Robert M. Wachter, MD

The Exodus of Primary Care Physicians

In the early days of our field, one of the major sources of pushback was the desire of many primary care doctors to continue managing their own inpatients. Beginning a decade ago, this pressure began to abate, as many primary care physicians began to recognize the potential advantages of working with hospitalists.2

Over the next several years, I predict that the growth in the patient‐centered medical home model3with the physician's new responsibilities to provide comprehensive patient‐centered carewill make it even less likely that primary care doctors will have the time to manage their own inpatients. Luckily, information systems now being installed throughout the country (fueled by federal subsidies) will lead to unprecedented connectivity between the inpatient and outpatient worlds,4 hopefully resulting in improving handoffs.

Moreover, the increasing scrutiny of, and upcoming penalties for, high readmission rates are driving hospitals and clinics into creating more robust systems of care to improve inpatientoutpatient communications. The bottom line is that the main Achilles heel of hospitalist systemsthe handoff at hospital admission and dischargeshould improve over the next few years, making it easier than ever for primary care doctors to forego hospital care without losing track of critical patient information.

The Specialists Have Left the Building

One of the more interesting phenomena in the recent history of the hospitalist field is the growth of what I call hyphenated hospitalists: neurology hospitalists, ob‐gyn hospitalists, surgical hospitalists, and the like. The forces promoting these models are similar to those that catalyzed the hospitalist model: the recognition that bifurcating inpatient and outpatient care sometimes makes sense when several conditions are met (Table 1).

The emergence of hyphenated hospitalists raises all sorts of questions for the hospitalist field, many of which I have addressed elsewhere.5 But the bottom line is that the growth of specialty hospitalists may help create a new hospital home teama group of dedicated inpatient physicians spanning virtually every specialty who share best practices, work together on systems improvements, and operate under similar accountabilities. This development may well be the most exciting one in the field's recent history.

Comanagement of Nonmedical Patients

The same forces that led to the emergence of the hospitalist field are also catalyzing the growth of hospitalist comanagement programs. There is a shortage of general surgeons, and in teaching hospitals, there are fewer surgical residents available to help provide floor‐based pre‐ and post‐operative care. And surgical patients are under the same value pressures as medical patients, with increasing public reporting of quality processes and outcomes and new pay for performance programs coming on line. Although the evidence of benefit is mixed,68 many hospitalists are finding that increasing parts of their work involve comanagement.

Comanagement raises several issues, all of which need to be addressed. How do we define clear boundaries between what the hospitalist does and what the specialist does? Comanagement programs, to be effective, need very clear rules of engagement and open lines of communication to work through inevitable conflicts.6 How does the money flow? Most hospitalist programs receive hospital support, but it is legitimate to wonder whether the specialists, particularly surgeons, should chip in to support the program, particularly if they continue to collect a global case rate that was predicated on their provision of pre‐ and post‐operative care. How do comanagement programs and specialty hospitalist programs interrelate, and what are the relative advantages and disadvantages of each? To my mind, programs that meet the conditions outlined in Table 1 probably would do well to start a specialty hospitalist program, assuming that they can find high‐quality specialists to staff it. But there will be myriad variations on these themes. In my hospital, for example, we have both neurohospitalists and medical hospitalists who co‐manage neurosurgery patients.

New Opportunities in Systems Leadership

The growth of the hospitalist field will partly come from individuals who begin their careers performing clinical work, but who transition over time to managerial and leadership roles. This is a natural transition: Who better than a hospitalist to help organize and deliver educational programs, manage clinical operations, implement information technology systems, or lead quality, safety, or utilization management efforts? Of course, as hospitalists assume these roles, others need to take their places covering their clinical shifts.

This might seem like a relatively unimportant driver of personnel growth, but in more advanced systems, it can become a major one. Table 2 lists the faculty in my Division of Hospital Medicine at the University of California, San Francisco (UCSF) who have major institutional (i.e., nondivisional) roles. These roles, spread across eight faculty, account for 3.7 full‐time equivalents (FTEs).

Dealing with New ACGME Regulations

In 2003, the Accreditation Council for Graduate Medical Education (ACGME) issued its first housestaff duty hours reductions (limiting housestaff to a maximum of 80 hours per week, with no single shift lasting longer than 30 hours). This reduction led to the development of nonteaching services in most teaching hospitals; the vast majority of such programs have hospitalists at their core.

In July 2011, new ACGME regulations go into effect,10 which will further cut the availability of housestaff to cover clinical services. Although the 80‐hour weekly limit remains, intern shifts are now limited to 16 hours, meaning that the traditional long call system involving interns must be replaced by a shift‐based system. Like the earlier changes, these new regulations are leading to additional hospitalist growth in the nation's teaching hospitals. By the time the changes are fully implemented, many hospitalist programs will have half or more of their hospitalist FTEs devoted to covering patients previously cared for by residents.

The Exodus of Primary Care Physicians

In the early days of our field, one of the major sources of pushback was the desire of many primary care doctors to continue managing their own inpatients. Beginning a decade ago, this pressure began to abate, as many primary care physicians began to recognize the potential advantages of working with hospitalists.2

Over the next several years, I predict that the growth in the patient‐centered medical home model3with the physician's new responsibilities to provide comprehensive patient‐centered carewill make it even less likely that primary care doctors will have the time to manage their own inpatients. Luckily, information systems now being installed throughout the country (fueled by federal subsidies) will lead to unprecedented connectivity between the inpatient and outpatient worlds,4 hopefully resulting in improving handoffs.

Moreover, the increasing scrutiny of, and upcoming penalties for, high readmission rates are driving hospitals and clinics into creating more robust systems of care to improve inpatientoutpatient communications. The bottom line is that the main Achilles heel of hospitalist systemsthe handoff at hospital admission and dischargeshould improve over the next few years, making it easier than ever for primary care doctors to forego hospital care without losing track of critical patient information.

The Specialists Have Left the Building

One of the more interesting phenomena in the recent history of the hospitalist field is the growth of what I call hyphenated hospitalists: neurology hospitalists, ob‐gyn hospitalists, surgical hospitalists, and the like. The forces promoting these models are similar to those that catalyzed the hospitalist model: the recognition that bifurcating inpatient and outpatient care sometimes makes sense when several conditions are met (Table 1).

The emergence of hyphenated hospitalists raises all sorts of questions for the hospitalist field, many of which I have addressed elsewhere.5 But the bottom line is that the growth of specialty hospitalists may help create a new hospital home teama group of dedicated inpatient physicians spanning virtually every specialty who share best practices, work together on systems improvements, and operate under similar accountabilities. This development may well be the most exciting one in the field's recent history.

Comanagement of Nonmedical Patients

The same forces that led to the emergence of the hospitalist field are also catalyzing the growth of hospitalist comanagement programs. There is a shortage of general surgeons, and in teaching hospitals, there are fewer surgical residents available to help provide floor‐based pre‐ and post‐operative care. And surgical patients are under the same value pressures as medical patients, with increasing public reporting of quality processes and outcomes and new pay for performance programs coming on line. Although the evidence of benefit is mixed,68 many hospitalists are finding that increasing parts of their work involve comanagement.

Comanagement raises several issues, all of which need to be addressed. How do we define clear boundaries between what the hospitalist does and what the specialist does? Comanagement programs, to be effective, need very clear rules of engagement and open lines of communication to work through inevitable conflicts.6 How does the money flow? Most hospitalist programs receive hospital support, but it is legitimate to wonder whether the specialists, particularly surgeons, should chip in to support the program, particularly if they continue to collect a global case rate that was predicated on their provision of pre‐ and post‐operative care. How do comanagement programs and specialty hospitalist programs interrelate, and what are the relative advantages and disadvantages of each? To my mind, programs that meet the conditions outlined in Table 1 probably would do well to start a specialty hospitalist program, assuming that they can find high‐quality specialists to staff it. But there will be myriad variations on these themes. In my hospital, for example, we have both neurohospitalists and medical hospitalists who co‐manage neurosurgery patients.

New Opportunities in Systems Leadership

The growth of the hospitalist field will partly come from individuals who begin their careers performing clinical work, but who transition over time to managerial and leadership roles. This is a natural transition: Who better than a hospitalist to help organize and deliver educational programs, manage clinical operations, implement information technology systems, or lead quality, safety, or utilization management efforts? Of course, as hospitalists assume these roles, others need to take their places covering their clinical shifts.

This might seem like a relatively unimportant driver of personnel growth, but in more advanced systems, it can become a major one. Table 2 lists the faculty in my Division of Hospital Medicine at the University of California, San Francisco (UCSF) who have major institutional (i.e., nondivisional) roles. These roles, spread across eight faculty, account for 3.7 full‐time equivalents (FTEs).

Dealing with New ACGME Regulations

In 2003, the Accreditation Council for Graduate Medical Education (ACGME) issued its first housestaff duty hours reductions (limiting housestaff to a maximum of 80 hours per week, with no single shift lasting longer than 30 hours). This reduction led to the development of nonteaching services in most teaching hospitals; the vast majority of such programs have hospitalists at their core.

In July 2011, new ACGME regulations go into effect,10 which will further cut the availability of housestaff to cover clinical services. Although the 80‐hour weekly limit remains, intern shifts are now limited to 16 hours, meaning that the traditional long call system involving interns must be replaced by a shift‐based system. Like the earlier changes, these new regulations are leading to additional hospitalist growth in the nation's teaching hospitals. By the time the changes are fully implemented, many hospitalist programs will have half or more of their hospitalist FTEs devoted to covering patients previously cared for by residents.

The Exodus of Primary Care Physicians

In the early days of our field, one of the major sources of pushback was the desire of many primary care doctors to continue managing their own inpatients. Beginning a decade ago, this pressure began to abate, as many primary care physicians began to recognize the potential advantages of working with hospitalists.2

Over the next several years, I predict that the growth in the patient‐centered medical home model3with the physician's new responsibilities to provide comprehensive patient‐centered carewill make it even less likely that primary care doctors will have the time to manage their own inpatients. Luckily, information systems now being installed throughout the country (fueled by federal subsidies) will lead to unprecedented connectivity between the inpatient and outpatient worlds,4 hopefully resulting in improving handoffs.

Moreover, the increasing scrutiny of, and upcoming penalties for, high readmission rates are driving hospitals and clinics into creating more robust systems of care to improve inpatientoutpatient communications. The bottom line is that the main Achilles heel of hospitalist systemsthe handoff at hospital admission and dischargeshould improve over the next few years, making it easier than ever for primary care doctors to forego hospital care without losing track of critical patient information.

The Specialists Have Left the Building

One of the more interesting phenomena in the recent history of the hospitalist field is the growth of what I call hyphenated hospitalists: neurology hospitalists, ob‐gyn hospitalists, surgical hospitalists, and the like. The forces promoting these models are similar to those that catalyzed the hospitalist model: the recognition that bifurcating inpatient and outpatient care sometimes makes sense when several conditions are met (Table 1).

The emergence of hyphenated hospitalists raises all sorts of questions for the hospitalist field, many of which I have addressed elsewhere.5 But the bottom line is that the growth of specialty hospitalists may help create a new hospital home teama group of dedicated inpatient physicians spanning virtually every specialty who share best practices, work together on systems improvements, and operate under similar accountabilities. This development may well be the most exciting one in the field's recent history.

Comanagement of Nonmedical Patients

The same forces that led to the emergence of the hospitalist field are also catalyzing the growth of hospitalist comanagement programs. There is a shortage of general surgeons, and in teaching hospitals, there are fewer surgical residents available to help provide floor‐based pre‐ and post‐operative care. And surgical patients are under the same value pressures as medical patients, with increasing public reporting of quality processes and outcomes and new pay for performance programs coming on line. Although the evidence of benefit is mixed,68 many hospitalists are finding that increasing parts of their work involve comanagement.

Comanagement raises several issues, all of which need to be addressed. How do we define clear boundaries between what the hospitalist does and what the specialist does? Comanagement programs, to be effective, need very clear rules of engagement and open lines of communication to work through inevitable conflicts.6 How does the money flow? Most hospitalist programs receive hospital support, but it is legitimate to wonder whether the specialists, particularly surgeons, should chip in to support the program, particularly if they continue to collect a global case rate that was predicated on their provision of pre‐ and post‐operative care. How do comanagement programs and specialty hospitalist programs interrelate, and what are the relative advantages and disadvantages of each? To my mind, programs that meet the conditions outlined in Table 1 probably would do well to start a specialty hospitalist program, assuming that they can find high‐quality specialists to staff it. But there will be myriad variations on these themes. In my hospital, for example, we have both neurohospitalists and medical hospitalists who co‐manage neurosurgery patients.

New Opportunities in Systems Leadership

The growth of the hospitalist field will partly come from individuals who begin their careers performing clinical work, but who transition over time to managerial and leadership roles. This is a natural transition: Who better than a hospitalist to help organize and deliver educational programs, manage clinical operations, implement information technology systems, or lead quality, safety, or utilization management efforts? Of course, as hospitalists assume these roles, others need to take their places covering their clinical shifts.

This might seem like a relatively unimportant driver of personnel growth, but in more advanced systems, it can become a major one. Table 2 lists the faculty in my Division of Hospital Medicine at the University of California, San Francisco (UCSF) who have major institutional (i.e., nondivisional) roles. These roles, spread across eight faculty, account for 3.7 full‐time equivalents (FTEs).

Dealing with New ACGME Regulations

In 2003, the Accreditation Council for Graduate Medical Education (ACGME) issued its first housestaff duty hours reductions (limiting housestaff to a maximum of 80 hours per week, with no single shift lasting longer than 30 hours). This reduction led to the development of nonteaching services in most teaching hospitals; the vast majority of such programs have hospitalists at their core.

In July 2011, new ACGME regulations go into effect,10 which will further cut the availability of housestaff to cover clinical services. Although the 80‐hour weekly limit remains, intern shifts are now limited to 16 hours, meaning that the traditional long call system involving interns must be replaced by a shift‐based system. Like the earlier changes, these new regulations are leading to additional hospitalist growth in the nation's teaching hospitals. By the time the changes are fully implemented, many hospitalist programs will have half or more of their hospitalist FTEs devoted to covering patients previously cared for by residents.

Nurse

The nurse reviews the medication list, notices antibiotics and bronchodilators, and wonders why aren't we administering steroids for his COPD? Do any of these medications need to be given now? Is there anything the physician is worried about? What specific things should prompt me to call the physician with an update or change in condition? I'm not sure if it's safe to send the patient down for the ordered radiographic study because he still looks pretty short of breath. I hate paging the physician several times to get these questions answered because I know that person is busy as well. I also know the patient will have questions about the care plans, which I won't be able to answer. I wonder if I should finish administering evening medications for my other patients as I'm running behind schedule on my other tasks.

Respiratory therapist

At the same time, the respiratory therapist (RT) is contacted to assist with nebulizer therapy for the patient. In reviewing the order for bronchodilators, the RT silently asks, do we think he is going to need continuous nebulizers? What is our oxygen saturation goaldo we want him at 90% or above 95%? I wonder if this patient has a history of CO² retention and if I should have a BiPAP machine at the bedside.

Physician

After completing the orders for the patient, the physician remains in the emergency department to admit a different patient with a gastrointestinal bleed. This is the fifth admission in the past few hours. The physician feels the impact of constant paging interruptions. A unit clerk pages asking for clarification about a radiographic study that was ordered. A bedside nurse pages and asks if the physician can come and speak to the family about the diagnosis and treatment plans for an earlier admission (something the nurse is not clear about, either). A second bedside nurse pages, stating a different admission is still tachycardic after 3 liters of intravenous fluids and wants to know whether the fluids should be continued. Finally, the bedside nurse pages about whether the new COPD admission can go off the floor for the ordered chest CT or remain on continuous pulse oximetry because of shortness of breath.

Our case scenario is representative of most non‐surgical admissions to a hospital. The hypothetical questions posed from different provider perspectives are also common and often remain unanswered in a timely fashion. Partly because there is no site to mark and no anesthesia to deliver, the clinical encounter escapes attention as an opportunity for error prevention. In our experience, there are specific times during a hospitalization when communication failures are most likely to compromise patient care: the time of admission, the time of discharge,9 and any time when a patient's clinical condition changes acutely. Whereas handoff communications focus on transitions between providers (eg, shift changes), these circumstances are driven by patient transitions. Indirect communications, such as phone, email, or faxes, are suboptimal forms of communication at such times.10 We believe that there should be an expectation for direct communication at these junctures, and we define these direct communications as Critical Conversations.

Making Critical Conversations Happen

Integrating Critical Conversations into practice requires both buy‐in among providers and a plan for monitoring the interactions. We recommend beginning with educational efforts (eg, at a physician or nurse staff meeting) and reinforcing them with visual cues, such as posters on the unit (Figure 1). These actions promote awareness and generate expectations that this new clinical policy is being supported by clinical and hospital leadership. Our experiences have demonstrated tremendous learning, including numerous anecdotes about the value of Critical Conversations (Table 3). Our implementation efforts also raised a number of questions that ultimately led to improved clarity in later iterations.

Figure 1

Who should be involved in a Critical Conversation?

Identifying which healthcare team members should be involved in Critical Conversations is best determined by the conversation owner. That is, we found communication was most effective when the individual initiating the Critical Conversation directed others who needed to be involved. At admission, the physician writing the admission orders is best suited to make this determination; at a minimum, he or she should engage the bedside nurse but, as in the case example presented, the physician may also need to engage other services in particularly complex situations (eg, respiratory therapy, pharmacy). At time of discharge, there should be a physiciannurse Critical Conversation; however, the owner of the discharge process may determine that other conversations should occur, and this may be inclusive of or driven by a case manager or social worker. Because local culture and practices may drive specific ownership, it's key to outline a protocol for how this should occur. For instance, at admission, we asked the admitting physicians to take responsibility in contacting the bedside nurse. In other venues, this may work more effectively if the bedside nurse pages the physician once the orders are received and reviewed.

Conclusions

We introduced Critical Conversations as an innovative tool and policy that promotes communication and teamwork in a structured format and at a consistent time. Developing formal systems that decrease communication failures in high‐risk circumstances remains a focus in patient safety, evidenced by guidelines for TOs in procedural settings, handoffs in patient care (eg, sign‐out between providers),14, 15 and transitions into and from the hospital setting.16 Furthermore, there is growing evidence that such structured times for communication and teamwork, such as with briefings, can improve efficiency and reduce delays in care.17, 18 However, handoffs, which address provider transitions, and daily multidisciplinary rounds, which bring providers together regularly, are provider‐centered rather than patient‐centered. Critical Conversations focus on times when patients require direct communication about their care plans to ensure safe and high quality outcomes.

Implementation of Critical Conversations provides an opportunity to codify a professional standard for patient‐centered communication at times when it should be expected. Critical Conversations also help build a system that supports a positive safety culture and encourages teamwork and direct communication. This is particularly true at a time when rapid adoption of information technology may have the unintended and opposite effect. For instance, as our hospital moved toward an entirely electronic health record, providers were increasingly relocating from patient care units into remote offices, corner hideaways, or designated computer rooms to complete orders and documentation. Although this may reduce many related errors in these processes and potentially improve communication via shared access to an electronic record, it does allow for less direct communicationa circumstance that traditionally occurs (even informally) when providers share the same clinical work areas. This situation is aggravated where the nurses are unit‐based and other providers (eg, physicians, therapists, case managers) are service‐based.

Integrating Critical Conversations into practice comes with expected challenges, most notably around workflow (eg, adds a step, although may save steps down the line) and the expectations concomitant with any change in standard of care (possible enforcement or auditing of their occurrence). Certain cultural barriers may also play a significant role, such as the presence of hierarchies that can hinder open communication and the related ability to speak up with concerns, as related in the TO literature. Where these cultural barriers highlight historical descriptions of the doctornurse relationship and its effect on patient care,1921 Critical Conversations provide an opportunity to improve such interdisciplinary relationships by providing a shared tool for direct communication.

In summary, we described an innovative communication tool that promotes direct communication at critical junctures during a hospitalization. With the growing complexity of hospital care and greater interdependence between teams that deliver this care, Critical Conversations provide an opportunity to further address the known communication failures that contribute to medical errors.

Nurse

The nurse reviews the medication list, notices antibiotics and bronchodilators, and wonders why aren't we administering steroids for his COPD? Do any of these medications need to be given now? Is there anything the physician is worried about? What specific things should prompt me to call the physician with an update or change in condition? I'm not sure if it's safe to send the patient down for the ordered radiographic study because he still looks pretty short of breath. I hate paging the physician several times to get these questions answered because I know that person is busy as well. I also know the patient will have questions about the care plans, which I won't be able to answer. I wonder if I should finish administering evening medications for my other patients as I'm running behind schedule on my other tasks.

Respiratory therapist

At the same time, the respiratory therapist (RT) is contacted to assist with nebulizer therapy for the patient. In reviewing the order for bronchodilators, the RT silently asks, do we think he is going to need continuous nebulizers? What is our oxygen saturation goaldo we want him at 90% or above 95%? I wonder if this patient has a history of CO² retention and if I should have a BiPAP machine at the bedside.

Physician

After completing the orders for the patient, the physician remains in the emergency department to admit a different patient with a gastrointestinal bleed. This is the fifth admission in the past few hours. The physician feels the impact of constant paging interruptions. A unit clerk pages asking for clarification about a radiographic study that was ordered. A bedside nurse pages and asks if the physician can come and speak to the family about the diagnosis and treatment plans for an earlier admission (something the nurse is not clear about, either). A second bedside nurse pages, stating a different admission is still tachycardic after 3 liters of intravenous fluids and wants to know whether the fluids should be continued. Finally, the bedside nurse pages about whether the new COPD admission can go off the floor for the ordered chest CT or remain on continuous pulse oximetry because of shortness of breath.

Our case scenario is representative of most non‐surgical admissions to a hospital. The hypothetical questions posed from different provider perspectives are also common and often remain unanswered in a timely fashion. Partly because there is no site to mark and no anesthesia to deliver, the clinical encounter escapes attention as an opportunity for error prevention. In our experience, there are specific times during a hospitalization when communication failures are most likely to compromise patient care: the time of admission, the time of discharge,9 and any time when a patient's clinical condition changes acutely. Whereas handoff communications focus on transitions between providers (eg, shift changes), these circumstances are driven by patient transitions. Indirect communications, such as phone, email, or faxes, are suboptimal forms of communication at such times.10 We believe that there should be an expectation for direct communication at these junctures, and we define these direct communications as Critical Conversations.

Making Critical Conversations Happen

Integrating Critical Conversations into practice requires both buy‐in among providers and a plan for monitoring the interactions. We recommend beginning with educational efforts (eg, at a physician or nurse staff meeting) and reinforcing them with visual cues, such as posters on the unit (Figure 1). These actions promote awareness and generate expectations that this new clinical policy is being supported by clinical and hospital leadership. Our experiences have demonstrated tremendous learning, including numerous anecdotes about the value of Critical Conversations (Table 3). Our implementation efforts also raised a number of questions that ultimately led to improved clarity in later iterations.

Figure 1

Who should be involved in a Critical Conversation?

Identifying which healthcare team members should be involved in Critical Conversations is best determined by the conversation owner. That is, we found communication was most effective when the individual initiating the Critical Conversation directed others who needed to be involved. At admission, the physician writing the admission orders is best suited to make this determination; at a minimum, he or she should engage the bedside nurse but, as in the case example presented, the physician may also need to engage other services in particularly complex situations (eg, respiratory therapy, pharmacy). At time of discharge, there should be a physiciannurse Critical Conversation; however, the owner of the discharge process may determine that other conversations should occur, and this may be inclusive of or driven by a case manager or social worker. Because local culture and practices may drive specific ownership, it's key to outline a protocol for how this should occur. For instance, at admission, we asked the admitting physicians to take responsibility in contacting the bedside nurse. In other venues, this may work more effectively if the bedside nurse pages the physician once the orders are received and reviewed.

Conclusions

We introduced Critical Conversations as an innovative tool and policy that promotes communication and teamwork in a structured format and at a consistent time. Developing formal systems that decrease communication failures in high‐risk circumstances remains a focus in patient safety, evidenced by guidelines for TOs in procedural settings, handoffs in patient care (eg, sign‐out between providers),14, 15 and transitions into and from the hospital setting.16 Furthermore, there is growing evidence that such structured times for communication and teamwork, such as with briefings, can improve efficiency and reduce delays in care.17, 18 However, handoffs, which address provider transitions, and daily multidisciplinary rounds, which bring providers together regularly, are provider‐centered rather than patient‐centered. Critical Conversations focus on times when patients require direct communication about their care plans to ensure safe and high quality outcomes.

Implementation of Critical Conversations provides an opportunity to codify a professional standard for patient‐centered communication at times when it should be expected. Critical Conversations also help build a system that supports a positive safety culture and encourages teamwork and direct communication. This is particularly true at a time when rapid adoption of information technology may have the unintended and opposite effect. For instance, as our hospital moved toward an entirely electronic health record, providers were increasingly relocating from patient care units into remote offices, corner hideaways, or designated computer rooms to complete orders and documentation. Although this may reduce many related errors in these processes and potentially improve communication via shared access to an electronic record, it does allow for less direct communicationa circumstance that traditionally occurs (even informally) when providers share the same clinical work areas. This situation is aggravated where the nurses are unit‐based and other providers (eg, physicians, therapists, case managers) are service‐based.

Integrating Critical Conversations into practice comes with expected challenges, most notably around workflow (eg, adds a step, although may save steps down the line) and the expectations concomitant with any change in standard of care (possible enforcement or auditing of their occurrence). Certain cultural barriers may also play a significant role, such as the presence of hierarchies that can hinder open communication and the related ability to speak up with concerns, as related in the TO literature. Where these cultural barriers highlight historical descriptions of the doctornurse relationship and its effect on patient care,1921 Critical Conversations provide an opportunity to improve such interdisciplinary relationships by providing a shared tool for direct communication.

In summary, we described an innovative communication tool that promotes direct communication at critical junctures during a hospitalization. With the growing complexity of hospital care and greater interdependence between teams that deliver this care, Critical Conversations provide an opportunity to further address the known communication failures that contribute to medical errors.

Nurse

The nurse reviews the medication list, notices antibiotics and bronchodilators, and wonders why aren't we administering steroids for his COPD? Do any of these medications need to be given now? Is there anything the physician is worried about? What specific things should prompt me to call the physician with an update or change in condition? I'm not sure if it's safe to send the patient down for the ordered radiographic study because he still looks pretty short of breath. I hate paging the physician several times to get these questions answered because I know that person is busy as well. I also know the patient will have questions about the care plans, which I won't be able to answer. I wonder if I should finish administering evening medications for my other patients as I'm running behind schedule on my other tasks.

Respiratory therapist

At the same time, the respiratory therapist (RT) is contacted to assist with nebulizer therapy for the patient. In reviewing the order for bronchodilators, the RT silently asks, do we think he is going to need continuous nebulizers? What is our oxygen saturation goaldo we want him at 90% or above 95%? I wonder if this patient has a history of CO² retention and if I should have a BiPAP machine at the bedside.

Physician

After completing the orders for the patient, the physician remains in the emergency department to admit a different patient with a gastrointestinal bleed. This is the fifth admission in the past few hours. The physician feels the impact of constant paging interruptions. A unit clerk pages asking for clarification about a radiographic study that was ordered. A bedside nurse pages and asks if the physician can come and speak to the family about the diagnosis and treatment plans for an earlier admission (something the nurse is not clear about, either). A second bedside nurse pages, stating a different admission is still tachycardic after 3 liters of intravenous fluids and wants to know whether the fluids should be continued. Finally, the bedside nurse pages about whether the new COPD admission can go off the floor for the ordered chest CT or remain on continuous pulse oximetry because of shortness of breath.

Our case scenario is representative of most non‐surgical admissions to a hospital. The hypothetical questions posed from different provider perspectives are also common and often remain unanswered in a timely fashion. Partly because there is no site to mark and no anesthesia to deliver, the clinical encounter escapes attention as an opportunity for error prevention. In our experience, there are specific times during a hospitalization when communication failures are most likely to compromise patient care: the time of admission, the time of discharge,9 and any time when a patient's clinical condition changes acutely. Whereas handoff communications focus on transitions between providers (eg, shift changes), these circumstances are driven by patient transitions. Indirect communications, such as phone, email, or faxes, are suboptimal forms of communication at such times.10 We believe that there should be an expectation for direct communication at these junctures, and we define these direct communications as Critical Conversations.

Making Critical Conversations Happen

Integrating Critical Conversations into practice requires both buy‐in among providers and a plan for monitoring the interactions. We recommend beginning with educational efforts (eg, at a physician or nurse staff meeting) and reinforcing them with visual cues, such as posters on the unit (Figure 1). These actions promote awareness and generate expectations that this new clinical policy is being supported by clinical and hospital leadership. Our experiences have demonstrated tremendous learning, including numerous anecdotes about the value of Critical Conversations (Table 3). Our implementation efforts also raised a number of questions that ultimately led to improved clarity in later iterations.

Figure 1

Who should be involved in a Critical Conversation?

Identifying which healthcare team members should be involved in Critical Conversations is best determined by the conversation owner. That is, we found communication was most effective when the individual initiating the Critical Conversation directed others who needed to be involved. At admission, the physician writing the admission orders is best suited to make this determination; at a minimum, he or she should engage the bedside nurse but, as in the case example presented, the physician may also need to engage other services in particularly complex situations (eg, respiratory therapy, pharmacy). At time of discharge, there should be a physiciannurse Critical Conversation; however, the owner of the discharge process may determine that other conversations should occur, and this may be inclusive of or driven by a case manager or social worker. Because local culture and practices may drive specific ownership, it's key to outline a protocol for how this should occur. For instance, at admission, we asked the admitting physicians to take responsibility in contacting the bedside nurse. In other venues, this may work more effectively if the bedside nurse pages the physician once the orders are received and reviewed.

Conclusions

We introduced Critical Conversations as an innovative tool and policy that promotes communication and teamwork in a structured format and at a consistent time. Developing formal systems that decrease communication failures in high‐risk circumstances remains a focus in patient safety, evidenced by guidelines for TOs in procedural settings, handoffs in patient care (eg, sign‐out between providers),14, 15 and transitions into and from the hospital setting.16 Furthermore, there is growing evidence that such structured times for communication and teamwork, such as with briefings, can improve efficiency and reduce delays in care.17, 18 However, handoffs, which address provider transitions, and daily multidisciplinary rounds, which bring providers together regularly, are provider‐centered rather than patient‐centered. Critical Conversations focus on times when patients require direct communication about their care plans to ensure safe and high quality outcomes.

Implementation of Critical Conversations provides an opportunity to codify a professional standard for patient‐centered communication at times when it should be expected. Critical Conversations also help build a system that supports a positive safety culture and encourages teamwork and direct communication. This is particularly true at a time when rapid adoption of information technology may have the unintended and opposite effect. For instance, as our hospital moved toward an entirely electronic health record, providers were increasingly relocating from patient care units into remote offices, corner hideaways, or designated computer rooms to complete orders and documentation. Although this may reduce many related errors in these processes and potentially improve communication via shared access to an electronic record, it does allow for less direct communicationa circumstance that traditionally occurs (even informally) when providers share the same clinical work areas. This situation is aggravated where the nurses are unit‐based and other providers (eg, physicians, therapists, case managers) are service‐based.

Integrating Critical Conversations into practice comes with expected challenges, most notably around workflow (eg, adds a step, although may save steps down the line) and the expectations concomitant with any change in standard of care (possible enforcement or auditing of their occurrence). Certain cultural barriers may also play a significant role, such as the presence of hierarchies that can hinder open communication and the related ability to speak up with concerns, as related in the TO literature. Where these cultural barriers highlight historical descriptions of the doctornurse relationship and its effect on patient care,1921 Critical Conversations provide an opportunity to improve such interdisciplinary relationships by providing a shared tool for direct communication.

In summary, we described an innovative communication tool that promotes direct communication at critical junctures during a hospitalization. With the growing complexity of hospital care and greater interdependence between teams that deliver this care, Critical Conversations provide an opportunity to further address the known communication failures that contribute to medical errors.

Problem Identification

The University of California, San Francisco (UCSF) Medical Center operates nearly 800 beds across 2 hospitals (Parnassus and Mount Zion campuses). The UCSF Division of Hospital Medicine (DHM) provides care on the teaching service (90% of all ward months covered by a hospitalist faculty), a nonhousestaff medical service based at Mount Zion,4 a palliative care service,10 a medical consultation service, a neurosurgical comanagement service, a procedure service, and comanagement on advanced heart failure and cancer services. Like many AHM groups, ours has experienced explosive growth, more than doubling in faculty size in 3 years (50+ faculty by July 2010).

In addition, many of our new faculty joined the division directly after residency training whereas our early hospitalists were mostly former chief residents and/or fellowship‐trained. During a 2‐year period, our division lost several faculty to burnout from clinically heavy positions or because they felt their ultimate academic success was in doubt. During a 2008 divisional retreat, the single greatest need identified was to invest in the development of our first‐year faculty who were felt to be at greatest risk for burnout, dissatisfaction, and failing to integrate into the divisional mission. Based on this result, we set out to develop a program to meet this pressing need.

Needs Assessment

We formed a FD steering committee comprised of faculty from all ranks and career paths in our division (eg, educator, administrator, and investigator), with overrepresentation of recent hires to ascertain how best to meet their needs. Information from the division retreat provided the basis for the program and its priorities. The FD steering committee then outlined ideas that guided program development, which included:

• 1

  New faculty should be required to meet regularly with assigned faculty mentors during their first year, and expectations for that relationship should be outlined for both parties

• 2

  New faculty should be required to attend dedicated sessions that build their teaching skills

• 3

  New faculty should receive a specially designed first year curriculum to provide learnings focused on high‐yield and relevant topics

• 4

  New faculty should receive a set of goals, or scholarly expectations, for their first year that would foster a partnership between individual faculty and the division to meet those goals

• 5

  The division should create new structures for FD that promote collaboration, sharing of personal and professional growth and challenges, and a culture of continuous learning

• 6

  All of the activities that comprise our new FD program must be aligned with our stated mission: to provide the highest quality clinical care, education, system improvements, and research that benefit our patients and trainees by developing successful academic hospitalist faculty.

Program Goals and Objectives

Our DHM FD program established the goal to provide our new faculty with clinical, educational, leadership, and scholarly skills that would promote academic output and foster work satisfaction. From a broader divisional standpoint, the goal was simply to create new FD structures that fostered the division's commitment to the program. The primary objectives of the program were for new faculty to:

• Increase their knowledge, skills, and attitudes about key academic hospitalist domains following participation in the program;

• Demonstrate successful production of scholarly output, participation in a hospital committee, and participation in a quality or safety improvement initiative by the end of their first year;

• Report high levels of satisfaction with the FD program and their first year on faculty.

Program Development Principles

We began by conducting a literature review to draw on the successes and lessons learned from existing FD programs, particularly in large departments, academic centers, and the hospitalist field.1115 We focused our program development on a set of FD principles, which included instructional improvement, organizational development, the development of professional academic skills, and the teaching of specific content.11 Furthermore, whereas many FD programs traditionally focus on mentoring or a longitudinal set of seminars, we believed a multifaceted approach could help shift our culture towards one that prioritized FD and generated a sense of community. We hoped this cultural shift would create an environment that increased faculty satisfaction with their work, with their colleagues, and in our division.

This context drove us to build programmatic activities that not only targeted new faculty, the initial focus of our planning efforts, but also the division more broadly. We wanted to adopt known strategies (eg, mentoring relationships, teaching methods for FD, and grand rounds) but also weave in new ones that targeted AHM and our Division. It was clear that successful programs used a variety of instructional methods, and often combined methods, to create active and engaged faculty. We similarly wanted to create venues for didactic and small‐group learning, but also opportunities for peer learning and facilitated discussions around important topics. Allowing new faculty to learn from each other, and having them observe more senior faculty do the same, would be an important and explicit programmatic element.

Program Description and Implementation

All new faculty meet with Divisional leadership (RMW/BAS), administrative staff (they receive an orientation binder that highlights frequently asked questions and provides service‐specific orientation documents), and the Director of FD (NLS). The latter introduces the DHM FD Program and provides the road map for their first year (Supporting Information). The checklist serves to orient, guide, and emphasize the various programmatic goals, expectations, and logistics. Discussion focuses on the activities targeted to new faculty followed by wider divisional offerings. New faculty activities include:

Program Evaluation

Our evaluation focused on measuring the FD program's impact on our new faculty. We tracked their success in completing the stated scholarly expectations and surveyed them about their satisfaction with the programmatic activities, their first year on faculty, and their preparation for year 2. Prior to implementing the program, we surveyed the previous 2 years of new faculty to provide a comparison.

Problem Identification

The University of California, San Francisco (UCSF) Medical Center operates nearly 800 beds across 2 hospitals (Parnassus and Mount Zion campuses). The UCSF Division of Hospital Medicine (DHM) provides care on the teaching service (90% of all ward months covered by a hospitalist faculty), a nonhousestaff medical service based at Mount Zion,4 a palliative care service,10 a medical consultation service, a neurosurgical comanagement service, a procedure service, and comanagement on advanced heart failure and cancer services. Like many AHM groups, ours has experienced explosive growth, more than doubling in faculty size in 3 years (50+ faculty by July 2010).

In addition, many of our new faculty joined the division directly after residency training whereas our early hospitalists were mostly former chief residents and/or fellowship‐trained. During a 2‐year period, our division lost several faculty to burnout from clinically heavy positions or because they felt their ultimate academic success was in doubt. During a 2008 divisional retreat, the single greatest need identified was to invest in the development of our first‐year faculty who were felt to be at greatest risk for burnout, dissatisfaction, and failing to integrate into the divisional mission. Based on this result, we set out to develop a program to meet this pressing need.

Needs Assessment

We formed a FD steering committee comprised of faculty from all ranks and career paths in our division (eg, educator, administrator, and investigator), with overrepresentation of recent hires to ascertain how best to meet their needs. Information from the division retreat provided the basis for the program and its priorities. The FD steering committee then outlined ideas that guided program development, which included:

• 1

  New faculty should be required to meet regularly with assigned faculty mentors during their first year, and expectations for that relationship should be outlined for both parties

• 2

  New faculty should be required to attend dedicated sessions that build their teaching skills

• 3

  New faculty should receive a specially designed first year curriculum to provide learnings focused on high‐yield and relevant topics

• 4

  New faculty should receive a set of goals, or scholarly expectations, for their first year that would foster a partnership between individual faculty and the division to meet those goals

• 5

  The division should create new structures for FD that promote collaboration, sharing of personal and professional growth and challenges, and a culture of continuous learning

• 6

  All of the activities that comprise our new FD program must be aligned with our stated mission: to provide the highest quality clinical care, education, system improvements, and research that benefit our patients and trainees by developing successful academic hospitalist faculty.

Program Goals and Objectives

Our DHM FD program established the goal to provide our new faculty with clinical, educational, leadership, and scholarly skills that would promote academic output and foster work satisfaction. From a broader divisional standpoint, the goal was simply to create new FD structures that fostered the division's commitment to the program. The primary objectives of the program were for new faculty to:

• Increase their knowledge, skills, and attitudes about key academic hospitalist domains following participation in the program;

• Demonstrate successful production of scholarly output, participation in a hospital committee, and participation in a quality or safety improvement initiative by the end of their first year;

• Report high levels of satisfaction with the FD program and their first year on faculty.

Program Development Principles

We began by conducting a literature review to draw on the successes and lessons learned from existing FD programs, particularly in large departments, academic centers, and the hospitalist field.1115 We focused our program development on a set of FD principles, which included instructional improvement, organizational development, the development of professional academic skills, and the teaching of specific content.11 Furthermore, whereas many FD programs traditionally focus on mentoring or a longitudinal set of seminars, we believed a multifaceted approach could help shift our culture towards one that prioritized FD and generated a sense of community. We hoped this cultural shift would create an environment that increased faculty satisfaction with their work, with their colleagues, and in our division.

This context drove us to build programmatic activities that not only targeted new faculty, the initial focus of our planning efforts, but also the division more broadly. We wanted to adopt known strategies (eg, mentoring relationships, teaching methods for FD, and grand rounds) but also weave in new ones that targeted AHM and our Division. It was clear that successful programs used a variety of instructional methods, and often combined methods, to create active and engaged faculty. We similarly wanted to create venues for didactic and small‐group learning, but also opportunities for peer learning and facilitated discussions around important topics. Allowing new faculty to learn from each other, and having them observe more senior faculty do the same, would be an important and explicit programmatic element.

Program Description and Implementation

All new faculty meet with Divisional leadership (RMW/BAS), administrative staff (they receive an orientation binder that highlights frequently asked questions and provides service‐specific orientation documents), and the Director of FD (NLS). The latter introduces the DHM FD Program and provides the road map for their first year (Supporting Information). The checklist serves to orient, guide, and emphasize the various programmatic goals, expectations, and logistics. Discussion focuses on the activities targeted to new faculty followed by wider divisional offerings. New faculty activities include:

Program Evaluation

Our evaluation focused on measuring the FD program's impact on our new faculty. We tracked their success in completing the stated scholarly expectations and surveyed them about their satisfaction with the programmatic activities, their first year on faculty, and their preparation for year 2. Prior to implementing the program, we surveyed the previous 2 years of new faculty to provide a comparison.

Problem Identification

The University of California, San Francisco (UCSF) Medical Center operates nearly 800 beds across 2 hospitals (Parnassus and Mount Zion campuses). The UCSF Division of Hospital Medicine (DHM) provides care on the teaching service (90% of all ward months covered by a hospitalist faculty), a nonhousestaff medical service based at Mount Zion,4 a palliative care service,10 a medical consultation service, a neurosurgical comanagement service, a procedure service, and comanagement on advanced heart failure and cancer services. Like many AHM groups, ours has experienced explosive growth, more than doubling in faculty size in 3 years (50+ faculty by July 2010).

In addition, many of our new faculty joined the division directly after residency training whereas our early hospitalists were mostly former chief residents and/or fellowship‐trained. During a 2‐year period, our division lost several faculty to burnout from clinically heavy positions or because they felt their ultimate academic success was in doubt. During a 2008 divisional retreat, the single greatest need identified was to invest in the development of our first‐year faculty who were felt to be at greatest risk for burnout, dissatisfaction, and failing to integrate into the divisional mission. Based on this result, we set out to develop a program to meet this pressing need.

Needs Assessment

We formed a FD steering committee comprised of faculty from all ranks and career paths in our division (eg, educator, administrator, and investigator), with overrepresentation of recent hires to ascertain how best to meet their needs. Information from the division retreat provided the basis for the program and its priorities. The FD steering committee then outlined ideas that guided program development, which included:

• 1

  New faculty should be required to meet regularly with assigned faculty mentors during their first year, and expectations for that relationship should be outlined for both parties

• 2

  New faculty should be required to attend dedicated sessions that build their teaching skills

• 3

  New faculty should receive a specially designed first year curriculum to provide learnings focused on high‐yield and relevant topics

• 4

  New faculty should receive a set of goals, or scholarly expectations, for their first year that would foster a partnership between individual faculty and the division to meet those goals

• 5

  The division should create new structures for FD that promote collaboration, sharing of personal and professional growth and challenges, and a culture of continuous learning

• 6

  All of the activities that comprise our new FD program must be aligned with our stated mission: to provide the highest quality clinical care, education, system improvements, and research that benefit our patients and trainees by developing successful academic hospitalist faculty.

Program Goals and Objectives

Our DHM FD program established the goal to provide our new faculty with clinical, educational, leadership, and scholarly skills that would promote academic output and foster work satisfaction. From a broader divisional standpoint, the goal was simply to create new FD structures that fostered the division's commitment to the program. The primary objectives of the program were for new faculty to:

• Increase their knowledge, skills, and attitudes about key academic hospitalist domains following participation in the program;

• Demonstrate successful production of scholarly output, participation in a hospital committee, and participation in a quality or safety improvement initiative by the end of their first year;

• Report high levels of satisfaction with the FD program and their first year on faculty.

Program Development Principles

We began by conducting a literature review to draw on the successes and lessons learned from existing FD programs, particularly in large departments, academic centers, and the hospitalist field.1115 We focused our program development on a set of FD principles, which included instructional improvement, organizational development, the development of professional academic skills, and the teaching of specific content.11 Furthermore, whereas many FD programs traditionally focus on mentoring or a longitudinal set of seminars, we believed a multifaceted approach could help shift our culture towards one that prioritized FD and generated a sense of community. We hoped this cultural shift would create an environment that increased faculty satisfaction with their work, with their colleagues, and in our division.

This context drove us to build programmatic activities that not only targeted new faculty, the initial focus of our planning efforts, but also the division more broadly. We wanted to adopt known strategies (eg, mentoring relationships, teaching methods for FD, and grand rounds) but also weave in new ones that targeted AHM and our Division. It was clear that successful programs used a variety of instructional methods, and often combined methods, to create active and engaged faculty. We similarly wanted to create venues for didactic and small‐group learning, but also opportunities for peer learning and facilitated discussions around important topics. Allowing new faculty to learn from each other, and having them observe more senior faculty do the same, would be an important and explicit programmatic element.

Program Description and Implementation

All new faculty meet with Divisional leadership (RMW/BAS), administrative staff (they receive an orientation binder that highlights frequently asked questions and provides service‐specific orientation documents), and the Director of FD (NLS). The latter introduces the DHM FD Program and provides the road map for their first year (Supporting Information). The checklist serves to orient, guide, and emphasize the various programmatic goals, expectations, and logistics. Discussion focuses on the activities targeted to new faculty followed by wider divisional offerings. New faculty activities include:

Program Evaluation

Our evaluation focused on measuring the FD program's impact on our new faculty. We tracked their success in completing the stated scholarly expectations and surveyed them about their satisfaction with the programmatic activities, their first year on faculty, and their preparation for year 2. Prior to implementing the program, we surveyed the previous 2 years of new faculty to provide a comparison.

Attract

Increasingly, companies approach talented prospects with dedicated marketing campaigns to convey the value of a work environment.11 Silicon Valley employee lounges with free massages and foosball tables are the iconic example of attraction, but the concept runs deeper. Today's workers seek access to state‐of‐the‐art ideas and technology and often want to be part of a larger vision. Many seek opportunities to integrate their own professional and personal aspirations into a particular job description.

Hospital executives have long recognized the importance of attracting physicians to their facility (after all, the physicians draw patients and thus generate revenue). The traditional approach has surrounded perks, from comfortable doctor's lounges to the latest in surgical technology. But, the stakes seem greater now than before, and successful talent facilitation strategies are going beyond the tried and true.

Clearly, physicians seek financially stable practice settings with historical success. But they may also seek evidence of a defined strategic plan focused on more than mere profitability. Physicians may gravitate to practice environments that endorse progressive movements like the No One Dies Alone campaign.12 Similarly, recognition of movements beyond healthcarea commitment to Leadership in Energy and Environmental Design (LEED) (Green Building Rating System; US Green Building Council [USGBC]; http://www.usgbc.org) designation,13 for examplemay help attract talented staff physicians or enhance a hospital system's ability to facilitate partnerships with desirable physician groups. Within small private practices, this may take the form of a collaborative dedication to physician wellness and burnout prevention, or in a shared commitment to some form of local or international service.

The current recruitment campaign of California's prison healthcare system offers an unlikely source of inspiration. The prison system was placed in receivership to address a shortage of competent physician staff and other inadequacies. A central feature of the campaign is an attractive starting salary and good benefits. But, the campaign does not rely on money alone. For example, the campaign's website (http://changingprisonhealthcare.org) promises that prison physicians will create the standard for correctional healthcare and join an historic effort to make a difference in people's lives (Figure 1). The campaign thus rebrands what might be seen as an unpalatable job into a legitimate and noble career option. Of course, the long‐term success of the campaign will rely on a genuine commitment to the campaign's ideals. But the point is this: if a prison system can deploy innovative attraction strategies, so can healthcare leaders at all levels.

Figure 1

Engage

The corporate tool being employed at this stage is a strategy called on‐boarding, which emphasizes a streamlined integration of newcomers with existing workers and culture, and prioritizes aligning organizational roles with a worker's specific skills and interests. On‐boarding also emphasizes the value of early and frequent provision of constructive feedback from same‐level peers or managers with advanced coaching skills.

Many companies use formal survey tools to measure employee engagement and regularly evaluate the proficiency of system leaders in the ability to engage their employees. An engineering firm executive recently told us (P.K., C.K.) that he performs detailed and frequent on‐the‐job interviews, even with company veterans. The primary goal of these interviews is to ensure that engineers spend at least 85% of their time on work that: (1) they find interesting and (2) allows for the application of their best skills. Wherever possible, traditional job descriptions are altered to achieve this. Inevitably, there is still work (15% in this particular corporate vision) that no one prefers but needs to get done, but this process of active recalibration minimizes this fraction to the degree possible.

Even within a small physician practice group, one can imagine how a strategic approach of inviting and acknowledging individual physician's professional goals and particular talents may challenge the long‐held belief that everyone within a group enjoys and must do the exact same job. Once these goals and talents are articulated, groups may find that allowing for more customized roles within the practice enhances professional satisfaction.

Social networking, collaboration, and sharing of best practices are staples of engaging companies. The Cisco and Qualcomm companies, for example, utilize elaborate e‐networks (rough corporate equivalents to Facebook) to foster collegial interaction within and across traditional hierarchical boundaries so that managers and executives directly engage the ideas of employees at every level.14 The premise is logical: engaged employees will be more likely to contribute innovative ideas which, when listened to, are more likely to engage employees.

Most physicians will recognize the traditional resident report as a model for engagement. Beyond its educational value, interaction with program leadership, social bonding, collaborative effort, and exploration of best practices add tremendous value. Many companies would jump at the chance to engrain a similar cultural staple. Enhancing this type of interaction in a postresidency setting may promote engagement in a given system, especially if it facilitates interactions between physicians and senior hospital leaders. Absent these types of interactions, ensuring regular provision of peer review and/or constructive feedback can help systematically enhance 2‐way communication and enhance engagement.

Develop

Talent development relies on mentorship reflecting a genuine interest in an individual's future. Development strategies include pairing formal annual talent reviews or (in the case of practice partners) formal peer review with strategic development plans. Effective development strategy may include transparent succession planning so that individuals are aware they are being groomed for future roles.

A well‐known adage suggests, People quit the manager or administrator, not the job. Development in this sense relies on presenting new opportunities and knowing that people flourish when allowed to explore multiple paths forward. In many companies, the role of Chief Experience or Chief Learning Officers is to enhance development planning. Consider how career coaching of young hospitalists could transform an infinitely portable and volatile commodity job, prone to burnout, into an engaged specialist of sorts with immense value to a hospital. Hospitalists have already demonstrated their potential as quality improvement leaders.15 Imagine if hospital leadership enlisted a young hospitalist in a relevant quality improvement task force, such as one working on preventing falls. With appropriate support, the physician could obtain skills for quality improvement evaluation that would not only enhance his or her engagement with the hospital system but also provide a valuable analysis for the hospital.

As an example of development strategy within a small practice setting, consider the following real‐life anecdote: a group of 4 physicians recently completed a long and expensive recruitment of a new partner. The new partner, intrigued by the local hospital's surgical robot technology, sought the support of her partners (who are not currently using the technology) to partake in an expensive robotics training program. The partners decided not to provide the financial support. The new partner subsequently left the group for a nearby practice opportunity that would provide for the training, and the group was faced with the loss of a partner (one‐fourth of the practice!) and the cost of repeating the recruiting process. A preemptive evaluation of the value of investing in the development of the new partner and enhancing that partner's professional development may have proven wise despite the significant up‐front costs. In this case the manager the new partner quit was the inflexibility of the practice trajectory.

Retain

The economic incentive to retain talented workers is not subtle. If it was, companies would not be funneling resources into Chief Experience Officers. Likewise, the estimated cost for a medical practice to replace an individual physician is as at least $250,000.16, 17

In retention, as in attraction, salary is only part of the equation.18 People want fair and competitive compensation, and may leave if they are not getting it, but they will not stay (and will not stay engaged) only for a salary bump. Retention is enhanced when workers can advance according to skills and talent, rather than mere tenure. An effective retention policy responds to people's desire to incorporate individual professional goals into their work and allows for people to customize their career rather than simply occupy a job class. Effective retention policy respects worklife balance and recognizes that this balance might look different for 2 people with the same job. It may take the form of positive reinforcement (rather than subtle disdain) for using vacation time or allowing for participation in international service projects. Many literally feel that they need to quit their job in order to take time off or explore other interests.

Worklife balance has been a longstanding issue in medicine, and innovative augmentation strategies may well help retain top talent. Today's successful medical school applicants not only show aptitude in the classroom, they often have many well‐developed nonmedical skills. No one can expect that medical training will somehow convince them to leave everything else behind. Moreover, today's residency graduates, already with Generation Y sensibilities, have completed their entire training under the auspices of the Accreditation Council for Graduate Medical Education (ACGME) duty hours regulations, which has made residents far more comfortable with shift work and defined hours.

At the other end of the generation spectrum, as large numbers of physicians ready for retirement, effective talent facilitation strategies may evaluate how to reoffer medicine as a valid option for senior physicians who still wish to work. Retaining these physicians will require an appreciation of their lifestyle goals, as they will likely find continuing a traditional practice role untenable. A recent survey of orthopedic surgeons 50 years of age or older found that having a part‐time option was a common reason they continued practicing, and that the option to work part‐time would have the most impact on keeping these surgeons working past age 65 years.19 Those working part‐time were doing so in a wide range of practice arrangements including private practice. However, one‐third of those surveyed said a part‐time option was not available to them. Clearly, in an environment of workforce shortages, physician‐leaders must begin to think about worklife balance not only for new doctors but for those considering retirement.

Critics will point out the financial drawbacks in the provision of worklife balance. But the cost may pale in comparison to the cost of replacing physician leaders. Moreover, engaged physicians are more likely to add value in the form of intangible capital such as patient satisfaction and practice innovation. As such, we argue that effective retention strategy in medicine is likely to be cost‐effective, even if it requires significant new up‐front resources.

Attract

Increasingly, companies approach talented prospects with dedicated marketing campaigns to convey the value of a work environment.11 Silicon Valley employee lounges with free massages and foosball tables are the iconic example of attraction, but the concept runs deeper. Today's workers seek access to state‐of‐the‐art ideas and technology and often want to be part of a larger vision. Many seek opportunities to integrate their own professional and personal aspirations into a particular job description.

Hospital executives have long recognized the importance of attracting physicians to their facility (after all, the physicians draw patients and thus generate revenue). The traditional approach has surrounded perks, from comfortable doctor's lounges to the latest in surgical technology. But, the stakes seem greater now than before, and successful talent facilitation strategies are going beyond the tried and true.

Clearly, physicians seek financially stable practice settings with historical success. But they may also seek evidence of a defined strategic plan focused on more than mere profitability. Physicians may gravitate to practice environments that endorse progressive movements like the No One Dies Alone campaign.12 Similarly, recognition of movements beyond healthcarea commitment to Leadership in Energy and Environmental Design (LEED) (Green Building Rating System; US Green Building Council [USGBC]; http://www.usgbc.org) designation,13 for examplemay help attract talented staff physicians or enhance a hospital system's ability to facilitate partnerships with desirable physician groups. Within small private practices, this may take the form of a collaborative dedication to physician wellness and burnout prevention, or in a shared commitment to some form of local or international service.

The current recruitment campaign of California's prison healthcare system offers an unlikely source of inspiration. The prison system was placed in receivership to address a shortage of competent physician staff and other inadequacies. A central feature of the campaign is an attractive starting salary and good benefits. But, the campaign does not rely on money alone. For example, the campaign's website (http://changingprisonhealthcare.org) promises that prison physicians will create the standard for correctional healthcare and join an historic effort to make a difference in people's lives (Figure 1). The campaign thus rebrands what might be seen as an unpalatable job into a legitimate and noble career option. Of course, the long‐term success of the campaign will rely on a genuine commitment to the campaign's ideals. But the point is this: if a prison system can deploy innovative attraction strategies, so can healthcare leaders at all levels.

Figure 1

Engage

The corporate tool being employed at this stage is a strategy called on‐boarding, which emphasizes a streamlined integration of newcomers with existing workers and culture, and prioritizes aligning organizational roles with a worker's specific skills and interests. On‐boarding also emphasizes the value of early and frequent provision of constructive feedback from same‐level peers or managers with advanced coaching skills.

Many companies use formal survey tools to measure employee engagement and regularly evaluate the proficiency of system leaders in the ability to engage their employees. An engineering firm executive recently told us (P.K., C.K.) that he performs detailed and frequent on‐the‐job interviews, even with company veterans. The primary goal of these interviews is to ensure that engineers spend at least 85% of their time on work that: (1) they find interesting and (2) allows for the application of their best skills. Wherever possible, traditional job descriptions are altered to achieve this. Inevitably, there is still work (15% in this particular corporate vision) that no one prefers but needs to get done, but this process of active recalibration minimizes this fraction to the degree possible.

Even within a small physician practice group, one can imagine how a strategic approach of inviting and acknowledging individual physician's professional goals and particular talents may challenge the long‐held belief that everyone within a group enjoys and must do the exact same job. Once these goals and talents are articulated, groups may find that allowing for more customized roles within the practice enhances professional satisfaction.

Social networking, collaboration, and sharing of best practices are staples of engaging companies. The Cisco and Qualcomm companies, for example, utilize elaborate e‐networks (rough corporate equivalents to Facebook) to foster collegial interaction within and across traditional hierarchical boundaries so that managers and executives directly engage the ideas of employees at every level.14 The premise is logical: engaged employees will be more likely to contribute innovative ideas which, when listened to, are more likely to engage employees.

Most physicians will recognize the traditional resident report as a model for engagement. Beyond its educational value, interaction with program leadership, social bonding, collaborative effort, and exploration of best practices add tremendous value. Many companies would jump at the chance to engrain a similar cultural staple. Enhancing this type of interaction in a postresidency setting may promote engagement in a given system, especially if it facilitates interactions between physicians and senior hospital leaders. Absent these types of interactions, ensuring regular provision of peer review and/or constructive feedback can help systematically enhance 2‐way communication and enhance engagement.

Develop

Talent development relies on mentorship reflecting a genuine interest in an individual's future. Development strategies include pairing formal annual talent reviews or (in the case of practice partners) formal peer review with strategic development plans. Effective development strategy may include transparent succession planning so that individuals are aware they are being groomed for future roles.

A well‐known adage suggests, People quit the manager or administrator, not the job. Development in this sense relies on presenting new opportunities and knowing that people flourish when allowed to explore multiple paths forward. In many companies, the role of Chief Experience or Chief Learning Officers is to enhance development planning. Consider how career coaching of young hospitalists could transform an infinitely portable and volatile commodity job, prone to burnout, into an engaged specialist of sorts with immense value to a hospital. Hospitalists have already demonstrated their potential as quality improvement leaders.15 Imagine if hospital leadership enlisted a young hospitalist in a relevant quality improvement task force, such as one working on preventing falls. With appropriate support, the physician could obtain skills for quality improvement evaluation that would not only enhance his or her engagement with the hospital system but also provide a valuable analysis for the hospital.

As an example of development strategy within a small practice setting, consider the following real‐life anecdote: a group of 4 physicians recently completed a long and expensive recruitment of a new partner. The new partner, intrigued by the local hospital's surgical robot technology, sought the support of her partners (who are not currently using the technology) to partake in an expensive robotics training program. The partners decided not to provide the financial support. The new partner subsequently left the group for a nearby practice opportunity that would provide for the training, and the group was faced with the loss of a partner (one‐fourth of the practice!) and the cost of repeating the recruiting process. A preemptive evaluation of the value of investing in the development of the new partner and enhancing that partner's professional development may have proven wise despite the significant up‐front costs. In this case the manager the new partner quit was the inflexibility of the practice trajectory.

Retain

The economic incentive to retain talented workers is not subtle. If it was, companies would not be funneling resources into Chief Experience Officers. Likewise, the estimated cost for a medical practice to replace an individual physician is as at least $250,000.16, 17

In retention, as in attraction, salary is only part of the equation.18 People want fair and competitive compensation, and may leave if they are not getting it, but they will not stay (and will not stay engaged) only for a salary bump. Retention is enhanced when workers can advance according to skills and talent, rather than mere tenure. An effective retention policy responds to people's desire to incorporate individual professional goals into their work and allows for people to customize their career rather than simply occupy a job class. Effective retention policy respects worklife balance and recognizes that this balance might look different for 2 people with the same job. It may take the form of positive reinforcement (rather than subtle disdain) for using vacation time or allowing for participation in international service projects. Many literally feel that they need to quit their job in order to take time off or explore other interests.

Worklife balance has been a longstanding issue in medicine, and innovative augmentation strategies may well help retain top talent. Today's successful medical school applicants not only show aptitude in the classroom, they often have many well‐developed nonmedical skills. No one can expect that medical training will somehow convince them to leave everything else behind. Moreover, today's residency graduates, already with Generation Y sensibilities, have completed their entire training under the auspices of the Accreditation Council for Graduate Medical Education (ACGME) duty hours regulations, which has made residents far more comfortable with shift work and defined hours.

At the other end of the generation spectrum, as large numbers of physicians ready for retirement, effective talent facilitation strategies may evaluate how to reoffer medicine as a valid option for senior physicians who still wish to work. Retaining these physicians will require an appreciation of their lifestyle goals, as they will likely find continuing a traditional practice role untenable. A recent survey of orthopedic surgeons 50 years of age or older found that having a part‐time option was a common reason they continued practicing, and that the option to work part‐time would have the most impact on keeping these surgeons working past age 65 years.19 Those working part‐time were doing so in a wide range of practice arrangements including private practice. However, one‐third of those surveyed said a part‐time option was not available to them. Clearly, in an environment of workforce shortages, physician‐leaders must begin to think about worklife balance not only for new doctors but for those considering retirement.

Critics will point out the financial drawbacks in the provision of worklife balance. But the cost may pale in comparison to the cost of replacing physician leaders. Moreover, engaged physicians are more likely to add value in the form of intangible capital such as patient satisfaction and practice innovation. As such, we argue that effective retention strategy in medicine is likely to be cost‐effective, even if it requires significant new up‐front resources.

Attract

Increasingly, companies approach talented prospects with dedicated marketing campaigns to convey the value of a work environment.11 Silicon Valley employee lounges with free massages and foosball tables are the iconic example of attraction, but the concept runs deeper. Today's workers seek access to state‐of‐the‐art ideas and technology and often want to be part of a larger vision. Many seek opportunities to integrate their own professional and personal aspirations into a particular job description.

Hospital executives have long recognized the importance of attracting physicians to their facility (after all, the physicians draw patients and thus generate revenue). The traditional approach has surrounded perks, from comfortable doctor's lounges to the latest in surgical technology. But, the stakes seem greater now than before, and successful talent facilitation strategies are going beyond the tried and true.

Clearly, physicians seek financially stable practice settings with historical success. But they may also seek evidence of a defined strategic plan focused on more than mere profitability. Physicians may gravitate to practice environments that endorse progressive movements like the No One Dies Alone campaign.12 Similarly, recognition of movements beyond healthcarea commitment to Leadership in Energy and Environmental Design (LEED) (Green Building Rating System; US Green Building Council [USGBC]; http://www.usgbc.org) designation,13 for examplemay help attract talented staff physicians or enhance a hospital system's ability to facilitate partnerships with desirable physician groups. Within small private practices, this may take the form of a collaborative dedication to physician wellness and burnout prevention, or in a shared commitment to some form of local or international service.

The current recruitment campaign of California's prison healthcare system offers an unlikely source of inspiration. The prison system was placed in receivership to address a shortage of competent physician staff and other inadequacies. A central feature of the campaign is an attractive starting salary and good benefits. But, the campaign does not rely on money alone. For example, the campaign's website (http://changingprisonhealthcare.org) promises that prison physicians will create the standard for correctional healthcare and join an historic effort to make a difference in people's lives (Figure 1). The campaign thus rebrands what might be seen as an unpalatable job into a legitimate and noble career option. Of course, the long‐term success of the campaign will rely on a genuine commitment to the campaign's ideals. But the point is this: if a prison system can deploy innovative attraction strategies, so can healthcare leaders at all levels.

Figure 1

Engage

The corporate tool being employed at this stage is a strategy called on‐boarding, which emphasizes a streamlined integration of newcomers with existing workers and culture, and prioritizes aligning organizational roles with a worker's specific skills and interests. On‐boarding also emphasizes the value of early and frequent provision of constructive feedback from same‐level peers or managers with advanced coaching skills.

Many companies use formal survey tools to measure employee engagement and regularly evaluate the proficiency of system leaders in the ability to engage their employees. An engineering firm executive recently told us (P.K., C.K.) that he performs detailed and frequent on‐the‐job interviews, even with company veterans. The primary goal of these interviews is to ensure that engineers spend at least 85% of their time on work that: (1) they find interesting and (2) allows for the application of their best skills. Wherever possible, traditional job descriptions are altered to achieve this. Inevitably, there is still work (15% in this particular corporate vision) that no one prefers but needs to get done, but this process of active recalibration minimizes this fraction to the degree possible.

Even within a small physician practice group, one can imagine how a strategic approach of inviting and acknowledging individual physician's professional goals and particular talents may challenge the long‐held belief that everyone within a group enjoys and must do the exact same job. Once these goals and talents are articulated, groups may find that allowing for more customized roles within the practice enhances professional satisfaction.

Social networking, collaboration, and sharing of best practices are staples of engaging companies. The Cisco and Qualcomm companies, for example, utilize elaborate e‐networks (rough corporate equivalents to Facebook) to foster collegial interaction within and across traditional hierarchical boundaries so that managers and executives directly engage the ideas of employees at every level.14 The premise is logical: engaged employees will be more likely to contribute innovative ideas which, when listened to, are more likely to engage employees.

Most physicians will recognize the traditional resident report as a model for engagement. Beyond its educational value, interaction with program leadership, social bonding, collaborative effort, and exploration of best practices add tremendous value. Many companies would jump at the chance to engrain a similar cultural staple. Enhancing this type of interaction in a postresidency setting may promote engagement in a given system, especially if it facilitates interactions between physicians and senior hospital leaders. Absent these types of interactions, ensuring regular provision of peer review and/or constructive feedback can help systematically enhance 2‐way communication and enhance engagement.

Develop

Talent development relies on mentorship reflecting a genuine interest in an individual's future. Development strategies include pairing formal annual talent reviews or (in the case of practice partners) formal peer review with strategic development plans. Effective development strategy may include transparent succession planning so that individuals are aware they are being groomed for future roles.

A well‐known adage suggests, People quit the manager or administrator, not the job. Development in this sense relies on presenting new opportunities and knowing that people flourish when allowed to explore multiple paths forward. In many companies, the role of Chief Experience or Chief Learning Officers is to enhance development planning. Consider how career coaching of young hospitalists could transform an infinitely portable and volatile commodity job, prone to burnout, into an engaged specialist of sorts with immense value to a hospital. Hospitalists have already demonstrated their potential as quality improvement leaders.15 Imagine if hospital leadership enlisted a young hospitalist in a relevant quality improvement task force, such as one working on preventing falls. With appropriate support, the physician could obtain skills for quality improvement evaluation that would not only enhance his or her engagement with the hospital system but also provide a valuable analysis for the hospital.

As an example of development strategy within a small practice setting, consider the following real‐life anecdote: a group of 4 physicians recently completed a long and expensive recruitment of a new partner. The new partner, intrigued by the local hospital's surgical robot technology, sought the support of her partners (who are not currently using the technology) to partake in an expensive robotics training program. The partners decided not to provide the financial support. The new partner subsequently left the group for a nearby practice opportunity that would provide for the training, and the group was faced with the loss of a partner (one‐fourth of the practice!) and the cost of repeating the recruiting process. A preemptive evaluation of the value of investing in the development of the new partner and enhancing that partner's professional development may have proven wise despite the significant up‐front costs. In this case the manager the new partner quit was the inflexibility of the practice trajectory.

Retain

The economic incentive to retain talented workers is not subtle. If it was, companies would not be funneling resources into Chief Experience Officers. Likewise, the estimated cost for a medical practice to replace an individual physician is as at least $250,000.16, 17

In retention, as in attraction, salary is only part of the equation.18 People want fair and competitive compensation, and may leave if they are not getting it, but they will not stay (and will not stay engaged) only for a salary bump. Retention is enhanced when workers can advance according to skills and talent, rather than mere tenure. An effective retention policy responds to people's desire to incorporate individual professional goals into their work and allows for people to customize their career rather than simply occupy a job class. Effective retention policy respects worklife balance and recognizes that this balance might look different for 2 people with the same job. It may take the form of positive reinforcement (rather than subtle disdain) for using vacation time or allowing for participation in international service projects. Many literally feel that they need to quit their job in order to take time off or explore other interests.

Worklife balance has been a longstanding issue in medicine, and innovative augmentation strategies may well help retain top talent. Today's successful medical school applicants not only show aptitude in the classroom, they often have many well‐developed nonmedical skills. No one can expect that medical training will somehow convince them to leave everything else behind. Moreover, today's residency graduates, already with Generation Y sensibilities, have completed their entire training under the auspices of the Accreditation Council for Graduate Medical Education (ACGME) duty hours regulations, which has made residents far more comfortable with shift work and defined hours.

At the other end of the generation spectrum, as large numbers of physicians ready for retirement, effective talent facilitation strategies may evaluate how to reoffer medicine as a valid option for senior physicians who still wish to work. Retaining these physicians will require an appreciation of their lifestyle goals, as they will likely find continuing a traditional practice role untenable. A recent survey of orthopedic surgeons 50 years of age or older found that having a part‐time option was a common reason they continued practicing, and that the option to work part‐time would have the most impact on keeping these surgeons working past age 65 years.19 Those working part‐time were doing so in a wide range of practice arrangements including private practice. However, one‐third of those surveyed said a part‐time option was not available to them. Clearly, in an environment of workforce shortages, physician‐leaders must begin to think about worklife balance not only for new doctors but for those considering retirement.

Critics will point out the financial drawbacks in the provision of worklife balance. But the cost may pale in comparison to the cost of replacing physician leaders. Moreover, engaged physicians are more likely to add value in the form of intangible capital such as patient satisfaction and practice innovation. As such, we argue that effective retention strategy in medicine is likely to be cost‐effective, even if it requires significant new up‐front resources.

Study Sites

We examined the performance of 209 hospitals (63% of all 334 non‐federal facilities in California) participating in the California Hospital Assessment and Reporting Taskforce (CHART) at the time of the survey. CHART is a voluntary quality reporting initiative that began publicly reporting hospital quality data in January 2006.

Hospital‐level Organizational, Case‐mix, and Quality Data

Hospital organizational characteristics (eg, bed size) were obtained from publicly available discharge and utilization data sets from the California Office of Statewide Health Planning and Development (OSHPD). We also linked hospital‐level patient‐mix data (eg, race) from these OSHPD files.

We obtained quality of care data from CHART for January 2006 through June 2007, the time period corresponding to the survey. Quality metrics included 16 measures collected by the Center for Medicare and Medicaid Services (www.cms.hhs.gov) and extensively used in quality research.1, 4, 13, 15‐17 Rather than define a single measure, we examined multiple process measures, anticipating differential impacts of hospitalists on various processes of care for AMI, CHF, and pneumonia. Measures were further divided among those that are usually measured upon initial presentation to the hospital and those that are measured throughout the entire hospitalization and discharge. This division reflects the division of care in the hospital, where emergency room physicians are likely to have a more critical role for admission processes.

Survey Process

We surveyed all nonfederal, acute care hospitals in California that participated in CHART.2 We first identified contacts at each site via professional society mailing lists. We then sent web‐based surveys to all with available email addresses and a fax/paper survey to the remainder. We surveyed individuals between October 2006 and April 2007 and repeated the process at intervals of 1 to 3 weeks. For remaining nonrespondents, we placed a direct call unless consent to survey had been specifically refused. We contacted the following persons in sequence: (1) hospital executives or administrative leaders; (2) hospital medicine department leaders; (3) admitting emergency room personnel or medical staff officers; and (4) hospital website information. In the case of multiple responses with disagreement, the hospital/hospitalist leader's response was treated as the primary source. At each step, respondents were asked to answer questions only if they had a direct working knowledge of their hospitalist services.

Survey Data

Our key survey question to all respondents included whether the respondents could confirm their hospitals had at least one hospitalist medicine group. Hospital leaders were also asked to participate in a more comprehensive survey of their organizational and clinical characteristics. Within the comprehensive survey, leaders also provided estimates of the percent of general medical patients admitted by hospitalists. This measure, used in prior surveys of hospital leaders,9 was intended to be an easily understood approximation of the intensity of hospitalist utilization in any given hospital. A more rigorous, direct measure was not feasible due to the complexity of obtaining admission data over such a large, diverse set of hospitals.

Process Performance Measures

AMI measures assessed at admission included aspirin and ‐blocker administration within 24 hours of arrival. AMI measures assessed at discharge included aspirin administration, ‐blocker administration, angiotensin converting enzyme inhibitor (ACE‐I) (or angiotensin receptor blocker [ARB]) administration for left ventricular (LV) dysfunction, and smoking cessation counseling. There were no CHF admission measures. CHF discharge measures included assessment of LV function, the use of an ACE‐I or ARB for LV dysfunction, and smoking cessation counseling. Pneumonia admission measures included the drawing of blood cultures prior to the receipt of antibiotics, timely administration of initial antibiotics (<8 hours), and antibiotics consistent with recommendations. Pneumonia discharge measures included pneumococcal vaccination, flu vaccination, and smoking cessation counseling.

For each performance measure, we quantified the percentage of missed quality opportunities, defined as the number of patients who did not receive a care process divided by the number of eligible patients, multiplied by 100. In addition, we calculated composite scores for admission and discharge measures across each condition. We summed the numerators and denominators of individual performance measures to generate a disease‐specific composite numerator and denominator. Both individual and composite scores were produced using methodology outlined by the Center for Medicare & Medicaid Services.18 In order to retain as representative a sample of hospitals as possible, we calculated composite scores for hospitals that had a minimum of 25 observations in at least 2 of the quality indicators that made up each composite score.

Statistical Analysis

We used chi‐square tests, Student t tests, and Mann‐Whitney tests, where appropriate, to compare hospital‐level characteristics of hospitals that utilized hospitalists vs. those that did not. Similar analyses were performed among the subset of hospitals that utilized hospitalists. Among this subgroup of hospitals, we compared hospital‐level characteristics between hospitals that provided information regarding the percent of patients admitted by hospitalists vs. those who did not provide this information.

We used multivariable, generalized linear regression models to assess the relationship between having at least 1 hospitalist group and the percentage of missed quality of care measures. Because percentages were not normally distributed (ie, a majority of hospitals had few missed opportunities, while a minority had many), multivariable models employed log‐link functions with a gamma distribution.19, 20 Coefficients for our key predictor (presence of hospitalists) were transformed back to the original units (percentage of missed quality opportunities) so that a positive coefficient represented a higher number of quality measures missed relative to hospitals without hospitalists. Models were adjusted for factors previously reported to be associated with care quality. Hospital organizational characteristics included the number of beds, teaching status, registered nursing (RN) hours per adjusted patient day, and hospital ownership (for‐profit vs. not‐for‐profit). Hospital patient mix factors included annual percentage of admissions by insurance status (Medicare, Medicaid, other), annual percentage of admissions by race (white vs. nonwhite), annual percentage of do‐not‐resuscitate status at admission, and mean diagnosis‐related group‐based case‐mix index.21 We additionally adjusted for the number of cardiac catheterizations, a measure that moderately correlates with the number of cardiologists and technology utilization.22‐24 In our subset analysis among those hospitals with hospitalists, our key predictor for regression analyses was the percentage of patients admitted by hospitalists. For ease of interpretation, the percentage of patients admitted by hospitalists was centered on the mean across all respondent hospitals, and we report the effect of increasing by 10% the percentage of patients admitted by hospitalists. Models were adjusted for the same hospital organizational characteristics listed above. For those models, a positive coefficient also meant a higher number of measures missed.

For both sets of predictors, we additionally tested for the presence of interactions between the predictors and hospital bed size (both continuous as well as dichotomized at 150 beds) in composite measure performance, given the possibility that any hospitalist effect may be greater among smaller, resource‐limited hospitals. Tests for interaction were performed with the likelihood ratio test. In addition, to minimize any potential bias or loss of power that might result from limiting the analysis to hospitals with complete data, we used the multivariate imputation by chained equations method, as implemented in STATA 9.2 (StataCorp, College Station, TX), to create 10 imputed datasets.25 Imputation of missing values was restricted to confounding variables. Standard methods were then used to combine results over the 10 imputed datasets. We also applied Bonferroni corrections to composite measure tests based on the number of composites generated (n = 5). Thus, for the 5 inpatient composites created, standard definitions of significance (P 0.05) were corrected by dividing composite P values by 5, requiring P 0.01 for significance. The institutional review board of the University of California, San Francisco, approved the study. All analyses were performed using STATA 9.2.

Characteristics of Participating Sites

There were 209 eligible hospitals. All 209 (100%) hospitals provided data about the presence or absence of hospitalists via at least 1 of our survey strategies. The majority of identification of hospitalist utilization was via contact with either hospital or hospitalist leaders, n = 147 (70.3%). Web‐sites informed hospitalist prevalence in only 3 (1.4%) hospitals. There were 8 (3.8%) occurrences of disagreement between sources, all of which had available hospital/hospitalist leader responses. Only 1 (0.5%) hospital did not have the minimum 25 patients eligible for any disease‐specific quality measures during the data reporting period. Collectively, the remaining 208 hospitals accounted for 81% of California's acute care hospital population.

Comparisons of Sites With Hospitalists and Those Without

A total of 170 hospitals (82%) participating in CHART used hospitalists. Hospitals with and without hospitalists differed by a variety of characteristics (Table 1). Sites with hospitalists were larger, less likely to be for‐profit, had more registered nursing hours per day, and performed more cardiac catheterizations.

Relationship Between Hospitalist Group Utilization and the Percentage of Missed Quality Opportunities

Table 2 shows the frequency of missed quality opportunities in sites with hospitalists compared to those without. In general, for both individual and composite measures of quality, multivariable adjustment modestly attenuated the observed differences between the 2 groups of hospitals. We present only the more conservative adjusted estimates.

Compared to hospitals without hospitalists, those with hospitalists did not have any statistically significant differences in the individual and composite admission measures for each of the disease processes. In contrast, there were statistically significant differences between hospitalist and nonhospitalist sites for many individual cardiac processes of care that typically occur after admission from the emergency room (ie, LV function assessment for CHF) or those that occurred at discharge (ie, aspirin and ACE‐I/ARB at discharge for AMI). Similarly, the composite discharge scores for AMI and CHF revealed better overall process measure performance at sites with hospitalists, although the AMI composite did not meet statistical significance. There were no statistically significant differences between groups for the pneumonia process measures assessed at discharge. In addition, for composite measures there were no statistically significant interactions between hospitalist prevalence and bed size, although there was a trend (P = 0.06) for the CHF discharge composite, with a larger effect of hospitalists among smaller hospitals.

Percent of Patients Admitted by Hospitalists

Of the 171 hospitals with hospitalists, 71 (42%) estimated the percent of patients admitted by their hospitalist physicians. Among the respondents, the mean and median percentages of medical patients admitted by hospitalists were 51% (SD = 25%) and 49% (IQR = 30‐70%), respectively. Thirty hospitals were above the sample mean. Compared to nonrespondent sites, respondent hospitals took care of more white patients; otherwise, respondent and nonrespondent hospitals were similar in terms of bed size, location, performance across each measure, and other observable characteristics (Supporting Information, Appendix 1).

Relationship Between the Estimated Percentages of Medical Patients Admitted by Hospitalists and Missed Quality Opportunities

Table 3 displays the change in missed quality measures associated with each additional 10% of patients estimated to be admitted by hospitalists. A higher estimated percentage of patients admitted by hospitalists was associated with statistically significant improvements in quality of care across a majority of individual measures and for all composite discharge measures regardless of condition. For example, every 10% increase in the mean estimated number of patients admitted by hospitalists was associated with a mean of 0.6% (P < 0.001), 0.5% (P = 0.004), and 1.5% (P = 0.006) fewer missed quality opportunities for AMI, CHF, and pneumonia discharge process measures composites, respectively. In addition, for these composite measures, there were no statistically significant interactions between the estimated percentage of patients admitted by hospitalists and bed size (dichotomized at 150 beds), although there was a trend (P = 0.09) for the AMI discharge composite, with a larger effect of hospitalists among smaller hospitals.

In order to test the robustness of our results, we carried out 2 secondary analyses. First, we used multivariable models to generate a propensity score representing the predicted probability of being assigned to a hospital with hospitalists. We then used the propensity score as an additional covariate in subsequent multivariable models. In addition, we performed a complete‐case analysis (including only hospitals with complete data, n = 204) as a check on the sensitivity of our results to missing data. Neither analysis produced results substantially different from those presented.

Study Sites

We examined the performance of 209 hospitals (63% of all 334 non‐federal facilities in California) participating in the California Hospital Assessment and Reporting Taskforce (CHART) at the time of the survey. CHART is a voluntary quality reporting initiative that began publicly reporting hospital quality data in January 2006.

Hospital‐level Organizational, Case‐mix, and Quality Data

Hospital organizational characteristics (eg, bed size) were obtained from publicly available discharge and utilization data sets from the California Office of Statewide Health Planning and Development (OSHPD). We also linked hospital‐level patient‐mix data (eg, race) from these OSHPD files.

We obtained quality of care data from CHART for January 2006 through June 2007, the time period corresponding to the survey. Quality metrics included 16 measures collected by the Center for Medicare and Medicaid Services (www.cms.hhs.gov) and extensively used in quality research.1, 4, 13, 15‐17 Rather than define a single measure, we examined multiple process measures, anticipating differential impacts of hospitalists on various processes of care for AMI, CHF, and pneumonia. Measures were further divided among those that are usually measured upon initial presentation to the hospital and those that are measured throughout the entire hospitalization and discharge. This division reflects the division of care in the hospital, where emergency room physicians are likely to have a more critical role for admission processes.

Survey Process

We surveyed all nonfederal, acute care hospitals in California that participated in CHART.2 We first identified contacts at each site via professional society mailing lists. We then sent web‐based surveys to all with available email addresses and a fax/paper survey to the remainder. We surveyed individuals between October 2006 and April 2007 and repeated the process at intervals of 1 to 3 weeks. For remaining nonrespondents, we placed a direct call unless consent to survey had been specifically refused. We contacted the following persons in sequence: (1) hospital executives or administrative leaders; (2) hospital medicine department leaders; (3) admitting emergency room personnel or medical staff officers; and (4) hospital website information. In the case of multiple responses with disagreement, the hospital/hospitalist leader's response was treated as the primary source. At each step, respondents were asked to answer questions only if they had a direct working knowledge of their hospitalist services.

Survey Data

Our key survey question to all respondents included whether the respondents could confirm their hospitals had at least one hospitalist medicine group. Hospital leaders were also asked to participate in a more comprehensive survey of their organizational and clinical characteristics. Within the comprehensive survey, leaders also provided estimates of the percent of general medical patients admitted by hospitalists. This measure, used in prior surveys of hospital leaders,9 was intended to be an easily understood approximation of the intensity of hospitalist utilization in any given hospital. A more rigorous, direct measure was not feasible due to the complexity of obtaining admission data over such a large, diverse set of hospitals.

Process Performance Measures

AMI measures assessed at admission included aspirin and ‐blocker administration within 24 hours of arrival. AMI measures assessed at discharge included aspirin administration, ‐blocker administration, angiotensin converting enzyme inhibitor (ACE‐I) (or angiotensin receptor blocker [ARB]) administration for left ventricular (LV) dysfunction, and smoking cessation counseling. There were no CHF admission measures. CHF discharge measures included assessment of LV function, the use of an ACE‐I or ARB for LV dysfunction, and smoking cessation counseling. Pneumonia admission measures included the drawing of blood cultures prior to the receipt of antibiotics, timely administration of initial antibiotics (<8 hours), and antibiotics consistent with recommendations. Pneumonia discharge measures included pneumococcal vaccination, flu vaccination, and smoking cessation counseling.

For each performance measure, we quantified the percentage of missed quality opportunities, defined as the number of patients who did not receive a care process divided by the number of eligible patients, multiplied by 100. In addition, we calculated composite scores for admission and discharge measures across each condition. We summed the numerators and denominators of individual performance measures to generate a disease‐specific composite numerator and denominator. Both individual and composite scores were produced using methodology outlined by the Center for Medicare & Medicaid Services.18 In order to retain as representative a sample of hospitals as possible, we calculated composite scores for hospitals that had a minimum of 25 observations in at least 2 of the quality indicators that made up each composite score.

Statistical Analysis

We used chi‐square tests, Student t tests, and Mann‐Whitney tests, where appropriate, to compare hospital‐level characteristics of hospitals that utilized hospitalists vs. those that did not. Similar analyses were performed among the subset of hospitals that utilized hospitalists. Among this subgroup of hospitals, we compared hospital‐level characteristics between hospitals that provided information regarding the percent of patients admitted by hospitalists vs. those who did not provide this information.

We used multivariable, generalized linear regression models to assess the relationship between having at least 1 hospitalist group and the percentage of missed quality of care measures. Because percentages were not normally distributed (ie, a majority of hospitals had few missed opportunities, while a minority had many), multivariable models employed log‐link functions with a gamma distribution.19, 20 Coefficients for our key predictor (presence of hospitalists) were transformed back to the original units (percentage of missed quality opportunities) so that a positive coefficient represented a higher number of quality measures missed relative to hospitals without hospitalists. Models were adjusted for factors previously reported to be associated with care quality. Hospital organizational characteristics included the number of beds, teaching status, registered nursing (RN) hours per adjusted patient day, and hospital ownership (for‐profit vs. not‐for‐profit). Hospital patient mix factors included annual percentage of admissions by insurance status (Medicare, Medicaid, other), annual percentage of admissions by race (white vs. nonwhite), annual percentage of do‐not‐resuscitate status at admission, and mean diagnosis‐related group‐based case‐mix index.21 We additionally adjusted for the number of cardiac catheterizations, a measure that moderately correlates with the number of cardiologists and technology utilization.22‐24 In our subset analysis among those hospitals with hospitalists, our key predictor for regression analyses was the percentage of patients admitted by hospitalists. For ease of interpretation, the percentage of patients admitted by hospitalists was centered on the mean across all respondent hospitals, and we report the effect of increasing by 10% the percentage of patients admitted by hospitalists. Models were adjusted for the same hospital organizational characteristics listed above. For those models, a positive coefficient also meant a higher number of measures missed.

For both sets of predictors, we additionally tested for the presence of interactions between the predictors and hospital bed size (both continuous as well as dichotomized at 150 beds) in composite measure performance, given the possibility that any hospitalist effect may be greater among smaller, resource‐limited hospitals. Tests for interaction were performed with the likelihood ratio test. In addition, to minimize any potential bias or loss of power that might result from limiting the analysis to hospitals with complete data, we used the multivariate imputation by chained equations method, as implemented in STATA 9.2 (StataCorp, College Station, TX), to create 10 imputed datasets.25 Imputation of missing values was restricted to confounding variables. Standard methods were then used to combine results over the 10 imputed datasets. We also applied Bonferroni corrections to composite measure tests based on the number of composites generated (n = 5). Thus, for the 5 inpatient composites created, standard definitions of significance (P 0.05) were corrected by dividing composite P values by 5, requiring P 0.01 for significance. The institutional review board of the University of California, San Francisco, approved the study. All analyses were performed using STATA 9.2.

Characteristics of Participating Sites

There were 209 eligible hospitals. All 209 (100%) hospitals provided data about the presence or absence of hospitalists via at least 1 of our survey strategies. The majority of identification of hospitalist utilization was via contact with either hospital or hospitalist leaders, n = 147 (70.3%). Web‐sites informed hospitalist prevalence in only 3 (1.4%) hospitals. There were 8 (3.8%) occurrences of disagreement between sources, all of which had available hospital/hospitalist leader responses. Only 1 (0.5%) hospital did not have the minimum 25 patients eligible for any disease‐specific quality measures during the data reporting period. Collectively, the remaining 208 hospitals accounted for 81% of California's acute care hospital population.

Comparisons of Sites With Hospitalists and Those Without

A total of 170 hospitals (82%) participating in CHART used hospitalists. Hospitals with and without hospitalists differed by a variety of characteristics (Table 1). Sites with hospitalists were larger, less likely to be for‐profit, had more registered nursing hours per day, and performed more cardiac catheterizations.

Relationship Between Hospitalist Group Utilization and the Percentage of Missed Quality Opportunities

Table 2 shows the frequency of missed quality opportunities in sites with hospitalists compared to those without. In general, for both individual and composite measures of quality, multivariable adjustment modestly attenuated the observed differences between the 2 groups of hospitals. We present only the more conservative adjusted estimates.

Compared to hospitals without hospitalists, those with hospitalists did not have any statistically significant differences in the individual and composite admission measures for each of the disease processes. In contrast, there were statistically significant differences between hospitalist and nonhospitalist sites for many individual cardiac processes of care that typically occur after admission from the emergency room (ie, LV function assessment for CHF) or those that occurred at discharge (ie, aspirin and ACE‐I/ARB at discharge for AMI). Similarly, the composite discharge scores for AMI and CHF revealed better overall process measure performance at sites with hospitalists, although the AMI composite did not meet statistical significance. There were no statistically significant differences between groups for the pneumonia process measures assessed at discharge. In addition, for composite measures there were no statistically significant interactions between hospitalist prevalence and bed size, although there was a trend (P = 0.06) for the CHF discharge composite, with a larger effect of hospitalists among smaller hospitals.

Percent of Patients Admitted by Hospitalists

Of the 171 hospitals with hospitalists, 71 (42%) estimated the percent of patients admitted by their hospitalist physicians. Among the respondents, the mean and median percentages of medical patients admitted by hospitalists were 51% (SD = 25%) and 49% (IQR = 30‐70%), respectively. Thirty hospitals were above the sample mean. Compared to nonrespondent sites, respondent hospitals took care of more white patients; otherwise, respondent and nonrespondent hospitals were similar in terms of bed size, location, performance across each measure, and other observable characteristics (Supporting Information, Appendix 1).

Relationship Between the Estimated Percentages of Medical Patients Admitted by Hospitalists and Missed Quality Opportunities

Table 3 displays the change in missed quality measures associated with each additional 10% of patients estimated to be admitted by hospitalists. A higher estimated percentage of patients admitted by hospitalists was associated with statistically significant improvements in quality of care across a majority of individual measures and for all composite discharge measures regardless of condition. For example, every 10% increase in the mean estimated number of patients admitted by hospitalists was associated with a mean of 0.6% (P < 0.001), 0.5% (P = 0.004), and 1.5% (P = 0.006) fewer missed quality opportunities for AMI, CHF, and pneumonia discharge process measures composites, respectively. In addition, for these composite measures, there were no statistically significant interactions between the estimated percentage of patients admitted by hospitalists and bed size (dichotomized at 150 beds), although there was a trend (P = 0.09) for the AMI discharge composite, with a larger effect of hospitalists among smaller hospitals.

In order to test the robustness of our results, we carried out 2 secondary analyses. First, we used multivariable models to generate a propensity score representing the predicted probability of being assigned to a hospital with hospitalists. We then used the propensity score as an additional covariate in subsequent multivariable models. In addition, we performed a complete‐case analysis (including only hospitals with complete data, n = 204) as a check on the sensitivity of our results to missing data. Neither analysis produced results substantially different from those presented.

Study Sites

We examined the performance of 209 hospitals (63% of all 334 non‐federal facilities in California) participating in the California Hospital Assessment and Reporting Taskforce (CHART) at the time of the survey. CHART is a voluntary quality reporting initiative that began publicly reporting hospital quality data in January 2006.

Hospital‐level Organizational, Case‐mix, and Quality Data

Hospital organizational characteristics (eg, bed size) were obtained from publicly available discharge and utilization data sets from the California Office of Statewide Health Planning and Development (OSHPD). We also linked hospital‐level patient‐mix data (eg, race) from these OSHPD files.

We obtained quality of care data from CHART for January 2006 through June 2007, the time period corresponding to the survey. Quality metrics included 16 measures collected by the Center for Medicare and Medicaid Services (www.cms.hhs.gov) and extensively used in quality research.1, 4, 13, 15‐17 Rather than define a single measure, we examined multiple process measures, anticipating differential impacts of hospitalists on various processes of care for AMI, CHF, and pneumonia. Measures were further divided among those that are usually measured upon initial presentation to the hospital and those that are measured throughout the entire hospitalization and discharge. This division reflects the division of care in the hospital, where emergency room physicians are likely to have a more critical role for admission processes.

Survey Process

We surveyed all nonfederal, acute care hospitals in California that participated in CHART.2 We first identified contacts at each site via professional society mailing lists. We then sent web‐based surveys to all with available email addresses and a fax/paper survey to the remainder. We surveyed individuals between October 2006 and April 2007 and repeated the process at intervals of 1 to 3 weeks. For remaining nonrespondents, we placed a direct call unless consent to survey had been specifically refused. We contacted the following persons in sequence: (1) hospital executives or administrative leaders; (2) hospital medicine department leaders; (3) admitting emergency room personnel or medical staff officers; and (4) hospital website information. In the case of multiple responses with disagreement, the hospital/hospitalist leader's response was treated as the primary source. At each step, respondents were asked to answer questions only if they had a direct working knowledge of their hospitalist services.

Survey Data

Our key survey question to all respondents included whether the respondents could confirm their hospitals had at least one hospitalist medicine group. Hospital leaders were also asked to participate in a more comprehensive survey of their organizational and clinical characteristics. Within the comprehensive survey, leaders also provided estimates of the percent of general medical patients admitted by hospitalists. This measure, used in prior surveys of hospital leaders,9 was intended to be an easily understood approximation of the intensity of hospitalist utilization in any given hospital. A more rigorous, direct measure was not feasible due to the complexity of obtaining admission data over such a large, diverse set of hospitals.

Process Performance Measures

AMI measures assessed at admission included aspirin and ‐blocker administration within 24 hours of arrival. AMI measures assessed at discharge included aspirin administration, ‐blocker administration, angiotensin converting enzyme inhibitor (ACE‐I) (or angiotensin receptor blocker [ARB]) administration for left ventricular (LV) dysfunction, and smoking cessation counseling. There were no CHF admission measures. CHF discharge measures included assessment of LV function, the use of an ACE‐I or ARB for LV dysfunction, and smoking cessation counseling. Pneumonia admission measures included the drawing of blood cultures prior to the receipt of antibiotics, timely administration of initial antibiotics (<8 hours), and antibiotics consistent with recommendations. Pneumonia discharge measures included pneumococcal vaccination, flu vaccination, and smoking cessation counseling.

For each performance measure, we quantified the percentage of missed quality opportunities, defined as the number of patients who did not receive a care process divided by the number of eligible patients, multiplied by 100. In addition, we calculated composite scores for admission and discharge measures across each condition. We summed the numerators and denominators of individual performance measures to generate a disease‐specific composite numerator and denominator. Both individual and composite scores were produced using methodology outlined by the Center for Medicare & Medicaid Services.18 In order to retain as representative a sample of hospitals as possible, we calculated composite scores for hospitals that had a minimum of 25 observations in at least 2 of the quality indicators that made up each composite score.

Statistical Analysis

We used chi‐square tests, Student t tests, and Mann‐Whitney tests, where appropriate, to compare hospital‐level characteristics of hospitals that utilized hospitalists vs. those that did not. Similar analyses were performed among the subset of hospitals that utilized hospitalists. Among this subgroup of hospitals, we compared hospital‐level characteristics between hospitals that provided information regarding the percent of patients admitted by hospitalists vs. those who did not provide this information.

We used multivariable, generalized linear regression models to assess the relationship between having at least 1 hospitalist group and the percentage of missed quality of care measures. Because percentages were not normally distributed (ie, a majority of hospitals had few missed opportunities, while a minority had many), multivariable models employed log‐link functions with a gamma distribution.19, 20 Coefficients for our key predictor (presence of hospitalists) were transformed back to the original units (percentage of missed quality opportunities) so that a positive coefficient represented a higher number of quality measures missed relative to hospitals without hospitalists. Models were adjusted for factors previously reported to be associated with care quality. Hospital organizational characteristics included the number of beds, teaching status, registered nursing (RN) hours per adjusted patient day, and hospital ownership (for‐profit vs. not‐for‐profit). Hospital patient mix factors included annual percentage of admissions by insurance status (Medicare, Medicaid, other), annual percentage of admissions by race (white vs. nonwhite), annual percentage of do‐not‐resuscitate status at admission, and mean diagnosis‐related group‐based case‐mix index.21 We additionally adjusted for the number of cardiac catheterizations, a measure that moderately correlates with the number of cardiologists and technology utilization.22‐24 In our subset analysis among those hospitals with hospitalists, our key predictor for regression analyses was the percentage of patients admitted by hospitalists. For ease of interpretation, the percentage of patients admitted by hospitalists was centered on the mean across all respondent hospitals, and we report the effect of increasing by 10% the percentage of patients admitted by hospitalists. Models were adjusted for the same hospital organizational characteristics listed above. For those models, a positive coefficient also meant a higher number of measures missed.

For both sets of predictors, we additionally tested for the presence of interactions between the predictors and hospital bed size (both continuous as well as dichotomized at 150 beds) in composite measure performance, given the possibility that any hospitalist effect may be greater among smaller, resource‐limited hospitals. Tests for interaction were performed with the likelihood ratio test. In addition, to minimize any potential bias or loss of power that might result from limiting the analysis to hospitals with complete data, we used the multivariate imputation by chained equations method, as implemented in STATA 9.2 (StataCorp, College Station, TX), to create 10 imputed datasets.25 Imputation of missing values was restricted to confounding variables. Standard methods were then used to combine results over the 10 imputed datasets. We also applied Bonferroni corrections to composite measure tests based on the number of composites generated (n = 5). Thus, for the 5 inpatient composites created, standard definitions of significance (P 0.05) were corrected by dividing composite P values by 5, requiring P 0.01 for significance. The institutional review board of the University of California, San Francisco, approved the study. All analyses were performed using STATA 9.2.

Characteristics of Participating Sites

There were 209 eligible hospitals. All 209 (100%) hospitals provided data about the presence or absence of hospitalists via at least 1 of our survey strategies. The majority of identification of hospitalist utilization was via contact with either hospital or hospitalist leaders, n = 147 (70.3%). Web‐sites informed hospitalist prevalence in only 3 (1.4%) hospitals. There were 8 (3.8%) occurrences of disagreement between sources, all of which had available hospital/hospitalist leader responses. Only 1 (0.5%) hospital did not have the minimum 25 patients eligible for any disease‐specific quality measures during the data reporting period. Collectively, the remaining 208 hospitals accounted for 81% of California's acute care hospital population.

Comparisons of Sites With Hospitalists and Those Without

A total of 170 hospitals (82%) participating in CHART used hospitalists. Hospitals with and without hospitalists differed by a variety of characteristics (Table 1). Sites with hospitalists were larger, less likely to be for‐profit, had more registered nursing hours per day, and performed more cardiac catheterizations.