Kevin J. O'Leary, MD, MS

METHODS

RESULTS

DISCUSSION

CONCLUSIONS

METHODS

RESULTS

DISCUSSION

CONCLUSIONS

METHODS

RESULTS

DISCUSSION

CONCLUSIONS

Care of hospitalized patients requires effective teamwork within groups composed of physicians (eg, residents, hospitalists, specialists), advanced practice providers, nurses, patient‐care technicians, pharmacists, social workers, and therapists. Sadly, hospital‐based team members often fail to communicate. For example, 2 studies found that nurses and physicians communicated with one another on only 50% to 60% of their patients' hospital days, resulting in a lack of a mutual understanding of the plan of care.[1, 2]

Failure to communicate effectively may be because the hospital setting poses important challenges to teamwork, including the use of large teams with membership that changes frequently because of the need to provide care around the clock. Furthermore, individual team members often have high workloads, care for multiple patients simultaneously, and are seldom in the same place at the same time.

Interdisciplinary rounds (IDR) are a microsystem‐level solution with the goal to share information, achieve mutual understanding, and collaboratively revise the plan of care within care teams. Though common, IDR look very different across hospitals, making studies that evaluate novel strategies to improve IDR and measure their impact of great interest to hospital medicine.

In this issue of the Journal of Hospital Medicine, Bhamidipati and colleagues present a systematic review of published studies evaluating the effect of IDR on patient outcomes.[3] The systematic review included 22 studies, including 12 experimental/quasiexperimental and 10 observational studies. Overall, 13 studies were of low to medium quality, and 9 were high quality. Importantly, relatively few studies reported the degree to which IDR were implemented as planned. The investigators found evidence that IDR had a positive effect on length of stay (LOS) and staff satisfaction, but little evidence to support an effect on patient safety or satisfaction. Furthermore, the investigators found significant variability in IDR design and team composition. Some of this variation is to be expected, as IDR, like other interventions to improve quality and safety of patient care in complex settings, should be implemented with an expectation that the team may need to make adaptations based on local contextual factors such as workload (eg, daily census), environment (eg, open vs closed intensive care unit), local politics (eg, uniquely strong support for/against the intervention), and prior experience (eg, prior failed, similar interventions).[4, 5] Moreover, objectives for IDR may differ across settings. Some hospitals may have room (and a need) to improve LOS, whereas others may prioritize improving patient safety or patient experience metrics.

Bhamidipati and colleagues explain that their review did not reveal a causal pathway between IDR design and outcomes. We believe this lack of association is because most of the included studies did not propose a causal pathway between the IDR components implemented and the outcomes assessed. That is, few studies referred to conceptual models that explain how components of the IDR intervention might influence downstream patient outcomes.

IDR have the potential to influence a number of patient outcomes, including those reflecting efficiency (eg, length of stay), patient safety (eg, adverse events), and patient centeredness (eg, patient satisfaction). However, these outcomes are influenced by many factors, including patient characteristics and other efforts to improve care. As explained by the investigators, the results of many of the included studies may have been confounded due to relatively weak study designs and statistical analyses. Importantly, few of the studies included in this review report the more proximal measure of teamwork. If we hypothesize that IDR improve patient outcomes, they do so by improving teamwork. After all, the purpose of IDR is to assemble team members so they can communicate about and coordinate care. Measuring teamwork behaviors is difficult, especially on medical services. Measuring teamwork climate, the measurable aspects of team culture, is relatively easy. A recent systematic review of teamwork climate assessments in internal medicine identified the Safety Attitudes Questionnaire and the Team Climate Inventory as having substantial validity evidence and association with improved patient outcomes.[6]

Bhamidipati and colleagues proposed a definition for IDR and taxonomy for IDR design and reporting based on their systematic review. Although very useful, the IDR definition may be too limiting as evidenced by the fact that very few studies would be included in a systematic review using this definition as the inclusion criteria. Their proposed taxonomy should serve as a useful framework for future research efforts and appropriately recommends reporting of site characteristics, components of IDR design, and outcomes.

The systematic review by Bhamidipati et al. must also be interpreted in conjunction with another recently published systematic review by Pannick and colleagues assessing the effect of interdisciplinary team care interventions on general medical wards.[7] Contrary to the findings of the Bhamidipati et al. study, Pannick and colleagues found that most interdisciplinary team care interventions had no effect on LOS, but that half of the studies found an improvement in complications of care. Importantly, Pannick and colleagues included only experimental and quasiexperimental studies in their systematic review (ie, no observational studies).

There is clearly more work to be done in researching IDR and other interventions to improve teamwork in general medical settings. Larger studies are needed to provide sufficient power to detect improvement in outcomes. Future studies need to report the degree to which interventions are implemented as planned and need to use stronger study designs (eg, cluster randomized control or interrupted time series) to avoid the influence of confounders. Qualitative methods should be used to assess the influence of contextual factors on the success of interventions.[4] Most importantly, future studies should be based on conceptual models that explain how components of the intervention influence proximal measures of teamwork and downstream patient outcomes.

In the meantime, what is a hospital leader to do? We believe efforts to improve IDR are warranted, but that IDR program leaders need to first specify their primary objective(s). For example, in some hospitals, there may be little room to further reduce LOS, so another goalreducing preventable readmissions or reducing adverse eventsmight be specified as the key performance indicator. This crucial first step of creating a shared goal informs the design, implementation, and evaluation of IDR. We also believe that geographic localization of physicians to specific units is foundational to improving IDR. Physicians cannot feasibly attend IDR if their patients are spread across multiple units (or buildings). Finally, hospital leaders also need to view IDR as part of a larger set of interventions to improve teamwork. Leaders need to assess the adequacy of staffing levels, workflow, and team composition.[8] Unit‐based interdisciplinary leadership models should be used to help link efforts at various levels within a larger system.[9] These models designate a unit medical director and nurse manager who are jointly responsible for unit performance.

In conclusion, IDR play an important role in improving patient outcomes, but only do so by improving teamwork. In redesigning IDR, leaders need to be thoughtful about what outcomes IDR can affect, how IDR affect them, and how IDR fit into larger‐scale efforts to improve performance.

Care of hospitalized patients requires effective teamwork within groups composed of physicians (eg, residents, hospitalists, specialists), advanced practice providers, nurses, patient‐care technicians, pharmacists, social workers, and therapists. Sadly, hospital‐based team members often fail to communicate. For example, 2 studies found that nurses and physicians communicated with one another on only 50% to 60% of their patients' hospital days, resulting in a lack of a mutual understanding of the plan of care.[1, 2]

Failure to communicate effectively may be because the hospital setting poses important challenges to teamwork, including the use of large teams with membership that changes frequently because of the need to provide care around the clock. Furthermore, individual team members often have high workloads, care for multiple patients simultaneously, and are seldom in the same place at the same time.

Interdisciplinary rounds (IDR) are a microsystem‐level solution with the goal to share information, achieve mutual understanding, and collaboratively revise the plan of care within care teams. Though common, IDR look very different across hospitals, making studies that evaluate novel strategies to improve IDR and measure their impact of great interest to hospital medicine.

In this issue of the Journal of Hospital Medicine, Bhamidipati and colleagues present a systematic review of published studies evaluating the effect of IDR on patient outcomes.[3] The systematic review included 22 studies, including 12 experimental/quasiexperimental and 10 observational studies. Overall, 13 studies were of low to medium quality, and 9 were high quality. Importantly, relatively few studies reported the degree to which IDR were implemented as planned. The investigators found evidence that IDR had a positive effect on length of stay (LOS) and staff satisfaction, but little evidence to support an effect on patient safety or satisfaction. Furthermore, the investigators found significant variability in IDR design and team composition. Some of this variation is to be expected, as IDR, like other interventions to improve quality and safety of patient care in complex settings, should be implemented with an expectation that the team may need to make adaptations based on local contextual factors such as workload (eg, daily census), environment (eg, open vs closed intensive care unit), local politics (eg, uniquely strong support for/against the intervention), and prior experience (eg, prior failed, similar interventions).[4, 5] Moreover, objectives for IDR may differ across settings. Some hospitals may have room (and a need) to improve LOS, whereas others may prioritize improving patient safety or patient experience metrics.

Bhamidipati and colleagues explain that their review did not reveal a causal pathway between IDR design and outcomes. We believe this lack of association is because most of the included studies did not propose a causal pathway between the IDR components implemented and the outcomes assessed. That is, few studies referred to conceptual models that explain how components of the IDR intervention might influence downstream patient outcomes.

IDR have the potential to influence a number of patient outcomes, including those reflecting efficiency (eg, length of stay), patient safety (eg, adverse events), and patient centeredness (eg, patient satisfaction). However, these outcomes are influenced by many factors, including patient characteristics and other efforts to improve care. As explained by the investigators, the results of many of the included studies may have been confounded due to relatively weak study designs and statistical analyses. Importantly, few of the studies included in this review report the more proximal measure of teamwork. If we hypothesize that IDR improve patient outcomes, they do so by improving teamwork. After all, the purpose of IDR is to assemble team members so they can communicate about and coordinate care. Measuring teamwork behaviors is difficult, especially on medical services. Measuring teamwork climate, the measurable aspects of team culture, is relatively easy. A recent systematic review of teamwork climate assessments in internal medicine identified the Safety Attitudes Questionnaire and the Team Climate Inventory as having substantial validity evidence and association with improved patient outcomes.[6]

Bhamidipati and colleagues proposed a definition for IDR and taxonomy for IDR design and reporting based on their systematic review. Although very useful, the IDR definition may be too limiting as evidenced by the fact that very few studies would be included in a systematic review using this definition as the inclusion criteria. Their proposed taxonomy should serve as a useful framework for future research efforts and appropriately recommends reporting of site characteristics, components of IDR design, and outcomes.

The systematic review by Bhamidipati et al. must also be interpreted in conjunction with another recently published systematic review by Pannick and colleagues assessing the effect of interdisciplinary team care interventions on general medical wards.[7] Contrary to the findings of the Bhamidipati et al. study, Pannick and colleagues found that most interdisciplinary team care interventions had no effect on LOS, but that half of the studies found an improvement in complications of care. Importantly, Pannick and colleagues included only experimental and quasiexperimental studies in their systematic review (ie, no observational studies).

There is clearly more work to be done in researching IDR and other interventions to improve teamwork in general medical settings. Larger studies are needed to provide sufficient power to detect improvement in outcomes. Future studies need to report the degree to which interventions are implemented as planned and need to use stronger study designs (eg, cluster randomized control or interrupted time series) to avoid the influence of confounders. Qualitative methods should be used to assess the influence of contextual factors on the success of interventions.[4] Most importantly, future studies should be based on conceptual models that explain how components of the intervention influence proximal measures of teamwork and downstream patient outcomes.

In the meantime, what is a hospital leader to do? We believe efforts to improve IDR are warranted, but that IDR program leaders need to first specify their primary objective(s). For example, in some hospitals, there may be little room to further reduce LOS, so another goalreducing preventable readmissions or reducing adverse eventsmight be specified as the key performance indicator. This crucial first step of creating a shared goal informs the design, implementation, and evaluation of IDR. We also believe that geographic localization of physicians to specific units is foundational to improving IDR. Physicians cannot feasibly attend IDR if their patients are spread across multiple units (or buildings). Finally, hospital leaders also need to view IDR as part of a larger set of interventions to improve teamwork. Leaders need to assess the adequacy of staffing levels, workflow, and team composition.[8] Unit‐based interdisciplinary leadership models should be used to help link efforts at various levels within a larger system.[9] These models designate a unit medical director and nurse manager who are jointly responsible for unit performance.

In conclusion, IDR play an important role in improving patient outcomes, but only do so by improving teamwork. In redesigning IDR, leaders need to be thoughtful about what outcomes IDR can affect, how IDR affect them, and how IDR fit into larger‐scale efforts to improve performance.

Care of hospitalized patients requires effective teamwork within groups composed of physicians (eg, residents, hospitalists, specialists), advanced practice providers, nurses, patient‐care technicians, pharmacists, social workers, and therapists. Sadly, hospital‐based team members often fail to communicate. For example, 2 studies found that nurses and physicians communicated with one another on only 50% to 60% of their patients' hospital days, resulting in a lack of a mutual understanding of the plan of care.[1, 2]

Failure to communicate effectively may be because the hospital setting poses important challenges to teamwork, including the use of large teams with membership that changes frequently because of the need to provide care around the clock. Furthermore, individual team members often have high workloads, care for multiple patients simultaneously, and are seldom in the same place at the same time.

Interdisciplinary rounds (IDR) are a microsystem‐level solution with the goal to share information, achieve mutual understanding, and collaboratively revise the plan of care within care teams. Though common, IDR look very different across hospitals, making studies that evaluate novel strategies to improve IDR and measure their impact of great interest to hospital medicine.

In this issue of the Journal of Hospital Medicine, Bhamidipati and colleagues present a systematic review of published studies evaluating the effect of IDR on patient outcomes.[3] The systematic review included 22 studies, including 12 experimental/quasiexperimental and 10 observational studies. Overall, 13 studies were of low to medium quality, and 9 were high quality. Importantly, relatively few studies reported the degree to which IDR were implemented as planned. The investigators found evidence that IDR had a positive effect on length of stay (LOS) and staff satisfaction, but little evidence to support an effect on patient safety or satisfaction. Furthermore, the investigators found significant variability in IDR design and team composition. Some of this variation is to be expected, as IDR, like other interventions to improve quality and safety of patient care in complex settings, should be implemented with an expectation that the team may need to make adaptations based on local contextual factors such as workload (eg, daily census), environment (eg, open vs closed intensive care unit), local politics (eg, uniquely strong support for/against the intervention), and prior experience (eg, prior failed, similar interventions).[4, 5] Moreover, objectives for IDR may differ across settings. Some hospitals may have room (and a need) to improve LOS, whereas others may prioritize improving patient safety or patient experience metrics.

Bhamidipati and colleagues explain that their review did not reveal a causal pathway between IDR design and outcomes. We believe this lack of association is because most of the included studies did not propose a causal pathway between the IDR components implemented and the outcomes assessed. That is, few studies referred to conceptual models that explain how components of the IDR intervention might influence downstream patient outcomes.

IDR have the potential to influence a number of patient outcomes, including those reflecting efficiency (eg, length of stay), patient safety (eg, adverse events), and patient centeredness (eg, patient satisfaction). However, these outcomes are influenced by many factors, including patient characteristics and other efforts to improve care. As explained by the investigators, the results of many of the included studies may have been confounded due to relatively weak study designs and statistical analyses. Importantly, few of the studies included in this review report the more proximal measure of teamwork. If we hypothesize that IDR improve patient outcomes, they do so by improving teamwork. After all, the purpose of IDR is to assemble team members so they can communicate about and coordinate care. Measuring teamwork behaviors is difficult, especially on medical services. Measuring teamwork climate, the measurable aspects of team culture, is relatively easy. A recent systematic review of teamwork climate assessments in internal medicine identified the Safety Attitudes Questionnaire and the Team Climate Inventory as having substantial validity evidence and association with improved patient outcomes.[6]

Bhamidipati and colleagues proposed a definition for IDR and taxonomy for IDR design and reporting based on their systematic review. Although very useful, the IDR definition may be too limiting as evidenced by the fact that very few studies would be included in a systematic review using this definition as the inclusion criteria. Their proposed taxonomy should serve as a useful framework for future research efforts and appropriately recommends reporting of site characteristics, components of IDR design, and outcomes.

The systematic review by Bhamidipati et al. must also be interpreted in conjunction with another recently published systematic review by Pannick and colleagues assessing the effect of interdisciplinary team care interventions on general medical wards.[7] Contrary to the findings of the Bhamidipati et al. study, Pannick and colleagues found that most interdisciplinary team care interventions had no effect on LOS, but that half of the studies found an improvement in complications of care. Importantly, Pannick and colleagues included only experimental and quasiexperimental studies in their systematic review (ie, no observational studies).

There is clearly more work to be done in researching IDR and other interventions to improve teamwork in general medical settings. Larger studies are needed to provide sufficient power to detect improvement in outcomes. Future studies need to report the degree to which interventions are implemented as planned and need to use stronger study designs (eg, cluster randomized control or interrupted time series) to avoid the influence of confounders. Qualitative methods should be used to assess the influence of contextual factors on the success of interventions.[4] Most importantly, future studies should be based on conceptual models that explain how components of the intervention influence proximal measures of teamwork and downstream patient outcomes.

In the meantime, what is a hospital leader to do? We believe efforts to improve IDR are warranted, but that IDR program leaders need to first specify their primary objective(s). For example, in some hospitals, there may be little room to further reduce LOS, so another goalreducing preventable readmissions or reducing adverse eventsmight be specified as the key performance indicator. This crucial first step of creating a shared goal informs the design, implementation, and evaluation of IDR. We also believe that geographic localization of physicians to specific units is foundational to improving IDR. Physicians cannot feasibly attend IDR if their patients are spread across multiple units (or buildings). Finally, hospital leaders also need to view IDR as part of a larger set of interventions to improve teamwork. Leaders need to assess the adequacy of staffing levels, workflow, and team composition.[8] Unit‐based interdisciplinary leadership models should be used to help link efforts at various levels within a larger system.[9] These models designate a unit medical director and nurse manager who are jointly responsible for unit performance.

In conclusion, IDR play an important role in improving patient outcomes, but only do so by improving teamwork. In redesigning IDR, leaders need to be thoughtful about what outcomes IDR can affect, how IDR affect them, and how IDR fit into larger‐scale efforts to improve performance.

We greatly appreciate the thoughtful points made by Dr. Kerman regarding our recently published study evaluating the association of hospitalist continuity on adverse events (AEs).[1] We agree that a 7‐on/7‐off staffing model may limit discontinuity relative to models using shorter rotations lengths. Many hospital medicine programs use a 7‐on/7‐off model to optimize continuity. Longer rotation lengths are uncommon, as they may lead to fatigue and negatively affect physician work‐life balance. Shorter rotation lengths do exist, and we acknowledge that a study in a setting with greater fragmentation may have detected an effect.

We respectfully disagree with Dr. Kerman's concern that our methods for AE detection and confirmation may have been insensitive. We did not rely on incident reports, as these systems suffer from under‐reporting and often represent only a fraction of true AEs. We used a modified version of the classic 2‐stage method to identify and confirm AEs.[2] In the first stage, we used computerized screens, based on criteria from the Harvard Medical Practice Study and Institute for Healthcare Improvement global trigger tool, to identify potential AEs.[3, 4, 5] A research nurse created narrative summaries of potential AEs. A physician researcher then reviewed the narrative summaries to confirm whether an AE was truly present. This time‐consuming method is much more sensitive and specific than other options for patient safety measurement, including administrative data analyses and incident reporting systems.[6, 7]

With respect to other outcomes that may be affected by hospitalist continuity, we recently published a separate study showing that lower inpatient physician continuity was significantly associated with modest increases in hospital costs.[8] We found no association between continuity and patient satisfaction, but were likely underpowered to detect one. Interestingly, some of the models in our study suggested a slightly reduced risk of readmission with lower continuity. We were surprised by this finding and hypothesized that countervailing forces may be at play during handoffs of care from 1 hospitalist to another. Transitions of care introduce the opportunity for critical information to be lost, but they also introduce the potential for patient reassessment. A hospitalist newly taking over care from another may not be anchored to the initial diagnostic impressions and management plan established by the first. Of course, the potential benefit of a reassessment could only occur if the new hospitalist has time to perform one. At extremely high patient volumes, this theoretical benefit is unlikely to exist.

We did not include length of stay (LOS) as an outcome because hospitalist continuity and LOS are interdependent. Although discontinuity may lead to longer LOS, longer LOS definitely increases the probability of discontinuity. Thus, we controlled for LOS in our statistical models to isolate the effect of continuity. The study by Epstein and colleagues did not take into account the interdependence between LOS and hospitalist continuity.[9] Observational studies are not ideal for determining the effect of continuity on LOS. The Combing Incentives and Continuity Leading to Efficiency (CICLE) study by Chandra and colleagues was a pre‐post evaluation of a hospitalist staffing model specifically designed to improve continuity.[10] In the CICLE model, physicians work in a 4‐day rotation. On day 1, physicians exclusively admit patients. On day 2, physicians care for patients admitted on day 1 and accept patients admitted overnight. On days 3 and 4, physicians continue to care for patients received on days 1 and 2, but receive no additional patients. The remaining patients are transitioned to the next physician entering the cycle at the end of day 4. Chandra and colleagues found a 7.5% reduction in LOS and an 8.5% reduction in charges. Interestingly, they also found a 13.5% increase in readmissions that did not achieve statistical significance (P=0.08). The CICLE study suggests continuity does affect LOS, but is limited in that it did not account for a potential preexisting trend toward lower LOS.

Dr. Kerman presents data showing that it takes longer for a physician to care for a patient who is new to him or her than for a patient who is previously known. This finding has face validity. However, as we have suggested, the extra time spent by the oncoming physician may have both advantages and disadvantages. The disadvantages include time‐consuming cognitive work for the physician and the potential for information loss affecting patient care. The potential advantage is a second physician reassessing the diagnosis and management decisions established by the first, potentially correcting errors and optimizing care.

Ultimately, more research is needed to illuminate the effect of hospitalist continuity on patient outcomes. For now, we feel that hospital medicine group leaders need not institute lengthy rotations or staffing models that prioritize continuity above all other factors, as continuity appears to have little impact on patient outcomes.

We greatly appreciate the thoughtful points made by Dr. Kerman regarding our recently published study evaluating the association of hospitalist continuity on adverse events (AEs).[1] We agree that a 7‐on/7‐off staffing model may limit discontinuity relative to models using shorter rotations lengths. Many hospital medicine programs use a 7‐on/7‐off model to optimize continuity. Longer rotation lengths are uncommon, as they may lead to fatigue and negatively affect physician work‐life balance. Shorter rotation lengths do exist, and we acknowledge that a study in a setting with greater fragmentation may have detected an effect.

We respectfully disagree with Dr. Kerman's concern that our methods for AE detection and confirmation may have been insensitive. We did not rely on incident reports, as these systems suffer from under‐reporting and often represent only a fraction of true AEs. We used a modified version of the classic 2‐stage method to identify and confirm AEs.[2] In the first stage, we used computerized screens, based on criteria from the Harvard Medical Practice Study and Institute for Healthcare Improvement global trigger tool, to identify potential AEs.[3, 4, 5] A research nurse created narrative summaries of potential AEs. A physician researcher then reviewed the narrative summaries to confirm whether an AE was truly present. This time‐consuming method is much more sensitive and specific than other options for patient safety measurement, including administrative data analyses and incident reporting systems.[6, 7]

With respect to other outcomes that may be affected by hospitalist continuity, we recently published a separate study showing that lower inpatient physician continuity was significantly associated with modest increases in hospital costs.[8] We found no association between continuity and patient satisfaction, but were likely underpowered to detect one. Interestingly, some of the models in our study suggested a slightly reduced risk of readmission with lower continuity. We were surprised by this finding and hypothesized that countervailing forces may be at play during handoffs of care from 1 hospitalist to another. Transitions of care introduce the opportunity for critical information to be lost, but they also introduce the potential for patient reassessment. A hospitalist newly taking over care from another may not be anchored to the initial diagnostic impressions and management plan established by the first. Of course, the potential benefit of a reassessment could only occur if the new hospitalist has time to perform one. At extremely high patient volumes, this theoretical benefit is unlikely to exist.

We did not include length of stay (LOS) as an outcome because hospitalist continuity and LOS are interdependent. Although discontinuity may lead to longer LOS, longer LOS definitely increases the probability of discontinuity. Thus, we controlled for LOS in our statistical models to isolate the effect of continuity. The study by Epstein and colleagues did not take into account the interdependence between LOS and hospitalist continuity.[9] Observational studies are not ideal for determining the effect of continuity on LOS. The Combing Incentives and Continuity Leading to Efficiency (CICLE) study by Chandra and colleagues was a pre‐post evaluation of a hospitalist staffing model specifically designed to improve continuity.[10] In the CICLE model, physicians work in a 4‐day rotation. On day 1, physicians exclusively admit patients. On day 2, physicians care for patients admitted on day 1 and accept patients admitted overnight. On days 3 and 4, physicians continue to care for patients received on days 1 and 2, but receive no additional patients. The remaining patients are transitioned to the next physician entering the cycle at the end of day 4. Chandra and colleagues found a 7.5% reduction in LOS and an 8.5% reduction in charges. Interestingly, they also found a 13.5% increase in readmissions that did not achieve statistical significance (P=0.08). The CICLE study suggests continuity does affect LOS, but is limited in that it did not account for a potential preexisting trend toward lower LOS.

Dr. Kerman presents data showing that it takes longer for a physician to care for a patient who is new to him or her than for a patient who is previously known. This finding has face validity. However, as we have suggested, the extra time spent by the oncoming physician may have both advantages and disadvantages. The disadvantages include time‐consuming cognitive work for the physician and the potential for information loss affecting patient care. The potential advantage is a second physician reassessing the diagnosis and management decisions established by the first, potentially correcting errors and optimizing care.

Ultimately, more research is needed to illuminate the effect of hospitalist continuity on patient outcomes. For now, we feel that hospital medicine group leaders need not institute lengthy rotations or staffing models that prioritize continuity above all other factors, as continuity appears to have little impact on patient outcomes.

We greatly appreciate the thoughtful points made by Dr. Kerman regarding our recently published study evaluating the association of hospitalist continuity on adverse events (AEs).[1] We agree that a 7‐on/7‐off staffing model may limit discontinuity relative to models using shorter rotations lengths. Many hospital medicine programs use a 7‐on/7‐off model to optimize continuity. Longer rotation lengths are uncommon, as they may lead to fatigue and negatively affect physician work‐life balance. Shorter rotation lengths do exist, and we acknowledge that a study in a setting with greater fragmentation may have detected an effect.

We respectfully disagree with Dr. Kerman's concern that our methods for AE detection and confirmation may have been insensitive. We did not rely on incident reports, as these systems suffer from under‐reporting and often represent only a fraction of true AEs. We used a modified version of the classic 2‐stage method to identify and confirm AEs.[2] In the first stage, we used computerized screens, based on criteria from the Harvard Medical Practice Study and Institute for Healthcare Improvement global trigger tool, to identify potential AEs.[3, 4, 5] A research nurse created narrative summaries of potential AEs. A physician researcher then reviewed the narrative summaries to confirm whether an AE was truly present. This time‐consuming method is much more sensitive and specific than other options for patient safety measurement, including administrative data analyses and incident reporting systems.[6, 7]

With respect to other outcomes that may be affected by hospitalist continuity, we recently published a separate study showing that lower inpatient physician continuity was significantly associated with modest increases in hospital costs.[8] We found no association between continuity and patient satisfaction, but were likely underpowered to detect one. Interestingly, some of the models in our study suggested a slightly reduced risk of readmission with lower continuity. We were surprised by this finding and hypothesized that countervailing forces may be at play during handoffs of care from 1 hospitalist to another. Transitions of care introduce the opportunity for critical information to be lost, but they also introduce the potential for patient reassessment. A hospitalist newly taking over care from another may not be anchored to the initial diagnostic impressions and management plan established by the first. Of course, the potential benefit of a reassessment could only occur if the new hospitalist has time to perform one. At extremely high patient volumes, this theoretical benefit is unlikely to exist.

We did not include length of stay (LOS) as an outcome because hospitalist continuity and LOS are interdependent. Although discontinuity may lead to longer LOS, longer LOS definitely increases the probability of discontinuity. Thus, we controlled for LOS in our statistical models to isolate the effect of continuity. The study by Epstein and colleagues did not take into account the interdependence between LOS and hospitalist continuity.[9] Observational studies are not ideal for determining the effect of continuity on LOS. The Combing Incentives and Continuity Leading to Efficiency (CICLE) study by Chandra and colleagues was a pre‐post evaluation of a hospitalist staffing model specifically designed to improve continuity.[10] In the CICLE model, physicians work in a 4‐day rotation. On day 1, physicians exclusively admit patients. On day 2, physicians care for patients admitted on day 1 and accept patients admitted overnight. On days 3 and 4, physicians continue to care for patients received on days 1 and 2, but receive no additional patients. The remaining patients are transitioned to the next physician entering the cycle at the end of day 4. Chandra and colleagues found a 7.5% reduction in LOS and an 8.5% reduction in charges. Interestingly, they also found a 13.5% increase in readmissions that did not achieve statistical significance (P=0.08). The CICLE study suggests continuity does affect LOS, but is limited in that it did not account for a potential preexisting trend toward lower LOS.

Dr. Kerman presents data showing that it takes longer for a physician to care for a patient who is new to him or her than for a patient who is previously known. This finding has face validity. However, as we have suggested, the extra time spent by the oncoming physician may have both advantages and disadvantages. The disadvantages include time‐consuming cognitive work for the physician and the potential for information loss affecting patient care. The potential advantage is a second physician reassessing the diagnosis and management decisions established by the first, potentially correcting errors and optimizing care.

Ultimately, more research is needed to illuminate the effect of hospitalist continuity on patient outcomes. For now, we feel that hospital medicine group leaders need not institute lengthy rotations or staffing models that prioritize continuity above all other factors, as continuity appears to have little impact on patient outcomes.

Patient satisfaction has received increased attention in recent years, which we believe is well deserved and long overdue. Anyone who has been hospitalized, or has had a loved one hospitalized, can appreciate that there is room to improve the patient experience. Dedicating time and effort to improving the patient experience is consistent with our professional commitment to comfort, empathize, and partner with our patients. Though patient satisfaction itself is an outcome worthy of our attention, it is also positively associated with measures related to patient safety and clinical effectiveness.[1, 2] Moreover, patient satisfaction is the only publicly reported measure that represents the patient's voice,[3] and accounts for a substantial portion of the Centers for Medicare and Medicaid Services payment adjustments under the Hospital Value Based Purchasing Program.[4]

However, all healthcare professionals should understand some key fundamental issues related to the measurement of patient satisfaction. The survey from which data are publicly reported and used for hospital payment adjustment is the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey, developed by the Agency for Healthcare Research and Quality.[5, 6] HCAHPS is sent to a random sample of 40% of hospitalized patients between 48 hours and 6 weeks after discharge. The HCAHPS survey uses ordinal response scales (eg, never, sometimes, usually, always) that generate highly skewed results toward favorable responses. Therefore, results are reported as the percent top box (ie, the percentage of responses in the most favorable category) rather than as a median score. The skewed distribution of results indicates that most patients are generally satisfied with care (ie, most respondents do not have an axe to grind), but also makes meaningful improvement difficult to achieve. Prior to public reporting and determination of effect on hospital payment, results are adjusted for mode of survey administration and patient mix. The same is not true when patient satisfaction data are used for internal purposes. Hospital leaders typically do not perform statistical adjustment and therefore need to be careful not to make apples‐to‐orangestype comparisons. For example, obstetric patient satisfaction scores should not be compared to general medical patient satisfaction scores, as these populations tend to rate satisfaction differently.

The HCAHPS survey questions are organized into domains of care, including satisfaction with nurses and satisfaction with doctors. Importantly, other healthcare team members may influence patients' perception in these domains. For example, a patient responding to nurse communication questions may also reflect on experiences with patient care technicians, social workers, and therapists. A patient responding to physician communication questions might also reflect on experiences with advanced practice providers. A common mistake is the practice of attributing satisfaction with doctors to the individual who served as the discharge physician. Many readers have likely seen patient satisfaction reports broken out by discharge physician with the expectation that giving this information to individual physicians will serve as useful formative feedback. The reality is that patients see many doctors during a hospitalization. To illustrate this point, we analyzed data from 420 patients admitted to our nonteaching hospitalist service who had completed an HCAHPS survey in 2014. We found that the discharge hospitalist accounted for only 34% of all physician encounters. Furthermore, research has shown that patients' experiences with specialist physicians also have a strong influence on their overall satisfaction with physicians.[7]

Having reliable patient satisfaction data on specific individuals would be a truly powerful formative assessment tool. In this issue of the Journal of Hospital Medicine, Banka and colleagues report on an impressive approach incorporating such a tool to give constructive feedback to physicians.[8] Since 2006, the study site had administered surveys to hospitalized patients that assess their satisfaction with specific resident physicians.[9] However, residency programs only reviewed the survey results with resident physicians about twice a year. The multifaceted intervention developed by Banka and colleagues included directly emailing the survey results to internal medicine resident physicians in real time while they were in service, a 1‐hour conference on best communication practices, and a reward program in which 3 residents were identified monthly to receive department‐wide recognition via email and a generous movie package. Using difference‐in‐differences regression analysis, the investigators compared changes in patient satisfaction results for internal medicine residents to results for residents from other specialties (who were not part of the intervention). The percentage of patients who gave top box responses to all 3 physician‐related questions and to the overall hospital rating was significantly higher for the internal medicine residents.

The findings from this study are important, because no prior study of an intervention, to our knowledge, has shown a significant improvement in patient satisfaction scores. In this study, feedback was believed to be the most powerful factor. The importance of meaningful, timely feedback in medical education is well recognized.[10] Without feedback there is poor insight into how intended results from specific actions compare with actual results. When feedback is lacking from external sources (in this case the voice of the patient), an uncontested sense of mastery develops, allowing mistakes to go uncorrected. This false sense of mastery contributes to an emotional and defensive response when performance is finally revealed to be less than optimal. The simple act of giving more timely feedback in this study encouraged self‐motivated reflection and practice change aimed at improving patient satisfaction, with remarkable results.

The study should inspire physician leaders from various hospital settings, and researchers, to develop and evaluate similar programs to improve patient satisfaction. We agree with the investigators that the approach should be multifaceted. Feedback to specific physicians is a powerful motivator, but needs to be combined with strategies to enhance communication skills. Brief conferences are less likely to have a lasting impact on behaviors than strategies like coaching and simulation based training.[11] Interventions should include recognition and reward to acknowledge exceptional performance and build friendly competition.

The biggest challenge to adopting an intervention such as the one used in the Banka study relates to the feasibility of implementing physician‐specific patient satisfaction reporting. Several survey instruments are available for use as tools to assess satisfaction with specific physicians.[9, 12, 13] However, who will administer these instruments? Most hospitals do not have undergraduate students available. Hospitals could use their volunteers, but this is not likely to be a sustainable solution. Hospitals could consider administering the survey via email, but many hospitals are just starting to collect patient email addresses and many patients do not use email. Once data are collected, who will conduct analyses and create comparative reports? Press Ganey recently developed a survey assessing satisfaction with specific hospitalists, using photographs, and offers the ability to create comparative reports.[14] Their service addresses the analytic challenge, but the quandary of survey administration remains.

In conclusion, we encourage hospital medicine leaders to develop and evaluate multifaceted interventions to improve patient satisfaction such as the one reported by Banka et al. Timely, specific feedback to physicians is an essential feature. The collection of physician‐specific data is a major challenge, but not an insurmountable one. Novel use of personnel and/or technology is likely to play a role in these efforts.

Disclosure: Nothing to report.

Patient satisfaction has received increased attention in recent years, which we believe is well deserved and long overdue. Anyone who has been hospitalized, or has had a loved one hospitalized, can appreciate that there is room to improve the patient experience. Dedicating time and effort to improving the patient experience is consistent with our professional commitment to comfort, empathize, and partner with our patients. Though patient satisfaction itself is an outcome worthy of our attention, it is also positively associated with measures related to patient safety and clinical effectiveness.[1, 2] Moreover, patient satisfaction is the only publicly reported measure that represents the patient's voice,[3] and accounts for a substantial portion of the Centers for Medicare and Medicaid Services payment adjustments under the Hospital Value Based Purchasing Program.[4]

However, all healthcare professionals should understand some key fundamental issues related to the measurement of patient satisfaction. The survey from which data are publicly reported and used for hospital payment adjustment is the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey, developed by the Agency for Healthcare Research and Quality.[5, 6] HCAHPS is sent to a random sample of 40% of hospitalized patients between 48 hours and 6 weeks after discharge. The HCAHPS survey uses ordinal response scales (eg, never, sometimes, usually, always) that generate highly skewed results toward favorable responses. Therefore, results are reported as the percent top box (ie, the percentage of responses in the most favorable category) rather than as a median score. The skewed distribution of results indicates that most patients are generally satisfied with care (ie, most respondents do not have an axe to grind), but also makes meaningful improvement difficult to achieve. Prior to public reporting and determination of effect on hospital payment, results are adjusted for mode of survey administration and patient mix. The same is not true when patient satisfaction data are used for internal purposes. Hospital leaders typically do not perform statistical adjustment and therefore need to be careful not to make apples‐to‐orangestype comparisons. For example, obstetric patient satisfaction scores should not be compared to general medical patient satisfaction scores, as these populations tend to rate satisfaction differently.

The HCAHPS survey questions are organized into domains of care, including satisfaction with nurses and satisfaction with doctors. Importantly, other healthcare team members may influence patients' perception in these domains. For example, a patient responding to nurse communication questions may also reflect on experiences with patient care technicians, social workers, and therapists. A patient responding to physician communication questions might also reflect on experiences with advanced practice providers. A common mistake is the practice of attributing satisfaction with doctors to the individual who served as the discharge physician. Many readers have likely seen patient satisfaction reports broken out by discharge physician with the expectation that giving this information to individual physicians will serve as useful formative feedback. The reality is that patients see many doctors during a hospitalization. To illustrate this point, we analyzed data from 420 patients admitted to our nonteaching hospitalist service who had completed an HCAHPS survey in 2014. We found that the discharge hospitalist accounted for only 34% of all physician encounters. Furthermore, research has shown that patients' experiences with specialist physicians also have a strong influence on their overall satisfaction with physicians.[7]

Having reliable patient satisfaction data on specific individuals would be a truly powerful formative assessment tool. In this issue of the Journal of Hospital Medicine, Banka and colleagues report on an impressive approach incorporating such a tool to give constructive feedback to physicians.[8] Since 2006, the study site had administered surveys to hospitalized patients that assess their satisfaction with specific resident physicians.[9] However, residency programs only reviewed the survey results with resident physicians about twice a year. The multifaceted intervention developed by Banka and colleagues included directly emailing the survey results to internal medicine resident physicians in real time while they were in service, a 1‐hour conference on best communication practices, and a reward program in which 3 residents were identified monthly to receive department‐wide recognition via email and a generous movie package. Using difference‐in‐differences regression analysis, the investigators compared changes in patient satisfaction results for internal medicine residents to results for residents from other specialties (who were not part of the intervention). The percentage of patients who gave top box responses to all 3 physician‐related questions and to the overall hospital rating was significantly higher for the internal medicine residents.

The findings from this study are important, because no prior study of an intervention, to our knowledge, has shown a significant improvement in patient satisfaction scores. In this study, feedback was believed to be the most powerful factor. The importance of meaningful, timely feedback in medical education is well recognized.[10] Without feedback there is poor insight into how intended results from specific actions compare with actual results. When feedback is lacking from external sources (in this case the voice of the patient), an uncontested sense of mastery develops, allowing mistakes to go uncorrected. This false sense of mastery contributes to an emotional and defensive response when performance is finally revealed to be less than optimal. The simple act of giving more timely feedback in this study encouraged self‐motivated reflection and practice change aimed at improving patient satisfaction, with remarkable results.

The study should inspire physician leaders from various hospital settings, and researchers, to develop and evaluate similar programs to improve patient satisfaction. We agree with the investigators that the approach should be multifaceted. Feedback to specific physicians is a powerful motivator, but needs to be combined with strategies to enhance communication skills. Brief conferences are less likely to have a lasting impact on behaviors than strategies like coaching and simulation based training.[11] Interventions should include recognition and reward to acknowledge exceptional performance and build friendly competition.

The biggest challenge to adopting an intervention such as the one used in the Banka study relates to the feasibility of implementing physician‐specific patient satisfaction reporting. Several survey instruments are available for use as tools to assess satisfaction with specific physicians.[9, 12, 13] However, who will administer these instruments? Most hospitals do not have undergraduate students available. Hospitals could use their volunteers, but this is not likely to be a sustainable solution. Hospitals could consider administering the survey via email, but many hospitals are just starting to collect patient email addresses and many patients do not use email. Once data are collected, who will conduct analyses and create comparative reports? Press Ganey recently developed a survey assessing satisfaction with specific hospitalists, using photographs, and offers the ability to create comparative reports.[14] Their service addresses the analytic challenge, but the quandary of survey administration remains.

In conclusion, we encourage hospital medicine leaders to develop and evaluate multifaceted interventions to improve patient satisfaction such as the one reported by Banka et al. Timely, specific feedback to physicians is an essential feature. The collection of physician‐specific data is a major challenge, but not an insurmountable one. Novel use of personnel and/or technology is likely to play a role in these efforts.

Disclosure: Nothing to report.

Patient satisfaction has received increased attention in recent years, which we believe is well deserved and long overdue. Anyone who has been hospitalized, or has had a loved one hospitalized, can appreciate that there is room to improve the patient experience. Dedicating time and effort to improving the patient experience is consistent with our professional commitment to comfort, empathize, and partner with our patients. Though patient satisfaction itself is an outcome worthy of our attention, it is also positively associated with measures related to patient safety and clinical effectiveness.[1, 2] Moreover, patient satisfaction is the only publicly reported measure that represents the patient's voice,[3] and accounts for a substantial portion of the Centers for Medicare and Medicaid Services payment adjustments under the Hospital Value Based Purchasing Program.[4]

However, all healthcare professionals should understand some key fundamental issues related to the measurement of patient satisfaction. The survey from which data are publicly reported and used for hospital payment adjustment is the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey, developed by the Agency for Healthcare Research and Quality.[5, 6] HCAHPS is sent to a random sample of 40% of hospitalized patients between 48 hours and 6 weeks after discharge. The HCAHPS survey uses ordinal response scales (eg, never, sometimes, usually, always) that generate highly skewed results toward favorable responses. Therefore, results are reported as the percent top box (ie, the percentage of responses in the most favorable category) rather than as a median score. The skewed distribution of results indicates that most patients are generally satisfied with care (ie, most respondents do not have an axe to grind), but also makes meaningful improvement difficult to achieve. Prior to public reporting and determination of effect on hospital payment, results are adjusted for mode of survey administration and patient mix. The same is not true when patient satisfaction data are used for internal purposes. Hospital leaders typically do not perform statistical adjustment and therefore need to be careful not to make apples‐to‐orangestype comparisons. For example, obstetric patient satisfaction scores should not be compared to general medical patient satisfaction scores, as these populations tend to rate satisfaction differently.

The HCAHPS survey questions are organized into domains of care, including satisfaction with nurses and satisfaction with doctors. Importantly, other healthcare team members may influence patients' perception in these domains. For example, a patient responding to nurse communication questions may also reflect on experiences with patient care technicians, social workers, and therapists. A patient responding to physician communication questions might also reflect on experiences with advanced practice providers. A common mistake is the practice of attributing satisfaction with doctors to the individual who served as the discharge physician. Many readers have likely seen patient satisfaction reports broken out by discharge physician with the expectation that giving this information to individual physicians will serve as useful formative feedback. The reality is that patients see many doctors during a hospitalization. To illustrate this point, we analyzed data from 420 patients admitted to our nonteaching hospitalist service who had completed an HCAHPS survey in 2014. We found that the discharge hospitalist accounted for only 34% of all physician encounters. Furthermore, research has shown that patients' experiences with specialist physicians also have a strong influence on their overall satisfaction with physicians.[7]

Having reliable patient satisfaction data on specific individuals would be a truly powerful formative assessment tool. In this issue of the Journal of Hospital Medicine, Banka and colleagues report on an impressive approach incorporating such a tool to give constructive feedback to physicians.[8] Since 2006, the study site had administered surveys to hospitalized patients that assess their satisfaction with specific resident physicians.[9] However, residency programs only reviewed the survey results with resident physicians about twice a year. The multifaceted intervention developed by Banka and colleagues included directly emailing the survey results to internal medicine resident physicians in real time while they were in service, a 1‐hour conference on best communication practices, and a reward program in which 3 residents were identified monthly to receive department‐wide recognition via email and a generous movie package. Using difference‐in‐differences regression analysis, the investigators compared changes in patient satisfaction results for internal medicine residents to results for residents from other specialties (who were not part of the intervention). The percentage of patients who gave top box responses to all 3 physician‐related questions and to the overall hospital rating was significantly higher for the internal medicine residents.

The findings from this study are important, because no prior study of an intervention, to our knowledge, has shown a significant improvement in patient satisfaction scores. In this study, feedback was believed to be the most powerful factor. The importance of meaningful, timely feedback in medical education is well recognized.[10] Without feedback there is poor insight into how intended results from specific actions compare with actual results. When feedback is lacking from external sources (in this case the voice of the patient), an uncontested sense of mastery develops, allowing mistakes to go uncorrected. This false sense of mastery contributes to an emotional and defensive response when performance is finally revealed to be less than optimal. The simple act of giving more timely feedback in this study encouraged self‐motivated reflection and practice change aimed at improving patient satisfaction, with remarkable results.

The study should inspire physician leaders from various hospital settings, and researchers, to develop and evaluate similar programs to improve patient satisfaction. We agree with the investigators that the approach should be multifaceted. Feedback to specific physicians is a powerful motivator, but needs to be combined with strategies to enhance communication skills. Brief conferences are less likely to have a lasting impact on behaviors than strategies like coaching and simulation based training.[11] Interventions should include recognition and reward to acknowledge exceptional performance and build friendly competition.

The biggest challenge to adopting an intervention such as the one used in the Banka study relates to the feasibility of implementing physician‐specific patient satisfaction reporting. Several survey instruments are available for use as tools to assess satisfaction with specific physicians.[9, 12, 13] However, who will administer these instruments? Most hospitals do not have undergraduate students available. Hospitals could use their volunteers, but this is not likely to be a sustainable solution. Hospitals could consider administering the survey via email, but many hospitals are just starting to collect patient email addresses and many patients do not use email. Once data are collected, who will conduct analyses and create comparative reports? Press Ganey recently developed a survey assessing satisfaction with specific hospitalists, using photographs, and offers the ability to create comparative reports.[14] Their service addresses the analytic challenge, but the quandary of survey administration remains.

In conclusion, we encourage hospital medicine leaders to develop and evaluate multifaceted interventions to improve patient satisfaction such as the one reported by Banka et al. Timely, specific feedback to physicians is an essential feature. The collection of physician‐specific data is a major challenge, but not an insurmountable one. Novel use of personnel and/or technology is likely to play a role in these efforts.

Disclosure: Nothing to report.

In this issue of the Journal of Hospital Medicine, Butcher and colleagues report on residents' perceptions of a rapid response team's (RRT) impact on their training.[1] RRTs mobilize key clinicians in an attempt to rescue acutely decompensating hospitalized patients. Early recognition is essential, and most systems allow any concerned health professional to activate the RRT. Although the evidence for benefit is somewhat controversial,[2, 3] an overwhelming majority of hospitals have implemented RRTs.[4, 5]

The use of RRTs in teaching hospitals raises important concerns. The ability of nurses and other professionals to activate the RRT without need for prior approval from a physician could potentially undermine resident physician autonomy. Residents may feel that their clinical judgment has been usurped or second guessed. Whether nurse led or physician led, RRTs always introduce new members to the care team.[6] These new team members share in decision making, which may theoretically reduce residents' opportunities to hone their decision‐making skills when caring for potentially critically ill patients.

Despite these potential disadvantages, Butcher and colleagues report that the vast majority of residents found working with the RRT to be a valuable educational experience and disagreed that the RRT decreased their clinical autonomy. Interestingly, surgical residents were less likely to agree that working with the RRT was a valuable educational experience and much more likely to feel that nurses should contact them before activating the RRT.

The results of the study by Butcher et al. highlight several evolving paradigms in medical education and quality improvement. Over the past 10 to 15 years, and fostered in large part by Accreditation Council for Graduate Medical Education (ACGME) duty‐hour revisions,[7] teaching hospitals have moved away from the traditional practice of using residents primarily to fill their clinical service needs to an approach that treats residents more as learners. Resident training requires clinical care, but the provision of clinical care in teaching hospitals does not necessarily require residents. At the same time, healthcare organizations have moved away from the traditional culture characterized by reliance on individual skill, physician autonomy, and steep hierarchies, to an enlightened culture emphasizing teamwork with flattened hierarchies and systems redesigned to provide safe and effective care.[8]

For the most part, the paradigm shifts in medical education and quality improvement have been aligned. In fact, the primary goal of duty‐hour policy revisions was to improve patient safety.[9] Yet, Butcher and colleagues' study highlights the need to continuously and deliberately integrate our efforts to enhance medical education and quality of care, and more rigorously study the effects. Rather than be pleasantly surprised that residents understand the intrinsic value of an RRT to patient care and their education, we should ensure that residents understand the rationale for an RRT and consider using the RRT to complement other efforts to educate resident physicians in managing unstable patients. RRTs introduce a wonderful opportunity to develop novel interprofessional curricula. Learning objectives should include the management of common clinical syndromes represented in RRT calls, but should also focus on communication, leadership, and other essential teamwork skills. Simulation‐based training is an ideal teaching strategy for these objectives, and prior studies support the effectiveness of this approach.[10, 11]

The ACGME has now implemented the Next Accreditation System (NAS) across all specialties. Of the 22 reporting milestones within internal medicine, 12 relate directly to quality improvement and patient safety objectives, whereas 6 relate directly to pathophysiology and disease management.[12] Educating residents on systems of care is further highlighted by the Clinical Learning Environment Review (CLER), a key component of the NAS. The CLER program uses site visits to identify teaching hospitals' efforts to engage residents in 6 focus areas: patient safety; healthcare quality; transitions of care; supervision; duty hours, fatigue management, and mitigation; and professionalism.[13] CLER site visits include discussions and observations with hospital executive leadership, residents, graduate medical education leadership, nursing, and other hospital staff. The CLER program raises the bar for integrating medical education and quality improvement efforts even further. Quality improvement activities that previously supported an informal curriculum must now be made explicit to, and deliberately engage, our residents. Teaching hospitals are being tasked with including residents in safety initiatives and on all quality committees, especially those with cross‐departmental boundaries such as the Emergency Response Team/RRT Committee. Residents should meaningfully participate, and whenever possible, lead quality improvement projects, the focus of which may ideally be identified by residents themselves. An important resource for medical educators is the Quality and Safety Educators Academy, a program developed by the Society of Hospital Medicine and the Alliance for Academic Internal Medicine, which provides educators with the knowledge and tools to integrate quality improvement and patient safety objectives into their training programs.[14]

In conclusion, we are reassured that residents understand the intrinsic value of an RRT to patient care and their education. We encourage medical educators to use RRTs as an opportunity to develop interprofessional curricula, including those that aim to enhance teamwork skills. Beyond curricular innovation, quality‐improvement activities in teaching hospitals must deliberately engage our residents at every level of the organization.

In this issue of the Journal of Hospital Medicine, Butcher and colleagues report on residents' perceptions of a rapid response team's (RRT) impact on their training.[1] RRTs mobilize key clinicians in an attempt to rescue acutely decompensating hospitalized patients. Early recognition is essential, and most systems allow any concerned health professional to activate the RRT. Although the evidence for benefit is somewhat controversial,[2, 3] an overwhelming majority of hospitals have implemented RRTs.[4, 5]

The use of RRTs in teaching hospitals raises important concerns. The ability of nurses and other professionals to activate the RRT without need for prior approval from a physician could potentially undermine resident physician autonomy. Residents may feel that their clinical judgment has been usurped or second guessed. Whether nurse led or physician led, RRTs always introduce new members to the care team.[6] These new team members share in decision making, which may theoretically reduce residents' opportunities to hone their decision‐making skills when caring for potentially critically ill patients.

Despite these potential disadvantages, Butcher and colleagues report that the vast majority of residents found working with the RRT to be a valuable educational experience and disagreed that the RRT decreased their clinical autonomy. Interestingly, surgical residents were less likely to agree that working with the RRT was a valuable educational experience and much more likely to feel that nurses should contact them before activating the RRT.

The results of the study by Butcher et al. highlight several evolving paradigms in medical education and quality improvement. Over the past 10 to 15 years, and fostered in large part by Accreditation Council for Graduate Medical Education (ACGME) duty‐hour revisions,[7] teaching hospitals have moved away from the traditional practice of using residents primarily to fill their clinical service needs to an approach that treats residents more as learners. Resident training requires clinical care, but the provision of clinical care in teaching hospitals does not necessarily require residents. At the same time, healthcare organizations have moved away from the traditional culture characterized by reliance on individual skill, physician autonomy, and steep hierarchies, to an enlightened culture emphasizing teamwork with flattened hierarchies and systems redesigned to provide safe and effective care.[8]

For the most part, the paradigm shifts in medical education and quality improvement have been aligned. In fact, the primary goal of duty‐hour policy revisions was to improve patient safety.[9] Yet, Butcher and colleagues' study highlights the need to continuously and deliberately integrate our efforts to enhance medical education and quality of care, and more rigorously study the effects. Rather than be pleasantly surprised that residents understand the intrinsic value of an RRT to patient care and their education, we should ensure that residents understand the rationale for an RRT and consider using the RRT to complement other efforts to educate resident physicians in managing unstable patients. RRTs introduce a wonderful opportunity to develop novel interprofessional curricula. Learning objectives should include the management of common clinical syndromes represented in RRT calls, but should also focus on communication, leadership, and other essential teamwork skills. Simulation‐based training is an ideal teaching strategy for these objectives, and prior studies support the effectiveness of this approach.[10, 11]

The ACGME has now implemented the Next Accreditation System (NAS) across all specialties. Of the 22 reporting milestones within internal medicine, 12 relate directly to quality improvement and patient safety objectives, whereas 6 relate directly to pathophysiology and disease management.[12] Educating residents on systems of care is further highlighted by the Clinical Learning Environment Review (CLER), a key component of the NAS. The CLER program uses site visits to identify teaching hospitals' efforts to engage residents in 6 focus areas: patient safety; healthcare quality; transitions of care; supervision; duty hours, fatigue management, and mitigation; and professionalism.[13] CLER site visits include discussions and observations with hospital executive leadership, residents, graduate medical education leadership, nursing, and other hospital staff. The CLER program raises the bar for integrating medical education and quality improvement efforts even further. Quality improvement activities that previously supported an informal curriculum must now be made explicit to, and deliberately engage, our residents. Teaching hospitals are being tasked with including residents in safety initiatives and on all quality committees, especially those with cross‐departmental boundaries such as the Emergency Response Team/RRT Committee. Residents should meaningfully participate, and whenever possible, lead quality improvement projects, the focus of which may ideally be identified by residents themselves. An important resource for medical educators is the Quality and Safety Educators Academy, a program developed by the Society of Hospital Medicine and the Alliance for Academic Internal Medicine, which provides educators with the knowledge and tools to integrate quality improvement and patient safety objectives into their training programs.[14]

In conclusion, we are reassured that residents understand the intrinsic value of an RRT to patient care and their education. We encourage medical educators to use RRTs as an opportunity to develop interprofessional curricula, including those that aim to enhance teamwork skills. Beyond curricular innovation, quality‐improvement activities in teaching hospitals must deliberately engage our residents at every level of the organization.

In this issue of the Journal of Hospital Medicine, Butcher and colleagues report on residents' perceptions of a rapid response team's (RRT) impact on their training.[1] RRTs mobilize key clinicians in an attempt to rescue acutely decompensating hospitalized patients. Early recognition is essential, and most systems allow any concerned health professional to activate the RRT. Although the evidence for benefit is somewhat controversial,[2, 3] an overwhelming majority of hospitals have implemented RRTs.[4, 5]

The use of RRTs in teaching hospitals raises important concerns. The ability of nurses and other professionals to activate the RRT without need for prior approval from a physician could potentially undermine resident physician autonomy. Residents may feel that their clinical judgment has been usurped or second guessed. Whether nurse led or physician led, RRTs always introduce new members to the care team.[6] These new team members share in decision making, which may theoretically reduce residents' opportunities to hone their decision‐making skills when caring for potentially critically ill patients.

Despite these potential disadvantages, Butcher and colleagues report that the vast majority of residents found working with the RRT to be a valuable educational experience and disagreed that the RRT decreased their clinical autonomy. Interestingly, surgical residents were less likely to agree that working with the RRT was a valuable educational experience and much more likely to feel that nurses should contact them before activating the RRT.

The results of the study by Butcher et al. highlight several evolving paradigms in medical education and quality improvement. Over the past 10 to 15 years, and fostered in large part by Accreditation Council for Graduate Medical Education (ACGME) duty‐hour revisions,[7] teaching hospitals have moved away from the traditional practice of using residents primarily to fill their clinical service needs to an approach that treats residents more as learners. Resident training requires clinical care, but the provision of clinical care in teaching hospitals does not necessarily require residents. At the same time, healthcare organizations have moved away from the traditional culture characterized by reliance on individual skill, physician autonomy, and steep hierarchies, to an enlightened culture emphasizing teamwork with flattened hierarchies and systems redesigned to provide safe and effective care.[8]

For the most part, the paradigm shifts in medical education and quality improvement have been aligned. In fact, the primary goal of duty‐hour policy revisions was to improve patient safety.[9] Yet, Butcher and colleagues' study highlights the need to continuously and deliberately integrate our efforts to enhance medical education and quality of care, and more rigorously study the effects. Rather than be pleasantly surprised that residents understand the intrinsic value of an RRT to patient care and their education, we should ensure that residents understand the rationale for an RRT and consider using the RRT to complement other efforts to educate resident physicians in managing unstable patients. RRTs introduce a wonderful opportunity to develop novel interprofessional curricula. Learning objectives should include the management of common clinical syndromes represented in RRT calls, but should also focus on communication, leadership, and other essential teamwork skills. Simulation‐based training is an ideal teaching strategy for these objectives, and prior studies support the effectiveness of this approach.[10, 11]

The ACGME has now implemented the Next Accreditation System (NAS) across all specialties. Of the 22 reporting milestones within internal medicine, 12 relate directly to quality improvement and patient safety objectives, whereas 6 relate directly to pathophysiology and disease management.[12] Educating residents on systems of care is further highlighted by the Clinical Learning Environment Review (CLER), a key component of the NAS. The CLER program uses site visits to identify teaching hospitals' efforts to engage residents in 6 focus areas: patient safety; healthcare quality; transitions of care; supervision; duty hours, fatigue management, and mitigation; and professionalism.[13] CLER site visits include discussions and observations with hospital executive leadership, residents, graduate medical education leadership, nursing, and other hospital staff. The CLER program raises the bar for integrating medical education and quality improvement efforts even further. Quality improvement activities that previously supported an informal curriculum must now be made explicit to, and deliberately engage, our residents. Teaching hospitals are being tasked with including residents in safety initiatives and on all quality committees, especially those with cross‐departmental boundaries such as the Emergency Response Team/RRT Committee. Residents should meaningfully participate, and whenever possible, lead quality improvement projects, the focus of which may ideally be identified by residents themselves. An important resource for medical educators is the Quality and Safety Educators Academy, a program developed by the Society of Hospital Medicine and the Alliance for Academic Internal Medicine, which provides educators with the knowledge and tools to integrate quality improvement and patient safety objectives into their training programs.[14]

In conclusion, we are reassured that residents understand the intrinsic value of an RRT to patient care and their education. We encourage medical educators to use RRTs as an opportunity to develop interprofessional curricula, including those that aim to enhance teamwork skills. Beyond curricular innovation, quality‐improvement activities in teaching hospitals must deliberately engage our residents at every level of the organization.

Although definitions vary, continuity of care can be thought of as the patient's experience of a continuous caring relationship with an identified healthcare professional.[1] Research in ambulatory settings has found that patients who see their primary care physician for a higher proportion of office visits have higher patient satisfaction, better hypertensive control, lower risk of hospitalization, and fewer emergency department visits.[2, 3, 4, 5] Continuity with a single hospital‐based physician is difficult to achieve because of the need to provide care 24 hours a day, 7 days a week. Key clinical information may be lost during physician‐to‐physician handoffs (eg, at admission, at the end of rotations on service) during hospitalization. Our research group recently found that lower hospital physician continuity was associated with modestly increased hospital costs, but also a trend toward lower readmissions.[6] We speculated that physicians newly taking over patient care from colleagues reassess diagnoses and treatment plans. This reassessment may identify errors missed by the previous hospital physician. Thus, discontinuity may theoretically help or hinder the provision of safe hospital care.

We sought to examine the relationship between hospital physician continuity and the incidence of adverse events (AEs). We combined data from 2 previously published studies by our research group; one investigated the relationship between hospital physician continuity and costs and 30‐day readmissions, the other assessed the impact of unit‐based interventions on AEs.[6, 7]

METHODS

RESULTS

DISCUSSION

We found that hospitalist physician continuity was not associated with the incidence of AEs. Our findings are somewhat surprising because of the high value placed on continuity of care and patient safety concerns related to handoffs. Key clinical information may be lost when patient care is transitioned to a new hospitalist shortly after admission (eg, from a night hospitalist) or at the end of a rotation. Thus, it is logical to assume that discontinuity inherently increases the risk for harm. On the other hand, a physician newly taking over patient care from another may not be anchored to the initial diagnosis and treatment plan established by the first. This second look could potentially prevent missed/delayed diagnoses and optimize the plan of care.[19] These countervailing forces may explain our findings.

Several other potential explanations for our findings should be considered. First, the quality of handoffs may have been sufficient to overcome the potential for information loss. We feel this is unlikely given that little attention had been dedicated to improving the quality of patient handoffs among hospitalists in our institution. Notably, though a number of studies have evaluated resident physician handoffs, most of the work has focused on night coverage, and little is known about the quality of attending handoffs.[20] Second, access to a fully integrated electronic health record may have assisted hospitalists in complementing information received during handoffs. For example, a hospitalist about to start his or her rotation may have remotely accessed and reviewed patient medical records prior to receiving the phone handoff from the outgoing hospitalist. Third, other efforts to improve patient safety may have reduced the overall risk and provided some resilience in the system. Unit‐based interventions, including structured interdisciplinary rounds and nurse‐physician coleadership, improved teamwork climate and reduced AEs in the study hospital over time.[7]

Another factor to consider relates to the fact that hospital care is provided by teams of clinicians (eg, nurses, specialist physicians, therapists, social workers). Hospital teams are often large and have dynamic team membership. Similar to hospitalists, nurses, physician specialists, and other team members handoff care throughout the course of a patient's hospital stay. Yet, discontinuity for each professional type may occur at different times and frequencies. For example, a patient may be handed off from one hospitalist to another, yet the care continues with the same cardiologist or nurse. Future research should better characterize hospital team complexity (eg, size, relationships among members) and dynamics (eg, continuity for various professional types) and the impact of these factors on patient outcomes.

Our findings are important because hospitalist physician discontinuity is common during hospital stays. Hospital medicine groups vary in their staffing and scheduling models. Policies related to admission distribution and rotation length (consecutive days worked) systematically impact physician continuity. Few studies have evaluated the effect on continuity on hospitalized patient outcomes, and no prior research, to our knowledge, has explored the association of continuity on measures of patient safety.[6, 21, 22] Though our study might suggest that staffing models have little impact on patient safety, as previously mentioned, other team factors may influence patient outcomes.

Our study has several limitations. First, we assessed the impact of continuity on AEs in a single site. Although the 7 days on/7 days off model is the most common scheduling pattern used by adult hospital medicine groups,[23] staffing models and patient safety practices vary across hospitals, potentially limiting the generalizability of our study. Second, continuity can be defined and measured in a variety of ways. We used 2 different measures of physician continuity. As previously mentioned, assessing continuity of other clinicians may allow for a more complete understanding of the potential problems related to fragmentation of care. Third, this study excluded patients who experienced care transitions from other hospitals or other units within the hospital. Patients transferred from other hospitals are often complex, severely ill, and may be at higher risk for loss of key clinical information. Fourth, we used automated screens of an EDW to identify potential AEs. Although our prior research found that this method identified a similar number of AEs as manual medical record review screening, there was poor agreement between the 2 methods. Unfortunately, there is no gold standard to identify AEs. The EDW‐facilitated method allowed us to feasibly screen a larger number of charts, increasing statistical power, and minimized any potential bias that might occur during a manual review to identify potential AEs. Finally, we used data available from 2 prior studies and may have been underpowered to detect a significant association between continuity and AEs due to the relatively low percentage of patients experiencing an AE. In a post hoc power calculation, we estimated that we had 70% power to detect a 33% change in the proportion of patients with 1 or more AE for each 1‐unit increase in NPI, and 80% power to detect a 20% change for each 0.1‐unit decrease in UPC.

CONCLUSION

In conclusion, we found that hospitalist physician continuity was not associated with the incidence of AEs. We speculate that hospitalist continuity is only 1 of many team factors that may influence patient safety, and that prior efforts within our institution may have reduced our ability to detect an association. Future research should better characterize hospital team complexity and dynamics and the impact of these factors on patient outcomes.

Although definitions vary, continuity of care can be thought of as the patient's experience of a continuous caring relationship with an identified healthcare professional.[1] Research in ambulatory settings has found that patients who see their primary care physician for a higher proportion of office visits have higher patient satisfaction, better hypertensive control, lower risk of hospitalization, and fewer emergency department visits.[2, 3, 4, 5] Continuity with a single hospital‐based physician is difficult to achieve because of the need to provide care 24 hours a day, 7 days a week. Key clinical information may be lost during physician‐to‐physician handoffs (eg, at admission, at the end of rotations on service) during hospitalization. Our research group recently found that lower hospital physician continuity was associated with modestly increased hospital costs, but also a trend toward lower readmissions.[6] We speculated that physicians newly taking over patient care from colleagues reassess diagnoses and treatment plans. This reassessment may identify errors missed by the previous hospital physician. Thus, discontinuity may theoretically help or hinder the provision of safe hospital care.

We sought to examine the relationship between hospital physician continuity and the incidence of adverse events (AEs). We combined data from 2 previously published studies by our research group; one investigated the relationship between hospital physician continuity and costs and 30‐day readmissions, the other assessed the impact of unit‐based interventions on AEs.[6, 7]

METHODS

RESULTS

DISCUSSION

We found that hospitalist physician continuity was not associated with the incidence of AEs. Our findings are somewhat surprising because of the high value placed on continuity of care and patient safety concerns related to handoffs. Key clinical information may be lost when patient care is transitioned to a new hospitalist shortly after admission (eg, from a night hospitalist) or at the end of a rotation. Thus, it is logical to assume that discontinuity inherently increases the risk for harm. On the other hand, a physician newly taking over patient care from another may not be anchored to the initial diagnosis and treatment plan established by the first. This second look could potentially prevent missed/delayed diagnoses and optimize the plan of care.[19] These countervailing forces may explain our findings.

Several other potential explanations for our findings should be considered. First, the quality of handoffs may have been sufficient to overcome the potential for information loss. We feel this is unlikely given that little attention had been dedicated to improving the quality of patient handoffs among hospitalists in our institution. Notably, though a number of studies have evaluated resident physician handoffs, most of the work has focused on night coverage, and little is known about the quality of attending handoffs.[20] Second, access to a fully integrated electronic health record may have assisted hospitalists in complementing information received during handoffs. For example, a hospitalist about to start his or her rotation may have remotely accessed and reviewed patient medical records prior to receiving the phone handoff from the outgoing hospitalist. Third, other efforts to improve patient safety may have reduced the overall risk and provided some resilience in the system. Unit‐based interventions, including structured interdisciplinary rounds and nurse‐physician coleadership, improved teamwork climate and reduced AEs in the study hospital over time.[7]

Another factor to consider relates to the fact that hospital care is provided by teams of clinicians (eg, nurses, specialist physicians, therapists, social workers). Hospital teams are often large and have dynamic team membership. Similar to hospitalists, nurses, physician specialists, and other team members handoff care throughout the course of a patient's hospital stay. Yet, discontinuity for each professional type may occur at different times and frequencies. For example, a patient may be handed off from one hospitalist to another, yet the care continues with the same cardiologist or nurse. Future research should better characterize hospital team complexity (eg, size, relationships among members) and dynamics (eg, continuity for various professional types) and the impact of these factors on patient outcomes.

Our findings are important because hospitalist physician discontinuity is common during hospital stays. Hospital medicine groups vary in their staffing and scheduling models. Policies related to admission distribution and rotation length (consecutive days worked) systematically impact physician continuity. Few studies have evaluated the effect on continuity on hospitalized patient outcomes, and no prior research, to our knowledge, has explored the association of continuity on measures of patient safety.[6, 21, 22] Though our study might suggest that staffing models have little impact on patient safety, as previously mentioned, other team factors may influence patient outcomes.

Our study has several limitations. First, we assessed the impact of continuity on AEs in a single site. Although the 7 days on/7 days off model is the most common scheduling pattern used by adult hospital medicine groups,[23] staffing models and patient safety practices vary across hospitals, potentially limiting the generalizability of our study. Second, continuity can be defined and measured in a variety of ways. We used 2 different measures of physician continuity. As previously mentioned, assessing continuity of other clinicians may allow for a more complete understanding of the potential problems related to fragmentation of care. Third, this study excluded patients who experienced care transitions from other hospitals or other units within the hospital. Patients transferred from other hospitals are often complex, severely ill, and may be at higher risk for loss of key clinical information. Fourth, we used automated screens of an EDW to identify potential AEs. Although our prior research found that this method identified a similar number of AEs as manual medical record review screening, there was poor agreement between the 2 methods. Unfortunately, there is no gold standard to identify AEs. The EDW‐facilitated method allowed us to feasibly screen a larger number of charts, increasing statistical power, and minimized any potential bias that might occur during a manual review to identify potential AEs. Finally, we used data available from 2 prior studies and may have been underpowered to detect a significant association between continuity and AEs due to the relatively low percentage of patients experiencing an AE. In a post hoc power calculation, we estimated that we had 70% power to detect a 33% change in the proportion of patients with 1 or more AE for each 1‐unit increase in NPI, and 80% power to detect a 20% change for each 0.1‐unit decrease in UPC.

CONCLUSION

In conclusion, we found that hospitalist physician continuity was not associated with the incidence of AEs. We speculate that hospitalist continuity is only 1 of many team factors that may influence patient safety, and that prior efforts within our institution may have reduced our ability to detect an association. Future research should better characterize hospital team complexity and dynamics and the impact of these factors on patient outcomes.

Although definitions vary, continuity of care can be thought of as the patient's experience of a continuous caring relationship with an identified healthcare professional.[1] Research in ambulatory settings has found that patients who see their primary care physician for a higher proportion of office visits have higher patient satisfaction, better hypertensive control, lower risk of hospitalization, and fewer emergency department visits.[2, 3, 4, 5] Continuity with a single hospital‐based physician is difficult to achieve because of the need to provide care 24 hours a day, 7 days a week. Key clinical information may be lost during physician‐to‐physician handoffs (eg, at admission, at the end of rotations on service) during hospitalization. Our research group recently found that lower hospital physician continuity was associated with modestly increased hospital costs, but also a trend toward lower readmissions.[6] We speculated that physicians newly taking over patient care from colleagues reassess diagnoses and treatment plans. This reassessment may identify errors missed by the previous hospital physician. Thus, discontinuity may theoretically help or hinder the provision of safe hospital care.

We sought to examine the relationship between hospital physician continuity and the incidence of adverse events (AEs). We combined data from 2 previously published studies by our research group; one investigated the relationship between hospital physician continuity and costs and 30‐day readmissions, the other assessed the impact of unit‐based interventions on AEs.[6, 7]

METHODS

RESULTS

DISCUSSION

We found that hospitalist physician continuity was not associated with the incidence of AEs. Our findings are somewhat surprising because of the high value placed on continuity of care and patient safety concerns related to handoffs. Key clinical information may be lost when patient care is transitioned to a new hospitalist shortly after admission (eg, from a night hospitalist) or at the end of a rotation. Thus, it is logical to assume that discontinuity inherently increases the risk for harm. On the other hand, a physician newly taking over patient care from another may not be anchored to the initial diagnosis and treatment plan established by the first. This second look could potentially prevent missed/delayed diagnoses and optimize the plan of care.[19] These countervailing forces may explain our findings.

Several other potential explanations for our findings should be considered. First, the quality of handoffs may have been sufficient to overcome the potential for information loss. We feel this is unlikely given that little attention had been dedicated to improving the quality of patient handoffs among hospitalists in our institution. Notably, though a number of studies have evaluated resident physician handoffs, most of the work has focused on night coverage, and little is known about the quality of attending handoffs.[20] Second, access to a fully integrated electronic health record may have assisted hospitalists in complementing information received during handoffs. For example, a hospitalist about to start his or her rotation may have remotely accessed and reviewed patient medical records prior to receiving the phone handoff from the outgoing hospitalist. Third, other efforts to improve patient safety may have reduced the overall risk and provided some resilience in the system. Unit‐based interventions, including structured interdisciplinary rounds and nurse‐physician coleadership, improved teamwork climate and reduced AEs in the study hospital over time.[7]

Another factor to consider relates to the fact that hospital care is provided by teams of clinicians (eg, nurses, specialist physicians, therapists, social workers). Hospital teams are often large and have dynamic team membership. Similar to hospitalists, nurses, physician specialists, and other team members handoff care throughout the course of a patient's hospital stay. Yet, discontinuity for each professional type may occur at different times and frequencies. For example, a patient may be handed off from one hospitalist to another, yet the care continues with the same cardiologist or nurse. Future research should better characterize hospital team complexity (eg, size, relationships among members) and dynamics (eg, continuity for various professional types) and the impact of these factors on patient outcomes.

Our findings are important because hospitalist physician discontinuity is common during hospital stays. Hospital medicine groups vary in their staffing and scheduling models. Policies related to admission distribution and rotation length (consecutive days worked) systematically impact physician continuity. Few studies have evaluated the effect on continuity on hospitalized patient outcomes, and no prior research, to our knowledge, has explored the association of continuity on measures of patient safety.[6, 21, 22] Though our study might suggest that staffing models have little impact on patient safety, as previously mentioned, other team factors may influence patient outcomes.

Our study has several limitations. First, we assessed the impact of continuity on AEs in a single site. Although the 7 days on/7 days off model is the most common scheduling pattern used by adult hospital medicine groups,[23] staffing models and patient safety practices vary across hospitals, potentially limiting the generalizability of our study. Second, continuity can be defined and measured in a variety of ways. We used 2 different measures of physician continuity. As previously mentioned, assessing continuity of other clinicians may allow for a more complete understanding of the potential problems related to fragmentation of care. Third, this study excluded patients who experienced care transitions from other hospitals or other units within the hospital. Patients transferred from other hospitals are often complex, severely ill, and may be at higher risk for loss of key clinical information. Fourth, we used automated screens of an EDW to identify potential AEs. Although our prior research found that this method identified a similar number of AEs as manual medical record review screening, there was poor agreement between the 2 methods. Unfortunately, there is no gold standard to identify AEs. The EDW‐facilitated method allowed us to feasibly screen a larger number of charts, increasing statistical power, and minimized any potential bias that might occur during a manual review to identify potential AEs. Finally, we used data available from 2 prior studies and may have been underpowered to detect a significant association between continuity and AEs due to the relatively low percentage of patients experiencing an AE. In a post hoc power calculation, we estimated that we had 70% power to detect a 33% change in the proportion of patients with 1 or more AE for each 1‐unit increase in NPI, and 80% power to detect a 20% change for each 0.1‐unit decrease in UPC.

CONCLUSION

In conclusion, we found that hospitalist physician continuity was not associated with the incidence of AEs. We speculate that hospitalist continuity is only 1 of many team factors that may influence patient safety, and that prior efforts within our institution may have reduced our ability to detect an association. Future research should better characterize hospital team complexity and dynamics and the impact of these factors on patient outcomes.

In this issue of the Journal of Hospital Medicine, Schaffer and colleagues report their analysis of malpractice claims against hospitalists compared to other physician specialties.[1] In contrast to previous work examining medical liability,[2, 3] Schaffer and colleagues have been able to identify hospitalists specifically.[2, 3]

Perhaps surprisingly, their main finding was that the rate of claims against hospitalists was significantly lower than for nonhospitalist internists, emergency medicine physicians, general surgeons, and obstetriciansgynecologists. We say surprisingly, because health systems utilizing hospitalists generally include features that might increase the risk for malpractice claims.

For example, new patients are typically assigned to whichever hospitalist is up for the next admission. Research shows that strained patientphysician relationships increase the risk for malpractice claims.[4, 5] Schaffer's data suggest that lack of a preexisting relationship is a challenge, but one to which most hospitalists have grown accustomed. Hospitalists develop and hone skills that allow them to quickly establish rapport with patients and families. Moreover, though patients seldom choose their hospitalist, they often do select the hospital in which they receive their care. The research group of 1 of the authors was recently surprised to find patients had high levels of trust with their hospital physicians, despite frequently being unable to name them or identify their role.[6] We suspect patients in the study had high levels of trust with the hospital and transferred this trust to their assigned physicians as representatives of the organization. Certainly, this hypothesis needs to be tested, and in no way does it minimize the importance of a strong patient‐physician relationship.

In addition, patientphysician continuity has long been felt to be paramount to safe and effective care; however, it is difficult to achieve in hospitalist systems. Hospitalized patients experience multiple handoffs, including those at admission, for night coverage, and at the time of service change (ie, end of rotation/stint). The potential for loss of information is enormous. Though increased attention has been dedicated to handoffs among housestaff, little work has been done to describe issues related to handoffs among practicing physicians. However, some discontinuity may be advantageous. A physician newly taking over patient care from another may not be anchored to the initial diagnosis and treatment plan established by the first. This free second look may actually prevent missed/delayed diagnoses and optimize plans of care, further reducing harm from care and risk of malpractice.[7]

Hospital discharge is another highly risky time, due to issues such as tests pending at the time of discharge and the need to manage ongoing workup and treatment of unresolved issues.[8, 9] The responsibility for tying up these loose ends may be unclear as patients are transitioned from the care of hospitalists to outpatient physicians. Prior research has shown that patients are at particularly high risk for preventable adverse events after hospital discharge.[10, 11] More recently, healthcare policy has focused on measuring and incentivizing the reduction of readmissions.[12] Although only a portion of readmissions are truly preventable,[13] and many patients who suffer adverse events after discharge are not readmitted,[11] the efforts resulting from these policy initiatives may have improved the overall safety of transitions of care.

A particularly important contribution of Schaffer and colleagues' study is that it helps us identify patient safety issues related to hospital medicine. Despite intense national efforts over the past 10 to 15 years, progress has been slow in reducing the rate of adverse events among hospitalized patients.[14, 15, 16] Although adverse events and medical liability do not always correlate,[17, 18] the contributing factors identified in Schaffer and colleagues' study help direct our patient safety efforts.

Clinical judgment was the most common factor associated with hospitalist malpractice claims, with examples including failure or delay in ordering a necessary diagnostic test or specialist consultation. These results may be misinterpreted by some to suggest that ordering more tests and services may reduce risk for malpractice claims. However, there is no evidence to support the belief that these defensive medicine behaviors actually reduce risk. In fact, the opposite may be true. Research shows that abnormal tests are frequently overlooked,[9, 19] and failure to act on abnormal results is a common cause of diagnostic error.[20] Experts have called for the development of diagnosis‐related quality measures and better strategies to enhance trainees' clinical reasoning skills.[21] We suggest that future research also clarify the effect of interruptions, distractions, and workload on cognitive errors in hospital settings.

Communication failures were the second most common contributing factor. As previously mentioned, communication failures may occur between hospitalists during handoffs. We also have major opportunities to improve interprofessional teamwork, especially between physicians and nurses.[22, 23] An increasing number of hospitalist groups are collaborating with other hospital‐based professionals to implement novel strategies to improve teamwork,[24, 25] many of which were recently summarized in a review published in this journal.[26]

Documentation was the third most common contributing factor. Most malpractice claims are filed long after the alleged injury has occurred.[18] Unless the clinicians involved and the hospital in which they work are aware of an event that might result in a malpractice claim, the investigation may be severely delayed. As time goes on, professionals are less able to recall details pertinent to understanding contributing factors to an event. Thus, documentation is critical. As the saying goes, if it wasn't documented, it didn't happen. The flipside of too little documentation is, of course, too much. The increasing use of electronic health records makes it easy to copy and paste outdated information, the sloppiness of which can only hurt when attempting to defend a malpractice claim.[27]

In conclusion, despite a model with inherent features that might contribute to medical malpractice risk, hospital medicine has a claim rate lower than many other specialties. Though reassuring, hospitalists should remember that the most productive way to approach malpractice risk is reframe the problem as one that attempts to reduce risk for patients, rather than for physicians. Improving patient safety is a core value for hospital medicine. Schaffer and colleagues' study identifies factors contributing to patient safety risk in hospital medicine, allowing us to renew our efforts in focused areas.