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4.12 Healthcare Systems: Leadership in Healthcare
Introduction
Healthcare is complex and dynamic. As such, it requires leaders who understand its multiple components, including highly technical professions, longstanding institutions of care and education, third-party payers, and large supporting industries. Regulatory frameworks, fragmented incentives, and multidimensional determinants of health serve to further complicate healthcare processes. Leadership is a broad construct that involves individuals, interactions, and change. Leaders motivate and influence others using a combination of virtuous behavior and process-oriented management of change. Pediatric hospitalists are required to be leaders on a daily basis, in communication, interprofessional practice, high-performing teams, operational efficiency, quality improvement efforts, and family centered care. They often are involved in administration, where additional competencies in business and strategy are also useful. Pediatric hospitalists work in the most complex and expensive part of the healthcare system and are therefore well positioned to lead at the bedside, in programs, and in the larger healthcare system.
Knowledge
Pediatric hospitalists should be able to:
- Identify some common models or styles of leadership, such as transformational, transactional, autocratic, laissez-faire, task-oriented, and relationship-oriented leadership.
- Review the impact that differing leadership styles may have on quality improvement and patient safety efforts.
- Compare and contrast leadership styles with communication styles.
- Illustrate how utilizing leadership skills enhances performance when working clinically at the bedside, as well as when leading projects, programs, or other larger efforts.
- Identify the key aspects of a high-performing healthcare system, attending to continuous learning, equity, cost, patient experience, access, clinical quality, and patient safety.
- Identify the key aspects of a high-performing team, attending to mutual respect, recognition, communication, cohesion, mutual support, and situational awareness.
- Describe the importance of task and role clarity in team performance.
- List factors that impact team dynamics.
- Explain how respecting dignity and embracing cultural diversity in the context of family centered and interprofessional health care is central to effective leadership.
- Compare and contrast between leadership and management.
- Explain the importance of setting vision and strategy in leadership.
- List examples of commonly used group decision-making techniques, such as brainstorming, nominal group, Delphi, and dialectical inquiry.
- Define “change management” and review the role of leaders as change agents for projects and quality improvement processes.
- Discuss the impact of effective leadership of interprofessional teams on hospital daily operational efficiency and throughput.
- Describe the impact of effective leadership on quality improvement efforts, patient safety, high value care, hospital business, and population health outcomes.
Skills
Pediatric hospitalists should be able to:
- Demonstrate effective leadership skills in communication, de-escalation and conflict resolution and management of team dynamic problems.
- Lead family centered rounds with an interprofessional team.
- Execute efficient operations, such as hospital throughput, in collaboration with hospital administrative initiatives.
- Collaborate in interprofessional improvement initiatives.
- Demonstrate basic skills in leading an effective meeting that results in a specific outcome, decision, or action.
Attitudes
Pediatric hospitalists should be able to:
- Realize the value of cultural and professional diversity in interprofessional practice and family centered care.
- Model self-awareness, ethical behavior, integrity, and inclusiveness.
- Reflect on the importance of leadership as a journey of self-development.
- Exemplify effective delivery and receipt of constructive feedback.
- Recognize the interaction between business performance, healthcare delivery, and clinical outcomes in an evolving health care landscape.
Systems Organization and Improvement
In order to improve efficiency and quality within their organizations, pediatric hospitalists should:
- Lead, coordinate or participate in efforts to expand education and mentorship in leadership skills in pediatric hospital medicine.
- Participate and lead where appropriate in division, department or group, and hospital level committees to advocate for care of hospitalized children.
- Collaborate with and actively participate and lead where appropriate in medical staff related activities.
1. Kotter JP. Leading change: Why transformation efforts fail, Harv Bus Rev. 1995;73:59-67.
2. Kotter JP. What leaders really do. Harv Bus Rev. 1990;68(3):103-11.
3. Conway P, Chjopra V, Saint S., Moniz MH, et al. Leadership and Professional Development Series. Journal of Hospital Medicine. 2019;14(2-8) https://www.journalofhospitalmedicine.com/jhospmed/leadership-and-professional-development. Accessed August 23, 2019.
Introduction
Healthcare is complex and dynamic. As such, it requires leaders who understand its multiple components, including highly technical professions, longstanding institutions of care and education, third-party payers, and large supporting industries. Regulatory frameworks, fragmented incentives, and multidimensional determinants of health serve to further complicate healthcare processes. Leadership is a broad construct that involves individuals, interactions, and change. Leaders motivate and influence others using a combination of virtuous behavior and process-oriented management of change. Pediatric hospitalists are required to be leaders on a daily basis, in communication, interprofessional practice, high-performing teams, operational efficiency, quality improvement efforts, and family centered care. They often are involved in administration, where additional competencies in business and strategy are also useful. Pediatric hospitalists work in the most complex and expensive part of the healthcare system and are therefore well positioned to lead at the bedside, in programs, and in the larger healthcare system.
Knowledge
Pediatric hospitalists should be able to:
- Identify some common models or styles of leadership, such as transformational, transactional, autocratic, laissez-faire, task-oriented, and relationship-oriented leadership.
- Review the impact that differing leadership styles may have on quality improvement and patient safety efforts.
- Compare and contrast leadership styles with communication styles.
- Illustrate how utilizing leadership skills enhances performance when working clinically at the bedside, as well as when leading projects, programs, or other larger efforts.
- Identify the key aspects of a high-performing healthcare system, attending to continuous learning, equity, cost, patient experience, access, clinical quality, and patient safety.
- Identify the key aspects of a high-performing team, attending to mutual respect, recognition, communication, cohesion, mutual support, and situational awareness.
- Describe the importance of task and role clarity in team performance.
- List factors that impact team dynamics.
- Explain how respecting dignity and embracing cultural diversity in the context of family centered and interprofessional health care is central to effective leadership.
- Compare and contrast between leadership and management.
- Explain the importance of setting vision and strategy in leadership.
- List examples of commonly used group decision-making techniques, such as brainstorming, nominal group, Delphi, and dialectical inquiry.
- Define “change management” and review the role of leaders as change agents for projects and quality improvement processes.
- Discuss the impact of effective leadership of interprofessional teams on hospital daily operational efficiency and throughput.
- Describe the impact of effective leadership on quality improvement efforts, patient safety, high value care, hospital business, and population health outcomes.
Skills
Pediatric hospitalists should be able to:
- Demonstrate effective leadership skills in communication, de-escalation and conflict resolution and management of team dynamic problems.
- Lead family centered rounds with an interprofessional team.
- Execute efficient operations, such as hospital throughput, in collaboration with hospital administrative initiatives.
- Collaborate in interprofessional improvement initiatives.
- Demonstrate basic skills in leading an effective meeting that results in a specific outcome, decision, or action.
Attitudes
Pediatric hospitalists should be able to:
- Realize the value of cultural and professional diversity in interprofessional practice and family centered care.
- Model self-awareness, ethical behavior, integrity, and inclusiveness.
- Reflect on the importance of leadership as a journey of self-development.
- Exemplify effective delivery and receipt of constructive feedback.
- Recognize the interaction between business performance, healthcare delivery, and clinical outcomes in an evolving health care landscape.
Systems Organization and Improvement
In order to improve efficiency and quality within their organizations, pediatric hospitalists should:
- Lead, coordinate or participate in efforts to expand education and mentorship in leadership skills in pediatric hospital medicine.
- Participate and lead where appropriate in division, department or group, and hospital level committees to advocate for care of hospitalized children.
- Collaborate with and actively participate and lead where appropriate in medical staff related activities.
Introduction
Healthcare is complex and dynamic. As such, it requires leaders who understand its multiple components, including highly technical professions, longstanding institutions of care and education, third-party payers, and large supporting industries. Regulatory frameworks, fragmented incentives, and multidimensional determinants of health serve to further complicate healthcare processes. Leadership is a broad construct that involves individuals, interactions, and change. Leaders motivate and influence others using a combination of virtuous behavior and process-oriented management of change. Pediatric hospitalists are required to be leaders on a daily basis, in communication, interprofessional practice, high-performing teams, operational efficiency, quality improvement efforts, and family centered care. They often are involved in administration, where additional competencies in business and strategy are also useful. Pediatric hospitalists work in the most complex and expensive part of the healthcare system and are therefore well positioned to lead at the bedside, in programs, and in the larger healthcare system.
Knowledge
Pediatric hospitalists should be able to:
- Identify some common models or styles of leadership, such as transformational, transactional, autocratic, laissez-faire, task-oriented, and relationship-oriented leadership.
- Review the impact that differing leadership styles may have on quality improvement and patient safety efforts.
- Compare and contrast leadership styles with communication styles.
- Illustrate how utilizing leadership skills enhances performance when working clinically at the bedside, as well as when leading projects, programs, or other larger efforts.
- Identify the key aspects of a high-performing healthcare system, attending to continuous learning, equity, cost, patient experience, access, clinical quality, and patient safety.
- Identify the key aspects of a high-performing team, attending to mutual respect, recognition, communication, cohesion, mutual support, and situational awareness.
- Describe the importance of task and role clarity in team performance.
- List factors that impact team dynamics.
- Explain how respecting dignity and embracing cultural diversity in the context of family centered and interprofessional health care is central to effective leadership.
- Compare and contrast between leadership and management.
- Explain the importance of setting vision and strategy in leadership.
- List examples of commonly used group decision-making techniques, such as brainstorming, nominal group, Delphi, and dialectical inquiry.
- Define “change management” and review the role of leaders as change agents for projects and quality improvement processes.
- Discuss the impact of effective leadership of interprofessional teams on hospital daily operational efficiency and throughput.
- Describe the impact of effective leadership on quality improvement efforts, patient safety, high value care, hospital business, and population health outcomes.
Skills
Pediatric hospitalists should be able to:
- Demonstrate effective leadership skills in communication, de-escalation and conflict resolution and management of team dynamic problems.
- Lead family centered rounds with an interprofessional team.
- Execute efficient operations, such as hospital throughput, in collaboration with hospital administrative initiatives.
- Collaborate in interprofessional improvement initiatives.
- Demonstrate basic skills in leading an effective meeting that results in a specific outcome, decision, or action.
Attitudes
Pediatric hospitalists should be able to:
- Realize the value of cultural and professional diversity in interprofessional practice and family centered care.
- Model self-awareness, ethical behavior, integrity, and inclusiveness.
- Reflect on the importance of leadership as a journey of self-development.
- Exemplify effective delivery and receipt of constructive feedback.
- Recognize the interaction between business performance, healthcare delivery, and clinical outcomes in an evolving health care landscape.
Systems Organization and Improvement
In order to improve efficiency and quality within their organizations, pediatric hospitalists should:
- Lead, coordinate or participate in efforts to expand education and mentorship in leadership skills in pediatric hospital medicine.
- Participate and lead where appropriate in division, department or group, and hospital level committees to advocate for care of hospitalized children.
- Collaborate with and actively participate and lead where appropriate in medical staff related activities.
1. Kotter JP. Leading change: Why transformation efforts fail, Harv Bus Rev. 1995;73:59-67.
2. Kotter JP. What leaders really do. Harv Bus Rev. 1990;68(3):103-11.
3. Conway P, Chjopra V, Saint S., Moniz MH, et al. Leadership and Professional Development Series. Journal of Hospital Medicine. 2019;14(2-8) https://www.journalofhospitalmedicine.com/jhospmed/leadership-and-professional-development. Accessed August 23, 2019.
1. Kotter JP. Leading change: Why transformation efforts fail, Harv Bus Rev. 1995;73:59-67.
2. Kotter JP. What leaders really do. Harv Bus Rev. 1990;68(3):103-11.
3. Conway P, Chjopra V, Saint S., Moniz MH, et al. Leadership and Professional Development Series. Journal of Hospital Medicine. 2019;14(2-8) https://www.journalofhospitalmedicine.com/jhospmed/leadership-and-professional-development. Accessed August 23, 2019.
4.11 Healthcare Systems: Infection Control and Antimicrobial Stewardship
Introduction
Infections are one of the most common causes of hospitalization, morbidity, and mortality among children. Infections due to antibiotic resistant bacteria are an increasing burden on public health. Antibiotic exposure in both the ambulatory and hospital settings is a prime driver for development of antibiotic resistance and is a risk factor for developing infections which are increasingly due to multi-drug resistant organisms (MDROs). As the number of children surviving with significant medical complexity grows, the incidence of device-associated infections and of hospital-acquired (nosocomial) infections (HAI) is also rising. In addition, children are often more severely impacted when community outbreaks of infectious diseases occur, requiring rapid identification, containment, and treatment while limiting unnecessary antibiotic exposure. Pediatric hospitalists play a vital role in minimizing antimicrobial treatment risks to children through the judicious use of antimicrobials and participation in antimicrobial stewardship programs and practices.
Knowledge
Pediatric hospitalists should be able to:
- Describe common infection prevention measures used to reduce the spread of infection, including vaccinations, hand hygiene, and the use of personal protective equipment (PPE).
- Define commonly used infection control terms for precautions, such as standard, contact, droplet, airborne, protective (reverse) isolation, and transmission-based, and give an example of each.
- Explain the difference between community-acquired and hospital-acquired infections.
- Explain why antibiotic exposure is a prime driver of antibiotic resistance.
- Cite examples of commonly used daily practices that are integral to antimicrobial stewardship, such as judicious initiation of antimicrobials, appropriate use and interpretation of diagnostic microbiology, and narrowing the spectrum or discontinuation of antimicrobials.
- Delineate the risk for and types of infections associated with commonly used temporary medical devices, such as urinary catheters, intravenous access lines, chest tubes, nasogastric tubes, and others.
- Delineate the risk for and types of infections associated with common chronic medical devices, such as tracheostomy tubes, ventriculoperitoneal shunts, and others.
- Distinguish between empirical and definitive antimicrobial prescribing.
- Review the risks of repeated antimicrobial empiric therapy use for children with chronic medical complexity, attending to antimicrobial resistance for the host and community, antimicrobial side effects, and drug-drug interactions that may limit antimicrobial effectiveness.
- List common adverse effects of frequently prescribed antibiotics and antivirals for children hospitalized with routine infections, such as pneumonia, cellulitis, and fever in the infant, and discuss how antimicrobial stewardship and infection control practices may minimize these risks.
- List common strategies used by antimicrobial stewardship programs to optimize appropriate antimicrobial use, including prospective audit and feedback, formulary restrictions, automated stop dates for prescribed antibiotics, and 48-hour timeouts.
- Summarize common infection control practices used to minimize the risk of HAIs, including catheter-related bloodstream infections, urinary catheter infections, and others.
- List common multiple-drug resistant organisms (MDROs) and distinguish between infection control practices for these organisms compared to other infectious organisms.
- Review the clinical presentation of Clostridium difficile infection in children and discuss risk factors for it, including antibiotic exposure.
- Describe the relationship between antimicrobial stewardship, patient safety, and quality improvement, including clinical practice guidelines.
- Discuss how the hospital may be a potential venue for initial recognition of a community infectious disease outbreak and review the role that pediatric hospitalists can play in patient triage, admission decision-making, management, and hospital flow, attending to local context and resources.
- Review the relationship between community infection outbreaks and vaccination rates and discuss the role pediatric hospitalists can play in vaccination of hospitalized children.
- List which communicable diseases are mandatory to report to the local or state Department of Health.
Skills
Pediatric hospitalists should be able to:
- Demonstrate skills in recognizing the need for and ordering appropriate isolation precautions for children hospitalized with acute infection symptoms.
- Determine the need for and order appropriate contact precautions for children hospitalized with a history of MDRO infection, including methicillin-resistant Staphylococcus aureus (MRSA) and multi-drug resistant gram-negative bacteria.
- Select and order appropriate diagnostic studies for commonly encountered infections, including serologies, polymerase chain reaction (PCR) tests, cultures and sensitivities for varied organisms (including bacterial, viral, and fungal), and other rapid diagnostic testing for pathogens as available in the local context.
- Interpret diagnostic testing results efficiently and initiate appropriate treatment based on the results.
- Interpret diagnostic testing performed related to medical devices, distinguishing between infection and colonization, and initiate or change treatment based on the results.
- Participate actively in infection prevention and control programs.
- Utilize antimicrobial best practices that are embedded in local clinical pathways.
- Identify common signs and symptoms of possible device-associated infection.
- Interpret a hospital antibiogram to guide selection of antibiotic therapy.
- Identify opportunities to limit antimicrobial exposure among hospitalized children receiving empirical antibiotic therapy and initiate action for a given patient or population of patients.
- Develop and execute antibiotic treatment plans that maximize the safety of antibiotic use, including transitions to oral antibiotics when appropriate, limiting treatment duration, and discontinuing antibiotics.
- Communicate and educate patient and the family/caregivers regarding the risks and benefits of antimicrobial treatment and the importance of adhering to infection control practices, including rules regarding visitation during infectious seasons or outbreaks.
Attitudes
Pediatric hospitalists should be able to:
- Recognize that infection control practices are a primary means of reducing the risk of harm to hospitalized children.
- Reflect on the importance of collaboration with infectious diseases specialists and pharmacists to improve the judicious use of antibiotics.
- Role model infection control practices at the bedside including appropriate empirical and definitive antibiotic therapy practices.
- Reflect on the impact that infection control practices may have on patients and the family/caregivers.
- Recognize how adhering to infection control practices and antimicrobial stewardship for a given patient influences risks for the patient and the larger community.
Systems Organization and Improvement
In order to improve efficiency and quality within their organizations, pediatric hospitalists should:
- Collaborate with hospital staff, infection prevention specialists, hospital epidemiologists, microbiology laboratory, and others in multidisciplinary initiatives to monitor and prevent community-acquired and nosocomial infections.
- Coordinate or participate in the local antimicrobial stewardship program to develop and implement evidence-based guidelines for antimicrobial use.
- Lead, coordinate, or participate in the local program to reduce the incidence of hospital-acquired infections.
- Lead, coordinate, or participate in efforts to educate staff, trainees, patients, and the family/caregivers on the importance of infection control and antimicrobial stewardship.
1. Centers for Disease Control and Prevention. Core Elements of Hospital Antibiotic Stewardship Programs. 2019 Edition. https://www.cdc.gov/antibiotic-use/core-elements/hospital.html?CDC_AA_refVal=https%3A%2F%2Fwww.cdc.gov%2Fantibiotic-use%2Fhealthcare%2Fimplementation%2Fcore-elements.html. Accessed August 26, 2019.
2. Fishman N, Patterson J, Saiman L, et al. Policy statement on antimicrobial stewardship by the Society for Healthcare Epidemiology of America (SHEA), the Infectious Diseases Society of America (IDSA), and the Pediatric Infectious Diseases Society (PIDS). Pediatric Infect Control Hosp Epidemiol. 2012;33(4):322-327. https://doi.org/10.1086/665010.
3. Baur D, Gladstone BP, Burkert F, et al. Effect of antibiotic stewardship on the incidence of infection and colonization with antibiotic-resistant bacteria and Clostridium difficile infection: A systematic review and meta-analysis. Lancet Infect Dis. 2017;17(9):990-1001. https://doi.org/10.1016/S1473-3099(17)30325-0.
Introduction
Infections are one of the most common causes of hospitalization, morbidity, and mortality among children. Infections due to antibiotic resistant bacteria are an increasing burden on public health. Antibiotic exposure in both the ambulatory and hospital settings is a prime driver for development of antibiotic resistance and is a risk factor for developing infections which are increasingly due to multi-drug resistant organisms (MDROs). As the number of children surviving with significant medical complexity grows, the incidence of device-associated infections and of hospital-acquired (nosocomial) infections (HAI) is also rising. In addition, children are often more severely impacted when community outbreaks of infectious diseases occur, requiring rapid identification, containment, and treatment while limiting unnecessary antibiotic exposure. Pediatric hospitalists play a vital role in minimizing antimicrobial treatment risks to children through the judicious use of antimicrobials and participation in antimicrobial stewardship programs and practices.
Knowledge
Pediatric hospitalists should be able to:
- Describe common infection prevention measures used to reduce the spread of infection, including vaccinations, hand hygiene, and the use of personal protective equipment (PPE).
- Define commonly used infection control terms for precautions, such as standard, contact, droplet, airborne, protective (reverse) isolation, and transmission-based, and give an example of each.
- Explain the difference between community-acquired and hospital-acquired infections.
- Explain why antibiotic exposure is a prime driver of antibiotic resistance.
- Cite examples of commonly used daily practices that are integral to antimicrobial stewardship, such as judicious initiation of antimicrobials, appropriate use and interpretation of diagnostic microbiology, and narrowing the spectrum or discontinuation of antimicrobials.
- Delineate the risk for and types of infections associated with commonly used temporary medical devices, such as urinary catheters, intravenous access lines, chest tubes, nasogastric tubes, and others.
- Delineate the risk for and types of infections associated with common chronic medical devices, such as tracheostomy tubes, ventriculoperitoneal shunts, and others.
- Distinguish between empirical and definitive antimicrobial prescribing.
- Review the risks of repeated antimicrobial empiric therapy use for children with chronic medical complexity, attending to antimicrobial resistance for the host and community, antimicrobial side effects, and drug-drug interactions that may limit antimicrobial effectiveness.
- List common adverse effects of frequently prescribed antibiotics and antivirals for children hospitalized with routine infections, such as pneumonia, cellulitis, and fever in the infant, and discuss how antimicrobial stewardship and infection control practices may minimize these risks.
- List common strategies used by antimicrobial stewardship programs to optimize appropriate antimicrobial use, including prospective audit and feedback, formulary restrictions, automated stop dates for prescribed antibiotics, and 48-hour timeouts.
- Summarize common infection control practices used to minimize the risk of HAIs, including catheter-related bloodstream infections, urinary catheter infections, and others.
- List common multiple-drug resistant organisms (MDROs) and distinguish between infection control practices for these organisms compared to other infectious organisms.
- Review the clinical presentation of Clostridium difficile infection in children and discuss risk factors for it, including antibiotic exposure.
- Describe the relationship between antimicrobial stewardship, patient safety, and quality improvement, including clinical practice guidelines.
- Discuss how the hospital may be a potential venue for initial recognition of a community infectious disease outbreak and review the role that pediatric hospitalists can play in patient triage, admission decision-making, management, and hospital flow, attending to local context and resources.
- Review the relationship between community infection outbreaks and vaccination rates and discuss the role pediatric hospitalists can play in vaccination of hospitalized children.
- List which communicable diseases are mandatory to report to the local or state Department of Health.
Skills
Pediatric hospitalists should be able to:
- Demonstrate skills in recognizing the need for and ordering appropriate isolation precautions for children hospitalized with acute infection symptoms.
- Determine the need for and order appropriate contact precautions for children hospitalized with a history of MDRO infection, including methicillin-resistant Staphylococcus aureus (MRSA) and multi-drug resistant gram-negative bacteria.
- Select and order appropriate diagnostic studies for commonly encountered infections, including serologies, polymerase chain reaction (PCR) tests, cultures and sensitivities for varied organisms (including bacterial, viral, and fungal), and other rapid diagnostic testing for pathogens as available in the local context.
- Interpret diagnostic testing results efficiently and initiate appropriate treatment based on the results.
- Interpret diagnostic testing performed related to medical devices, distinguishing between infection and colonization, and initiate or change treatment based on the results.
- Participate actively in infection prevention and control programs.
- Utilize antimicrobial best practices that are embedded in local clinical pathways.
- Identify common signs and symptoms of possible device-associated infection.
- Interpret a hospital antibiogram to guide selection of antibiotic therapy.
- Identify opportunities to limit antimicrobial exposure among hospitalized children receiving empirical antibiotic therapy and initiate action for a given patient or population of patients.
- Develop and execute antibiotic treatment plans that maximize the safety of antibiotic use, including transitions to oral antibiotics when appropriate, limiting treatment duration, and discontinuing antibiotics.
- Communicate and educate patient and the family/caregivers regarding the risks and benefits of antimicrobial treatment and the importance of adhering to infection control practices, including rules regarding visitation during infectious seasons or outbreaks.
Attitudes
Pediatric hospitalists should be able to:
- Recognize that infection control practices are a primary means of reducing the risk of harm to hospitalized children.
- Reflect on the importance of collaboration with infectious diseases specialists and pharmacists to improve the judicious use of antibiotics.
- Role model infection control practices at the bedside including appropriate empirical and definitive antibiotic therapy practices.
- Reflect on the impact that infection control practices may have on patients and the family/caregivers.
- Recognize how adhering to infection control practices and antimicrobial stewardship for a given patient influences risks for the patient and the larger community.
Systems Organization and Improvement
In order to improve efficiency and quality within their organizations, pediatric hospitalists should:
- Collaborate with hospital staff, infection prevention specialists, hospital epidemiologists, microbiology laboratory, and others in multidisciplinary initiatives to monitor and prevent community-acquired and nosocomial infections.
- Coordinate or participate in the local antimicrobial stewardship program to develop and implement evidence-based guidelines for antimicrobial use.
- Lead, coordinate, or participate in the local program to reduce the incidence of hospital-acquired infections.
- Lead, coordinate, or participate in efforts to educate staff, trainees, patients, and the family/caregivers on the importance of infection control and antimicrobial stewardship.
Introduction
Infections are one of the most common causes of hospitalization, morbidity, and mortality among children. Infections due to antibiotic resistant bacteria are an increasing burden on public health. Antibiotic exposure in both the ambulatory and hospital settings is a prime driver for development of antibiotic resistance and is a risk factor for developing infections which are increasingly due to multi-drug resistant organisms (MDROs). As the number of children surviving with significant medical complexity grows, the incidence of device-associated infections and of hospital-acquired (nosocomial) infections (HAI) is also rising. In addition, children are often more severely impacted when community outbreaks of infectious diseases occur, requiring rapid identification, containment, and treatment while limiting unnecessary antibiotic exposure. Pediatric hospitalists play a vital role in minimizing antimicrobial treatment risks to children through the judicious use of antimicrobials and participation in antimicrobial stewardship programs and practices.
Knowledge
Pediatric hospitalists should be able to:
- Describe common infection prevention measures used to reduce the spread of infection, including vaccinations, hand hygiene, and the use of personal protective equipment (PPE).
- Define commonly used infection control terms for precautions, such as standard, contact, droplet, airborne, protective (reverse) isolation, and transmission-based, and give an example of each.
- Explain the difference between community-acquired and hospital-acquired infections.
- Explain why antibiotic exposure is a prime driver of antibiotic resistance.
- Cite examples of commonly used daily practices that are integral to antimicrobial stewardship, such as judicious initiation of antimicrobials, appropriate use and interpretation of diagnostic microbiology, and narrowing the spectrum or discontinuation of antimicrobials.
- Delineate the risk for and types of infections associated with commonly used temporary medical devices, such as urinary catheters, intravenous access lines, chest tubes, nasogastric tubes, and others.
- Delineate the risk for and types of infections associated with common chronic medical devices, such as tracheostomy tubes, ventriculoperitoneal shunts, and others.
- Distinguish between empirical and definitive antimicrobial prescribing.
- Review the risks of repeated antimicrobial empiric therapy use for children with chronic medical complexity, attending to antimicrobial resistance for the host and community, antimicrobial side effects, and drug-drug interactions that may limit antimicrobial effectiveness.
- List common adverse effects of frequently prescribed antibiotics and antivirals for children hospitalized with routine infections, such as pneumonia, cellulitis, and fever in the infant, and discuss how antimicrobial stewardship and infection control practices may minimize these risks.
- List common strategies used by antimicrobial stewardship programs to optimize appropriate antimicrobial use, including prospective audit and feedback, formulary restrictions, automated stop dates for prescribed antibiotics, and 48-hour timeouts.
- Summarize common infection control practices used to minimize the risk of HAIs, including catheter-related bloodstream infections, urinary catheter infections, and others.
- List common multiple-drug resistant organisms (MDROs) and distinguish between infection control practices for these organisms compared to other infectious organisms.
- Review the clinical presentation of Clostridium difficile infection in children and discuss risk factors for it, including antibiotic exposure.
- Describe the relationship between antimicrobial stewardship, patient safety, and quality improvement, including clinical practice guidelines.
- Discuss how the hospital may be a potential venue for initial recognition of a community infectious disease outbreak and review the role that pediatric hospitalists can play in patient triage, admission decision-making, management, and hospital flow, attending to local context and resources.
- Review the relationship between community infection outbreaks and vaccination rates and discuss the role pediatric hospitalists can play in vaccination of hospitalized children.
- List which communicable diseases are mandatory to report to the local or state Department of Health.
Skills
Pediatric hospitalists should be able to:
- Demonstrate skills in recognizing the need for and ordering appropriate isolation precautions for children hospitalized with acute infection symptoms.
- Determine the need for and order appropriate contact precautions for children hospitalized with a history of MDRO infection, including methicillin-resistant Staphylococcus aureus (MRSA) and multi-drug resistant gram-negative bacteria.
- Select and order appropriate diagnostic studies for commonly encountered infections, including serologies, polymerase chain reaction (PCR) tests, cultures and sensitivities for varied organisms (including bacterial, viral, and fungal), and other rapid diagnostic testing for pathogens as available in the local context.
- Interpret diagnostic testing results efficiently and initiate appropriate treatment based on the results.
- Interpret diagnostic testing performed related to medical devices, distinguishing between infection and colonization, and initiate or change treatment based on the results.
- Participate actively in infection prevention and control programs.
- Utilize antimicrobial best practices that are embedded in local clinical pathways.
- Identify common signs and symptoms of possible device-associated infection.
- Interpret a hospital antibiogram to guide selection of antibiotic therapy.
- Identify opportunities to limit antimicrobial exposure among hospitalized children receiving empirical antibiotic therapy and initiate action for a given patient or population of patients.
- Develop and execute antibiotic treatment plans that maximize the safety of antibiotic use, including transitions to oral antibiotics when appropriate, limiting treatment duration, and discontinuing antibiotics.
- Communicate and educate patient and the family/caregivers regarding the risks and benefits of antimicrobial treatment and the importance of adhering to infection control practices, including rules regarding visitation during infectious seasons or outbreaks.
Attitudes
Pediatric hospitalists should be able to:
- Recognize that infection control practices are a primary means of reducing the risk of harm to hospitalized children.
- Reflect on the importance of collaboration with infectious diseases specialists and pharmacists to improve the judicious use of antibiotics.
- Role model infection control practices at the bedside including appropriate empirical and definitive antibiotic therapy practices.
- Reflect on the impact that infection control practices may have on patients and the family/caregivers.
- Recognize how adhering to infection control practices and antimicrobial stewardship for a given patient influences risks for the patient and the larger community.
Systems Organization and Improvement
In order to improve efficiency and quality within their organizations, pediatric hospitalists should:
- Collaborate with hospital staff, infection prevention specialists, hospital epidemiologists, microbiology laboratory, and others in multidisciplinary initiatives to monitor and prevent community-acquired and nosocomial infections.
- Coordinate or participate in the local antimicrobial stewardship program to develop and implement evidence-based guidelines for antimicrobial use.
- Lead, coordinate, or participate in the local program to reduce the incidence of hospital-acquired infections.
- Lead, coordinate, or participate in efforts to educate staff, trainees, patients, and the family/caregivers on the importance of infection control and antimicrobial stewardship.
1. Centers for Disease Control and Prevention. Core Elements of Hospital Antibiotic Stewardship Programs. 2019 Edition. https://www.cdc.gov/antibiotic-use/core-elements/hospital.html?CDC_AA_refVal=https%3A%2F%2Fwww.cdc.gov%2Fantibiotic-use%2Fhealthcare%2Fimplementation%2Fcore-elements.html. Accessed August 26, 2019.
2. Fishman N, Patterson J, Saiman L, et al. Policy statement on antimicrobial stewardship by the Society for Healthcare Epidemiology of America (SHEA), the Infectious Diseases Society of America (IDSA), and the Pediatric Infectious Diseases Society (PIDS). Pediatric Infect Control Hosp Epidemiol. 2012;33(4):322-327. https://doi.org/10.1086/665010.
3. Baur D, Gladstone BP, Burkert F, et al. Effect of antibiotic stewardship on the incidence of infection and colonization with antibiotic-resistant bacteria and Clostridium difficile infection: A systematic review and meta-analysis. Lancet Infect Dis. 2017;17(9):990-1001. https://doi.org/10.1016/S1473-3099(17)30325-0.
1. Centers for Disease Control and Prevention. Core Elements of Hospital Antibiotic Stewardship Programs. 2019 Edition. https://www.cdc.gov/antibiotic-use/core-elements/hospital.html?CDC_AA_refVal=https%3A%2F%2Fwww.cdc.gov%2Fantibiotic-use%2Fhealthcare%2Fimplementation%2Fcore-elements.html. Accessed August 26, 2019.
2. Fishman N, Patterson J, Saiman L, et al. Policy statement on antimicrobial stewardship by the Society for Healthcare Epidemiology of America (SHEA), the Infectious Diseases Society of America (IDSA), and the Pediatric Infectious Diseases Society (PIDS). Pediatric Infect Control Hosp Epidemiol. 2012;33(4):322-327. https://doi.org/10.1086/665010.
3. Baur D, Gladstone BP, Burkert F, et al. Effect of antibiotic stewardship on the incidence of infection and colonization with antibiotic-resistant bacteria and Clostridium difficile infection: A systematic review and meta-analysis. Lancet Infect Dis. 2017;17(9):990-1001. https://doi.org/10.1016/S1473-3099(17)30325-0.
4.10 Healthcare Systems: High Value Care
Introduction
Value in healthcare is defined as quality achieved relative to cost. Quality encompasses individual patient and population health outcomes, safety, and experience while cost includes resource utilization and opportunity costs. In order to operationalize high value care (HVC), the Centers for Medicare and Medicaid chose to apply the Institute of Healthcare Improvement’s Triple Aim framework – improving the patient experience, improving the health of populations, and reducing the cost of health care. Pediatric hospitalists are well positioned to promote high value care by decreasing costs, increasing safety, enhancing the patient experience, improving efficiency of care delivery, and improving clinical outcomes. Pediatric hospitalists should deliver healthcare in a manner that optimizes value to the patient, patient populations, and the healthcare system.
Knowledge
Pediatric hospitalists should be able to:
- Discuss how providing “the right care at the right time in the right place” is necessary to optimize value to the patient and the system.
- Summarize the basic structure of the patient-centered health care delivery system, including the macro system (national and regional systems), the mesosystem (integrated inpatient and outpatient settings), and the microsystem (front line care between physician and patient).
- Summarize the National Academy of Medicine’s (formerly Institute of Medicine) six aims of healthcare: Safe, Timely, Efficient, Equitable, Effective, and Patient-centered care.
- State the importance of defining healthcare value as the ratio of quality over cost and compare and contrast value for a single episode of care for one patient versus for a population over time.
- Discuss how coordinated management of complex chronic diseases and development of integrated delivery systems can impact healthcare value for patients, the family/caregivers, and the healthcare system.
- Cite examples of how failure to coordinate and align care in and across each of the above systems can fragment healthcare delivery.
- Compare and contrast the definition of healthcare quality from the perspectives of different stakeholders, including the government, other payors, healthcare systems, hospital and medical staff, and patients and family/caregivers.
- Define the terms “overuse,” “over-diagnosis,” “over-testing,” and “over-treatment” and review how these may impact patient safety, the patient experience, and costs of care.
- Using evidence-based medicine principles, describe how best practices and streamlined clinical care result in increased healthcare value.
- Explain why hospitalists should have a working knowledge of the risks, benefits, harms, pretest probability, and relative costs of commonly performed healthcare tests and treatments.
- Review the goals of shared decision-making discussions and cite how healthcare value should reflect the patients’ and family/caregivers’ unique perspectives on goals of care .
- Provide examples of hospital care costs under control of the hospitalist and review how controlling costs for a single patient or population of patients impacts the value equation.
- Illustrate the importance of local considerations when prescribing a treatment plan, such as total cost, compliance, pediatric formulation, and insurance formulary lists.
- Summarize the relationship between patient safety, quality improvement, and high value care.
Skills
Pediatric hospitalists should be able to:
- Demonstrate skills in communicating indications for tests, procedures, and medications, with patients, the family/caregivers, consultants, and the healthcare team.
- Provide education and information to patients and the family/caregivers that assists them in understanding and choosing care that is supported by evidence.
- Identify costs to patients (including time, anxiety, expense, and clinical harm) and the healthcare system (including time, resources, and expense).
- Educate trainees on the definition of healthcare value and importance of cost considerations of medical care.
- Demonstrate proficiency in adhering to best practice protocols and guidelines.
- Identify interventions that provide no benefit to overall clinical health outcome and/or may be harmful and participate in abating or eliminating these practices.
- Participate in developing, utilizing, or reviewing performance reports to improve delivery of value-based care.
- Apply the concept of “Right patient, right place, right time” in practice, to maximize value to the patient and the healthcare system.
- Work effectively and collaboratively to integrate hospital discharge and post discharge care.
Attitudes
Pediatric hospitalists should be able to:
- Recognize the importance of providing preventive healthcare as part of a high value care.
- Role model resource utilization stewardship by allocating resources that result in high-value and evidence-based care.
- Realize the value of working collaboratively with other stakeholders to continuously improve health care outcomes in a patient centered and cost-effective manner.
- Demonstrate leadership and professionalism by proactively seeking feedback on clinical practice patterns to identify actions viewed as low-value or harmful to patients.
Systems Organization and Improvement
In order to improve efficiency and quality within their organizations, pediatric hospitalists should:
- Collaborate with hospital administration, colleagues, and other hospital staff to identify and share information about costs of care, including drugs, medical imaging, devices, procedures, and consultations.
- Support healthcare system efforts to gather and disseminate cost, quality, and safety data for use in monitoring quality and business improvement efforts.
- Promote standardization of clinical care based on local pathways or protocols and national clinical practice guidelines as tangible ways to improve adherence to best practices and increase value.
- Collaborate with hospital administrators to determine and direct policies that impact healthcare utilization.
- Provide leadership to affect change on a systemic level by identifying opportunities to improve outcomes, minimize harm, and reduce health care waste.
1. American Board of Internal Medicine. Choosing Wisely. http://www.choosingwisely.org. Accessed August 21, 2019.
2. Moriates C, Arora V, Shah N. Understanding Value-based Healthcare. New York, NY: McGraw–Hill, 2015.
3. Quinonez RA, Garber MD, Schroeder AR, et al. Choosing wisely in pediatric medicine: five opportunities for improved healthcare value. J Hosp Med. 2013;9;479-485. https://doi.org/10.1002/jhm.2064.
Introduction
Value in healthcare is defined as quality achieved relative to cost. Quality encompasses individual patient and population health outcomes, safety, and experience while cost includes resource utilization and opportunity costs. In order to operationalize high value care (HVC), the Centers for Medicare and Medicaid chose to apply the Institute of Healthcare Improvement’s Triple Aim framework – improving the patient experience, improving the health of populations, and reducing the cost of health care. Pediatric hospitalists are well positioned to promote high value care by decreasing costs, increasing safety, enhancing the patient experience, improving efficiency of care delivery, and improving clinical outcomes. Pediatric hospitalists should deliver healthcare in a manner that optimizes value to the patient, patient populations, and the healthcare system.
Knowledge
Pediatric hospitalists should be able to:
- Discuss how providing “the right care at the right time in the right place” is necessary to optimize value to the patient and the system.
- Summarize the basic structure of the patient-centered health care delivery system, including the macro system (national and regional systems), the mesosystem (integrated inpatient and outpatient settings), and the microsystem (front line care between physician and patient).
- Summarize the National Academy of Medicine’s (formerly Institute of Medicine) six aims of healthcare: Safe, Timely, Efficient, Equitable, Effective, and Patient-centered care.
- State the importance of defining healthcare value as the ratio of quality over cost and compare and contrast value for a single episode of care for one patient versus for a population over time.
- Discuss how coordinated management of complex chronic diseases and development of integrated delivery systems can impact healthcare value for patients, the family/caregivers, and the healthcare system.
- Cite examples of how failure to coordinate and align care in and across each of the above systems can fragment healthcare delivery.
- Compare and contrast the definition of healthcare quality from the perspectives of different stakeholders, including the government, other payors, healthcare systems, hospital and medical staff, and patients and family/caregivers.
- Define the terms “overuse,” “over-diagnosis,” “over-testing,” and “over-treatment” and review how these may impact patient safety, the patient experience, and costs of care.
- Using evidence-based medicine principles, describe how best practices and streamlined clinical care result in increased healthcare value.
- Explain why hospitalists should have a working knowledge of the risks, benefits, harms, pretest probability, and relative costs of commonly performed healthcare tests and treatments.
- Review the goals of shared decision-making discussions and cite how healthcare value should reflect the patients’ and family/caregivers’ unique perspectives on goals of care .
- Provide examples of hospital care costs under control of the hospitalist and review how controlling costs for a single patient or population of patients impacts the value equation.
- Illustrate the importance of local considerations when prescribing a treatment plan, such as total cost, compliance, pediatric formulation, and insurance formulary lists.
- Summarize the relationship between patient safety, quality improvement, and high value care.
Skills
Pediatric hospitalists should be able to:
- Demonstrate skills in communicating indications for tests, procedures, and medications, with patients, the family/caregivers, consultants, and the healthcare team.
- Provide education and information to patients and the family/caregivers that assists them in understanding and choosing care that is supported by evidence.
- Identify costs to patients (including time, anxiety, expense, and clinical harm) and the healthcare system (including time, resources, and expense).
- Educate trainees on the definition of healthcare value and importance of cost considerations of medical care.
- Demonstrate proficiency in adhering to best practice protocols and guidelines.
- Identify interventions that provide no benefit to overall clinical health outcome and/or may be harmful and participate in abating or eliminating these practices.
- Participate in developing, utilizing, or reviewing performance reports to improve delivery of value-based care.
- Apply the concept of “Right patient, right place, right time” in practice, to maximize value to the patient and the healthcare system.
- Work effectively and collaboratively to integrate hospital discharge and post discharge care.
Attitudes
Pediatric hospitalists should be able to:
- Recognize the importance of providing preventive healthcare as part of a high value care.
- Role model resource utilization stewardship by allocating resources that result in high-value and evidence-based care.
- Realize the value of working collaboratively with other stakeholders to continuously improve health care outcomes in a patient centered and cost-effective manner.
- Demonstrate leadership and professionalism by proactively seeking feedback on clinical practice patterns to identify actions viewed as low-value or harmful to patients.
Systems Organization and Improvement
In order to improve efficiency and quality within their organizations, pediatric hospitalists should:
- Collaborate with hospital administration, colleagues, and other hospital staff to identify and share information about costs of care, including drugs, medical imaging, devices, procedures, and consultations.
- Support healthcare system efforts to gather and disseminate cost, quality, and safety data for use in monitoring quality and business improvement efforts.
- Promote standardization of clinical care based on local pathways or protocols and national clinical practice guidelines as tangible ways to improve adherence to best practices and increase value.
- Collaborate with hospital administrators to determine and direct policies that impact healthcare utilization.
- Provide leadership to affect change on a systemic level by identifying opportunities to improve outcomes, minimize harm, and reduce health care waste.
Introduction
Value in healthcare is defined as quality achieved relative to cost. Quality encompasses individual patient and population health outcomes, safety, and experience while cost includes resource utilization and opportunity costs. In order to operationalize high value care (HVC), the Centers for Medicare and Medicaid chose to apply the Institute of Healthcare Improvement’s Triple Aim framework – improving the patient experience, improving the health of populations, and reducing the cost of health care. Pediatric hospitalists are well positioned to promote high value care by decreasing costs, increasing safety, enhancing the patient experience, improving efficiency of care delivery, and improving clinical outcomes. Pediatric hospitalists should deliver healthcare in a manner that optimizes value to the patient, patient populations, and the healthcare system.
Knowledge
Pediatric hospitalists should be able to:
- Discuss how providing “the right care at the right time in the right place” is necessary to optimize value to the patient and the system.
- Summarize the basic structure of the patient-centered health care delivery system, including the macro system (national and regional systems), the mesosystem (integrated inpatient and outpatient settings), and the microsystem (front line care between physician and patient).
- Summarize the National Academy of Medicine’s (formerly Institute of Medicine) six aims of healthcare: Safe, Timely, Efficient, Equitable, Effective, and Patient-centered care.
- State the importance of defining healthcare value as the ratio of quality over cost and compare and contrast value for a single episode of care for one patient versus for a population over time.
- Discuss how coordinated management of complex chronic diseases and development of integrated delivery systems can impact healthcare value for patients, the family/caregivers, and the healthcare system.
- Cite examples of how failure to coordinate and align care in and across each of the above systems can fragment healthcare delivery.
- Compare and contrast the definition of healthcare quality from the perspectives of different stakeholders, including the government, other payors, healthcare systems, hospital and medical staff, and patients and family/caregivers.
- Define the terms “overuse,” “over-diagnosis,” “over-testing,” and “over-treatment” and review how these may impact patient safety, the patient experience, and costs of care.
- Using evidence-based medicine principles, describe how best practices and streamlined clinical care result in increased healthcare value.
- Explain why hospitalists should have a working knowledge of the risks, benefits, harms, pretest probability, and relative costs of commonly performed healthcare tests and treatments.
- Review the goals of shared decision-making discussions and cite how healthcare value should reflect the patients’ and family/caregivers’ unique perspectives on goals of care .
- Provide examples of hospital care costs under control of the hospitalist and review how controlling costs for a single patient or population of patients impacts the value equation.
- Illustrate the importance of local considerations when prescribing a treatment plan, such as total cost, compliance, pediatric formulation, and insurance formulary lists.
- Summarize the relationship between patient safety, quality improvement, and high value care.
Skills
Pediatric hospitalists should be able to:
- Demonstrate skills in communicating indications for tests, procedures, and medications, with patients, the family/caregivers, consultants, and the healthcare team.
- Provide education and information to patients and the family/caregivers that assists them in understanding and choosing care that is supported by evidence.
- Identify costs to patients (including time, anxiety, expense, and clinical harm) and the healthcare system (including time, resources, and expense).
- Educate trainees on the definition of healthcare value and importance of cost considerations of medical care.
- Demonstrate proficiency in adhering to best practice protocols and guidelines.
- Identify interventions that provide no benefit to overall clinical health outcome and/or may be harmful and participate in abating or eliminating these practices.
- Participate in developing, utilizing, or reviewing performance reports to improve delivery of value-based care.
- Apply the concept of “Right patient, right place, right time” in practice, to maximize value to the patient and the healthcare system.
- Work effectively and collaboratively to integrate hospital discharge and post discharge care.
Attitudes
Pediatric hospitalists should be able to:
- Recognize the importance of providing preventive healthcare as part of a high value care.
- Role model resource utilization stewardship by allocating resources that result in high-value and evidence-based care.
- Realize the value of working collaboratively with other stakeholders to continuously improve health care outcomes in a patient centered and cost-effective manner.
- Demonstrate leadership and professionalism by proactively seeking feedback on clinical practice patterns to identify actions viewed as low-value or harmful to patients.
Systems Organization and Improvement
In order to improve efficiency and quality within their organizations, pediatric hospitalists should:
- Collaborate with hospital administration, colleagues, and other hospital staff to identify and share information about costs of care, including drugs, medical imaging, devices, procedures, and consultations.
- Support healthcare system efforts to gather and disseminate cost, quality, and safety data for use in monitoring quality and business improvement efforts.
- Promote standardization of clinical care based on local pathways or protocols and national clinical practice guidelines as tangible ways to improve adherence to best practices and increase value.
- Collaborate with hospital administrators to determine and direct policies that impact healthcare utilization.
- Provide leadership to affect change on a systemic level by identifying opportunities to improve outcomes, minimize harm, and reduce health care waste.
1. American Board of Internal Medicine. Choosing Wisely. http://www.choosingwisely.org. Accessed August 21, 2019.
2. Moriates C, Arora V, Shah N. Understanding Value-based Healthcare. New York, NY: McGraw–Hill, 2015.
3. Quinonez RA, Garber MD, Schroeder AR, et al. Choosing wisely in pediatric medicine: five opportunities for improved healthcare value. J Hosp Med. 2013;9;479-485. https://doi.org/10.1002/jhm.2064.
1. American Board of Internal Medicine. Choosing Wisely. http://www.choosingwisely.org. Accessed August 21, 2019.
2. Moriates C, Arora V, Shah N. Understanding Value-based Healthcare. New York, NY: McGraw–Hill, 2015.
3. Quinonez RA, Garber MD, Schroeder AR, et al. Choosing wisely in pediatric medicine: five opportunities for improved healthcare value. J Hosp Med. 2013;9;479-485. https://doi.org/10.1002/jhm.2064.
4.09 Healthcare Systems: Health Information Technology
Introduction
Health information technology (Health IT) is comprised of a range of digital tools used within the health care systems to collect, store, analyze, and share medical data. In today’s healthcare systems, health IT is an invaluable component for delivery of high-quality and safe care. Recognizing the role of health IT, the Institute of Medicine (now the National Academies of Medicine), in 1999, issued reports highlighting the potential of the electronic health record (EHR) in reducing medical errors through electronic order entry, facilitating care coordination, and improving clinical efficiencies. Despite these benefits, hospitals were slow to adopt these technologies until Congress passed the Health Information Technology for Economic and Clinical Health (HITECH) Act in 2009. Under this act, standards were set for ‘meaningful use’ of health IT and substantial resources and incentives were provided to eligible hospitals and providers to offset EHR implementation costs. The result over the past decade has been widespread adoption of the EHR across the United States, although children’s hospitals remain at the slower end of the adoption curve. Pediatric hospitalists use health IT systems for clinical care, education, quality improvement (QI), patient safety efforts, and for research and thus play a critical role in implementing and optimizing health IT use within hospital systems.
Knowledge
Pediatric hospitalists should be able to:
- Describe the unique role of health IT in providing care to hospitalized children and the importance of careful design and implementation of health IT systems within hospitals and hospital systems that care for children.
- Describe the impact of the Health Insurance Portability and Accountability Act (HIPAA) Privacy Rule on health IT security and the importance of secure storage and retrieval of protected health information.
- Explain the value of clinical decision support in rendering patient care.
- Compare and contrast the influence of health IT systems on practice management, clinical decision-making, QI initiatives, safety initiatives, and research in the healthcare setting.
- List resources that can be accessed to address questions about information systems, such as local system super users, hospital IT support, vendor support lines, online access to other healthcare providers who use the system, and others.
- Delineate how staff dedicated to health IT support quality and safety efforts and data retrieval.
- List information resources and tools available to support life-long learning in dynamic health IT.
- Discuss the importance of pediatric hospitalists in developing, modifying, and evaluating changes to health IT systems on an ongoing basis to optimize workflow and patient care.
- Recognize that dependence on technology for some clinical tasks is an unintended consequence that has arisen since the institution of the EHR.
- Give examples of human errors that can occur when using an EHR, such as medication entry errors, documenting in the wrong patient record, and others.
- Identify problems of a poorly designed EHR and describe how pediatric hospitalists can partner with hospital systems to mitigate these problems.
- Cite common risks that may occur when utilizing an EHR designed for adult aged patients and review actions to mitigate these risks for pediatric patients.
Skills
Pediatric hospitalists should be able to:
- Demonstrate proficiency with the local EHR or computerized provider order entry system.
- Access and use web-based educational resources for continuing education and enrichment of trainee learning experiences.
- Utilize local health IT systems for clinical care, education, QI and patient safety initiatives, and research in an effective and efficient manner.
- Assist in or champion the creation, ongoing maintenance, and optimization of electronic order sets and documentation templates.
- Assess and assist with improving and optimizing clinical decision support tools, including rules and alerts, to meet the changing needs of the health care system and hospitalized children.
- Use hospital health IT system downtime procedures to provide safe continued medical care to patients in the event of a system failure or shutdown.
- Demonstrate best practices in use of the EHR, such as use of “navigators” and order sets, importing relevant medical records where available, and avoiding potentially risky practices such as copy-paste where appropriate.
- Educate trainees on correct use of the EHR and edit and attest to trainee notes as appropriate.
Attitudes
Pediatric hospitalists should be able to:
- Exemplify accountability by adhering to regulations around proper use of health IT.
- Acknowledge the value of collaboration with healthcare providers, patients and the family/caregivers, and hospital administration to ensure the successful functioning of health IT systems.
- Advocate for the proper alignment of health IT system choices with clinical needs, particularly for pediatric-specific needs in predominantly adult healthcare systems.
- Realize the importance of communicating effectively with health IT system managers and leaders.
- Recognize and respect patient confidentiality by using the security-directed features of information systems.
Systems Organization and Improvement
In order to improve efficiency and quality within their organizations, pediatric hospitalists should:
- Lead, coordinate, or participate in appropriate hospital and health systems committees to assist in developing and optimizing health IT solutions to improve quality, safety, and workflow efficiencies.
- Partner with hospital leaders and administration to optimize use of the EHR to improve clinical documentation and develop performance measures and dashboards for the hospitalist practice and the hospital system.
- Collaborate with family advisory groups, hospital administration, healthcare providers, and community partners to support and enhance the use of the EHR by patients and the family/caregivers.
- Partner with hospital administration and healthcare providers to integrate new technologies that improve pediatric hospital medicine practice and care delivery to the hospitalized child, such as clinical decision support tools, telemedicine, health information exchange, registries, and others.
- Seek opportunities to improve the role of health IT in managing costs and supporting quality and clinical research, as applicable.
1. Institute of Medicine. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: The National Academies Press: 2001.
2. Koutkias V, Bouaud J. Contributions from the 2017 Literature on Clinical Decision Support. Yearb Med Inform. 2018;27(1):122–128. https://doi.org/10.1055/s-0038-1641222.
3. Vélez-Díaz-Pallarés M, Pérez-Menéndez-Conde C, Bermejo-Vicedo T. Systematic review of computerized prescriber order entry and clinical decision support. Am J Health Syst Pharm. 2018;75(23):1909-1921. https://doi.org/10.2146/ajhp170870.
Introduction
Health information technology (Health IT) is comprised of a range of digital tools used within the health care systems to collect, store, analyze, and share medical data. In today’s healthcare systems, health IT is an invaluable component for delivery of high-quality and safe care. Recognizing the role of health IT, the Institute of Medicine (now the National Academies of Medicine), in 1999, issued reports highlighting the potential of the electronic health record (EHR) in reducing medical errors through electronic order entry, facilitating care coordination, and improving clinical efficiencies. Despite these benefits, hospitals were slow to adopt these technologies until Congress passed the Health Information Technology for Economic and Clinical Health (HITECH) Act in 2009. Under this act, standards were set for ‘meaningful use’ of health IT and substantial resources and incentives were provided to eligible hospitals and providers to offset EHR implementation costs. The result over the past decade has been widespread adoption of the EHR across the United States, although children’s hospitals remain at the slower end of the adoption curve. Pediatric hospitalists use health IT systems for clinical care, education, quality improvement (QI), patient safety efforts, and for research and thus play a critical role in implementing and optimizing health IT use within hospital systems.
Knowledge
Pediatric hospitalists should be able to:
- Describe the unique role of health IT in providing care to hospitalized children and the importance of careful design and implementation of health IT systems within hospitals and hospital systems that care for children.
- Describe the impact of the Health Insurance Portability and Accountability Act (HIPAA) Privacy Rule on health IT security and the importance of secure storage and retrieval of protected health information.
- Explain the value of clinical decision support in rendering patient care.
- Compare and contrast the influence of health IT systems on practice management, clinical decision-making, QI initiatives, safety initiatives, and research in the healthcare setting.
- List resources that can be accessed to address questions about information systems, such as local system super users, hospital IT support, vendor support lines, online access to other healthcare providers who use the system, and others.
- Delineate how staff dedicated to health IT support quality and safety efforts and data retrieval.
- List information resources and tools available to support life-long learning in dynamic health IT.
- Discuss the importance of pediatric hospitalists in developing, modifying, and evaluating changes to health IT systems on an ongoing basis to optimize workflow and patient care.
- Recognize that dependence on technology for some clinical tasks is an unintended consequence that has arisen since the institution of the EHR.
- Give examples of human errors that can occur when using an EHR, such as medication entry errors, documenting in the wrong patient record, and others.
- Identify problems of a poorly designed EHR and describe how pediatric hospitalists can partner with hospital systems to mitigate these problems.
- Cite common risks that may occur when utilizing an EHR designed for adult aged patients and review actions to mitigate these risks for pediatric patients.
Skills
Pediatric hospitalists should be able to:
- Demonstrate proficiency with the local EHR or computerized provider order entry system.
- Access and use web-based educational resources for continuing education and enrichment of trainee learning experiences.
- Utilize local health IT systems for clinical care, education, QI and patient safety initiatives, and research in an effective and efficient manner.
- Assist in or champion the creation, ongoing maintenance, and optimization of electronic order sets and documentation templates.
- Assess and assist with improving and optimizing clinical decision support tools, including rules and alerts, to meet the changing needs of the health care system and hospitalized children.
- Use hospital health IT system downtime procedures to provide safe continued medical care to patients in the event of a system failure or shutdown.
- Demonstrate best practices in use of the EHR, such as use of “navigators” and order sets, importing relevant medical records where available, and avoiding potentially risky practices such as copy-paste where appropriate.
- Educate trainees on correct use of the EHR and edit and attest to trainee notes as appropriate.
Attitudes
Pediatric hospitalists should be able to:
- Exemplify accountability by adhering to regulations around proper use of health IT.
- Acknowledge the value of collaboration with healthcare providers, patients and the family/caregivers, and hospital administration to ensure the successful functioning of health IT systems.
- Advocate for the proper alignment of health IT system choices with clinical needs, particularly for pediatric-specific needs in predominantly adult healthcare systems.
- Realize the importance of communicating effectively with health IT system managers and leaders.
- Recognize and respect patient confidentiality by using the security-directed features of information systems.
Systems Organization and Improvement
In order to improve efficiency and quality within their organizations, pediatric hospitalists should:
- Lead, coordinate, or participate in appropriate hospital and health systems committees to assist in developing and optimizing health IT solutions to improve quality, safety, and workflow efficiencies.
- Partner with hospital leaders and administration to optimize use of the EHR to improve clinical documentation and develop performance measures and dashboards for the hospitalist practice and the hospital system.
- Collaborate with family advisory groups, hospital administration, healthcare providers, and community partners to support and enhance the use of the EHR by patients and the family/caregivers.
- Partner with hospital administration and healthcare providers to integrate new technologies that improve pediatric hospital medicine practice and care delivery to the hospitalized child, such as clinical decision support tools, telemedicine, health information exchange, registries, and others.
- Seek opportunities to improve the role of health IT in managing costs and supporting quality and clinical research, as applicable.
Introduction
Health information technology (Health IT) is comprised of a range of digital tools used within the health care systems to collect, store, analyze, and share medical data. In today’s healthcare systems, health IT is an invaluable component for delivery of high-quality and safe care. Recognizing the role of health IT, the Institute of Medicine (now the National Academies of Medicine), in 1999, issued reports highlighting the potential of the electronic health record (EHR) in reducing medical errors through electronic order entry, facilitating care coordination, and improving clinical efficiencies. Despite these benefits, hospitals were slow to adopt these technologies until Congress passed the Health Information Technology for Economic and Clinical Health (HITECH) Act in 2009. Under this act, standards were set for ‘meaningful use’ of health IT and substantial resources and incentives were provided to eligible hospitals and providers to offset EHR implementation costs. The result over the past decade has been widespread adoption of the EHR across the United States, although children’s hospitals remain at the slower end of the adoption curve. Pediatric hospitalists use health IT systems for clinical care, education, quality improvement (QI), patient safety efforts, and for research and thus play a critical role in implementing and optimizing health IT use within hospital systems.
Knowledge
Pediatric hospitalists should be able to:
- Describe the unique role of health IT in providing care to hospitalized children and the importance of careful design and implementation of health IT systems within hospitals and hospital systems that care for children.
- Describe the impact of the Health Insurance Portability and Accountability Act (HIPAA) Privacy Rule on health IT security and the importance of secure storage and retrieval of protected health information.
- Explain the value of clinical decision support in rendering patient care.
- Compare and contrast the influence of health IT systems on practice management, clinical decision-making, QI initiatives, safety initiatives, and research in the healthcare setting.
- List resources that can be accessed to address questions about information systems, such as local system super users, hospital IT support, vendor support lines, online access to other healthcare providers who use the system, and others.
- Delineate how staff dedicated to health IT support quality and safety efforts and data retrieval.
- List information resources and tools available to support life-long learning in dynamic health IT.
- Discuss the importance of pediatric hospitalists in developing, modifying, and evaluating changes to health IT systems on an ongoing basis to optimize workflow and patient care.
- Recognize that dependence on technology for some clinical tasks is an unintended consequence that has arisen since the institution of the EHR.
- Give examples of human errors that can occur when using an EHR, such as medication entry errors, documenting in the wrong patient record, and others.
- Identify problems of a poorly designed EHR and describe how pediatric hospitalists can partner with hospital systems to mitigate these problems.
- Cite common risks that may occur when utilizing an EHR designed for adult aged patients and review actions to mitigate these risks for pediatric patients.
Skills
Pediatric hospitalists should be able to:
- Demonstrate proficiency with the local EHR or computerized provider order entry system.
- Access and use web-based educational resources for continuing education and enrichment of trainee learning experiences.
- Utilize local health IT systems for clinical care, education, QI and patient safety initiatives, and research in an effective and efficient manner.
- Assist in or champion the creation, ongoing maintenance, and optimization of electronic order sets and documentation templates.
- Assess and assist with improving and optimizing clinical decision support tools, including rules and alerts, to meet the changing needs of the health care system and hospitalized children.
- Use hospital health IT system downtime procedures to provide safe continued medical care to patients in the event of a system failure or shutdown.
- Demonstrate best practices in use of the EHR, such as use of “navigators” and order sets, importing relevant medical records where available, and avoiding potentially risky practices such as copy-paste where appropriate.
- Educate trainees on correct use of the EHR and edit and attest to trainee notes as appropriate.
Attitudes
Pediatric hospitalists should be able to:
- Exemplify accountability by adhering to regulations around proper use of health IT.
- Acknowledge the value of collaboration with healthcare providers, patients and the family/caregivers, and hospital administration to ensure the successful functioning of health IT systems.
- Advocate for the proper alignment of health IT system choices with clinical needs, particularly for pediatric-specific needs in predominantly adult healthcare systems.
- Realize the importance of communicating effectively with health IT system managers and leaders.
- Recognize and respect patient confidentiality by using the security-directed features of information systems.
Systems Organization and Improvement
In order to improve efficiency and quality within their organizations, pediatric hospitalists should:
- Lead, coordinate, or participate in appropriate hospital and health systems committees to assist in developing and optimizing health IT solutions to improve quality, safety, and workflow efficiencies.
- Partner with hospital leaders and administration to optimize use of the EHR to improve clinical documentation and develop performance measures and dashboards for the hospitalist practice and the hospital system.
- Collaborate with family advisory groups, hospital administration, healthcare providers, and community partners to support and enhance the use of the EHR by patients and the family/caregivers.
- Partner with hospital administration and healthcare providers to integrate new technologies that improve pediatric hospital medicine practice and care delivery to the hospitalized child, such as clinical decision support tools, telemedicine, health information exchange, registries, and others.
- Seek opportunities to improve the role of health IT in managing costs and supporting quality and clinical research, as applicable.
1. Institute of Medicine. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: The National Academies Press: 2001.
2. Koutkias V, Bouaud J. Contributions from the 2017 Literature on Clinical Decision Support. Yearb Med Inform. 2018;27(1):122–128. https://doi.org/10.1055/s-0038-1641222.
3. Vélez-Díaz-Pallarés M, Pérez-Menéndez-Conde C, Bermejo-Vicedo T. Systematic review of computerized prescriber order entry and clinical decision support. Am J Health Syst Pharm. 2018;75(23):1909-1921. https://doi.org/10.2146/ajhp170870.
1. Institute of Medicine. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: The National Academies Press: 2001.
2. Koutkias V, Bouaud J. Contributions from the 2017 Literature on Clinical Decision Support. Yearb Med Inform. 2018;27(1):122–128. https://doi.org/10.1055/s-0038-1641222.
3. Vélez-Díaz-Pallarés M, Pérez-Menéndez-Conde C, Bermejo-Vicedo T. Systematic review of computerized prescriber order entry and clinical decision support. Am J Health Syst Pharm. 2018;75(23):1909-1921. https://doi.org/10.2146/ajhp170870.
4.08 Healthcare Systems: Handoffs and Transitions of Care
Introduction
Transitions of care are patient-centered events. They therefore describe when a patient moves from one level of care to another, from one institution to another, or from one system to another as occurs with pediatric to adult care transitions. One component of transitions of care is the patient handoff, which is a provider-centered event that also occurs outside of a patient transition, such as during shift change. Handoffs refer to the interaction between providers when responsibility for patient care is transferred from one provider to another. Ineffective transitions of care and handoffs jeopardize patient safety and may result in adverse events, increased healthcare utilization, and stress for patients or the family/caregivers. Thus, every transition of care and handoff should involve a set of actions designed to ensure that the transfer is safe, efficient, and effective. Pediatric hospitalists routinely utilize handoffs in daily work, are integral in patient transitions of care, and should be competent in both.
Knowledge
Pediatric hospitalists should be able to:
- Compare and contrast patient handoffs with transitions of care.
- Discuss the critical elements that should be communicated between providers at the time of a patient handoff and how these elements may vary depending on characteristics of the patient or the provider.
- Discuss the value of using available handoff aides such as communication patient safety acronyms, handoff tools, and checklists.
- Describe the benefits and risks of automated electronic medical record data integration into handoff aides.
- Discuss the value of using available discharge toolkits to integrate processes, checklists, education, and assessment of quality outcome metrics related to discharge transition of care.
- Compare and contrast the value of potential discharge transition of care metrics, such as patient experience, unplanned returns for care, post discharge planned visit adherence, retained understanding of medication and treatment plans, and others.
- List the relevant information that should be communicated during each transition of care to ensure patient safety and promote the continuum of care.
- Explain the benefits and risks of different modes of communication in the context of the various types of patient transfers.
- Differentiate between the available levels of care and determine the most appropriate option for each patient.
- Describe the impact of the Emergency Medical Treatment and Active Labor Act (EMTALA) on patient transfers.
- Summarize the care commonly available for children at post-acute care facilities, such as rehabilitation facilities.
- Review the steps needed to ensure safe hospital discharge transition of care for patients who will receive home care services, including collaborating with discharge planning staff, placing appropriate orders, securing a post-discharge responsible provider, and other steps.
- Discuss elements important to the safe transition of care at hospital discharge for the patient and family/caregivers, including use of teach-back, handouts, and other tools for patient and family/caregivers’ engagement and empowerment in care planning for the home environment.
- Cite the benefits of and barriers to ongoing discharge transition of care education from the time of admission for patients and the family/caregivers.
- Summarize the approach toward initiating transition of care discussions with the family/caregivers of adolescent patients with chronic conditions, attending to patient age, developmental status, empowerment, healthcare system barriers, and others within the local context.
Skills
Pediatric hospitalists should be able to:
- Prepare concise clinical summaries in preparation for patient handoffs or transitions of care, incorporating key elements as appropriate.
- Standardize handoffs to ensure accuracy and concise and complete transfer of information.
- Demonstrate skills in utilizing local handoff tools, acronyms, and checklists.
- Educate trainees on proper handoff communications.
- Utilize the most efficient and reliable mode of communication for each transition of care.
- Arrange safe and efficient transfers to, from, and within the hospital setting.
- Review the medical information received from referring providers and clarify any discrepancies when accepting a new patient.
- Anticipate needs prior to the time of discharge to begin discharge planning early in the hospitalization.
- Provide clear discharge instructions that consider the primary language and reading level of patients and the family/caregivers and include key components (such as diagnosis specific instructions, contingency plan, medications, follow up recommendations/appointments, information about available resources, and others).
- Communicate effectively with the primary care and other providers as necessary at the time of admission, discharge, and other transitions of care.
- Select and order appropriate post-acute care facilities and services within the local context.
- Accurately and completely reconcile medications during transitions of care.
- Coordinate care that ensures the future comprehensive review of patient data that was pending at the time of discharge.
Attitudes
Pediatric hospitalists should be able to:
- Recognize the impact of ineffective handoffs and transitions of care on patient safety and quality of care.
- Demonstrate respect for referring physicians and seek their input when developing protocols for communication during transitions of care.
- Recognize the impact of the transfer on patients and the family/caregivers and the importance of ensuring their goals and preferences are incorporated into the care plan at all stages of the transition of care.
- Exemplify responsible coordination of a multidisciplinary approach to patient and the family/caregiver education in preparation for the transition of care.
- Realize the need to provide support for patients, the family/caregivers, and healthcare providers after transitions of care should questions arise.
Systems Organization and Improvement
In order to improve efficiency and quality within their organizations, pediatric hospitalists should:
- Lead, coordinate, or participate with key stakeholders in the ongoing evaluation and improvement of the referral, admission, and discharge processes.
- Lead, coordinate, or participate in initiatives to develop and implement systems that promote timely and effective communication between providers during handoffs and transitions of care.
- Collaborate with hospital administration and community partners to develop and sustain referral networks between local facilities and referral centers for hospitalized patients and for those transitioning to adult healthcare systems.
1. Rauch DA, and the AAP Committee on Hospital Care and the AAP Section on Hospital Care. Physician’s role in coordinating care of hospitalized children. Pediatrics. 2018;142(2): e20181503. https://pediatrics.aappublications.org/content/pediatrics/early/2018/07/26/peds.2018-1503.full.pdf. Accessed August 28, 2019.
2. Starmer AJ, Spector ND, West DC, et al. Integrating research, quality improvement, and medical education for better handoffs and safer care: Disseminating, adapting, and implementing the I-PASS Program. Jt Comm J Qual Patient Saf. 2017; 43(7):319-329. https://doi.org/10.1016/j.jcjq.2017.04.001.
3. Fisher E, Rosenbluth G, Shaikh U, and the Society of Hospital Medicine and University of California Quality Improvement Network. Ped-BOOST: Pediatric Effective Discharge: Better Handoff to Home through Safer Transitions Implementation Guide. https://www.hospitalmedicine.org/clinical-topics/care-transitions/. Accessed August 21, 2019.
Introduction
Transitions of care are patient-centered events. They therefore describe when a patient moves from one level of care to another, from one institution to another, or from one system to another as occurs with pediatric to adult care transitions. One component of transitions of care is the patient handoff, which is a provider-centered event that also occurs outside of a patient transition, such as during shift change. Handoffs refer to the interaction between providers when responsibility for patient care is transferred from one provider to another. Ineffective transitions of care and handoffs jeopardize patient safety and may result in adverse events, increased healthcare utilization, and stress for patients or the family/caregivers. Thus, every transition of care and handoff should involve a set of actions designed to ensure that the transfer is safe, efficient, and effective. Pediatric hospitalists routinely utilize handoffs in daily work, are integral in patient transitions of care, and should be competent in both.
Knowledge
Pediatric hospitalists should be able to:
- Compare and contrast patient handoffs with transitions of care.
- Discuss the critical elements that should be communicated between providers at the time of a patient handoff and how these elements may vary depending on characteristics of the patient or the provider.
- Discuss the value of using available handoff aides such as communication patient safety acronyms, handoff tools, and checklists.
- Describe the benefits and risks of automated electronic medical record data integration into handoff aides.
- Discuss the value of using available discharge toolkits to integrate processes, checklists, education, and assessment of quality outcome metrics related to discharge transition of care.
- Compare and contrast the value of potential discharge transition of care metrics, such as patient experience, unplanned returns for care, post discharge planned visit adherence, retained understanding of medication and treatment plans, and others.
- List the relevant information that should be communicated during each transition of care to ensure patient safety and promote the continuum of care.
- Explain the benefits and risks of different modes of communication in the context of the various types of patient transfers.
- Differentiate between the available levels of care and determine the most appropriate option for each patient.
- Describe the impact of the Emergency Medical Treatment and Active Labor Act (EMTALA) on patient transfers.
- Summarize the care commonly available for children at post-acute care facilities, such as rehabilitation facilities.
- Review the steps needed to ensure safe hospital discharge transition of care for patients who will receive home care services, including collaborating with discharge planning staff, placing appropriate orders, securing a post-discharge responsible provider, and other steps.
- Discuss elements important to the safe transition of care at hospital discharge for the patient and family/caregivers, including use of teach-back, handouts, and other tools for patient and family/caregivers’ engagement and empowerment in care planning for the home environment.
- Cite the benefits of and barriers to ongoing discharge transition of care education from the time of admission for patients and the family/caregivers.
- Summarize the approach toward initiating transition of care discussions with the family/caregivers of adolescent patients with chronic conditions, attending to patient age, developmental status, empowerment, healthcare system barriers, and others within the local context.
Skills
Pediatric hospitalists should be able to:
- Prepare concise clinical summaries in preparation for patient handoffs or transitions of care, incorporating key elements as appropriate.
- Standardize handoffs to ensure accuracy and concise and complete transfer of information.
- Demonstrate skills in utilizing local handoff tools, acronyms, and checklists.
- Educate trainees on proper handoff communications.
- Utilize the most efficient and reliable mode of communication for each transition of care.
- Arrange safe and efficient transfers to, from, and within the hospital setting.
- Review the medical information received from referring providers and clarify any discrepancies when accepting a new patient.
- Anticipate needs prior to the time of discharge to begin discharge planning early in the hospitalization.
- Provide clear discharge instructions that consider the primary language and reading level of patients and the family/caregivers and include key components (such as diagnosis specific instructions, contingency plan, medications, follow up recommendations/appointments, information about available resources, and others).
- Communicate effectively with the primary care and other providers as necessary at the time of admission, discharge, and other transitions of care.
- Select and order appropriate post-acute care facilities and services within the local context.
- Accurately and completely reconcile medications during transitions of care.
- Coordinate care that ensures the future comprehensive review of patient data that was pending at the time of discharge.
Attitudes
Pediatric hospitalists should be able to:
- Recognize the impact of ineffective handoffs and transitions of care on patient safety and quality of care.
- Demonstrate respect for referring physicians and seek their input when developing protocols for communication during transitions of care.
- Recognize the impact of the transfer on patients and the family/caregivers and the importance of ensuring their goals and preferences are incorporated into the care plan at all stages of the transition of care.
- Exemplify responsible coordination of a multidisciplinary approach to patient and the family/caregiver education in preparation for the transition of care.
- Realize the need to provide support for patients, the family/caregivers, and healthcare providers after transitions of care should questions arise.
Systems Organization and Improvement
In order to improve efficiency and quality within their organizations, pediatric hospitalists should:
- Lead, coordinate, or participate with key stakeholders in the ongoing evaluation and improvement of the referral, admission, and discharge processes.
- Lead, coordinate, or participate in initiatives to develop and implement systems that promote timely and effective communication between providers during handoffs and transitions of care.
- Collaborate with hospital administration and community partners to develop and sustain referral networks between local facilities and referral centers for hospitalized patients and for those transitioning to adult healthcare systems.
Introduction
Transitions of care are patient-centered events. They therefore describe when a patient moves from one level of care to another, from one institution to another, or from one system to another as occurs with pediatric to adult care transitions. One component of transitions of care is the patient handoff, which is a provider-centered event that also occurs outside of a patient transition, such as during shift change. Handoffs refer to the interaction between providers when responsibility for patient care is transferred from one provider to another. Ineffective transitions of care and handoffs jeopardize patient safety and may result in adverse events, increased healthcare utilization, and stress for patients or the family/caregivers. Thus, every transition of care and handoff should involve a set of actions designed to ensure that the transfer is safe, efficient, and effective. Pediatric hospitalists routinely utilize handoffs in daily work, are integral in patient transitions of care, and should be competent in both.
Knowledge
Pediatric hospitalists should be able to:
- Compare and contrast patient handoffs with transitions of care.
- Discuss the critical elements that should be communicated between providers at the time of a patient handoff and how these elements may vary depending on characteristics of the patient or the provider.
- Discuss the value of using available handoff aides such as communication patient safety acronyms, handoff tools, and checklists.
- Describe the benefits and risks of automated electronic medical record data integration into handoff aides.
- Discuss the value of using available discharge toolkits to integrate processes, checklists, education, and assessment of quality outcome metrics related to discharge transition of care.
- Compare and contrast the value of potential discharge transition of care metrics, such as patient experience, unplanned returns for care, post discharge planned visit adherence, retained understanding of medication and treatment plans, and others.
- List the relevant information that should be communicated during each transition of care to ensure patient safety and promote the continuum of care.
- Explain the benefits and risks of different modes of communication in the context of the various types of patient transfers.
- Differentiate between the available levels of care and determine the most appropriate option for each patient.
- Describe the impact of the Emergency Medical Treatment and Active Labor Act (EMTALA) on patient transfers.
- Summarize the care commonly available for children at post-acute care facilities, such as rehabilitation facilities.
- Review the steps needed to ensure safe hospital discharge transition of care for patients who will receive home care services, including collaborating with discharge planning staff, placing appropriate orders, securing a post-discharge responsible provider, and other steps.
- Discuss elements important to the safe transition of care at hospital discharge for the patient and family/caregivers, including use of teach-back, handouts, and other tools for patient and family/caregivers’ engagement and empowerment in care planning for the home environment.
- Cite the benefits of and barriers to ongoing discharge transition of care education from the time of admission for patients and the family/caregivers.
- Summarize the approach toward initiating transition of care discussions with the family/caregivers of adolescent patients with chronic conditions, attending to patient age, developmental status, empowerment, healthcare system barriers, and others within the local context.
Skills
Pediatric hospitalists should be able to:
- Prepare concise clinical summaries in preparation for patient handoffs or transitions of care, incorporating key elements as appropriate.
- Standardize handoffs to ensure accuracy and concise and complete transfer of information.
- Demonstrate skills in utilizing local handoff tools, acronyms, and checklists.
- Educate trainees on proper handoff communications.
- Utilize the most efficient and reliable mode of communication for each transition of care.
- Arrange safe and efficient transfers to, from, and within the hospital setting.
- Review the medical information received from referring providers and clarify any discrepancies when accepting a new patient.
- Anticipate needs prior to the time of discharge to begin discharge planning early in the hospitalization.
- Provide clear discharge instructions that consider the primary language and reading level of patients and the family/caregivers and include key components (such as diagnosis specific instructions, contingency plan, medications, follow up recommendations/appointments, information about available resources, and others).
- Communicate effectively with the primary care and other providers as necessary at the time of admission, discharge, and other transitions of care.
- Select and order appropriate post-acute care facilities and services within the local context.
- Accurately and completely reconcile medications during transitions of care.
- Coordinate care that ensures the future comprehensive review of patient data that was pending at the time of discharge.
Attitudes
Pediatric hospitalists should be able to:
- Recognize the impact of ineffective handoffs and transitions of care on patient safety and quality of care.
- Demonstrate respect for referring physicians and seek their input when developing protocols for communication during transitions of care.
- Recognize the impact of the transfer on patients and the family/caregivers and the importance of ensuring their goals and preferences are incorporated into the care plan at all stages of the transition of care.
- Exemplify responsible coordination of a multidisciplinary approach to patient and the family/caregiver education in preparation for the transition of care.
- Realize the need to provide support for patients, the family/caregivers, and healthcare providers after transitions of care should questions arise.
Systems Organization and Improvement
In order to improve efficiency and quality within their organizations, pediatric hospitalists should:
- Lead, coordinate, or participate with key stakeholders in the ongoing evaluation and improvement of the referral, admission, and discharge processes.
- Lead, coordinate, or participate in initiatives to develop and implement systems that promote timely and effective communication between providers during handoffs and transitions of care.
- Collaborate with hospital administration and community partners to develop and sustain referral networks between local facilities and referral centers for hospitalized patients and for those transitioning to adult healthcare systems.
1. Rauch DA, and the AAP Committee on Hospital Care and the AAP Section on Hospital Care. Physician’s role in coordinating care of hospitalized children. Pediatrics. 2018;142(2): e20181503. https://pediatrics.aappublications.org/content/pediatrics/early/2018/07/26/peds.2018-1503.full.pdf. Accessed August 28, 2019.
2. Starmer AJ, Spector ND, West DC, et al. Integrating research, quality improvement, and medical education for better handoffs and safer care: Disseminating, adapting, and implementing the I-PASS Program. Jt Comm J Qual Patient Saf. 2017; 43(7):319-329. https://doi.org/10.1016/j.jcjq.2017.04.001.
3. Fisher E, Rosenbluth G, Shaikh U, and the Society of Hospital Medicine and University of California Quality Improvement Network. Ped-BOOST: Pediatric Effective Discharge: Better Handoff to Home through Safer Transitions Implementation Guide. https://www.hospitalmedicine.org/clinical-topics/care-transitions/. Accessed August 21, 2019.
1. Rauch DA, and the AAP Committee on Hospital Care and the AAP Section on Hospital Care. Physician’s role in coordinating care of hospitalized children. Pediatrics. 2018;142(2): e20181503. https://pediatrics.aappublications.org/content/pediatrics/early/2018/07/26/peds.2018-1503.full.pdf. Accessed August 28, 2019.
2. Starmer AJ, Spector ND, West DC, et al. Integrating research, quality improvement, and medical education for better handoffs and safer care: Disseminating, adapting, and implementing the I-PASS Program. Jt Comm J Qual Patient Saf. 2017; 43(7):319-329. https://doi.org/10.1016/j.jcjq.2017.04.001.
3. Fisher E, Rosenbluth G, Shaikh U, and the Society of Hospital Medicine and University of California Quality Improvement Network. Ped-BOOST: Pediatric Effective Discharge: Better Handoff to Home through Safer Transitions Implementation Guide. https://www.hospitalmedicine.org/clinical-topics/care-transitions/. Accessed August 21, 2019.
4.07 Healthcare Systems: Family Centered Care
Introduction
The National Academy of Medicine (NAM; previously the Institute of Medicine [IOM]), the American Academy of Pediatrics, and the Accreditation Council for Graduate Medical Education have all called for an increased emphasis on patient and family centered care. Family centered care (FCC) involves collaboration between patients, the family/caregivers, healthcare providers, and hospital administration to address the needs of individual patients, populations, and healthcare systems. It can inform policy, facility design, healthcare outcomes evaluation, and individual daily interactions. Thus, FCC is used to plan, deliver, and evaluate healthcare; conduct research; provide education; and improve healthcare quality. Pediatric hospitalists were first to lead national efforts to espouse family centered rounds (FCR), which is a cornerstone of a larger FCC program. Pediatric hospitalists promote high quality FCC by embedding it into daily interactions with patients and the family/caregivers, modeling and teaching it to trainees, and applying it to clinical care, medical education, research, quality improvement, hospital operations, and patient safety.
Knowledge
Pediatric hospitalists should be able to:
- Summarize the features of FCC, drawing upon existing frameworks from organizations such as the NAM, the Agency for Healthcare Research and Quality, and the Picker Institute.
- Describe the Picker Institute’s 8 Principles of Patient Centered Care: 1) respect for patient preferences, 2) coordination and integration of care, 3) information and education, 4) physical comfort, 5) emotional support, 6) involvement of family and friends, 7) continuity and transition, and 8) access to care.
- Summarize common components of a comprehensive healthcare system FCC program, attending to family involvement on advisory councils and boards, research committees, and electronic medical record groups, as well as healthcare system community partnerships and other relationships.
- Review the concept of “co-production”, which involves co-execution, co-planning, and civil discourse between patients, professionals, the healthcare system, and the community and society in order to achieve high-value healthcare and promote good health for all.
- Give examples of common best practices for FCR, including the family/caregivers speaking first, healthcare providers speaking in language understood by the family/caregivers, making plans and goal setting with the family/caregivers, asking open-ended questions, and assessing family/caregivers’ understanding.
- Describe the role of “patient activation” (patients attaining the confidence, knowledge, and skills to manage and maintain one’s health and healthcare needs) in promoting FCC in the inpatient setting.
- Discuss the steps of shared decision-making, including 1) seeking a patient’s participation, 2) helping a patient to explore and compare treatment options, 3) assessing a patient’s values and preferences, 4) reaching a decision with a patient, and 5) evaluating a patient’s decision.
- Discuss best practices of shared decision-making and give examples of where shared decision-making may be used inside and outside the setting of hospital rounds.
- Give examples of universal health literacy precautions use during communications with patients and the family/caregivers, including using plain language, minimizing unnecessary medical jargon, breaking down complex concepts into understandable pieces, bidirectional communication, and reinforcement with written or internet-based educational materials.
- Define implicit bias and review how unconscious, automatic stereotypes can affect understanding and decisions, leading to inconsistent management and healthcare outcome disparities.
- Discuss how differing experiences and views on race, ethnicity, sexual orientation, gender identity, religion, culture, immigration, disability, language, literacy, health literacy, and socioeconomic status may influence the approach toward and success of FCR and a comprehensive FCC program.
Skills
Pediatric hospitalists should be able to:
- Model, teach, and integrate FCC principles throughout the inpatient continuum of care delivery, from admission and medication reconciliation to rounds, transitions of care, and discharge planning.
- Demonstrate basic skills in co-production specific to hospital medicine including those affecting policy (co-commissioning), clinical care and education (co-design, co-delivery), and quality/safety/research (co-assessment) within the local context.
- Coordinate, lead, and adapt FCR to meet specific patient needs, such as low English proficiency (LEP) children, adolescents, caregivers, and family members.
- Educate trainees about the core elements of FCC.
- Utilize strategies to include nursing staff and other ancillary staff (such as pharmacists, social workers, care coordinators, and others) in FCC.
- Utilize strategies to activate patients and the family/caregivers.
- Demonstrate skills in shared decision-making.
- Integrate the consistent use of universal health literacy precautions into daily practice.
- Demonstrate culturally competent communication skills.
- Engage interpreters effectively for LEP patients.
- Identify and abate potential implicit biases.
- Demonstrate skill in using information technology, including electronic medical record portals, to promote patient engagement.
Attitudes
Pediatric hospitalists should be able to:
- Recognize the role that implicit bias plays in impeding FCC.
- Reflect on the importance of being respectful of religious, cultural, and personal preferences in communication and involvement in care.
- Realize the patient and family/caregivers’ important role in promoting health and partnering in care decisions, both in the hospital and after discharge.
- Consider that all patients and the family/caregivers benefit from clear communication and universal health literacy precautions.
- Recognize the unique roles of the patient and the family/caregivers as “vigilant partners” in care and in patient safety, including in safety promotion and safety reporting.
- Appreciate the unique needs of underserved and marginalized communities, including LEP patients, Lesbian Gay Bisexual Transgender (LGBT) youth, religious and ethnic minorities, and immigrants.
Systems Organization and Improvement
In order to improve efficiency and quality within their organizations, pediatric hospitalists should:
- Lead, coordinate, or participate in interdisciplinary efforts to ensure effective patient and family engagement in hospital committees, research activities including prioritizing research questions, and hospital quality improvement initiatives.
- Work with hospital administration and other hospital leaders to create and sustain patient and family/caregiver involvement in safety reporting and safety promotion.
- Collaborate with graduate medical education leaders and other educators to create and sustain education around FCC for medical students, residents, faculty, and other healthcare providers.
- Collaborate with hospital administration and community leaders to engage patients and the family/caregivers in design and development of pediatric hospitals and healthcare systems, within local context.
1. Institute for Patient- and Family-Centered Care. https://www.ipfcc.org/. Accessed August 23, 2019.
2. Committee on Hospital Care and Institute for Patient- and Family-Centered Care. Patient- and family-centered care and the pediatrician’s role. Pediatrics. 2012;129(2):394-404. https://doi.org/10.1542/peds.2011-3084.
3. Rea KE, Rao P, Hill E, Saylor KM, Cousino MK. Families’ experiences with pediatric family-centered rounds: A systematic review. Pediatrics. 2018;141(3): e20171883. https://pediatrics.aappublications.org/content/141/3e20171883.long. Accessed August 28, 2019.
Introduction
The National Academy of Medicine (NAM; previously the Institute of Medicine [IOM]), the American Academy of Pediatrics, and the Accreditation Council for Graduate Medical Education have all called for an increased emphasis on patient and family centered care. Family centered care (FCC) involves collaboration between patients, the family/caregivers, healthcare providers, and hospital administration to address the needs of individual patients, populations, and healthcare systems. It can inform policy, facility design, healthcare outcomes evaluation, and individual daily interactions. Thus, FCC is used to plan, deliver, and evaluate healthcare; conduct research; provide education; and improve healthcare quality. Pediatric hospitalists were first to lead national efforts to espouse family centered rounds (FCR), which is a cornerstone of a larger FCC program. Pediatric hospitalists promote high quality FCC by embedding it into daily interactions with patients and the family/caregivers, modeling and teaching it to trainees, and applying it to clinical care, medical education, research, quality improvement, hospital operations, and patient safety.
Knowledge
Pediatric hospitalists should be able to:
- Summarize the features of FCC, drawing upon existing frameworks from organizations such as the NAM, the Agency for Healthcare Research and Quality, and the Picker Institute.
- Describe the Picker Institute’s 8 Principles of Patient Centered Care: 1) respect for patient preferences, 2) coordination and integration of care, 3) information and education, 4) physical comfort, 5) emotional support, 6) involvement of family and friends, 7) continuity and transition, and 8) access to care.
- Summarize common components of a comprehensive healthcare system FCC program, attending to family involvement on advisory councils and boards, research committees, and electronic medical record groups, as well as healthcare system community partnerships and other relationships.
- Review the concept of “co-production”, which involves co-execution, co-planning, and civil discourse between patients, professionals, the healthcare system, and the community and society in order to achieve high-value healthcare and promote good health for all.
- Give examples of common best practices for FCR, including the family/caregivers speaking first, healthcare providers speaking in language understood by the family/caregivers, making plans and goal setting with the family/caregivers, asking open-ended questions, and assessing family/caregivers’ understanding.
- Describe the role of “patient activation” (patients attaining the confidence, knowledge, and skills to manage and maintain one’s health and healthcare needs) in promoting FCC in the inpatient setting.
- Discuss the steps of shared decision-making, including 1) seeking a patient’s participation, 2) helping a patient to explore and compare treatment options, 3) assessing a patient’s values and preferences, 4) reaching a decision with a patient, and 5) evaluating a patient’s decision.
- Discuss best practices of shared decision-making and give examples of where shared decision-making may be used inside and outside the setting of hospital rounds.
- Give examples of universal health literacy precautions use during communications with patients and the family/caregivers, including using plain language, minimizing unnecessary medical jargon, breaking down complex concepts into understandable pieces, bidirectional communication, and reinforcement with written or internet-based educational materials.
- Define implicit bias and review how unconscious, automatic stereotypes can affect understanding and decisions, leading to inconsistent management and healthcare outcome disparities.
- Discuss how differing experiences and views on race, ethnicity, sexual orientation, gender identity, religion, culture, immigration, disability, language, literacy, health literacy, and socioeconomic status may influence the approach toward and success of FCR and a comprehensive FCC program.
Skills
Pediatric hospitalists should be able to:
- Model, teach, and integrate FCC principles throughout the inpatient continuum of care delivery, from admission and medication reconciliation to rounds, transitions of care, and discharge planning.
- Demonstrate basic skills in co-production specific to hospital medicine including those affecting policy (co-commissioning), clinical care and education (co-design, co-delivery), and quality/safety/research (co-assessment) within the local context.
- Coordinate, lead, and adapt FCR to meet specific patient needs, such as low English proficiency (LEP) children, adolescents, caregivers, and family members.
- Educate trainees about the core elements of FCC.
- Utilize strategies to include nursing staff and other ancillary staff (such as pharmacists, social workers, care coordinators, and others) in FCC.
- Utilize strategies to activate patients and the family/caregivers.
- Demonstrate skills in shared decision-making.
- Integrate the consistent use of universal health literacy precautions into daily practice.
- Demonstrate culturally competent communication skills.
- Engage interpreters effectively for LEP patients.
- Identify and abate potential implicit biases.
- Demonstrate skill in using information technology, including electronic medical record portals, to promote patient engagement.
Attitudes
Pediatric hospitalists should be able to:
- Recognize the role that implicit bias plays in impeding FCC.
- Reflect on the importance of being respectful of religious, cultural, and personal preferences in communication and involvement in care.
- Realize the patient and family/caregivers’ important role in promoting health and partnering in care decisions, both in the hospital and after discharge.
- Consider that all patients and the family/caregivers benefit from clear communication and universal health literacy precautions.
- Recognize the unique roles of the patient and the family/caregivers as “vigilant partners” in care and in patient safety, including in safety promotion and safety reporting.
- Appreciate the unique needs of underserved and marginalized communities, including LEP patients, Lesbian Gay Bisexual Transgender (LGBT) youth, religious and ethnic minorities, and immigrants.
Systems Organization and Improvement
In order to improve efficiency and quality within their organizations, pediatric hospitalists should:
- Lead, coordinate, or participate in interdisciplinary efforts to ensure effective patient and family engagement in hospital committees, research activities including prioritizing research questions, and hospital quality improvement initiatives.
- Work with hospital administration and other hospital leaders to create and sustain patient and family/caregiver involvement in safety reporting and safety promotion.
- Collaborate with graduate medical education leaders and other educators to create and sustain education around FCC for medical students, residents, faculty, and other healthcare providers.
- Collaborate with hospital administration and community leaders to engage patients and the family/caregivers in design and development of pediatric hospitals and healthcare systems, within local context.
Introduction
The National Academy of Medicine (NAM; previously the Institute of Medicine [IOM]), the American Academy of Pediatrics, and the Accreditation Council for Graduate Medical Education have all called for an increased emphasis on patient and family centered care. Family centered care (FCC) involves collaboration between patients, the family/caregivers, healthcare providers, and hospital administration to address the needs of individual patients, populations, and healthcare systems. It can inform policy, facility design, healthcare outcomes evaluation, and individual daily interactions. Thus, FCC is used to plan, deliver, and evaluate healthcare; conduct research; provide education; and improve healthcare quality. Pediatric hospitalists were first to lead national efforts to espouse family centered rounds (FCR), which is a cornerstone of a larger FCC program. Pediatric hospitalists promote high quality FCC by embedding it into daily interactions with patients and the family/caregivers, modeling and teaching it to trainees, and applying it to clinical care, medical education, research, quality improvement, hospital operations, and patient safety.
Knowledge
Pediatric hospitalists should be able to:
- Summarize the features of FCC, drawing upon existing frameworks from organizations such as the NAM, the Agency for Healthcare Research and Quality, and the Picker Institute.
- Describe the Picker Institute’s 8 Principles of Patient Centered Care: 1) respect for patient preferences, 2) coordination and integration of care, 3) information and education, 4) physical comfort, 5) emotional support, 6) involvement of family and friends, 7) continuity and transition, and 8) access to care.
- Summarize common components of a comprehensive healthcare system FCC program, attending to family involvement on advisory councils and boards, research committees, and electronic medical record groups, as well as healthcare system community partnerships and other relationships.
- Review the concept of “co-production”, which involves co-execution, co-planning, and civil discourse between patients, professionals, the healthcare system, and the community and society in order to achieve high-value healthcare and promote good health for all.
- Give examples of common best practices for FCR, including the family/caregivers speaking first, healthcare providers speaking in language understood by the family/caregivers, making plans and goal setting with the family/caregivers, asking open-ended questions, and assessing family/caregivers’ understanding.
- Describe the role of “patient activation” (patients attaining the confidence, knowledge, and skills to manage and maintain one’s health and healthcare needs) in promoting FCC in the inpatient setting.
- Discuss the steps of shared decision-making, including 1) seeking a patient’s participation, 2) helping a patient to explore and compare treatment options, 3) assessing a patient’s values and preferences, 4) reaching a decision with a patient, and 5) evaluating a patient’s decision.
- Discuss best practices of shared decision-making and give examples of where shared decision-making may be used inside and outside the setting of hospital rounds.
- Give examples of universal health literacy precautions use during communications with patients and the family/caregivers, including using plain language, minimizing unnecessary medical jargon, breaking down complex concepts into understandable pieces, bidirectional communication, and reinforcement with written or internet-based educational materials.
- Define implicit bias and review how unconscious, automatic stereotypes can affect understanding and decisions, leading to inconsistent management and healthcare outcome disparities.
- Discuss how differing experiences and views on race, ethnicity, sexual orientation, gender identity, religion, culture, immigration, disability, language, literacy, health literacy, and socioeconomic status may influence the approach toward and success of FCR and a comprehensive FCC program.
Skills
Pediatric hospitalists should be able to:
- Model, teach, and integrate FCC principles throughout the inpatient continuum of care delivery, from admission and medication reconciliation to rounds, transitions of care, and discharge planning.
- Demonstrate basic skills in co-production specific to hospital medicine including those affecting policy (co-commissioning), clinical care and education (co-design, co-delivery), and quality/safety/research (co-assessment) within the local context.
- Coordinate, lead, and adapt FCR to meet specific patient needs, such as low English proficiency (LEP) children, adolescents, caregivers, and family members.
- Educate trainees about the core elements of FCC.
- Utilize strategies to include nursing staff and other ancillary staff (such as pharmacists, social workers, care coordinators, and others) in FCC.
- Utilize strategies to activate patients and the family/caregivers.
- Demonstrate skills in shared decision-making.
- Integrate the consistent use of universal health literacy precautions into daily practice.
- Demonstrate culturally competent communication skills.
- Engage interpreters effectively for LEP patients.
- Identify and abate potential implicit biases.
- Demonstrate skill in using information technology, including electronic medical record portals, to promote patient engagement.
Attitudes
Pediatric hospitalists should be able to:
- Recognize the role that implicit bias plays in impeding FCC.
- Reflect on the importance of being respectful of religious, cultural, and personal preferences in communication and involvement in care.
- Realize the patient and family/caregivers’ important role in promoting health and partnering in care decisions, both in the hospital and after discharge.
- Consider that all patients and the family/caregivers benefit from clear communication and universal health literacy precautions.
- Recognize the unique roles of the patient and the family/caregivers as “vigilant partners” in care and in patient safety, including in safety promotion and safety reporting.
- Appreciate the unique needs of underserved and marginalized communities, including LEP patients, Lesbian Gay Bisexual Transgender (LGBT) youth, religious and ethnic minorities, and immigrants.
Systems Organization and Improvement
In order to improve efficiency and quality within their organizations, pediatric hospitalists should:
- Lead, coordinate, or participate in interdisciplinary efforts to ensure effective patient and family engagement in hospital committees, research activities including prioritizing research questions, and hospital quality improvement initiatives.
- Work with hospital administration and other hospital leaders to create and sustain patient and family/caregiver involvement in safety reporting and safety promotion.
- Collaborate with graduate medical education leaders and other educators to create and sustain education around FCC for medical students, residents, faculty, and other healthcare providers.
- Collaborate with hospital administration and community leaders to engage patients and the family/caregivers in design and development of pediatric hospitals and healthcare systems, within local context.
1. Institute for Patient- and Family-Centered Care. https://www.ipfcc.org/. Accessed August 23, 2019.
2. Committee on Hospital Care and Institute for Patient- and Family-Centered Care. Patient- and family-centered care and the pediatrician’s role. Pediatrics. 2012;129(2):394-404. https://doi.org/10.1542/peds.2011-3084.
3. Rea KE, Rao P, Hill E, Saylor KM, Cousino MK. Families’ experiences with pediatric family-centered rounds: A systematic review. Pediatrics. 2018;141(3): e20171883. https://pediatrics.aappublications.org/content/141/3e20171883.long. Accessed August 28, 2019.
1. Institute for Patient- and Family-Centered Care. https://www.ipfcc.org/. Accessed August 23, 2019.
2. Committee on Hospital Care and Institute for Patient- and Family-Centered Care. Patient- and family-centered care and the pediatrician’s role. Pediatrics. 2012;129(2):394-404. https://doi.org/10.1542/peds.2011-3084.
3. Rea KE, Rao P, Hill E, Saylor KM, Cousino MK. Families’ experiences with pediatric family-centered rounds: A systematic review. Pediatrics. 2018;141(3): e20171883. https://pediatrics.aappublications.org/content/141/3e20171883.long. Accessed August 28, 2019.
4.06 Healthcare Systems: Evidence-based Medicine
Introduction
Evidence-based medicine (EBM) is the conscientious, explicit, and judicious use of current best evidence in making decisions about patient care. This scientific evidence includes data obtained from many study types that are found in varied published manuscripts, society guidelines, or other reputable sources. Sources of evidence must be interpreted and applied to clinical decision-making in a thorough and thoughtful manner in order to achieve best practice. Clinical decisions are therefore made considering a combination of the value systems of patients and the family/caregivers, specific clinical circumstances, and a thorough assessment of the EBM literature regarding the clinical condition. Pediatric hospitalists address multiple clinical questions daily and should utilize EBM to make clinical care decisions, teach trainees and engage patients and the family/caregivers in shared decision-making, perform quality improvement (QI) and research studies, and advance personal lifelong learning.
Knowledge
Pediatric hospitalists should be able to:
- Define EBM and list databases and other resources commonly used to search for this medical evidence.
- Discuss the benefits and limitations of commonly used scientific medical resources, considering issues such as publication bias, consensus statement methodology used, national versus international web indexed articles, and others.
- State how EBM is integrated into clinical decision-making for a patient or a population.
- Review how EBM supports QI and patient safety efforts.
- List examples of where EBM may be integrated into common educational efforts for trainees and clinical groups or divisions, attending to scheduled and spontaneous sessions.
- Explain common classification systems used to grade the strength of evidence in a given published work and discuss how this can help guide clinical decision-making.
- Explain how each of the components of a well composed, searchable clinical question using a method such as patient-intervention-control-outcomes (PICO) aids in obtaining a more accurate and comprehensive list of references.
- Distinguish among commonly used study designs, such as retrospective, prospective, case control, randomized controlled trial, and others, and list the benefits and limitations of each.
- Define commonly used terms such as relative and absolute risk reduction, number needed to treat (NNT), sensitivity, specificity, positive and negative predictive values (PPV, NPV), and likelihood ratios (LR).
- Review how EBM is integrated into lifelong learning, including ongoing certification by professional certifying boards.
Skills
Pediatric hospitalists should be able to:
- Identify information deficits and perform accurate EBM review to address the deficits in the context of clinical practice.
- Translate a clinical question into a searchable PICO question or search string.
- Identify the most appropriate study designs to answer a specific clinical question.
- Demonstrate proficient performance of a literature search using electronic resources such as PubMed.
- Appraise the quality of varied published manuscripts, society guidelines, or other reputable sources of medical literature using a consistent method.
- Interpret the level of evidence and risk/benefit ratio of study results and utilize EBM methods to select appropriate tests and treatments for patients.
- Apply relevant results from the available evidence to assist with creating and implementing clinical guidelines for populations, within local context.
- Integrate the consistent use of EBM into activities for personal lifelong learning.
- Develop, implement, and maintain a personal strategy to consistently incorporate evidence, balance of harm and benefits, and values of patients and the family/caregivers into shared clinical decision-making to deliver the highest quality care.
Attitudes
Pediatric hospitalists should be able to:
- Recognize the importance of seeking the best available evidence to support clinical decision-making.
- Realize that acquiring and maintaining EBM skills requires integration into daily practice and pursuit of ongoing continuing education.
- Recognize how personal practice patterns are influenced by the integration of EBM.
- Role model use of EBM at the bedside.
Systems Organization and Improvement
In order to improve efficiency and quality within their organizations, pediatric hospitalists should:
- Lead, coordinate, or participate in the development and implementation of evidence-based care pathways to standardize the evaluation and management of hospitalized children in the local system.
- Engage with hospital staff, trainees, colleagues, subspecialists, and others in a multidisciplinary team approach toward integrating EBM into clinical decision-making processes.
- Collaborate with hospital administrators to acquire and maintain effective, efficient electronic resources for the performance of EBM.
1. Sackett DL, Rosenberg W, Mc Gray JA, Haynes RB, Richardson WS. Evidence-based medicine: what it is and what it isn’t. BMJ. 1996; 312:71-72. https://doi.org/10.1136/bmj.312.7023.71
2. The Centre for Evidence-Based Medicine. https://www.cebm.net/. Accessed August 28, 2019.
3. Horwitz RI, Hayes-Conroy A, Caricchio R, Singer BH. From Evidence Based Medicine to Medicine Based Evidence. Am J Med. 2017;130(11):1246-1250. https://doi.org/10.1016/j.amjmed.2017.06.012.
Introduction
Evidence-based medicine (EBM) is the conscientious, explicit, and judicious use of current best evidence in making decisions about patient care. This scientific evidence includes data obtained from many study types that are found in varied published manuscripts, society guidelines, or other reputable sources. Sources of evidence must be interpreted and applied to clinical decision-making in a thorough and thoughtful manner in order to achieve best practice. Clinical decisions are therefore made considering a combination of the value systems of patients and the family/caregivers, specific clinical circumstances, and a thorough assessment of the EBM literature regarding the clinical condition. Pediatric hospitalists address multiple clinical questions daily and should utilize EBM to make clinical care decisions, teach trainees and engage patients and the family/caregivers in shared decision-making, perform quality improvement (QI) and research studies, and advance personal lifelong learning.
Knowledge
Pediatric hospitalists should be able to:
- Define EBM and list databases and other resources commonly used to search for this medical evidence.
- Discuss the benefits and limitations of commonly used scientific medical resources, considering issues such as publication bias, consensus statement methodology used, national versus international web indexed articles, and others.
- State how EBM is integrated into clinical decision-making for a patient or a population.
- Review how EBM supports QI and patient safety efforts.
- List examples of where EBM may be integrated into common educational efforts for trainees and clinical groups or divisions, attending to scheduled and spontaneous sessions.
- Explain common classification systems used to grade the strength of evidence in a given published work and discuss how this can help guide clinical decision-making.
- Explain how each of the components of a well composed, searchable clinical question using a method such as patient-intervention-control-outcomes (PICO) aids in obtaining a more accurate and comprehensive list of references.
- Distinguish among commonly used study designs, such as retrospective, prospective, case control, randomized controlled trial, and others, and list the benefits and limitations of each.
- Define commonly used terms such as relative and absolute risk reduction, number needed to treat (NNT), sensitivity, specificity, positive and negative predictive values (PPV, NPV), and likelihood ratios (LR).
- Review how EBM is integrated into lifelong learning, including ongoing certification by professional certifying boards.
Skills
Pediatric hospitalists should be able to:
- Identify information deficits and perform accurate EBM review to address the deficits in the context of clinical practice.
- Translate a clinical question into a searchable PICO question or search string.
- Identify the most appropriate study designs to answer a specific clinical question.
- Demonstrate proficient performance of a literature search using electronic resources such as PubMed.
- Appraise the quality of varied published manuscripts, society guidelines, or other reputable sources of medical literature using a consistent method.
- Interpret the level of evidence and risk/benefit ratio of study results and utilize EBM methods to select appropriate tests and treatments for patients.
- Apply relevant results from the available evidence to assist with creating and implementing clinical guidelines for populations, within local context.
- Integrate the consistent use of EBM into activities for personal lifelong learning.
- Develop, implement, and maintain a personal strategy to consistently incorporate evidence, balance of harm and benefits, and values of patients and the family/caregivers into shared clinical decision-making to deliver the highest quality care.
Attitudes
Pediatric hospitalists should be able to:
- Recognize the importance of seeking the best available evidence to support clinical decision-making.
- Realize that acquiring and maintaining EBM skills requires integration into daily practice and pursuit of ongoing continuing education.
- Recognize how personal practice patterns are influenced by the integration of EBM.
- Role model use of EBM at the bedside.
Systems Organization and Improvement
In order to improve efficiency and quality within their organizations, pediatric hospitalists should:
- Lead, coordinate, or participate in the development and implementation of evidence-based care pathways to standardize the evaluation and management of hospitalized children in the local system.
- Engage with hospital staff, trainees, colleagues, subspecialists, and others in a multidisciplinary team approach toward integrating EBM into clinical decision-making processes.
- Collaborate with hospital administrators to acquire and maintain effective, efficient electronic resources for the performance of EBM.
Introduction
Evidence-based medicine (EBM) is the conscientious, explicit, and judicious use of current best evidence in making decisions about patient care. This scientific evidence includes data obtained from many study types that are found in varied published manuscripts, society guidelines, or other reputable sources. Sources of evidence must be interpreted and applied to clinical decision-making in a thorough and thoughtful manner in order to achieve best practice. Clinical decisions are therefore made considering a combination of the value systems of patients and the family/caregivers, specific clinical circumstances, and a thorough assessment of the EBM literature regarding the clinical condition. Pediatric hospitalists address multiple clinical questions daily and should utilize EBM to make clinical care decisions, teach trainees and engage patients and the family/caregivers in shared decision-making, perform quality improvement (QI) and research studies, and advance personal lifelong learning.
Knowledge
Pediatric hospitalists should be able to:
- Define EBM and list databases and other resources commonly used to search for this medical evidence.
- Discuss the benefits and limitations of commonly used scientific medical resources, considering issues such as publication bias, consensus statement methodology used, national versus international web indexed articles, and others.
- State how EBM is integrated into clinical decision-making for a patient or a population.
- Review how EBM supports QI and patient safety efforts.
- List examples of where EBM may be integrated into common educational efforts for trainees and clinical groups or divisions, attending to scheduled and spontaneous sessions.
- Explain common classification systems used to grade the strength of evidence in a given published work and discuss how this can help guide clinical decision-making.
- Explain how each of the components of a well composed, searchable clinical question using a method such as patient-intervention-control-outcomes (PICO) aids in obtaining a more accurate and comprehensive list of references.
- Distinguish among commonly used study designs, such as retrospective, prospective, case control, randomized controlled trial, and others, and list the benefits and limitations of each.
- Define commonly used terms such as relative and absolute risk reduction, number needed to treat (NNT), sensitivity, specificity, positive and negative predictive values (PPV, NPV), and likelihood ratios (LR).
- Review how EBM is integrated into lifelong learning, including ongoing certification by professional certifying boards.
Skills
Pediatric hospitalists should be able to:
- Identify information deficits and perform accurate EBM review to address the deficits in the context of clinical practice.
- Translate a clinical question into a searchable PICO question or search string.
- Identify the most appropriate study designs to answer a specific clinical question.
- Demonstrate proficient performance of a literature search using electronic resources such as PubMed.
- Appraise the quality of varied published manuscripts, society guidelines, or other reputable sources of medical literature using a consistent method.
- Interpret the level of evidence and risk/benefit ratio of study results and utilize EBM methods to select appropriate tests and treatments for patients.
- Apply relevant results from the available evidence to assist with creating and implementing clinical guidelines for populations, within local context.
- Integrate the consistent use of EBM into activities for personal lifelong learning.
- Develop, implement, and maintain a personal strategy to consistently incorporate evidence, balance of harm and benefits, and values of patients and the family/caregivers into shared clinical decision-making to deliver the highest quality care.
Attitudes
Pediatric hospitalists should be able to:
- Recognize the importance of seeking the best available evidence to support clinical decision-making.
- Realize that acquiring and maintaining EBM skills requires integration into daily practice and pursuit of ongoing continuing education.
- Recognize how personal practice patterns are influenced by the integration of EBM.
- Role model use of EBM at the bedside.
Systems Organization and Improvement
In order to improve efficiency and quality within their organizations, pediatric hospitalists should:
- Lead, coordinate, or participate in the development and implementation of evidence-based care pathways to standardize the evaluation and management of hospitalized children in the local system.
- Engage with hospital staff, trainees, colleagues, subspecialists, and others in a multidisciplinary team approach toward integrating EBM into clinical decision-making processes.
- Collaborate with hospital administrators to acquire and maintain effective, efficient electronic resources for the performance of EBM.
1. Sackett DL, Rosenberg W, Mc Gray JA, Haynes RB, Richardson WS. Evidence-based medicine: what it is and what it isn’t. BMJ. 1996; 312:71-72. https://doi.org/10.1136/bmj.312.7023.71
2. The Centre for Evidence-Based Medicine. https://www.cebm.net/. Accessed August 28, 2019.
3. Horwitz RI, Hayes-Conroy A, Caricchio R, Singer BH. From Evidence Based Medicine to Medicine Based Evidence. Am J Med. 2017;130(11):1246-1250. https://doi.org/10.1016/j.amjmed.2017.06.012.
1. Sackett DL, Rosenberg W, Mc Gray JA, Haynes RB, Richardson WS. Evidence-based medicine: what it is and what it isn’t. BMJ. 1996; 312:71-72. https://doi.org/10.1136/bmj.312.7023.71
2. The Centre for Evidence-Based Medicine. https://www.cebm.net/. Accessed August 28, 2019.
3. Horwitz RI, Hayes-Conroy A, Caricchio R, Singer BH. From Evidence Based Medicine to Medicine Based Evidence. Am J Med. 2017;130(11):1246-1250. https://doi.org/10.1016/j.amjmed.2017.06.012.
4.05 Healthcare Systems: Ethics
Introduction
Medicine is a profession; it is not merely a composite of simple commercial transactions but is an inherently moral enterprise. Hospitalized patients are particularly vulnerable due to the impact of their illnesses and their dependence on healthcare providers who have specialized knowledge and control over its use. Physicians have fiduciary obligations to their patients and are expected to prioritize patients’ interests over their own. Physicians should make decisions that promote patients’ own interpretations of what are good or beneficial outcomes. Pediatric patients are even more vulnerable because their parents/guardians interpret what is good and make decisions on their behalf. Ethical dilemmas are increasingly encountered due to medical advances, patient complexity, questioning of science, and conflicts between cultures and societies. Pediatric hospitalists should have the knowledge, skills, and attitudes required to identify, analyze, and assist with resolving ethical issues, and to act ethically.
Knowledge
Pediatric hospitalists should be able to:
- Compare and contrast “business ethics” (the accountability of organizations to use policies and procedures to justify and take responsibility for their activities) with “professional ethics” (application of defined expertise [knowledge and skill] to the practical benefit of others).
- Describe the principles of respect for autonomy, beneficence, nonmaleficence, and justice.
- Distinguish between the concepts of privacy and confidentiality and describe an example of an ethically justifiable violation of a patient’s confidentiality.
- Discuss the differences between advance care planning, advance directives (such as durable powers of attorney for healthcare and living wills), Physician Orders for Life-Sustaining Treatment (POLST), and do not attempt resuscitation (DNAR) orders.
- Describe the elements of medical decision-making capacity and informed consent.
- Compare and contrast between informed consent and assent.
- Compare and contrast between the best interest and substituted judgment standards.
- Describe when it is ethically acceptable to withhold or withdraw life-sustaining treatment, including medically provided nutrition and hydration.
- Cite examples of differing types of futility, including physiologic (proposed intervention cannot achieve the desired effect), quantitative (proposed intervention is highly unlikely to achieve the desired effect or benefit the patient) and qualitative (the quality of benefit of the proposed intervention will produce is exceedingly poor), and review the response to requests for “potentially inappropriate treatments” as recommended by the American Thoracic Society and other professional organizations.
- Describe scenarios when ethics consultation may be of value, attending to conflicts around potentially life-changing decisions between any of the following: patient, family/caregivers, healthcare team members, and others.
- Articulate the criteria for justifiably overriding a parent’s or guardian’s refusal of recommended treatment, such as in cases of medical neglect.
- Review the process for requesting an ethics consult within the local context.
- Summarize the goals of and steps involved in an ethics consultation.
- Cite common reasons for consulting risk management and/or legal representatives.
- Discuss the different roles played by ethics consultants, risk managers, and lawyers.
- Compare and contrast the ethical obligations of clinicians versus researchers.
- Review the potential adverse effects of actual or perceived conflicts of interest in the various roles pediatric hospitalists perform, including clinical care, research, and administration, and discuss the strategies used to manage these conflicts.
Skills
Pediatric hospitalists should be able to:
- Provide competent care while fulfilling ethical duties to patients and the family/caregivers.
- Communicate honestly and compassionately, maintaining patient privacy and confidentiality.
- Demonstrate professionalism, completing all professional responsibilities in an ethical manner.
- Demonstrate skills in initiating an ethics consult and in collaborating with an ethics consulting team.
- Demonstrate basic skills in resolving ethical conflicts with patients and the family/caregivers, in collaboration with ethics consultants as appropriate.
- Demonstrate the ability to identify in oneself and among care team members any moral distress or conscientious objection and develop a plan for reasonable accommodation.
- Evaluate medical decision-making capacity and identify appropriate proxies as needed.
- Demonstrate skills in communicating indications, benefits, risks, and alternatives for various interventions consistent with the decision makers’ health literacy.
- Elicit goals of care and recommend treatments consistent with these goals and against treatments that conflict with them as appropriate.
- Identify patients for whom advance care planning is appropriate and collaborate in and/or refer for advance care planning.
- Complete and implement POLST forms, advance directives, and DNAR orders.
- Identify and manage potential conflicts of interests.
- Identify and avoid boundary violations.
- Identify personal biases and avoid unjust discrimination.
- Report impaired healthcare providers and those with unethical behavior to appropriate entities using pertinent procedures.
- Consistently adhere to appropriate documentation and coding practices.
Attitudes
Pediatric hospitalists should be able to:
- Respect patients and their family/caregivers and value their participation in shared decision-making.
- Recognize the importance of a patient’s own experiences on their quality of life.
- Reflect on and provide support for family/caregivers as they express their values and the goals they have for their children.
- Realize the need to include an ethical perspective in the approach toward healthcare decision-making, regardless of role in clinical care, administration, research, or education.
Systems Organization and Improvement
In order to improve efficiency and quality within their organizations, pediatric hospitalists should:
- Collaborate with hospital administration to develop and maintain ethically sound institutional practices, policies, and culture.
- Advocate for healthcare policy that improves the quality of and access to pediatric healthcare services.
1. Katz AL, Webb SA, and the Committee on Bioethics. Informed consent in decision-making in pediatric practice. Pediatrics. 2016;138(2) e20161484. https://pediatrics.aappublications.org/content/138/2/e20161484.long. Accessed August 28, 2019.
2. Fleischman AR. Pediatric Ethics: Protecting the Interests of Children. New York, NY: Oxford University Press; 2016.
3. Bosslet GT, Pope TM, Rubenfeld GD, et al. An official ATS/AACN/ACCP/ESICM/SCCM policy statement: Responding to requests for potentially inappropriate treatments in intensive care units. Am J Respir Crit Care Med. 2015;191(11):1318-1330. https://doi.org/10.1164/rccm.201505-0924ST.
Introduction
Medicine is a profession; it is not merely a composite of simple commercial transactions but is an inherently moral enterprise. Hospitalized patients are particularly vulnerable due to the impact of their illnesses and their dependence on healthcare providers who have specialized knowledge and control over its use. Physicians have fiduciary obligations to their patients and are expected to prioritize patients’ interests over their own. Physicians should make decisions that promote patients’ own interpretations of what are good or beneficial outcomes. Pediatric patients are even more vulnerable because their parents/guardians interpret what is good and make decisions on their behalf. Ethical dilemmas are increasingly encountered due to medical advances, patient complexity, questioning of science, and conflicts between cultures and societies. Pediatric hospitalists should have the knowledge, skills, and attitudes required to identify, analyze, and assist with resolving ethical issues, and to act ethically.
Knowledge
Pediatric hospitalists should be able to:
- Compare and contrast “business ethics” (the accountability of organizations to use policies and procedures to justify and take responsibility for their activities) with “professional ethics” (application of defined expertise [knowledge and skill] to the practical benefit of others).
- Describe the principles of respect for autonomy, beneficence, nonmaleficence, and justice.
- Distinguish between the concepts of privacy and confidentiality and describe an example of an ethically justifiable violation of a patient’s confidentiality.
- Discuss the differences between advance care planning, advance directives (such as durable powers of attorney for healthcare and living wills), Physician Orders for Life-Sustaining Treatment (POLST), and do not attempt resuscitation (DNAR) orders.
- Describe the elements of medical decision-making capacity and informed consent.
- Compare and contrast between informed consent and assent.
- Compare and contrast between the best interest and substituted judgment standards.
- Describe when it is ethically acceptable to withhold or withdraw life-sustaining treatment, including medically provided nutrition and hydration.
- Cite examples of differing types of futility, including physiologic (proposed intervention cannot achieve the desired effect), quantitative (proposed intervention is highly unlikely to achieve the desired effect or benefit the patient) and qualitative (the quality of benefit of the proposed intervention will produce is exceedingly poor), and review the response to requests for “potentially inappropriate treatments” as recommended by the American Thoracic Society and other professional organizations.
- Describe scenarios when ethics consultation may be of value, attending to conflicts around potentially life-changing decisions between any of the following: patient, family/caregivers, healthcare team members, and others.
- Articulate the criteria for justifiably overriding a parent’s or guardian’s refusal of recommended treatment, such as in cases of medical neglect.
- Review the process for requesting an ethics consult within the local context.
- Summarize the goals of and steps involved in an ethics consultation.
- Cite common reasons for consulting risk management and/or legal representatives.
- Discuss the different roles played by ethics consultants, risk managers, and lawyers.
- Compare and contrast the ethical obligations of clinicians versus researchers.
- Review the potential adverse effects of actual or perceived conflicts of interest in the various roles pediatric hospitalists perform, including clinical care, research, and administration, and discuss the strategies used to manage these conflicts.
Skills
Pediatric hospitalists should be able to:
- Provide competent care while fulfilling ethical duties to patients and the family/caregivers.
- Communicate honestly and compassionately, maintaining patient privacy and confidentiality.
- Demonstrate professionalism, completing all professional responsibilities in an ethical manner.
- Demonstrate skills in initiating an ethics consult and in collaborating with an ethics consulting team.
- Demonstrate basic skills in resolving ethical conflicts with patients and the family/caregivers, in collaboration with ethics consultants as appropriate.
- Demonstrate the ability to identify in oneself and among care team members any moral distress or conscientious objection and develop a plan for reasonable accommodation.
- Evaluate medical decision-making capacity and identify appropriate proxies as needed.
- Demonstrate skills in communicating indications, benefits, risks, and alternatives for various interventions consistent with the decision makers’ health literacy.
- Elicit goals of care and recommend treatments consistent with these goals and against treatments that conflict with them as appropriate.
- Identify patients for whom advance care planning is appropriate and collaborate in and/or refer for advance care planning.
- Complete and implement POLST forms, advance directives, and DNAR orders.
- Identify and manage potential conflicts of interests.
- Identify and avoid boundary violations.
- Identify personal biases and avoid unjust discrimination.
- Report impaired healthcare providers and those with unethical behavior to appropriate entities using pertinent procedures.
- Consistently adhere to appropriate documentation and coding practices.
Attitudes
Pediatric hospitalists should be able to:
- Respect patients and their family/caregivers and value their participation in shared decision-making.
- Recognize the importance of a patient’s own experiences on their quality of life.
- Reflect on and provide support for family/caregivers as they express their values and the goals they have for their children.
- Realize the need to include an ethical perspective in the approach toward healthcare decision-making, regardless of role in clinical care, administration, research, or education.
Systems Organization and Improvement
In order to improve efficiency and quality within their organizations, pediatric hospitalists should:
- Collaborate with hospital administration to develop and maintain ethically sound institutional practices, policies, and culture.
- Advocate for healthcare policy that improves the quality of and access to pediatric healthcare services.
Introduction
Medicine is a profession; it is not merely a composite of simple commercial transactions but is an inherently moral enterprise. Hospitalized patients are particularly vulnerable due to the impact of their illnesses and their dependence on healthcare providers who have specialized knowledge and control over its use. Physicians have fiduciary obligations to their patients and are expected to prioritize patients’ interests over their own. Physicians should make decisions that promote patients’ own interpretations of what are good or beneficial outcomes. Pediatric patients are even more vulnerable because their parents/guardians interpret what is good and make decisions on their behalf. Ethical dilemmas are increasingly encountered due to medical advances, patient complexity, questioning of science, and conflicts between cultures and societies. Pediatric hospitalists should have the knowledge, skills, and attitudes required to identify, analyze, and assist with resolving ethical issues, and to act ethically.
Knowledge
Pediatric hospitalists should be able to:
- Compare and contrast “business ethics” (the accountability of organizations to use policies and procedures to justify and take responsibility for their activities) with “professional ethics” (application of defined expertise [knowledge and skill] to the practical benefit of others).
- Describe the principles of respect for autonomy, beneficence, nonmaleficence, and justice.
- Distinguish between the concepts of privacy and confidentiality and describe an example of an ethically justifiable violation of a patient’s confidentiality.
- Discuss the differences between advance care planning, advance directives (such as durable powers of attorney for healthcare and living wills), Physician Orders for Life-Sustaining Treatment (POLST), and do not attempt resuscitation (DNAR) orders.
- Describe the elements of medical decision-making capacity and informed consent.
- Compare and contrast between informed consent and assent.
- Compare and contrast between the best interest and substituted judgment standards.
- Describe when it is ethically acceptable to withhold or withdraw life-sustaining treatment, including medically provided nutrition and hydration.
- Cite examples of differing types of futility, including physiologic (proposed intervention cannot achieve the desired effect), quantitative (proposed intervention is highly unlikely to achieve the desired effect or benefit the patient) and qualitative (the quality of benefit of the proposed intervention will produce is exceedingly poor), and review the response to requests for “potentially inappropriate treatments” as recommended by the American Thoracic Society and other professional organizations.
- Describe scenarios when ethics consultation may be of value, attending to conflicts around potentially life-changing decisions between any of the following: patient, family/caregivers, healthcare team members, and others.
- Articulate the criteria for justifiably overriding a parent’s or guardian’s refusal of recommended treatment, such as in cases of medical neglect.
- Review the process for requesting an ethics consult within the local context.
- Summarize the goals of and steps involved in an ethics consultation.
- Cite common reasons for consulting risk management and/or legal representatives.
- Discuss the different roles played by ethics consultants, risk managers, and lawyers.
- Compare and contrast the ethical obligations of clinicians versus researchers.
- Review the potential adverse effects of actual or perceived conflicts of interest in the various roles pediatric hospitalists perform, including clinical care, research, and administration, and discuss the strategies used to manage these conflicts.
Skills
Pediatric hospitalists should be able to:
- Provide competent care while fulfilling ethical duties to patients and the family/caregivers.
- Communicate honestly and compassionately, maintaining patient privacy and confidentiality.
- Demonstrate professionalism, completing all professional responsibilities in an ethical manner.
- Demonstrate skills in initiating an ethics consult and in collaborating with an ethics consulting team.
- Demonstrate basic skills in resolving ethical conflicts with patients and the family/caregivers, in collaboration with ethics consultants as appropriate.
- Demonstrate the ability to identify in oneself and among care team members any moral distress or conscientious objection and develop a plan for reasonable accommodation.
- Evaluate medical decision-making capacity and identify appropriate proxies as needed.
- Demonstrate skills in communicating indications, benefits, risks, and alternatives for various interventions consistent with the decision makers’ health literacy.
- Elicit goals of care and recommend treatments consistent with these goals and against treatments that conflict with them as appropriate.
- Identify patients for whom advance care planning is appropriate and collaborate in and/or refer for advance care planning.
- Complete and implement POLST forms, advance directives, and DNAR orders.
- Identify and manage potential conflicts of interests.
- Identify and avoid boundary violations.
- Identify personal biases and avoid unjust discrimination.
- Report impaired healthcare providers and those with unethical behavior to appropriate entities using pertinent procedures.
- Consistently adhere to appropriate documentation and coding practices.
Attitudes
Pediatric hospitalists should be able to:
- Respect patients and their family/caregivers and value their participation in shared decision-making.
- Recognize the importance of a patient’s own experiences on their quality of life.
- Reflect on and provide support for family/caregivers as they express their values and the goals they have for their children.
- Realize the need to include an ethical perspective in the approach toward healthcare decision-making, regardless of role in clinical care, administration, research, or education.
Systems Organization and Improvement
In order to improve efficiency and quality within their organizations, pediatric hospitalists should:
- Collaborate with hospital administration to develop and maintain ethically sound institutional practices, policies, and culture.
- Advocate for healthcare policy that improves the quality of and access to pediatric healthcare services.
1. Katz AL, Webb SA, and the Committee on Bioethics. Informed consent in decision-making in pediatric practice. Pediatrics. 2016;138(2) e20161484. https://pediatrics.aappublications.org/content/138/2/e20161484.long. Accessed August 28, 2019.
2. Fleischman AR. Pediatric Ethics: Protecting the Interests of Children. New York, NY: Oxford University Press; 2016.
3. Bosslet GT, Pope TM, Rubenfeld GD, et al. An official ATS/AACN/ACCP/ESICM/SCCM policy statement: Responding to requests for potentially inappropriate treatments in intensive care units. Am J Respir Crit Care Med. 2015;191(11):1318-1330. https://doi.org/10.1164/rccm.201505-0924ST.
1. Katz AL, Webb SA, and the Committee on Bioethics. Informed consent in decision-making in pediatric practice. Pediatrics. 2016;138(2) e20161484. https://pediatrics.aappublications.org/content/138/2/e20161484.long. Accessed August 28, 2019.
2. Fleischman AR. Pediatric Ethics: Protecting the Interests of Children. New York, NY: Oxford University Press; 2016.
3. Bosslet GT, Pope TM, Rubenfeld GD, et al. An official ATS/AACN/ACCP/ESICM/SCCM policy statement: Responding to requests for potentially inappropriate treatments in intensive care units. Am J Respir Crit Care Med. 2015;191(11):1318-1330. https://doi.org/10.1164/rccm.201505-0924ST.
4.04 Healthcare Systems: Education
Introduction
Pediatric hospitalists can serve many roles in education, including teaching others in clinical settings, creating curriculum, directing educational programs, and serving in formal roles in both undergraduate and graduate medical education administration. Additional educational opportunities include training future hospitalists and directing continuing medical education programs. Pediatric hospitalists are teachers, educating hospital staff, learners (medical students, other health profession students, residents, and fellows), community clinicians, organizations, patients and the family/caregivers, and colleagues. Hospitalists in community and university/children’s hospital systems serve a pivotal role in teaching learners and/or other healthcare providers on the hospital wards and via hospital related didactic or simulation sessions. In addition to educating others, lifelong learning requires hospitalists to engage in ongoing education targeting personal goals and career plans. Education is therefore essential for all pediatric hospitalists, with specific competencies addressed in the context of the specific learner-educator environment.
Knowledge
Pediatric hospitalists should be able to:
- Explain why a continuum of competencies throughout a professional career is required and illustrate the benefits and challenges of this expectation.
- Review the use of education for patients and the family/caregivers, attending to daily discussions around clinical care and transition of care needs.
- Cite examples of using of evidence-based medicine literature review for education, including discussions on ward rounds, journal club, and self-learning.
- List resources and activities for continuous learning to maintain current knowledge and skills.
- Compare and contrast teaching from supervision of learners.
- Compare and contrast different teaching and learning preferences, attending to elements such as sensory modes (visual, auditory, kinesthetic/motor), group size, setting, and other factors.
- Define common terms and phrases used in adult learning theory, including assessing learner needs, establishing learner goals, active learning, self-directed learning, reflection, and others.
- Discuss how the principles of adult learning theory can be used in leading daily learning activities in clinical and didactic settings.
- Cite the value of ongoing self-directed learning and continued use of an individualized learning plan at all career stages.
- Describe how competencies and performance indicators are used in the evaluation of physicians at all career stages.
- Describe the pediatric competencies currently required by regulatory agencies such as the Liaison Committee of Medical Education (LCME), Accreditation Council for Graduate Medical Education (ACGME), and the American Board of Pediatrics (ABP).
- Describe the six mandated ACGME competency domains: patient care, medical knowledge, practice-based learning and improvement, interpersonal skills and communications, professionalism, and systems-based practice.
- Articulate how pediatric hospitalists can use each of the six core competencies to educate in the context of the inpatient setting and the larger healthcare system.
- Explain how learners benefit from knowing their learning goals at the beginning of an educational experience.
- Compare and contrast the advantages and limitations of the following evaluation methods: oral exams, written tests, global evaluations, direct observations with checklists, and multi-source (360 degree) evaluations.
- Describe the elements of effective feedback.
- Define “formative feedback” and “summative evaluation,” identifying the similarities and differences in each.
- Describe the common effects of evaluation on the motivation and learning priorities of learners.
- Review the steps involved in curriculum development, including performing a needs assessment, creating competency-based goals and objectives, selecting teaching activities to match learning objectives, creating a learner assessment and a program evaluation, and securing resources.
- Summarize how a curriculum can be applied to a single learning activity, a longitudinal curriculum, or a comprehensive educational program.
Skills
Pediatric hospitalists should be able to:
- Orient learners to inpatient ward rotation expectations, including learning goals and objectives, patient care and team responsibilities, systems, policies, and procedures for the rotation.
- Integrate use of established clinical pathways and educate learners on their correct use.
- Educate learners about the important blend between service and education.
- Identify and abate potential issues related to patient safety, professionalism, and communication that may occur when learners are involved in care teams.
- Identify learner needs and deliver education to best match the individual or learner group.
- Determine the level of a learner’s ability and allow graduated autonomy in clinical decision-making.
- Utilize “teachable moments,” such as case-based learning and role modeling, in the context of teaching in the inpatient setting.
- Demonstrate efficient and flexible use of time when adaptively teaching and using self-directed learning activities.
- Demonstrate basic skills in teaching and supervision methods, including bedside teaching, teaching during rounds, and case-based discussions.
- Provide role modeling, with priming, articulation of thought process, and debriefing.
- Create and deliver didactic teaching on relevant topics in pediatric hospital medicine.
- Teach a specific skill or procedure in the clinical and/or simulation environments.
- Utilize basic skills in questioning, including broadening, justifying, hypothetical, and alternative.
- Educate patients and the family/caregivers about the diagnostic testing, management plan, and prognosis in an interactive, family centered manner.
- Promote and facilitate learner reflection on own performance at clinical encounters to enhance learning.
- Provide frequent, effective feedback based upon direct observation of learners’ clinical, communication, technical skills, and professionalism.
- Write effective learner summative evaluations that reflect verbal feedback given.
Attitudes
Pediatric hospitalists should be able to:
- Realize the importance of promoting a climate of continuous learning by acknowledging personal knowledge gaps and prompting learners to teach each other.
- Model effective and empathetic communication with patients and the family/caregivers when educating.
- Encourage learners to be self-directed and to learn independently.
- Exemplify professional behavior by being prompt, prepared, available, and approachable in educational efforts.
- Acknowledge the value of building and maintaining teamwork by providing reinforcing as well as corrective feedback.
- Role model effective balance of clinical care, communication, and teaching needs during family centered rounds.
Systems Organization and Improvement
In order to improve efficiency and quality within their organizations, pediatric hospitalists should:
- Participate with training programs to create, maintain, and implement education in the hospital setting.
- Collaborate with hospital administrators to maintain adequate learner supervision to ensure patient safety, while encouraging development of autonomous practice.
- Lead, coordinate, or participate in multidisciplinary initiatives to promote quality improvement, patient safety, cost effective care, evidence-based medicine, and effective communication around inpatient pediatric care.
- Collaborate with hospital administration and training program directors to balance teaching, patient care responsibilities, and patient safety and maximize the effectiveness of each.
- Collaborate with hospital administration to ensure adequate teaching facilities.
1. Ende J. Feedback in clinical medical education. JAMA. 1983;250:777-781.
2. Fromme HB, Bhansali P, Singhal G, Yudkowsky R, Humphrey H, Harris I. The qualities and skills of exemplary pediatric hospitalist educators: a qualitative study. Acad Med. 2010;85(12):1905-1913. https://doi.org/10.1097/ACM.0b013e3181fa3560.
3. Thomas PA, Kern DE, Hughes MT, Chen BY. Curriculum Development for Medical Education: A Six-Step Approach. Baltimore, MD: Johns Hopkins University Press; 2016.
Introduction
Pediatric hospitalists can serve many roles in education, including teaching others in clinical settings, creating curriculum, directing educational programs, and serving in formal roles in both undergraduate and graduate medical education administration. Additional educational opportunities include training future hospitalists and directing continuing medical education programs. Pediatric hospitalists are teachers, educating hospital staff, learners (medical students, other health profession students, residents, and fellows), community clinicians, organizations, patients and the family/caregivers, and colleagues. Hospitalists in community and university/children’s hospital systems serve a pivotal role in teaching learners and/or other healthcare providers on the hospital wards and via hospital related didactic or simulation sessions. In addition to educating others, lifelong learning requires hospitalists to engage in ongoing education targeting personal goals and career plans. Education is therefore essential for all pediatric hospitalists, with specific competencies addressed in the context of the specific learner-educator environment.
Knowledge
Pediatric hospitalists should be able to:
- Explain why a continuum of competencies throughout a professional career is required and illustrate the benefits and challenges of this expectation.
- Review the use of education for patients and the family/caregivers, attending to daily discussions around clinical care and transition of care needs.
- Cite examples of using of evidence-based medicine literature review for education, including discussions on ward rounds, journal club, and self-learning.
- List resources and activities for continuous learning to maintain current knowledge and skills.
- Compare and contrast teaching from supervision of learners.
- Compare and contrast different teaching and learning preferences, attending to elements such as sensory modes (visual, auditory, kinesthetic/motor), group size, setting, and other factors.
- Define common terms and phrases used in adult learning theory, including assessing learner needs, establishing learner goals, active learning, self-directed learning, reflection, and others.
- Discuss how the principles of adult learning theory can be used in leading daily learning activities in clinical and didactic settings.
- Cite the value of ongoing self-directed learning and continued use of an individualized learning plan at all career stages.
- Describe how competencies and performance indicators are used in the evaluation of physicians at all career stages.
- Describe the pediatric competencies currently required by regulatory agencies such as the Liaison Committee of Medical Education (LCME), Accreditation Council for Graduate Medical Education (ACGME), and the American Board of Pediatrics (ABP).
- Describe the six mandated ACGME competency domains: patient care, medical knowledge, practice-based learning and improvement, interpersonal skills and communications, professionalism, and systems-based practice.
- Articulate how pediatric hospitalists can use each of the six core competencies to educate in the context of the inpatient setting and the larger healthcare system.
- Explain how learners benefit from knowing their learning goals at the beginning of an educational experience.
- Compare and contrast the advantages and limitations of the following evaluation methods: oral exams, written tests, global evaluations, direct observations with checklists, and multi-source (360 degree) evaluations.
- Describe the elements of effective feedback.
- Define “formative feedback” and “summative evaluation,” identifying the similarities and differences in each.
- Describe the common effects of evaluation on the motivation and learning priorities of learners.
- Review the steps involved in curriculum development, including performing a needs assessment, creating competency-based goals and objectives, selecting teaching activities to match learning objectives, creating a learner assessment and a program evaluation, and securing resources.
- Summarize how a curriculum can be applied to a single learning activity, a longitudinal curriculum, or a comprehensive educational program.
Skills
Pediatric hospitalists should be able to:
- Orient learners to inpatient ward rotation expectations, including learning goals and objectives, patient care and team responsibilities, systems, policies, and procedures for the rotation.
- Integrate use of established clinical pathways and educate learners on their correct use.
- Educate learners about the important blend between service and education.
- Identify and abate potential issues related to patient safety, professionalism, and communication that may occur when learners are involved in care teams.
- Identify learner needs and deliver education to best match the individual or learner group.
- Determine the level of a learner’s ability and allow graduated autonomy in clinical decision-making.
- Utilize “teachable moments,” such as case-based learning and role modeling, in the context of teaching in the inpatient setting.
- Demonstrate efficient and flexible use of time when adaptively teaching and using self-directed learning activities.
- Demonstrate basic skills in teaching and supervision methods, including bedside teaching, teaching during rounds, and case-based discussions.
- Provide role modeling, with priming, articulation of thought process, and debriefing.
- Create and deliver didactic teaching on relevant topics in pediatric hospital medicine.
- Teach a specific skill or procedure in the clinical and/or simulation environments.
- Utilize basic skills in questioning, including broadening, justifying, hypothetical, and alternative.
- Educate patients and the family/caregivers about the diagnostic testing, management plan, and prognosis in an interactive, family centered manner.
- Promote and facilitate learner reflection on own performance at clinical encounters to enhance learning.
- Provide frequent, effective feedback based upon direct observation of learners’ clinical, communication, technical skills, and professionalism.
- Write effective learner summative evaluations that reflect verbal feedback given.
Attitudes
Pediatric hospitalists should be able to:
- Realize the importance of promoting a climate of continuous learning by acknowledging personal knowledge gaps and prompting learners to teach each other.
- Model effective and empathetic communication with patients and the family/caregivers when educating.
- Encourage learners to be self-directed and to learn independently.
- Exemplify professional behavior by being prompt, prepared, available, and approachable in educational efforts.
- Acknowledge the value of building and maintaining teamwork by providing reinforcing as well as corrective feedback.
- Role model effective balance of clinical care, communication, and teaching needs during family centered rounds.
Systems Organization and Improvement
In order to improve efficiency and quality within their organizations, pediatric hospitalists should:
- Participate with training programs to create, maintain, and implement education in the hospital setting.
- Collaborate with hospital administrators to maintain adequate learner supervision to ensure patient safety, while encouraging development of autonomous practice.
- Lead, coordinate, or participate in multidisciplinary initiatives to promote quality improvement, patient safety, cost effective care, evidence-based medicine, and effective communication around inpatient pediatric care.
- Collaborate with hospital administration and training program directors to balance teaching, patient care responsibilities, and patient safety and maximize the effectiveness of each.
- Collaborate with hospital administration to ensure adequate teaching facilities.
Introduction
Pediatric hospitalists can serve many roles in education, including teaching others in clinical settings, creating curriculum, directing educational programs, and serving in formal roles in both undergraduate and graduate medical education administration. Additional educational opportunities include training future hospitalists and directing continuing medical education programs. Pediatric hospitalists are teachers, educating hospital staff, learners (medical students, other health profession students, residents, and fellows), community clinicians, organizations, patients and the family/caregivers, and colleagues. Hospitalists in community and university/children’s hospital systems serve a pivotal role in teaching learners and/or other healthcare providers on the hospital wards and via hospital related didactic or simulation sessions. In addition to educating others, lifelong learning requires hospitalists to engage in ongoing education targeting personal goals and career plans. Education is therefore essential for all pediatric hospitalists, with specific competencies addressed in the context of the specific learner-educator environment.
Knowledge
Pediatric hospitalists should be able to:
- Explain why a continuum of competencies throughout a professional career is required and illustrate the benefits and challenges of this expectation.
- Review the use of education for patients and the family/caregivers, attending to daily discussions around clinical care and transition of care needs.
- Cite examples of using of evidence-based medicine literature review for education, including discussions on ward rounds, journal club, and self-learning.
- List resources and activities for continuous learning to maintain current knowledge and skills.
- Compare and contrast teaching from supervision of learners.
- Compare and contrast different teaching and learning preferences, attending to elements such as sensory modes (visual, auditory, kinesthetic/motor), group size, setting, and other factors.
- Define common terms and phrases used in adult learning theory, including assessing learner needs, establishing learner goals, active learning, self-directed learning, reflection, and others.
- Discuss how the principles of adult learning theory can be used in leading daily learning activities in clinical and didactic settings.
- Cite the value of ongoing self-directed learning and continued use of an individualized learning plan at all career stages.
- Describe how competencies and performance indicators are used in the evaluation of physicians at all career stages.
- Describe the pediatric competencies currently required by regulatory agencies such as the Liaison Committee of Medical Education (LCME), Accreditation Council for Graduate Medical Education (ACGME), and the American Board of Pediatrics (ABP).
- Describe the six mandated ACGME competency domains: patient care, medical knowledge, practice-based learning and improvement, interpersonal skills and communications, professionalism, and systems-based practice.
- Articulate how pediatric hospitalists can use each of the six core competencies to educate in the context of the inpatient setting and the larger healthcare system.
- Explain how learners benefit from knowing their learning goals at the beginning of an educational experience.
- Compare and contrast the advantages and limitations of the following evaluation methods: oral exams, written tests, global evaluations, direct observations with checklists, and multi-source (360 degree) evaluations.
- Describe the elements of effective feedback.
- Define “formative feedback” and “summative evaluation,” identifying the similarities and differences in each.
- Describe the common effects of evaluation on the motivation and learning priorities of learners.
- Review the steps involved in curriculum development, including performing a needs assessment, creating competency-based goals and objectives, selecting teaching activities to match learning objectives, creating a learner assessment and a program evaluation, and securing resources.
- Summarize how a curriculum can be applied to a single learning activity, a longitudinal curriculum, or a comprehensive educational program.
Skills
Pediatric hospitalists should be able to:
- Orient learners to inpatient ward rotation expectations, including learning goals and objectives, patient care and team responsibilities, systems, policies, and procedures for the rotation.
- Integrate use of established clinical pathways and educate learners on their correct use.
- Educate learners about the important blend between service and education.
- Identify and abate potential issues related to patient safety, professionalism, and communication that may occur when learners are involved in care teams.
- Identify learner needs and deliver education to best match the individual or learner group.
- Determine the level of a learner’s ability and allow graduated autonomy in clinical decision-making.
- Utilize “teachable moments,” such as case-based learning and role modeling, in the context of teaching in the inpatient setting.
- Demonstrate efficient and flexible use of time when adaptively teaching and using self-directed learning activities.
- Demonstrate basic skills in teaching and supervision methods, including bedside teaching, teaching during rounds, and case-based discussions.
- Provide role modeling, with priming, articulation of thought process, and debriefing.
- Create and deliver didactic teaching on relevant topics in pediatric hospital medicine.
- Teach a specific skill or procedure in the clinical and/or simulation environments.
- Utilize basic skills in questioning, including broadening, justifying, hypothetical, and alternative.
- Educate patients and the family/caregivers about the diagnostic testing, management plan, and prognosis in an interactive, family centered manner.
- Promote and facilitate learner reflection on own performance at clinical encounters to enhance learning.
- Provide frequent, effective feedback based upon direct observation of learners’ clinical, communication, technical skills, and professionalism.
- Write effective learner summative evaluations that reflect verbal feedback given.
Attitudes
Pediatric hospitalists should be able to:
- Realize the importance of promoting a climate of continuous learning by acknowledging personal knowledge gaps and prompting learners to teach each other.
- Model effective and empathetic communication with patients and the family/caregivers when educating.
- Encourage learners to be self-directed and to learn independently.
- Exemplify professional behavior by being prompt, prepared, available, and approachable in educational efforts.
- Acknowledge the value of building and maintaining teamwork by providing reinforcing as well as corrective feedback.
- Role model effective balance of clinical care, communication, and teaching needs during family centered rounds.
Systems Organization and Improvement
In order to improve efficiency and quality within their organizations, pediatric hospitalists should:
- Participate with training programs to create, maintain, and implement education in the hospital setting.
- Collaborate with hospital administrators to maintain adequate learner supervision to ensure patient safety, while encouraging development of autonomous practice.
- Lead, coordinate, or participate in multidisciplinary initiatives to promote quality improvement, patient safety, cost effective care, evidence-based medicine, and effective communication around inpatient pediatric care.
- Collaborate with hospital administration and training program directors to balance teaching, patient care responsibilities, and patient safety and maximize the effectiveness of each.
- Collaborate with hospital administration to ensure adequate teaching facilities.
1. Ende J. Feedback in clinical medical education. JAMA. 1983;250:777-781.
2. Fromme HB, Bhansali P, Singhal G, Yudkowsky R, Humphrey H, Harris I. The qualities and skills of exemplary pediatric hospitalist educators: a qualitative study. Acad Med. 2010;85(12):1905-1913. https://doi.org/10.1097/ACM.0b013e3181fa3560.
3. Thomas PA, Kern DE, Hughes MT, Chen BY. Curriculum Development for Medical Education: A Six-Step Approach. Baltimore, MD: Johns Hopkins University Press; 2016.
1. Ende J. Feedback in clinical medical education. JAMA. 1983;250:777-781.
2. Fromme HB, Bhansali P, Singhal G, Yudkowsky R, Humphrey H, Harris I. The qualities and skills of exemplary pediatric hospitalist educators: a qualitative study. Acad Med. 2010;85(12):1905-1913. https://doi.org/10.1097/ACM.0b013e3181fa3560.
3. Thomas PA, Kern DE, Hughes MT, Chen BY. Curriculum Development for Medical Education: A Six-Step Approach. Baltimore, MD: Johns Hopkins University Press; 2016.
4.03 Healthcare Systems: Consultation and Co-management
Introduction
Pediatric hospitalists are often asked to offer clinical guidance, recommendations, or support to healthcare providers in managing children in a variety of contexts. These providers are usually adult providers or other pediatric subspecialists. There are two general models for this arrangement: consultation and co-management. Consultation generally refers to a paradigm in which the primary team requests input to manage a specific clinical problem or set of problems that would benefit from specific expertise. Co-management describes a model in which a patient requires ongoing care served via a partnership between the primary team and another specialty service. Consultation and co-management roles for pediatric hospitalists involve caring for medical and surgical patients. Many different models exist within these two broad categories. These models vary based on setting, local needs, or local pediatric expertise. Regardless of model, similar skills are required, especially involving communication and coordination of care. Pediatric hospitalists are in a unique position to improve care delivery and advocate for the needs of children within consultation and co-management roles.
Knowledge
Pediatric hospitalists should be able to:
- Describe consultation and co-management models, including characteristics of local models.
- Articulate the responsibilities typically defined by consultation and co-management models.
- Review the importance of clear communication, multidisciplinary team engagement, and roles of different care providers within a consulting and co-management model.
- Compare and contrast the value of verbal versus written agreements for consultation and co-management relationships and discuss their impact on patient safety.
- Discuss the intent and impact of mandatory consultation for hospitalized children based on certain criteria, such as age or underlying condition, especially regarding patient safety and the role of pediatric hospitalists.
- Recognize opportunities for pediatric consultation to offer recommendations for the whole child, attending to immunizations, dental care, and other preventative needs.
- State examples where a one-time consultation may be appropriate.
- Describe common failures in consultation and co-management, especially regarding handoffs, patient communication, documentation, billing, and others.
- Summarize basic surgical conditions, indications for common surgical procedures, and list common complications of surgical procedures.
- Describe the principles of preoperative and perioperative care, including roles for anesthesiologists, subspecialists, surgeons, and pediatric hospitalists.
- Describe common pain management modalities, including medication and non-medication interventions, attending to potential side effects of medications including narcotics.
- Compare and contrast billing procedures for consultation and co-management from billing as primary attending of record, with attention to the impact of billing by other providers.
Skills
Pediatric hospitalists should be able to:
- Provide a timely and comprehensive evaluation of pediatric patients and pediatric-specific recommendations.
- Demonstrate strong diagnostic and management skills in the care of hospitalized children, including those with medical complexity and common surgical conditions.
- Communicate recommendations clearly and efficiently to other subspecialists and healthcare providers.
- Diagnose complications of common surgical procedures, including features of clinical deterioration.
- Communicate effectively with the primary team regarding complications or other declines in status and triage to a higher level of care as appropriate.
- Identify and abate pediatric-specific patient risks due to age, underlying condition, local resources, or other factors.
- Coordinate care and communicate clearly and effectively with patients, the family/caregivers, and all team members.
- Demonstrate expertise in pain management, especially in the perioperative patient.
- Describe principles of perioperative fluid management in the pediatric surgical patient.
- Explain the pediatric hospitalist’s role in consultation and co-management with the patient and the family/caregivers.
- Maintain clear, timely communication and documentation of clinical recommendations.
- Place patient care orders when appropriate.
- Educate trainees, including pediatric and surgical trainees, about models of consultation and co-management.
- Create a comprehensive discharge plan in partnership with the primary team.
Attitudes
Pediatric hospitalists should be able to:
- Exemplify responsible and accountable care of hospitalized children within the scope of the consultation and co-management relationship across differing clinical specialties.
- Reflect on the importance of providing timely patient care, documentation of recommendations, and written orders as appropriate.
- Realize the importance of communicating effectively with patients, the family/caregivers, subspecialists, and other healthcare providers.
- Respect the contributions of all healthcare team members.
- Recognize that gaps in knowledge and skills may adversely impact patient care and role model behaviors that promote patient safety and quality care.
Systems Organization and Improvement
In order to improve efficiency and quality within their organizations, pediatric hospitalists should:
- Collaborate with other subspecialist leaders by providing input to improve consultation and co-management programs.
- Identify opportunities to lead, coordinate, or participate in activities to enhance teamwork between healthcare professionals.
- Lead, coordinate, or participate in identifying and managing aspects of consultation and co-management care that may be targets for quality improvement.
- Collaborate with administrators and colleagues to optimize hospitalist value provided and assure practice is appropriately within the scope of the hospital medicine.
- Lead, coordinate, or participate in the development of guidelines for consultation and co-management programs.
1. Rappaport DI, Rosenberg RE, Shaughnessy EE, et al. Pediatric hospitalist comanagement of surgical patients: Structural, quality, and financial considerations. J Hosp Med. 2014 Nov;9(11):737–742. https://doi.org/10.1002/jhm.2266.
2. Society for Hospital Medicine. Resources for Effective Co-Management of Hospitalized Patients. https://www.hospitalmedicine.org/practice-management/co-management/. Accessed August 26, 2019.
Introduction
Pediatric hospitalists are often asked to offer clinical guidance, recommendations, or support to healthcare providers in managing children in a variety of contexts. These providers are usually adult providers or other pediatric subspecialists. There are two general models for this arrangement: consultation and co-management. Consultation generally refers to a paradigm in which the primary team requests input to manage a specific clinical problem or set of problems that would benefit from specific expertise. Co-management describes a model in which a patient requires ongoing care served via a partnership between the primary team and another specialty service. Consultation and co-management roles for pediatric hospitalists involve caring for medical and surgical patients. Many different models exist within these two broad categories. These models vary based on setting, local needs, or local pediatric expertise. Regardless of model, similar skills are required, especially involving communication and coordination of care. Pediatric hospitalists are in a unique position to improve care delivery and advocate for the needs of children within consultation and co-management roles.
Knowledge
Pediatric hospitalists should be able to:
- Describe consultation and co-management models, including characteristics of local models.
- Articulate the responsibilities typically defined by consultation and co-management models.
- Review the importance of clear communication, multidisciplinary team engagement, and roles of different care providers within a consulting and co-management model.
- Compare and contrast the value of verbal versus written agreements for consultation and co-management relationships and discuss their impact on patient safety.
- Discuss the intent and impact of mandatory consultation for hospitalized children based on certain criteria, such as age or underlying condition, especially regarding patient safety and the role of pediatric hospitalists.
- Recognize opportunities for pediatric consultation to offer recommendations for the whole child, attending to immunizations, dental care, and other preventative needs.
- State examples where a one-time consultation may be appropriate.
- Describe common failures in consultation and co-management, especially regarding handoffs, patient communication, documentation, billing, and others.
- Summarize basic surgical conditions, indications for common surgical procedures, and list common complications of surgical procedures.
- Describe the principles of preoperative and perioperative care, including roles for anesthesiologists, subspecialists, surgeons, and pediatric hospitalists.
- Describe common pain management modalities, including medication and non-medication interventions, attending to potential side effects of medications including narcotics.
- Compare and contrast billing procedures for consultation and co-management from billing as primary attending of record, with attention to the impact of billing by other providers.
Skills
Pediatric hospitalists should be able to:
- Provide a timely and comprehensive evaluation of pediatric patients and pediatric-specific recommendations.
- Demonstrate strong diagnostic and management skills in the care of hospitalized children, including those with medical complexity and common surgical conditions.
- Communicate recommendations clearly and efficiently to other subspecialists and healthcare providers.
- Diagnose complications of common surgical procedures, including features of clinical deterioration.
- Communicate effectively with the primary team regarding complications or other declines in status and triage to a higher level of care as appropriate.
- Identify and abate pediatric-specific patient risks due to age, underlying condition, local resources, or other factors.
- Coordinate care and communicate clearly and effectively with patients, the family/caregivers, and all team members.
- Demonstrate expertise in pain management, especially in the perioperative patient.
- Describe principles of perioperative fluid management in the pediatric surgical patient.
- Explain the pediatric hospitalist’s role in consultation and co-management with the patient and the family/caregivers.
- Maintain clear, timely communication and documentation of clinical recommendations.
- Place patient care orders when appropriate.
- Educate trainees, including pediatric and surgical trainees, about models of consultation and co-management.
- Create a comprehensive discharge plan in partnership with the primary team.
Attitudes
Pediatric hospitalists should be able to:
- Exemplify responsible and accountable care of hospitalized children within the scope of the consultation and co-management relationship across differing clinical specialties.
- Reflect on the importance of providing timely patient care, documentation of recommendations, and written orders as appropriate.
- Realize the importance of communicating effectively with patients, the family/caregivers, subspecialists, and other healthcare providers.
- Respect the contributions of all healthcare team members.
- Recognize that gaps in knowledge and skills may adversely impact patient care and role model behaviors that promote patient safety and quality care.
Systems Organization and Improvement
In order to improve efficiency and quality within their organizations, pediatric hospitalists should:
- Collaborate with other subspecialist leaders by providing input to improve consultation and co-management programs.
- Identify opportunities to lead, coordinate, or participate in activities to enhance teamwork between healthcare professionals.
- Lead, coordinate, or participate in identifying and managing aspects of consultation and co-management care that may be targets for quality improvement.
- Collaborate with administrators and colleagues to optimize hospitalist value provided and assure practice is appropriately within the scope of the hospital medicine.
- Lead, coordinate, or participate in the development of guidelines for consultation and co-management programs.
Introduction
Pediatric hospitalists are often asked to offer clinical guidance, recommendations, or support to healthcare providers in managing children in a variety of contexts. These providers are usually adult providers or other pediatric subspecialists. There are two general models for this arrangement: consultation and co-management. Consultation generally refers to a paradigm in which the primary team requests input to manage a specific clinical problem or set of problems that would benefit from specific expertise. Co-management describes a model in which a patient requires ongoing care served via a partnership between the primary team and another specialty service. Consultation and co-management roles for pediatric hospitalists involve caring for medical and surgical patients. Many different models exist within these two broad categories. These models vary based on setting, local needs, or local pediatric expertise. Regardless of model, similar skills are required, especially involving communication and coordination of care. Pediatric hospitalists are in a unique position to improve care delivery and advocate for the needs of children within consultation and co-management roles.
Knowledge
Pediatric hospitalists should be able to:
- Describe consultation and co-management models, including characteristics of local models.
- Articulate the responsibilities typically defined by consultation and co-management models.
- Review the importance of clear communication, multidisciplinary team engagement, and roles of different care providers within a consulting and co-management model.
- Compare and contrast the value of verbal versus written agreements for consultation and co-management relationships and discuss their impact on patient safety.
- Discuss the intent and impact of mandatory consultation for hospitalized children based on certain criteria, such as age or underlying condition, especially regarding patient safety and the role of pediatric hospitalists.
- Recognize opportunities for pediatric consultation to offer recommendations for the whole child, attending to immunizations, dental care, and other preventative needs.
- State examples where a one-time consultation may be appropriate.
- Describe common failures in consultation and co-management, especially regarding handoffs, patient communication, documentation, billing, and others.
- Summarize basic surgical conditions, indications for common surgical procedures, and list common complications of surgical procedures.
- Describe the principles of preoperative and perioperative care, including roles for anesthesiologists, subspecialists, surgeons, and pediatric hospitalists.
- Describe common pain management modalities, including medication and non-medication interventions, attending to potential side effects of medications including narcotics.
- Compare and contrast billing procedures for consultation and co-management from billing as primary attending of record, with attention to the impact of billing by other providers.
Skills
Pediatric hospitalists should be able to:
- Provide a timely and comprehensive evaluation of pediatric patients and pediatric-specific recommendations.
- Demonstrate strong diagnostic and management skills in the care of hospitalized children, including those with medical complexity and common surgical conditions.
- Communicate recommendations clearly and efficiently to other subspecialists and healthcare providers.
- Diagnose complications of common surgical procedures, including features of clinical deterioration.
- Communicate effectively with the primary team regarding complications or other declines in status and triage to a higher level of care as appropriate.
- Identify and abate pediatric-specific patient risks due to age, underlying condition, local resources, or other factors.
- Coordinate care and communicate clearly and effectively with patients, the family/caregivers, and all team members.
- Demonstrate expertise in pain management, especially in the perioperative patient.
- Describe principles of perioperative fluid management in the pediatric surgical patient.
- Explain the pediatric hospitalist’s role in consultation and co-management with the patient and the family/caregivers.
- Maintain clear, timely communication and documentation of clinical recommendations.
- Place patient care orders when appropriate.
- Educate trainees, including pediatric and surgical trainees, about models of consultation and co-management.
- Create a comprehensive discharge plan in partnership with the primary team.
Attitudes
Pediatric hospitalists should be able to:
- Exemplify responsible and accountable care of hospitalized children within the scope of the consultation and co-management relationship across differing clinical specialties.
- Reflect on the importance of providing timely patient care, documentation of recommendations, and written orders as appropriate.
- Realize the importance of communicating effectively with patients, the family/caregivers, subspecialists, and other healthcare providers.
- Respect the contributions of all healthcare team members.
- Recognize that gaps in knowledge and skills may adversely impact patient care and role model behaviors that promote patient safety and quality care.
Systems Organization and Improvement
In order to improve efficiency and quality within their organizations, pediatric hospitalists should:
- Collaborate with other subspecialist leaders by providing input to improve consultation and co-management programs.
- Identify opportunities to lead, coordinate, or participate in activities to enhance teamwork between healthcare professionals.
- Lead, coordinate, or participate in identifying and managing aspects of consultation and co-management care that may be targets for quality improvement.
- Collaborate with administrators and colleagues to optimize hospitalist value provided and assure practice is appropriately within the scope of the hospital medicine.
- Lead, coordinate, or participate in the development of guidelines for consultation and co-management programs.
1. Rappaport DI, Rosenberg RE, Shaughnessy EE, et al. Pediatric hospitalist comanagement of surgical patients: Structural, quality, and financial considerations. J Hosp Med. 2014 Nov;9(11):737–742. https://doi.org/10.1002/jhm.2266.
2. Society for Hospital Medicine. Resources for Effective Co-Management of Hospitalized Patients. https://www.hospitalmedicine.org/practice-management/co-management/. Accessed August 26, 2019.
1. Rappaport DI, Rosenberg RE, Shaughnessy EE, et al. Pediatric hospitalist comanagement of surgical patients: Structural, quality, and financial considerations. J Hosp Med. 2014 Nov;9(11):737–742. https://doi.org/10.1002/jhm.2266.
2. Society for Hospital Medicine. Resources for Effective Co-Management of Hospitalized Patients. https://www.hospitalmedicine.org/practice-management/co-management/. Accessed August 26, 2019.