Robert M. Wachter, MD

METHODS

RESULTS

DISCUSSION

METHODS

RESULTS

DISCUSSION

METHODS

RESULTS

DISCUSSION

This year, we celebrate the 10th anniversary of this esteemed publication, and it is indeed an occasion for celebration. For those of us who were there at the creation of the hospitalist field, the establishment of a vibrant academic journal was a dream, one whose fulfillment was central to the legitimization of our field as a full‐fledged specialty. After a decade and 83 issues, the Journal of Hospital Medicine is a formidable source of information, cohesion, and pride.

The anniversary comes at a particularly interesting time for hospitals and hospitalists. Our field's lifeblood has been in trailblazing and continuous reinvention. We were the first physician specialty that embraced the mantra of systems thinking, as captured in our famous metaphor that we care for two sick patients: the person and the system. We were the first field that proudly, and without a hint of shame, allied ourselves with hospital leaders, believing that we were mutually dependent on one another, and that our ability to make change happen and stick was better if we were working with our institutions' leaders. In creating our professional society (and this journal), we took unusual pains to be inclusiveof academic and community‐based hospitalists, or hospitalists entering the field from a variety of backgrounds, of hospitalists caring for adults and kids, and of nonphysician providers.

Our efforts have paid off. Leaders as prominent as Don Berwick have observed that hospitalists have become the essential army of improvers in hospitals and healthcare systems. Hospitalists have made immense contributions at their own institutions, and are increasingly assuming leadership roles both locally and nationally. It is not a coincidence that Medicare's top physician (Patrick Conway) and the Surgeon General (Vivek Murthy) are both hospitalists. Although there have been a few bumps along the way, hospitalists are generally satisfied with their careers, respected by their colleagues, accepted by their patients, and pleased to be members of the fastest growing specialty in the history of modern medicine.

All of this should leave us all feeling warm, proud and more than a little nervous. We are now a mature medical specialty, no longer upstarts, and the natural inclination, in a changing world, will be to hunker down and protect what we have. Of course, some of that is reasonable and appropriate (for example, to fight for our fair share of a bundled payment pie),[1] but some of it will be wrong, even self‐defeating. The world of healthcare is changing fast, and our ability to stay relevant and indispensable will depend on our ability to evolve to meet new conditions and needs.

Let us consider some of the major trends playing out in healthcare. The biggest is the brisk and unmistakable shift from volume to value.[2] This is a trend we have been on top of, because this really has been our field's raison d'tre: improving value in the hospital by cutting costs and length of stay while improving (or at least keeping neutral) quality and safety.[3] However, a world under intense value pressure will work hard to move patients from hospital to less expensive postacute settings, and will insist on seamless handoffs between the hospital and such settings. Thoughtful hospital medicine groups are thinking hard about this trend, and many are placing colleagues in skilled nursing facilities, or at the very least tightening their connections to the postacute facilities in their healthcare ecosystem. We no longer have the luxury of confining our talents and energies to those things that take place within the 4 walls of the hospital.

Another trend is the digitization of healthcare, a trend turbocharged by $30 billion in federal incentive payments distributed between 2009 and 2014.[4] Here too, hospitalists have emerged as leaders in information technology (IT) implementations, and a disproportionate number of chief medical information officers and other IT leaders seem to be hospitalists. Splendid. But it is also up to us to help figure out how to use IT tools effectively. The notes have morphed into bloated, copy‐and‐pasteridden monstrosities: let us figure out what a good note should look like in the digital era, and then implement educational and system changes to create a new standard. We no longer go to radiology because we do not need to to see our films; let us think about what the loss of the collegial exchange with our radiology colleagues has cost, and then set out to develop new systems to reimagine it. Right now, big data are mostly hype and unrequited promise. Who better than hospitalists to dive in and start making sense of the data to predict risks or help point to better treatments?

Another trend is population health. Although I do not foresee a return to the Marcus Welby model of a kindly physician following the patient everywhere, I can imagine certain patients (mostly those with several social and clinical comorbidities and at least 3 admissions per year) who might be well served by a back‐to‐the‐future system in which a primary care provider follows them into the hospital, perhaps comanaging the patients with the on‐service hospitalist. David Meltzer, at the University of Chicago, is currently studying such a model, and I look forward to seeing his results.[5] Rather than rejecting such experiments as violating the usual hospitalist structure, we must embrace them, at least until the evidence is in.

In the end, the field of hospital medicine emerged and thrived because of the promise, and later the evidence, that our presence led to better quality, safety, patient experience, education, and efficiency. This mandate must remain our mantra, even if it means that we have to evolve our model in keeping with a changing healthcare landscape. The minute we stop evolving is the minute our field starts planting the seeds of its own destruction.

This year, we celebrate the 10th anniversary of this esteemed publication, and it is indeed an occasion for celebration. For those of us who were there at the creation of the hospitalist field, the establishment of a vibrant academic journal was a dream, one whose fulfillment was central to the legitimization of our field as a full‐fledged specialty. After a decade and 83 issues, the Journal of Hospital Medicine is a formidable source of information, cohesion, and pride.

The anniversary comes at a particularly interesting time for hospitals and hospitalists. Our field's lifeblood has been in trailblazing and continuous reinvention. We were the first physician specialty that embraced the mantra of systems thinking, as captured in our famous metaphor that we care for two sick patients: the person and the system. We were the first field that proudly, and without a hint of shame, allied ourselves with hospital leaders, believing that we were mutually dependent on one another, and that our ability to make change happen and stick was better if we were working with our institutions' leaders. In creating our professional society (and this journal), we took unusual pains to be inclusiveof academic and community‐based hospitalists, or hospitalists entering the field from a variety of backgrounds, of hospitalists caring for adults and kids, and of nonphysician providers.

Our efforts have paid off. Leaders as prominent as Don Berwick have observed that hospitalists have become the essential army of improvers in hospitals and healthcare systems. Hospitalists have made immense contributions at their own institutions, and are increasingly assuming leadership roles both locally and nationally. It is not a coincidence that Medicare's top physician (Patrick Conway) and the Surgeon General (Vivek Murthy) are both hospitalists. Although there have been a few bumps along the way, hospitalists are generally satisfied with their careers, respected by their colleagues, accepted by their patients, and pleased to be members of the fastest growing specialty in the history of modern medicine.

All of this should leave us all feeling warm, proud and more than a little nervous. We are now a mature medical specialty, no longer upstarts, and the natural inclination, in a changing world, will be to hunker down and protect what we have. Of course, some of that is reasonable and appropriate (for example, to fight for our fair share of a bundled payment pie),[1] but some of it will be wrong, even self‐defeating. The world of healthcare is changing fast, and our ability to stay relevant and indispensable will depend on our ability to evolve to meet new conditions and needs.

Let us consider some of the major trends playing out in healthcare. The biggest is the brisk and unmistakable shift from volume to value.[2] This is a trend we have been on top of, because this really has been our field's raison d'tre: improving value in the hospital by cutting costs and length of stay while improving (or at least keeping neutral) quality and safety.[3] However, a world under intense value pressure will work hard to move patients from hospital to less expensive postacute settings, and will insist on seamless handoffs between the hospital and such settings. Thoughtful hospital medicine groups are thinking hard about this trend, and many are placing colleagues in skilled nursing facilities, or at the very least tightening their connections to the postacute facilities in their healthcare ecosystem. We no longer have the luxury of confining our talents and energies to those things that take place within the 4 walls of the hospital.

Another trend is the digitization of healthcare, a trend turbocharged by $30 billion in federal incentive payments distributed between 2009 and 2014.[4] Here too, hospitalists have emerged as leaders in information technology (IT) implementations, and a disproportionate number of chief medical information officers and other IT leaders seem to be hospitalists. Splendid. But it is also up to us to help figure out how to use IT tools effectively. The notes have morphed into bloated, copy‐and‐pasteridden monstrosities: let us figure out what a good note should look like in the digital era, and then implement educational and system changes to create a new standard. We no longer go to radiology because we do not need to to see our films; let us think about what the loss of the collegial exchange with our radiology colleagues has cost, and then set out to develop new systems to reimagine it. Right now, big data are mostly hype and unrequited promise. Who better than hospitalists to dive in and start making sense of the data to predict risks or help point to better treatments?

Another trend is population health. Although I do not foresee a return to the Marcus Welby model of a kindly physician following the patient everywhere, I can imagine certain patients (mostly those with several social and clinical comorbidities and at least 3 admissions per year) who might be well served by a back‐to‐the‐future system in which a primary care provider follows them into the hospital, perhaps comanaging the patients with the on‐service hospitalist. David Meltzer, at the University of Chicago, is currently studying such a model, and I look forward to seeing his results.[5] Rather than rejecting such experiments as violating the usual hospitalist structure, we must embrace them, at least until the evidence is in.

In the end, the field of hospital medicine emerged and thrived because of the promise, and later the evidence, that our presence led to better quality, safety, patient experience, education, and efficiency. This mandate must remain our mantra, even if it means that we have to evolve our model in keeping with a changing healthcare landscape. The minute we stop evolving is the minute our field starts planting the seeds of its own destruction.

This year, we celebrate the 10th anniversary of this esteemed publication, and it is indeed an occasion for celebration. For those of us who were there at the creation of the hospitalist field, the establishment of a vibrant academic journal was a dream, one whose fulfillment was central to the legitimization of our field as a full‐fledged specialty. After a decade and 83 issues, the Journal of Hospital Medicine is a formidable source of information, cohesion, and pride.

The anniversary comes at a particularly interesting time for hospitals and hospitalists. Our field's lifeblood has been in trailblazing and continuous reinvention. We were the first physician specialty that embraced the mantra of systems thinking, as captured in our famous metaphor that we care for two sick patients: the person and the system. We were the first field that proudly, and without a hint of shame, allied ourselves with hospital leaders, believing that we were mutually dependent on one another, and that our ability to make change happen and stick was better if we were working with our institutions' leaders. In creating our professional society (and this journal), we took unusual pains to be inclusiveof academic and community‐based hospitalists, or hospitalists entering the field from a variety of backgrounds, of hospitalists caring for adults and kids, and of nonphysician providers.

Our efforts have paid off. Leaders as prominent as Don Berwick have observed that hospitalists have become the essential army of improvers in hospitals and healthcare systems. Hospitalists have made immense contributions at their own institutions, and are increasingly assuming leadership roles both locally and nationally. It is not a coincidence that Medicare's top physician (Patrick Conway) and the Surgeon General (Vivek Murthy) are both hospitalists. Although there have been a few bumps along the way, hospitalists are generally satisfied with their careers, respected by their colleagues, accepted by their patients, and pleased to be members of the fastest growing specialty in the history of modern medicine.

All of this should leave us all feeling warm, proud and more than a little nervous. We are now a mature medical specialty, no longer upstarts, and the natural inclination, in a changing world, will be to hunker down and protect what we have. Of course, some of that is reasonable and appropriate (for example, to fight for our fair share of a bundled payment pie),[1] but some of it will be wrong, even self‐defeating. The world of healthcare is changing fast, and our ability to stay relevant and indispensable will depend on our ability to evolve to meet new conditions and needs.

Let us consider some of the major trends playing out in healthcare. The biggest is the brisk and unmistakable shift from volume to value.[2] This is a trend we have been on top of, because this really has been our field's raison d'tre: improving value in the hospital by cutting costs and length of stay while improving (or at least keeping neutral) quality and safety.[3] However, a world under intense value pressure will work hard to move patients from hospital to less expensive postacute settings, and will insist on seamless handoffs between the hospital and such settings. Thoughtful hospital medicine groups are thinking hard about this trend, and many are placing colleagues in skilled nursing facilities, or at the very least tightening their connections to the postacute facilities in their healthcare ecosystem. We no longer have the luxury of confining our talents and energies to those things that take place within the 4 walls of the hospital.

Another trend is the digitization of healthcare, a trend turbocharged by $30 billion in federal incentive payments distributed between 2009 and 2014.[4] Here too, hospitalists have emerged as leaders in information technology (IT) implementations, and a disproportionate number of chief medical information officers and other IT leaders seem to be hospitalists. Splendid. But it is also up to us to help figure out how to use IT tools effectively. The notes have morphed into bloated, copy‐and‐pasteridden monstrosities: let us figure out what a good note should look like in the digital era, and then implement educational and system changes to create a new standard. We no longer go to radiology because we do not need to to see our films; let us think about what the loss of the collegial exchange with our radiology colleagues has cost, and then set out to develop new systems to reimagine it. Right now, big data are mostly hype and unrequited promise. Who better than hospitalists to dive in and start making sense of the data to predict risks or help point to better treatments?

Another trend is population health. Although I do not foresee a return to the Marcus Welby model of a kindly physician following the patient everywhere, I can imagine certain patients (mostly those with several social and clinical comorbidities and at least 3 admissions per year) who might be well served by a back‐to‐the‐future system in which a primary care provider follows them into the hospital, perhaps comanaging the patients with the on‐service hospitalist. David Meltzer, at the University of Chicago, is currently studying such a model, and I look forward to seeing his results.[5] Rather than rejecting such experiments as violating the usual hospitalist structure, we must embrace them, at least until the evidence is in.

In the end, the field of hospital medicine emerged and thrived because of the promise, and later the evidence, that our presence led to better quality, safety, patient experience, education, and efficiency. This mandate must remain our mantra, even if it means that we have to evolve our model in keeping with a changing healthcare landscape. The minute we stop evolving is the minute our field starts planting the seeds of its own destruction.

With a United States medical system that spends as much as $750 billion each year on care that does not result in improved health outcomes,[1] many policy initiatives, including the Centers for Medicare and Medicaid Services' Value‐Based Purchasing program, seek to realign hospitals' financial incentives from a focus on production to one on value (quality divided by cost).[2, 3] Professional organizations have now deemed resource stewardship an ethical responsibility for professionalism,[4, 5] and campaigns such as the American Board of Internal Medicine (ABIM) Foundation's Choosing Wisely effort and the American College of Physicians' High‐Value Care platform are calling on frontline clinicians to address unnecessary and wasteful services.[6, 7]

Despite these pressures and initiatives, most physicians lack the knowledge and tools necessary to prioritize the delivery of their own healthcare services according to value.[8, 9, 10] Hospital medicine physicians are unaware of the costs associated with the interventions they order,[10] and the majority of medical training programs lack curricula focused on healthcare costs,[11] creating a large gap between physicians' perceived, desired, and actual knowledge related to costs.[12] Novel frameworks and frontline physician engagement are required if clinicians are to improve the value of the care they deliver.

We describe 1 of our first steps at the University of California, San Francisco (UCSF) to promote high‐value care (HVC) delivery: the creation of a HVC program led by clinicians and administrators focused on identifying and addressing wasteful practices within our hospitalist group. The program aims to (1) use financial and clinical data to identify areas with clear evidence of waste in the hospital, (2) promote evidence‐based interventions that improve both quality of care and value, and (3) pair interventions with evidence‐based cost awareness education to drive culture change. Our experience and inaugural projects provide a model of the key features, inherent challenges, and lessons learned, which may help inform similar efforts.

METHODS

In March 2012, we launched an HVC program within our Division of Hospital Medicine at UCSF Medical Center, a 600‐bed academic medical center in an urban setting. During the 2013 academic year, our division included 45 physicians. The medicine service, comprised of 8 teaching medical ward teams (1 attending, 1 resident, 2 interns, and variable number of medical students), and 1 nonteaching medical ward team (1 attending), admitted 4700 patients that year.

Framework for Identifying Target Projects

Robust Analysis of Costs

We created a framework for identifying, designing, and promoting projects specifically aimed at improving healthcare value (Figure 1). Financial data were used to identify areas with clear evidence of waste in the hospital, areas of high cost with no benefit in health outcomes. We focused particularly on obtaining cost and billing data for our medical service, which provided important insight into potential targets for improvements in value. For example, in 2011, the Division of Hospital Medicine spent more than $1 million annually in direct costs for the administration of nebulized bronchodilator therapies (nebs) to nonintensive care unit patients on the medical service.[13] These high costs, exposed by billing data, were believed to represent potential unnecessary testing and/or procedures. Not every area of high cost was deemed a target for intervention. For example, the use of recombinant factor VIII appeared a necessary expenditure (over $1 million per year) for our patients with hemophilia. Although our efforts focused on reducing waste, it is worth noting that healthcare value can also be increased by improving the delivery of high‐value services.

Figure 1

Recognized Benefits in Quality of Care

The program also evaluated the impact of cost reduction efforts on the quality of care, based on a high standard of current evidence. Though value can be improved by interventions that decrease costs while being quality neutral, our group chose to focus first on projects that would simultaneously improve quality while decreasing costs. We felt that this win‐win strategy would help obtain buy‐in from clinicians weary of prior cost‐cutting programs. For example, we pursued interventions aimed at reducing inappropriate gastric stress ulcer prophylaxis, which had the potential to both cut costs and minimize risks of hospital‐acquired pneumonia and Clostridium difficile infections.[14, 15] All proposed HVC targets were vetted through a review of the literature and published guidelines. In general, our initial projects had to be strongly supported by evidence, with high‐quality studies, preferably meta‐analyses or systematic reviews, that displayed the safety of our recommended changes. We reviewed the literature with experts. For example, we met with faculty pulmonologists to discuss the evidence supporting the use of inhalers instead of nebulizers in adults with obstructive pulmonary disease. The goals of our projects were chosen by our HVC committee, based on an analysis of our baseline data and the perceived potential effects of our proposed interventions.

Educational Intervention

Last, we paired interventions with evidence‐based cost awareness education to drive culture change. At UCSF we have an ongoing longitudinal cost‐awareness curriculum for residents, which has previously been described.[16] We took advantage of this educational forum to address gaps in clinician knowledge related to the targeted areas. When launching the initiative to decrease unnecessary inpatient nebulizer usage and improve transitions to inhalers, we utilized the chronic obstructive pulmonary disease case in the cost‐awareness series. Doing so allowed us to both review the evidence behind the effectiveness of inhalers, and introduce our Nebs No More After 24 campaign, which sought to transition adult inpatients with obstructive pulmonary symptoms from nebs to inhalers within 24 hours of admission.[13]

Intervention Strategy

Our general approach has been to design and implement multifaceted interventions, adapted from previous QI literature (Figure 1).[17] Given the importance of frontline clinician engagement to successful project implementation,[18, 19, 20] our interventions are physician‐driven and are vetted by a large group of clinicians prior to launch. The HVC program also explicitly seeks stakeholder input, perspective, and buy‐in prior to implementation. For example, we involved respiratory therapists (RTs) in the design of the Nebs No More After 24 project, thus ensuring that the interventions fit within their workflow and align with their care‐delivery goals.

Local publicity campaigns provide education and reminders for clinicians. Posters, such as the Nebs No More After 24 poster (Figure 2), were hung in physician, nursing, and RT work areas. Pens featuring the catchphrase Nebs No More After 24 were distributed to clinicians.

Figure 2

In addition to presentations to residents through the UCSF cost awareness curriculum, educational presentations were also delivered to attending physicians and to other allied members of the healthcare team (eg, nurses, RTs) during regularly scheduled staff meetings.

The metrics for each of the projects were regularly monitored, and targeted feedback was provided to clinicians. For the Nebs No More After 24 campaign, data for the number of nebs delivered on the target floor were provided to resident physicians during the cost awareness conference each month, and the data were presented to attending hospitalists in the monthly QI newsletter. This academic year, transfusion and telemetry data are presented via the same strategy.

Stakeholder recruitment, education, and promotional campaigns are important to program launches, but to sustain projects over the long‐term, system changes may be necessary. We have pursued changes in the computerized provider order entry (CPOE) system, such as removing nebs from the admission order set or putting a default duration for certain telemetry orders. Systems‐level interventions, although more difficult to achieve, play an important role in creating enduring changes when paired with educational interventions.

RESULTS

During our first 2 years we have initiated ongoing projects directed at 6 major targets (Table 1). Our flagship project, Nebs No More After 24, resulted in a decrease of nebulizer rates by more than 50% on a high‐acuity medical floor, as previously published.[13] We created a financial model that primarily accounted for RT time and pharmaceutical costs, and estimated a savings of approximately $250,000 annually on this single medical ward (see Supporting Information, Table 1, in the online version of this article).[13]

The HVC program also provided an arena for collaborating with and supporting value‐based projects launched by other groups, such as the UCSF Medication Outcomes Center's inappropriate gastric stress ulcer prophylaxis program.[21] Our group helped support the development and implementation of evidence‐based clinical practice guidelines, and we assisted educational interventions targeting clinicians. This program resulted in a decrease in inappropriate stress ulcer prophylaxis in intensive care unit patients from 19% to 6.6% within 1 month following implementation.[21]

DISCUSSION

Physicians are increasingly being asked to embrace and lead efforts to improve healthcare value and reduce costs. Our program provides a framework to guide physician‐led initiatives to identify and address areas of healthcare waste.

CONCLUSIONS

Our HVC program has been successful in promoting improved healthcare value and engaging clinicians in this effort. The program is guided by the use of financial data to identify areas with clear evidence of waste in the hospital, the creation of evidence‐based interventions that improve quality of care while cutting costs, and the pairing of interventions with evidence‐based cost awareness education to drive culture change.

With a United States medical system that spends as much as $750 billion each year on care that does not result in improved health outcomes,[1] many policy initiatives, including the Centers for Medicare and Medicaid Services' Value‐Based Purchasing program, seek to realign hospitals' financial incentives from a focus on production to one on value (quality divided by cost).[2, 3] Professional organizations have now deemed resource stewardship an ethical responsibility for professionalism,[4, 5] and campaigns such as the American Board of Internal Medicine (ABIM) Foundation's Choosing Wisely effort and the American College of Physicians' High‐Value Care platform are calling on frontline clinicians to address unnecessary and wasteful services.[6, 7]

Despite these pressures and initiatives, most physicians lack the knowledge and tools necessary to prioritize the delivery of their own healthcare services according to value.[8, 9, 10] Hospital medicine physicians are unaware of the costs associated with the interventions they order,[10] and the majority of medical training programs lack curricula focused on healthcare costs,[11] creating a large gap between physicians' perceived, desired, and actual knowledge related to costs.[12] Novel frameworks and frontline physician engagement are required if clinicians are to improve the value of the care they deliver.

We describe 1 of our first steps at the University of California, San Francisco (UCSF) to promote high‐value care (HVC) delivery: the creation of a HVC program led by clinicians and administrators focused on identifying and addressing wasteful practices within our hospitalist group. The program aims to (1) use financial and clinical data to identify areas with clear evidence of waste in the hospital, (2) promote evidence‐based interventions that improve both quality of care and value, and (3) pair interventions with evidence‐based cost awareness education to drive culture change. Our experience and inaugural projects provide a model of the key features, inherent challenges, and lessons learned, which may help inform similar efforts.

METHODS

In March 2012, we launched an HVC program within our Division of Hospital Medicine at UCSF Medical Center, a 600‐bed academic medical center in an urban setting. During the 2013 academic year, our division included 45 physicians. The medicine service, comprised of 8 teaching medical ward teams (1 attending, 1 resident, 2 interns, and variable number of medical students), and 1 nonteaching medical ward team (1 attending), admitted 4700 patients that year.

Framework for Identifying Target Projects

Robust Analysis of Costs

We created a framework for identifying, designing, and promoting projects specifically aimed at improving healthcare value (Figure 1). Financial data were used to identify areas with clear evidence of waste in the hospital, areas of high cost with no benefit in health outcomes. We focused particularly on obtaining cost and billing data for our medical service, which provided important insight into potential targets for improvements in value. For example, in 2011, the Division of Hospital Medicine spent more than $1 million annually in direct costs for the administration of nebulized bronchodilator therapies (nebs) to nonintensive care unit patients on the medical service.[13] These high costs, exposed by billing data, were believed to represent potential unnecessary testing and/or procedures. Not every area of high cost was deemed a target for intervention. For example, the use of recombinant factor VIII appeared a necessary expenditure (over $1 million per year) for our patients with hemophilia. Although our efforts focused on reducing waste, it is worth noting that healthcare value can also be increased by improving the delivery of high‐value services.

Figure 1

Recognized Benefits in Quality of Care

The program also evaluated the impact of cost reduction efforts on the quality of care, based on a high standard of current evidence. Though value can be improved by interventions that decrease costs while being quality neutral, our group chose to focus first on projects that would simultaneously improve quality while decreasing costs. We felt that this win‐win strategy would help obtain buy‐in from clinicians weary of prior cost‐cutting programs. For example, we pursued interventions aimed at reducing inappropriate gastric stress ulcer prophylaxis, which had the potential to both cut costs and minimize risks of hospital‐acquired pneumonia and Clostridium difficile infections.[14, 15] All proposed HVC targets were vetted through a review of the literature and published guidelines. In general, our initial projects had to be strongly supported by evidence, with high‐quality studies, preferably meta‐analyses or systematic reviews, that displayed the safety of our recommended changes. We reviewed the literature with experts. For example, we met with faculty pulmonologists to discuss the evidence supporting the use of inhalers instead of nebulizers in adults with obstructive pulmonary disease. The goals of our projects were chosen by our HVC committee, based on an analysis of our baseline data and the perceived potential effects of our proposed interventions.

Educational Intervention

Last, we paired interventions with evidence‐based cost awareness education to drive culture change. At UCSF we have an ongoing longitudinal cost‐awareness curriculum for residents, which has previously been described.[16] We took advantage of this educational forum to address gaps in clinician knowledge related to the targeted areas. When launching the initiative to decrease unnecessary inpatient nebulizer usage and improve transitions to inhalers, we utilized the chronic obstructive pulmonary disease case in the cost‐awareness series. Doing so allowed us to both review the evidence behind the effectiveness of inhalers, and introduce our Nebs No More After 24 campaign, which sought to transition adult inpatients with obstructive pulmonary symptoms from nebs to inhalers within 24 hours of admission.[13]

Intervention Strategy

Our general approach has been to design and implement multifaceted interventions, adapted from previous QI literature (Figure 1).[17] Given the importance of frontline clinician engagement to successful project implementation,[18, 19, 20] our interventions are physician‐driven and are vetted by a large group of clinicians prior to launch. The HVC program also explicitly seeks stakeholder input, perspective, and buy‐in prior to implementation. For example, we involved respiratory therapists (RTs) in the design of the Nebs No More After 24 project, thus ensuring that the interventions fit within their workflow and align with their care‐delivery goals.

Local publicity campaigns provide education and reminders for clinicians. Posters, such as the Nebs No More After 24 poster (Figure 2), were hung in physician, nursing, and RT work areas. Pens featuring the catchphrase Nebs No More After 24 were distributed to clinicians.

Figure 2

In addition to presentations to residents through the UCSF cost awareness curriculum, educational presentations were also delivered to attending physicians and to other allied members of the healthcare team (eg, nurses, RTs) during regularly scheduled staff meetings.

The metrics for each of the projects were regularly monitored, and targeted feedback was provided to clinicians. For the Nebs No More After 24 campaign, data for the number of nebs delivered on the target floor were provided to resident physicians during the cost awareness conference each month, and the data were presented to attending hospitalists in the monthly QI newsletter. This academic year, transfusion and telemetry data are presented via the same strategy.

Stakeholder recruitment, education, and promotional campaigns are important to program launches, but to sustain projects over the long‐term, system changes may be necessary. We have pursued changes in the computerized provider order entry (CPOE) system, such as removing nebs from the admission order set or putting a default duration for certain telemetry orders. Systems‐level interventions, although more difficult to achieve, play an important role in creating enduring changes when paired with educational interventions.

RESULTS

During our first 2 years we have initiated ongoing projects directed at 6 major targets (Table 1). Our flagship project, Nebs No More After 24, resulted in a decrease of nebulizer rates by more than 50% on a high‐acuity medical floor, as previously published.[13] We created a financial model that primarily accounted for RT time and pharmaceutical costs, and estimated a savings of approximately $250,000 annually on this single medical ward (see Supporting Information, Table 1, in the online version of this article).[13]

The HVC program also provided an arena for collaborating with and supporting value‐based projects launched by other groups, such as the UCSF Medication Outcomes Center's inappropriate gastric stress ulcer prophylaxis program.[21] Our group helped support the development and implementation of evidence‐based clinical practice guidelines, and we assisted educational interventions targeting clinicians. This program resulted in a decrease in inappropriate stress ulcer prophylaxis in intensive care unit patients from 19% to 6.6% within 1 month following implementation.[21]

DISCUSSION

Physicians are increasingly being asked to embrace and lead efforts to improve healthcare value and reduce costs. Our program provides a framework to guide physician‐led initiatives to identify and address areas of healthcare waste.

CONCLUSIONS

Our HVC program has been successful in promoting improved healthcare value and engaging clinicians in this effort. The program is guided by the use of financial data to identify areas with clear evidence of waste in the hospital, the creation of evidence‐based interventions that improve quality of care while cutting costs, and the pairing of interventions with evidence‐based cost awareness education to drive culture change.

With a United States medical system that spends as much as $750 billion each year on care that does not result in improved health outcomes,[1] many policy initiatives, including the Centers for Medicare and Medicaid Services' Value‐Based Purchasing program, seek to realign hospitals' financial incentives from a focus on production to one on value (quality divided by cost).[2, 3] Professional organizations have now deemed resource stewardship an ethical responsibility for professionalism,[4, 5] and campaigns such as the American Board of Internal Medicine (ABIM) Foundation's Choosing Wisely effort and the American College of Physicians' High‐Value Care platform are calling on frontline clinicians to address unnecessary and wasteful services.[6, 7]

Despite these pressures and initiatives, most physicians lack the knowledge and tools necessary to prioritize the delivery of their own healthcare services according to value.[8, 9, 10] Hospital medicine physicians are unaware of the costs associated with the interventions they order,[10] and the majority of medical training programs lack curricula focused on healthcare costs,[11] creating a large gap between physicians' perceived, desired, and actual knowledge related to costs.[12] Novel frameworks and frontline physician engagement are required if clinicians are to improve the value of the care they deliver.

We describe 1 of our first steps at the University of California, San Francisco (UCSF) to promote high‐value care (HVC) delivery: the creation of a HVC program led by clinicians and administrators focused on identifying and addressing wasteful practices within our hospitalist group. The program aims to (1) use financial and clinical data to identify areas with clear evidence of waste in the hospital, (2) promote evidence‐based interventions that improve both quality of care and value, and (3) pair interventions with evidence‐based cost awareness education to drive culture change. Our experience and inaugural projects provide a model of the key features, inherent challenges, and lessons learned, which may help inform similar efforts.

METHODS

In March 2012, we launched an HVC program within our Division of Hospital Medicine at UCSF Medical Center, a 600‐bed academic medical center in an urban setting. During the 2013 academic year, our division included 45 physicians. The medicine service, comprised of 8 teaching medical ward teams (1 attending, 1 resident, 2 interns, and variable number of medical students), and 1 nonteaching medical ward team (1 attending), admitted 4700 patients that year.

Framework for Identifying Target Projects

Robust Analysis of Costs

We created a framework for identifying, designing, and promoting projects specifically aimed at improving healthcare value (Figure 1). Financial data were used to identify areas with clear evidence of waste in the hospital, areas of high cost with no benefit in health outcomes. We focused particularly on obtaining cost and billing data for our medical service, which provided important insight into potential targets for improvements in value. For example, in 2011, the Division of Hospital Medicine spent more than $1 million annually in direct costs for the administration of nebulized bronchodilator therapies (nebs) to nonintensive care unit patients on the medical service.[13] These high costs, exposed by billing data, were believed to represent potential unnecessary testing and/or procedures. Not every area of high cost was deemed a target for intervention. For example, the use of recombinant factor VIII appeared a necessary expenditure (over $1 million per year) for our patients with hemophilia. Although our efforts focused on reducing waste, it is worth noting that healthcare value can also be increased by improving the delivery of high‐value services.

Figure 1

Recognized Benefits in Quality of Care

The program also evaluated the impact of cost reduction efforts on the quality of care, based on a high standard of current evidence. Though value can be improved by interventions that decrease costs while being quality neutral, our group chose to focus first on projects that would simultaneously improve quality while decreasing costs. We felt that this win‐win strategy would help obtain buy‐in from clinicians weary of prior cost‐cutting programs. For example, we pursued interventions aimed at reducing inappropriate gastric stress ulcer prophylaxis, which had the potential to both cut costs and minimize risks of hospital‐acquired pneumonia and Clostridium difficile infections.[14, 15] All proposed HVC targets were vetted through a review of the literature and published guidelines. In general, our initial projects had to be strongly supported by evidence, with high‐quality studies, preferably meta‐analyses or systematic reviews, that displayed the safety of our recommended changes. We reviewed the literature with experts. For example, we met with faculty pulmonologists to discuss the evidence supporting the use of inhalers instead of nebulizers in adults with obstructive pulmonary disease. The goals of our projects were chosen by our HVC committee, based on an analysis of our baseline data and the perceived potential effects of our proposed interventions.

Educational Intervention

Last, we paired interventions with evidence‐based cost awareness education to drive culture change. At UCSF we have an ongoing longitudinal cost‐awareness curriculum for residents, which has previously been described.[16] We took advantage of this educational forum to address gaps in clinician knowledge related to the targeted areas. When launching the initiative to decrease unnecessary inpatient nebulizer usage and improve transitions to inhalers, we utilized the chronic obstructive pulmonary disease case in the cost‐awareness series. Doing so allowed us to both review the evidence behind the effectiveness of inhalers, and introduce our Nebs No More After 24 campaign, which sought to transition adult inpatients with obstructive pulmonary symptoms from nebs to inhalers within 24 hours of admission.[13]

Intervention Strategy

Our general approach has been to design and implement multifaceted interventions, adapted from previous QI literature (Figure 1).[17] Given the importance of frontline clinician engagement to successful project implementation,[18, 19, 20] our interventions are physician‐driven and are vetted by a large group of clinicians prior to launch. The HVC program also explicitly seeks stakeholder input, perspective, and buy‐in prior to implementation. For example, we involved respiratory therapists (RTs) in the design of the Nebs No More After 24 project, thus ensuring that the interventions fit within their workflow and align with their care‐delivery goals.

Local publicity campaigns provide education and reminders for clinicians. Posters, such as the Nebs No More After 24 poster (Figure 2), were hung in physician, nursing, and RT work areas. Pens featuring the catchphrase Nebs No More After 24 were distributed to clinicians.

Figure 2

In addition to presentations to residents through the UCSF cost awareness curriculum, educational presentations were also delivered to attending physicians and to other allied members of the healthcare team (eg, nurses, RTs) during regularly scheduled staff meetings.

The metrics for each of the projects were regularly monitored, and targeted feedback was provided to clinicians. For the Nebs No More After 24 campaign, data for the number of nebs delivered on the target floor were provided to resident physicians during the cost awareness conference each month, and the data were presented to attending hospitalists in the monthly QI newsletter. This academic year, transfusion and telemetry data are presented via the same strategy.

Stakeholder recruitment, education, and promotional campaigns are important to program launches, but to sustain projects over the long‐term, system changes may be necessary. We have pursued changes in the computerized provider order entry (CPOE) system, such as removing nebs from the admission order set or putting a default duration for certain telemetry orders. Systems‐level interventions, although more difficult to achieve, play an important role in creating enduring changes when paired with educational interventions.

RESULTS

During our first 2 years we have initiated ongoing projects directed at 6 major targets (Table 1). Our flagship project, Nebs No More After 24, resulted in a decrease of nebulizer rates by more than 50% on a high‐acuity medical floor, as previously published.[13] We created a financial model that primarily accounted for RT time and pharmaceutical costs, and estimated a savings of approximately $250,000 annually on this single medical ward (see Supporting Information, Table 1, in the online version of this article).[13]

The HVC program also provided an arena for collaborating with and supporting value‐based projects launched by other groups, such as the UCSF Medication Outcomes Center's inappropriate gastric stress ulcer prophylaxis program.[21] Our group helped support the development and implementation of evidence‐based clinical practice guidelines, and we assisted educational interventions targeting clinicians. This program resulted in a decrease in inappropriate stress ulcer prophylaxis in intensive care unit patients from 19% to 6.6% within 1 month following implementation.[21]

DISCUSSION

Physicians are increasingly being asked to embrace and lead efforts to improve healthcare value and reduce costs. Our program provides a framework to guide physician‐led initiatives to identify and address areas of healthcare waste.

CONCLUSIONS

Our HVC program has been successful in promoting improved healthcare value and engaging clinicians in this effort. The program is guided by the use of financial data to identify areas with clear evidence of waste in the hospital, the creation of evidence‐based interventions that improve quality of care while cutting costs, and the pairing of interventions with evidence‐based cost awareness education to drive culture change.

Healthcare delivery organizations are under increasing pressure to improve patient safety. The fundamental underpinning of efforts to improve safety has been the establishment of a no‐blame culture, one that focuses less on individual transgressions and more on system improvement.[1, 2] As evidence‐based practices to improve care have emerged, and the pressures to deliver tangible improvements in safety and quality have grown, providers, healthcare system leaders, and policymakers are struggling with how best to balance the need for accountability with this no‐blame paradigm.

In dealing with areas such as hand hygiene, where there is strong evidence for the value of the practice yet relatively poor adherence in many institutions, Wachter and Pronovost have argued that the scales need to tip more in the direction of accountability, including the imposition of penalties for clinicians who habitually fail to follow certain safety practices.[3] Although not obviating the critical importance of systems improvement, they argue that a failure to enforce such measures undermines trust in the system and invites external regulation. Chassin and colleagues made a similar point in arguing for the identification of certain accountability measures that could be used in public reporting and pay‐for‐performance programs.[4]

Few organizations have enacted robust systems to hold providers responsible for adhering to accountability measures.[4] Although many hospitals have policies to suspend clinical privileges for failing to sign discharge summaries or obtain a yearly purified protein derivative test, few have formal programs to identify and deal with clinicians whose behavior is persistently problematic.[3] Furthermore, existing modes of physician accountability, such as state licensing boards, only discipline physicians retroactively (and rarely) when healthcare organizations report poor performance. State boards typically do not consider prevention of injury, such as adherence to safety practices, to be part of their responsibility.[5] Similarly, credentialing boards (eg, the American Board of Internal Medicine) do not assess adherence to such practices in coming to their decisions.

It is estimated that strict adherence to infection control practices, such as hand hygiene, could prevent over 100,000 hospital deaths every year; adherence to other evidence‐based safety practices such as the use of a preoperative time‐out would likely prevent many more deaths and cases of medical injury.[3, 6] Although there are practical issues, such as how to audit individual clinician adherence in ways that are feasible and fair, that make enforcing individual provider accountability challenging, there seems little doubt that attitudes regarding the appropriateness of enacting penalties for safety transgressions will be key determinants of whether such measures are considered. Yet no study to date has assessed the opinions of different stakeholders (physicians, nurses, trainees, patients) regarding various strategies, including public reporting and penalties, to improve adherence to safety practices. We aimed to assess these attitudes across a variety of such stakeholders.

METHODS

RESULTS

A total of 287 individuals were given surveys, and 183 completed them: 22 attending physicians, 33 resident physicians, 61 nurses, 47 medical students, and 20 patients (overall response rate 64%). Response rate for attending and resident physicians was 73%, for nurses 59%, and for medical students 54%. Among patients who were approached and agreed to accept a survey, 87% returned completed surveys (Table 1). The average age of attending physicians was 35.8 years (standard deviation [SD]: 5.3), residents was 28.3 years (SD: 1.7), nurses was 43.6 years (SD: 11.1), medical students was 26.6 years (SD: 2.9), and inpatients was 48.2 years (SD: 15.9). Thirty‐two percent of attending physicians were female, 67% of resident physicians were female, 88% of nurses were female, 66% of medical students were female, and 47% of inpatients were female.

Perceived Harm

Out of the 3 scenarios presented in in the survey, participants believed that not conducting preoperative time‐outs in surgery presented the highest risk to patient safety, with 57% (residents) to 86% (nurses) rating the potential harm as high (Figure 1). Not conducting fall risk assessments was perceived as second most potentially harmful, and not properly practicing hand hygiene was perceived as least potentially harmful to patient safety. There were significant differences among groups in perceptions of potential harm for all 3 scenarios (P<0.001 for all).

Figure 1

Appropriateness of Public Reporting and Penalties

Public reporting was viewed as ever appropriate by 34% of all respondents for hand‐hygiene protocol lapses, 58% for surgical time‐out lapses, and 43% for fall risk assessment lapses. There were no significant differences among groups in endorsement of public reporting for individual scenarios (Figure 2). Penalties were endorsed more frequently than public reporting for all groups and all scenarios. The proportion of attending physicians and patients who rated penalties as ever appropriate were similar for each scenario. Residents, medical students, and nurses were less likely than patients and attending physicians to support penalties (P<0.05 for all differences).

Figure 2

The aggregated analysis revealed that nurses and medical students were significantly less likely than patients to endorse public reporting across scenarios. In terms of endorsement of penalties, we found no significant differences between attending physicians and patients, but residents (odds ratio [OR]: 0.09, 95% confidence interval [CI]: 0.03‐0.32), students (OR: 0.12, 95% CI: 0.04‐0.34), and nurses (OR: 0.17, 95% CI: 0.03‐0.41) had significantly lower odds of favoring penalties than did patients (Table 2).

Table 2.Likelihood of Endorsing Public Reporting or Penalties at Any Time by Group and Scenario

	Odds Ratio (95% CI)
	Public Reporting	Penalty
NOTE: Odds ratios and proportions were derived from logistic regression models including group, scenario, age, and sex adjusting for clustering within individuals. Abbreviations: CI, confidence interval.
Group, across all scenarios
Patients	Reference	Reference
Attending physicians	0.58 (0.172.01)	0.88 (0.203.84)
Resident physicians	0.42 (0.121.52)	0.09 (0.020.32)
Nurses	0.32 (0.120.88)	0.17 (0.030.41)
Medical students	0.22 (0.060.80)	0.12 (0.040.34)
Scenario, across all groups
Hand hygiene	Reference	Reference
Surgical time‐out	2.82 (2.033.91)	4.29 (2.976.20)
Fall assessment	1.47 (1.091.98)	1.74 (1.272.37)

Across all surveyed groups, public reporting was more often supported for lapses of surgical timeout (OR: 2.82, 95% CI: 2.03‐3.91) and fall risk assessment protocols (OR: 1.47, 95% CI: 1.09‐1.98) than for the referent, hand‐hygiene lapses. Across all groups, penalties were more likely to be supported for surgical timeout (OR: 4.29, 95% CI: 2.97‐6.20) and fall risk assessment protocol lapses (OR: 1.74, 95% CI: 1.27‐2.37) than for hand‐hygiene lapses.

Thresholds for Public Reporting and Penalties

The log‐rank test showed no significant differences among the surveyed groups in the number of transgressions at which public reporting was deemed appropriate in any of the 3 scenarios (P=0.37, P=0.71, and P=0.32 for hand hygiene, surgical time‐out, and fall risk assessment, respectively) (Figure 3). However, patients endorsed penalties after significantly fewer occurrences than residents, medical students, and nurses for all 3 scenarios (P<0.001 for all differences), and at a significantly lower threshold than attending physicians for surgical timeout and fall risk assessment (P<0.001 and P=0.03, respectively).

Figure 3

DISCUSSION

This survey assessed attitudes of healthcare professionals, trainees, and inpatients toward public reporting and penalties when clinicians do not follow basic safety protocols. Respondents tended to favor more aggressive measures when they deemed the safety risk from protocol violations to be higher. Almost all participants favored providing feedback after safety protocol lapses. Healthcare professionals tended to favor punitive measures, such as fines, suspension, and firing, more than public reporting of transgressions. Patients had a lower threshold than both providers and trainees for public reporting and punitive measures. In aggregate, our study suggests that after a decade of emphasis on a no‐blame response to patient safety hazards, both healthcare providers and patients now believe clinicians should be held accountable for following basic safety protocols, though their thresholds and triggers vary.

A surprising finding was that providers were more likely to favor penalties (such as fines, suspension, or firing) than public reporting of safety transgressions. Multiple studies have suggested that public reporting of hospital quality data has improved adherence to care processes and may improve patient outcomes.[15, 16, 17] Although our data do not tell us why clinicians appear to be more worried about public reporting than penalties, they do help explain why transparency has been a relatively powerful strategy to motivate changes in practice, even when it is unaccompanied by significant shifts in consumer choices.[18] It would be natural to consider public reporting to be a softer strategy than fines, suspension, or firing; however, our results indicate that many clinicians do not see it that way. Alternatively, the results could also suggest that clinicians prefer measures that provide more immediate feedback than public reporting generally provides. These attitudes should be considered when enacting public reporting strategies.

Another interesting finding was that patients and attending physicians tended to track together regarding their attitudes toward penalties for safety lapses. Although patients had a lower threshold for favoring penalties than attendings, similar proportions of patients and attending physicians believed that penalties should be enacted for safety transgressions, and both groups were more penal than physician trainees and nurses. We speculate that attendings and patients may have the most skin in the game, patients as the ones directly harmed by a preventable adverse event, and attending physicians as the most responsible clinicians, at least in the eyes of the malpractice system, licensing boards, and credentials committees.

Even though our study illustrates relatively high levels of endorsement for aggressive measures to deal with clinicians who fail to follow evidence‐based safety practices, a shift in this direction has risks and benefits. The no‐blame paradigm in patient safety grew out of a need to encourage open discussion about medical mistakes.[2] Whereas shifting away from a purely no‐ blame approach may lead to greater adherence with safety practices, and one hopes fewer cases of preventable harm, it also risks stifling the open discussions about medical errors that characterize learning organizations.[13, 19] Because of this, a movement in this direction should be undertaken carefully, starting first with a small number of well‐established safety practices, and ensuring that robust education and system improvements precede and accompany the imposition of penalties for nonadherence.

Our study has limitations. The survey was developed using convenience samples of UCSF faculty and medical students, so broader inclusion of physicians, nurses, trainees, and patients may have yielded a different survey instrument. As a survey, we cannot be certain that any of the groups' responses in real life (eg, in a vote of the medical staff on a given policy) would mirror their survey response. Additionally, the responses to protocol lapses did not include all possible administrative responses, such as mandatory training/remediation or rewards for positive behaviors. The responses could have also been different if participants were presented with different patient safety scenarios. The study population was limited in several ways. Attending and resident physicians were drawn from an academic department of internal medicine; it is possible that other specialties would have different attitudes. Patients were relatively young (likely due to the inclusion criteria), as were attending physicians (due to oversampling of hospitalist physicians). The relatively small number of participants could also limit statistical power to detect differences among groups. Additionally, the study population was limited to patients and healthcare professionals in academic medical centers in San Francisco. It is possible that attitudes would be different in other regions and practice settings.

The no‐blame approach to patient safety has been crucial in refocusing the lens on systems failures and in encouraging the active engagement by clinicians, particularly physicians.[2, 3] On the other hand, there are legitimate concerns that a unidimensional no‐blame approach has permitted, perhaps even promoted, nonadherence to evidence‐based safety practices that could prevent many cases of harm. Although it may not be surprising that patients favor harsher consequences for providers who do not follow basic safety protocols, our study demonstrates relatively widespread support for such consequences even among clinicians and trainees. However, all groups appear to recognize the nuances underlying this set of issues, with varying levels of enthusiasm for punitive responses based on perceived risk and number of transgressions. Future studies are needed to investigate how best to implement public reporting and penalties in ways that can maximize the patient safety benefits.

Healthcare delivery organizations are under increasing pressure to improve patient safety. The fundamental underpinning of efforts to improve safety has been the establishment of a no‐blame culture, one that focuses less on individual transgressions and more on system improvement.[1, 2] As evidence‐based practices to improve care have emerged, and the pressures to deliver tangible improvements in safety and quality have grown, providers, healthcare system leaders, and policymakers are struggling with how best to balance the need for accountability with this no‐blame paradigm.

In dealing with areas such as hand hygiene, where there is strong evidence for the value of the practice yet relatively poor adherence in many institutions, Wachter and Pronovost have argued that the scales need to tip more in the direction of accountability, including the imposition of penalties for clinicians who habitually fail to follow certain safety practices.[3] Although not obviating the critical importance of systems improvement, they argue that a failure to enforce such measures undermines trust in the system and invites external regulation. Chassin and colleagues made a similar point in arguing for the identification of certain accountability measures that could be used in public reporting and pay‐for‐performance programs.[4]

Few organizations have enacted robust systems to hold providers responsible for adhering to accountability measures.[4] Although many hospitals have policies to suspend clinical privileges for failing to sign discharge summaries or obtain a yearly purified protein derivative test, few have formal programs to identify and deal with clinicians whose behavior is persistently problematic.[3] Furthermore, existing modes of physician accountability, such as state licensing boards, only discipline physicians retroactively (and rarely) when healthcare organizations report poor performance. State boards typically do not consider prevention of injury, such as adherence to safety practices, to be part of their responsibility.[5] Similarly, credentialing boards (eg, the American Board of Internal Medicine) do not assess adherence to such practices in coming to their decisions.

It is estimated that strict adherence to infection control practices, such as hand hygiene, could prevent over 100,000 hospital deaths every year; adherence to other evidence‐based safety practices such as the use of a preoperative time‐out would likely prevent many more deaths and cases of medical injury.[3, 6] Although there are practical issues, such as how to audit individual clinician adherence in ways that are feasible and fair, that make enforcing individual provider accountability challenging, there seems little doubt that attitudes regarding the appropriateness of enacting penalties for safety transgressions will be key determinants of whether such measures are considered. Yet no study to date has assessed the opinions of different stakeholders (physicians, nurses, trainees, patients) regarding various strategies, including public reporting and penalties, to improve adherence to safety practices. We aimed to assess these attitudes across a variety of such stakeholders.

METHODS

RESULTS

A total of 287 individuals were given surveys, and 183 completed them: 22 attending physicians, 33 resident physicians, 61 nurses, 47 medical students, and 20 patients (overall response rate 64%). Response rate for attending and resident physicians was 73%, for nurses 59%, and for medical students 54%. Among patients who were approached and agreed to accept a survey, 87% returned completed surveys (Table 1). The average age of attending physicians was 35.8 years (standard deviation [SD]: 5.3), residents was 28.3 years (SD: 1.7), nurses was 43.6 years (SD: 11.1), medical students was 26.6 years (SD: 2.9), and inpatients was 48.2 years (SD: 15.9). Thirty‐two percent of attending physicians were female, 67% of resident physicians were female, 88% of nurses were female, 66% of medical students were female, and 47% of inpatients were female.

Perceived Harm

Out of the 3 scenarios presented in in the survey, participants believed that not conducting preoperative time‐outs in surgery presented the highest risk to patient safety, with 57% (residents) to 86% (nurses) rating the potential harm as high (Figure 1). Not conducting fall risk assessments was perceived as second most potentially harmful, and not properly practicing hand hygiene was perceived as least potentially harmful to patient safety. There were significant differences among groups in perceptions of potential harm for all 3 scenarios (P<0.001 for all).

Figure 1

Appropriateness of Public Reporting and Penalties

Public reporting was viewed as ever appropriate by 34% of all respondents for hand‐hygiene protocol lapses, 58% for surgical time‐out lapses, and 43% for fall risk assessment lapses. There were no significant differences among groups in endorsement of public reporting for individual scenarios (Figure 2). Penalties were endorsed more frequently than public reporting for all groups and all scenarios. The proportion of attending physicians and patients who rated penalties as ever appropriate were similar for each scenario. Residents, medical students, and nurses were less likely than patients and attending physicians to support penalties (P<0.05 for all differences).

Figure 2

The aggregated analysis revealed that nurses and medical students were significantly less likely than patients to endorse public reporting across scenarios. In terms of endorsement of penalties, we found no significant differences between attending physicians and patients, but residents (odds ratio [OR]: 0.09, 95% confidence interval [CI]: 0.03‐0.32), students (OR: 0.12, 95% CI: 0.04‐0.34), and nurses (OR: 0.17, 95% CI: 0.03‐0.41) had significantly lower odds of favoring penalties than did patients (Table 2).

Table 2.Likelihood of Endorsing Public Reporting or Penalties at Any Time by Group and Scenario

	Odds Ratio (95% CI)
	Public Reporting	Penalty
NOTE: Odds ratios and proportions were derived from logistic regression models including group, scenario, age, and sex adjusting for clustering within individuals. Abbreviations: CI, confidence interval.
Group, across all scenarios
Patients	Reference	Reference
Attending physicians	0.58 (0.172.01)	0.88 (0.203.84)
Resident physicians	0.42 (0.121.52)	0.09 (0.020.32)
Nurses	0.32 (0.120.88)	0.17 (0.030.41)
Medical students	0.22 (0.060.80)	0.12 (0.040.34)
Scenario, across all groups
Hand hygiene	Reference	Reference
Surgical time‐out	2.82 (2.033.91)	4.29 (2.976.20)
Fall assessment	1.47 (1.091.98)	1.74 (1.272.37)

Across all surveyed groups, public reporting was more often supported for lapses of surgical timeout (OR: 2.82, 95% CI: 2.03‐3.91) and fall risk assessment protocols (OR: 1.47, 95% CI: 1.09‐1.98) than for the referent, hand‐hygiene lapses. Across all groups, penalties were more likely to be supported for surgical timeout (OR: 4.29, 95% CI: 2.97‐6.20) and fall risk assessment protocol lapses (OR: 1.74, 95% CI: 1.27‐2.37) than for hand‐hygiene lapses.

Thresholds for Public Reporting and Penalties

The log‐rank test showed no significant differences among the surveyed groups in the number of transgressions at which public reporting was deemed appropriate in any of the 3 scenarios (P=0.37, P=0.71, and P=0.32 for hand hygiene, surgical time‐out, and fall risk assessment, respectively) (Figure 3). However, patients endorsed penalties after significantly fewer occurrences than residents, medical students, and nurses for all 3 scenarios (P<0.001 for all differences), and at a significantly lower threshold than attending physicians for surgical timeout and fall risk assessment (P<0.001 and P=0.03, respectively).

Figure 3

DISCUSSION

This survey assessed attitudes of healthcare professionals, trainees, and inpatients toward public reporting and penalties when clinicians do not follow basic safety protocols. Respondents tended to favor more aggressive measures when they deemed the safety risk from protocol violations to be higher. Almost all participants favored providing feedback after safety protocol lapses. Healthcare professionals tended to favor punitive measures, such as fines, suspension, and firing, more than public reporting of transgressions. Patients had a lower threshold than both providers and trainees for public reporting and punitive measures. In aggregate, our study suggests that after a decade of emphasis on a no‐blame response to patient safety hazards, both healthcare providers and patients now believe clinicians should be held accountable for following basic safety protocols, though their thresholds and triggers vary.

A surprising finding was that providers were more likely to favor penalties (such as fines, suspension, or firing) than public reporting of safety transgressions. Multiple studies have suggested that public reporting of hospital quality data has improved adherence to care processes and may improve patient outcomes.[15, 16, 17] Although our data do not tell us why clinicians appear to be more worried about public reporting than penalties, they do help explain why transparency has been a relatively powerful strategy to motivate changes in practice, even when it is unaccompanied by significant shifts in consumer choices.[18] It would be natural to consider public reporting to be a softer strategy than fines, suspension, or firing; however, our results indicate that many clinicians do not see it that way. Alternatively, the results could also suggest that clinicians prefer measures that provide more immediate feedback than public reporting generally provides. These attitudes should be considered when enacting public reporting strategies.

Another interesting finding was that patients and attending physicians tended to track together regarding their attitudes toward penalties for safety lapses. Although patients had a lower threshold for favoring penalties than attendings, similar proportions of patients and attending physicians believed that penalties should be enacted for safety transgressions, and both groups were more penal than physician trainees and nurses. We speculate that attendings and patients may have the most skin in the game, patients as the ones directly harmed by a preventable adverse event, and attending physicians as the most responsible clinicians, at least in the eyes of the malpractice system, licensing boards, and credentials committees.

Even though our study illustrates relatively high levels of endorsement for aggressive measures to deal with clinicians who fail to follow evidence‐based safety practices, a shift in this direction has risks and benefits. The no‐blame paradigm in patient safety grew out of a need to encourage open discussion about medical mistakes.[2] Whereas shifting away from a purely no‐ blame approach may lead to greater adherence with safety practices, and one hopes fewer cases of preventable harm, it also risks stifling the open discussions about medical errors that characterize learning organizations.[13, 19] Because of this, a movement in this direction should be undertaken carefully, starting first with a small number of well‐established safety practices, and ensuring that robust education and system improvements precede and accompany the imposition of penalties for nonadherence.

Our study has limitations. The survey was developed using convenience samples of UCSF faculty and medical students, so broader inclusion of physicians, nurses, trainees, and patients may have yielded a different survey instrument. As a survey, we cannot be certain that any of the groups' responses in real life (eg, in a vote of the medical staff on a given policy) would mirror their survey response. Additionally, the responses to protocol lapses did not include all possible administrative responses, such as mandatory training/remediation or rewards for positive behaviors. The responses could have also been different if participants were presented with different patient safety scenarios. The study population was limited in several ways. Attending and resident physicians were drawn from an academic department of internal medicine; it is possible that other specialties would have different attitudes. Patients were relatively young (likely due to the inclusion criteria), as were attending physicians (due to oversampling of hospitalist physicians). The relatively small number of participants could also limit statistical power to detect differences among groups. Additionally, the study population was limited to patients and healthcare professionals in academic medical centers in San Francisco. It is possible that attitudes would be different in other regions and practice settings.

The no‐blame approach to patient safety has been crucial in refocusing the lens on systems failures and in encouraging the active engagement by clinicians, particularly physicians.[2, 3] On the other hand, there are legitimate concerns that a unidimensional no‐blame approach has permitted, perhaps even promoted, nonadherence to evidence‐based safety practices that could prevent many cases of harm. Although it may not be surprising that patients favor harsher consequences for providers who do not follow basic safety protocols, our study demonstrates relatively widespread support for such consequences even among clinicians and trainees. However, all groups appear to recognize the nuances underlying this set of issues, with varying levels of enthusiasm for punitive responses based on perceived risk and number of transgressions. Future studies are needed to investigate how best to implement public reporting and penalties in ways that can maximize the patient safety benefits.

Healthcare delivery organizations are under increasing pressure to improve patient safety. The fundamental underpinning of efforts to improve safety has been the establishment of a no‐blame culture, one that focuses less on individual transgressions and more on system improvement.[1, 2] As evidence‐based practices to improve care have emerged, and the pressures to deliver tangible improvements in safety and quality have grown, providers, healthcare system leaders, and policymakers are struggling with how best to balance the need for accountability with this no‐blame paradigm.

In dealing with areas such as hand hygiene, where there is strong evidence for the value of the practice yet relatively poor adherence in many institutions, Wachter and Pronovost have argued that the scales need to tip more in the direction of accountability, including the imposition of penalties for clinicians who habitually fail to follow certain safety practices.[3] Although not obviating the critical importance of systems improvement, they argue that a failure to enforce such measures undermines trust in the system and invites external regulation. Chassin and colleagues made a similar point in arguing for the identification of certain accountability measures that could be used in public reporting and pay‐for‐performance programs.[4]

Few organizations have enacted robust systems to hold providers responsible for adhering to accountability measures.[4] Although many hospitals have policies to suspend clinical privileges for failing to sign discharge summaries or obtain a yearly purified protein derivative test, few have formal programs to identify and deal with clinicians whose behavior is persistently problematic.[3] Furthermore, existing modes of physician accountability, such as state licensing boards, only discipline physicians retroactively (and rarely) when healthcare organizations report poor performance. State boards typically do not consider prevention of injury, such as adherence to safety practices, to be part of their responsibility.[5] Similarly, credentialing boards (eg, the American Board of Internal Medicine) do not assess adherence to such practices in coming to their decisions.

It is estimated that strict adherence to infection control practices, such as hand hygiene, could prevent over 100,000 hospital deaths every year; adherence to other evidence‐based safety practices such as the use of a preoperative time‐out would likely prevent many more deaths and cases of medical injury.[3, 6] Although there are practical issues, such as how to audit individual clinician adherence in ways that are feasible and fair, that make enforcing individual provider accountability challenging, there seems little doubt that attitudes regarding the appropriateness of enacting penalties for safety transgressions will be key determinants of whether such measures are considered. Yet no study to date has assessed the opinions of different stakeholders (physicians, nurses, trainees, patients) regarding various strategies, including public reporting and penalties, to improve adherence to safety practices. We aimed to assess these attitudes across a variety of such stakeholders.

METHODS

RESULTS

A total of 287 individuals were given surveys, and 183 completed them: 22 attending physicians, 33 resident physicians, 61 nurses, 47 medical students, and 20 patients (overall response rate 64%). Response rate for attending and resident physicians was 73%, for nurses 59%, and for medical students 54%. Among patients who were approached and agreed to accept a survey, 87% returned completed surveys (Table 1). The average age of attending physicians was 35.8 years (standard deviation [SD]: 5.3), residents was 28.3 years (SD: 1.7), nurses was 43.6 years (SD: 11.1), medical students was 26.6 years (SD: 2.9), and inpatients was 48.2 years (SD: 15.9). Thirty‐two percent of attending physicians were female, 67% of resident physicians were female, 88% of nurses were female, 66% of medical students were female, and 47% of inpatients were female.

Perceived Harm

Out of the 3 scenarios presented in in the survey, participants believed that not conducting preoperative time‐outs in surgery presented the highest risk to patient safety, with 57% (residents) to 86% (nurses) rating the potential harm as high (Figure 1). Not conducting fall risk assessments was perceived as second most potentially harmful, and not properly practicing hand hygiene was perceived as least potentially harmful to patient safety. There were significant differences among groups in perceptions of potential harm for all 3 scenarios (P<0.001 for all).

Figure 1

Appropriateness of Public Reporting and Penalties

Public reporting was viewed as ever appropriate by 34% of all respondents for hand‐hygiene protocol lapses, 58% for surgical time‐out lapses, and 43% for fall risk assessment lapses. There were no significant differences among groups in endorsement of public reporting for individual scenarios (Figure 2). Penalties were endorsed more frequently than public reporting for all groups and all scenarios. The proportion of attending physicians and patients who rated penalties as ever appropriate were similar for each scenario. Residents, medical students, and nurses were less likely than patients and attending physicians to support penalties (P<0.05 for all differences).

Figure 2

The aggregated analysis revealed that nurses and medical students were significantly less likely than patients to endorse public reporting across scenarios. In terms of endorsement of penalties, we found no significant differences between attending physicians and patients, but residents (odds ratio [OR]: 0.09, 95% confidence interval [CI]: 0.03‐0.32), students (OR: 0.12, 95% CI: 0.04‐0.34), and nurses (OR: 0.17, 95% CI: 0.03‐0.41) had significantly lower odds of favoring penalties than did patients (Table 2).

Table 2.Likelihood of Endorsing Public Reporting or Penalties at Any Time by Group and Scenario

	Odds Ratio (95% CI)
	Public Reporting	Penalty
NOTE: Odds ratios and proportions were derived from logistic regression models including group, scenario, age, and sex adjusting for clustering within individuals. Abbreviations: CI, confidence interval.
Group, across all scenarios
Patients	Reference	Reference
Attending physicians	0.58 (0.172.01)	0.88 (0.203.84)
Resident physicians	0.42 (0.121.52)	0.09 (0.020.32)
Nurses	0.32 (0.120.88)	0.17 (0.030.41)
Medical students	0.22 (0.060.80)	0.12 (0.040.34)
Scenario, across all groups
Hand hygiene	Reference	Reference
Surgical time‐out	2.82 (2.033.91)	4.29 (2.976.20)
Fall assessment	1.47 (1.091.98)	1.74 (1.272.37)

Across all surveyed groups, public reporting was more often supported for lapses of surgical timeout (OR: 2.82, 95% CI: 2.03‐3.91) and fall risk assessment protocols (OR: 1.47, 95% CI: 1.09‐1.98) than for the referent, hand‐hygiene lapses. Across all groups, penalties were more likely to be supported for surgical timeout (OR: 4.29, 95% CI: 2.97‐6.20) and fall risk assessment protocol lapses (OR: 1.74, 95% CI: 1.27‐2.37) than for hand‐hygiene lapses.

Thresholds for Public Reporting and Penalties

The log‐rank test showed no significant differences among the surveyed groups in the number of transgressions at which public reporting was deemed appropriate in any of the 3 scenarios (P=0.37, P=0.71, and P=0.32 for hand hygiene, surgical time‐out, and fall risk assessment, respectively) (Figure 3). However, patients endorsed penalties after significantly fewer occurrences than residents, medical students, and nurses for all 3 scenarios (P<0.001 for all differences), and at a significantly lower threshold than attending physicians for surgical timeout and fall risk assessment (P<0.001 and P=0.03, respectively).

Figure 3

DISCUSSION

This survey assessed attitudes of healthcare professionals, trainees, and inpatients toward public reporting and penalties when clinicians do not follow basic safety protocols. Respondents tended to favor more aggressive measures when they deemed the safety risk from protocol violations to be higher. Almost all participants favored providing feedback after safety protocol lapses. Healthcare professionals tended to favor punitive measures, such as fines, suspension, and firing, more than public reporting of transgressions. Patients had a lower threshold than both providers and trainees for public reporting and punitive measures. In aggregate, our study suggests that after a decade of emphasis on a no‐blame response to patient safety hazards, both healthcare providers and patients now believe clinicians should be held accountable for following basic safety protocols, though their thresholds and triggers vary.

A surprising finding was that providers were more likely to favor penalties (such as fines, suspension, or firing) than public reporting of safety transgressions. Multiple studies have suggested that public reporting of hospital quality data has improved adherence to care processes and may improve patient outcomes.[15, 16, 17] Although our data do not tell us why clinicians appear to be more worried about public reporting than penalties, they do help explain why transparency has been a relatively powerful strategy to motivate changes in practice, even when it is unaccompanied by significant shifts in consumer choices.[18] It would be natural to consider public reporting to be a softer strategy than fines, suspension, or firing; however, our results indicate that many clinicians do not see it that way. Alternatively, the results could also suggest that clinicians prefer measures that provide more immediate feedback than public reporting generally provides. These attitudes should be considered when enacting public reporting strategies.

Another interesting finding was that patients and attending physicians tended to track together regarding their attitudes toward penalties for safety lapses. Although patients had a lower threshold for favoring penalties than attendings, similar proportions of patients and attending physicians believed that penalties should be enacted for safety transgressions, and both groups were more penal than physician trainees and nurses. We speculate that attendings and patients may have the most skin in the game, patients as the ones directly harmed by a preventable adverse event, and attending physicians as the most responsible clinicians, at least in the eyes of the malpractice system, licensing boards, and credentials committees.

Even though our study illustrates relatively high levels of endorsement for aggressive measures to deal with clinicians who fail to follow evidence‐based safety practices, a shift in this direction has risks and benefits. The no‐blame paradigm in patient safety grew out of a need to encourage open discussion about medical mistakes.[2] Whereas shifting away from a purely no‐ blame approach may lead to greater adherence with safety practices, and one hopes fewer cases of preventable harm, it also risks stifling the open discussions about medical errors that characterize learning organizations.[13, 19] Because of this, a movement in this direction should be undertaken carefully, starting first with a small number of well‐established safety practices, and ensuring that robust education and system improvements precede and accompany the imposition of penalties for nonadherence.

Our study has limitations. The survey was developed using convenience samples of UCSF faculty and medical students, so broader inclusion of physicians, nurses, trainees, and patients may have yielded a different survey instrument. As a survey, we cannot be certain that any of the groups' responses in real life (eg, in a vote of the medical staff on a given policy) would mirror their survey response. Additionally, the responses to protocol lapses did not include all possible administrative responses, such as mandatory training/remediation or rewards for positive behaviors. The responses could have also been different if participants were presented with different patient safety scenarios. The study population was limited in several ways. Attending and resident physicians were drawn from an academic department of internal medicine; it is possible that other specialties would have different attitudes. Patients were relatively young (likely due to the inclusion criteria), as were attending physicians (due to oversampling of hospitalist physicians). The relatively small number of participants could also limit statistical power to detect differences among groups. Additionally, the study population was limited to patients and healthcare professionals in academic medical centers in San Francisco. It is possible that attitudes would be different in other regions and practice settings.

The no‐blame approach to patient safety has been crucial in refocusing the lens on systems failures and in encouraging the active engagement by clinicians, particularly physicians.[2, 3] On the other hand, there are legitimate concerns that a unidimensional no‐blame approach has permitted, perhaps even promoted, nonadherence to evidence‐based safety practices that could prevent many cases of harm. Although it may not be surprising that patients favor harsher consequences for providers who do not follow basic safety protocols, our study demonstrates relatively widespread support for such consequences even among clinicians and trainees. However, all groups appear to recognize the nuances underlying this set of issues, with varying levels of enthusiasm for punitive responses based on perceived risk and number of transgressions. Future studies are needed to investigate how best to implement public reporting and penalties in ways that can maximize the patient safety benefits.

I hear and I forget, I see and I remember, I do and I understand.

Confucius

Hospital medicine, first described in 1996,[1] is the fastest growing specialty in United States medical history, now with approximately 40,000 practitioners.[2] Although hospitalists undoubtedly learned many of their key clinical skills during residency training, there is no hospitalist‐specific residency training pathway and a limited number of largely research‐oriented fellowships.[3] Furthermore, hospitalists are often asked to care for surgical patients, those with acute neurologic disorders, and patients in intensive care units, while also contributing to quality improvement and patient safety initiatives.[4] This suggests that the vast majority of hospitalists have not had specific training in many key competencies for the field.[5]

Continuing medical education (CME) has traditionally been the mechanism to maintain, develop, or increase the knowledge, skills, and professional performance of physicians.[6] Most CME activities, including those for hospitalists, are staged as live events in hotel conference rooms or as local events in a similarly passive learning environment (eg, grand rounds and medical staff meetings). Online programs, audiotapes, and expanding electronic media provide increasing and alternate methods for hospitalists to obtain their required CME. All of these activities passively deliver content to a group of diverse and experienced learners. They fail to take advantage of adult learning principles and may have little direct impact on professional practice.[7, 8] Traditional CME is often derided as a barrier to innovative educational methods for these reasons, as adults learn best through active participation, when the information is relevant and practically applied.[9, 10]

To provide practicing hospitalists with necessary continuing education, we designed the University of California, San Francisco (UCSF) Hospitalist Mini‐College (UHMC). This 3‐day course brings adult learners to the bedside for small‐group and active learning focused on content areas relevant to today's hospitalists. We describe the development, content, outcomes, and lessons learned from UHMC's first 5 years.

METHODS

Program Description

Figure 1 is a representative calendar view of the 3‐day UHMC course. The curricular topics were selected based on the findings from our needs assessment, our ability to deliver that curriculum using our small‐group active learning framework, and to minimize overlap with content of the larger course. Course curriculum was refined annually based on participant feedback and course director observations.

Figure 1

The program was built on a structure of 4 clinical domains and 2 clinical skills labs. The clinical domains included: (1) Hospital‐Based Neurology, (2) Critical Care Medicine in the Intensive Care Unit, (3) Surgical Comanagement and Medical Consultation, and (4) Hospital‐Based Dermatology. Participants were divided into 3 groups of 10 participants each and rotated through each domain in the afternoons. The clinical skills labs included: (1) Interpretation of Radiographic Studies and (2) Use of Ultrasound and Enhancing Confidence in Performing Bedside Procedures. We also developed specific sessions to teach about patient safety and to allow course attendees to participate in traditional academic learning vehicles (eg, a Morning Report and Morbidity and Mortality case conference). Below, we describe each session's format and content.

RESULTS

DISCUSSION

We developed an innovative CME program that brought participants to an academic health center for a participatory, hands‐on, and small‐group experience. They learned about topics relevant to today's hospitalists, rated the experience very highly, and reported a nearly unanimous likelihood to change their practice. Reflecting on our program's first 5 years, there were several lessons learned that may guide others committed to providing a similar CME experience.

First, hospital medicine is a dynamic field. Conducting a needs assessment to match clinical topics to what attendees required in their own practice was critical. Iterative changes from year to year reflected formal participant feedback as well as informal conversations with the teaching faculty. For instance, attendees were not only interested in the clinical topics but often wanted to see examples of clinical pathways, order sets, and other systems in place to improve care for patients with common conditions. Our participant presurvey also helped identify and reinforce the curricular topics that teaching faculty focused on each year. Being responsive to the changing needs of hospitalists and the environment is a crucial part of providing a relevant CME experience.

We also used an innovative approach to teaching, founded in adult and effective CME learning principles. CME activities are geared toward adult physicians, and studies of their effectiveness recommend that sessions should be interactive and utilize multiple modalities of learning.[12] When attendees actively participate and are provided an opportunity to practice skills, it may have a positive effect on patient outcomes.[13] All UHMC faculty were required to couple presentations of the latest evidence for clinical topics with small‐group and hands‐on learning modalities. This also required that we utilize a teaching faculty known for both their clinical expertise and teaching recognition. Together, the learning modalities and the teaching faculty likely accounted for the highly rated course experience and likelihood to change practice.

Finally, our course brought participants to an academic medical center and into the mix of clinical care as opposed to the more traditional hotel venue. This was necessary to deliver the curriculum as described, but also had the unexpected benefit of energizing the participants. Many had not been in a teaching setting since their residency training, and bringing them back into this milieu motivated them to learn and share their inspiration. As there are no published studies of CME experiences in the clinical environment, this observation is noteworthy and deserves to be explored and evaluated further.

What are the limitations of our approach to bringing CME to the bedside? First, the economics of an intensive 3‐day course with a maximum of 33 attendees are far different than those of a large hotel‐based offering. There are no exhibitors or outside contributions. The cost of the course to participants is $2500 (discounted if attending the larger course as well), which is 2 to 3 times higher than most traditional CME courses of the same length. Although the cost is high, the course has sold out each year with a waiting list. Part of the cost is also faculty time. The time, preparation, and need to teach on the fly to meet the differing participant educational needs is fundamentally different than delivering a single lecture in a hotel conference room. Not surprisingly, our faculty enjoy this teaching opportunity and find it equally unique and valuable; no faculty have dropped out of teaching the course, and many describe it as 1 of the teaching highlights of the year. Scalability of the UHMC is challenging for these reasons, but our model could be replicated in other teaching institutions, even as a local offering for their own providers.

In summary, we developed a hospital‐based, highly interactive, small‐group CME course that emphasizes case‐based teaching. The course has sold out each year, and evaluations suggest that it is highly valued and is meeting curricular goals better than more traditional CME courses. We hope our course description and success may motivate others to consider moving beyond the traditional CME for hospitalists and explore further innovations. With the field growing and changing at a rapid pace, innovative CME experiences will be necessary to assure that hospitalists continue to provide exemplary and safe care to their patients.

I hear and I forget, I see and I remember, I do and I understand.

Confucius

Hospital medicine, first described in 1996,[1] is the fastest growing specialty in United States medical history, now with approximately 40,000 practitioners.[2] Although hospitalists undoubtedly learned many of their key clinical skills during residency training, there is no hospitalist‐specific residency training pathway and a limited number of largely research‐oriented fellowships.[3] Furthermore, hospitalists are often asked to care for surgical patients, those with acute neurologic disorders, and patients in intensive care units, while also contributing to quality improvement and patient safety initiatives.[4] This suggests that the vast majority of hospitalists have not had specific training in many key competencies for the field.[5]

Continuing medical education (CME) has traditionally been the mechanism to maintain, develop, or increase the knowledge, skills, and professional performance of physicians.[6] Most CME activities, including those for hospitalists, are staged as live events in hotel conference rooms or as local events in a similarly passive learning environment (eg, grand rounds and medical staff meetings). Online programs, audiotapes, and expanding electronic media provide increasing and alternate methods for hospitalists to obtain their required CME. All of these activities passively deliver content to a group of diverse and experienced learners. They fail to take advantage of adult learning principles and may have little direct impact on professional practice.[7, 8] Traditional CME is often derided as a barrier to innovative educational methods for these reasons, as adults learn best through active participation, when the information is relevant and practically applied.[9, 10]

To provide practicing hospitalists with necessary continuing education, we designed the University of California, San Francisco (UCSF) Hospitalist Mini‐College (UHMC). This 3‐day course brings adult learners to the bedside for small‐group and active learning focused on content areas relevant to today's hospitalists. We describe the development, content, outcomes, and lessons learned from UHMC's first 5 years.

METHODS

Program Description

Figure 1 is a representative calendar view of the 3‐day UHMC course. The curricular topics were selected based on the findings from our needs assessment, our ability to deliver that curriculum using our small‐group active learning framework, and to minimize overlap with content of the larger course. Course curriculum was refined annually based on participant feedback and course director observations.

Figure 1

The program was built on a structure of 4 clinical domains and 2 clinical skills labs. The clinical domains included: (1) Hospital‐Based Neurology, (2) Critical Care Medicine in the Intensive Care Unit, (3) Surgical Comanagement and Medical Consultation, and (4) Hospital‐Based Dermatology. Participants were divided into 3 groups of 10 participants each and rotated through each domain in the afternoons. The clinical skills labs included: (1) Interpretation of Radiographic Studies and (2) Use of Ultrasound and Enhancing Confidence in Performing Bedside Procedures. We also developed specific sessions to teach about patient safety and to allow course attendees to participate in traditional academic learning vehicles (eg, a Morning Report and Morbidity and Mortality case conference). Below, we describe each session's format and content.

RESULTS

DISCUSSION

We developed an innovative CME program that brought participants to an academic health center for a participatory, hands‐on, and small‐group experience. They learned about topics relevant to today's hospitalists, rated the experience very highly, and reported a nearly unanimous likelihood to change their practice. Reflecting on our program's first 5 years, there were several lessons learned that may guide others committed to providing a similar CME experience.

First, hospital medicine is a dynamic field. Conducting a needs assessment to match clinical topics to what attendees required in their own practice was critical. Iterative changes from year to year reflected formal participant feedback as well as informal conversations with the teaching faculty. For instance, attendees were not only interested in the clinical topics but often wanted to see examples of clinical pathways, order sets, and other systems in place to improve care for patients with common conditions. Our participant presurvey also helped identify and reinforce the curricular topics that teaching faculty focused on each year. Being responsive to the changing needs of hospitalists and the environment is a crucial part of providing a relevant CME experience.

We also used an innovative approach to teaching, founded in adult and effective CME learning principles. CME activities are geared toward adult physicians, and studies of their effectiveness recommend that sessions should be interactive and utilize multiple modalities of learning.[12] When attendees actively participate and are provided an opportunity to practice skills, it may have a positive effect on patient outcomes.[13] All UHMC faculty were required to couple presentations of the latest evidence for clinical topics with small‐group and hands‐on learning modalities. This also required that we utilize a teaching faculty known for both their clinical expertise and teaching recognition. Together, the learning modalities and the teaching faculty likely accounted for the highly rated course experience and likelihood to change practice.

Finally, our course brought participants to an academic medical center and into the mix of clinical care as opposed to the more traditional hotel venue. This was necessary to deliver the curriculum as described, but also had the unexpected benefit of energizing the participants. Many had not been in a teaching setting since their residency training, and bringing them back into this milieu motivated them to learn and share their inspiration. As there are no published studies of CME experiences in the clinical environment, this observation is noteworthy and deserves to be explored and evaluated further.

What are the limitations of our approach to bringing CME to the bedside? First, the economics of an intensive 3‐day course with a maximum of 33 attendees are far different than those of a large hotel‐based offering. There are no exhibitors or outside contributions. The cost of the course to participants is $2500 (discounted if attending the larger course as well), which is 2 to 3 times higher than most traditional CME courses of the same length. Although the cost is high, the course has sold out each year with a waiting list. Part of the cost is also faculty time. The time, preparation, and need to teach on the fly to meet the differing participant educational needs is fundamentally different than delivering a single lecture in a hotel conference room. Not surprisingly, our faculty enjoy this teaching opportunity and find it equally unique and valuable; no faculty have dropped out of teaching the course, and many describe it as 1 of the teaching highlights of the year. Scalability of the UHMC is challenging for these reasons, but our model could be replicated in other teaching institutions, even as a local offering for their own providers.

In summary, we developed a hospital‐based, highly interactive, small‐group CME course that emphasizes case‐based teaching. The course has sold out each year, and evaluations suggest that it is highly valued and is meeting curricular goals better than more traditional CME courses. We hope our course description and success may motivate others to consider moving beyond the traditional CME for hospitalists and explore further innovations. With the field growing and changing at a rapid pace, innovative CME experiences will be necessary to assure that hospitalists continue to provide exemplary and safe care to their patients.

I hear and I forget, I see and I remember, I do and I understand.

Confucius

Hospital medicine, first described in 1996,[1] is the fastest growing specialty in United States medical history, now with approximately 40,000 practitioners.[2] Although hospitalists undoubtedly learned many of their key clinical skills during residency training, there is no hospitalist‐specific residency training pathway and a limited number of largely research‐oriented fellowships.[3] Furthermore, hospitalists are often asked to care for surgical patients, those with acute neurologic disorders, and patients in intensive care units, while also contributing to quality improvement and patient safety initiatives.[4] This suggests that the vast majority of hospitalists have not had specific training in many key competencies for the field.[5]

Continuing medical education (CME) has traditionally been the mechanism to maintain, develop, or increase the knowledge, skills, and professional performance of physicians.[6] Most CME activities, including those for hospitalists, are staged as live events in hotel conference rooms or as local events in a similarly passive learning environment (eg, grand rounds and medical staff meetings). Online programs, audiotapes, and expanding electronic media provide increasing and alternate methods for hospitalists to obtain their required CME. All of these activities passively deliver content to a group of diverse and experienced learners. They fail to take advantage of adult learning principles and may have little direct impact on professional practice.[7, 8] Traditional CME is often derided as a barrier to innovative educational methods for these reasons, as adults learn best through active participation, when the information is relevant and practically applied.[9, 10]

To provide practicing hospitalists with necessary continuing education, we designed the University of California, San Francisco (UCSF) Hospitalist Mini‐College (UHMC). This 3‐day course brings adult learners to the bedside for small‐group and active learning focused on content areas relevant to today's hospitalists. We describe the development, content, outcomes, and lessons learned from UHMC's first 5 years.

METHODS

Program Description

Figure 1 is a representative calendar view of the 3‐day UHMC course. The curricular topics were selected based on the findings from our needs assessment, our ability to deliver that curriculum using our small‐group active learning framework, and to minimize overlap with content of the larger course. Course curriculum was refined annually based on participant feedback and course director observations.

Figure 1

The program was built on a structure of 4 clinical domains and 2 clinical skills labs. The clinical domains included: (1) Hospital‐Based Neurology, (2) Critical Care Medicine in the Intensive Care Unit, (3) Surgical Comanagement and Medical Consultation, and (4) Hospital‐Based Dermatology. Participants were divided into 3 groups of 10 participants each and rotated through each domain in the afternoons. The clinical skills labs included: (1) Interpretation of Radiographic Studies and (2) Use of Ultrasound and Enhancing Confidence in Performing Bedside Procedures. We also developed specific sessions to teach about patient safety and to allow course attendees to participate in traditional academic learning vehicles (eg, a Morning Report and Morbidity and Mortality case conference). Below, we describe each session's format and content.

RESULTS

DISCUSSION

We developed an innovative CME program that brought participants to an academic health center for a participatory, hands‐on, and small‐group experience. They learned about topics relevant to today's hospitalists, rated the experience very highly, and reported a nearly unanimous likelihood to change their practice. Reflecting on our program's first 5 years, there were several lessons learned that may guide others committed to providing a similar CME experience.

First, hospital medicine is a dynamic field. Conducting a needs assessment to match clinical topics to what attendees required in their own practice was critical. Iterative changes from year to year reflected formal participant feedback as well as informal conversations with the teaching faculty. For instance, attendees were not only interested in the clinical topics but often wanted to see examples of clinical pathways, order sets, and other systems in place to improve care for patients with common conditions. Our participant presurvey also helped identify and reinforce the curricular topics that teaching faculty focused on each year. Being responsive to the changing needs of hospitalists and the environment is a crucial part of providing a relevant CME experience.

We also used an innovative approach to teaching, founded in adult and effective CME learning principles. CME activities are geared toward adult physicians, and studies of their effectiveness recommend that sessions should be interactive and utilize multiple modalities of learning.[12] When attendees actively participate and are provided an opportunity to practice skills, it may have a positive effect on patient outcomes.[13] All UHMC faculty were required to couple presentations of the latest evidence for clinical topics with small‐group and hands‐on learning modalities. This also required that we utilize a teaching faculty known for both their clinical expertise and teaching recognition. Together, the learning modalities and the teaching faculty likely accounted for the highly rated course experience and likelihood to change practice.

Finally, our course brought participants to an academic medical center and into the mix of clinical care as opposed to the more traditional hotel venue. This was necessary to deliver the curriculum as described, but also had the unexpected benefit of energizing the participants. Many had not been in a teaching setting since their residency training, and bringing them back into this milieu motivated them to learn and share their inspiration. As there are no published studies of CME experiences in the clinical environment, this observation is noteworthy and deserves to be explored and evaluated further.

What are the limitations of our approach to bringing CME to the bedside? First, the economics of an intensive 3‐day course with a maximum of 33 attendees are far different than those of a large hotel‐based offering. There are no exhibitors or outside contributions. The cost of the course to participants is $2500 (discounted if attending the larger course as well), which is 2 to 3 times higher than most traditional CME courses of the same length. Although the cost is high, the course has sold out each year with a waiting list. Part of the cost is also faculty time. The time, preparation, and need to teach on the fly to meet the differing participant educational needs is fundamentally different than delivering a single lecture in a hotel conference room. Not surprisingly, our faculty enjoy this teaching opportunity and find it equally unique and valuable; no faculty have dropped out of teaching the course, and many describe it as 1 of the teaching highlights of the year. Scalability of the UHMC is challenging for these reasons, but our model could be replicated in other teaching institutions, even as a local offering for their own providers.

In summary, we developed a hospital‐based, highly interactive, small‐group CME course that emphasizes case‐based teaching. The course has sold out each year, and evaluations suggest that it is highly valued and is meeting curricular goals better than more traditional CME courses. We hope our course description and success may motivate others to consider moving beyond the traditional CME for hospitalists and explore further innovations. With the field growing and changing at a rapid pace, innovative CME experiences will be necessary to assure that hospitalists continue to provide exemplary and safe care to their patients.

Over the last 30 years, rounds of therapeutic treatments with cost consciousness and cost containment have been administered to the healthcare industry, with generally disappointing clinical response. The last treatment cycle came in the 1990s, with the combination therapy of prospective payment and managed care, treatments that produced a transient remission in cost inflation but that left the healthcare system spent and decidedly unenthusiastic about another round of intensive therapy. For the next 15 years or so, the underlying conditions remained untreated, and unsurprisingly, runaway healthcare inflation returned. To continue this metaphor only a bit further, in 2013 the healthcare system is again facing intensive treatments, but in this case the treatments seem more likely to produce a strong and durable clinical response.

Although some argue that current efforts shall also pass, we believe that the present day is clearly different. A major difference is the implementation of the Affordable Care Act, which creates new structures to facilitate and incentives to promote cost reductions. More importantly, there has been a sea change in how the publicnot just payors or employersview healthcare costs. The ideas that care is too expensive and that much of it adds no value to patients have gained wide acceptance across the political spectrum, among patients, and increasingly among physicians.

It was in this context that the American Board of Internal Medicine Foundation (ABIMF) launched its Choosing Wisely campaign in 2011.[1] The stated goal of the campaign was to promote important conversations [between doctors and patients] necessary to ensure the right care is delivered at the right time. Importantly, this careful framing successfully avoided the caricatures of rationing or death panels, reactions that doomed prior efforts to engage all stakeholders in a reasoned national dialogue about costs and value.

The ABIMF chose an approach of having physicians identify tests and procedures that may be unnecessary in certain situations. Working with Consumer Reports, the Foundation asked a wide range of medical specialty societies to develop their own list of tests and procedures that could potentially be avoided with no harm to patients. The vast majority, 25 as of July 2013, chose to participate.

In February 2013, the Society of Hospital Medicine (SHM) joined the initiative when it posted adult and pediatric versions of Five Things Physicians and Patients Should Question.[2] We are pleased to publish summaries of the recommendations and the processes by which the 2 working groups produced their lists in the Journal of Hospital Medicine.[3, 4]

In reading these articles, we are struck by the importance of the SHM's work to reduce costs and improve value. However, it really is a first step: both articles must now catalyze a body of work to create and sustain meaningful change.

Although many of the 10 targets have strong face validity, it is not clear whether they are in fact the most common, costly, or low‐value practices under the purview of hospitalists. Given the fact that the selection process involved both evidence‐based reviews and consensus, it is possible that other, potentially more contentious, practices may provide even more bang for the buck, or in this case, nonbuck.

Nevertheless, these are quibbles. These lists are good starting points, and in fact many hospitalist groups, including our own, are using the SHM practices as a foundation for our waste‐reduction efforts. The next challenge will be translating these recommendations into actionable measures and then clinical practice. For example, 1 of the adult recommendations is to avoid repeat blood counts and chemistries in patients who are clinically stable. Concepts of clinical stability are notoriously difficult to define within specific patient subgroups, much less across the diverse patient populations seen by hospitalists. One approach here would be to narrow the focus (eg, do not order repeated blood counts in patients with gastrointestinal bleeding whose labs have been stable for 48 hours), but this step would limit the cost savings. Other measures, such as those related to urinary catheters, are more clearly defined and seem closer to being widely adoptable.

For all these measures, the ultimate question remains: How much can actually be saved and how do we measure the savings? The marginal cost of a complete blood count is extraordinarily small in comparison to an entire hospital stay, but it is possible that eliminating redundant testing also reduces the costs related to follow‐up of false positive findings. Reducing the use of urinary catheters can cut the costs of urinary tract infections and the complications of treatment, but these costs could be offset by the higher‐level nursing care needed to mobilize patients earlier or assist patients in toileting, squeezing the proverbial balloon. For all these measures, it is unclear whether what might be relatively small variable cost reductions related to specific tests/procedures can lead to subsequent reduction in fixed costs related to facilities and equipment, where more than 70% of healthcare costs lie.[5] In other words, reducing the number of lab technicians and the amount of laboratory equipment needed will lead to far greater cost reductions than reducing individual test utilization.

None of this is to say that the Choosing Wisely campaign is without merit. To the contrary, the campaign and the efforts of the SHM are early and critical steps in changing the behavior of a profession. Since the early days of hospital medicine, hospitalists have embraced cost reduction and value improvement as a central focus. By successfully engaging consumers and the community of medical specialties, Choosing Wisely has created a language and a framework that will allow our field and others to tackle the crucial work of resource stewardship with new purpose, and we hope, unprecedented success.

Over the last 30 years, rounds of therapeutic treatments with cost consciousness and cost containment have been administered to the healthcare industry, with generally disappointing clinical response. The last treatment cycle came in the 1990s, with the combination therapy of prospective payment and managed care, treatments that produced a transient remission in cost inflation but that left the healthcare system spent and decidedly unenthusiastic about another round of intensive therapy. For the next 15 years or so, the underlying conditions remained untreated, and unsurprisingly, runaway healthcare inflation returned. To continue this metaphor only a bit further, in 2013 the healthcare system is again facing intensive treatments, but in this case the treatments seem more likely to produce a strong and durable clinical response.

Although some argue that current efforts shall also pass, we believe that the present day is clearly different. A major difference is the implementation of the Affordable Care Act, which creates new structures to facilitate and incentives to promote cost reductions. More importantly, there has been a sea change in how the publicnot just payors or employersview healthcare costs. The ideas that care is too expensive and that much of it adds no value to patients have gained wide acceptance across the political spectrum, among patients, and increasingly among physicians.

It was in this context that the American Board of Internal Medicine Foundation (ABIMF) launched its Choosing Wisely campaign in 2011.[1] The stated goal of the campaign was to promote important conversations [between doctors and patients] necessary to ensure the right care is delivered at the right time. Importantly, this careful framing successfully avoided the caricatures of rationing or death panels, reactions that doomed prior efforts to engage all stakeholders in a reasoned national dialogue about costs and value.

The ABIMF chose an approach of having physicians identify tests and procedures that may be unnecessary in certain situations. Working with Consumer Reports, the Foundation asked a wide range of medical specialty societies to develop their own list of tests and procedures that could potentially be avoided with no harm to patients. The vast majority, 25 as of July 2013, chose to participate.

In February 2013, the Society of Hospital Medicine (SHM) joined the initiative when it posted adult and pediatric versions of Five Things Physicians and Patients Should Question.[2] We are pleased to publish summaries of the recommendations and the processes by which the 2 working groups produced their lists in the Journal of Hospital Medicine.[3, 4]

In reading these articles, we are struck by the importance of the SHM's work to reduce costs and improve value. However, it really is a first step: both articles must now catalyze a body of work to create and sustain meaningful change.

Although many of the 10 targets have strong face validity, it is not clear whether they are in fact the most common, costly, or low‐value practices under the purview of hospitalists. Given the fact that the selection process involved both evidence‐based reviews and consensus, it is possible that other, potentially more contentious, practices may provide even more bang for the buck, or in this case, nonbuck.

Nevertheless, these are quibbles. These lists are good starting points, and in fact many hospitalist groups, including our own, are using the SHM practices as a foundation for our waste‐reduction efforts. The next challenge will be translating these recommendations into actionable measures and then clinical practice. For example, 1 of the adult recommendations is to avoid repeat blood counts and chemistries in patients who are clinically stable. Concepts of clinical stability are notoriously difficult to define within specific patient subgroups, much less across the diverse patient populations seen by hospitalists. One approach here would be to narrow the focus (eg, do not order repeated blood counts in patients with gastrointestinal bleeding whose labs have been stable for 48 hours), but this step would limit the cost savings. Other measures, such as those related to urinary catheters, are more clearly defined and seem closer to being widely adoptable.

For all these measures, the ultimate question remains: How much can actually be saved and how do we measure the savings? The marginal cost of a complete blood count is extraordinarily small in comparison to an entire hospital stay, but it is possible that eliminating redundant testing also reduces the costs related to follow‐up of false positive findings. Reducing the use of urinary catheters can cut the costs of urinary tract infections and the complications of treatment, but these costs could be offset by the higher‐level nursing care needed to mobilize patients earlier or assist patients in toileting, squeezing the proverbial balloon. For all these measures, it is unclear whether what might be relatively small variable cost reductions related to specific tests/procedures can lead to subsequent reduction in fixed costs related to facilities and equipment, where more than 70% of healthcare costs lie.[5] In other words, reducing the number of lab technicians and the amount of laboratory equipment needed will lead to far greater cost reductions than reducing individual test utilization.

None of this is to say that the Choosing Wisely campaign is without merit. To the contrary, the campaign and the efforts of the SHM are early and critical steps in changing the behavior of a profession. Since the early days of hospital medicine, hospitalists have embraced cost reduction and value improvement as a central focus. By successfully engaging consumers and the community of medical specialties, Choosing Wisely has created a language and a framework that will allow our field and others to tackle the crucial work of resource stewardship with new purpose, and we hope, unprecedented success.

Over the last 30 years, rounds of therapeutic treatments with cost consciousness and cost containment have been administered to the healthcare industry, with generally disappointing clinical response. The last treatment cycle came in the 1990s, with the combination therapy of prospective payment and managed care, treatments that produced a transient remission in cost inflation but that left the healthcare system spent and decidedly unenthusiastic about another round of intensive therapy. For the next 15 years or so, the underlying conditions remained untreated, and unsurprisingly, runaway healthcare inflation returned. To continue this metaphor only a bit further, in 2013 the healthcare system is again facing intensive treatments, but in this case the treatments seem more likely to produce a strong and durable clinical response.

Although some argue that current efforts shall also pass, we believe that the present day is clearly different. A major difference is the implementation of the Affordable Care Act, which creates new structures to facilitate and incentives to promote cost reductions. More importantly, there has been a sea change in how the publicnot just payors or employersview healthcare costs. The ideas that care is too expensive and that much of it adds no value to patients have gained wide acceptance across the political spectrum, among patients, and increasingly among physicians.

It was in this context that the American Board of Internal Medicine Foundation (ABIMF) launched its Choosing Wisely campaign in 2011.[1] The stated goal of the campaign was to promote important conversations [between doctors and patients] necessary to ensure the right care is delivered at the right time. Importantly, this careful framing successfully avoided the caricatures of rationing or death panels, reactions that doomed prior efforts to engage all stakeholders in a reasoned national dialogue about costs and value.

The ABIMF chose an approach of having physicians identify tests and procedures that may be unnecessary in certain situations. Working with Consumer Reports, the Foundation asked a wide range of medical specialty societies to develop their own list of tests and procedures that could potentially be avoided with no harm to patients. The vast majority, 25 as of July 2013, chose to participate.

In February 2013, the Society of Hospital Medicine (SHM) joined the initiative when it posted adult and pediatric versions of Five Things Physicians and Patients Should Question.[2] We are pleased to publish summaries of the recommendations and the processes by which the 2 working groups produced their lists in the Journal of Hospital Medicine.[3, 4]

In reading these articles, we are struck by the importance of the SHM's work to reduce costs and improve value. However, it really is a first step: both articles must now catalyze a body of work to create and sustain meaningful change.

Although many of the 10 targets have strong face validity, it is not clear whether they are in fact the most common, costly, or low‐value practices under the purview of hospitalists. Given the fact that the selection process involved both evidence‐based reviews and consensus, it is possible that other, potentially more contentious, practices may provide even more bang for the buck, or in this case, nonbuck.

Nevertheless, these are quibbles. These lists are good starting points, and in fact many hospitalist groups, including our own, are using the SHM practices as a foundation for our waste‐reduction efforts. The next challenge will be translating these recommendations into actionable measures and then clinical practice. For example, 1 of the adult recommendations is to avoid repeat blood counts and chemistries in patients who are clinically stable. Concepts of clinical stability are notoriously difficult to define within specific patient subgroups, much less across the diverse patient populations seen by hospitalists. One approach here would be to narrow the focus (eg, do not order repeated blood counts in patients with gastrointestinal bleeding whose labs have been stable for 48 hours), but this step would limit the cost savings. Other measures, such as those related to urinary catheters, are more clearly defined and seem closer to being widely adoptable.

For all these measures, the ultimate question remains: How much can actually be saved and how do we measure the savings? The marginal cost of a complete blood count is extraordinarily small in comparison to an entire hospital stay, but it is possible that eliminating redundant testing also reduces the costs related to follow‐up of false positive findings. Reducing the use of urinary catheters can cut the costs of urinary tract infections and the complications of treatment, but these costs could be offset by the higher‐level nursing care needed to mobilize patients earlier or assist patients in toileting, squeezing the proverbial balloon. For all these measures, it is unclear whether what might be relatively small variable cost reductions related to specific tests/procedures can lead to subsequent reduction in fixed costs related to facilities and equipment, where more than 70% of healthcare costs lie.[5] In other words, reducing the number of lab technicians and the amount of laboratory equipment needed will lead to far greater cost reductions than reducing individual test utilization.

None of this is to say that the Choosing Wisely campaign is without merit. To the contrary, the campaign and the efforts of the SHM are early and critical steps in changing the behavior of a profession. Since the early days of hospital medicine, hospitalists have embraced cost reduction and value improvement as a central focus. By successfully engaging consumers and the community of medical specialties, Choosing Wisely has created a language and a framework that will allow our field and others to tackle the crucial work of resource stewardship with new purpose, and we hope, unprecedented success.

The field of hospital medicine, now the fastest growing specialty in medical history,[1] was born out of pressure to improve the efficiency and quality of clinical care in US hospitals.[2] Delivering safe and high‐value clinical care is a central goal of the field and has been an essential component of its growth and success.

The clinical demands on academic hospitalists have grown recently, fueled by the need to staff services previously covered by housestaff, whose hours are now restricted. Despite these new demands, expectations have grown in other arenas as well. Academic hospitalist groups (AHGs) are often expected to make significant contributions in quality improvement, patient safety, education, research, and administration. With broad expectations beyond clinical care, AHGs face unique challenges. Groups that focus mainly on providing coverage and improving clinical performance may find that they are unable to fully contribute in these other domains. To be successful, AHGs must develop strategies that balance their energies, resources, and performance.

The balanced scorecard (BSC) was introduced by Kaplan and Norton in 1992 to allow corporations to view their performance broadly, rather than narrowly focusing on financial measures. The BSC requires organizations to develop a balanced portfolio of performance metrics across 4 key perspectives: financial, customers, internal processes, and learning and growth. Metrics within these perspectives should help answer fundamental questions about the organization (Table 1).[3] Over time, the BSC evolved from a performance measurement tool to a strategic management system.[4] Successful organizations translate their mission and vision to specific strategic objectives in each of the 4 perspectives, delineate how these objectives will help the organization reach its vision with a strategy map,[5] and then utilize the BSC to track and monitor performance to ensure that the vision is achieved.[6]

Although originally conceived for businesses, the BSC has found its way into the healthcare industry, with reports of successful implementation in organizations ranging from individual departments to research collaboratives[7] to national healthcare systems.[8] However, there are few reports of BSC implementation in academic health centers.[9, 10] Because most academic centers are not‐for‐profit, Zelman suggests that the 4 BSC perspectives be modified to better fit their unique characteristics (Table 1).[11] To the best of our knowledge, there is no literature describing the development of a BSC in an academic hospitalist group. In this article, we describe the development of, and early experiences with, an academic hospital medicine BSC developed as part of a strategic planning initiative.

METHODS

The University of California, San Francisco (UCSF) Division of Hospital Medicine (DHM) was established in 2005. Currently, there are more than 50 faculty members, having doubled in the last 4 years. In addition to staffing several housestaff and nonhousestaff clinical services, faculty are involved in a wide variety of nonclinical endeavors at local and national levels. They participate and lead initiatives in education, faculty development, patient safety, care efficiency, quality improvement, information technology, and global health. There is an active research enterprise that generates nearly $5 million in grant funding annually.

RESULTS

There were 41 initial metrics considered by the division BSC task force (Table 3). Of these, 16 were chosen for the initial BSC through the modified Delphi method. Over the past 2 years, these initial metrics have been modified to reflect current strategic goals and objectives. Figure 1 illustrates the BSC for fiscal year (FY) 2012. An online version of this, complete with graphical representations of the data and metric definitions, can be found at http://hospitalmedicine.ucsf.edu/bsc/fy2012.html. Our strategy map (Figure 2) demonstrates how these metrics are interconnected across the 4 BSC perspectives and how they fit into our overall strategic plan.

Figure 1

Figure 2

DISCUSSION

Like many hospitalist groups, our division has experienced tremendous growth, both in our numbers and the breadth of roles that we fill. With this growth has come increasing expectations in multiple domains, competing priorities, and limited resources. We successfully developed a BSC as a tool to help our division reach its vision: balancing high quality clinical care, education, academics, and faculty development while maintaining a strong sense of community. We have found that the BSC has helped us meet several key goals.

The first goal was to allow for a broad view of our performance. This is the BSC's most basic function, and we saw immediate and tangible benefits. The scorecard provided a broad snapshot of our performance in a single place. For example, in the clinical domain, we saw that our direct cost per case was increasing despite our adjusted average length of stay remaining stable from FY2010‐FY2011. In academics and research, we saw that the number of abstracts accepted at national meetings increased by almost 30% in FY2011 (Figure 1).

The second goal was to create transparency and accountability. By measuring performance and displaying it on the division Web site, the BSC has promoted transparency. If performance does not meet our targets, the division as a whole becomes accountable. Leadership must understand why performance fell short and initiate changes to improve it. For instance, the rising direct cost per case has spurred the development of a high‐value care committee tasked with finding ways of reducing cost while providing high‐quality care.[12]

The third goal was to communicate goals and engage our faculty. As our division has grown, ensuring a shared vision among our entire faculty became an increasing challenge. The BSC functions as a communication platform between leadership and faculty, and yielded multiple benefits. As the metrics were born out of our mission and vision, the BSC has become a tangible representation of our core values. Moreover, individual faculty can see that they are part of a greater, high‐performing organization and realize they can impact the group's performance through their individual effort. For example, this has helped promote receptivity to carefully disseminated individual performance measures for billing and documentation, and patient satisfaction, in conjunction with faculty development in these areas.

The fourth goal was to ensure that we use data to guide strategic decisions. We felt that strategic decisions needed to be based on objective, rather than perceived or anecdotal, information. This meant translating our vision into measurable objectives that would drive performance improvement. For example, before the BSC, we were committed to the dissemination of our research and innovations. Yet, we quickly realized that we did not have a system to collect even basic data on academic performancea deficit we filled by leveraging information gathered from online databases and faculty curricula vitae. These data allowed us, for the first time, to objectively reflect on this as a strategic goal and to have an ongoing mechanism to monitor academic productivity.

Disclosure

Nothing to report.

The field of hospital medicine, now the fastest growing specialty in medical history,[1] was born out of pressure to improve the efficiency and quality of clinical care in US hospitals.[2] Delivering safe and high‐value clinical care is a central goal of the field and has been an essential component of its growth and success.

The clinical demands on academic hospitalists have grown recently, fueled by the need to staff services previously covered by housestaff, whose hours are now restricted. Despite these new demands, expectations have grown in other arenas as well. Academic hospitalist groups (AHGs) are often expected to make significant contributions in quality improvement, patient safety, education, research, and administration. With broad expectations beyond clinical care, AHGs face unique challenges. Groups that focus mainly on providing coverage and improving clinical performance may find that they are unable to fully contribute in these other domains. To be successful, AHGs must develop strategies that balance their energies, resources, and performance.

The balanced scorecard (BSC) was introduced by Kaplan and Norton in 1992 to allow corporations to view their performance broadly, rather than narrowly focusing on financial measures. The BSC requires organizations to develop a balanced portfolio of performance metrics across 4 key perspectives: financial, customers, internal processes, and learning and growth. Metrics within these perspectives should help answer fundamental questions about the organization (Table 1).[3] Over time, the BSC evolved from a performance measurement tool to a strategic management system.[4] Successful organizations translate their mission and vision to specific strategic objectives in each of the 4 perspectives, delineate how these objectives will help the organization reach its vision with a strategy map,[5] and then utilize the BSC to track and monitor performance to ensure that the vision is achieved.[6]

Although originally conceived for businesses, the BSC has found its way into the healthcare industry, with reports of successful implementation in organizations ranging from individual departments to research collaboratives[7] to national healthcare systems.[8] However, there are few reports of BSC implementation in academic health centers.[9, 10] Because most academic centers are not‐for‐profit, Zelman suggests that the 4 BSC perspectives be modified to better fit their unique characteristics (Table 1).[11] To the best of our knowledge, there is no literature describing the development of a BSC in an academic hospitalist group. In this article, we describe the development of, and early experiences with, an academic hospital medicine BSC developed as part of a strategic planning initiative.

METHODS

The University of California, San Francisco (UCSF) Division of Hospital Medicine (DHM) was established in 2005. Currently, there are more than 50 faculty members, having doubled in the last 4 years. In addition to staffing several housestaff and nonhousestaff clinical services, faculty are involved in a wide variety of nonclinical endeavors at local and national levels. They participate and lead initiatives in education, faculty development, patient safety, care efficiency, quality improvement, information technology, and global health. There is an active research enterprise that generates nearly $5 million in grant funding annually.

RESULTS

There were 41 initial metrics considered by the division BSC task force (Table 3). Of these, 16 were chosen for the initial BSC through the modified Delphi method. Over the past 2 years, these initial metrics have been modified to reflect current strategic goals and objectives. Figure 1 illustrates the BSC for fiscal year (FY) 2012. An online version of this, complete with graphical representations of the data and metric definitions, can be found at http://hospitalmedicine.ucsf.edu/bsc/fy2012.html. Our strategy map (Figure 2) demonstrates how these metrics are interconnected across the 4 BSC perspectives and how they fit into our overall strategic plan.

Figure 1

Figure 2

DISCUSSION

Like many hospitalist groups, our division has experienced tremendous growth, both in our numbers and the breadth of roles that we fill. With this growth has come increasing expectations in multiple domains, competing priorities, and limited resources. We successfully developed a BSC as a tool to help our division reach its vision: balancing high quality clinical care, education, academics, and faculty development while maintaining a strong sense of community. We have found that the BSC has helped us meet several key goals.

The first goal was to allow for a broad view of our performance. This is the BSC's most basic function, and we saw immediate and tangible benefits. The scorecard provided a broad snapshot of our performance in a single place. For example, in the clinical domain, we saw that our direct cost per case was increasing despite our adjusted average length of stay remaining stable from FY2010‐FY2011. In academics and research, we saw that the number of abstracts accepted at national meetings increased by almost 30% in FY2011 (Figure 1).

The second goal was to create transparency and accountability. By measuring performance and displaying it on the division Web site, the BSC has promoted transparency. If performance does not meet our targets, the division as a whole becomes accountable. Leadership must understand why performance fell short and initiate changes to improve it. For instance, the rising direct cost per case has spurred the development of a high‐value care committee tasked with finding ways of reducing cost while providing high‐quality care.[12]

The third goal was to communicate goals and engage our faculty. As our division has grown, ensuring a shared vision among our entire faculty became an increasing challenge. The BSC functions as a communication platform between leadership and faculty, and yielded multiple benefits. As the metrics were born out of our mission and vision, the BSC has become a tangible representation of our core values. Moreover, individual faculty can see that they are part of a greater, high‐performing organization and realize they can impact the group's performance through their individual effort. For example, this has helped promote receptivity to carefully disseminated individual performance measures for billing and documentation, and patient satisfaction, in conjunction with faculty development in these areas.

The fourth goal was to ensure that we use data to guide strategic decisions. We felt that strategic decisions needed to be based on objective, rather than perceived or anecdotal, information. This meant translating our vision into measurable objectives that would drive performance improvement. For example, before the BSC, we were committed to the dissemination of our research and innovations. Yet, we quickly realized that we did not have a system to collect even basic data on academic performancea deficit we filled by leveraging information gathered from online databases and faculty curricula vitae. These data allowed us, for the first time, to objectively reflect on this as a strategic goal and to have an ongoing mechanism to monitor academic productivity.

Disclosure

Nothing to report.

The field of hospital medicine, now the fastest growing specialty in medical history,[1] was born out of pressure to improve the efficiency and quality of clinical care in US hospitals.[2] Delivering safe and high‐value clinical care is a central goal of the field and has been an essential component of its growth and success.

The clinical demands on academic hospitalists have grown recently, fueled by the need to staff services previously covered by housestaff, whose hours are now restricted. Despite these new demands, expectations have grown in other arenas as well. Academic hospitalist groups (AHGs) are often expected to make significant contributions in quality improvement, patient safety, education, research, and administration. With broad expectations beyond clinical care, AHGs face unique challenges. Groups that focus mainly on providing coverage and improving clinical performance may find that they are unable to fully contribute in these other domains. To be successful, AHGs must develop strategies that balance their energies, resources, and performance.

The balanced scorecard (BSC) was introduced by Kaplan and Norton in 1992 to allow corporations to view their performance broadly, rather than narrowly focusing on financial measures. The BSC requires organizations to develop a balanced portfolio of performance metrics across 4 key perspectives: financial, customers, internal processes, and learning and growth. Metrics within these perspectives should help answer fundamental questions about the organization (Table 1).[3] Over time, the BSC evolved from a performance measurement tool to a strategic management system.[4] Successful organizations translate their mission and vision to specific strategic objectives in each of the 4 perspectives, delineate how these objectives will help the organization reach its vision with a strategy map,[5] and then utilize the BSC to track and monitor performance to ensure that the vision is achieved.[6]

Although originally conceived for businesses, the BSC has found its way into the healthcare industry, with reports of successful implementation in organizations ranging from individual departments to research collaboratives[7] to national healthcare systems.[8] However, there are few reports of BSC implementation in academic health centers.[9, 10] Because most academic centers are not‐for‐profit, Zelman suggests that the 4 BSC perspectives be modified to better fit their unique characteristics (Table 1).[11] To the best of our knowledge, there is no literature describing the development of a BSC in an academic hospitalist group. In this article, we describe the development of, and early experiences with, an academic hospital medicine BSC developed as part of a strategic planning initiative.

METHODS

The University of California, San Francisco (UCSF) Division of Hospital Medicine (DHM) was established in 2005. Currently, there are more than 50 faculty members, having doubled in the last 4 years. In addition to staffing several housestaff and nonhousestaff clinical services, faculty are involved in a wide variety of nonclinical endeavors at local and national levels. They participate and lead initiatives in education, faculty development, patient safety, care efficiency, quality improvement, information technology, and global health. There is an active research enterprise that generates nearly $5 million in grant funding annually.

RESULTS

There were 41 initial metrics considered by the division BSC task force (Table 3). Of these, 16 were chosen for the initial BSC through the modified Delphi method. Over the past 2 years, these initial metrics have been modified to reflect current strategic goals and objectives. Figure 1 illustrates the BSC for fiscal year (FY) 2012. An online version of this, complete with graphical representations of the data and metric definitions, can be found at http://hospitalmedicine.ucsf.edu/bsc/fy2012.html. Our strategy map (Figure 2) demonstrates how these metrics are interconnected across the 4 BSC perspectives and how they fit into our overall strategic plan.

Figure 1

Figure 2