Tina Budnitz, MPH

Enactment of federal legislation imposing hospital reimbursement penalties for excess rates of rehospitalizations among Medicare fee for service beneficiaries markedly increased interest in hospital quality improvement (QI) efforts to reduce the observed 30‐day rehospitalization of 19.6% in this elderly population.[1, 2] The Congressional Budget Office estimated that reimbursement penalties to hospitals for high readmission rates are expected to save the Medicare program approximately $7 billion between 2010 and 2019.[3] These penalties are complemented by resources from the Center for Medicare and Medicaid Innovation aiming to reduce hospital readmissions by 20% by the end of 2013 through the Partnership for Patients campaign.[4] Although potential financial penalties and provision of resources for QI intensified efforts to enhance the quality of the hospital discharge transition, patient safety risks associated with hospital discharge are well documented.[5, 6] Approximately 20% of patients discharged from the hospital may suffer adverse events,[7, 8] of which up to three‐quarters (72%) are medication related,[9] and over one‐third of required follow‐up testing after discharge is not completed.[10] Such findings indicate opportunities for improvement in the discharge process.[11]

Numerous publications describe studies aiming to improve the hospital discharge process and mitigate these hazards, though a systematic review of interventions to reduce 30‐day rehospitalization indicated that the existing evidence base for the effectiveness of transition interventions demonstrates irregular effectiveness and limitations to generalizability.[12] Most studies showing effectiveness are confined to single academic medical centers. Existing evidence supports multifaceted interventions implemented in both the pre‐ and postdischarge periods and focused on risk assessment and tailored, patient‐centered application of interventions to mitigate risk. For example Project RED (Re‐Engineered Discharge) applied a bundled intervention consisting of intensified patient education and discharge planning, improved medication reconciliation and discharge instructions, and longitudinal patient contact with follow‐up phone calls and a dedicated discharge advocate.[13] However, the mean age of patients participating in the study was 50 years, and it excluded patients admitted from or discharged to skilled nursing facilities, making generalizability to the geriatric population uncertain.

An integral aspect of QI projects is the contribution of local context to translation of best practices to disparate settings.[14, 15, 16] Most available reports of successful interventions to reduce rehospitalization have not fully described the specifics of either the intervention context or design. Moreover, the available evidence base for common interventions to reduce rehospitalization was developed in the academic setting. Validation of single academic center studies in a broader healthcare context is necessary.

Project BOOST (Better Outcomes for Older adults through Safe Transitions) recruited a diverse national cohort of both academic and nonacademic hospitals to participate in a QI effort to implement best practices for hospital discharge care transitions using a national collaborative approach facilitated by external expert mentorship. This study aimed to determine the effectiveness of BOOST in lowering hospital readmission rates and impact on length of stay.

METHODS

The study of Project BOOST was undertaken in accordance with the SQUIRE (Standards for Quality Improvement Reporting Excellence) Guidelines.[17]

RESULTS

Eleven hospitals provided rehospitalization and length‐of‐stay outcome data for both a BOOST and control unit for the pre‐ and postimplementation periods. Compared to the 19 sites that did not participate in the analysis, these 11 sites were significantly larger (559188 beds vs 350205 beds, P=0.003), more likely to be located in an urban area (100.0% [n=11] vs 78.9% [n=15], P=0.035), and more likely to be academic medical centers (45.5% [n=5] vs 26.3% [n=5], P=0.036) (Table 1).

The mean number of tools implemented by sites participating in the analysis was 3.50.9. All sites implemented at least 2 tools. The duration between attendance at the BOOST kickoff event and first tool implementation ranged from 3 months (first tool implemented prior to attending the kickoff) and 9 months (mean duration, 3.34.3 months) (Table 2).

The average rate of 30‐day rehospitalization among BOOST units was 14.7% in the preimplementation period and 12.7% during the postimplementation period (P=0.010) (Figure 1). Rehospitalization rates for matched control units were 14.0% in the preintervention period and 14.1% in the postintervention period (P=0.831). The mean absolute reduction in readmission rates over the 1‐year study period in BOOST units compared to control units was 2.0%, or a relative reduction of 13.6% (P=0.054 for signed rank test comparing differences in readmission rate reduction in BOOST units compared to site‐matched control units). Length of stay in BOOST and control units decreased an average of 0.5 days and 0.3 days, respectively. There was no difference in length of stay change between BOOST units and control units (P=0.966).

Figure 1

DISCUSSION

As hospitals strive to reduce their readmission rates to avoid Centers for Medicare and Medicaid Services penalties, Project BOOST may be a viable QI approach to achieve their goals. This initial evaluation of participation in Project BOOST by 11 hospitals of varying sizes across the United States showed an associated reduction in rehospitalization rates (absolute=2.0% and relative=13.6%, P=0.054). We did not find any significant change in length of stay among these hospitals implementing BOOST tools.

The tools provided to participating hospitals were developed from evidence found in peer‐reviewed literature established through experimental methods in well‐controlled academic settings. Further tool development was informed by recommendations of an advisory board consisting of expert representatives and advocates involved in the hospital discharge process: patients, caregivers, physicians, nurses, case managers, social workers, insurers, and regulatory and research agencies.[19] The toolkit components address multiple aspects of hospital discharge and follow‐up with the goal of improving health by optimizing the safety of care transitions. Our observation that readmission rates appeared to improve in a diverse hospital sample including nonacademic and community hospitals engaged in Project BOOST is reassuring that the benefits seen in existing research literature, developed in distinctly academic settings, can be replicated in diverse acute‐care settings.

The effect size observed in our study was modest but consistent with several studies identified in a recent review of trials measuring interventions to reduce rehospitalization, where 7 of 16 studies showing a significant improvement registered change in the 0% to 5% absolute range.[12] Impact of this project may have been tempered by the need to translate external QI content to the local setting. Additionally, in contrast to experimental studies that are limited in scope and timing and often scaled to a research budget, BOOST sites were encouraged to implement Project BOOST in the clinical setting even if no new funds were available to support the effort.[12]

The recruitment of a national sample of both academic and nonacademic hospital participants imposed several limitations on our study and analysis. We recognize that intervention units selected by hospitals may have had unmeasured unit and patient characteristics that facilitated successful change and contributed to the observed improvements. However, because external pressure to reduce readmission is present across all hospitals independent of the BOOST intervention, we felt site‐matched controls were essential to understanding effects attributable to the BOOST tools. Differences between units would be expected to be stable over the course of the study period, and comparison of outcome differences between 2 different time periods would be reasonable. Additionally, we could not collect data on readmissions to other hospitals. Theoretically, patients discharged from BOOST units might be more likely to have been rehospitalized elsewhere, but the fraction of rehospitalizations occurring at alternate facilities would also be expected to be similar on the matched control unit.

We report findings from a voluntary cohort willing and capable of designating a comparison clinical unit and contributing the requested data outcomes. Pilot sites that did not report outcomes were not analyzed, but comparison of hospital characteristics shows that participating hospitals were more likely to be large, urban, academic medical centers. Although barriers to data submission were not formally analyzed, reports from nonparticipating sites describe data submission limited by local implementation design (no geographic rollout or simultaneous rollout on all appropriate clinical units), site specific inability to generate unit level outcome statistics, and competing organizational priorities for data analyst time (electronic medical record deployment, alternative QI initiatives). The external validity of our results may be limited to organizations capable of analytics at the level of the individual clinical unit as well as those with sufficient QI resources to support reporting to a national database in the absence of a payer mandate. It is possible that additional financial support for on‐site data collection would have bolstered participation, making the example of participation rates we present potentially informative to organizations hoping to widely disseminate a QI agenda.

Nonetheless, the effectiveness demonstrated in the 11 sites that did participate is encouraging, and ongoing collaboration with subsequent BOOST cohorts has been designed to further facilitate data collection. Among the insights gained from this pilot experience, and incorporated into ongoing BOOST cohorts, is the importance of intensive mentor engagement to foster accountability among participant sites, assist with implementation troubleshooting, and offer expertise that is often particularly effective in gaining local support. We now encourage sites to have 2 mentor site visits to further these roles and more frequent conference calls. Further research to understand the marginal benefit of the mentored implementation approach is ongoing.

The limitations in data submission we experienced with the pilot cohort likely reflect resource constraints not uncommon at many hospitals. Increasing pressure placed on hospitals as a result of the Readmission Reduction Program within the Affordable Care Act as well as increasing interest from private and Medicaid payors to incorporate similar readmission‐based penalties provide encouragement for hospitals to enhance their data and analytic skills. National incentives for implementation of electronic health records (EHR) should also foster such capabilities, though we often saw EHRs as a barrier to QI, especially rapid cycle trials. Fortunately, hospitals are increasingly being afforded access to comprehensive claims databases to assist in tracking readmission rates to other facilities, and these data are becoming available in a more timely fashion. This more robust data collection, facilitated by private payors, state QI organizations, and state hospital associations, will support additional analytic methods such as multivariate regression models and interrupted time series designs to appreciate the experience of current BOOST participants.

Additional research is needed to understand the role of organizational context in the effectiveness of Project BOOST. Differences in rates of tool implementation and changes in clinical outcomes are likely dependent on local implementation context at the level of the healthcare organization and individual clinical unit.[20] Progress reports from site mentors and previously described experiences of QI implementation indicate that successful implementation of a multidimensional bundle of interventions may have reflected a higher level of institutional support, more robust team engagement in the work of reducing readmissions, increased clinical staff support for change, the presence of an effective project champion, or a key facilitating role of external mentorship.[21, 22] Ongoing data collection will continue to measure the sustainability of tool use and observed outcome changes to inform strategies to maintain gains associated with implementation. The role of mentored implementation in facilitating gains also requires further study.

Increasing attention to the problem of avoidable rehospitalization is driving hospitals, insurers, and policy makers to pursue QI efforts that favorably impact readmission rates. Our analysis of the BOOST intervention suggests that modest gains can be achieved following evidence‐based hospital process change facilitated by a mentored implementation model. However, realization of the goal of a 20% reduction in rehospitalization proposed by the Center for Medicare and Medicaid Services' Partnership for Patients initiative may be difficult to achieve on a national scale,[23] especially if efforts focus on just the hospital.

Disclosures

Project BOOST was funded by a grant from The John A. Hartford Foundation. Project BOOST is administered by the Society of Hospital Medicine (SHM). The development of the Project BOOST toolkit, recruitment of sites for this study, mentorship of the pilot cohort, project evaluation planning, and collection of pilot data were funded by a grant from The John A. Harford Foundation. Additional funding for continued data collection and analysis was funded by the SHM through funds from hospitals to participate in Project BOOST, specifically with funding support for Dr. Hansen. Dr. Williams has received funding to serve as Principal Investigator for Project BOOST. Since the time of initial cohort participation, approximately 125 additional hospitals have participated in the mentored implementation of Project BOOST. This participation was funded through a combination of site‐based tuition, third‐party payor support from private insurers, foundations, and federal funding through the Center for Medicare and Medicaid Innovation Partnership for Patients program. Drs. Greenwald, Hansen, and Williams are Project BOOST mentors for current Project BOOST sites and receive financial support through the SHM for this work. Dr. Howell has previously received funding as a Project BOOST mentor. Ms. Budnitz is the BOOST Project Director and is Chief Strategy and Development Officer for the HM. Dr. Maynard is the Senior Vice President of the SHM's Center for Hospital Innovation and Improvement.

Enactment of federal legislation imposing hospital reimbursement penalties for excess rates of rehospitalizations among Medicare fee for service beneficiaries markedly increased interest in hospital quality improvement (QI) efforts to reduce the observed 30‐day rehospitalization of 19.6% in this elderly population.[1, 2] The Congressional Budget Office estimated that reimbursement penalties to hospitals for high readmission rates are expected to save the Medicare program approximately $7 billion between 2010 and 2019.[3] These penalties are complemented by resources from the Center for Medicare and Medicaid Innovation aiming to reduce hospital readmissions by 20% by the end of 2013 through the Partnership for Patients campaign.[4] Although potential financial penalties and provision of resources for QI intensified efforts to enhance the quality of the hospital discharge transition, patient safety risks associated with hospital discharge are well documented.[5, 6] Approximately 20% of patients discharged from the hospital may suffer adverse events,[7, 8] of which up to three‐quarters (72%) are medication related,[9] and over one‐third of required follow‐up testing after discharge is not completed.[10] Such findings indicate opportunities for improvement in the discharge process.[11]

Numerous publications describe studies aiming to improve the hospital discharge process and mitigate these hazards, though a systematic review of interventions to reduce 30‐day rehospitalization indicated that the existing evidence base for the effectiveness of transition interventions demonstrates irregular effectiveness and limitations to generalizability.[12] Most studies showing effectiveness are confined to single academic medical centers. Existing evidence supports multifaceted interventions implemented in both the pre‐ and postdischarge periods and focused on risk assessment and tailored, patient‐centered application of interventions to mitigate risk. For example Project RED (Re‐Engineered Discharge) applied a bundled intervention consisting of intensified patient education and discharge planning, improved medication reconciliation and discharge instructions, and longitudinal patient contact with follow‐up phone calls and a dedicated discharge advocate.[13] However, the mean age of patients participating in the study was 50 years, and it excluded patients admitted from or discharged to skilled nursing facilities, making generalizability to the geriatric population uncertain.

An integral aspect of QI projects is the contribution of local context to translation of best practices to disparate settings.[14, 15, 16] Most available reports of successful interventions to reduce rehospitalization have not fully described the specifics of either the intervention context or design. Moreover, the available evidence base for common interventions to reduce rehospitalization was developed in the academic setting. Validation of single academic center studies in a broader healthcare context is necessary.

Project BOOST (Better Outcomes for Older adults through Safe Transitions) recruited a diverse national cohort of both academic and nonacademic hospitals to participate in a QI effort to implement best practices for hospital discharge care transitions using a national collaborative approach facilitated by external expert mentorship. This study aimed to determine the effectiveness of BOOST in lowering hospital readmission rates and impact on length of stay.

METHODS

The study of Project BOOST was undertaken in accordance with the SQUIRE (Standards for Quality Improvement Reporting Excellence) Guidelines.[17]

RESULTS

Eleven hospitals provided rehospitalization and length‐of‐stay outcome data for both a BOOST and control unit for the pre‐ and postimplementation periods. Compared to the 19 sites that did not participate in the analysis, these 11 sites were significantly larger (559188 beds vs 350205 beds, P=0.003), more likely to be located in an urban area (100.0% [n=11] vs 78.9% [n=15], P=0.035), and more likely to be academic medical centers (45.5% [n=5] vs 26.3% [n=5], P=0.036) (Table 1).

The mean number of tools implemented by sites participating in the analysis was 3.50.9. All sites implemented at least 2 tools. The duration between attendance at the BOOST kickoff event and first tool implementation ranged from 3 months (first tool implemented prior to attending the kickoff) and 9 months (mean duration, 3.34.3 months) (Table 2).

The average rate of 30‐day rehospitalization among BOOST units was 14.7% in the preimplementation period and 12.7% during the postimplementation period (P=0.010) (Figure 1). Rehospitalization rates for matched control units were 14.0% in the preintervention period and 14.1% in the postintervention period (P=0.831). The mean absolute reduction in readmission rates over the 1‐year study period in BOOST units compared to control units was 2.0%, or a relative reduction of 13.6% (P=0.054 for signed rank test comparing differences in readmission rate reduction in BOOST units compared to site‐matched control units). Length of stay in BOOST and control units decreased an average of 0.5 days and 0.3 days, respectively. There was no difference in length of stay change between BOOST units and control units (P=0.966).

Figure 1

DISCUSSION

As hospitals strive to reduce their readmission rates to avoid Centers for Medicare and Medicaid Services penalties, Project BOOST may be a viable QI approach to achieve their goals. This initial evaluation of participation in Project BOOST by 11 hospitals of varying sizes across the United States showed an associated reduction in rehospitalization rates (absolute=2.0% and relative=13.6%, P=0.054). We did not find any significant change in length of stay among these hospitals implementing BOOST tools.

The tools provided to participating hospitals were developed from evidence found in peer‐reviewed literature established through experimental methods in well‐controlled academic settings. Further tool development was informed by recommendations of an advisory board consisting of expert representatives and advocates involved in the hospital discharge process: patients, caregivers, physicians, nurses, case managers, social workers, insurers, and regulatory and research agencies.[19] The toolkit components address multiple aspects of hospital discharge and follow‐up with the goal of improving health by optimizing the safety of care transitions. Our observation that readmission rates appeared to improve in a diverse hospital sample including nonacademic and community hospitals engaged in Project BOOST is reassuring that the benefits seen in existing research literature, developed in distinctly academic settings, can be replicated in diverse acute‐care settings.

The effect size observed in our study was modest but consistent with several studies identified in a recent review of trials measuring interventions to reduce rehospitalization, where 7 of 16 studies showing a significant improvement registered change in the 0% to 5% absolute range.[12] Impact of this project may have been tempered by the need to translate external QI content to the local setting. Additionally, in contrast to experimental studies that are limited in scope and timing and often scaled to a research budget, BOOST sites were encouraged to implement Project BOOST in the clinical setting even if no new funds were available to support the effort.[12]

The recruitment of a national sample of both academic and nonacademic hospital participants imposed several limitations on our study and analysis. We recognize that intervention units selected by hospitals may have had unmeasured unit and patient characteristics that facilitated successful change and contributed to the observed improvements. However, because external pressure to reduce readmission is present across all hospitals independent of the BOOST intervention, we felt site‐matched controls were essential to understanding effects attributable to the BOOST tools. Differences between units would be expected to be stable over the course of the study period, and comparison of outcome differences between 2 different time periods would be reasonable. Additionally, we could not collect data on readmissions to other hospitals. Theoretically, patients discharged from BOOST units might be more likely to have been rehospitalized elsewhere, but the fraction of rehospitalizations occurring at alternate facilities would also be expected to be similar on the matched control unit.

We report findings from a voluntary cohort willing and capable of designating a comparison clinical unit and contributing the requested data outcomes. Pilot sites that did not report outcomes were not analyzed, but comparison of hospital characteristics shows that participating hospitals were more likely to be large, urban, academic medical centers. Although barriers to data submission were not formally analyzed, reports from nonparticipating sites describe data submission limited by local implementation design (no geographic rollout or simultaneous rollout on all appropriate clinical units), site specific inability to generate unit level outcome statistics, and competing organizational priorities for data analyst time (electronic medical record deployment, alternative QI initiatives). The external validity of our results may be limited to organizations capable of analytics at the level of the individual clinical unit as well as those with sufficient QI resources to support reporting to a national database in the absence of a payer mandate. It is possible that additional financial support for on‐site data collection would have bolstered participation, making the example of participation rates we present potentially informative to organizations hoping to widely disseminate a QI agenda.

Nonetheless, the effectiveness demonstrated in the 11 sites that did participate is encouraging, and ongoing collaboration with subsequent BOOST cohorts has been designed to further facilitate data collection. Among the insights gained from this pilot experience, and incorporated into ongoing BOOST cohorts, is the importance of intensive mentor engagement to foster accountability among participant sites, assist with implementation troubleshooting, and offer expertise that is often particularly effective in gaining local support. We now encourage sites to have 2 mentor site visits to further these roles and more frequent conference calls. Further research to understand the marginal benefit of the mentored implementation approach is ongoing.

The limitations in data submission we experienced with the pilot cohort likely reflect resource constraints not uncommon at many hospitals. Increasing pressure placed on hospitals as a result of the Readmission Reduction Program within the Affordable Care Act as well as increasing interest from private and Medicaid payors to incorporate similar readmission‐based penalties provide encouragement for hospitals to enhance their data and analytic skills. National incentives for implementation of electronic health records (EHR) should also foster such capabilities, though we often saw EHRs as a barrier to QI, especially rapid cycle trials. Fortunately, hospitals are increasingly being afforded access to comprehensive claims databases to assist in tracking readmission rates to other facilities, and these data are becoming available in a more timely fashion. This more robust data collection, facilitated by private payors, state QI organizations, and state hospital associations, will support additional analytic methods such as multivariate regression models and interrupted time series designs to appreciate the experience of current BOOST participants.

Additional research is needed to understand the role of organizational context in the effectiveness of Project BOOST. Differences in rates of tool implementation and changes in clinical outcomes are likely dependent on local implementation context at the level of the healthcare organization and individual clinical unit.[20] Progress reports from site mentors and previously described experiences of QI implementation indicate that successful implementation of a multidimensional bundle of interventions may have reflected a higher level of institutional support, more robust team engagement in the work of reducing readmissions, increased clinical staff support for change, the presence of an effective project champion, or a key facilitating role of external mentorship.[21, 22] Ongoing data collection will continue to measure the sustainability of tool use and observed outcome changes to inform strategies to maintain gains associated with implementation. The role of mentored implementation in facilitating gains also requires further study.

Increasing attention to the problem of avoidable rehospitalization is driving hospitals, insurers, and policy makers to pursue QI efforts that favorably impact readmission rates. Our analysis of the BOOST intervention suggests that modest gains can be achieved following evidence‐based hospital process change facilitated by a mentored implementation model. However, realization of the goal of a 20% reduction in rehospitalization proposed by the Center for Medicare and Medicaid Services' Partnership for Patients initiative may be difficult to achieve on a national scale,[23] especially if efforts focus on just the hospital.

Disclosures

Project BOOST was funded by a grant from The John A. Hartford Foundation. Project BOOST is administered by the Society of Hospital Medicine (SHM). The development of the Project BOOST toolkit, recruitment of sites for this study, mentorship of the pilot cohort, project evaluation planning, and collection of pilot data were funded by a grant from The John A. Harford Foundation. Additional funding for continued data collection and analysis was funded by the SHM through funds from hospitals to participate in Project BOOST, specifically with funding support for Dr. Hansen. Dr. Williams has received funding to serve as Principal Investigator for Project BOOST. Since the time of initial cohort participation, approximately 125 additional hospitals have participated in the mentored implementation of Project BOOST. This participation was funded through a combination of site‐based tuition, third‐party payor support from private insurers, foundations, and federal funding through the Center for Medicare and Medicaid Innovation Partnership for Patients program. Drs. Greenwald, Hansen, and Williams are Project BOOST mentors for current Project BOOST sites and receive financial support through the SHM for this work. Dr. Howell has previously received funding as a Project BOOST mentor. Ms. Budnitz is the BOOST Project Director and is Chief Strategy and Development Officer for the HM. Dr. Maynard is the Senior Vice President of the SHM's Center for Hospital Innovation and Improvement.

Enactment of federal legislation imposing hospital reimbursement penalties for excess rates of rehospitalizations among Medicare fee for service beneficiaries markedly increased interest in hospital quality improvement (QI) efforts to reduce the observed 30‐day rehospitalization of 19.6% in this elderly population.[1, 2] The Congressional Budget Office estimated that reimbursement penalties to hospitals for high readmission rates are expected to save the Medicare program approximately $7 billion between 2010 and 2019.[3] These penalties are complemented by resources from the Center for Medicare and Medicaid Innovation aiming to reduce hospital readmissions by 20% by the end of 2013 through the Partnership for Patients campaign.[4] Although potential financial penalties and provision of resources for QI intensified efforts to enhance the quality of the hospital discharge transition, patient safety risks associated with hospital discharge are well documented.[5, 6] Approximately 20% of patients discharged from the hospital may suffer adverse events,[7, 8] of which up to three‐quarters (72%) are medication related,[9] and over one‐third of required follow‐up testing after discharge is not completed.[10] Such findings indicate opportunities for improvement in the discharge process.[11]

Numerous publications describe studies aiming to improve the hospital discharge process and mitigate these hazards, though a systematic review of interventions to reduce 30‐day rehospitalization indicated that the existing evidence base for the effectiveness of transition interventions demonstrates irregular effectiveness and limitations to generalizability.[12] Most studies showing effectiveness are confined to single academic medical centers. Existing evidence supports multifaceted interventions implemented in both the pre‐ and postdischarge periods and focused on risk assessment and tailored, patient‐centered application of interventions to mitigate risk. For example Project RED (Re‐Engineered Discharge) applied a bundled intervention consisting of intensified patient education and discharge planning, improved medication reconciliation and discharge instructions, and longitudinal patient contact with follow‐up phone calls and a dedicated discharge advocate.[13] However, the mean age of patients participating in the study was 50 years, and it excluded patients admitted from or discharged to skilled nursing facilities, making generalizability to the geriatric population uncertain.

An integral aspect of QI projects is the contribution of local context to translation of best practices to disparate settings.[14, 15, 16] Most available reports of successful interventions to reduce rehospitalization have not fully described the specifics of either the intervention context or design. Moreover, the available evidence base for common interventions to reduce rehospitalization was developed in the academic setting. Validation of single academic center studies in a broader healthcare context is necessary.

Project BOOST (Better Outcomes for Older adults through Safe Transitions) recruited a diverse national cohort of both academic and nonacademic hospitals to participate in a QI effort to implement best practices for hospital discharge care transitions using a national collaborative approach facilitated by external expert mentorship. This study aimed to determine the effectiveness of BOOST in lowering hospital readmission rates and impact on length of stay.

METHODS

The study of Project BOOST was undertaken in accordance with the SQUIRE (Standards for Quality Improvement Reporting Excellence) Guidelines.[17]

RESULTS

Eleven hospitals provided rehospitalization and length‐of‐stay outcome data for both a BOOST and control unit for the pre‐ and postimplementation periods. Compared to the 19 sites that did not participate in the analysis, these 11 sites were significantly larger (559188 beds vs 350205 beds, P=0.003), more likely to be located in an urban area (100.0% [n=11] vs 78.9% [n=15], P=0.035), and more likely to be academic medical centers (45.5% [n=5] vs 26.3% [n=5], P=0.036) (Table 1).

The mean number of tools implemented by sites participating in the analysis was 3.50.9. All sites implemented at least 2 tools. The duration between attendance at the BOOST kickoff event and first tool implementation ranged from 3 months (first tool implemented prior to attending the kickoff) and 9 months (mean duration, 3.34.3 months) (Table 2).

The average rate of 30‐day rehospitalization among BOOST units was 14.7% in the preimplementation period and 12.7% during the postimplementation period (P=0.010) (Figure 1). Rehospitalization rates for matched control units were 14.0% in the preintervention period and 14.1% in the postintervention period (P=0.831). The mean absolute reduction in readmission rates over the 1‐year study period in BOOST units compared to control units was 2.0%, or a relative reduction of 13.6% (P=0.054 for signed rank test comparing differences in readmission rate reduction in BOOST units compared to site‐matched control units). Length of stay in BOOST and control units decreased an average of 0.5 days and 0.3 days, respectively. There was no difference in length of stay change between BOOST units and control units (P=0.966).

Figure 1

DISCUSSION

As hospitals strive to reduce their readmission rates to avoid Centers for Medicare and Medicaid Services penalties, Project BOOST may be a viable QI approach to achieve their goals. This initial evaluation of participation in Project BOOST by 11 hospitals of varying sizes across the United States showed an associated reduction in rehospitalization rates (absolute=2.0% and relative=13.6%, P=0.054). We did not find any significant change in length of stay among these hospitals implementing BOOST tools.

The tools provided to participating hospitals were developed from evidence found in peer‐reviewed literature established through experimental methods in well‐controlled academic settings. Further tool development was informed by recommendations of an advisory board consisting of expert representatives and advocates involved in the hospital discharge process: patients, caregivers, physicians, nurses, case managers, social workers, insurers, and regulatory and research agencies.[19] The toolkit components address multiple aspects of hospital discharge and follow‐up with the goal of improving health by optimizing the safety of care transitions. Our observation that readmission rates appeared to improve in a diverse hospital sample including nonacademic and community hospitals engaged in Project BOOST is reassuring that the benefits seen in existing research literature, developed in distinctly academic settings, can be replicated in diverse acute‐care settings.

The effect size observed in our study was modest but consistent with several studies identified in a recent review of trials measuring interventions to reduce rehospitalization, where 7 of 16 studies showing a significant improvement registered change in the 0% to 5% absolute range.[12] Impact of this project may have been tempered by the need to translate external QI content to the local setting. Additionally, in contrast to experimental studies that are limited in scope and timing and often scaled to a research budget, BOOST sites were encouraged to implement Project BOOST in the clinical setting even if no new funds were available to support the effort.[12]

The recruitment of a national sample of both academic and nonacademic hospital participants imposed several limitations on our study and analysis. We recognize that intervention units selected by hospitals may have had unmeasured unit and patient characteristics that facilitated successful change and contributed to the observed improvements. However, because external pressure to reduce readmission is present across all hospitals independent of the BOOST intervention, we felt site‐matched controls were essential to understanding effects attributable to the BOOST tools. Differences between units would be expected to be stable over the course of the study period, and comparison of outcome differences between 2 different time periods would be reasonable. Additionally, we could not collect data on readmissions to other hospitals. Theoretically, patients discharged from BOOST units might be more likely to have been rehospitalized elsewhere, but the fraction of rehospitalizations occurring at alternate facilities would also be expected to be similar on the matched control unit.

We report findings from a voluntary cohort willing and capable of designating a comparison clinical unit and contributing the requested data outcomes. Pilot sites that did not report outcomes were not analyzed, but comparison of hospital characteristics shows that participating hospitals were more likely to be large, urban, academic medical centers. Although barriers to data submission were not formally analyzed, reports from nonparticipating sites describe data submission limited by local implementation design (no geographic rollout or simultaneous rollout on all appropriate clinical units), site specific inability to generate unit level outcome statistics, and competing organizational priorities for data analyst time (electronic medical record deployment, alternative QI initiatives). The external validity of our results may be limited to organizations capable of analytics at the level of the individual clinical unit as well as those with sufficient QI resources to support reporting to a national database in the absence of a payer mandate. It is possible that additional financial support for on‐site data collection would have bolstered participation, making the example of participation rates we present potentially informative to organizations hoping to widely disseminate a QI agenda.

Nonetheless, the effectiveness demonstrated in the 11 sites that did participate is encouraging, and ongoing collaboration with subsequent BOOST cohorts has been designed to further facilitate data collection. Among the insights gained from this pilot experience, and incorporated into ongoing BOOST cohorts, is the importance of intensive mentor engagement to foster accountability among participant sites, assist with implementation troubleshooting, and offer expertise that is often particularly effective in gaining local support. We now encourage sites to have 2 mentor site visits to further these roles and more frequent conference calls. Further research to understand the marginal benefit of the mentored implementation approach is ongoing.

The limitations in data submission we experienced with the pilot cohort likely reflect resource constraints not uncommon at many hospitals. Increasing pressure placed on hospitals as a result of the Readmission Reduction Program within the Affordable Care Act as well as increasing interest from private and Medicaid payors to incorporate similar readmission‐based penalties provide encouragement for hospitals to enhance their data and analytic skills. National incentives for implementation of electronic health records (EHR) should also foster such capabilities, though we often saw EHRs as a barrier to QI, especially rapid cycle trials. Fortunately, hospitals are increasingly being afforded access to comprehensive claims databases to assist in tracking readmission rates to other facilities, and these data are becoming available in a more timely fashion. This more robust data collection, facilitated by private payors, state QI organizations, and state hospital associations, will support additional analytic methods such as multivariate regression models and interrupted time series designs to appreciate the experience of current BOOST participants.

Additional research is needed to understand the role of organizational context in the effectiveness of Project BOOST. Differences in rates of tool implementation and changes in clinical outcomes are likely dependent on local implementation context at the level of the healthcare organization and individual clinical unit.[20] Progress reports from site mentors and previously described experiences of QI implementation indicate that successful implementation of a multidimensional bundle of interventions may have reflected a higher level of institutional support, more robust team engagement in the work of reducing readmissions, increased clinical staff support for change, the presence of an effective project champion, or a key facilitating role of external mentorship.[21, 22] Ongoing data collection will continue to measure the sustainability of tool use and observed outcome changes to inform strategies to maintain gains associated with implementation. The role of mentored implementation in facilitating gains also requires further study.

Increasing attention to the problem of avoidable rehospitalization is driving hospitals, insurers, and policy makers to pursue QI efforts that favorably impact readmission rates. Our analysis of the BOOST intervention suggests that modest gains can be achieved following evidence‐based hospital process change facilitated by a mentored implementation model. However, realization of the goal of a 20% reduction in rehospitalization proposed by the Center for Medicare and Medicaid Services' Partnership for Patients initiative may be difficult to achieve on a national scale,[23] especially if efforts focus on just the hospital.

Disclosures

Project BOOST was funded by a grant from The John A. Hartford Foundation. Project BOOST is administered by the Society of Hospital Medicine (SHM). The development of the Project BOOST toolkit, recruitment of sites for this study, mentorship of the pilot cohort, project evaluation planning, and collection of pilot data were funded by a grant from The John A. Harford Foundation. Additional funding for continued data collection and analysis was funded by the SHM through funds from hospitals to participate in Project BOOST, specifically with funding support for Dr. Hansen. Dr. Williams has received funding to serve as Principal Investigator for Project BOOST. Since the time of initial cohort participation, approximately 125 additional hospitals have participated in the mentored implementation of Project BOOST. This participation was funded through a combination of site‐based tuition, third‐party payor support from private insurers, foundations, and federal funding through the Center for Medicare and Medicaid Innovation Partnership for Patients program. Drs. Greenwald, Hansen, and Williams are Project BOOST mentors for current Project BOOST sites and receive financial support through the SHM for this work. Dr. Howell has previously received funding as a Project BOOST mentor. Ms. Budnitz is the BOOST Project Director and is Chief Strategy and Development Officer for the HM. Dr. Maynard is the Senior Vice President of the SHM's Center for Hospital Innovation and Improvement.

Healthcare quality is defined as the degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge.1 Delivering high quality care to patients in the hospital setting is especially challenging, given the rapid pace of clinical care, the severity and multitude of patient conditions, and the interdependence of complex processes within the hospital system. Research has shown that hospitalized patients do not consistently receive recommended care2 and are at risk for experiencing preventable harm.3 In an effort to stimulate improvement, stakeholders have called for increased accountability, including enhanced transparency and differential payment based on performance. A growing number of hospital process and outcome measures are readily available to the public via the Internet.46 The Joint Commission, which accredits US hospitals, requires the collection of core quality measure data7 and sets the expectation that National Patient Safety Goals be met to maintain accreditation.8 Moreover, the Center for Medicare and Medicaid Services (CMS) has developed a Value‐Based Purchasing (VBP) plan intended to adjust hospital payment based on quality measures and the occurrence of certain hospital‐acquired conditions.9, 10

Because of their clinical expertise, understanding of hospital clinical operations, leadership of multidisciplinary inpatient teams, and vested interest to improve the systems in which they work, hospitalists are perfectly positioned to collaborate with their institutions to improve the quality of care delivered to inpatients. However, many hospitalists are inadequately prepared to engage in efforts to improve quality, because medical schools and residency programs have not traditionally included or emphasized healthcare quality and patient safety in their curricula.1113 In a survey of 389 internal medicine‐trained hospitalists, significant educational deficiencies were identified in the area of systems‐based practice.14 Specifically, the topics of quality improvement, team management, practice guideline development, health information systems management, and coordination of care between healthcare settings were listed as essential skills for hospitalist practice but underemphasized in residency training. Recognizing the gap between the needs of practicing physicians and current medical education provided in healthcare quality, professional societies have recently published position papers calling for increased training in quality, safety, and systems, both in medical school11 and residency training.15, 16

The Society of Hospital Medicine (SHM) convened a Quality Summit in December 2008 to develop strategic plans related to healthcare quality. Summit attendees felt that most hospitalists lack the formal training necessary to evaluate, implement, and sustain system changes within the hospital. In response, the SHM Hospital Quality and Patient Safety (HQPS) Committee formed a Quality Improvement Education (QIE) subcommittee in 2009 to assess the needs of hospitalists with respect to hospital quality and patient safety, and to evaluate and expand upon existing educational programs in this area. Membership of the QIE subcommittee consisted of hospitalists with extensive experience in healthcare quality and medical education. The QIE subcommittee refined and expanded upon the healthcare quality and patient safety‐related competencies initially described in the Core Competencies in Hospital Medicine.17 The purpose of this report is to describe the development, provide definitions, and make recommendations on the use of the Hospital Quality and Patient Safety (HQPS) Competencies.

Development of The Hospital Quality and Patient Safety Competencies

The multistep process used by the SHM QIE subcommittee to develop the HQPS Competencies is summarized in Figure 1. We performed an in‐depth evaluation of current educational materials and offerings, including a review of the Core Competencies in Hospital Medicine, past annual SHM Quality Improvement Pre‐Course objectives, and the content of training courses offered by other organizations.1722 Throughout our analysis, we emphasized the identification of gaps in content relevant to hospitalists. We then used the Institute of Medicine's (IOM) 6 aims for healthcare quality as a foundation for developing the HQPS Competencies.1 Specifically, the IOM states that healthcare should be safe, effective, patient‐centered, timely, efficient, and equitable. Additionally, we reviewed and integrated elements of the Practice‐Based Learning and Improvement (PBLI) and Systems‐Based Practice (SBP) competencies as defined by the Accreditation Council for Graduate Medical Education (ACGME).23 We defined general areas of competence and specific standards for knowledge, skills, and attitudes within each area. Subcommittee members reflected on their own experience, as clinicians, educators, and leaders in healthcare quality and patient safety, to inform and refine the competency definitions and standards. Acknowledging that some hospitalists may serve as collaborators or clinical content experts, while others may serve as leaders of hospital quality initiatives, 3 levels of expertise were established: basic, intermediate, and advanced.

Figure 1

The QIE subcommittee presented a draft version of the HQPS Competencies to the HQPS Committee in the fall of 2009 and incorporated suggested revisions. The revised set of competencies was then reviewed by members of the Leadership and Education Committees during the winter of 2009‐2010, and additional recommendations were included in the final version now described.

Description of The Competencies

The 8 areas of competence include: Quality Measurement and Stakeholder Interests, Data Acquisition and Interpretation, Organizational Knowledge and Leadership Skills, Patient Safety Principles, Teamwork and Communication, Quality and Safety Improvement Methods, Health Information Systems, and Patient Centeredness. Three levels of competence and standards within each level and area are defined in Table 1. Standards use carefully selected action verbs to reflect educational goals for hospitalists at each level.24 The basic level represents a minimum level of competency for all practicing hospitalists. The intermediate level represents a hospitalist who is prepared to meaningfully engage and collaborate with his or her institution in quality improvement efforts. A hospitalist at this level may also lead uncomplicated improvement projects for his or her medical center and/or hospital medicine group. The advanced level represents a hospitalist prepared to lead quality improvement efforts for his or her institution and/or hospital medicine group. Many hospitalists at this level will have, or will be prepared to have, leadership positions in quality and patient safety at their institutions. Advanced level hospitalists will also have the expertise to teach and mentor other individuals in their quality improvement efforts.

Recommended Use of The Competencies

The HQPS Competencies provide a framework for curricula and other professional development experiences in healthcare quality and patient safety. We recommend a step‐wise approach to curriculum development which includes conducting a targeted needs assessment, defining goals and specific learning objectives, and evaluation of the curriculum.25 The HQPS Competencies can be used at each step and provide educational targets for learners across a range of interest and experience.

Conclusion

Hospitalists are poised to have a tremendous impact on improving the quality of care for hospitalized patients. The lack of training in quality improvement in traditional medical education programs, in which most current hospitalists were trained, can be overcome through appropriate use of the HQPS Competencies. Formal incorporation of the HQPS Competencies into professional development programs, and innovative educational initiatives and curricula, will help provide current hospitalists and the next generations of hospitalists with the needed skills to be successful.

Healthcare quality is defined as the degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge.1 Delivering high quality care to patients in the hospital setting is especially challenging, given the rapid pace of clinical care, the severity and multitude of patient conditions, and the interdependence of complex processes within the hospital system. Research has shown that hospitalized patients do not consistently receive recommended care2 and are at risk for experiencing preventable harm.3 In an effort to stimulate improvement, stakeholders have called for increased accountability, including enhanced transparency and differential payment based on performance. A growing number of hospital process and outcome measures are readily available to the public via the Internet.46 The Joint Commission, which accredits US hospitals, requires the collection of core quality measure data7 and sets the expectation that National Patient Safety Goals be met to maintain accreditation.8 Moreover, the Center for Medicare and Medicaid Services (CMS) has developed a Value‐Based Purchasing (VBP) plan intended to adjust hospital payment based on quality measures and the occurrence of certain hospital‐acquired conditions.9, 10

Because of their clinical expertise, understanding of hospital clinical operations, leadership of multidisciplinary inpatient teams, and vested interest to improve the systems in which they work, hospitalists are perfectly positioned to collaborate with their institutions to improve the quality of care delivered to inpatients. However, many hospitalists are inadequately prepared to engage in efforts to improve quality, because medical schools and residency programs have not traditionally included or emphasized healthcare quality and patient safety in their curricula.1113 In a survey of 389 internal medicine‐trained hospitalists, significant educational deficiencies were identified in the area of systems‐based practice.14 Specifically, the topics of quality improvement, team management, practice guideline development, health information systems management, and coordination of care between healthcare settings were listed as essential skills for hospitalist practice but underemphasized in residency training. Recognizing the gap between the needs of practicing physicians and current medical education provided in healthcare quality, professional societies have recently published position papers calling for increased training in quality, safety, and systems, both in medical school11 and residency training.15, 16

The Society of Hospital Medicine (SHM) convened a Quality Summit in December 2008 to develop strategic plans related to healthcare quality. Summit attendees felt that most hospitalists lack the formal training necessary to evaluate, implement, and sustain system changes within the hospital. In response, the SHM Hospital Quality and Patient Safety (HQPS) Committee formed a Quality Improvement Education (QIE) subcommittee in 2009 to assess the needs of hospitalists with respect to hospital quality and patient safety, and to evaluate and expand upon existing educational programs in this area. Membership of the QIE subcommittee consisted of hospitalists with extensive experience in healthcare quality and medical education. The QIE subcommittee refined and expanded upon the healthcare quality and patient safety‐related competencies initially described in the Core Competencies in Hospital Medicine.17 The purpose of this report is to describe the development, provide definitions, and make recommendations on the use of the Hospital Quality and Patient Safety (HQPS) Competencies.

Development of The Hospital Quality and Patient Safety Competencies

The multistep process used by the SHM QIE subcommittee to develop the HQPS Competencies is summarized in Figure 1. We performed an in‐depth evaluation of current educational materials and offerings, including a review of the Core Competencies in Hospital Medicine, past annual SHM Quality Improvement Pre‐Course objectives, and the content of training courses offered by other organizations.1722 Throughout our analysis, we emphasized the identification of gaps in content relevant to hospitalists. We then used the Institute of Medicine's (IOM) 6 aims for healthcare quality as a foundation for developing the HQPS Competencies.1 Specifically, the IOM states that healthcare should be safe, effective, patient‐centered, timely, efficient, and equitable. Additionally, we reviewed and integrated elements of the Practice‐Based Learning and Improvement (PBLI) and Systems‐Based Practice (SBP) competencies as defined by the Accreditation Council for Graduate Medical Education (ACGME).23 We defined general areas of competence and specific standards for knowledge, skills, and attitudes within each area. Subcommittee members reflected on their own experience, as clinicians, educators, and leaders in healthcare quality and patient safety, to inform and refine the competency definitions and standards. Acknowledging that some hospitalists may serve as collaborators or clinical content experts, while others may serve as leaders of hospital quality initiatives, 3 levels of expertise were established: basic, intermediate, and advanced.

Figure 1

The QIE subcommittee presented a draft version of the HQPS Competencies to the HQPS Committee in the fall of 2009 and incorporated suggested revisions. The revised set of competencies was then reviewed by members of the Leadership and Education Committees during the winter of 2009‐2010, and additional recommendations were included in the final version now described.

Description of The Competencies

The 8 areas of competence include: Quality Measurement and Stakeholder Interests, Data Acquisition and Interpretation, Organizational Knowledge and Leadership Skills, Patient Safety Principles, Teamwork and Communication, Quality and Safety Improvement Methods, Health Information Systems, and Patient Centeredness. Three levels of competence and standards within each level and area are defined in Table 1. Standards use carefully selected action verbs to reflect educational goals for hospitalists at each level.24 The basic level represents a minimum level of competency for all practicing hospitalists. The intermediate level represents a hospitalist who is prepared to meaningfully engage and collaborate with his or her institution in quality improvement efforts. A hospitalist at this level may also lead uncomplicated improvement projects for his or her medical center and/or hospital medicine group. The advanced level represents a hospitalist prepared to lead quality improvement efforts for his or her institution and/or hospital medicine group. Many hospitalists at this level will have, or will be prepared to have, leadership positions in quality and patient safety at their institutions. Advanced level hospitalists will also have the expertise to teach and mentor other individuals in their quality improvement efforts.

Recommended Use of The Competencies

The HQPS Competencies provide a framework for curricula and other professional development experiences in healthcare quality and patient safety. We recommend a step‐wise approach to curriculum development which includes conducting a targeted needs assessment, defining goals and specific learning objectives, and evaluation of the curriculum.25 The HQPS Competencies can be used at each step and provide educational targets for learners across a range of interest and experience.

Conclusion

Hospitalists are poised to have a tremendous impact on improving the quality of care for hospitalized patients. The lack of training in quality improvement in traditional medical education programs, in which most current hospitalists were trained, can be overcome through appropriate use of the HQPS Competencies. Formal incorporation of the HQPS Competencies into professional development programs, and innovative educational initiatives and curricula, will help provide current hospitalists and the next generations of hospitalists with the needed skills to be successful.

Healthcare quality is defined as the degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge.1 Delivering high quality care to patients in the hospital setting is especially challenging, given the rapid pace of clinical care, the severity and multitude of patient conditions, and the interdependence of complex processes within the hospital system. Research has shown that hospitalized patients do not consistently receive recommended care2 and are at risk for experiencing preventable harm.3 In an effort to stimulate improvement, stakeholders have called for increased accountability, including enhanced transparency and differential payment based on performance. A growing number of hospital process and outcome measures are readily available to the public via the Internet.46 The Joint Commission, which accredits US hospitals, requires the collection of core quality measure data7 and sets the expectation that National Patient Safety Goals be met to maintain accreditation.8 Moreover, the Center for Medicare and Medicaid Services (CMS) has developed a Value‐Based Purchasing (VBP) plan intended to adjust hospital payment based on quality measures and the occurrence of certain hospital‐acquired conditions.9, 10

Because of their clinical expertise, understanding of hospital clinical operations, leadership of multidisciplinary inpatient teams, and vested interest to improve the systems in which they work, hospitalists are perfectly positioned to collaborate with their institutions to improve the quality of care delivered to inpatients. However, many hospitalists are inadequately prepared to engage in efforts to improve quality, because medical schools and residency programs have not traditionally included or emphasized healthcare quality and patient safety in their curricula.1113 In a survey of 389 internal medicine‐trained hospitalists, significant educational deficiencies were identified in the area of systems‐based practice.14 Specifically, the topics of quality improvement, team management, practice guideline development, health information systems management, and coordination of care between healthcare settings were listed as essential skills for hospitalist practice but underemphasized in residency training. Recognizing the gap between the needs of practicing physicians and current medical education provided in healthcare quality, professional societies have recently published position papers calling for increased training in quality, safety, and systems, both in medical school11 and residency training.15, 16

The Society of Hospital Medicine (SHM) convened a Quality Summit in December 2008 to develop strategic plans related to healthcare quality. Summit attendees felt that most hospitalists lack the formal training necessary to evaluate, implement, and sustain system changes within the hospital. In response, the SHM Hospital Quality and Patient Safety (HQPS) Committee formed a Quality Improvement Education (QIE) subcommittee in 2009 to assess the needs of hospitalists with respect to hospital quality and patient safety, and to evaluate and expand upon existing educational programs in this area. Membership of the QIE subcommittee consisted of hospitalists with extensive experience in healthcare quality and medical education. The QIE subcommittee refined and expanded upon the healthcare quality and patient safety‐related competencies initially described in the Core Competencies in Hospital Medicine.17 The purpose of this report is to describe the development, provide definitions, and make recommendations on the use of the Hospital Quality and Patient Safety (HQPS) Competencies.

Development of The Hospital Quality and Patient Safety Competencies

The multistep process used by the SHM QIE subcommittee to develop the HQPS Competencies is summarized in Figure 1. We performed an in‐depth evaluation of current educational materials and offerings, including a review of the Core Competencies in Hospital Medicine, past annual SHM Quality Improvement Pre‐Course objectives, and the content of training courses offered by other organizations.1722 Throughout our analysis, we emphasized the identification of gaps in content relevant to hospitalists. We then used the Institute of Medicine's (IOM) 6 aims for healthcare quality as a foundation for developing the HQPS Competencies.1 Specifically, the IOM states that healthcare should be safe, effective, patient‐centered, timely, efficient, and equitable. Additionally, we reviewed and integrated elements of the Practice‐Based Learning and Improvement (PBLI) and Systems‐Based Practice (SBP) competencies as defined by the Accreditation Council for Graduate Medical Education (ACGME).23 We defined general areas of competence and specific standards for knowledge, skills, and attitudes within each area. Subcommittee members reflected on their own experience, as clinicians, educators, and leaders in healthcare quality and patient safety, to inform and refine the competency definitions and standards. Acknowledging that some hospitalists may serve as collaborators or clinical content experts, while others may serve as leaders of hospital quality initiatives, 3 levels of expertise were established: basic, intermediate, and advanced.

Figure 1

The QIE subcommittee presented a draft version of the HQPS Competencies to the HQPS Committee in the fall of 2009 and incorporated suggested revisions. The revised set of competencies was then reviewed by members of the Leadership and Education Committees during the winter of 2009‐2010, and additional recommendations were included in the final version now described.

Description of The Competencies

The 8 areas of competence include: Quality Measurement and Stakeholder Interests, Data Acquisition and Interpretation, Organizational Knowledge and Leadership Skills, Patient Safety Principles, Teamwork and Communication, Quality and Safety Improvement Methods, Health Information Systems, and Patient Centeredness. Three levels of competence and standards within each level and area are defined in Table 1. Standards use carefully selected action verbs to reflect educational goals for hospitalists at each level.24 The basic level represents a minimum level of competency for all practicing hospitalists. The intermediate level represents a hospitalist who is prepared to meaningfully engage and collaborate with his or her institution in quality improvement efforts. A hospitalist at this level may also lead uncomplicated improvement projects for his or her medical center and/or hospital medicine group. The advanced level represents a hospitalist prepared to lead quality improvement efforts for his or her institution and/or hospital medicine group. Many hospitalists at this level will have, or will be prepared to have, leadership positions in quality and patient safety at their institutions. Advanced level hospitalists will also have the expertise to teach and mentor other individuals in their quality improvement efforts.

Recommended Use of The Competencies

The HQPS Competencies provide a framework for curricula and other professional development experiences in healthcare quality and patient safety. We recommend a step‐wise approach to curriculum development which includes conducting a targeted needs assessment, defining goals and specific learning objectives, and evaluation of the curriculum.25 The HQPS Competencies can be used at each step and provide educational targets for learners across a range of interest and experience.

Conclusion

Hospitalists are poised to have a tremendous impact on improving the quality of care for hospitalized patients. The lack of training in quality improvement in traditional medical education programs, in which most current hospitalists were trained, can be overcome through appropriate use of the HQPS Competencies. Formal incorporation of the HQPS Competencies into professional development programs, and innovative educational initiatives and curricula, will help provide current hospitalists and the next generations of hospitalists with the needed skills to be successful.

Studies of the transition of care between inpatient and outpatient settings have shown that there are significant patient safety and quality deficiencies in our current system. The transition from the hospital setting to the outpatient setting has been more extensively studied than the transition from the outpatient setting to the inpatient setting. One prospective cohort study of 400 patients found that 1 in 5 patients discharged from the hospital to home experienced an adverse event, which was defined as an injury resulting from medical management rather than the underlying disease, within 3 weeks of discharge.1 This study also concluded that 66% of these were drug‐related adverse events, many of which could have been avoided or mitigated. Another prospective cross‐sectional study of 2644 patient discharges found that approximately 40% of the patients had pending test results at the time of discharge and that 10% of these required some action, yet the outpatient physicians and patients were unaware of these results.2 Medication discrepancies have also been shown to be prevalent, with 1 prospective observational study of 375 patients showing that 14% of elderly patients had 1 or more medication discrepancies and 14% of those patients with medication discrepancies were rehospitalized within 30 days versus 6% of the patients who did not experience a medication discrepancy.3 A recent review of the literature cited improving transitional care as a key area of opportunity for improving postdischarge care4

Lack of communication has clearly been shown to adversely affect postdischarge care transitions.5 A recent summary of the literature by a Society of Hospital Medicine (SHM)/Society of General Internal Medicine (SGIM) task force found that direct communication between hospital physicians and primary care physicians occurs infrequently (in 3%‐20% of cases studied), and the availability of a discharge summary at the first postdischarge visit is low (12%‐34%) and does not improve greatly even after 4 weeks (51%‐77%); this affects the quality of care in approximately 25% of follow‐up visits.5 This systematic review of the literature also found that discharge summaries often lack important information such as diagnostic test results, the treatment or hospital course, discharge medications, test results pending at discharge, patient or family counseling, and follow‐up plans.

However, the lack of studies of the communication between ambulatory physicians and hospital physicians prior to admission or during emergency department (ED) visits does not imply that this communication is not equally important and essential to high‐quality care. According to the Centers for Disease Control, the greatest source of hospital admissions in many institutions is the ED. Over 115,000,000 visits were made to the nation's approximately 4828 EDs in 2005, and about 85.2% of ED visits end in discharge.6 The ED is also the point of re‐entry into the system for individuals who may have had an adverse outcome linked to a prior hospitalization.6 Communication between hospital physicians and primary care physicians must be established to create a loop of continuous care and diminish morbidity and mortality at this critical transition point.

While transitions can be a risky period for patient safety, observational studies suggest there are benefits to transitions. A new physician may notice something overlooked by the current caregivers.712 Another factor contributing to the challenges of care transitions is the lack of a single clinician or clinical entity taking responsibility for coordination across the continuum of the patient's overall healthcare, regardless of setting.13 Studies indicate that a relationship with a medical home is associated with better health on both the individual and population levels, with lower overall costs of care and with reductions in disparities in health between socially disadvantaged subpopulations and more socially advantaged populations.14 Several medical societies have addressed this issue, including the American College of Physicians (ACP), SGIM, American Academy of Family Physicians, and American Academy of Pediatrics, and they have proposed the concept of the medical home or patient‐centered medical home, which calls for clinicians to assume this responsibility for coordinating their patients' care across settings and for the healthcare system to value and reimburse clinicians for this patient‐centered and comprehensive method of practice.1517

Finally, patients and their families or caregivers have an important role to play in transitions of care. Several observational and cross‐sectional studies have shown that patients and their caregivers and families express significant feelings of anxiety during care transitions. This anxiety can be caused by a lack of understanding and preparation for their self‐care role in the next care setting, confusion due to conflicting advice from different practitioners, and a sense of abandonment attributable to the inability to contact an appropriate healthcare practitioner for guidance, and they report an overall disregard for their preferences and input into the design of the care plan.1820 Clearly, there is room for improvement in all these areas of the inpatient and outpatient care transition, and the Transitions of Care Consensus Conference (TOCCC) attempted to address these areas by developing standards for the transition of care that also harmonize with the work of the Stepping up to the Plate (SUTTP) Alliance of the American Board of Internal Medicine (ABIM) Foundation.21 In addition, other important stakeholders are addressing this topic and actively working to improve communication and continuity in care, including the Centers for Medicare and Medicaid Services (CMS) and the National Quality Forum (NQF). CMS recently developed the Continuity Assessment Record & Evaluation (CARE) tool, a data collection instrument designed to be a standardized, interoperable, common assessment tool to capture key patient characteristics that will provide information related to resource utilization, clinical outcomes, and postdischarge disposition. NQF held a national forum on care coordination in the spring of 2008.

In summary, it is clear that there are qualitative and quantitative deficiencies in transitions of care between the inpatient and outpatient setting that are affecting patient safety and experience with care. The transition from the inpatient setting to the outpatient setting has been more extensively studied, and this body of literature has underscored for the TOCCC several important areas in need of guidance and improvement. Because of this, the scope of application of this document should initially emphasize inpatient‐to‐outpatient transitions as a first step in learning how to improve these processes. However, the transition from the outpatient setting to the inpatient setting also is a clear priority. Because the needs for transfer of information, authority, and responsibility may be different in these situations, a second phase of additional work to develop principles to guide these transitions should be undertaken as quickly as possible. Experience gained in applying these principles to inpatient‐to‐outpatient transitions might usefully inform such work.

Communication among providers and with the patients and their families arose as a clear priority. Medication discrepancies, pending tests, and unknown diagnostic or treatment plans have an immediate impact on patients' health and outcomes. The TOCCC discussed what elements should be among the standard pieces of information exchanged among providers during these transition points. The dire need for coordination of care or a coordinating clinician/medical home became a clear theme in the deliberations of the TOCCC. Most importantly, the role of the patients and their families/caregivers in their continuing care is apparent, and the TOCCC felt this must be an integral part of any principles or standards for transitions of care.

Methods

In the fall/winter of 2006, the executive committees of ACP, SGIM, and SHM agreed to jointly develop a policy statement on transitions of care. Transitions of care specifically between the inpatient and outpatient settings were selected as an ideal topic for collaboration for the 3 societies as they represent the continuum of care for internal medicine within these settings. To accomplish this, the 3 organizations decided to convene a consensus conference to develop consensus guidelines and standards concerning transitions between inpatient and outpatient settings through a multi‐stakeholder process. A steering committee was convened with representatives from ACP, SGIM, SHM, the Agency for Healthcare Research and Quality (AHRQ), ABIM, and the American Geriatric Society (AGS). The steering committee developed the agenda and invitee list for the consensus conference. After the conference was held, the steering committee was expanded to include representation from the American College of Emergency Physicians (ACEP) and the Society for Academic Emergency Medicine (SAEM).

During the planning stages of the TOCCC, the steering committee became aware of the SUTTP Alliance of the ABIM Foundation. The SUTTP Alliance has representation from medical specialties such as internal medicine and its subspecialties, family medicine, and surgery. The alliance was formed in 2006 and has been working on care coordination across multiple settings and specialties. The SUTTP Alliance had developed a set of principles and standards for care transitions and agreed to provide the draft document to the TOCCC for review, input, and further development and refinement.

Recommendations on Principles and Standards for Managing Transitions in Care Between the Inpatient and Outpatient Settings from ACP, SGIM, SHM, AGS, ACEP, and SAEM

The SUTTP Alliance presented a draft document entitled Principles and Standards for Managing Transitions in Care. In this document, the SUTTP Alliance proposes 5 principles and 8 standards for effective care transitions. A key element of the conference was a presentation by NQF on how to move from principles to standards and eventually to measures. This presentation provided the TOCCC with the theoretical underpinnings for the discussion of these principles and standards and how the TOCCC would provide input on them. The presentation provided an outline for the flow from principles to measures. First, there needs to be a framework that provides guiding principles for what we would like to measure and eventually report. From those principles, a set of preferred practices or standards are developed; the standards are more granular and allow for more specificity in describing the desired practice or outcome and its elements. Standards then provide a roadmap for identification and development of performance measures. With this framework in mind, the TOCCC then discussed in detail the SUTTP principles and standards.

The 5 principles for effective care transitions developed by the SUTTP Alliance are as follows:

• Accountability.

• Communication: clear and direct communication of treatment plans and follow‐up expectations.

• Timely feedback and feed‐forward of information.

• Involvement of the patient and family member, unless inappropriate, in all steps.

• Respect of the hub of coordination of care.

The TOCCC re‐affirmed these principles and added 4 additional principles to this list. Three of the new principles were statements within the 8 standards developed by the SUTTP, but when taking into consideration the framework for the development of principles into standards, the TOCCC felt that the statements were better represented as principles. They are as follows:

• All patients and their families/caregivers should have and should be able to identify their medical home or coordinating clinician (ie, practice or practitioner). (This was originally part of the coordinating clinicians standard, and the TOCCC voted to elevate this to a principle).

• At every point along the transition, the patients and/or their families/caregivers need to know who is responsible for care at that point and who to contact and how.

• National standards should be established for transitions in care and should be adopted and implemented at the national and community level through public health institutions, national accreditation bodies, medical societies, medical institutions, and so forth in order to improve patient outcomes and patient safety. (This was originally part of the SUTTP community standards standard, and the TOCCC moved to elevate this to a principle).

• For monitoring and improving transitions, standardized metrics related to these standards should be used in order to lead to continuous quality improvement and accountability. (This was originally part of the measurement standard, and the TOCCC voted to elevate this to a principle).

The SUTTP Alliance proposed the following 8 standards for care transitions:

• Coordinating clinicians.

• Care plans.

• Communication infrastructure.

• Standard communication formats.

• Transition responsibility.

• Timeliness.

• Community standards.

• Measurement.

The TOCCC affirmed these standards and through a consensus process added more specificity to most of them and elevated components of some of them to principles, as discussed previously. The TOCCC proposes that the following be merged with the SUTTP standards:

• Coordinating clinicians. Communication and information exchange between the medical home and the receiving provider should occur in an amount of time that will allow the receiving provider to effectively treat the patient. This communication and information exchange should ideally occur whenever patients are at a transition of care (eg, at discharge from the inpatient setting). The timeliness of this communication should be consistent with the patient's clinical presentation and, in the case of a patient being discharged, the urgency of the follow‐up required. Guidelines will need to be developed that address both the timeliness and means of communication between the discharging physician and the medical home. Communication and information exchange between the medical home and other physicians may be in the form of a call, voice mail, fax, or other secure, private, and accessible means including mutual access to an electronic health record.

  The ED represents a unique subset of transitions of care. The potential transition can generally be described as outpatient to outpatient or outpatient to inpatient, depending on whether or not the patient is admitted to the hospital. The outpatient‐to‐outpatient transition can also encompass a number of potential variations. Patients with a medical home may be referred to the ED by the medical home, or they may self‐refer. A significant number of patients do not have a physician and self‐refer to the ED. The disposition from the ED, either outpatient to outpatient or outpatient to inpatient, is similarly represented by a number of variables. Discharged patients may or may not have a medical home, may or may not need a specialist, and may or may not require urgent (<24 hours) follow‐up. Admitted patients may or may not have a medical home and may or may not require specialty care. This variety of variables precludes a single approach to ED transition of care coordination. The determination of which scenarios will be appropriate for the development of standards (coordinating clinicians and transition responsibility) will require further contributions from ACEP and SAEM and review by the steering committee.

• Care plans/transition record. The TOCCC also agreed that there is a minimal set of data elements that should always be part of the transition record. The TOCCC suggested that this minimal data set be part of an initial implementation of this standard. That list includes the following:

  The TOCCC discussed what components should be included in an ideal transition record and agreed on the following elements:

  The TOCCC also added a new standard under this heading: Patients and/or their families/caregivers must receive, understand, and be encouraged to participate in the development of the transition record, which should take into consideration patients' health literacy and insurance status and be culturally sensitive.

• Principle diagnosis and problem list.

• Medication list (reconciliation) including over‐the‐counter medications/herbals, allergies, and drug interactions.

• Clear identification of the medical home/transferring coordinating physician/emnstitution and the contact information.

• Patient's cognitive status.

• Test results/pending results.

• Principle diagnosis and problem list.

• Medication list (reconciliation) including over‐the‐counter medications/herbals, allergies, and drug interactions.

• Emergency plan and contact number and person.

• Treatment and diagnostic plan.

• Prognosis and goals of care.

• Test results/pending results.

• Clear identification of the medical home and/or transferring coordinating physician/emnstitution.

• Patient's cognitive status.

• Advance directives, power of attorney, and consent.

• Planned interventions, durable medical equipment, wound care, and so forth.

• Assessment of caregiver status.

• Communication infrastructure. All communications between providers and between providers and patients and families/caregivers need to be secure, private, Health Insurance Portability and Accountability Actcompliant, and accessible to patients and those practitioners who care for them. Communication needs to be 2‐way with an opportunity for clarification and feedback. Each sending provider needs to provide a contact name and the number of an individual who can respond to questions or concerns. The content of transferred information needs to include a core standardized data set. This information needs to be transferred as a living database; that is, it is created only once, and then each subsequent provider only needs to update, validate, or modify the information. Patient information should be available to the provider prior to the patient's arrival. Information transfer needs to adhere to national data standards. Patients should be provided with a medication list that is accessible (paper or electronic), clear, and dated.

• Standard communication formats. Communities need to develop standard data transfer forms (templates and transmission protocols). Access to a patient's medical history needs to be on a current and ongoing basis with the ability to modify information as a patient's condition changes. Patients, families, and caregivers should have access to their information (nothing about me without me). A section on the transfer record should be devoted to communicating a patient's preferences, priorities, goals, and values (eg, the patient does not want intubation).

• Transition responsibility. The sending provider/emnstitution/team at the clinical organization maintains responsibility for the care of the patient until the receiving clinician/location confirms that the transfer and assumption of responsibility is complete (within a reasonable timeframe for the receiving clinician to receive the information; ie, transfers that occur in the middle of the night can be communicated during standard working hours). The sending provider should be available for clarification with issues of care within a reasonable timeframe after the transfer has been completed, and this timeframe should be based on the conditions of the transfer settings. The patient should be able to identify the responsible provider. In the case of patients who do not have an ongoing ambulatory care provider or whose ambulatory care provider has not assumed responsibility, the hospital‐based clinicians will not be required to assume responsibility for the care of these patients once they are discharged.

• Timeliness. Timeliness of feedback and feed‐forward of information from a sending provider to a receiving provider should be contingent on 4 factors:

  This information should be available at the time of the patient encounter.

• Transition settings.

• Patient circumstances.

• Level of acuity.

• Clear transition responsibility.

• Community standards. Medical communities/emnstitutions must demonstrate accountability for transitions of care by adopting national standards, and processes should be established to promote effective transitions of care.

• Measurement. For monitoring and improving transitions, standardized metrics related to these standards should be used. These metrics/measures should be evidence‐based, address documented gaps, and have a demonstrated impact on improving care (complying with performance measure standards) whenever feasible. Results from measurements using standardized metrics must lead to continuous improvement of the transition process. The validity, reliability, cost, and impact, including unintended consequences, of these measures should be assessed and re‐evaluated.

All these standards should be applied with special attention to the various transition settings and should be appropriate to each transition setting. Measure developers will need to take this into account when developing measures based on these proposed standards.

The TOCCC also went through a consensus prioritization exercise to rank‐order the consensus standards. All meeting participants were asked to rank their top 3 priorities of the 7 standards, giving a numeric score of 1 for their highest priority, a score of 2 for their second highest priority, and a score of 3 for their third highest priority. Summary scores were calculated, and the standards were rank‐ordered from the lowest summary score to the highest. The TOCCC recognizes that full implementation of all of these standards may not be feasible and that these standards may be implemented on a stepped or incremental basis. This prioritization can assist in deciding which of these to implement. The results of the prioritization exercise are as follows:

• 1

  All transitions must include a transition record

• 2

  Transition responsibility

• 3

  Coordinating clinicians

• 4

  Patient and family involvement and ownership of the transition record

• 5

  Communication infrastructure

• 6

  Timeliness

• 7

  Community standards

Future Challenges

In addition to the work on the principles and standards, the TOCCC uncovered six further challenges which are described below.

Next Steps for the TOCCC

The TOCCC focuses only on the transitions between the inpatient and outpatient settings and does not address the equally important transitions between many other different care settings, such as the transition from a hospital to a nursing home or rehabilitation facility. The intent of the TOCCC is to provide this document to national measure developers such as the Physician Consortium for Performance Improvement and others in order to guide measure development and ultimately lead to improvements in quality and safety in care transitions.

Studies of the transition of care between inpatient and outpatient settings have shown that there are significant patient safety and quality deficiencies in our current system. The transition from the hospital setting to the outpatient setting has been more extensively studied than the transition from the outpatient setting to the inpatient setting. One prospective cohort study of 400 patients found that 1 in 5 patients discharged from the hospital to home experienced an adverse event, which was defined as an injury resulting from medical management rather than the underlying disease, within 3 weeks of discharge.1 This study also concluded that 66% of these were drug‐related adverse events, many of which could have been avoided or mitigated. Another prospective cross‐sectional study of 2644 patient discharges found that approximately 40% of the patients had pending test results at the time of discharge and that 10% of these required some action, yet the outpatient physicians and patients were unaware of these results.2 Medication discrepancies have also been shown to be prevalent, with 1 prospective observational study of 375 patients showing that 14% of elderly patients had 1 or more medication discrepancies and 14% of those patients with medication discrepancies were rehospitalized within 30 days versus 6% of the patients who did not experience a medication discrepancy.3 A recent review of the literature cited improving transitional care as a key area of opportunity for improving postdischarge care4

Lack of communication has clearly been shown to adversely affect postdischarge care transitions.5 A recent summary of the literature by a Society of Hospital Medicine (SHM)/Society of General Internal Medicine (SGIM) task force found that direct communication between hospital physicians and primary care physicians occurs infrequently (in 3%‐20% of cases studied), and the availability of a discharge summary at the first postdischarge visit is low (12%‐34%) and does not improve greatly even after 4 weeks (51%‐77%); this affects the quality of care in approximately 25% of follow‐up visits.5 This systematic review of the literature also found that discharge summaries often lack important information such as diagnostic test results, the treatment or hospital course, discharge medications, test results pending at discharge, patient or family counseling, and follow‐up plans.

However, the lack of studies of the communication between ambulatory physicians and hospital physicians prior to admission or during emergency department (ED) visits does not imply that this communication is not equally important and essential to high‐quality care. According to the Centers for Disease Control, the greatest source of hospital admissions in many institutions is the ED. Over 115,000,000 visits were made to the nation's approximately 4828 EDs in 2005, and about 85.2% of ED visits end in discharge.6 The ED is also the point of re‐entry into the system for individuals who may have had an adverse outcome linked to a prior hospitalization.6 Communication between hospital physicians and primary care physicians must be established to create a loop of continuous care and diminish morbidity and mortality at this critical transition point.

While transitions can be a risky period for patient safety, observational studies suggest there are benefits to transitions. A new physician may notice something overlooked by the current caregivers.712 Another factor contributing to the challenges of care transitions is the lack of a single clinician or clinical entity taking responsibility for coordination across the continuum of the patient's overall healthcare, regardless of setting.13 Studies indicate that a relationship with a medical home is associated with better health on both the individual and population levels, with lower overall costs of care and with reductions in disparities in health between socially disadvantaged subpopulations and more socially advantaged populations.14 Several medical societies have addressed this issue, including the American College of Physicians (ACP), SGIM, American Academy of Family Physicians, and American Academy of Pediatrics, and they have proposed the concept of the medical home or patient‐centered medical home, which calls for clinicians to assume this responsibility for coordinating their patients' care across settings and for the healthcare system to value and reimburse clinicians for this patient‐centered and comprehensive method of practice.1517

Finally, patients and their families or caregivers have an important role to play in transitions of care. Several observational and cross‐sectional studies have shown that patients and their caregivers and families express significant feelings of anxiety during care transitions. This anxiety can be caused by a lack of understanding and preparation for their self‐care role in the next care setting, confusion due to conflicting advice from different practitioners, and a sense of abandonment attributable to the inability to contact an appropriate healthcare practitioner for guidance, and they report an overall disregard for their preferences and input into the design of the care plan.1820 Clearly, there is room for improvement in all these areas of the inpatient and outpatient care transition, and the Transitions of Care Consensus Conference (TOCCC) attempted to address these areas by developing standards for the transition of care that also harmonize with the work of the Stepping up to the Plate (SUTTP) Alliance of the American Board of Internal Medicine (ABIM) Foundation.21 In addition, other important stakeholders are addressing this topic and actively working to improve communication and continuity in care, including the Centers for Medicare and Medicaid Services (CMS) and the National Quality Forum (NQF). CMS recently developed the Continuity Assessment Record & Evaluation (CARE) tool, a data collection instrument designed to be a standardized, interoperable, common assessment tool to capture key patient characteristics that will provide information related to resource utilization, clinical outcomes, and postdischarge disposition. NQF held a national forum on care coordination in the spring of 2008.

In summary, it is clear that there are qualitative and quantitative deficiencies in transitions of care between the inpatient and outpatient setting that are affecting patient safety and experience with care. The transition from the inpatient setting to the outpatient setting has been more extensively studied, and this body of literature has underscored for the TOCCC several important areas in need of guidance and improvement. Because of this, the scope of application of this document should initially emphasize inpatient‐to‐outpatient transitions as a first step in learning how to improve these processes. However, the transition from the outpatient setting to the inpatient setting also is a clear priority. Because the needs for transfer of information, authority, and responsibility may be different in these situations, a second phase of additional work to develop principles to guide these transitions should be undertaken as quickly as possible. Experience gained in applying these principles to inpatient‐to‐outpatient transitions might usefully inform such work.

Communication among providers and with the patients and their families arose as a clear priority. Medication discrepancies, pending tests, and unknown diagnostic or treatment plans have an immediate impact on patients' health and outcomes. The TOCCC discussed what elements should be among the standard pieces of information exchanged among providers during these transition points. The dire need for coordination of care or a coordinating clinician/medical home became a clear theme in the deliberations of the TOCCC. Most importantly, the role of the patients and their families/caregivers in their continuing care is apparent, and the TOCCC felt this must be an integral part of any principles or standards for transitions of care.

Methods

In the fall/winter of 2006, the executive committees of ACP, SGIM, and SHM agreed to jointly develop a policy statement on transitions of care. Transitions of care specifically between the inpatient and outpatient settings were selected as an ideal topic for collaboration for the 3 societies as they represent the continuum of care for internal medicine within these settings. To accomplish this, the 3 organizations decided to convene a consensus conference to develop consensus guidelines and standards concerning transitions between inpatient and outpatient settings through a multi‐stakeholder process. A steering committee was convened with representatives from ACP, SGIM, SHM, the Agency for Healthcare Research and Quality (AHRQ), ABIM, and the American Geriatric Society (AGS). The steering committee developed the agenda and invitee list for the consensus conference. After the conference was held, the steering committee was expanded to include representation from the American College of Emergency Physicians (ACEP) and the Society for Academic Emergency Medicine (SAEM).

During the planning stages of the TOCCC, the steering committee became aware of the SUTTP Alliance of the ABIM Foundation. The SUTTP Alliance has representation from medical specialties such as internal medicine and its subspecialties, family medicine, and surgery. The alliance was formed in 2006 and has been working on care coordination across multiple settings and specialties. The SUTTP Alliance had developed a set of principles and standards for care transitions and agreed to provide the draft document to the TOCCC for review, input, and further development and refinement.

Recommendations on Principles and Standards for Managing Transitions in Care Between the Inpatient and Outpatient Settings from ACP, SGIM, SHM, AGS, ACEP, and SAEM

The SUTTP Alliance presented a draft document entitled Principles and Standards for Managing Transitions in Care. In this document, the SUTTP Alliance proposes 5 principles and 8 standards for effective care transitions. A key element of the conference was a presentation by NQF on how to move from principles to standards and eventually to measures. This presentation provided the TOCCC with the theoretical underpinnings for the discussion of these principles and standards and how the TOCCC would provide input on them. The presentation provided an outline for the flow from principles to measures. First, there needs to be a framework that provides guiding principles for what we would like to measure and eventually report. From those principles, a set of preferred practices or standards are developed; the standards are more granular and allow for more specificity in describing the desired practice or outcome and its elements. Standards then provide a roadmap for identification and development of performance measures. With this framework in mind, the TOCCC then discussed in detail the SUTTP principles and standards.

The 5 principles for effective care transitions developed by the SUTTP Alliance are as follows:

• Accountability.

• Communication: clear and direct communication of treatment plans and follow‐up expectations.

• Timely feedback and feed‐forward of information.

• Involvement of the patient and family member, unless inappropriate, in all steps.

• Respect of the hub of coordination of care.

The TOCCC re‐affirmed these principles and added 4 additional principles to this list. Three of the new principles were statements within the 8 standards developed by the SUTTP, but when taking into consideration the framework for the development of principles into standards, the TOCCC felt that the statements were better represented as principles. They are as follows:

• All patients and their families/caregivers should have and should be able to identify their medical home or coordinating clinician (ie, practice or practitioner). (This was originally part of the coordinating clinicians standard, and the TOCCC voted to elevate this to a principle).

• At every point along the transition, the patients and/or their families/caregivers need to know who is responsible for care at that point and who to contact and how.

• National standards should be established for transitions in care and should be adopted and implemented at the national and community level through public health institutions, national accreditation bodies, medical societies, medical institutions, and so forth in order to improve patient outcomes and patient safety. (This was originally part of the SUTTP community standards standard, and the TOCCC moved to elevate this to a principle).

• For monitoring and improving transitions, standardized metrics related to these standards should be used in order to lead to continuous quality improvement and accountability. (This was originally part of the measurement standard, and the TOCCC voted to elevate this to a principle).

The SUTTP Alliance proposed the following 8 standards for care transitions:

• Coordinating clinicians.

• Care plans.

• Communication infrastructure.

• Standard communication formats.

• Transition responsibility.

• Timeliness.

• Community standards.

• Measurement.

The TOCCC affirmed these standards and through a consensus process added more specificity to most of them and elevated components of some of them to principles, as discussed previously. The TOCCC proposes that the following be merged with the SUTTP standards:

• Coordinating clinicians. Communication and information exchange between the medical home and the receiving provider should occur in an amount of time that will allow the receiving provider to effectively treat the patient. This communication and information exchange should ideally occur whenever patients are at a transition of care (eg, at discharge from the inpatient setting). The timeliness of this communication should be consistent with the patient's clinical presentation and, in the case of a patient being discharged, the urgency of the follow‐up required. Guidelines will need to be developed that address both the timeliness and means of communication between the discharging physician and the medical home. Communication and information exchange between the medical home and other physicians may be in the form of a call, voice mail, fax, or other secure, private, and accessible means including mutual access to an electronic health record.

  The ED represents a unique subset of transitions of care. The potential transition can generally be described as outpatient to outpatient or outpatient to inpatient, depending on whether or not the patient is admitted to the hospital. The outpatient‐to‐outpatient transition can also encompass a number of potential variations. Patients with a medical home may be referred to the ED by the medical home, or they may self‐refer. A significant number of patients do not have a physician and self‐refer to the ED. The disposition from the ED, either outpatient to outpatient or outpatient to inpatient, is similarly represented by a number of variables. Discharged patients may or may not have a medical home, may or may not need a specialist, and may or may not require urgent (<24 hours) follow‐up. Admitted patients may or may not have a medical home and may or may not require specialty care. This variety of variables precludes a single approach to ED transition of care coordination. The determination of which scenarios will be appropriate for the development of standards (coordinating clinicians and transition responsibility) will require further contributions from ACEP and SAEM and review by the steering committee.

• Care plans/transition record. The TOCCC also agreed that there is a minimal set of data elements that should always be part of the transition record. The TOCCC suggested that this minimal data set be part of an initial implementation of this standard. That list includes the following:

  The TOCCC discussed what components should be included in an ideal transition record and agreed on the following elements:

  The TOCCC also added a new standard under this heading: Patients and/or their families/caregivers must receive, understand, and be encouraged to participate in the development of the transition record, which should take into consideration patients' health literacy and insurance status and be culturally sensitive.

• Principle diagnosis and problem list.

• Medication list (reconciliation) including over‐the‐counter medications/herbals, allergies, and drug interactions.

• Clear identification of the medical home/transferring coordinating physician/emnstitution and the contact information.

• Patient's cognitive status.

• Test results/pending results.

• Principle diagnosis and problem list.

• Medication list (reconciliation) including over‐the‐counter medications/herbals, allergies, and drug interactions.

• Emergency plan and contact number and person.

• Treatment and diagnostic plan.

• Prognosis and goals of care.

• Test results/pending results.

• Clear identification of the medical home and/or transferring coordinating physician/emnstitution.

• Patient's cognitive status.

• Advance directives, power of attorney, and consent.

• Planned interventions, durable medical equipment, wound care, and so forth.

• Assessment of caregiver status.

• Communication infrastructure. All communications between providers and between providers and patients and families/caregivers need to be secure, private, Health Insurance Portability and Accountability Actcompliant, and accessible to patients and those practitioners who care for them. Communication needs to be 2‐way with an opportunity for clarification and feedback. Each sending provider needs to provide a contact name and the number of an individual who can respond to questions or concerns. The content of transferred information needs to include a core standardized data set. This information needs to be transferred as a living database; that is, it is created only once, and then each subsequent provider only needs to update, validate, or modify the information. Patient information should be available to the provider prior to the patient's arrival. Information transfer needs to adhere to national data standards. Patients should be provided with a medication list that is accessible (paper or electronic), clear, and dated.

• Standard communication formats. Communities need to develop standard data transfer forms (templates and transmission protocols). Access to a patient's medical history needs to be on a current and ongoing basis with the ability to modify information as a patient's condition changes. Patients, families, and caregivers should have access to their information (nothing about me without me). A section on the transfer record should be devoted to communicating a patient's preferences, priorities, goals, and values (eg, the patient does not want intubation).

• Transition responsibility. The sending provider/emnstitution/team at the clinical organization maintains responsibility for the care of the patient until the receiving clinician/location confirms that the transfer and assumption of responsibility is complete (within a reasonable timeframe for the receiving clinician to receive the information; ie, transfers that occur in the middle of the night can be communicated during standard working hours). The sending provider should be available for clarification with issues of care within a reasonable timeframe after the transfer has been completed, and this timeframe should be based on the conditions of the transfer settings. The patient should be able to identify the responsible provider. In the case of patients who do not have an ongoing ambulatory care provider or whose ambulatory care provider has not assumed responsibility, the hospital‐based clinicians will not be required to assume responsibility for the care of these patients once they are discharged.

• Timeliness. Timeliness of feedback and feed‐forward of information from a sending provider to a receiving provider should be contingent on 4 factors:

  This information should be available at the time of the patient encounter.

• Transition settings.

• Patient circumstances.

• Level of acuity.

• Clear transition responsibility.

• Community standards. Medical communities/emnstitutions must demonstrate accountability for transitions of care by adopting national standards, and processes should be established to promote effective transitions of care.

• Measurement. For monitoring and improving transitions, standardized metrics related to these standards should be used. These metrics/measures should be evidence‐based, address documented gaps, and have a demonstrated impact on improving care (complying with performance measure standards) whenever feasible. Results from measurements using standardized metrics must lead to continuous improvement of the transition process. The validity, reliability, cost, and impact, including unintended consequences, of these measures should be assessed and re‐evaluated.

All these standards should be applied with special attention to the various transition settings and should be appropriate to each transition setting. Measure developers will need to take this into account when developing measures based on these proposed standards.

The TOCCC also went through a consensus prioritization exercise to rank‐order the consensus standards. All meeting participants were asked to rank their top 3 priorities of the 7 standards, giving a numeric score of 1 for their highest priority, a score of 2 for their second highest priority, and a score of 3 for their third highest priority. Summary scores were calculated, and the standards were rank‐ordered from the lowest summary score to the highest. The TOCCC recognizes that full implementation of all of these standards may not be feasible and that these standards may be implemented on a stepped or incremental basis. This prioritization can assist in deciding which of these to implement. The results of the prioritization exercise are as follows:

• 1

  All transitions must include a transition record

• 2

  Transition responsibility

• 3

  Coordinating clinicians

• 4

  Patient and family involvement and ownership of the transition record

• 5

  Communication infrastructure

• 6

  Timeliness

• 7

  Community standards

Future Challenges

In addition to the work on the principles and standards, the TOCCC uncovered six further challenges which are described below.

Next Steps for the TOCCC

The TOCCC focuses only on the transitions between the inpatient and outpatient settings and does not address the equally important transitions between many other different care settings, such as the transition from a hospital to a nursing home or rehabilitation facility. The intent of the TOCCC is to provide this document to national measure developers such as the Physician Consortium for Performance Improvement and others in order to guide measure development and ultimately lead to improvements in quality and safety in care transitions.

Studies of the transition of care between inpatient and outpatient settings have shown that there are significant patient safety and quality deficiencies in our current system. The transition from the hospital setting to the outpatient setting has been more extensively studied than the transition from the outpatient setting to the inpatient setting. One prospective cohort study of 400 patients found that 1 in 5 patients discharged from the hospital to home experienced an adverse event, which was defined as an injury resulting from medical management rather than the underlying disease, within 3 weeks of discharge.1 This study also concluded that 66% of these were drug‐related adverse events, many of which could have been avoided or mitigated. Another prospective cross‐sectional study of 2644 patient discharges found that approximately 40% of the patients had pending test results at the time of discharge and that 10% of these required some action, yet the outpatient physicians and patients were unaware of these results.2 Medication discrepancies have also been shown to be prevalent, with 1 prospective observational study of 375 patients showing that 14% of elderly patients had 1 or more medication discrepancies and 14% of those patients with medication discrepancies were rehospitalized within 30 days versus 6% of the patients who did not experience a medication discrepancy.3 A recent review of the literature cited improving transitional care as a key area of opportunity for improving postdischarge care4

Lack of communication has clearly been shown to adversely affect postdischarge care transitions.5 A recent summary of the literature by a Society of Hospital Medicine (SHM)/Society of General Internal Medicine (SGIM) task force found that direct communication between hospital physicians and primary care physicians occurs infrequently (in 3%‐20% of cases studied), and the availability of a discharge summary at the first postdischarge visit is low (12%‐34%) and does not improve greatly even after 4 weeks (51%‐77%); this affects the quality of care in approximately 25% of follow‐up visits.5 This systematic review of the literature also found that discharge summaries often lack important information such as diagnostic test results, the treatment or hospital course, discharge medications, test results pending at discharge, patient or family counseling, and follow‐up plans.

However, the lack of studies of the communication between ambulatory physicians and hospital physicians prior to admission or during emergency department (ED) visits does not imply that this communication is not equally important and essential to high‐quality care. According to the Centers for Disease Control, the greatest source of hospital admissions in many institutions is the ED. Over 115,000,000 visits were made to the nation's approximately 4828 EDs in 2005, and about 85.2% of ED visits end in discharge.6 The ED is also the point of re‐entry into the system for individuals who may have had an adverse outcome linked to a prior hospitalization.6 Communication between hospital physicians and primary care physicians must be established to create a loop of continuous care and diminish morbidity and mortality at this critical transition point.

While transitions can be a risky period for patient safety, observational studies suggest there are benefits to transitions. A new physician may notice something overlooked by the current caregivers.712 Another factor contributing to the challenges of care transitions is the lack of a single clinician or clinical entity taking responsibility for coordination across the continuum of the patient's overall healthcare, regardless of setting.13 Studies indicate that a relationship with a medical home is associated with better health on both the individual and population levels, with lower overall costs of care and with reductions in disparities in health between socially disadvantaged subpopulations and more socially advantaged populations.14 Several medical societies have addressed this issue, including the American College of Physicians (ACP), SGIM, American Academy of Family Physicians, and American Academy of Pediatrics, and they have proposed the concept of the medical home or patient‐centered medical home, which calls for clinicians to assume this responsibility for coordinating their patients' care across settings and for the healthcare system to value and reimburse clinicians for this patient‐centered and comprehensive method of practice.1517

Finally, patients and their families or caregivers have an important role to play in transitions of care. Several observational and cross‐sectional studies have shown that patients and their caregivers and families express significant feelings of anxiety during care transitions. This anxiety can be caused by a lack of understanding and preparation for their self‐care role in the next care setting, confusion due to conflicting advice from different practitioners, and a sense of abandonment attributable to the inability to contact an appropriate healthcare practitioner for guidance, and they report an overall disregard for their preferences and input into the design of the care plan.1820 Clearly, there is room for improvement in all these areas of the inpatient and outpatient care transition, and the Transitions of Care Consensus Conference (TOCCC) attempted to address these areas by developing standards for the transition of care that also harmonize with the work of the Stepping up to the Plate (SUTTP) Alliance of the American Board of Internal Medicine (ABIM) Foundation.21 In addition, other important stakeholders are addressing this topic and actively working to improve communication and continuity in care, including the Centers for Medicare and Medicaid Services (CMS) and the National Quality Forum (NQF). CMS recently developed the Continuity Assessment Record & Evaluation (CARE) tool, a data collection instrument designed to be a standardized, interoperable, common assessment tool to capture key patient characteristics that will provide information related to resource utilization, clinical outcomes, and postdischarge disposition. NQF held a national forum on care coordination in the spring of 2008.

In summary, it is clear that there are qualitative and quantitative deficiencies in transitions of care between the inpatient and outpatient setting that are affecting patient safety and experience with care. The transition from the inpatient setting to the outpatient setting has been more extensively studied, and this body of literature has underscored for the TOCCC several important areas in need of guidance and improvement. Because of this, the scope of application of this document should initially emphasize inpatient‐to‐outpatient transitions as a first step in learning how to improve these processes. However, the transition from the outpatient setting to the inpatient setting also is a clear priority. Because the needs for transfer of information, authority, and responsibility may be different in these situations, a second phase of additional work to develop principles to guide these transitions should be undertaken as quickly as possible. Experience gained in applying these principles to inpatient‐to‐outpatient transitions might usefully inform such work.

Communication among providers and with the patients and their families arose as a clear priority. Medication discrepancies, pending tests, and unknown diagnostic or treatment plans have an immediate impact on patients' health and outcomes. The TOCCC discussed what elements should be among the standard pieces of information exchanged among providers during these transition points. The dire need for coordination of care or a coordinating clinician/medical home became a clear theme in the deliberations of the TOCCC. Most importantly, the role of the patients and their families/caregivers in their continuing care is apparent, and the TOCCC felt this must be an integral part of any principles or standards for transitions of care.

Methods

In the fall/winter of 2006, the executive committees of ACP, SGIM, and SHM agreed to jointly develop a policy statement on transitions of care. Transitions of care specifically between the inpatient and outpatient settings were selected as an ideal topic for collaboration for the 3 societies as they represent the continuum of care for internal medicine within these settings. To accomplish this, the 3 organizations decided to convene a consensus conference to develop consensus guidelines and standards concerning transitions between inpatient and outpatient settings through a multi‐stakeholder process. A steering committee was convened with representatives from ACP, SGIM, SHM, the Agency for Healthcare Research and Quality (AHRQ), ABIM, and the American Geriatric Society (AGS). The steering committee developed the agenda and invitee list for the consensus conference. After the conference was held, the steering committee was expanded to include representation from the American College of Emergency Physicians (ACEP) and the Society for Academic Emergency Medicine (SAEM).

During the planning stages of the TOCCC, the steering committee became aware of the SUTTP Alliance of the ABIM Foundation. The SUTTP Alliance has representation from medical specialties such as internal medicine and its subspecialties, family medicine, and surgery. The alliance was formed in 2006 and has been working on care coordination across multiple settings and specialties. The SUTTP Alliance had developed a set of principles and standards for care transitions and agreed to provide the draft document to the TOCCC for review, input, and further development and refinement.

Recommendations on Principles and Standards for Managing Transitions in Care Between the Inpatient and Outpatient Settings from ACP, SGIM, SHM, AGS, ACEP, and SAEM

The SUTTP Alliance presented a draft document entitled Principles and Standards for Managing Transitions in Care. In this document, the SUTTP Alliance proposes 5 principles and 8 standards for effective care transitions. A key element of the conference was a presentation by NQF on how to move from principles to standards and eventually to measures. This presentation provided the TOCCC with the theoretical underpinnings for the discussion of these principles and standards and how the TOCCC would provide input on them. The presentation provided an outline for the flow from principles to measures. First, there needs to be a framework that provides guiding principles for what we would like to measure and eventually report. From those principles, a set of preferred practices or standards are developed; the standards are more granular and allow for more specificity in describing the desired practice or outcome and its elements. Standards then provide a roadmap for identification and development of performance measures. With this framework in mind, the TOCCC then discussed in detail the SUTTP principles and standards.

The 5 principles for effective care transitions developed by the SUTTP Alliance are as follows:

• Accountability.

• Communication: clear and direct communication of treatment plans and follow‐up expectations.

• Timely feedback and feed‐forward of information.

• Involvement of the patient and family member, unless inappropriate, in all steps.

• Respect of the hub of coordination of care.

The TOCCC re‐affirmed these principles and added 4 additional principles to this list. Three of the new principles were statements within the 8 standards developed by the SUTTP, but when taking into consideration the framework for the development of principles into standards, the TOCCC felt that the statements were better represented as principles. They are as follows:

• All patients and their families/caregivers should have and should be able to identify their medical home or coordinating clinician (ie, practice or practitioner). (This was originally part of the coordinating clinicians standard, and the TOCCC voted to elevate this to a principle).

• At every point along the transition, the patients and/or their families/caregivers need to know who is responsible for care at that point and who to contact and how.

• National standards should be established for transitions in care and should be adopted and implemented at the national and community level through public health institutions, national accreditation bodies, medical societies, medical institutions, and so forth in order to improve patient outcomes and patient safety. (This was originally part of the SUTTP community standards standard, and the TOCCC moved to elevate this to a principle).

• For monitoring and improving transitions, standardized metrics related to these standards should be used in order to lead to continuous quality improvement and accountability. (This was originally part of the measurement standard, and the TOCCC voted to elevate this to a principle).

The SUTTP Alliance proposed the following 8 standards for care transitions:

• Coordinating clinicians.

• Care plans.

• Communication infrastructure.

• Standard communication formats.

• Transition responsibility.

• Timeliness.

• Community standards.

• Measurement.

The TOCCC affirmed these standards and through a consensus process added more specificity to most of them and elevated components of some of them to principles, as discussed previously. The TOCCC proposes that the following be merged with the SUTTP standards:

• Coordinating clinicians. Communication and information exchange between the medical home and the receiving provider should occur in an amount of time that will allow the receiving provider to effectively treat the patient. This communication and information exchange should ideally occur whenever patients are at a transition of care (eg, at discharge from the inpatient setting). The timeliness of this communication should be consistent with the patient's clinical presentation and, in the case of a patient being discharged, the urgency of the follow‐up required. Guidelines will need to be developed that address both the timeliness and means of communication between the discharging physician and the medical home. Communication and information exchange between the medical home and other physicians may be in the form of a call, voice mail, fax, or other secure, private, and accessible means including mutual access to an electronic health record.

  The ED represents a unique subset of transitions of care. The potential transition can generally be described as outpatient to outpatient or outpatient to inpatient, depending on whether or not the patient is admitted to the hospital. The outpatient‐to‐outpatient transition can also encompass a number of potential variations. Patients with a medical home may be referred to the ED by the medical home, or they may self‐refer. A significant number of patients do not have a physician and self‐refer to the ED. The disposition from the ED, either outpatient to outpatient or outpatient to inpatient, is similarly represented by a number of variables. Discharged patients may or may not have a medical home, may or may not need a specialist, and may or may not require urgent (<24 hours) follow‐up. Admitted patients may or may not have a medical home and may or may not require specialty care. This variety of variables precludes a single approach to ED transition of care coordination. The determination of which scenarios will be appropriate for the development of standards (coordinating clinicians and transition responsibility) will require further contributions from ACEP and SAEM and review by the steering committee.

• Care plans/transition record. The TOCCC also agreed that there is a minimal set of data elements that should always be part of the transition record. The TOCCC suggested that this minimal data set be part of an initial implementation of this standard. That list includes the following:

  The TOCCC discussed what components should be included in an ideal transition record and agreed on the following elements:

  The TOCCC also added a new standard under this heading: Patients and/or their families/caregivers must receive, understand, and be encouraged to participate in the development of the transition record, which should take into consideration patients' health literacy and insurance status and be culturally sensitive.

• Principle diagnosis and problem list.

• Medication list (reconciliation) including over‐the‐counter medications/herbals, allergies, and drug interactions.

• Clear identification of the medical home/transferring coordinating physician/emnstitution and the contact information.

• Patient's cognitive status.

• Test results/pending results.

• Principle diagnosis and problem list.

• Medication list (reconciliation) including over‐the‐counter medications/herbals, allergies, and drug interactions.

• Emergency plan and contact number and person.

• Treatment and diagnostic plan.

• Prognosis and goals of care.

• Test results/pending results.

• Clear identification of the medical home and/or transferring coordinating physician/emnstitution.

• Patient's cognitive status.

• Advance directives, power of attorney, and consent.

• Planned interventions, durable medical equipment, wound care, and so forth.

• Assessment of caregiver status.

• Communication infrastructure. All communications between providers and between providers and patients and families/caregivers need to be secure, private, Health Insurance Portability and Accountability Actcompliant, and accessible to patients and those practitioners who care for them. Communication needs to be 2‐way with an opportunity for clarification and feedback. Each sending provider needs to provide a contact name and the number of an individual who can respond to questions or concerns. The content of transferred information needs to include a core standardized data set. This information needs to be transferred as a living database; that is, it is created only once, and then each subsequent provider only needs to update, validate, or modify the information. Patient information should be available to the provider prior to the patient's arrival. Information transfer needs to adhere to national data standards. Patients should be provided with a medication list that is accessible (paper or electronic), clear, and dated.

• Standard communication formats. Communities need to develop standard data transfer forms (templates and transmission protocols). Access to a patient's medical history needs to be on a current and ongoing basis with the ability to modify information as a patient's condition changes. Patients, families, and caregivers should have access to their information (nothing about me without me). A section on the transfer record should be devoted to communicating a patient's preferences, priorities, goals, and values (eg, the patient does not want intubation).

• Transition responsibility. The sending provider/emnstitution/team at the clinical organization maintains responsibility for the care of the patient until the receiving clinician/location confirms that the transfer and assumption of responsibility is complete (within a reasonable timeframe for the receiving clinician to receive the information; ie, transfers that occur in the middle of the night can be communicated during standard working hours). The sending provider should be available for clarification with issues of care within a reasonable timeframe after the transfer has been completed, and this timeframe should be based on the conditions of the transfer settings. The patient should be able to identify the responsible provider. In the case of patients who do not have an ongoing ambulatory care provider or whose ambulatory care provider has not assumed responsibility, the hospital‐based clinicians will not be required to assume responsibility for the care of these patients once they are discharged.

• Timeliness. Timeliness of feedback and feed‐forward of information from a sending provider to a receiving provider should be contingent on 4 factors:

  This information should be available at the time of the patient encounter.

• Transition settings.

• Patient circumstances.

• Level of acuity.

• Clear transition responsibility.

• Community standards. Medical communities/emnstitutions must demonstrate accountability for transitions of care by adopting national standards, and processes should be established to promote effective transitions of care.

• Measurement. For monitoring and improving transitions, standardized metrics related to these standards should be used. These metrics/measures should be evidence‐based, address documented gaps, and have a demonstrated impact on improving care (complying with performance measure standards) whenever feasible. Results from measurements using standardized metrics must lead to continuous improvement of the transition process. The validity, reliability, cost, and impact, including unintended consequences, of these measures should be assessed and re‐evaluated.

All these standards should be applied with special attention to the various transition settings and should be appropriate to each transition setting. Measure developers will need to take this into account when developing measures based on these proposed standards.

The TOCCC also went through a consensus prioritization exercise to rank‐order the consensus standards. All meeting participants were asked to rank their top 3 priorities of the 7 standards, giving a numeric score of 1 for their highest priority, a score of 2 for their second highest priority, and a score of 3 for their third highest priority. Summary scores were calculated, and the standards were rank‐ordered from the lowest summary score to the highest. The TOCCC recognizes that full implementation of all of these standards may not be feasible and that these standards may be implemented on a stepped or incremental basis. This prioritization can assist in deciding which of these to implement. The results of the prioritization exercise are as follows:

• 1

  All transitions must include a transition record

• 2

  Transition responsibility

• 3

  Coordinating clinicians

• 4

  Patient and family involvement and ownership of the transition record

• 5

  Communication infrastructure

• 6

  Timeliness

• 7

  Community standards

Future Challenges

In addition to the work on the principles and standards, the TOCCC uncovered six further challenges which are described below.

Next Steps for the TOCCC

The TOCCC focuses only on the transitions between the inpatient and outpatient settings and does not address the equally important transitions between many other different care settings, such as the transition from a hospital to a nursing home or rehabilitation facility. The intent of the TOCCC is to provide this document to national measure developers such as the Physician Consortium for Performance Improvement and others in order to guide measure development and ultimately lead to improvements in quality and safety in care transitions.

In the United States, hospitalized patients are at risk of acquiring health careassociated infections that increase morbidity, mortality, length of hospital stay, and cost of care.1 If a health careassociated infection is caused by an antimicrobial‐resistant pathogen, treatment efforts may be further complicated.2, 3 With the decreasing effectiveness of antimicrobials and suboptimal adherence to certain infection control measures, new and multifaceted prevention strategies are necessary to address the problem of health careassociated infections and antimicrobial resistance.410

One strategy that hospitals can use to reduce the incidence of health careassociated infections and antimicrobial resistance is implementation of quality improvement programs. These programs require clinicians to employ techniques, such as root cause analysis (RCA), which investigates contributing factors to an event to prevent reoccurrence, and healthcare failure mode effects analysis (HFMEA), which applies a systematic method of identifying and preventing problems before they occur.1113 Programs and strategies such as these require leadership and adoption within the hospital. Because of their availability and specialized role in the hospital setting, hospitalists are in a unique position to promote and uphold quality improvement efforts.1417 Professional societies, health care organizations, and governmental agencies can play a role in engaging this group of physicians in improving the quality of patient care in hospitals by providing educational programs and materials.18

In 2004, the Society of Hospital Medicine (SHM) collaborated with the Centers for Disease Control and Prevention (CDC) to develop a quality improvement tool kit to reduce antimicrobial resistance and health careassociated infections. The tool kit was based on the CDC's Campaign to Prevent Antimicrobial Resistance in Healthcare Settings (Campaign), an educational program targeted at clinicians.19 The SHM/CDC tool kit contained campaign materials, a set of slides about quality improvement, worksheets, and additional materials such as infection control policies and guidelines to supplement a 90‐minute workshop consisting of didactic lectures about antimicrobial resistance, quality improvement initiatives, RCA, and HFMEA; a lecture and case study about intravascular catheter‐related infections; and small‐group activity and discussion. The complete toolkit is now available online via the SHM Antimicrobial Resistance Resource Room at http://www.hospitalmedicine.org/AM/Template.cfm?Section=Home&Template=/CM/HTMLDisplay.cfm&ContentID=7542.

The purpose of the workshop was to present the tool kit and increase hospitalists' knowledge and awareness about antimicrobial resistance, health careassociated infections, and quality improvement programs. We assessed the workshop participants' familiarity with the Campaign prior to the workshop, perceptions of antimicrobial resistance, knowledge gained as a result of the workshop, and opinions about the usefulness of the workshop.

METHODS

Data were collected from pretests and posttests administered to participants of one of the SHM workshops in May, June, or July 2005 in Denver, Colorado; Boston, Massachusetts; or Portland, Oregon. One SHM physician leader (D.D.D., coauthor of this article) presented all 3 workshops. The workshops were advertised by SHM using E‐mail to local chapter members. Individual sites used a variety of methods to encourage their hospitalists to attend, and participants were provided a complimentary dinner.

Prior to each workshop, participants completed a 10‐question pretest that had been pilot‐tested by hospitalists in other cities. The pretest assessed demographics; perceptions of the problem of antimicrobial resistance using a Likert scale; familiarity with the Campaign; and knowledge of common infection sites, RCA, HFMEA, and antimicrobial resistance prevention measures.

Immediately following each workshop, a 13‐question posttest was administered to participants. This posttest evaluated the workshop and materials using Likert scales, asked for suggestions for future programming using open‐ended questions, and repeated pretest questions to assess changes in perceptions and knowledge.

Data were entered into an Excel spreadsheet and analyzed using descriptive statistics and t tests to compare pre‐ and posttest changes in knowledge. Likert data assessing perceptions were dichotomized into strongly agree versus all other scale responses. Qualitative open‐ended responses were categorized by theme.

RESULTS

A total of 69 SHM members attended the workshops. Of the 69 participants, 65 completed the pretest, 53 completed the posttest, and 50 completed both the pre‐ and the posttests. Only participants who completed both the pretest and the posttest were included in the analyses (n = 21, Denver; n = 11, Boston; n = 18, Portland). Of the 50 participants who completed both the pre‐ and posttests, 44 (88%) classified themselves as hospitalists in practices ranging from 2 to more than 25 physicians. Participants averaged 9.2 years (range = 1‐27 years) in practice and 4.9 years (range = 1‐10 years) as practicing hospitalists, with no significant differences between the 3 groups. Only 17 participants (34%) were familiar with the Campaign prior to the workshop, and there was no significant variation between the 3 workshops. Those familiar with the Campaign had heard about or received the educational materials from colleagues (n = 5), their facilities (n = 4), professional journals (n = 4), medical conferences (n = 4), or the CDC or SHM websites (n = 4).

Overall, most participants strongly agreed with the statement that antimicrobial resistance was a problem nationally, institutionally, and within their individual practices (Table 1). These perceptions did not significantly differ between the pretest and the posttest. However, statistically significant differences were found when comparing perceptions of the problem of antimicrobial resistance at the national, institutional, and practice levels; more participants strongly agreed that antimicrobial resistance was a problem nationally than within their institutions (pretest, P = .01; posttest, P = .04) or within their practices (pretest, P < .0001; posttest, P = .01).

On the knowledge‐based questions, the overall average test score was 48% on the pretest and 63% on the posttest (P < .0001), with scores varying by question (Table 2). For example, knowledge of quality improvement initiatives/HFMEA was low (an average of 10% correct on the pretest, 48% on the posttest) compared with knowledge about the key prevention strategies from the Campaign to Prevent Antimicrobial Resistance (average of 94% correct on the pretest, 98% on the posttest). Furthermore, scores also varied by workshop location. On the pretest, participants in Boston and Portland scored higher (both 53%) than Denver participants (40%). On the posttest, Portland participants scored the highest (78%) followed by Boston participants (64%) and then Denver participants (50%). Boston and Denver participants differed significantly on pretest knowledge score (P = .04) and Portland and Denver participants differed significantly on posttest knowledge score (P < .0001).

Overall, 43 participants (85%) rated the workshop as either very good or excellent. All but 1 participant (n = 49, 98%) would encourage a colleague to attend the workshop, giving reasons such as that the workshop outlined a major program in delivering good and safe care, offered great information on antimicrobial resistance and methods of quality improvement systems implementation, assisted in find[ing] new tools for improving hospital practice, and addressed a significant factor in hospitals related to morbidity [and] mortality. When asked for general comments about the workshop and suggestions for future improvements, participants requested more direction, more detail, more discussion, specific examples of antimicrobial resistance, and protocols and processes for implementing quality improvement programs. On a scale from 1 (not useful) to 5 (essential), participants rated the usefulness of each workshop segment: intravascular catheter‐related infections lecture and case study (x̄ = 4.3, range = 3‐5), quality improvement initiatives lecture (x̄ = 4.1, range = 2‐5), background on antimicrobial resistance (x̄ = 3.9, range = 2‐5), RCA lecture (x̄ = 3.9, range = 2‐5), HFMEA lecture (x̄ = 3.8, range = 2‐5), and small‐group discussion (x̄ = 3.4, range = 2‐5). These ratings did not vary significantly between the 3 groups.

CONCLUSIONS

To address antimicrobial resistance and health careassociated infections in the hospital setting, the SHM and CDC developed a tool kit and presented a quality improvement workshop to hospitalists in 3 U.S. cities. Overall, the participants scored significantly higher on the knowledge‐based questions on the posttest than on the pretest, indicating that knowledge improved as a result of the workshop. By providing a format that combined didactic lectures with case‐based education, small‐group activities, and discussion, the SHM workshop may have optimized its ability to increase knowledge, similar to the findings in previous research.2021

There were no significant differences between the 3 groups in years of practice, perceptions of the problem, and overall evaluation of the workshop. However, differences were found in knowledge gained as a result of the workshop. For example, the Denver group scored lower on the knowledge‐based questions than did the Boston group on the pretest and the Portland group on the posttest, indicating that knowledge and learning styles may differ by location. These differences may be attributed to variations in hospital environments, hospital‐based educational programs, or medical school and residency training. Differences like these may impact the effectiveness of a program and should be a consideration in the program development process, especially when a program is national in scope, like the CDC's Campaign to Prevent Antimicrobial Resistance in Healthcare Settings. In addition, more than 90% of participants correctly identified key prevention strategies of the Campaign, whereas only 34% were familiar with the Campaign itself prior to the workshop. This result may be a result of the key prevention strategies of the Campaign being derived from well‐established and ‐recognized evidence‐based best practices for patient safety and care.

Although knowledge changed as a result of the workshop, overall perceptions of the problem of antimicrobial resistance did not change significantly from pretest to posttest. It is possible this is because changes in perception require a different or more intensive educational approach. This result also may reflect the initial levels of agreement on the pretest, the measurement instrument itself, and/or the inability to detect differences because of the small number of participants.

Difference did exist in perceptions of the problem of antimicrobial resistance at the national, institutional, and practice levels. Antimicrobial resistance was perceived to be a greater problem on the national level than on the institutional and practice levels. Other studies also have found that clinicians more strongly agree that antimicrobial resistance is a problem nationally than within their institutions and practices.2224 When antimicrobial resistance is not perceived as a problem within institutions and practices, physicians may be less likely to overcome the barriers to following recommended infection prevention guidelines or to implementing quality improvement projects.4 Therefore, educational and intervention efforts like this workshop should address hospitalists' perceptions of the problem of antimicrobial resistance on the individual level as a first step in motivating them to engage in quality improvement.

Although participants' knowledge scores increased from pretest to posttest, gaps in knowledge remained, as indicated by the significantly improved but low overall posttest scores related to RCA and HFMEA. As hospitalists are in a unique position to promote quality improvement programs, these topic areas should be given more attention in future workshops and in training. Furthermore, by adding more specific questions related to each section of the workshop, associations among presentation style, knowledge gained, and perceived usefulness of each section could be evaluated. For example, the participants significantly increased their scores from pretest to posttest on the catheter‐related knowledge‐based question and rated the lecture and case study on intravascular catheter‐related infections as the most useful sections. Future research may explore these possible relationships to better guide selection of presentation styles and topics to ensure that participants gain knowledge and perceive the sections as useful. In addition, by addressing the feedback from participants, such as offering more detail, examples, and discussion, future workshops may have greater perceived usefulness and be better able to increase the knowledge and awareness of quality improvement programs for the prevention of health careassociated infections and antimicrobial resistance.

Although there were 3 workshops conducted in 3 areas across the United States, the sample size at each site was small, and results may not be representative of hospitalists at large. In addition, power calculations should be considered in future studies to increase the ability to better detect differences between and within groups. Another limitation of this study was that the limited data available and participant anonymity meant it was not possible to follow‐up with participants after the workshop to evaluate whether the knowledge they gained was sustained and/or whether they reported changes in practice. However, possession of knowledge and skills to inform practice does not mean that practice will change; therefore, follow‐up is necessary to determine if this workshop was effective in changing behaviors in the long term.25 Although the SHM workshop improved knowledge, more intensive educational strategies may be necessary to affect perceptions and improve the leadership skills required for implementation of quality improvement programs at an institutional level.

Overall, the SHM workshop was found to be a useful tool for increasing knowledge and outlining methods by which hospitalists can lead, coordinate, or participate in measures to prevent infections and improve patient safety. In addition, through the workshop, the SHM and the CDC have provided an example of how professional societies and government agencies can collaborate to address emerging issues in the health care setting.