, after which too much stress led to decreased performance. If you have ever stared blankly at a computer screen trying to formulate a response to the simplest of e-mails, you have experienced both tails of the Yerkes-Dodson curve.

I suspect that there are few hospitalists faced with the problem of “not enough to do,” but I equally suspect that more and more hospitalists are finding themselves farther and farther to the right side of the Yerkes-Dodson curve. After the inflection point, with more and more stress comes less and less performance, a phenomenon felt in every performance-based career.

The bottom line is this: We have created more and more things for the hospitalist to consciously think about in ensuring patient safety and quality. If you had an index card for every guideline/core indicator/standard the hospitalist was supposed to remember, the stack would be 6 inches thick. And this list will only grow with time.

However, these admonishments “to the conscious mind” only improve performance if the physician has enough time to consciously think about each of them. If there is not enough time, then the physician’s mind reverts to the adaptive unconscious, which, because these QI measures have not been a part of his practice for the past several years, is unable to enact them. It’s captured by the simple sentiment when your patient has a DVT: “Wow, I knew to do that, but it just slipped my mind.” Moving too far to the right on the Yerkes-Dodson curve is more than just a risk for burnout; it has serious implications to ensuring that we design a strategy in quality and patient safety that actually comes to fruition.

And that’s Chapter 2 in the story of us: the need to ensure that our tactics and execution remain as important as our strategy, that one element of the system is never treated in isolation, that reflection on ordinary practice becomes a habit, and that efficiency remains a priority. TH

Dr. Wiese is president of SHM.

References

1. Chan PS, Krumholz HM, Nichol G, Nallamothu BK; American Heart Association National Registry of Cardiopulmonary Resuscitation Investigators. Delayed time to defibrillation after in-hospital cardiac arrest. N Engl J Med. 2008;358(1):9-17.
2. Yerkes RM, Dodson JD. The relation of strength of stimulus to rapidity of habit-formation. J Comparative Neuro Psych. 1908;18:459-482.

In the December 2010 issue of The Hospitalist (p. 43), I started the discussion of “The Story of Us” by outlining three threats that could limit our effectiveness in realizing our vision of quality and patient safety. The story continues here, with four additional threats to the culture of quality that is our mutual dream.

Threat 4: Strategy Trumps Tactics and Execution

There is no shortage of “strategery” in the context of healthcare reform, and it is tempting to succumb to the idea that the correct strategy automatically translates into intended results. But anyone who has suffered through a high-school rendition of Hamlet knows that while Shakespeare’s words might be the same, it is hardly a Broadway performance. Put another way, what is written in the coach’s playbook is the first step; execution of the playbook is what wins or loses the game.

Chan et al’s article “Delayed Time to Defibrillation after In-Hospital Cardiac Arrest” makes this point.¹ I doubt there is any physician who does not know that defibrillation is indicated in a cardiac arrest, but as the article illustrates, it took more than two minutes for 30% of patients with in-hospital cardiac arrest to be defibrillated. The upshot: If you have a cardiac arrest, you might be safer in a casino than you are in a hospital.

Healthcare reform and the expanding literature in patient safety and quality bring us closer to having the strategy we need, but what lags is execution of that strategy. Tactics, not strategy, is our greatest deficiency now. And while strategy can be designed for virtually all hospitals, tactics rest with each individual hospital, as each individual hospital system is unique.

Enter again the importance of the hospitalist: the physician intimately aware of the intricacies of their hospital system. There are reasons that defibrillation might be delayed in an individual hospital; perhaps it’s the location of the code cart, perhaps it is how patients are determined to need telemetry monitoring, perhaps it is the line of communication between telemetry and the responsible physician. But whatever the reason, it is not likely to be the same for all hospitals.

And here is the new challenge for the hospitalist: Discover the unique systems deficits in your hospital that prevent the perfect strategy from translating into perfect results.

Threat 5: Focus on One Component at a Time

The essence of systems-level change is simple: In a system, changing one component has effects (good or bad) on other components of the system. Unfortunately, our healthcare systems continue to exist in silos, with few people in leadership positions who are empowered with a perspective of the system as a whole.

Case in point: the yin-yang of length of stay (LOS) and hospital readmissions. I doubt there is a hospitalist who has not heard the words “discharge by 11 a.m.,” in large part because of the hospital truism “every medicine bed is a wasted ortho bed.” Patients who leave by 11 a.m. open up more beds for patients coming out of the operating rooms, and that translates into more surgical procedures. But discharge by 11 a.m. is not as simple as it appears. A sound discharge decision that does not result in readmissions is predicated upon multiple components of the system: results from diagnostic testing have to be obtainable early, the physician must not be dual-tasked during the early hours (e.g. receiving patients from the ED or ICU, performing procedures, etc.), and communication with the family and PCP has to be established early.

The hospitalist thus finds herself stuck between the proverbial rock and a hard place: Discharge early (i.e. before you are ready to do so safely) but ensure that patients don’t come back. There is no easy answer to this potential dilemma, except to say that the solution rests with people who do have a systemwide perspective. To this end, it will be the hospitalist “on the ground,” familiar with the need to prevent readmissions but sensitive to the need to discharge early, who will have the unique insight to design solutions, for all elements of the hospital system, that ensure meeting both ends.

Threat 6: Ignoring the Adaptive Unconscious

Think about whether this has ever happened to you: You finish a busy day at work, with many thoughts still on your mind as you begin your car drive home. Thirty minutes later, you find yourself sitting in your car in your driveway, wondering, “Wow, how did I get home? I don’t remember that drive at all.” Such is the benefit of what Timothy Wilson in his book Strangers to Ourselves calls the “adaptive unconscious.” See it as the mind’s ability to go on “autopilot” to accomplish repetitive tasks without requiring conscious thought, freeing up the mind to devote mental energy to something else. It’s adaptive, of course, because without it, it would be impossible to do any physical activity (i.e. collecting your wallet and keys as you leave the house) while simultaneously doing another activity (i.e. talking on the cell phone as you leave the house). The danger, however, is that tasks that are performed by the adaptive unconscious autopilot are quite inaccessible to the conscious mind for inspection and improvement.

Now consider this example. Have you ever seen a patient in the ED, sat down at the nurses’ station with the chart (contemplating all that needs to happen for the patient’s care), only to look down a few minutes later to see a fully completed set of admission orders? And you say, “Wow, how did these orders get done? I don’t remember writing these at all. Well, thanks for that.”

The focus of the quality- and patient-safety movements has been on changing the physician’s “conscious mind” decisions. But the reality is that the vast majority of what we do in our daily lives is performed without conscious thought. You can’t begrudge it, because again, without it, you would be paralyzed. But it has profound implications for the goal of advancing quality and patient safety in our practice of medicine.

There are two points to make in the context of this discussion. First, the adaptive unconscious is not a magical gift; it develops as a product of our repetitive tasks. You can make that drive home, or write those admission orders, without conscious thought only because you have done it hundreds of times before. And here’s the implication: Much of the behavior that is not conducive to optimal patient safety is a product of what we have done for the past five years. And what we do now in changing physician behavior has implications not only for today, but also for what we will do five years from now.

With this in mind, the bad decisions that result in adverse events do not concern me as much as the bad decisions that do not result in adverse events. The adverse outcome has enough drama to immediately bring the decision into the realm of the conscious, making it accessible for the physician to change behavior. But a bad decision (call it a “near miss”) that does not result in an adverse outcome remains inaccessible to the conscious mind. And should the bad decision be repeated again and again, it would insidiously become integrated into the adaptive unconscious, forever coloring the physician’s delivery of care.

The scary part of the adaptive unconscious is that it is inaccessible to the conscious mind because it is unconscious. But there is a way to modify the adaptive unconscious: reflection. I am not advocating candles, incense, and Kenny G. But reflection on physician behavior has to occur, and it must be much more than just focusing upon the adverse events (which, by virtue of being adverse, are fully in the conscious mind). Reflection that meaningfully changes unconscious behavior has to be focused upon what seemingly didn’t happen. It is a step-by-step analysis of a physician’s performance in ordinary time.

Put another way, every quarterback in the NFL leaves the football game thinking about the interceptions thrown (the dramatic mistakes), but only by virtue of reviewing the game film does he become aware of the interceptions he almost threw. Unlike the NFL quarterback, the hospitalist does not have the luxury of reviewing game film, but the need for reflection on the “near miss” events is no less important.

This takes time, and it likely takes an element of external discipline that the ordinary physician cannot provide for himself. Time is addressed in the next threat, but see the summary of this discussion as simply this: In the face of the prevailing culture of peer review and RCAs, there has to be equal attention paid to finding time and structure to reviewing a physician’s performance in the absence of adverse events. Perhaps this is structured alone time; perhaps its structured time with other hospitalists as a group discussion—I don’t know. But some element of reflection in the absence of “what went wrong” has to occur, lest we find ourselves in 2020 repetitively responding to adverse events, wondering why in 10 years’ time, the number of adverse events has not appreciably diminished.

Threat 7: Failure to Optimize Efficiency

Our story began in 1999 with a focus on hospitalists improving efficiency. The second chapter of our story, of course, has been on improving quality and patient safety. Interesting, isn’t it, that we find ourselves where we began? For Chapter 3 begins again with a focus on improving efficiency, not for financial ends, but for the meaningful enactment of quality and patient safety. Two points make the case.

If I were reading the discussion above, and not writing it, I am sure I would have your same response: “Great, more things (reflection time) to do with a fixed amount of time, and no additional money. Thanks for another unfunded mandate.” The reality is that until we get to an ultimately inspired healthcare system, there is unlikely to be financial support, or a discounting of RVU expectations, to support reflection. So with a fixed amount of time, and increasing activities to fit into that time, there is only one answer: We must become more efficient.

Taiichi Ohno, Toyota’s chief engineer, described what are essentially the bones of “LEAN” in optimizing efficiency. The challenge before us, despite what we have already done, is to further eliminate the “Muda”: activity that does not add value. Not only will this save money, but it will also create the additional time necessary for reflection, which is in turn requisite for a meaningful culture of patient safety and quality.

But there is another reason, one that makes improved efficiency essential in advancing patient safety. In the early part of the century, Yerkes and Dodson published the performance vs. stress curve.² Like preload to the heart, the authors postulated that performance (on the Y axis) was related to stress (on the X axis) in a rainbow curve. With very little stress, there was very little performance. As stress increased, so did performance, at least to the inflection point on the rainbow curve, after which too much stress led to decreased performance. If you have ever stared blankly at a computer screen trying to formulate a response to the simplest of e-mails, you have experienced both tails of the Yerkes-Dodson curve.

I suspect that there are few hospitalists faced with the problem of “not enough to do,” but I equally suspect that more and more hospitalists are finding themselves farther and farther to the right side of the Yerkes-Dodson curve. After the inflection point, with more and more stress comes less and less performance, a phenomenon felt in every performance-based career.

The bottom line is this: We have created more and more things for the hospitalist to consciously think about in ensuring patient safety and quality. If you had an index card for every guideline/core indicator/standard the hospitalist was supposed to remember, the stack would be 6 inches thick. And this list will only grow with time.

However, these admonishments “to the conscious mind” only improve performance if the physician has enough time to consciously think about each of them. If there is not enough time, then the physician’s mind reverts to the adaptive unconscious, which, because these QI measures have not been a part of his practice for the past several years, is unable to enact them. It’s captured by the simple sentiment when your patient has a DVT: “Wow, I knew to do that, but it just slipped my mind.” Moving too far to the right on the Yerkes-Dodson curve is more than just a risk for burnout; it has serious implications to ensuring that we design a strategy in quality and patient safety that actually comes to fruition.

And that’s Chapter 2 in the story of us: the need to ensure that our tactics and execution remain as important as our strategy, that one element of the system is never treated in isolation, that reflection on ordinary practice becomes a habit, and that efficiency remains a priority. TH

Dr. Wiese is president of SHM.

References

1. Chan PS, Krumholz HM, Nichol G, Nallamothu BK; American Heart Association National Registry of Cardiopulmonary Resuscitation Investigators. Delayed time to defibrillation after in-hospital cardiac arrest. N Engl J Med. 2008;358(1):9-17.
2. Yerkes RM, Dodson JD. The relation of strength of stimulus to rapidity of habit-formation. J Comparative Neuro Psych. 1908;18:459-482.

In the December 2010 issue of The Hospitalist (p. 43), I started the discussion of “The Story of Us” by outlining three threats that could limit our effectiveness in realizing our vision of quality and patient safety. The story continues here, with four additional threats to the culture of quality that is our mutual dream.

Threat 4: Strategy Trumps Tactics and Execution

There is no shortage of “strategery” in the context of healthcare reform, and it is tempting to succumb to the idea that the correct strategy automatically translates into intended results. But anyone who has suffered through a high-school rendition of Hamlet knows that while Shakespeare’s words might be the same, it is hardly a Broadway performance. Put another way, what is written in the coach’s playbook is the first step; execution of the playbook is what wins or loses the game.

Chan et al’s article “Delayed Time to Defibrillation after In-Hospital Cardiac Arrest” makes this point.¹ I doubt there is any physician who does not know that defibrillation is indicated in a cardiac arrest, but as the article illustrates, it took more than two minutes for 30% of patients with in-hospital cardiac arrest to be defibrillated. The upshot: If you have a cardiac arrest, you might be safer in a casino than you are in a hospital.

Healthcare reform and the expanding literature in patient safety and quality bring us closer to having the strategy we need, but what lags is execution of that strategy. Tactics, not strategy, is our greatest deficiency now. And while strategy can be designed for virtually all hospitals, tactics rest with each individual hospital, as each individual hospital system is unique.

Enter again the importance of the hospitalist: the physician intimately aware of the intricacies of their hospital system. There are reasons that defibrillation might be delayed in an individual hospital; perhaps it’s the location of the code cart, perhaps it is how patients are determined to need telemetry monitoring, perhaps it is the line of communication between telemetry and the responsible physician. But whatever the reason, it is not likely to be the same for all hospitals.

And here is the new challenge for the hospitalist: Discover the unique systems deficits in your hospital that prevent the perfect strategy from translating into perfect results.

Threat 5: Focus on One Component at a Time

The essence of systems-level change is simple: In a system, changing one component has effects (good or bad) on other components of the system. Unfortunately, our healthcare systems continue to exist in silos, with few people in leadership positions who are empowered with a perspective of the system as a whole.

Case in point: the yin-yang of length of stay (LOS) and hospital readmissions. I doubt there is a hospitalist who has not heard the words “discharge by 11 a.m.,” in large part because of the hospital truism “every medicine bed is a wasted ortho bed.” Patients who leave by 11 a.m. open up more beds for patients coming out of the operating rooms, and that translates into more surgical procedures. But discharge by 11 a.m. is not as simple as it appears. A sound discharge decision that does not result in readmissions is predicated upon multiple components of the system: results from diagnostic testing have to be obtainable early, the physician must not be dual-tasked during the early hours (e.g. receiving patients from the ED or ICU, performing procedures, etc.), and communication with the family and PCP has to be established early.

The hospitalist thus finds herself stuck between the proverbial rock and a hard place: Discharge early (i.e. before you are ready to do so safely) but ensure that patients don’t come back. There is no easy answer to this potential dilemma, except to say that the solution rests with people who do have a systemwide perspective. To this end, it will be the hospitalist “on the ground,” familiar with the need to prevent readmissions but sensitive to the need to discharge early, who will have the unique insight to design solutions, for all elements of the hospital system, that ensure meeting both ends.

Threat 6: Ignoring the Adaptive Unconscious

Think about whether this has ever happened to you: You finish a busy day at work, with many thoughts still on your mind as you begin your car drive home. Thirty minutes later, you find yourself sitting in your car in your driveway, wondering, “Wow, how did I get home? I don’t remember that drive at all.” Such is the benefit of what Timothy Wilson in his book Strangers to Ourselves calls the “adaptive unconscious.” See it as the mind’s ability to go on “autopilot” to accomplish repetitive tasks without requiring conscious thought, freeing up the mind to devote mental energy to something else. It’s adaptive, of course, because without it, it would be impossible to do any physical activity (i.e. collecting your wallet and keys as you leave the house) while simultaneously doing another activity (i.e. talking on the cell phone as you leave the house). The danger, however, is that tasks that are performed by the adaptive unconscious autopilot are quite inaccessible to the conscious mind for inspection and improvement.

Now consider this example. Have you ever seen a patient in the ED, sat down at the nurses’ station with the chart (contemplating all that needs to happen for the patient’s care), only to look down a few minutes later to see a fully completed set of admission orders? And you say, “Wow, how did these orders get done? I don’t remember writing these at all. Well, thanks for that.”

The focus of the quality- and patient-safety movements has been on changing the physician’s “conscious mind” decisions. But the reality is that the vast majority of what we do in our daily lives is performed without conscious thought. You can’t begrudge it, because again, without it, you would be paralyzed. But it has profound implications for the goal of advancing quality and patient safety in our practice of medicine.

There are two points to make in the context of this discussion. First, the adaptive unconscious is not a magical gift; it develops as a product of our repetitive tasks. You can make that drive home, or write those admission orders, without conscious thought only because you have done it hundreds of times before. And here’s the implication: Much of the behavior that is not conducive to optimal patient safety is a product of what we have done for the past five years. And what we do now in changing physician behavior has implications not only for today, but also for what we will do five years from now.

With this in mind, the bad decisions that result in adverse events do not concern me as much as the bad decisions that do not result in adverse events. The adverse outcome has enough drama to immediately bring the decision into the realm of the conscious, making it accessible for the physician to change behavior. But a bad decision (call it a “near miss”) that does not result in an adverse outcome remains inaccessible to the conscious mind. And should the bad decision be repeated again and again, it would insidiously become integrated into the adaptive unconscious, forever coloring the physician’s delivery of care.

The scary part of the adaptive unconscious is that it is inaccessible to the conscious mind because it is unconscious. But there is a way to modify the adaptive unconscious: reflection. I am not advocating candles, incense, and Kenny G. But reflection on physician behavior has to occur, and it must be much more than just focusing upon the adverse events (which, by virtue of being adverse, are fully in the conscious mind). Reflection that meaningfully changes unconscious behavior has to be focused upon what seemingly didn’t happen. It is a step-by-step analysis of a physician’s performance in ordinary time.

Put another way, every quarterback in the NFL leaves the football game thinking about the interceptions thrown (the dramatic mistakes), but only by virtue of reviewing the game film does he become aware of the interceptions he almost threw. Unlike the NFL quarterback, the hospitalist does not have the luxury of reviewing game film, but the need for reflection on the “near miss” events is no less important.

This takes time, and it likely takes an element of external discipline that the ordinary physician cannot provide for himself. Time is addressed in the next threat, but see the summary of this discussion as simply this: In the face of the prevailing culture of peer review and RCAs, there has to be equal attention paid to finding time and structure to reviewing a physician’s performance in the absence of adverse events. Perhaps this is structured alone time; perhaps its structured time with other hospitalists as a group discussion—I don’t know. But some element of reflection in the absence of “what went wrong” has to occur, lest we find ourselves in 2020 repetitively responding to adverse events, wondering why in 10 years’ time, the number of adverse events has not appreciably diminished.

Threat 7: Failure to Optimize Efficiency

Our story began in 1999 with a focus on hospitalists improving efficiency. The second chapter of our story, of course, has been on improving quality and patient safety. Interesting, isn’t it, that we find ourselves where we began? For Chapter 3 begins again with a focus on improving efficiency, not for financial ends, but for the meaningful enactment of quality and patient safety. Two points make the case.

If I were reading the discussion above, and not writing it, I am sure I would have your same response: “Great, more things (reflection time) to do with a fixed amount of time, and no additional money. Thanks for another unfunded mandate.” The reality is that until we get to an ultimately inspired healthcare system, there is unlikely to be financial support, or a discounting of RVU expectations, to support reflection. So with a fixed amount of time, and increasing activities to fit into that time, there is only one answer: We must become more efficient.

Taiichi Ohno, Toyota’s chief engineer, described what are essentially the bones of “LEAN” in optimizing efficiency. The challenge before us, despite what we have already done, is to further eliminate the “Muda”: activity that does not add value. Not only will this save money, but it will also create the additional time necessary for reflection, which is in turn requisite for a meaningful culture of patient safety and quality.

But there is another reason, one that makes improved efficiency essential in advancing patient safety. In the early part of the century, Yerkes and Dodson published the performance vs. stress curve.² Like preload to the heart, the authors postulated that performance (on the Y axis) was related to stress (on the X axis) in a rainbow curve. With very little stress, there was very little performance. As stress increased, so did performance, at least to the inflection point on the rainbow curve, after which too much stress led to decreased performance. If you have ever stared blankly at a computer screen trying to formulate a response to the simplest of e-mails, you have experienced both tails of the Yerkes-Dodson curve.

I suspect that there are few hospitalists faced with the problem of “not enough to do,” but I equally suspect that more and more hospitalists are finding themselves farther and farther to the right side of the Yerkes-Dodson curve. After the inflection point, with more and more stress comes less and less performance, a phenomenon felt in every performance-based career.

The bottom line is this: We have created more and more things for the hospitalist to consciously think about in ensuring patient safety and quality. If you had an index card for every guideline/core indicator/standard the hospitalist was supposed to remember, the stack would be 6 inches thick. And this list will only grow with time.

However, these admonishments “to the conscious mind” only improve performance if the physician has enough time to consciously think about each of them. If there is not enough time, then the physician’s mind reverts to the adaptive unconscious, which, because these QI measures have not been a part of his practice for the past several years, is unable to enact them. It’s captured by the simple sentiment when your patient has a DVT: “Wow, I knew to do that, but it just slipped my mind.” Moving too far to the right on the Yerkes-Dodson curve is more than just a risk for burnout; it has serious implications to ensuring that we design a strategy in quality and patient safety that actually comes to fruition.

And that’s Chapter 2 in the story of us: the need to ensure that our tactics and execution remain as important as our strategy, that one element of the system is never treated in isolation, that reflection on ordinary practice becomes a habit, and that efficiency remains a priority. TH

Dr. Wiese is president of SHM.

References

1. Chan PS, Krumholz HM, Nichol G, Nallamothu BK; American Heart Association National Registry of Cardiopulmonary Resuscitation Investigators. Delayed time to defibrillation after in-hospital cardiac arrest. N Engl J Med. 2008;358(1):9-17.
2. Yerkes RM, Dodson JD. The relation of strength of stimulus to rapidity of habit-formation. J Comparative Neuro Psych. 1908;18:459-482.

From the outset, HM has been about efficiency. And there was nothing wrong with that, for value is quality divided by cost. But in our story, we found that mere efficiency was not enough: The lowering of the denominator (cost) had to be met with an escalation of the numerator (quality) to ensure value.

And see us as being born in the right place at the right time. For with the national focus turning to the need for quality and patient safety, hospital medicine was in the right place and the right time to heed the call to action: appropriately stepping up to enact efforts to make the slope of the line (on a chart of quality vs. cost) “STEEEPER” … finding systems innovations to make care Safe, Timely, Efficient, Effective, Equitable, and Patient-centered.

Of course, the story continued with the Affordable Care Act and healthcare reform, greatly accelerating our evolution as change agents. And now we find ourselves fully invested in a “change the system” mentality, perfectly positioned to meaningfully change healthcare for millions of people. But threats loom—specifically, the “R” in the STEEEPER mnemonic: the risks to quality in the face of healthcare reform.

So in the next chapter of our story, I present to you our challenge: how to overcome the threats to quality in the context of healthcare reform. The first three are presented here; in subsequent articles, I will address the remainder. Overcoming all threats will hinge on mastering the four truisms of cultural change:

1. Systems drive function;
2. Every system is perfectly designed to produce the outcomes that it does;
3. This is not an issue of people needing to try harder; and
4. The “no blame” culture begins with a paradigm shift from the “person at fault” to the “system at fault.”

Threat 1: Failure to Fund Quality

SHM elected to merge its annual State of Hospital Medicine survey with the MGMA. Though not without risk, this has resulted in the anticipated benefits. The MGMA collaboration brings greater leverage in working with the C-suite, which is pre-programmed to react to MGMA surveys. From the most recent MGMA survey comes good news: The financial compensation for hospitalists has increased. A sobering insight, however, is that this increase in compensation has been met with a corresponding increase in work intensity—RVUs. Further, the link between RVUs and compensation appears to be tightening, quantifying what has long been of concern: The time devoted to the nonclinical “value added” duties of the hospitalist is shrinking.

The threat to the culture of quality is captured in the single question: How many RVUs is a quality-improvement (QI) project worth? I’m not sure we have that answer. But without an answer, it is difficult to believe that meaningful QI can be expected without time to do so. And again, as the gap between compensation and RVUs narrows, one is left wondering if there will soon be a day where there is no value-added time remaining to perform QI at all.

Fortunately, the Affordable Care Act might provide some movement in the right direction via value-based purchasing. Linking quality outcomes to financial reimbursement is a big step forward in the hospitalist’s quest to leverage the C-suite in trading RVUs for devoted QI time. Although we still are left asking the question of how many RVUs a QI project is worth, value-based purchasing at least sets the stage for the conversation. But in the interim, it is still upon hospitalists to design these QI projects, and to learn the skills necessary to see the design to its fruition.

Threat 2: Quality Stops at Core Measures

It is hard to argue that fulfilling “core measures” is a bad thing. Nonetheless, the core measures were not meant to be quality; instead, they were meant as surrogate measures of quality. The presumption of the core-measures initiative is that the system would exist without direct attention to the core measures, operating as it ordinarily would with generic attention to meeting all standards of quality for all diseases. And at some point in time, the core measures would be assessed to give an overall assessment of the system’s quality.

What has evolved, however, is a concerted attention to meeting the core measures, with little regard to the overall culture of quality.

Let’s say you were tasked with improving the public school system in your state. As a measure of the improvement, you choose five of the 1,000 schools as “core measure” schools. The state board of education is told that the performance of these five sample schools will be assessed at the end of the year, and financial support for the system as a whole will hinge on their performance. The intended result is that attention would be paid to improving the performance of every school in the system, and this improvement would be reflected in the performance of the five sample schools. The board of education could take the route of improving all schools, but the more pragmatic route would be to funnel all resources into these five schools, to the detriment of resources for the other 995 schools. The performance of the core measure schools would dramatically improve, and funding would be secured. But ask yourself: Did the performance of the school system as a whole actually improve?

Such is the risk of the core measures in healthcare. The original intent of the core measures was to instill a culture of QI for all points of care. And this has been a valuable contribution to changing the consciousness of the healthcare system. The presumption was that the core measures would be “seeds,” and that by emphasizing these select measures, the QI culture eventually would spread to all aspects of patient care. But this plan hinged on the presumption that that there is an unlimited amount of mental energy and resources to be devoted to all tasks within healthcare. The reality is that there is a fixed amount of intellectual energy and resources to be devoted to the various aspects of healthcare. One wonders if the overemphasis on meeting the core measures might actually have taken the wind out of the sails for QI in other non-core-measure patient care.

The implications are twofold. By definition, a core measure has to be applicable to all healthcare systems, and with a fixed amount of mental energy and resources, there is a real risk that what portion is reserved for QI finds its way only to the core indicators, especially if they are overemphasized in the system. The second implication is captured in our experience with time to antibiotics. With meeting the core indicator as the priority, many systems instituted the “work-around”: Give antibiotics to every patient presenting to the ED, and you will be sure to have met the four-hour window in the core indicator. The result was an exponential increase in inappropriate antibiotic administration and radiographic tests, all because meeting the indicator became more important than the overall goal.

As stewards of the hospital system, it is upon us to ensure that the original intent of core measures remains secure: The core measures seed a culture of quality, but do not become ends in and of themselves. QI apart from the core measures must remain an equal priority, and it is the hospitalist who will be central in ensuring this comes to fruition.

Threat 3: Misplaced Incentives

There is an interesting anecdote in Steven Levitt and Stephen Dubner’s book Freakonomics.¹ The story begins with a daycare center struggling with a problem: Some parents are showing up late to pick up their children at the end of the day, and this is costing the center in the way of overtime charges for the staff. To solve the problem, the center elects to institute a financial disincentive: Those showing up late to pick up their children will pay a modest financial penalty.

Fast-forward to months after the policy was put in place. The result? An exponential increase in the number of parents showing up late to pick up their children.

How do you explain worsening performance in spite of a financial disincentive? The answer resides in understanding human behavior. According to the authors, there are three primary motivations in life: financial, social, and moral. As ugly as it sounds, the decisions people make in life are driven by one of these three motivations. There is nothing wrong with providing incentives for behavior; incentives work.

But the danger arises when incentives are mismatched to behaviors. For example, if a financial outcome is the goal, then financial incentives make sense. If a social outcome (people should play better as a team) is the goal, the social incentives make sense (public recognition). But when the incentives get misaligned with their respective goals, trouble results.

What went wrong with the daycare’s plan is simple—most of the parents were motivated to pick up their children on time out of moral (“I gave my word”) or social (“I don’t want to be talked about by other parents”) incentives. But once a financial incentive was offered, the daycare center had essentially given the parents a way out in absolving their social and moral obligations. The parents had essentially cost-adjusted their behavior.

If you think this couldn’t happen to the healthcare system, let me ask you this. As a hospitalist, I see all of my patients early in the morning, because I see it as part of my obligation to the hospital team to discharge patients by 11 a.m. (social motivation).

But what if the CEO released this directive: “You will see all of your patients early in the morning, or you will take a $1,000 a year pay cut.” Is it possible that I might cost-adjust the $1,000 in exchange for sleeping in a little later and not having to deal with the morning traffic? I don’t know.

When it comes to financial incentives, there is a valley in the U-shaped curve. When the financial incentive is trivial, it is disregarded and the social/moral motivations of behavior persist (the kids are picked up on time; I persist in seeing patients early in the morning). When the financial incentive is huge, the financial incentive trumps all social/moral motivations, ensuring compliance with the goal behavior (every kid is picked up on time to avoid a penalty; I see all patients early in the day to avoid a larger penalty).

But in between is the risk zone: When the person feels they are paying an appropriate penance for not complying with the goal behavior, the financial disincentive absolves any social/moral guilt.

Healthcare reform is about incentives—and there is nothing wrong with that. But as the stewards of the inpatient healthcare system, it is upon us as hospitalists to ensure that the incentives remain matched to their intended goals, and that the untoward consequences of the incentives do not adversely affect the quality and safety of a patient’s care.

It is safe to say that the Affordable Care Act of 2010 moves us closer to a true environment of quality and patient safety. But it is equally safe to say that meaningful change will require more than what the law can provide. As stewards of the inpatient system, we have a responsibility to ensure that the healthcare system, particularly in how it responds to incentives, evolves to remain patient-centered, effective, and safe.

The next chapter in our story—the hospitalists’ story—will be one of accountability and responsibility. While there are things the government can do, the majority of what needs to be done will come directly from us. TH

Dr. Wiese is president of SHM.

Reference

1. Levitt SD, Dubner SJ. Freakonomics: A Rogue Economist Explores the Hidden Side of Everything. New York City: William Morrow; 2005.

From the outset, HM has been about efficiency. And there was nothing wrong with that, for value is quality divided by cost. But in our story, we found that mere efficiency was not enough: The lowering of the denominator (cost) had to be met with an escalation of the numerator (quality) to ensure value.

And see us as being born in the right place at the right time. For with the national focus turning to the need for quality and patient safety, hospital medicine was in the right place and the right time to heed the call to action: appropriately stepping up to enact efforts to make the slope of the line (on a chart of quality vs. cost) “STEEEPER” … finding systems innovations to make care Safe, Timely, Efficient, Effective, Equitable, and Patient-centered.

Of course, the story continued with the Affordable Care Act and healthcare reform, greatly accelerating our evolution as change agents. And now we find ourselves fully invested in a “change the system” mentality, perfectly positioned to meaningfully change healthcare for millions of people. But threats loom—specifically, the “R” in the STEEEPER mnemonic: the risks to quality in the face of healthcare reform.

So in the next chapter of our story, I present to you our challenge: how to overcome the threats to quality in the context of healthcare reform. The first three are presented here; in subsequent articles, I will address the remainder. Overcoming all threats will hinge on mastering the four truisms of cultural change:

1. Systems drive function;
2. Every system is perfectly designed to produce the outcomes that it does;
3. This is not an issue of people needing to try harder; and
4. The “no blame” culture begins with a paradigm shift from the “person at fault” to the “system at fault.”

Threat 1: Failure to Fund Quality

SHM elected to merge its annual State of Hospital Medicine survey with the MGMA. Though not without risk, this has resulted in the anticipated benefits. The MGMA collaboration brings greater leverage in working with the C-suite, which is pre-programmed to react to MGMA surveys. From the most recent MGMA survey comes good news: The financial compensation for hospitalists has increased. A sobering insight, however, is that this increase in compensation has been met with a corresponding increase in work intensity—RVUs. Further, the link between RVUs and compensation appears to be tightening, quantifying what has long been of concern: The time devoted to the nonclinical “value added” duties of the hospitalist is shrinking.

The threat to the culture of quality is captured in the single question: How many RVUs is a quality-improvement (QI) project worth? I’m not sure we have that answer. But without an answer, it is difficult to believe that meaningful QI can be expected without time to do so. And again, as the gap between compensation and RVUs narrows, one is left wondering if there will soon be a day where there is no value-added time remaining to perform QI at all.

Fortunately, the Affordable Care Act might provide some movement in the right direction via value-based purchasing. Linking quality outcomes to financial reimbursement is a big step forward in the hospitalist’s quest to leverage the C-suite in trading RVUs for devoted QI time. Although we still are left asking the question of how many RVUs a QI project is worth, value-based purchasing at least sets the stage for the conversation. But in the interim, it is still upon hospitalists to design these QI projects, and to learn the skills necessary to see the design to its fruition.

Threat 2: Quality Stops at Core Measures

It is hard to argue that fulfilling “core measures” is a bad thing. Nonetheless, the core measures were not meant to be quality; instead, they were meant as surrogate measures of quality. The presumption of the core-measures initiative is that the system would exist without direct attention to the core measures, operating as it ordinarily would with generic attention to meeting all standards of quality for all diseases. And at some point in time, the core measures would be assessed to give an overall assessment of the system’s quality.

What has evolved, however, is a concerted attention to meeting the core measures, with little regard to the overall culture of quality.

Let’s say you were tasked with improving the public school system in your state. As a measure of the improvement, you choose five of the 1,000 schools as “core measure” schools. The state board of education is told that the performance of these five sample schools will be assessed at the end of the year, and financial support for the system as a whole will hinge on their performance. The intended result is that attention would be paid to improving the performance of every school in the system, and this improvement would be reflected in the performance of the five sample schools. The board of education could take the route of improving all schools, but the more pragmatic route would be to funnel all resources into these five schools, to the detriment of resources for the other 995 schools. The performance of the core measure schools would dramatically improve, and funding would be secured. But ask yourself: Did the performance of the school system as a whole actually improve?

Such is the risk of the core measures in healthcare. The original intent of the core measures was to instill a culture of QI for all points of care. And this has been a valuable contribution to changing the consciousness of the healthcare system. The presumption was that the core measures would be “seeds,” and that by emphasizing these select measures, the QI culture eventually would spread to all aspects of patient care. But this plan hinged on the presumption that that there is an unlimited amount of mental energy and resources to be devoted to all tasks within healthcare. The reality is that there is a fixed amount of intellectual energy and resources to be devoted to the various aspects of healthcare. One wonders if the overemphasis on meeting the core measures might actually have taken the wind out of the sails for QI in other non-core-measure patient care.

The implications are twofold. By definition, a core measure has to be applicable to all healthcare systems, and with a fixed amount of mental energy and resources, there is a real risk that what portion is reserved for QI finds its way only to the core indicators, especially if they are overemphasized in the system. The second implication is captured in our experience with time to antibiotics. With meeting the core indicator as the priority, many systems instituted the “work-around”: Give antibiotics to every patient presenting to the ED, and you will be sure to have met the four-hour window in the core indicator. The result was an exponential increase in inappropriate antibiotic administration and radiographic tests, all because meeting the indicator became more important than the overall goal.

As stewards of the hospital system, it is upon us to ensure that the original intent of core measures remains secure: The core measures seed a culture of quality, but do not become ends in and of themselves. QI apart from the core measures must remain an equal priority, and it is the hospitalist who will be central in ensuring this comes to fruition.

Threat 3: Misplaced Incentives

There is an interesting anecdote in Steven Levitt and Stephen Dubner’s book Freakonomics.¹ The story begins with a daycare center struggling with a problem: Some parents are showing up late to pick up their children at the end of the day, and this is costing the center in the way of overtime charges for the staff. To solve the problem, the center elects to institute a financial disincentive: Those showing up late to pick up their children will pay a modest financial penalty.

Fast-forward to months after the policy was put in place. The result? An exponential increase in the number of parents showing up late to pick up their children.

How do you explain worsening performance in spite of a financial disincentive? The answer resides in understanding human behavior. According to the authors, there are three primary motivations in life: financial, social, and moral. As ugly as it sounds, the decisions people make in life are driven by one of these three motivations. There is nothing wrong with providing incentives for behavior; incentives work.

But the danger arises when incentives are mismatched to behaviors. For example, if a financial outcome is the goal, then financial incentives make sense. If a social outcome (people should play better as a team) is the goal, the social incentives make sense (public recognition). But when the incentives get misaligned with their respective goals, trouble results.

What went wrong with the daycare’s plan is simple—most of the parents were motivated to pick up their children on time out of moral (“I gave my word”) or social (“I don’t want to be talked about by other parents”) incentives. But once a financial incentive was offered, the daycare center had essentially given the parents a way out in absolving their social and moral obligations. The parents had essentially cost-adjusted their behavior.

If you think this couldn’t happen to the healthcare system, let me ask you this. As a hospitalist, I see all of my patients early in the morning, because I see it as part of my obligation to the hospital team to discharge patients by 11 a.m. (social motivation).

But what if the CEO released this directive: “You will see all of your patients early in the morning, or you will take a $1,000 a year pay cut.” Is it possible that I might cost-adjust the $1,000 in exchange for sleeping in a little later and not having to deal with the morning traffic? I don’t know.

When it comes to financial incentives, there is a valley in the U-shaped curve. When the financial incentive is trivial, it is disregarded and the social/moral motivations of behavior persist (the kids are picked up on time; I persist in seeing patients early in the morning). When the financial incentive is huge, the financial incentive trumps all social/moral motivations, ensuring compliance with the goal behavior (every kid is picked up on time to avoid a penalty; I see all patients early in the day to avoid a larger penalty).

But in between is the risk zone: When the person feels they are paying an appropriate penance for not complying with the goal behavior, the financial disincentive absolves any social/moral guilt.

Healthcare reform is about incentives—and there is nothing wrong with that. But as the stewards of the inpatient healthcare system, it is upon us as hospitalists to ensure that the incentives remain matched to their intended goals, and that the untoward consequences of the incentives do not adversely affect the quality and safety of a patient’s care.

It is safe to say that the Affordable Care Act of 2010 moves us closer to a true environment of quality and patient safety. But it is equally safe to say that meaningful change will require more than what the law can provide. As stewards of the inpatient system, we have a responsibility to ensure that the healthcare system, particularly in how it responds to incentives, evolves to remain patient-centered, effective, and safe.

The next chapter in our story—the hospitalists’ story—will be one of accountability and responsibility. While there are things the government can do, the majority of what needs to be done will come directly from us. TH

Dr. Wiese is president of SHM.

Reference

1. Levitt SD, Dubner SJ. Freakonomics: A Rogue Economist Explores the Hidden Side of Everything. New York City: William Morrow; 2005.

From the outset, HM has been about efficiency. And there was nothing wrong with that, for value is quality divided by cost. But in our story, we found that mere efficiency was not enough: The lowering of the denominator (cost) had to be met with an escalation of the numerator (quality) to ensure value.

And see us as being born in the right place at the right time. For with the national focus turning to the need for quality and patient safety, hospital medicine was in the right place and the right time to heed the call to action: appropriately stepping up to enact efforts to make the slope of the line (on a chart of quality vs. cost) “STEEEPER” … finding systems innovations to make care Safe, Timely, Efficient, Effective, Equitable, and Patient-centered.

Of course, the story continued with the Affordable Care Act and healthcare reform, greatly accelerating our evolution as change agents. And now we find ourselves fully invested in a “change the system” mentality, perfectly positioned to meaningfully change healthcare for millions of people. But threats loom—specifically, the “R” in the STEEEPER mnemonic: the risks to quality in the face of healthcare reform.

So in the next chapter of our story, I present to you our challenge: how to overcome the threats to quality in the context of healthcare reform. The first three are presented here; in subsequent articles, I will address the remainder. Overcoming all threats will hinge on mastering the four truisms of cultural change:

1. Systems drive function;
2. Every system is perfectly designed to produce the outcomes that it does;
3. This is not an issue of people needing to try harder; and
4. The “no blame” culture begins with a paradigm shift from the “person at fault” to the “system at fault.”

Threat 1: Failure to Fund Quality

SHM elected to merge its annual State of Hospital Medicine survey with the MGMA. Though not without risk, this has resulted in the anticipated benefits. The MGMA collaboration brings greater leverage in working with the C-suite, which is pre-programmed to react to MGMA surveys. From the most recent MGMA survey comes good news: The financial compensation for hospitalists has increased. A sobering insight, however, is that this increase in compensation has been met with a corresponding increase in work intensity—RVUs. Further, the link between RVUs and compensation appears to be tightening, quantifying what has long been of concern: The time devoted to the nonclinical “value added” duties of the hospitalist is shrinking.

The threat to the culture of quality is captured in the single question: How many RVUs is a quality-improvement (QI) project worth? I’m not sure we have that answer. But without an answer, it is difficult to believe that meaningful QI can be expected without time to do so. And again, as the gap between compensation and RVUs narrows, one is left wondering if there will soon be a day where there is no value-added time remaining to perform QI at all.

Fortunately, the Affordable Care Act might provide some movement in the right direction via value-based purchasing. Linking quality outcomes to financial reimbursement is a big step forward in the hospitalist’s quest to leverage the C-suite in trading RVUs for devoted QI time. Although we still are left asking the question of how many RVUs a QI project is worth, value-based purchasing at least sets the stage for the conversation. But in the interim, it is still upon hospitalists to design these QI projects, and to learn the skills necessary to see the design to its fruition.

Threat 2: Quality Stops at Core Measures

It is hard to argue that fulfilling “core measures” is a bad thing. Nonetheless, the core measures were not meant to be quality; instead, they were meant as surrogate measures of quality. The presumption of the core-measures initiative is that the system would exist without direct attention to the core measures, operating as it ordinarily would with generic attention to meeting all standards of quality for all diseases. And at some point in time, the core measures would be assessed to give an overall assessment of the system’s quality.

What has evolved, however, is a concerted attention to meeting the core measures, with little regard to the overall culture of quality.

Let’s say you were tasked with improving the public school system in your state. As a measure of the improvement, you choose five of the 1,000 schools as “core measure” schools. The state board of education is told that the performance of these five sample schools will be assessed at the end of the year, and financial support for the system as a whole will hinge on their performance. The intended result is that attention would be paid to improving the performance of every school in the system, and this improvement would be reflected in the performance of the five sample schools. The board of education could take the route of improving all schools, but the more pragmatic route would be to funnel all resources into these five schools, to the detriment of resources for the other 995 schools. The performance of the core measure schools would dramatically improve, and funding would be secured. But ask yourself: Did the performance of the school system as a whole actually improve?

Such is the risk of the core measures in healthcare. The original intent of the core measures was to instill a culture of QI for all points of care. And this has been a valuable contribution to changing the consciousness of the healthcare system. The presumption was that the core measures would be “seeds,” and that by emphasizing these select measures, the QI culture eventually would spread to all aspects of patient care. But this plan hinged on the presumption that that there is an unlimited amount of mental energy and resources to be devoted to all tasks within healthcare. The reality is that there is a fixed amount of intellectual energy and resources to be devoted to the various aspects of healthcare. One wonders if the overemphasis on meeting the core measures might actually have taken the wind out of the sails for QI in other non-core-measure patient care.

The implications are twofold. By definition, a core measure has to be applicable to all healthcare systems, and with a fixed amount of mental energy and resources, there is a real risk that what portion is reserved for QI finds its way only to the core indicators, especially if they are overemphasized in the system. The second implication is captured in our experience with time to antibiotics. With meeting the core indicator as the priority, many systems instituted the “work-around”: Give antibiotics to every patient presenting to the ED, and you will be sure to have met the four-hour window in the core indicator. The result was an exponential increase in inappropriate antibiotic administration and radiographic tests, all because meeting the indicator became more important than the overall goal.

As stewards of the hospital system, it is upon us to ensure that the original intent of core measures remains secure: The core measures seed a culture of quality, but do not become ends in and of themselves. QI apart from the core measures must remain an equal priority, and it is the hospitalist who will be central in ensuring this comes to fruition.

Threat 3: Misplaced Incentives

There is an interesting anecdote in Steven Levitt and Stephen Dubner’s book Freakonomics.¹ The story begins with a daycare center struggling with a problem: Some parents are showing up late to pick up their children at the end of the day, and this is costing the center in the way of overtime charges for the staff. To solve the problem, the center elects to institute a financial disincentive: Those showing up late to pick up their children will pay a modest financial penalty.

Fast-forward to months after the policy was put in place. The result? An exponential increase in the number of parents showing up late to pick up their children.

How do you explain worsening performance in spite of a financial disincentive? The answer resides in understanding human behavior. According to the authors, there are three primary motivations in life: financial, social, and moral. As ugly as it sounds, the decisions people make in life are driven by one of these three motivations. There is nothing wrong with providing incentives for behavior; incentives work.

But the danger arises when incentives are mismatched to behaviors. For example, if a financial outcome is the goal, then financial incentives make sense. If a social outcome (people should play better as a team) is the goal, the social incentives make sense (public recognition). But when the incentives get misaligned with their respective goals, trouble results.

What went wrong with the daycare’s plan is simple—most of the parents were motivated to pick up their children on time out of moral (“I gave my word”) or social (“I don’t want to be talked about by other parents”) incentives. But once a financial incentive was offered, the daycare center had essentially given the parents a way out in absolving their social and moral obligations. The parents had essentially cost-adjusted their behavior.

If you think this couldn’t happen to the healthcare system, let me ask you this. As a hospitalist, I see all of my patients early in the morning, because I see it as part of my obligation to the hospital team to discharge patients by 11 a.m. (social motivation).

But what if the CEO released this directive: “You will see all of your patients early in the morning, or you will take a $1,000 a year pay cut.” Is it possible that I might cost-adjust the $1,000 in exchange for sleeping in a little later and not having to deal with the morning traffic? I don’t know.

When it comes to financial incentives, there is a valley in the U-shaped curve. When the financial incentive is trivial, it is disregarded and the social/moral motivations of behavior persist (the kids are picked up on time; I persist in seeing patients early in the morning). When the financial incentive is huge, the financial incentive trumps all social/moral motivations, ensuring compliance with the goal behavior (every kid is picked up on time to avoid a penalty; I see all patients early in the day to avoid a larger penalty).

But in between is the risk zone: When the person feels they are paying an appropriate penance for not complying with the goal behavior, the financial disincentive absolves any social/moral guilt.

Healthcare reform is about incentives—and there is nothing wrong with that. But as the stewards of the inpatient healthcare system, it is upon us as hospitalists to ensure that the incentives remain matched to their intended goals, and that the untoward consequences of the incentives do not adversely affect the quality and safety of a patient’s care.

It is safe to say that the Affordable Care Act of 2010 moves us closer to a true environment of quality and patient safety. But it is equally safe to say that meaningful change will require more than what the law can provide. As stewards of the inpatient system, we have a responsibility to ensure that the healthcare system, particularly in how it responds to incentives, evolves to remain patient-centered, effective, and safe.

The next chapter in our story—the hospitalists’ story—will be one of accountability and responsibility. While there are things the government can do, the majority of what needs to be done will come directly from us. TH

Dr. Wiese is president of SHM.

Reference

1. Levitt SD, Dubner SJ. Freakonomics: A Rogue Economist Explores the Hidden Side of Everything. New York City: William Morrow; 2005.

The challenges facing SHM are very different than they were 10 years ago. In the 1990s, the focus was on building a society that would represent the needs of the practicing hospitalist. Converting NAIP, with its 200 members, to SHM, with its now 10,000 members, was certainly no easy task, but the society then enjoyed some luxuries no longer afforded to an organization the size of the modern-day SHM. Early on, SHM was far from the public eye, escaping public scrutiny for each of its actions. With only a few hundred members, the society was intimate: Almost every member knew of every action before it happened. And the agenda, compared with today’s standards, was reasonably focused.

But times are different now. The organization is much larger and complex, and the challenges we now face are collectively a product of our success. SHM is squarely in the spotlight; every decision is closely monitored by the public eye. We now have a voice such that when we speak, people listen. But with greatness comes responsibility, and because we are in the spotlight, we must be especially careful in how we speak, lest the message be misunderstood. Further, with more than 10,000 members, 50 full-time staff, 44 committees, and nearly 500 physician volunteers, the organization no longer has the luxury of every action being known by every member prior to its enactment.

More challenging still is our agenda, which has grown to be a diverse and far-reaching strategy. While impressive and admirable, the size of this “footprint” creates new challenges in balancing the need to be “nimble” (i.e., being able to act quickly enough to be timely and effective) versus being “thorough” (i.e., ensuring that each action is appropriately vetted prior to execution).

I suspect that there are few practicing hospitalists who have not read To Err is Human or Crossing the Quality Chasm.^1,2 Both make this essential point about quality: In complex systems, mistakes are bound to happen. And when errors do occur, each member of the team must be ready to take responsibility for the mistake, and immediately begin seeking systematic solutions to ensure that it does not happen again. SHM’s focus is to advance quality for all hospitalized patients. But an organization can only be effective if it emulates the principles that it hopes its members will individually espouse.

So let me start with this: There have been mistakes along the way.

That’s the hard truth. I believe that none of the mistakes have been intentional; rather, these missteps have been a product of an organization that has grown so fast, and whose success has gained so much public attention, that its infrastructure has struggled to keep pace with its growth. Any hospitalist who has seen his or her service size double in the span of a year or two knows of what I speak: As growth occurs, the approach to dealing with daily business has to evolve to meet new demands. If it does not, errors result.

One of the areas in which SHM’s growth has outpaced its policies and procedures regards SHM’s relationship with industry. I will say from the outset that having relationships with industry is not in and of itself a mistake. The reality is that without such relationships, in the setting of a landscape where governmental and philanthropic funding is disproportionately in deficit to the need, it would be almost impossible to advance the quality initiatives that have defined SHM’s success. SHM has, and will likely continue to have, relationships with industry. But requisite for having these relationships, especially for an organization that is a national leader, is going above and beyond the minimum standards to ensure transparency and ethics.

Two years ago, SHM began the arduous process of reviewing its partnerships and how it interacts with industry. I am pleased to announce that this has culminated in the Council of Medical Specialty Societies (CMSS; www.cmss.org) asking SHM to apply to become an affiliate member. Acceptance of SHM into CMSS is evidence of SHM’s demonstrated compliance with CMSS’s requirements, with respect to industry relationships, disclosure of conflicts of interest, and other measures of organizational transparency, all of which can be found at www.hospitalmedicine.org/industry.

But meeting the minimum standards has never been sufficient for SHM. The cost of greatness is responsibility, and as a national leader, SHM has a responsibility to ensure that its approaches to potential conflicts of interest and external relationships are above reproach.

COI Disclosure

The conflict of interest statements for each board member have long been posted on the SHM website. In an effort to go above and beyond the minimum standards, the format of the disclosure form has been revised, making it the most compete and detailed COI disclosure form of any physician organization in the country. In the coming months, SHM will make even tighter restrictions regarding disclosing potential conflicts of interest. While board members are required to report any and all financial receipts, the amended version will require board members who receive any contribution in excess of $5,000 to provide a detailed narrative as to what was required in service for the receipt of those funds. Further, to ensure collective accountability, any board member may call upon any other board member to provide a similarly detailed description of any item on his or her COI disclosure form.

Recognizing that other leaders in the organization might also have influence over important decisions, thereby being at risk for a conflict of interest, SHM is one of the first physician organizations to require public reporting of COI disclosures for all editors, course directors, and senior staff.

Next year, all committee chairs and quality-improvement (QI) project leaders will be required to submit similar COI disclosures.

But reporting potential conflicts is one thing; ensuring that those with significant conflicts are not put in a position of inescapable conflict of interest by virtue of their appointments is another. To be proactive, the executive committee has a designated meeting each year to individually review each nominee being considered for election to the board, committee chairs, editors, and course directors prior to their appointment.

The society will enforce CMSS Standard 1.4, which prohibits key society leaders (president, past-president, president-elect, CEO, editors, course directors) from having direct financial relationships with companies during his or her term of service. All people seeking such positions will be required to attest, at the time of the nomination, to cease all direct financial relationships prior to seeking office; failure to do so will negate their candidacy for the position they seek.

External Communications Regarding Industry

It is one thing to have potential conflicts disclosed on a website; it is quite another to ensure, with 100% confidence, that all recipients of all communications from SHM are aware of this website. Reminding all representatives of SHM to alert communication recipients to our potential conflicts of interest is a good start, but in quality parlance, this is tantamount to “telling people to try harder,” which is rarely an effective strategy to ensure 100% compliance. In response, SHM has designed a fail-safe systems solution to ensure that every communication alerts the recipient to SHM’s potential conflicts of interest. Beginning this year, SHM letterheads and e-mail, used for all written communications with external parties, will carry the following statement on the bottom of each page: “To Learn More About SHM’s Relationship with Industry Partners, Visit www.hospitalmedicine.org/industry.”

One of SHM’s missteps over the years has been the failure to distinguish external communications regarding pharmaceuticals/devices as being different from the organization’s other nonpharmaceutical communications. This unintentional oversight has been a product of the exponential increase in the society’s external communications during the past 10 years. But nonetheless, the distinction between these types of communications is important, especially for a society that receives industry support for its quality initiatives.

At the August board meeting in Chicago, a special ad hoc committee was appointed to develop specific policies regarding SHM’s communication strategy. This committee will bring to the board in November the following policy for approval: “Before SHM makes a specific comment, writes a letter, or posts an official statement on the SHM website about a pharmaceutical agent, a medical device, a specific disease state, or any medical IT services or products, the communication must be approved by the Executive Committee and reflected in the minutes of the Executive Committee. At the President’s discretion, the proposed communication will be brought to the entire Board for discussion and approval.”

As noted below, all agendas and decisions by the executive committee are communicated to the board, further ensuring accountability and oversight for any such decision.

Choices and Definitions

In the early years, all external relationships were initiated by SHM. Because SHM was a relative unknown on the national scene, if a relationship was to be entertained, it was based on SHM’s initiative to do so. Naturally, the smaller number of relationships, and the fact that the choice and nature of the relationship were initiated by SHM, made it easier to define the scope of such relationships. But now things are different: SHM’s agenda now encompasses a vast set of domains, and SHM is regularly on the receiving end of invitations to establish relationships with other organizations. Once again, as a leader of medical specialty organizations, SHM’s policies and procedures have to adapt to fit the needs of a larger and more diverse organization.

An intense amount of work has been devoted to evolving the mechanism by which SHM chooses and defines its relationships. An ad hoc committee from the board of directors has defined the 10 principles of SHM’s business relationships (see “10 Principles of SHM Business Relationships,” p. 42). In November, the board will adopt policies and procedures that will ensure that SHM will continue to only enter into relationships with external organizations with which it shares common interests or goals for advancing the quality and safety of patient care. SHM will continue to avoid influence from external organizations with respect to the policies, conduct, actions, and priorities of SHM.

Further, by policy, SHM will continue to reserve absolute control over all content and speakers at its educational conferences; content will continue to not be influenced by brand or product consideration during development or revisions. All potential partners will be informed from the outset that a partnership with SHM does not imply that SHM endorses the policies, values, and missions of the partner organization; any significant deviation from the values and mission of SHM will dissolve the partnership. SHM will establish from the outset that a partnership does not imply SHM’s support or endorsement of any products from a partner. As noted above, transparency of these relationships will be of paramount importance: All relationships, including the dollar amounts received as a product of those relationships, will be posted on SHM’s website.

Transparency in Decision-Making

As noted from the outset, the benefit of small organizations with limited agendas is that every member knows every decision. With limited decisions to be made, the vetting and review process is virtually assured. As organizations grow, as agendas expand exponentially, and as the pace quickens, the multiperson review of each decision becomes difficult to assure. The result is that errors start to appear—not due to intentional wrongdoing, but because the luxury of intense oversight is lost as the organization expands. For an organization to grow and still maintain oversight of its decision-making process, it is vital that the organization evolve to develop new methods of accountability and transparency.

To meet this need, SHM has enacted a change in its communication infrastructure to ensure “double-checks” for all of the important organizational decisions. An SHM leadership and staff “wiki” has been developed to promote and ensure transparency of all organizational decisions. Because it is accessible only to the SHM staff, board, and committee chairs, the wiki is invisible to the SHM membership. Nonetheless, you should know of this important innovation.

The wiki requires that all committee chairs post the results of their committee activities. This ensures that staff and committee leadership are on the same page, ensures that other committees are not duplicating work, augments collaboration across committees, and, most importantly, ensures collective accountability for each decision made.

Technology-based innovations have been enacted to improve the transparency of the executive leadership of the organization. The board of directors meets four times a year; the purpose of the board is to ensure oversight for all SHM decisions. Because the board comprises exclusively volunteer members meeting only four times a year, it is practically impossible for the board to approve every decision made by an organization as large as SHM. To ensure the necessary efficiency and effectiveness (i.e., being sufficiently “nimble” to act on important issues in between scheduled board meetings), the executive committee (EC) was established years ago. The EC, comprised of the president, the past-president, the president-elect, and the CEO, meets every two weeks via teleconference to review and approve all essential SHM decisions.

As an innovation to augment accountability and transparency, the agenda and minutes of the EC are now posted on the SHM board portal, allowing all board members to review and comment upon the decisions made by the president, the CEO, or the EC as a whole. Any board member, at any time, can request that the full board be convened to review an agenda item or decision.

And underlying all of these initiatives to improve an already exceptional organization are the tireless efforts of the SHM staff. Though there are nearly 50 staff members now, each continues to do the work of multiple people. SHM is arguably the fastest-growing organization in history, and advancing the organization to level after level has been an exceptional challenge. But regardless of the challenge, SHM leadership and staff has come through. I have no doubt that during this next chapter in SHM’s history, the result will be the same.

SHM is committed to advancing quality. Intrinsic to the “culture of quality” is the commitment to honesty, transparency, and ethics. Any permutation of the society that does not fully exemplify these standards will be ineffective in accomplishing our wished-for goal. In short, the actions of the society must model those that we wish to inspire in the day-to-day practice of our members. Although the unprecedented growth of the society is responsible for errors in the past, the importance of admitting our shortcomings is no less significant. We’ve had some missteps along the way, and while these mistakes are a product of events preceding my tenure, it does not matter. As president of the organization, I am taking responsibility for them, with a pledge to devote all time and energy, with all due speed, to finding systematic solutions that will prevent these errors from happening again.

And let me be even more honest. As we go forward, there are probably going to be more missteps; such is the nature of a growing and active organization. I cannot promise an error-free organization, but I can promise that if and when errors are made in the future, the same intensity will be applied to seek systematic solutions to ensure that we continue to evolve in becoming an organization that is emblematic of quality. Such is the promise of SHM; such is the promise of the hospitalist. TH

Dr. Wiese is president of SHM.

References

1. Kohn LT, Corrigan JM, Donaldson MS, et al. To Err Is Human: Building a Safer Health System. Washington, D.C.: National Academies Press; 2000.
2. Institute of Medicine Committee on Quality Health Care in America. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, D.C.: National Academies Press; 2001.

The challenges facing SHM are very different than they were 10 years ago. In the 1990s, the focus was on building a society that would represent the needs of the practicing hospitalist. Converting NAIP, with its 200 members, to SHM, with its now 10,000 members, was certainly no easy task, but the society then enjoyed some luxuries no longer afforded to an organization the size of the modern-day SHM. Early on, SHM was far from the public eye, escaping public scrutiny for each of its actions. With only a few hundred members, the society was intimate: Almost every member knew of every action before it happened. And the agenda, compared with today’s standards, was reasonably focused.

But times are different now. The organization is much larger and complex, and the challenges we now face are collectively a product of our success. SHM is squarely in the spotlight; every decision is closely monitored by the public eye. We now have a voice such that when we speak, people listen. But with greatness comes responsibility, and because we are in the spotlight, we must be especially careful in how we speak, lest the message be misunderstood. Further, with more than 10,000 members, 50 full-time staff, 44 committees, and nearly 500 physician volunteers, the organization no longer has the luxury of every action being known by every member prior to its enactment.

More challenging still is our agenda, which has grown to be a diverse and far-reaching strategy. While impressive and admirable, the size of this “footprint” creates new challenges in balancing the need to be “nimble” (i.e., being able to act quickly enough to be timely and effective) versus being “thorough” (i.e., ensuring that each action is appropriately vetted prior to execution).

I suspect that there are few practicing hospitalists who have not read To Err is Human or Crossing the Quality Chasm.^1,2 Both make this essential point about quality: In complex systems, mistakes are bound to happen. And when errors do occur, each member of the team must be ready to take responsibility for the mistake, and immediately begin seeking systematic solutions to ensure that it does not happen again. SHM’s focus is to advance quality for all hospitalized patients. But an organization can only be effective if it emulates the principles that it hopes its members will individually espouse.

So let me start with this: There have been mistakes along the way.

That’s the hard truth. I believe that none of the mistakes have been intentional; rather, these missteps have been a product of an organization that has grown so fast, and whose success has gained so much public attention, that its infrastructure has struggled to keep pace with its growth. Any hospitalist who has seen his or her service size double in the span of a year or two knows of what I speak: As growth occurs, the approach to dealing with daily business has to evolve to meet new demands. If it does not, errors result.

One of the areas in which SHM’s growth has outpaced its policies and procedures regards SHM’s relationship with industry. I will say from the outset that having relationships with industry is not in and of itself a mistake. The reality is that without such relationships, in the setting of a landscape where governmental and philanthropic funding is disproportionately in deficit to the need, it would be almost impossible to advance the quality initiatives that have defined SHM’s success. SHM has, and will likely continue to have, relationships with industry. But requisite for having these relationships, especially for an organization that is a national leader, is going above and beyond the minimum standards to ensure transparency and ethics.

Two years ago, SHM began the arduous process of reviewing its partnerships and how it interacts with industry. I am pleased to announce that this has culminated in the Council of Medical Specialty Societies (CMSS; www.cmss.org) asking SHM to apply to become an affiliate member. Acceptance of SHM into CMSS is evidence of SHM’s demonstrated compliance with CMSS’s requirements, with respect to industry relationships, disclosure of conflicts of interest, and other measures of organizational transparency, all of which can be found at www.hospitalmedicine.org/industry.

But meeting the minimum standards has never been sufficient for SHM. The cost of greatness is responsibility, and as a national leader, SHM has a responsibility to ensure that its approaches to potential conflicts of interest and external relationships are above reproach.

COI Disclosure

The conflict of interest statements for each board member have long been posted on the SHM website. In an effort to go above and beyond the minimum standards, the format of the disclosure form has been revised, making it the most compete and detailed COI disclosure form of any physician organization in the country. In the coming months, SHM will make even tighter restrictions regarding disclosing potential conflicts of interest. While board members are required to report any and all financial receipts, the amended version will require board members who receive any contribution in excess of $5,000 to provide a detailed narrative as to what was required in service for the receipt of those funds. Further, to ensure collective accountability, any board member may call upon any other board member to provide a similarly detailed description of any item on his or her COI disclosure form.

Recognizing that other leaders in the organization might also have influence over important decisions, thereby being at risk for a conflict of interest, SHM is one of the first physician organizations to require public reporting of COI disclosures for all editors, course directors, and senior staff.

Next year, all committee chairs and quality-improvement (QI) project leaders will be required to submit similar COI disclosures.

But reporting potential conflicts is one thing; ensuring that those with significant conflicts are not put in a position of inescapable conflict of interest by virtue of their appointments is another. To be proactive, the executive committee has a designated meeting each year to individually review each nominee being considered for election to the board, committee chairs, editors, and course directors prior to their appointment.

The society will enforce CMSS Standard 1.4, which prohibits key society leaders (president, past-president, president-elect, CEO, editors, course directors) from having direct financial relationships with companies during his or her term of service. All people seeking such positions will be required to attest, at the time of the nomination, to cease all direct financial relationships prior to seeking office; failure to do so will negate their candidacy for the position they seek.

External Communications Regarding Industry

It is one thing to have potential conflicts disclosed on a website; it is quite another to ensure, with 100% confidence, that all recipients of all communications from SHM are aware of this website. Reminding all representatives of SHM to alert communication recipients to our potential conflicts of interest is a good start, but in quality parlance, this is tantamount to “telling people to try harder,” which is rarely an effective strategy to ensure 100% compliance. In response, SHM has designed a fail-safe systems solution to ensure that every communication alerts the recipient to SHM’s potential conflicts of interest. Beginning this year, SHM letterheads and e-mail, used for all written communications with external parties, will carry the following statement on the bottom of each page: “To Learn More About SHM’s Relationship with Industry Partners, Visit www.hospitalmedicine.org/industry.”

One of SHM’s missteps over the years has been the failure to distinguish external communications regarding pharmaceuticals/devices as being different from the organization’s other nonpharmaceutical communications. This unintentional oversight has been a product of the exponential increase in the society’s external communications during the past 10 years. But nonetheless, the distinction between these types of communications is important, especially for a society that receives industry support for its quality initiatives.

At the August board meeting in Chicago, a special ad hoc committee was appointed to develop specific policies regarding SHM’s communication strategy. This committee will bring to the board in November the following policy for approval: “Before SHM makes a specific comment, writes a letter, or posts an official statement on the SHM website about a pharmaceutical agent, a medical device, a specific disease state, or any medical IT services or products, the communication must be approved by the Executive Committee and reflected in the minutes of the Executive Committee. At the President’s discretion, the proposed communication will be brought to the entire Board for discussion and approval.”

As noted below, all agendas and decisions by the executive committee are communicated to the board, further ensuring accountability and oversight for any such decision.

Choices and Definitions

In the early years, all external relationships were initiated by SHM. Because SHM was a relative unknown on the national scene, if a relationship was to be entertained, it was based on SHM’s initiative to do so. Naturally, the smaller number of relationships, and the fact that the choice and nature of the relationship were initiated by SHM, made it easier to define the scope of such relationships. But now things are different: SHM’s agenda now encompasses a vast set of domains, and SHM is regularly on the receiving end of invitations to establish relationships with other organizations. Once again, as a leader of medical specialty organizations, SHM’s policies and procedures have to adapt to fit the needs of a larger and more diverse organization.

An intense amount of work has been devoted to evolving the mechanism by which SHM chooses and defines its relationships. An ad hoc committee from the board of directors has defined the 10 principles of SHM’s business relationships (see “10 Principles of SHM Business Relationships,” p. 42). In November, the board will adopt policies and procedures that will ensure that SHM will continue to only enter into relationships with external organizations with which it shares common interests or goals for advancing the quality and safety of patient care. SHM will continue to avoid influence from external organizations with respect to the policies, conduct, actions, and priorities of SHM.

Further, by policy, SHM will continue to reserve absolute control over all content and speakers at its educational conferences; content will continue to not be influenced by brand or product consideration during development or revisions. All potential partners will be informed from the outset that a partnership with SHM does not imply that SHM endorses the policies, values, and missions of the partner organization; any significant deviation from the values and mission of SHM will dissolve the partnership. SHM will establish from the outset that a partnership does not imply SHM’s support or endorsement of any products from a partner. As noted above, transparency of these relationships will be of paramount importance: All relationships, including the dollar amounts received as a product of those relationships, will be posted on SHM’s website.

Transparency in Decision-Making

As noted from the outset, the benefit of small organizations with limited agendas is that every member knows every decision. With limited decisions to be made, the vetting and review process is virtually assured. As organizations grow, as agendas expand exponentially, and as the pace quickens, the multiperson review of each decision becomes difficult to assure. The result is that errors start to appear—not due to intentional wrongdoing, but because the luxury of intense oversight is lost as the organization expands. For an organization to grow and still maintain oversight of its decision-making process, it is vital that the organization evolve to develop new methods of accountability and transparency.

To meet this need, SHM has enacted a change in its communication infrastructure to ensure “double-checks” for all of the important organizational decisions. An SHM leadership and staff “wiki” has been developed to promote and ensure transparency of all organizational decisions. Because it is accessible only to the SHM staff, board, and committee chairs, the wiki is invisible to the SHM membership. Nonetheless, you should know of this important innovation.

The wiki requires that all committee chairs post the results of their committee activities. This ensures that staff and committee leadership are on the same page, ensures that other committees are not duplicating work, augments collaboration across committees, and, most importantly, ensures collective accountability for each decision made.

Technology-based innovations have been enacted to improve the transparency of the executive leadership of the organization. The board of directors meets four times a year; the purpose of the board is to ensure oversight for all SHM decisions. Because the board comprises exclusively volunteer members meeting only four times a year, it is practically impossible for the board to approve every decision made by an organization as large as SHM. To ensure the necessary efficiency and effectiveness (i.e., being sufficiently “nimble” to act on important issues in between scheduled board meetings), the executive committee (EC) was established years ago. The EC, comprised of the president, the past-president, the president-elect, and the CEO, meets every two weeks via teleconference to review and approve all essential SHM decisions.

As an innovation to augment accountability and transparency, the agenda and minutes of the EC are now posted on the SHM board portal, allowing all board members to review and comment upon the decisions made by the president, the CEO, or the EC as a whole. Any board member, at any time, can request that the full board be convened to review an agenda item or decision.

And underlying all of these initiatives to improve an already exceptional organization are the tireless efforts of the SHM staff. Though there are nearly 50 staff members now, each continues to do the work of multiple people. SHM is arguably the fastest-growing organization in history, and advancing the organization to level after level has been an exceptional challenge. But regardless of the challenge, SHM leadership and staff has come through. I have no doubt that during this next chapter in SHM’s history, the result will be the same.

SHM is committed to advancing quality. Intrinsic to the “culture of quality” is the commitment to honesty, transparency, and ethics. Any permutation of the society that does not fully exemplify these standards will be ineffective in accomplishing our wished-for goal. In short, the actions of the society must model those that we wish to inspire in the day-to-day practice of our members. Although the unprecedented growth of the society is responsible for errors in the past, the importance of admitting our shortcomings is no less significant. We’ve had some missteps along the way, and while these mistakes are a product of events preceding my tenure, it does not matter. As president of the organization, I am taking responsibility for them, with a pledge to devote all time and energy, with all due speed, to finding systematic solutions that will prevent these errors from happening again.

And let me be even more honest. As we go forward, there are probably going to be more missteps; such is the nature of a growing and active organization. I cannot promise an error-free organization, but I can promise that if and when errors are made in the future, the same intensity will be applied to seek systematic solutions to ensure that we continue to evolve in becoming an organization that is emblematic of quality. Such is the promise of SHM; such is the promise of the hospitalist. TH

Dr. Wiese is president of SHM.

References

1. Kohn LT, Corrigan JM, Donaldson MS, et al. To Err Is Human: Building a Safer Health System. Washington, D.C.: National Academies Press; 2000.
2. Institute of Medicine Committee on Quality Health Care in America. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, D.C.: National Academies Press; 2001.

The challenges facing SHM are very different than they were 10 years ago. In the 1990s, the focus was on building a society that would represent the needs of the practicing hospitalist. Converting NAIP, with its 200 members, to SHM, with its now 10,000 members, was certainly no easy task, but the society then enjoyed some luxuries no longer afforded to an organization the size of the modern-day SHM. Early on, SHM was far from the public eye, escaping public scrutiny for each of its actions. With only a few hundred members, the society was intimate: Almost every member knew of every action before it happened. And the agenda, compared with today’s standards, was reasonably focused.

But times are different now. The organization is much larger and complex, and the challenges we now face are collectively a product of our success. SHM is squarely in the spotlight; every decision is closely monitored by the public eye. We now have a voice such that when we speak, people listen. But with greatness comes responsibility, and because we are in the spotlight, we must be especially careful in how we speak, lest the message be misunderstood. Further, with more than 10,000 members, 50 full-time staff, 44 committees, and nearly 500 physician volunteers, the organization no longer has the luxury of every action being known by every member prior to its enactment.

More challenging still is our agenda, which has grown to be a diverse and far-reaching strategy. While impressive and admirable, the size of this “footprint” creates new challenges in balancing the need to be “nimble” (i.e., being able to act quickly enough to be timely and effective) versus being “thorough” (i.e., ensuring that each action is appropriately vetted prior to execution).

I suspect that there are few practicing hospitalists who have not read To Err is Human or Crossing the Quality Chasm.^1,2 Both make this essential point about quality: In complex systems, mistakes are bound to happen. And when errors do occur, each member of the team must be ready to take responsibility for the mistake, and immediately begin seeking systematic solutions to ensure that it does not happen again. SHM’s focus is to advance quality for all hospitalized patients. But an organization can only be effective if it emulates the principles that it hopes its members will individually espouse.

So let me start with this: There have been mistakes along the way.

That’s the hard truth. I believe that none of the mistakes have been intentional; rather, these missteps have been a product of an organization that has grown so fast, and whose success has gained so much public attention, that its infrastructure has struggled to keep pace with its growth. Any hospitalist who has seen his or her service size double in the span of a year or two knows of what I speak: As growth occurs, the approach to dealing with daily business has to evolve to meet new demands. If it does not, errors result.

One of the areas in which SHM’s growth has outpaced its policies and procedures regards SHM’s relationship with industry. I will say from the outset that having relationships with industry is not in and of itself a mistake. The reality is that without such relationships, in the setting of a landscape where governmental and philanthropic funding is disproportionately in deficit to the need, it would be almost impossible to advance the quality initiatives that have defined SHM’s success. SHM has, and will likely continue to have, relationships with industry. But requisite for having these relationships, especially for an organization that is a national leader, is going above and beyond the minimum standards to ensure transparency and ethics.

Two years ago, SHM began the arduous process of reviewing its partnerships and how it interacts with industry. I am pleased to announce that this has culminated in the Council of Medical Specialty Societies (CMSS; www.cmss.org) asking SHM to apply to become an affiliate member. Acceptance of SHM into CMSS is evidence of SHM’s demonstrated compliance with CMSS’s requirements, with respect to industry relationships, disclosure of conflicts of interest, and other measures of organizational transparency, all of which can be found at www.hospitalmedicine.org/industry.

But meeting the minimum standards has never been sufficient for SHM. The cost of greatness is responsibility, and as a national leader, SHM has a responsibility to ensure that its approaches to potential conflicts of interest and external relationships are above reproach.

COI Disclosure

The conflict of interest statements for each board member have long been posted on the SHM website. In an effort to go above and beyond the minimum standards, the format of the disclosure form has been revised, making it the most compete and detailed COI disclosure form of any physician organization in the country. In the coming months, SHM will make even tighter restrictions regarding disclosing potential conflicts of interest. While board members are required to report any and all financial receipts, the amended version will require board members who receive any contribution in excess of $5,000 to provide a detailed narrative as to what was required in service for the receipt of those funds. Further, to ensure collective accountability, any board member may call upon any other board member to provide a similarly detailed description of any item on his or her COI disclosure form.

Recognizing that other leaders in the organization might also have influence over important decisions, thereby being at risk for a conflict of interest, SHM is one of the first physician organizations to require public reporting of COI disclosures for all editors, course directors, and senior staff.

Next year, all committee chairs and quality-improvement (QI) project leaders will be required to submit similar COI disclosures.

But reporting potential conflicts is one thing; ensuring that those with significant conflicts are not put in a position of inescapable conflict of interest by virtue of their appointments is another. To be proactive, the executive committee has a designated meeting each year to individually review each nominee being considered for election to the board, committee chairs, editors, and course directors prior to their appointment.

The society will enforce CMSS Standard 1.4, which prohibits key society leaders (president, past-president, president-elect, CEO, editors, course directors) from having direct financial relationships with companies during his or her term of service. All people seeking such positions will be required to attest, at the time of the nomination, to cease all direct financial relationships prior to seeking office; failure to do so will negate their candidacy for the position they seek.

External Communications Regarding Industry

It is one thing to have potential conflicts disclosed on a website; it is quite another to ensure, with 100% confidence, that all recipients of all communications from SHM are aware of this website. Reminding all representatives of SHM to alert communication recipients to our potential conflicts of interest is a good start, but in quality parlance, this is tantamount to “telling people to try harder,” which is rarely an effective strategy to ensure 100% compliance. In response, SHM has designed a fail-safe systems solution to ensure that every communication alerts the recipient to SHM’s potential conflicts of interest. Beginning this year, SHM letterheads and e-mail, used for all written communications with external parties, will carry the following statement on the bottom of each page: “To Learn More About SHM’s Relationship with Industry Partners, Visit www.hospitalmedicine.org/industry.”

One of SHM’s missteps over the years has been the failure to distinguish external communications regarding pharmaceuticals/devices as being different from the organization’s other nonpharmaceutical communications. This unintentional oversight has been a product of the exponential increase in the society’s external communications during the past 10 years. But nonetheless, the distinction between these types of communications is important, especially for a society that receives industry support for its quality initiatives.

At the August board meeting in Chicago, a special ad hoc committee was appointed to develop specific policies regarding SHM’s communication strategy. This committee will bring to the board in November the following policy for approval: “Before SHM makes a specific comment, writes a letter, or posts an official statement on the SHM website about a pharmaceutical agent, a medical device, a specific disease state, or any medical IT services or products, the communication must be approved by the Executive Committee and reflected in the minutes of the Executive Committee. At the President’s discretion, the proposed communication will be brought to the entire Board for discussion and approval.”

As noted below, all agendas and decisions by the executive committee are communicated to the board, further ensuring accountability and oversight for any such decision.

Choices and Definitions

In the early years, all external relationships were initiated by SHM. Because SHM was a relative unknown on the national scene, if a relationship was to be entertained, it was based on SHM’s initiative to do so. Naturally, the smaller number of relationships, and the fact that the choice and nature of the relationship were initiated by SHM, made it easier to define the scope of such relationships. But now things are different: SHM’s agenda now encompasses a vast set of domains, and SHM is regularly on the receiving end of invitations to establish relationships with other organizations. Once again, as a leader of medical specialty organizations, SHM’s policies and procedures have to adapt to fit the needs of a larger and more diverse organization.

An intense amount of work has been devoted to evolving the mechanism by which SHM chooses and defines its relationships. An ad hoc committee from the board of directors has defined the 10 principles of SHM’s business relationships (see “10 Principles of SHM Business Relationships,” p. 42). In November, the board will adopt policies and procedures that will ensure that SHM will continue to only enter into relationships with external organizations with which it shares common interests or goals for advancing the quality and safety of patient care. SHM will continue to avoid influence from external organizations with respect to the policies, conduct, actions, and priorities of SHM.

Further, by policy, SHM will continue to reserve absolute control over all content and speakers at its educational conferences; content will continue to not be influenced by brand or product consideration during development or revisions. All potential partners will be informed from the outset that a partnership with SHM does not imply that SHM endorses the policies, values, and missions of the partner organization; any significant deviation from the values and mission of SHM will dissolve the partnership. SHM will establish from the outset that a partnership does not imply SHM’s support or endorsement of any products from a partner. As noted above, transparency of these relationships will be of paramount importance: All relationships, including the dollar amounts received as a product of those relationships, will be posted on SHM’s website.

Transparency in Decision-Making

As noted from the outset, the benefit of small organizations with limited agendas is that every member knows every decision. With limited decisions to be made, the vetting and review process is virtually assured. As organizations grow, as agendas expand exponentially, and as the pace quickens, the multiperson review of each decision becomes difficult to assure. The result is that errors start to appear—not due to intentional wrongdoing, but because the luxury of intense oversight is lost as the organization expands. For an organization to grow and still maintain oversight of its decision-making process, it is vital that the organization evolve to develop new methods of accountability and transparency.

To meet this need, SHM has enacted a change in its communication infrastructure to ensure “double-checks” for all of the important organizational decisions. An SHM leadership and staff “wiki” has been developed to promote and ensure transparency of all organizational decisions. Because it is accessible only to the SHM staff, board, and committee chairs, the wiki is invisible to the SHM membership. Nonetheless, you should know of this important innovation.

The wiki requires that all committee chairs post the results of their committee activities. This ensures that staff and committee leadership are on the same page, ensures that other committees are not duplicating work, augments collaboration across committees, and, most importantly, ensures collective accountability for each decision made.

Technology-based innovations have been enacted to improve the transparency of the executive leadership of the organization. The board of directors meets four times a year; the purpose of the board is to ensure oversight for all SHM decisions. Because the board comprises exclusively volunteer members meeting only four times a year, it is practically impossible for the board to approve every decision made by an organization as large as SHM. To ensure the necessary efficiency and effectiveness (i.e., being sufficiently “nimble” to act on important issues in between scheduled board meetings), the executive committee (EC) was established years ago. The EC, comprised of the president, the past-president, the president-elect, and the CEO, meets every two weeks via teleconference to review and approve all essential SHM decisions.

As an innovation to augment accountability and transparency, the agenda and minutes of the EC are now posted on the SHM board portal, allowing all board members to review and comment upon the decisions made by the president, the CEO, or the EC as a whole. Any board member, at any time, can request that the full board be convened to review an agenda item or decision.

And underlying all of these initiatives to improve an already exceptional organization are the tireless efforts of the SHM staff. Though there are nearly 50 staff members now, each continues to do the work of multiple people. SHM is arguably the fastest-growing organization in history, and advancing the organization to level after level has been an exceptional challenge. But regardless of the challenge, SHM leadership and staff has come through. I have no doubt that during this next chapter in SHM’s history, the result will be the same.

SHM is committed to advancing quality. Intrinsic to the “culture of quality” is the commitment to honesty, transparency, and ethics. Any permutation of the society that does not fully exemplify these standards will be ineffective in accomplishing our wished-for goal. In short, the actions of the society must model those that we wish to inspire in the day-to-day practice of our members. Although the unprecedented growth of the society is responsible for errors in the past, the importance of admitting our shortcomings is no less significant. We’ve had some missteps along the way, and while these mistakes are a product of events preceding my tenure, it does not matter. As president of the organization, I am taking responsibility for them, with a pledge to devote all time and energy, with all due speed, to finding systematic solutions that will prevent these errors from happening again.

And let me be even more honest. As we go forward, there are probably going to be more missteps; such is the nature of a growing and active organization. I cannot promise an error-free organization, but I can promise that if and when errors are made in the future, the same intensity will be applied to seek systematic solutions to ensure that we continue to evolve in becoming an organization that is emblematic of quality. Such is the promise of SHM; such is the promise of the hospitalist. TH

Dr. Wiese is president of SHM.

References

1. Kohn LT, Corrigan JM, Donaldson MS, et al. To Err Is Human: Building a Safer Health System. Washington, D.C.: National Academies Press; 2000.
2. Institute of Medicine Committee on Quality Health Care in America. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, D.C.: National Academies Press; 2001.

The mark of any great society is balance—balance between the production realized today and the preservation of “production capacity” to ensure the same or greater production in the future. HM is not exempt from this fundamental tenet. What we do now in the way of advancing quality, efficiency, and patient safety will matter little if our contributions are not sustained by the generation that follows us.

It is tempting to think that the issue of how we train residents is germane only to universities, but the reality is that it affects us all. There are 126 “university” medical school programs, but there are 384 residency programs, most of which are within community-based hospitals. The result is that most hospitalists encounter resident physicians in some capacity, and all hospitalists will encounter the results of residency training when they welcome a new recruit to their ranks.

The education and socialization of our residents will define the character of the hospitalists of the future. But the “residency” in which most of us trained does not exist anymore: The duty-hours changes and additional training requirements have dramatically changed the landscape of residency training in the past 10 years, and another series of sea changes is underway. As with all things HM, we again have a choice: Be reactive, wait for the dust to clear, and then lament the results, or be proactive and see this change for what it is—an opportunity to improve healthcare quality now, and in the future.

The ACGME

HM felt the impact of the first wave of duty-hours restrictions beginning in 2003, as many training programs opted to employ hospitalists to provide the coverage that could no longer be maintained by residents working under tighter admission caps and duty-hour restrictions. In doing so, hospitalists have provided a valuable service in preserving the integrity of training environments and fidelity to the Accreditation Council for Graduate Medical Education (ACGME) regulations (more than 85% of training programs have hospitalists working in their systems). But the model of hospitalists working solely as “resident-extenders” is not sustainable.

First, hospitalists who work solely on nonteaching services are at great risk of burning out, especially if the distribution of patients has been manipulated such that the more interesting patients are funneled away from the hospitalist’s service to the teaching service. Second, there is a risk in perception: In models in which the hospitalist is solely the “overflow cap coverage” or the night-float physician (i.e., the resident-extender), residents come to see hospitalists as the “PGY-4, 5, 6 …” physicians—that is, the physician who becomes a resident for life. The result is a serious pipeline issue for us, as the most talented resident physicians are unlikely to forego subspecialty training for a career in HM if hospitalists are perceived as perpetual residents.

The solution is simple: The hospitalist’s role in training environments has to be more than merely solving admission cap or duty-hour issues. It is fine for hospitalists to operate nonteaching services, but the hospitalist also has to be a part of the fulfillment that comes with overseeing teaching services. Further, residents have to see the hospitalist career for what it actually is: Academic or not, HM is much more than merely clinical service. HM is about the value-added services of system interventions to improve quality and patient safety; it is about developing a career as a systems architect. Getting the best and brightest residents to choose HM as a career is contingent upon residents seeing hospitalists in the training environment who are happy and fulfilled in the execution of this career goal.

The hospitalist’s plight was helped substantially on June 23, when ACGME released for comment the revised Common Program Requirements (www.acgme.org). The duty-hours changes are unlikely to substantially alter hospitalists’ lives; the only significant change was a limitation on intern shift durations to fewer than 16 hours in a row (upper-level residents still operate under the 24+6 hour rule, with increased flexibility to stay longer by volition). But the interesting part of the new requirements is an augmented focus on teaching residents transitions-of-care skills, improving direct supervision of residents, and constructing educational systems that minimize handoffs.

There is no specialty that is as suited as HM for fulfilling these unique (and, as of yet, unmet) requirements. Transitions, quality, being present on the hospital wards … this is what we do. And requiring instruction in transitions and quality is an unprecedented leverage point for HM to advance the quality of future physicians. How great it would be to attend HM20 and realize that the attendees had already learned the “Quality 101” lessons (i.e., those we are currently teaching at our annual meeting) as part of their residency? Freed from the need to do basic quality sessions, the content of the annual meeting could escalate to even higher-level principles that would result in substantial and sustainable quality improvement (QI).

MedPAC and GME Funding

Simultaneous with the ACGME changes are changes at the Medicare Payment Advisory Committee (MedPAC), the advisory organization responsible for recommending changes in the distribution of Centers for Medicare and Medicaid Services (CMS) funds to support graduate medical education. CMS is the primary funding agent for residency training. Each hospital receives direct medical expenditures to cover a resident’s salary and benefits. Each hospital has a pre-set per-resident allotment, or PRA. This number varies by hospital, but the average is $100,000 per resident. CMS reimburses the hospital a percentage of this number based upon the percentage of hospital days occupied by Medicare patients (e.g., 35% Medicare days=$35,000 per resident).

The hospital also receives indirect medical expenditures, or IME. IME is not a distinct payment to the hospital, but rather an “inflator” of the clinical-care payments the hospital receives from CMS. IME is paid to the hospital under the presumption that a typical training facility incurs greater cost due to higher patient severity, a higher indigent care percentage, and has higher resource utilization due to residents’ excessive testing, etc. The final presumption is that support is needed for the educational infrastructure (i.e., supervision and teaching).

IME is not inconsequential to a hospital; depending upon the payor mix, a 200-bed hospital might have from $4 million to $8 million in annual IME payments. CMS’ total IME payments to hospitals is more than $6 billion a year. Each hospital’s IME revenue can be found at www.graham-center.org/online/graham/home/tools-resources/data-tables/dt001-gme-2007.html.

The game-changing event occurred in April, when MedPAC announced its intent to reassess the mechanisms of IME funding, with a vision of IME funding eventually being linked to a hospital’s training programs’ ability to demonstrate substantial improvement in quality and patient safety. And here is the leverage point that is a unique opportunity for hospitalists in the training environment. For many hospitalists, especially if employed directly by the hospital, there is little financial incentive to engaging on a teaching service. The ACGME caps limit the service size, and this in turn limits the possible RVUs. Up until now, asking the hospital to compensate for teaching time (i.e., EVUs) was a pipe dream. But the linking of IME funding to quality outcomes (and quality instruction to residents) could change all of that.

If you put the two together: ACGME calling for instruction in quality and transitions, plus MedPAC calling for payments linked to resident outcomes in quality and patient safety, you have one inescapable conclusion—the residency of the future will hinge upon having supervisors with the necessary expertise to ensure that residents participate in, and understand the principles of, patient safety and quality as a part of the residency curriculum. And the people who can ensure that goal are likely to be in a position to warrant compensation for doing so.

Who is better to do this than the hospitalist?

SHM’s Proactive Strategy

This is the opportune time for HM to advance its stature as a profession and to ensure its future via a pipeline of residents adequately training in quality and patient safety. But it is not enough to merely wish for this to happen. There are real barriers that have kept hospitalists from being more intimately involved in physician training, the first of which is age.

HM is a young specialty (the average hospitalist is 37; the average HM leader is 41), and its youth makes it hard to compete with older subspecialists/generalists who have more experience in education. But deficits in experience can be compensated by additional training.

The Academic Hospitalist Academy (AHA)—cosponsored by SHM, the Society of General Internal Medicine (SGIM), and the Association of Chiefs and Leaders of General Internal Medicine (ACLGIM)—is the key to the strategy of catching up quickly. The academy will convene this month outside of Atlanta, and it is very important that each training facility think about sending one of its hospitalists to receive the advanced training in education necessary to compensate for not having years of experience in medical education. Academy details are available at http://academichospitalist.org.

SHM’s initiatives on this front do not stop with the academy. Over the past three months, Kevin O’Leary, MD, and his Quality Improvement Education Committee have been furiously building a “Quality and Patient Safety” curriculum, with a target audience of new hospitalists and resident physicians. The vision is to create a Web-based, interactive curriculum that teaches resident physicians the basics of quality and patient safety, design projects with their colleagues (under the supervision of their hospitalist mentor), and track their data to see real-time results.

Unlike other curricula on the market, the SHM Quality Curriculum for residents will be dynamic, requiring participating institutions commit to SHM’s modus operandi of mentored implementation by sponsoring a hospitalist to receive the training necessary to put the curriculum in motion. To this end, SHM has collaborated with the Alliance for Internal Medicine (AIM) in co-sponsoring the Quality Academy, with a focus on how to teach quality and patient safety. Jen Meyers, MD, FHM, and Jeff Glasheen, MD, SFHM, will be leading the team responsible for the development of this Quality Training Course, which should emerge in the fall of 2011.

As this project proceeds, Paul Grant, MD, chair of the Early Career Hospitalist Committee, and Cheryl O’Malley, MD, chair of the Pipeline Committee, will provide counsel. Both of these groups will continue efforts to improve the process by which residents transition from residency to HM practice, and supporting young physicians with distance mentoring.

The SHM vision of our production capacity is simple: Bring in the best and brightest hospitalists who are interested in teaching quality and patient safety, train them in the fundamentals of medical education, provide them with an “off the net” curriculum for how to teach quality, then return them to their respective training environments to coach residents on the principles of quality.

Training programs that invest in this vision will reap the rewards of fidelity to the new ACGME requirements. Hospitals that support such a vision will receive assurances, should MedPAC’s recommendation come to fruition, that DME and IME funding is secure. Hospitalists investing in this vision will find a fulfilling career in quality education.

And all of us will find assurances that, for as good as things are right now for HM, the future will be even better. TH

Dr. Wiese is president of SHM.

The mark of any great society is balance—balance between the production realized today and the preservation of “production capacity” to ensure the same or greater production in the future. HM is not exempt from this fundamental tenet. What we do now in the way of advancing quality, efficiency, and patient safety will matter little if our contributions are not sustained by the generation that follows us.

It is tempting to think that the issue of how we train residents is germane only to universities, but the reality is that it affects us all. There are 126 “university” medical school programs, but there are 384 residency programs, most of which are within community-based hospitals. The result is that most hospitalists encounter resident physicians in some capacity, and all hospitalists will encounter the results of residency training when they welcome a new recruit to their ranks.

The education and socialization of our residents will define the character of the hospitalists of the future. But the “residency” in which most of us trained does not exist anymore: The duty-hours changes and additional training requirements have dramatically changed the landscape of residency training in the past 10 years, and another series of sea changes is underway. As with all things HM, we again have a choice: Be reactive, wait for the dust to clear, and then lament the results, or be proactive and see this change for what it is—an opportunity to improve healthcare quality now, and in the future.

The ACGME

HM felt the impact of the first wave of duty-hours restrictions beginning in 2003, as many training programs opted to employ hospitalists to provide the coverage that could no longer be maintained by residents working under tighter admission caps and duty-hour restrictions. In doing so, hospitalists have provided a valuable service in preserving the integrity of training environments and fidelity to the Accreditation Council for Graduate Medical Education (ACGME) regulations (more than 85% of training programs have hospitalists working in their systems). But the model of hospitalists working solely as “resident-extenders” is not sustainable.

First, hospitalists who work solely on nonteaching services are at great risk of burning out, especially if the distribution of patients has been manipulated such that the more interesting patients are funneled away from the hospitalist’s service to the teaching service. Second, there is a risk in perception: In models in which the hospitalist is solely the “overflow cap coverage” or the night-float physician (i.e., the resident-extender), residents come to see hospitalists as the “PGY-4, 5, 6 …” physicians—that is, the physician who becomes a resident for life. The result is a serious pipeline issue for us, as the most talented resident physicians are unlikely to forego subspecialty training for a career in HM if hospitalists are perceived as perpetual residents.

The solution is simple: The hospitalist’s role in training environments has to be more than merely solving admission cap or duty-hour issues. It is fine for hospitalists to operate nonteaching services, but the hospitalist also has to be a part of the fulfillment that comes with overseeing teaching services. Further, residents have to see the hospitalist career for what it actually is: Academic or not, HM is much more than merely clinical service. HM is about the value-added services of system interventions to improve quality and patient safety; it is about developing a career as a systems architect. Getting the best and brightest residents to choose HM as a career is contingent upon residents seeing hospitalists in the training environment who are happy and fulfilled in the execution of this career goal.

The hospitalist’s plight was helped substantially on June 23, when ACGME released for comment the revised Common Program Requirements (www.acgme.org). The duty-hours changes are unlikely to substantially alter hospitalists’ lives; the only significant change was a limitation on intern shift durations to fewer than 16 hours in a row (upper-level residents still operate under the 24+6 hour rule, with increased flexibility to stay longer by volition). But the interesting part of the new requirements is an augmented focus on teaching residents transitions-of-care skills, improving direct supervision of residents, and constructing educational systems that minimize handoffs.

There is no specialty that is as suited as HM for fulfilling these unique (and, as of yet, unmet) requirements. Transitions, quality, being present on the hospital wards … this is what we do. And requiring instruction in transitions and quality is an unprecedented leverage point for HM to advance the quality of future physicians. How great it would be to attend HM20 and realize that the attendees had already learned the “Quality 101” lessons (i.e., those we are currently teaching at our annual meeting) as part of their residency? Freed from the need to do basic quality sessions, the content of the annual meeting could escalate to even higher-level principles that would result in substantial and sustainable quality improvement (QI).

MedPAC and GME Funding

Simultaneous with the ACGME changes are changes at the Medicare Payment Advisory Committee (MedPAC), the advisory organization responsible for recommending changes in the distribution of Centers for Medicare and Medicaid Services (CMS) funds to support graduate medical education. CMS is the primary funding agent for residency training. Each hospital receives direct medical expenditures to cover a resident’s salary and benefits. Each hospital has a pre-set per-resident allotment, or PRA. This number varies by hospital, but the average is $100,000 per resident. CMS reimburses the hospital a percentage of this number based upon the percentage of hospital days occupied by Medicare patients (e.g., 35% Medicare days=$35,000 per resident).

The hospital also receives indirect medical expenditures, or IME. IME is not a distinct payment to the hospital, but rather an “inflator” of the clinical-care payments the hospital receives from CMS. IME is paid to the hospital under the presumption that a typical training facility incurs greater cost due to higher patient severity, a higher indigent care percentage, and has higher resource utilization due to residents’ excessive testing, etc. The final presumption is that support is needed for the educational infrastructure (i.e., supervision and teaching).

IME is not inconsequential to a hospital; depending upon the payor mix, a 200-bed hospital might have from $4 million to $8 million in annual IME payments. CMS’ total IME payments to hospitals is more than $6 billion a year. Each hospital’s IME revenue can be found at www.graham-center.org/online/graham/home/tools-resources/data-tables/dt001-gme-2007.html.

The game-changing event occurred in April, when MedPAC announced its intent to reassess the mechanisms of IME funding, with a vision of IME funding eventually being linked to a hospital’s training programs’ ability to demonstrate substantial improvement in quality and patient safety. And here is the leverage point that is a unique opportunity for hospitalists in the training environment. For many hospitalists, especially if employed directly by the hospital, there is little financial incentive to engaging on a teaching service. The ACGME caps limit the service size, and this in turn limits the possible RVUs. Up until now, asking the hospital to compensate for teaching time (i.e., EVUs) was a pipe dream. But the linking of IME funding to quality outcomes (and quality instruction to residents) could change all of that.

If you put the two together: ACGME calling for instruction in quality and transitions, plus MedPAC calling for payments linked to resident outcomes in quality and patient safety, you have one inescapable conclusion—the residency of the future will hinge upon having supervisors with the necessary expertise to ensure that residents participate in, and understand the principles of, patient safety and quality as a part of the residency curriculum. And the people who can ensure that goal are likely to be in a position to warrant compensation for doing so.

Who is better to do this than the hospitalist?

SHM’s Proactive Strategy

This is the opportune time for HM to advance its stature as a profession and to ensure its future via a pipeline of residents adequately training in quality and patient safety. But it is not enough to merely wish for this to happen. There are real barriers that have kept hospitalists from being more intimately involved in physician training, the first of which is age.

HM is a young specialty (the average hospitalist is 37; the average HM leader is 41), and its youth makes it hard to compete with older subspecialists/generalists who have more experience in education. But deficits in experience can be compensated by additional training.

The Academic Hospitalist Academy (AHA)—cosponsored by SHM, the Society of General Internal Medicine (SGIM), and the Association of Chiefs and Leaders of General Internal Medicine (ACLGIM)—is the key to the strategy of catching up quickly. The academy will convene this month outside of Atlanta, and it is very important that each training facility think about sending one of its hospitalists to receive the advanced training in education necessary to compensate for not having years of experience in medical education. Academy details are available at http://academichospitalist.org.

SHM’s initiatives on this front do not stop with the academy. Over the past three months, Kevin O’Leary, MD, and his Quality Improvement Education Committee have been furiously building a “Quality and Patient Safety” curriculum, with a target audience of new hospitalists and resident physicians. The vision is to create a Web-based, interactive curriculum that teaches resident physicians the basics of quality and patient safety, design projects with their colleagues (under the supervision of their hospitalist mentor), and track their data to see real-time results.

Unlike other curricula on the market, the SHM Quality Curriculum for residents will be dynamic, requiring participating institutions commit to SHM’s modus operandi of mentored implementation by sponsoring a hospitalist to receive the training necessary to put the curriculum in motion. To this end, SHM has collaborated with the Alliance for Internal Medicine (AIM) in co-sponsoring the Quality Academy, with a focus on how to teach quality and patient safety. Jen Meyers, MD, FHM, and Jeff Glasheen, MD, SFHM, will be leading the team responsible for the development of this Quality Training Course, which should emerge in the fall of 2011.

As this project proceeds, Paul Grant, MD, chair of the Early Career Hospitalist Committee, and Cheryl O’Malley, MD, chair of the Pipeline Committee, will provide counsel. Both of these groups will continue efforts to improve the process by which residents transition from residency to HM practice, and supporting young physicians with distance mentoring.

The SHM vision of our production capacity is simple: Bring in the best and brightest hospitalists who are interested in teaching quality and patient safety, train them in the fundamentals of medical education, provide them with an “off the net” curriculum for how to teach quality, then return them to their respective training environments to coach residents on the principles of quality.

Training programs that invest in this vision will reap the rewards of fidelity to the new ACGME requirements. Hospitals that support such a vision will receive assurances, should MedPAC’s recommendation come to fruition, that DME and IME funding is secure. Hospitalists investing in this vision will find a fulfilling career in quality education.

And all of us will find assurances that, for as good as things are right now for HM, the future will be even better. TH

Dr. Wiese is president of SHM.

The mark of any great society is balance—balance between the production realized today and the preservation of “production capacity” to ensure the same or greater production in the future. HM is not exempt from this fundamental tenet. What we do now in the way of advancing quality, efficiency, and patient safety will matter little if our contributions are not sustained by the generation that follows us.

It is tempting to think that the issue of how we train residents is germane only to universities, but the reality is that it affects us all. There are 126 “university” medical school programs, but there are 384 residency programs, most of which are within community-based hospitals. The result is that most hospitalists encounter resident physicians in some capacity, and all hospitalists will encounter the results of residency training when they welcome a new recruit to their ranks.

The education and socialization of our residents will define the character of the hospitalists of the future. But the “residency” in which most of us trained does not exist anymore: The duty-hours changes and additional training requirements have dramatically changed the landscape of residency training in the past 10 years, and another series of sea changes is underway. As with all things HM, we again have a choice: Be reactive, wait for the dust to clear, and then lament the results, or be proactive and see this change for what it is—an opportunity to improve healthcare quality now, and in the future.

The ACGME

HM felt the impact of the first wave of duty-hours restrictions beginning in 2003, as many training programs opted to employ hospitalists to provide the coverage that could no longer be maintained by residents working under tighter admission caps and duty-hour restrictions. In doing so, hospitalists have provided a valuable service in preserving the integrity of training environments and fidelity to the Accreditation Council for Graduate Medical Education (ACGME) regulations (more than 85% of training programs have hospitalists working in their systems). But the model of hospitalists working solely as “resident-extenders” is not sustainable.

First, hospitalists who work solely on nonteaching services are at great risk of burning out, especially if the distribution of patients has been manipulated such that the more interesting patients are funneled away from the hospitalist’s service to the teaching service. Second, there is a risk in perception: In models in which the hospitalist is solely the “overflow cap coverage” or the night-float physician (i.e., the resident-extender), residents come to see hospitalists as the “PGY-4, 5, 6 …” physicians—that is, the physician who becomes a resident for life. The result is a serious pipeline issue for us, as the most talented resident physicians are unlikely to forego subspecialty training for a career in HM if hospitalists are perceived as perpetual residents.

The solution is simple: The hospitalist’s role in training environments has to be more than merely solving admission cap or duty-hour issues. It is fine for hospitalists to operate nonteaching services, but the hospitalist also has to be a part of the fulfillment that comes with overseeing teaching services. Further, residents have to see the hospitalist career for what it actually is: Academic or not, HM is much more than merely clinical service. HM is about the value-added services of system interventions to improve quality and patient safety; it is about developing a career as a systems architect. Getting the best and brightest residents to choose HM as a career is contingent upon residents seeing hospitalists in the training environment who are happy and fulfilled in the execution of this career goal.

The hospitalist’s plight was helped substantially on June 23, when ACGME released for comment the revised Common Program Requirements (www.acgme.org). The duty-hours changes are unlikely to substantially alter hospitalists’ lives; the only significant change was a limitation on intern shift durations to fewer than 16 hours in a row (upper-level residents still operate under the 24+6 hour rule, with increased flexibility to stay longer by volition). But the interesting part of the new requirements is an augmented focus on teaching residents transitions-of-care skills, improving direct supervision of residents, and constructing educational systems that minimize handoffs.

There is no specialty that is as suited as HM for fulfilling these unique (and, as of yet, unmet) requirements. Transitions, quality, being present on the hospital wards … this is what we do. And requiring instruction in transitions and quality is an unprecedented leverage point for HM to advance the quality of future physicians. How great it would be to attend HM20 and realize that the attendees had already learned the “Quality 101” lessons (i.e., those we are currently teaching at our annual meeting) as part of their residency? Freed from the need to do basic quality sessions, the content of the annual meeting could escalate to even higher-level principles that would result in substantial and sustainable quality improvement (QI).

MedPAC and GME Funding

Simultaneous with the ACGME changes are changes at the Medicare Payment Advisory Committee (MedPAC), the advisory organization responsible for recommending changes in the distribution of Centers for Medicare and Medicaid Services (CMS) funds to support graduate medical education. CMS is the primary funding agent for residency training. Each hospital receives direct medical expenditures to cover a resident’s salary and benefits. Each hospital has a pre-set per-resident allotment, or PRA. This number varies by hospital, but the average is $100,000 per resident. CMS reimburses the hospital a percentage of this number based upon the percentage of hospital days occupied by Medicare patients (e.g., 35% Medicare days=$35,000 per resident).

The hospital also receives indirect medical expenditures, or IME. IME is not a distinct payment to the hospital, but rather an “inflator” of the clinical-care payments the hospital receives from CMS. IME is paid to the hospital under the presumption that a typical training facility incurs greater cost due to higher patient severity, a higher indigent care percentage, and has higher resource utilization due to residents’ excessive testing, etc. The final presumption is that support is needed for the educational infrastructure (i.e., supervision and teaching).

IME is not inconsequential to a hospital; depending upon the payor mix, a 200-bed hospital might have from $4 million to $8 million in annual IME payments. CMS’ total IME payments to hospitals is more than $6 billion a year. Each hospital’s IME revenue can be found at www.graham-center.org/online/graham/home/tools-resources/data-tables/dt001-gme-2007.html.

The game-changing event occurred in April, when MedPAC announced its intent to reassess the mechanisms of IME funding, with a vision of IME funding eventually being linked to a hospital’s training programs’ ability to demonstrate substantial improvement in quality and patient safety. And here is the leverage point that is a unique opportunity for hospitalists in the training environment. For many hospitalists, especially if employed directly by the hospital, there is little financial incentive to engaging on a teaching service. The ACGME caps limit the service size, and this in turn limits the possible RVUs. Up until now, asking the hospital to compensate for teaching time (i.e., EVUs) was a pipe dream. But the linking of IME funding to quality outcomes (and quality instruction to residents) could change all of that.

If you put the two together: ACGME calling for instruction in quality and transitions, plus MedPAC calling for payments linked to resident outcomes in quality and patient safety, you have one inescapable conclusion—the residency of the future will hinge upon having supervisors with the necessary expertise to ensure that residents participate in, and understand the principles of, patient safety and quality as a part of the residency curriculum. And the people who can ensure that goal are likely to be in a position to warrant compensation for doing so.

Who is better to do this than the hospitalist?

SHM’s Proactive Strategy

This is the opportune time for HM to advance its stature as a profession and to ensure its future via a pipeline of residents adequately training in quality and patient safety. But it is not enough to merely wish for this to happen. There are real barriers that have kept hospitalists from being more intimately involved in physician training, the first of which is age.

HM is a young specialty (the average hospitalist is 37; the average HM leader is 41), and its youth makes it hard to compete with older subspecialists/generalists who have more experience in education. But deficits in experience can be compensated by additional training.

The Academic Hospitalist Academy (AHA)—cosponsored by SHM, the Society of General Internal Medicine (SGIM), and the Association of Chiefs and Leaders of General Internal Medicine (ACLGIM)—is the key to the strategy of catching up quickly. The academy will convene this month outside of Atlanta, and it is very important that each training facility think about sending one of its hospitalists to receive the advanced training in education necessary to compensate for not having years of experience in medical education. Academy details are available at http://academichospitalist.org.

SHM’s initiatives on this front do not stop with the academy. Over the past three months, Kevin O’Leary, MD, and his Quality Improvement Education Committee have been furiously building a “Quality and Patient Safety” curriculum, with a target audience of new hospitalists and resident physicians. The vision is to create a Web-based, interactive curriculum that teaches resident physicians the basics of quality and patient safety, design projects with their colleagues (under the supervision of their hospitalist mentor), and track their data to see real-time results.

Unlike other curricula on the market, the SHM Quality Curriculum for residents will be dynamic, requiring participating institutions commit to SHM’s modus operandi of mentored implementation by sponsoring a hospitalist to receive the training necessary to put the curriculum in motion. To this end, SHM has collaborated with the Alliance for Internal Medicine (AIM) in co-sponsoring the Quality Academy, with a focus on how to teach quality and patient safety. Jen Meyers, MD, FHM, and Jeff Glasheen, MD, SFHM, will be leading the team responsible for the development of this Quality Training Course, which should emerge in the fall of 2011.

As this project proceeds, Paul Grant, MD, chair of the Early Career Hospitalist Committee, and Cheryl O’Malley, MD, chair of the Pipeline Committee, will provide counsel. Both of these groups will continue efforts to improve the process by which residents transition from residency to HM practice, and supporting young physicians with distance mentoring.

The SHM vision of our production capacity is simple: Bring in the best and brightest hospitalists who are interested in teaching quality and patient safety, train them in the fundamentals of medical education, provide them with an “off the net” curriculum for how to teach quality, then return them to their respective training environments to coach residents on the principles of quality.

Training programs that invest in this vision will reap the rewards of fidelity to the new ACGME requirements. Hospitals that support such a vision will receive assurances, should MedPAC’s recommendation come to fruition, that DME and IME funding is secure. Hospitalists investing in this vision will find a fulfilling career in quality education.

And all of us will find assurances that, for as good as things are right now for HM, the future will be even better. TH

Dr. Wiese is president of SHM.

It’s unfortunate that medical organizations such as SHM do not have the equivalent of a national championship or a Super Bowl. If there was, given what SHM has accomplished in the past 13 years, there is no question that SHM would have won it.

­­So as my first act as SHM president, I hereby declare the Society of Hospital Medicine the national champions of physician organizations.

With that out of the way, now comes the hard part: because the only thing harder than winning a championship is keeping it. For with success comes the temptation to rest. The struggle to achieve success is about outward comparisons. But having achieved success, the perspective of the champion must shift if it is to be sustained. For in the mind of the champion, the perspective is internal, and the measure of competition is about besting oneself. For a champion such as SHM, future success will be measured solely upon an internal inventory of what we do well . . . and what could be done better. Allow me to make this more tangible.

Continued Growth and Inclusion

Our membership continues to grow. And with 10,000 members, it would be easy to rest. But given that there are 30,000 hospitalists, it would be convenient to ignore the question we have to answer: “Where are the other 20,000?”

Would they not benefit from our attention to quality and patient safety? SHM, like no other organization, has built an infrastructure of empowerment, particularly with respect to advancing the goals of quality and patient safety. It is not merely a self-serving goal to recruit these 20,000 hospitalists to SHM; in your heart, you have to believe that their time with SHM would improve the care of their patients. I am confident that Brian Curtis, Manoj Matthews, and their respective Membership and Chapter Support committees will be instrumental as we work toward this goal.

As we grow, for our colleagues in pediatrics, family medicine, the nonphysician providers, and practice administrators, will we make the right decision to maintain the “big tent” that has defined SHM’s success? Quality is quality, regardless of specialty, and the principles of improving a healthcare system that is safe and patient-centered apply to us all.

But as we continue to grow, sustaining the big tent will become increasingly difficult to maintain. Even so, it must remain our priority. Erin Stucky, Bob Harrington, Jeannette Kalupa, Ajay Kharbanda, and their respective teams will be central in preserving this important goal.

At HM10, our annual meeting, attendance topped out at more than 2,500 participants, and the quality of the programming has never been stronger. But there are new challenges that come with this success. Can we sustain the intimacy—the personal attention—necessary for networking and collaboration as the annual meeting continues to grow? There are homogenous messages that do, and will continue to, speak to us all.

But heterogeneity persists in hospitalist systems, and the ability to network with other hospitalists around these unique issues has been an incredibly valuable service of the national meeting. Yet as the meeting grows, it will become increasingly difficult to network hospitalists with similar needs. Preserving the intimacy of the annual meeting, despite its growing size, must be our goal. Dan Dressler, Jeff Glasheen, Mike Pistoria, and the Annual Meeting Committee will be tasked with finding creative solutions to achieving this goal.

Technology = Solutions

At the heart of the solution to both challenges is Kendall Rogers and his Information Technology team. IT sustains meaningful communication in the face of growth, and I believe this to be a central solution. However, the tasks for our IT team are not merely internal. Our profession is at the very beginning of a sharp upward slope on the IT curve, and IT will play an increasing role in patient care.

Technology should be the servant of the people, not the other way around. The unanticipated consequence of more IT has been the temptation to depersonalize patient care in lieu of practicing medicine via computer. IT unquestionably makes healthcare more efficient, but it has the equal prospect of making it less patient-centered; no efficiency is worth that.

Our goal as a society must be to take a leadership role in ensuring that the efficiencies brought about by IT leverage more time to spend with our patients, and empower systems solutions that prevent medical errors. SHM must be positioned so that we have a meaningful voice in advocating for health IT solutions that enable the hospitalist to meet PQRI standards, and to empower the hospitalist to be a leader in the advocacy of appropriate IT solutions that advance, not deter, our mission of quality care. At no time should a computer screen replace the provider’s time at the bedside with the patient; we must be the leaders in preserving this central tenet of patient-centered care.

One Voice—Credible, Unified, Patient-Focused

Hospitalists have spent a decade trying to a get a voice in the legislative discussion. Now that we have a voice in the national healthcare conversation, we must speak with credibility. And the measure of our credibility will be grounded in fidelity to our core mission: preserving what is best for the patient. We cannot succumb, as so many other organizations have done, to merely advocating what is best for SHM. If we do, our time at the table will be short.

Finding the balance between what is best for hospitalists without compromising what is best for the patient will be our challenge. Eric Siegal, Pat Torcson, Kirk Matthews, and their respective Advocacy, Practice Analysis, and Performance and Standards committees will be at the heart of this solution. But through it all, we must not be afraid of confronting the tough issues. Whatever might come with value-based purchasing, bundling, or PQRI, we must have a voice in designing legislation that not only ensures the welfare of the hospitalized patient, but also the sustainability of the hospitalist who is central to that care.

For if we are who we say we are, one is synonymous with the other.

Quality Remains Job No. 1

Perhaps the biggest challenge facing us is heterogeneity. Thanks to SHM’s mentored implementation programs, there is an increasing number of high-performance hospitalist teams. But we are only as strong as our weakest link, and our success will be ignored in light of our weakness until we can ensure, from a quality perspective, homogeneity across all hospital groups. Tex Landis, Steve Deitelzweig, and their respective Practice Management and Practice Analysis committees will be central to finding this solution.

SHM’s biannual hospitalist survey has partnered with industry leader MGMA, and as such, we have gained great credibility in leveraging the results of the survey with the C-suite. But surveys are only as good as the questions that are asked, and SHM must continue its role in collaborating with MGMA to ensure that we are asking the right questions. We need to know what defines the highest-performing teams, and we must find creative solutions to bring every hospitalist team to that same standard of quality by adopting the best practices of our strongest groups.

But at the heart of it all is quality: SHM’s universal mandate is that hospitalists ensure safe, timely, efficient, equitable, and patient-centered care. The leadership of Vikas Parekh and the Education Committee, and Nasim Afsarmanesh, Andrew Dunn, Kevin O’Leary, Greg Maynard and their respective Quality committees, will be central to the advancement of this mandate.

But this mandate must not go unsupported. Each hospitalist group must not be tasked with reinventing the wheel with each QI project, and each hospitalist group must not suffer from the same mistakes. Imagine a day when SHM becomes the repository of QI projects, enabling one hospitalist group to search a database to find QI projects designed and executed by other groups of similar size and character. It is an ambitious goal, but it is a measure that will ensure that all hospitalists can prosper from the success of our colleagues. It will close the heterogeneity gap and ensure that in five years’ time, if there is a hospitalist who does not engage in QI, it is not because they didn’t know how.

Properly designed, such a database could enable hospitalists to create and complete the Practice Improvement Module (PIM) for the American Board of Internal Medicine’s Focused Practice in Hospital Medicine Maintenance of Certification, and empower hospitalists to meet PQRI requirements.

Train Generation Next

As we make all of these advances, we must not lose sight of the importance of a balance between “production” and “production capacity.” For SHM to be a true leader in hospital quality, we must become more than reactionary. Via “user-inspired research,” we must produce new knowledge that improves the practice of us all. And we must address the “hole in the boat.”

Despite our success in improving the understanding of quality with our current membership, I fear we are losing ground: Each year, 10,000 new practitioners leave their residency having been inadequately trained in the principles of quality and patient safety. To make meaningful changes in healthcare quality, we have to fulfill our call to become the stewards of this training, ensuring that the next generations of physicians will be more adept in the fundamentals of quality and patient safety than we were. Jeff Glasheen, David Meltzer, Lorenz DiFrancesco, Paul Grant, Greg Seymann, and the Academic, Research, Pipeline, and Early Career Hospitalists teams will be tasked with this important legacy.

And so we come to a defining moment in SHM’s history. Will SHM be a one-and-done champion? Or will it be defined as a legacy?

Less ambitious goals and visions are certainly more comfortable, but it is not the spirit that has brought us this far. I doubt that the legendary figures of hospital medicine—John Nelson, Win Whitcomb, Bob Wachter, Larry Wellikson, et al—dreamed of a day when SHM would be “OK.” I suspect even our success as an organization is not enough for them, and personally, it’s not enough for me, either.

So digest this as an ambitious strategy that only a champion would be brave enough to design. No team wins without coaching, but no team wins on coaching alone. It will take all of us to make meaningful execution of this strategy a reality. Yes, we are the champions. Now, let’s play like it. TH

Dr. Wiese is president of SHM.

It’s unfortunate that medical organizations such as SHM do not have the equivalent of a national championship or a Super Bowl. If there was, given what SHM has accomplished in the past 13 years, there is no question that SHM would have won it.

­­So as my first act as SHM president, I hereby declare the Society of Hospital Medicine the national champions of physician organizations.

With that out of the way, now comes the hard part: because the only thing harder than winning a championship is keeping it. For with success comes the temptation to rest. The struggle to achieve success is about outward comparisons. But having achieved success, the perspective of the champion must shift if it is to be sustained. For in the mind of the champion, the perspective is internal, and the measure of competition is about besting oneself. For a champion such as SHM, future success will be measured solely upon an internal inventory of what we do well . . . and what could be done better. Allow me to make this more tangible.

Continued Growth and Inclusion

Our membership continues to grow. And with 10,000 members, it would be easy to rest. But given that there are 30,000 hospitalists, it would be convenient to ignore the question we have to answer: “Where are the other 20,000?”

Would they not benefit from our attention to quality and patient safety? SHM, like no other organization, has built an infrastructure of empowerment, particularly with respect to advancing the goals of quality and patient safety. It is not merely a self-serving goal to recruit these 20,000 hospitalists to SHM; in your heart, you have to believe that their time with SHM would improve the care of their patients. I am confident that Brian Curtis, Manoj Matthews, and their respective Membership and Chapter Support committees will be instrumental as we work toward this goal.

As we grow, for our colleagues in pediatrics, family medicine, the nonphysician providers, and practice administrators, will we make the right decision to maintain the “big tent” that has defined SHM’s success? Quality is quality, regardless of specialty, and the principles of improving a healthcare system that is safe and patient-centered apply to us all.

But as we continue to grow, sustaining the big tent will become increasingly difficult to maintain. Even so, it must remain our priority. Erin Stucky, Bob Harrington, Jeannette Kalupa, Ajay Kharbanda, and their respective teams will be central in preserving this important goal.

At HM10, our annual meeting, attendance topped out at more than 2,500 participants, and the quality of the programming has never been stronger. But there are new challenges that come with this success. Can we sustain the intimacy—the personal attention—necessary for networking and collaboration as the annual meeting continues to grow? There are homogenous messages that do, and will continue to, speak to us all.

But heterogeneity persists in hospitalist systems, and the ability to network with other hospitalists around these unique issues has been an incredibly valuable service of the national meeting. Yet as the meeting grows, it will become increasingly difficult to network hospitalists with similar needs. Preserving the intimacy of the annual meeting, despite its growing size, must be our goal. Dan Dressler, Jeff Glasheen, Mike Pistoria, and the Annual Meeting Committee will be tasked with finding creative solutions to achieving this goal.

Technology = Solutions

At the heart of the solution to both challenges is Kendall Rogers and his Information Technology team. IT sustains meaningful communication in the face of growth, and I believe this to be a central solution. However, the tasks for our IT team are not merely internal. Our profession is at the very beginning of a sharp upward slope on the IT curve, and IT will play an increasing role in patient care.

Technology should be the servant of the people, not the other way around. The unanticipated consequence of more IT has been the temptation to depersonalize patient care in lieu of practicing medicine via computer. IT unquestionably makes healthcare more efficient, but it has the equal prospect of making it less patient-centered; no efficiency is worth that.

Our goal as a society must be to take a leadership role in ensuring that the efficiencies brought about by IT leverage more time to spend with our patients, and empower systems solutions that prevent medical errors. SHM must be positioned so that we have a meaningful voice in advocating for health IT solutions that enable the hospitalist to meet PQRI standards, and to empower the hospitalist to be a leader in the advocacy of appropriate IT solutions that advance, not deter, our mission of quality care. At no time should a computer screen replace the provider’s time at the bedside with the patient; we must be the leaders in preserving this central tenet of patient-centered care.

One Voice—Credible, Unified, Patient-Focused

Hospitalists have spent a decade trying to a get a voice in the legislative discussion. Now that we have a voice in the national healthcare conversation, we must speak with credibility. And the measure of our credibility will be grounded in fidelity to our core mission: preserving what is best for the patient. We cannot succumb, as so many other organizations have done, to merely advocating what is best for SHM. If we do, our time at the table will be short.

Finding the balance between what is best for hospitalists without compromising what is best for the patient will be our challenge. Eric Siegal, Pat Torcson, Kirk Matthews, and their respective Advocacy, Practice Analysis, and Performance and Standards committees will be at the heart of this solution. But through it all, we must not be afraid of confronting the tough issues. Whatever might come with value-based purchasing, bundling, or PQRI, we must have a voice in designing legislation that not only ensures the welfare of the hospitalized patient, but also the sustainability of the hospitalist who is central to that care.

For if we are who we say we are, one is synonymous with the other.

Quality Remains Job No. 1

Perhaps the biggest challenge facing us is heterogeneity. Thanks to SHM’s mentored implementation programs, there is an increasing number of high-performance hospitalist teams. But we are only as strong as our weakest link, and our success will be ignored in light of our weakness until we can ensure, from a quality perspective, homogeneity across all hospital groups. Tex Landis, Steve Deitelzweig, and their respective Practice Management and Practice Analysis committees will be central to finding this solution.

SHM’s biannual hospitalist survey has partnered with industry leader MGMA, and as such, we have gained great credibility in leveraging the results of the survey with the C-suite. But surveys are only as good as the questions that are asked, and SHM must continue its role in collaborating with MGMA to ensure that we are asking the right questions. We need to know what defines the highest-performing teams, and we must find creative solutions to bring every hospitalist team to that same standard of quality by adopting the best practices of our strongest groups.

But at the heart of it all is quality: SHM’s universal mandate is that hospitalists ensure safe, timely, efficient, equitable, and patient-centered care. The leadership of Vikas Parekh and the Education Committee, and Nasim Afsarmanesh, Andrew Dunn, Kevin O’Leary, Greg Maynard and their respective Quality committees, will be central to the advancement of this mandate.

But this mandate must not go unsupported. Each hospitalist group must not be tasked with reinventing the wheel with each QI project, and each hospitalist group must not suffer from the same mistakes. Imagine a day when SHM becomes the repository of QI projects, enabling one hospitalist group to search a database to find QI projects designed and executed by other groups of similar size and character. It is an ambitious goal, but it is a measure that will ensure that all hospitalists can prosper from the success of our colleagues. It will close the heterogeneity gap and ensure that in five years’ time, if there is a hospitalist who does not engage in QI, it is not because they didn’t know how.

Properly designed, such a database could enable hospitalists to create and complete the Practice Improvement Module (PIM) for the American Board of Internal Medicine’s Focused Practice in Hospital Medicine Maintenance of Certification, and empower hospitalists to meet PQRI requirements.

Train Generation Next

As we make all of these advances, we must not lose sight of the importance of a balance between “production” and “production capacity.” For SHM to be a true leader in hospital quality, we must become more than reactionary. Via “user-inspired research,” we must produce new knowledge that improves the practice of us all. And we must address the “hole in the boat.”

Despite our success in improving the understanding of quality with our current membership, I fear we are losing ground: Each year, 10,000 new practitioners leave their residency having been inadequately trained in the principles of quality and patient safety. To make meaningful changes in healthcare quality, we have to fulfill our call to become the stewards of this training, ensuring that the next generations of physicians will be more adept in the fundamentals of quality and patient safety than we were. Jeff Glasheen, David Meltzer, Lorenz DiFrancesco, Paul Grant, Greg Seymann, and the Academic, Research, Pipeline, and Early Career Hospitalists teams will be tasked with this important legacy.

And so we come to a defining moment in SHM’s history. Will SHM be a one-and-done champion? Or will it be defined as a legacy?

Less ambitious goals and visions are certainly more comfortable, but it is not the spirit that has brought us this far. I doubt that the legendary figures of hospital medicine—John Nelson, Win Whitcomb, Bob Wachter, Larry Wellikson, et al—dreamed of a day when SHM would be “OK.” I suspect even our success as an organization is not enough for them, and personally, it’s not enough for me, either.

So digest this as an ambitious strategy that only a champion would be brave enough to design. No team wins without coaching, but no team wins on coaching alone. It will take all of us to make meaningful execution of this strategy a reality. Yes, we are the champions. Now, let’s play like it. TH

Dr. Wiese is president of SHM.

It’s unfortunate that medical organizations such as SHM do not have the equivalent of a national championship or a Super Bowl. If there was, given what SHM has accomplished in the past 13 years, there is no question that SHM would have won it.

­­So as my first act as SHM president, I hereby declare the Society of Hospital Medicine the national champions of physician organizations.

With that out of the way, now comes the hard part: because the only thing harder than winning a championship is keeping it. For with success comes the temptation to rest. The struggle to achieve success is about outward comparisons. But having achieved success, the perspective of the champion must shift if it is to be sustained. For in the mind of the champion, the perspective is internal, and the measure of competition is about besting oneself. For a champion such as SHM, future success will be measured solely upon an internal inventory of what we do well . . . and what could be done better. Allow me to make this more tangible.

Continued Growth and Inclusion

Our membership continues to grow. And with 10,000 members, it would be easy to rest. But given that there are 30,000 hospitalists, it would be convenient to ignore the question we have to answer: “Where are the other 20,000?”

Would they not benefit from our attention to quality and patient safety? SHM, like no other organization, has built an infrastructure of empowerment, particularly with respect to advancing the goals of quality and patient safety. It is not merely a self-serving goal to recruit these 20,000 hospitalists to SHM; in your heart, you have to believe that their time with SHM would improve the care of their patients. I am confident that Brian Curtis, Manoj Matthews, and their respective Membership and Chapter Support committees will be instrumental as we work toward this goal.

As we grow, for our colleagues in pediatrics, family medicine, the nonphysician providers, and practice administrators, will we make the right decision to maintain the “big tent” that has defined SHM’s success? Quality is quality, regardless of specialty, and the principles of improving a healthcare system that is safe and patient-centered apply to us all.

But as we continue to grow, sustaining the big tent will become increasingly difficult to maintain. Even so, it must remain our priority. Erin Stucky, Bob Harrington, Jeannette Kalupa, Ajay Kharbanda, and their respective teams will be central in preserving this important goal.

At HM10, our annual meeting, attendance topped out at more than 2,500 participants, and the quality of the programming has never been stronger. But there are new challenges that come with this success. Can we sustain the intimacy—the personal attention—necessary for networking and collaboration as the annual meeting continues to grow? There are homogenous messages that do, and will continue to, speak to us all.

But heterogeneity persists in hospitalist systems, and the ability to network with other hospitalists around these unique issues has been an incredibly valuable service of the national meeting. Yet as the meeting grows, it will become increasingly difficult to network hospitalists with similar needs. Preserving the intimacy of the annual meeting, despite its growing size, must be our goal. Dan Dressler, Jeff Glasheen, Mike Pistoria, and the Annual Meeting Committee will be tasked with finding creative solutions to achieving this goal.

Technology = Solutions

At the heart of the solution to both challenges is Kendall Rogers and his Information Technology team. IT sustains meaningful communication in the face of growth, and I believe this to be a central solution. However, the tasks for our IT team are not merely internal. Our profession is at the very beginning of a sharp upward slope on the IT curve, and IT will play an increasing role in patient care.

Technology should be the servant of the people, not the other way around. The unanticipated consequence of more IT has been the temptation to depersonalize patient care in lieu of practicing medicine via computer. IT unquestionably makes healthcare more efficient, but it has the equal prospect of making it less patient-centered; no efficiency is worth that.

Our goal as a society must be to take a leadership role in ensuring that the efficiencies brought about by IT leverage more time to spend with our patients, and empower systems solutions that prevent medical errors. SHM must be positioned so that we have a meaningful voice in advocating for health IT solutions that enable the hospitalist to meet PQRI standards, and to empower the hospitalist to be a leader in the advocacy of appropriate IT solutions that advance, not deter, our mission of quality care. At no time should a computer screen replace the provider’s time at the bedside with the patient; we must be the leaders in preserving this central tenet of patient-centered care.

One Voice—Credible, Unified, Patient-Focused

Hospitalists have spent a decade trying to a get a voice in the legislative discussion. Now that we have a voice in the national healthcare conversation, we must speak with credibility. And the measure of our credibility will be grounded in fidelity to our core mission: preserving what is best for the patient. We cannot succumb, as so many other organizations have done, to merely advocating what is best for SHM. If we do, our time at the table will be short.

Finding the balance between what is best for hospitalists without compromising what is best for the patient will be our challenge. Eric Siegal, Pat Torcson, Kirk Matthews, and their respective Advocacy, Practice Analysis, and Performance and Standards committees will be at the heart of this solution. But through it all, we must not be afraid of confronting the tough issues. Whatever might come with value-based purchasing, bundling, or PQRI, we must have a voice in designing legislation that not only ensures the welfare of the hospitalized patient, but also the sustainability of the hospitalist who is central to that care.

For if we are who we say we are, one is synonymous with the other.

Quality Remains Job No. 1

Perhaps the biggest challenge facing us is heterogeneity. Thanks to SHM’s mentored implementation programs, there is an increasing number of high-performance hospitalist teams. But we are only as strong as our weakest link, and our success will be ignored in light of our weakness until we can ensure, from a quality perspective, homogeneity across all hospital groups. Tex Landis, Steve Deitelzweig, and their respective Practice Management and Practice Analysis committees will be central to finding this solution.

SHM’s biannual hospitalist survey has partnered with industry leader MGMA, and as such, we have gained great credibility in leveraging the results of the survey with the C-suite. But surveys are only as good as the questions that are asked, and SHM must continue its role in collaborating with MGMA to ensure that we are asking the right questions. We need to know what defines the highest-performing teams, and we must find creative solutions to bring every hospitalist team to that same standard of quality by adopting the best practices of our strongest groups.

But at the heart of it all is quality: SHM’s universal mandate is that hospitalists ensure safe, timely, efficient, equitable, and patient-centered care. The leadership of Vikas Parekh and the Education Committee, and Nasim Afsarmanesh, Andrew Dunn, Kevin O’Leary, Greg Maynard and their respective Quality committees, will be central to the advancement of this mandate.

But this mandate must not go unsupported. Each hospitalist group must not be tasked with reinventing the wheel with each QI project, and each hospitalist group must not suffer from the same mistakes. Imagine a day when SHM becomes the repository of QI projects, enabling one hospitalist group to search a database to find QI projects designed and executed by other groups of similar size and character. It is an ambitious goal, but it is a measure that will ensure that all hospitalists can prosper from the success of our colleagues. It will close the heterogeneity gap and ensure that in five years’ time, if there is a hospitalist who does not engage in QI, it is not because they didn’t know how.

Properly designed, such a database could enable hospitalists to create and complete the Practice Improvement Module (PIM) for the American Board of Internal Medicine’s Focused Practice in Hospital Medicine Maintenance of Certification, and empower hospitalists to meet PQRI requirements.

Train Generation Next

As we make all of these advances, we must not lose sight of the importance of a balance between “production” and “production capacity.” For SHM to be a true leader in hospital quality, we must become more than reactionary. Via “user-inspired research,” we must produce new knowledge that improves the practice of us all. And we must address the “hole in the boat.”

Despite our success in improving the understanding of quality with our current membership, I fear we are losing ground: Each year, 10,000 new practitioners leave their residency having been inadequately trained in the principles of quality and patient safety. To make meaningful changes in healthcare quality, we have to fulfill our call to become the stewards of this training, ensuring that the next generations of physicians will be more adept in the fundamentals of quality and patient safety than we were. Jeff Glasheen, David Meltzer, Lorenz DiFrancesco, Paul Grant, Greg Seymann, and the Academic, Research, Pipeline, and Early Career Hospitalists teams will be tasked with this important legacy.

And so we come to a defining moment in SHM’s history. Will SHM be a one-and-done champion? Or will it be defined as a legacy?

Less ambitious goals and visions are certainly more comfortable, but it is not the spirit that has brought us this far. I doubt that the legendary figures of hospital medicine—John Nelson, Win Whitcomb, Bob Wachter, Larry Wellikson, et al—dreamed of a day when SHM would be “OK.” I suspect even our success as an organization is not enough for them, and personally, it’s not enough for me, either.

So digest this as an ambitious strategy that only a champion would be brave enough to design. No team wins without coaching, but no team wins on coaching alone. It will take all of us to make meaningful execution of this strategy a reality. Yes, we are the champions. Now, let’s play like it. TH

Dr. Wiese is president of SHM.

You’re a what?” he asked over the noise of the passing Mardi Gras parade.

“I’m a hospitalist,” I replied.

“Oh.” There was an extended pause. I could tell he was searching his mental database to determine if he had a family member who was a hospitalist. Nope, nothing there. Then it came: “What is that exactly?” I followed with a general description of “what a hospitalist does,” but his response made it apparent that my description hadn’t stuck: “So you’re like a generalist, but you work in the hospital?”

I let it go. Mardi Gras wasn’t the time to launch into all that a hospitalist truly embodies: quality improvement, systems redesign, patient safety, effective transitions of care. And he probably wouldn’t remember it tomorrow anyway. But my reveler friend’s summary statement stayed with me through the night, for it returned me to a core philosophical tenet: Esse est percipi. We are who we appear to be.

There are 30,000 of us now, all facing the same problem: How do we match who we are perceived to be with who we are? The hospitalist is much more than a “generalist who works in a hospital,” but what is perceived to be is equally as important as what is. At the root of the problem is a question of accountability: How do we hold ourselves out to the public as a specialty that possesses the knowledge and skills necessary to advance quality and safety for the hospitalized patient?

This question of public accountability is not new to the profession. The heterogeneity of physicians in the early 1900s, from the authentic to the snake-oil salesmen, prompted the need for independent validation of physicians’ qualifications. Dr. Derrick Vail introduced the concept of a board certification in 1908, with the goal of “issuing credentials that would assure the public of the specialist’s qualifications.” The American Board of Medical Specialties was formed in 1933, and continues to this day to be the entity responsible for ensuring this accountability.

While there are no “snake-oil salesmen” in HM, there is heterogeneity. There are many of us answering the call to advance quality and patient safety, but there are many more of us who are not yet there. And there are some (i.e., those practicing medicine in the hospital while awaiting a subspecialty fellowship) who, while referred to as “hospitalists,” do not embrace the central tenets of the career hospitalist. Thirty-thousand hospitalists is a spectacular achievement, but with that growth comes the new problem of dilution: Without some measure of distinguishing those who are authentic in the value-added services of quality and patient safety from those who have not embraced these tenets, the perception of us all will be merely “physicians who practice in the hospital.”

To my mind, the American Board of Internal Medicine’s (ABIM) Maintenance of Certification (MOC) Focused Practice in Hospital Medicine (FPHM) program answers this question of public accountability. This new MOC process provides an objective way of establishing that hospitalists who claim to be competent in their field have, in fact, demonstrated this competence. Paradoxically, it is even more compelling than a board certification following a residency or fellowship; skills and knowledge fade over time, and new knowledge consistently is added. The MOC certification assures the public that despite these challenges, the certified hospitalist has continued to maintain competence in the field.

Further, the components of the FPHM (www.abim.org/specialty/fphm.aspx) provide assurance that the certified hospitalist has the expertise to practice HM, and has the knowledge and skills necessary to offer the value-added services of quality, patient safety, and performance improvement.

Why Is It Important to Recertify?

Registration for the MOC in FPHM opened March 15, and more than 100 hospitalists enrolled in the program in the first two weeks. While exciting, this number is not enough; here I share with you my reflections on why this MOC is so important to our field.

As with all things SHM, the rationale begins with, “What is the best thing for the patient?” I completed my first recertification in 2008, and I can honestly say that this was the first “test” in my career that actually made me a better physician for my patients. I was skeptical at first, seeing the MOC as another bureaucratic hurdle for which I would have the opportunity to pay $1,000. But the reality was that it was much more than that; it made me a better physician. It alerted me to blind spots in my clinical repertoire: some topics I had never learned, some I had forgotten, and some that were new knowledge.

Preparing for the examination isn’t onerous, perhaps a couple extra hours a week of reading. Since the examination focused on the practical aspects of diagnosis and management, and not the basic- science minutiae that had characterized the earlier examinations in my career, I found that the preparation for the MOC exam improved my practice of medicine. The only downside was that I did not have the luxury of an HM-focused exam in 2008, and there were content areas on the standard internal medicine (IM) MOC that were not a part of my inpatient practice.

But it was the Practice Improvement Module (PIM) component of the MOC process, a shared feature of both the FPHM and the IM MOC processes, that most benefited my patients. As a hospitalist, this too was not onerous, as practice improvement is what I do on a daily basis. Moreover, it was the external discipline of completing the PIM that made it truly valuable: collecting data, reflecting on methods of improvement, enacting an intervention, and then reassessing the results. The process forced me to reflect on my practice, and it heightened my sensitivity to other parts of my practice, and the hospital system, that needed to be improved.

Further benefit came through collaboration with other physicians in my group, as encouraged by the ABIM, to complete the PIM. This teamwork fostered a heightened spirit of QI within our team, further augmenting quality of care and sensitivity to needed systems improvements. True, at the end of the process, I was $1,000 lighter … but my conscience was richer. I had improved as a physician, and I think it has translated into a benefit for my patients.

What Recertification Means to HM

Although the virtue of improving patient care is sufficient to justify participation in the MOC in FPHM, the passage of healthcare reform legislation raises the stakes for hospitalists. The Physician Quality Reporting Initiative (PQRI) is an ongoing reality, further voicing the public’s need for accountability.

The final impact will hinge on the Center for Medicare & Medicaid Services’ (CMS) interpretation and execution of the language in the final bill, but it is clear that physicians who participate in the PQRI (through claims-based or registry reporting) have the opportunity to receive an additional 0.5% bonus on their total allowable Medicare charges in 2011 through 2014, if they also meet MOC program requirements. (The health reform bill provides a 1.0% bonus in 2011 for PQRI participation and a 0.5% bonus through 2014.)

Subsequently, physicians who do not participate in the PQRI will face a 1.5% payment penalty in 2015, and a 2% payment penalty in 2016 and thereafter. With these incentives, it appears the day-to-day finances of practice will offset the cost of MOC participation.

The importance of FPHM extends to the remainder of the PQRI as well. Currently, HM is not recognized by CMS as its own specialty, which means that it does not have its own CMS specialty code. In turn, this means that the core measures CMS will apply to the hospitalist in fulfilling the PQRI standards will be those of the general internist, and these might or might not apply to HM practice. For those to whom the standards do not apply, PQRI becomes a practical impossibility, though the financial penalty remains an unfortunate reality.

The extent to which the core measures for general medicine do not apply to the inpatient environment is the extent to which PQRI will be less effective in incentivizing the advancement of inpatient healthcare quality. This is an opportunity missed. Preventing this systematic exclusion begins with recognizing HM as a specialty. In convincing CMS that HM is its own specialty, deserving of its own code and its own PQRI indices, I can think of no argument as compelling as pointing to 10,000 hospitalists certified in the MOC in FPHM program.

Financial incentives aside, the ultimate success of HM will be in our ability to change the healthcare system such that it provides safe, timely, equitable, efficient, and patient-centered care. We’ve spent more than 10 years trying to get into the conversation, and now we have a seat at the table. But to be effective in this audacious goal, we must speak with a stentorian voice—a timbre that comes only from the chords of the sincere. Society must know of our sincerity—not by our words, but by our actions.

As president of SHM, I am calling on you to join me in meeting this standard of public accountability. Let us prove to the world that our talk of quality and patient safety is much more than talk. Let us establish that we are willing to engage in the ongoing self-improvement necessary to reach this wished-for goal.

Esse est percipi. We are as we are perceived. Now is our time to make one with the other—fulfilling a covenant that promises that we will, eventually, close this quality chasm. TH

Dr. Wiese is president of SHM.

You’re a what?” he asked over the noise of the passing Mardi Gras parade.

“I’m a hospitalist,” I replied.

“Oh.” There was an extended pause. I could tell he was searching his mental database to determine if he had a family member who was a hospitalist. Nope, nothing there. Then it came: “What is that exactly?” I followed with a general description of “what a hospitalist does,” but his response made it apparent that my description hadn’t stuck: “So you’re like a generalist, but you work in the hospital?”

I let it go. Mardi Gras wasn’t the time to launch into all that a hospitalist truly embodies: quality improvement, systems redesign, patient safety, effective transitions of care. And he probably wouldn’t remember it tomorrow anyway. But my reveler friend’s summary statement stayed with me through the night, for it returned me to a core philosophical tenet: Esse est percipi. We are who we appear to be.

There are 30,000 of us now, all facing the same problem: How do we match who we are perceived to be with who we are? The hospitalist is much more than a “generalist who works in a hospital,” but what is perceived to be is equally as important as what is. At the root of the problem is a question of accountability: How do we hold ourselves out to the public as a specialty that possesses the knowledge and skills necessary to advance quality and safety for the hospitalized patient?

This question of public accountability is not new to the profession. The heterogeneity of physicians in the early 1900s, from the authentic to the snake-oil salesmen, prompted the need for independent validation of physicians’ qualifications. Dr. Derrick Vail introduced the concept of a board certification in 1908, with the goal of “issuing credentials that would assure the public of the specialist’s qualifications.” The American Board of Medical Specialties was formed in 1933, and continues to this day to be the entity responsible for ensuring this accountability.

While there are no “snake-oil salesmen” in HM, there is heterogeneity. There are many of us answering the call to advance quality and patient safety, but there are many more of us who are not yet there. And there are some (i.e., those practicing medicine in the hospital while awaiting a subspecialty fellowship) who, while referred to as “hospitalists,” do not embrace the central tenets of the career hospitalist. Thirty-thousand hospitalists is a spectacular achievement, but with that growth comes the new problem of dilution: Without some measure of distinguishing those who are authentic in the value-added services of quality and patient safety from those who have not embraced these tenets, the perception of us all will be merely “physicians who practice in the hospital.”

To my mind, the American Board of Internal Medicine’s (ABIM) Maintenance of Certification (MOC) Focused Practice in Hospital Medicine (FPHM) program answers this question of public accountability. This new MOC process provides an objective way of establishing that hospitalists who claim to be competent in their field have, in fact, demonstrated this competence. Paradoxically, it is even more compelling than a board certification following a residency or fellowship; skills and knowledge fade over time, and new knowledge consistently is added. The MOC certification assures the public that despite these challenges, the certified hospitalist has continued to maintain competence in the field.

Further, the components of the FPHM (www.abim.org/specialty/fphm.aspx) provide assurance that the certified hospitalist has the expertise to practice HM, and has the knowledge and skills necessary to offer the value-added services of quality, patient safety, and performance improvement.

Why Is It Important to Recertify?

Registration for the MOC in FPHM opened March 15, and more than 100 hospitalists enrolled in the program in the first two weeks. While exciting, this number is not enough; here I share with you my reflections on why this MOC is so important to our field.

As with all things SHM, the rationale begins with, “What is the best thing for the patient?” I completed my first recertification in 2008, and I can honestly say that this was the first “test” in my career that actually made me a better physician for my patients. I was skeptical at first, seeing the MOC as another bureaucratic hurdle for which I would have the opportunity to pay $1,000. But the reality was that it was much more than that; it made me a better physician. It alerted me to blind spots in my clinical repertoire: some topics I had never learned, some I had forgotten, and some that were new knowledge.

Preparing for the examination isn’t onerous, perhaps a couple extra hours a week of reading. Since the examination focused on the practical aspects of diagnosis and management, and not the basic- science minutiae that had characterized the earlier examinations in my career, I found that the preparation for the MOC exam improved my practice of medicine. The only downside was that I did not have the luxury of an HM-focused exam in 2008, and there were content areas on the standard internal medicine (IM) MOC that were not a part of my inpatient practice.

But it was the Practice Improvement Module (PIM) component of the MOC process, a shared feature of both the FPHM and the IM MOC processes, that most benefited my patients. As a hospitalist, this too was not onerous, as practice improvement is what I do on a daily basis. Moreover, it was the external discipline of completing the PIM that made it truly valuable: collecting data, reflecting on methods of improvement, enacting an intervention, and then reassessing the results. The process forced me to reflect on my practice, and it heightened my sensitivity to other parts of my practice, and the hospital system, that needed to be improved.

Further benefit came through collaboration with other physicians in my group, as encouraged by the ABIM, to complete the PIM. This teamwork fostered a heightened spirit of QI within our team, further augmenting quality of care and sensitivity to needed systems improvements. True, at the end of the process, I was $1,000 lighter … but my conscience was richer. I had improved as a physician, and I think it has translated into a benefit for my patients.

What Recertification Means to HM

Although the virtue of improving patient care is sufficient to justify participation in the MOC in FPHM, the passage of healthcare reform legislation raises the stakes for hospitalists. The Physician Quality Reporting Initiative (PQRI) is an ongoing reality, further voicing the public’s need for accountability.

The final impact will hinge on the Center for Medicare & Medicaid Services’ (CMS) interpretation and execution of the language in the final bill, but it is clear that physicians who participate in the PQRI (through claims-based or registry reporting) have the opportunity to receive an additional 0.5% bonus on their total allowable Medicare charges in 2011 through 2014, if they also meet MOC program requirements. (The health reform bill provides a 1.0% bonus in 2011 for PQRI participation and a 0.5% bonus through 2014.)

Subsequently, physicians who do not participate in the PQRI will face a 1.5% payment penalty in 2015, and a 2% payment penalty in 2016 and thereafter. With these incentives, it appears the day-to-day finances of practice will offset the cost of MOC participation.

The importance of FPHM extends to the remainder of the PQRI as well. Currently, HM is not recognized by CMS as its own specialty, which means that it does not have its own CMS specialty code. In turn, this means that the core measures CMS will apply to the hospitalist in fulfilling the PQRI standards will be those of the general internist, and these might or might not apply to HM practice. For those to whom the standards do not apply, PQRI becomes a practical impossibility, though the financial penalty remains an unfortunate reality.

The extent to which the core measures for general medicine do not apply to the inpatient environment is the extent to which PQRI will be less effective in incentivizing the advancement of inpatient healthcare quality. This is an opportunity missed. Preventing this systematic exclusion begins with recognizing HM as a specialty. In convincing CMS that HM is its own specialty, deserving of its own code and its own PQRI indices, I can think of no argument as compelling as pointing to 10,000 hospitalists certified in the MOC in FPHM program.

Financial incentives aside, the ultimate success of HM will be in our ability to change the healthcare system such that it provides safe, timely, equitable, efficient, and patient-centered care. We’ve spent more than 10 years trying to get into the conversation, and now we have a seat at the table. But to be effective in this audacious goal, we must speak with a stentorian voice—a timbre that comes only from the chords of the sincere. Society must know of our sincerity—not by our words, but by our actions.

As president of SHM, I am calling on you to join me in meeting this standard of public accountability. Let us prove to the world that our talk of quality and patient safety is much more than talk. Let us establish that we are willing to engage in the ongoing self-improvement necessary to reach this wished-for goal.

Esse est percipi. We are as we are perceived. Now is our time to make one with the other—fulfilling a covenant that promises that we will, eventually, close this quality chasm. TH

Dr. Wiese is president of SHM.

You’re a what?” he asked over the noise of the passing Mardi Gras parade.

“I’m a hospitalist,” I replied.

“Oh.” There was an extended pause. I could tell he was searching his mental database to determine if he had a family member who was a hospitalist. Nope, nothing there. Then it came: “What is that exactly?” I followed with a general description of “what a hospitalist does,” but his response made it apparent that my description hadn’t stuck: “So you’re like a generalist, but you work in the hospital?”

I let it go. Mardi Gras wasn’t the time to launch into all that a hospitalist truly embodies: quality improvement, systems redesign, patient safety, effective transitions of care. And he probably wouldn’t remember it tomorrow anyway. But my reveler friend’s summary statement stayed with me through the night, for it returned me to a core philosophical tenet: Esse est percipi. We are who we appear to be.

There are 30,000 of us now, all facing the same problem: How do we match who we are perceived to be with who we are? The hospitalist is much more than a “generalist who works in a hospital,” but what is perceived to be is equally as important as what is. At the root of the problem is a question of accountability: How do we hold ourselves out to the public as a specialty that possesses the knowledge and skills necessary to advance quality and safety for the hospitalized patient?

This question of public accountability is not new to the profession. The heterogeneity of physicians in the early 1900s, from the authentic to the snake-oil salesmen, prompted the need for independent validation of physicians’ qualifications. Dr. Derrick Vail introduced the concept of a board certification in 1908, with the goal of “issuing credentials that would assure the public of the specialist’s qualifications.” The American Board of Medical Specialties was formed in 1933, and continues to this day to be the entity responsible for ensuring this accountability.

While there are no “snake-oil salesmen” in HM, there is heterogeneity. There are many of us answering the call to advance quality and patient safety, but there are many more of us who are not yet there. And there are some (i.e., those practicing medicine in the hospital while awaiting a subspecialty fellowship) who, while referred to as “hospitalists,” do not embrace the central tenets of the career hospitalist. Thirty-thousand hospitalists is a spectacular achievement, but with that growth comes the new problem of dilution: Without some measure of distinguishing those who are authentic in the value-added services of quality and patient safety from those who have not embraced these tenets, the perception of us all will be merely “physicians who practice in the hospital.”

To my mind, the American Board of Internal Medicine’s (ABIM) Maintenance of Certification (MOC) Focused Practice in Hospital Medicine (FPHM) program answers this question of public accountability. This new MOC process provides an objective way of establishing that hospitalists who claim to be competent in their field have, in fact, demonstrated this competence. Paradoxically, it is even more compelling than a board certification following a residency or fellowship; skills and knowledge fade over time, and new knowledge consistently is added. The MOC certification assures the public that despite these challenges, the certified hospitalist has continued to maintain competence in the field.

Further, the components of the FPHM (www.abim.org/specialty/fphm.aspx) provide assurance that the certified hospitalist has the expertise to practice HM, and has the knowledge and skills necessary to offer the value-added services of quality, patient safety, and performance improvement.

Why Is It Important to Recertify?

Registration for the MOC in FPHM opened March 15, and more than 100 hospitalists enrolled in the program in the first two weeks. While exciting, this number is not enough; here I share with you my reflections on why this MOC is so important to our field.

As with all things SHM, the rationale begins with, “What is the best thing for the patient?” I completed my first recertification in 2008, and I can honestly say that this was the first “test” in my career that actually made me a better physician for my patients. I was skeptical at first, seeing the MOC as another bureaucratic hurdle for which I would have the opportunity to pay $1,000. But the reality was that it was much more than that; it made me a better physician. It alerted me to blind spots in my clinical repertoire: some topics I had never learned, some I had forgotten, and some that were new knowledge.

Preparing for the examination isn’t onerous, perhaps a couple extra hours a week of reading. Since the examination focused on the practical aspects of diagnosis and management, and not the basic- science minutiae that had characterized the earlier examinations in my career, I found that the preparation for the MOC exam improved my practice of medicine. The only downside was that I did not have the luxury of an HM-focused exam in 2008, and there were content areas on the standard internal medicine (IM) MOC that were not a part of my inpatient practice.

But it was the Practice Improvement Module (PIM) component of the MOC process, a shared feature of both the FPHM and the IM MOC processes, that most benefited my patients. As a hospitalist, this too was not onerous, as practice improvement is what I do on a daily basis. Moreover, it was the external discipline of completing the PIM that made it truly valuable: collecting data, reflecting on methods of improvement, enacting an intervention, and then reassessing the results. The process forced me to reflect on my practice, and it heightened my sensitivity to other parts of my practice, and the hospital system, that needed to be improved.

Further benefit came through collaboration with other physicians in my group, as encouraged by the ABIM, to complete the PIM. This teamwork fostered a heightened spirit of QI within our team, further augmenting quality of care and sensitivity to needed systems improvements. True, at the end of the process, I was $1,000 lighter … but my conscience was richer. I had improved as a physician, and I think it has translated into a benefit for my patients.

What Recertification Means to HM

Although the virtue of improving patient care is sufficient to justify participation in the MOC in FPHM, the passage of healthcare reform legislation raises the stakes for hospitalists. The Physician Quality Reporting Initiative (PQRI) is an ongoing reality, further voicing the public’s need for accountability.

The final impact will hinge on the Center for Medicare & Medicaid Services’ (CMS) interpretation and execution of the language in the final bill, but it is clear that physicians who participate in the PQRI (through claims-based or registry reporting) have the opportunity to receive an additional 0.5% bonus on their total allowable Medicare charges in 2011 through 2014, if they also meet MOC program requirements. (The health reform bill provides a 1.0% bonus in 2011 for PQRI participation and a 0.5% bonus through 2014.)

Subsequently, physicians who do not participate in the PQRI will face a 1.5% payment penalty in 2015, and a 2% payment penalty in 2016 and thereafter. With these incentives, it appears the day-to-day finances of practice will offset the cost of MOC participation.

The importance of FPHM extends to the remainder of the PQRI as well. Currently, HM is not recognized by CMS as its own specialty, which means that it does not have its own CMS specialty code. In turn, this means that the core measures CMS will apply to the hospitalist in fulfilling the PQRI standards will be those of the general internist, and these might or might not apply to HM practice. For those to whom the standards do not apply, PQRI becomes a practical impossibility, though the financial penalty remains an unfortunate reality.

The extent to which the core measures for general medicine do not apply to the inpatient environment is the extent to which PQRI will be less effective in incentivizing the advancement of inpatient healthcare quality. This is an opportunity missed. Preventing this systematic exclusion begins with recognizing HM as a specialty. In convincing CMS that HM is its own specialty, deserving of its own code and its own PQRI indices, I can think of no argument as compelling as pointing to 10,000 hospitalists certified in the MOC in FPHM program.

Financial incentives aside, the ultimate success of HM will be in our ability to change the healthcare system such that it provides safe, timely, equitable, efficient, and patient-centered care. We’ve spent more than 10 years trying to get into the conversation, and now we have a seat at the table. But to be effective in this audacious goal, we must speak with a stentorian voice—a timbre that comes only from the chords of the sincere. Society must know of our sincerity—not by our words, but by our actions.

As president of SHM, I am calling on you to join me in meeting this standard of public accountability. Let us prove to the world that our talk of quality and patient safety is much more than talk. Let us establish that we are willing to engage in the ongoing self-improvement necessary to reach this wished-for goal.

Esse est percipi. We are as we are perceived. Now is our time to make one with the other—fulfilling a covenant that promises that we will, eventually, close this quality chasm. TH

Dr. Wiese is president of SHM.