Magnet certification draws nurses to hospitals by documenting that these facilities are good places for them to work. But does magnet also suggest a positive environment for hospitalists and other physicians?

Ask Kathy Sparger, RN, MSN, chief nursing officer at South Miami Hospital in South Miami, Fla., who says her magnet facility perpetuates teamwork and collaboration in a way that creates a positive professional atmosphere for both nurses and physicians. She’s also emphatic that it enables high-quality care.

South Miami Nurses Kathleen Gori, RN, Melissa Korman, RN, and Zully Darby, RN, show off their magnet pride.

The mother of at least one patient likely agrees. Sparger tells the story of a baby born in the hospital with compromised circulation in his leg.

“When he was born, his leg was black,” she recalls. “We thought we would have to amputate.”

Devastated by the prospect of this decision, the physician-nurse team searched frantically for another solution. Then Sparger remembered an instance from years before when an elderly patient’s compromised circulation was resolved through the use of medicinal leeches. While the team had never heard of this procedure being used for an infant, they trusted Sparger and decided to follow her suggestion.

“We started therapy that night, and the baby went home with his leg intact,” she says, adding that she can recollect “hundreds of such scenarios” where the teamwork between physicians and nurses enabled positive outcomes. This is the essence of magnet, she notes: “Nurses know that their opinions are valued, so there is a better partnership with physicians.”

WHAT IS MAGNET?

Magnet certification is offered by the American Nurses Credentialing Center (ANCC) as a means of identifying hospitals that value nurses and provide optimal environments in which these professionals practice. According to ANCC, magnet designation is an important recognition of nurses’ work, the quality of a facility’s nursing program, and the importance of nurses to the entire organization’s success.

The concept of magnet dates back to the early 1980s. In 1981, the American Academy of Nurses developed the criteria for Magnet certification, which covered three broad areas:

• Administration: Participatory and supportive management style; well-prepared, decentralized organizational structure; “adequate” nurse staffing; deployment of opportunities;
• Professional practice: Professional practice models of care delivery; professional availability of specialist advice; emphasis on teaching staff responsibilities;
• Professional development: Planned staff orientation; emphasized in-service/competency-based clinical ladders; management development.1

A 1983 Magnet Hospital study identified variables found in a “magnet-like” environment, although these evolved over the next decade into 14 key forces used to determine magnet status.2-4 These include quality of nursing leadership, organizational structure, management style, personnel policies and programs, professional models of care, quality of care, autonomy, and quality improvement.

Applying for magnet certification is an elaborate process that involves extensive and detailed documentation, site visits, and interviews. Staff participation includes nurses, administrators, and physicians—among others. The certification process can take a year or more, and facilities must recertify every four years.

Magnet-certified facilities are required to submit quality data for the ANCC to track. However, the agency states on its Web site that “independently sponsored research” has shown that magnet-certified facilities:

• Consistently outperform nonmagnet organizations;
• Deliver better patient outcomes;
• Have shorter lengths of patient stays;
• Enjoy increased nurse retention rates;
• Report higher rates of nursing job satisfaction; and
• Report higher patient satisfaction.5

To date more than 100 U.S. healthcare facilities have earned magnet certification, and the number is growing almost daily. In fact, Allen Kaiser, MD, chief of staff at Vanderbilt

University Hospital in Tennessee, wonders if the point will come where so many facilities are magnet-certified that that status will lose its significance. Or, perhaps, “people will wonder what is wrong if a facility isn’t certified,” he says.

HOSPITALISTS AND MAGNET

An academic hospitalist and Assistant Professor at Chicago’s Rush University Medical Center, Richard Abrams, MD, said that nursing-physician collaboration is key to a positive environment for hospitalist practice.

“To me, the strongest suit of the nurses I work with here is that they are collaborators,” he explains. “Everyone brings something—some unique skill set—to the table. This, along with our proclivity for collaboration and mutual trust—makes our facility successful.”

Magnet certification didn’t cause this collaborative atmosphere, Dr. Abrams is quick to stress. “Our facility was magnet before there was such a thing,” he explains. “Magnet status is nice, but nursing care was always fantastic here. Magnet just put a name to what we are and recognizes it nationally.”

Dr. Abrams encourages his residents to look for this quality at facilities with which they are considering employment. In fact, he even uses Rush’s magnet status as a selling point to attract hospitalists to his program.

“Sometimes they ask what that is and what it means,” he says. “You know the quality of the nursing staff at a magnet hospital. You know that there is a minimal level of quality you can expect.”

Dr. Abrams emphasizes the importance of trust between hospitalists and nurses. “If you can’t trust each other, it makes it so much harder to care for patients,” he says. “Our nurses spend much more time with patients than anyone else. I wouldn’t do anything without input from the nursing staff.

“We have a rule in the hospital. If a nurse thinks a patient needs to be transferred to intensive care, the patient is transferred,” continues Dr. Abrams. “We put this policy in place four to five years ago, and no one has ever questioned or disputed it.”

The biggest plus for nurses is that I’m on the floor eight or more hours a day. We have repeated interactions, and relationships develop more quickly. This probably breaks down some barriers that can exist between physicians and nurses.

—Richard Abrams, MD

PERFECT TOGETHER

Magnet status and hospitalists represent a good match. Just as magnet nursing status provides benefits for hospitalists, the presence of hospitalists helps create a positive environment for nurses.

“The biggest plus for nurses is that I’m on the floor eight or more hours a day. We have repeated interactions, and relationships develop more quickly,” notes Dr. Abrams. “This probably breaks down some barriers that can exist between physicians and nurses.”

When nurses have to whether to call an attending physician at 3 a.m., this often creates additional stress or worries for them. With hospitalists around, they almost always have a physician onsite. Even when the hospitalist isn’t right there, they know who to call and theyare likely to have a trusting relationship with this individual.

“I would feel bad if a nurse didn’t feel that she could pick up the phone and call me about any case,” says Dr. Abrams. “The more you work with people, the more trust you build.”

Magnet status is particularly important for hospitalists, explains Dr. Kaiser. “Because they spend so much time with nursing staff, the quality of nurses is especially important to hospitalists. Therefore, if we want to attract good hospitalists, we have to have good nurses. Because we have magnet status, we not only can say that we have a great nursing program; we can prove it.”

Sparger concurs. “Magnet validates a facility’s quality efforts and teamwork,” she says. “It makes you sit back and look at evidence-based practices for how you do things. You have to have evidence-based practices to write a policy. As hospitalists are more familiar and comfortable with hospital policies and procedures, this makes them the perfect match for magnet hospitals.”

At the same time when facilities put the hospitalist model together with magnet certification, the result is improved quality of life for both physicians and nurses.

While ANCC is still collecting data about magnet status and quality, Sparger and many individuals who work at magnet-certified facilities firmly believe that the characteristics that make they magnet also lead to reduced mortality and infections.

THE WORD SPREADS

If they don’t know about magnet certification already, hospitalists and other physicians likely will hear more about it in the near future.

“Magnet certification is a quality indicator at some level for hospitals,” says Dr. Abrams. “We will see a big push nationally for magnet at many more facilities.”

Nurses already see magnet status as an important sign that a hospital is a good place to work where quality care is high and nurses are respected. Increasingly, Dr. Abrams proposes, physicians will consider magnet status when choosing facilities at which to work. In fact this already is happening.

“I had one physicians say that he came here with confidence because he knew that we had a magnet staff,” says Beverly Hancock, MS, RN, education/quality and magnet project coordinator at Rush University Medical Center. “Also, I recently noticed on our Web site that several departments and programs mention our magnet status in their recruitment announcements.”

In fact, physicians themselves sometimes are the greatest advertisement for magnet hospitals. “If you talk to our physicians, they say that they tell everyone about the great nurses here,” says Hancock. “They say that they heard about it in their interviews and now they’re seeing it in person.”

At the same time, the word is spreading rapidly beyond practitioners. Just this year, U.S. News & World Report added magnet certification to its criteria for determining its annual list of the country’s best hospitals.

“There is no question that patients, insurers, and other healthcare groups will begin to place a lot of emphasis on magnet status as well,” concludes Dr. Abrams. TH

Contributor Joanne Kaldy is based in Maryland.

REFERENCES

1. McClure M, Poulin M, Sovie M, Wandelt M. Magnet Hospitals: Attraction and Retention of Professional Nurses. American Academy of Nursing Task Force and Nursing Practice in Hospitals. Kansas City, MO: American Nurses Association 1983.
2. Kramer M, Schmalenberg C. Magnet hospitals talk about the impact of DRGs on nursing care, part I. Nursing Management. 1987;18(9):38-42.
3. Kramer M, Schmalenberg C. Magnet hospitals talk about the impact of DRGs on nursing car, part II. Nursing Management. 1987; 18(10):33-40.
4. Kramer M, Schmalenberg C. Job satisfaction and retention. Insights for the ‘90s, part I. Nursing. 1991;3(3):50-55.
5. American Nurses Credentialing Center Web site. www.nursingworld.org/ancc/magnet/consumer/benefits.html. Benefits of magnet. Last accessed 8/16/05.

Magnet certification draws nurses to hospitals by documenting that these facilities are good places for them to work. But does magnet also suggest a positive environment for hospitalists and other physicians?

Ask Kathy Sparger, RN, MSN, chief nursing officer at South Miami Hospital in South Miami, Fla., who says her magnet facility perpetuates teamwork and collaboration in a way that creates a positive professional atmosphere for both nurses and physicians. She’s also emphatic that it enables high-quality care.

South Miami Nurses Kathleen Gori, RN, Melissa Korman, RN, and Zully Darby, RN, show off their magnet pride.

The mother of at least one patient likely agrees. Sparger tells the story of a baby born in the hospital with compromised circulation in his leg.

“When he was born, his leg was black,” she recalls. “We thought we would have to amputate.”

Devastated by the prospect of this decision, the physician-nurse team searched frantically for another solution. Then Sparger remembered an instance from years before when an elderly patient’s compromised circulation was resolved through the use of medicinal leeches. While the team had never heard of this procedure being used for an infant, they trusted Sparger and decided to follow her suggestion.

“We started therapy that night, and the baby went home with his leg intact,” she says, adding that she can recollect “hundreds of such scenarios” where the teamwork between physicians and nurses enabled positive outcomes. This is the essence of magnet, she notes: “Nurses know that their opinions are valued, so there is a better partnership with physicians.”

WHAT IS MAGNET?

Magnet certification is offered by the American Nurses Credentialing Center (ANCC) as a means of identifying hospitals that value nurses and provide optimal environments in which these professionals practice. According to ANCC, magnet designation is an important recognition of nurses’ work, the quality of a facility’s nursing program, and the importance of nurses to the entire organization’s success.

The concept of magnet dates back to the early 1980s. In 1981, the American Academy of Nurses developed the criteria for Magnet certification, which covered three broad areas:

• Administration: Participatory and supportive management style; well-prepared, decentralized organizational structure; “adequate” nurse staffing; deployment of opportunities;
• Professional practice: Professional practice models of care delivery; professional availability of specialist advice; emphasis on teaching staff responsibilities;
• Professional development: Planned staff orientation; emphasized in-service/competency-based clinical ladders; management development.1

A 1983 Magnet Hospital study identified variables found in a “magnet-like” environment, although these evolved over the next decade into 14 key forces used to determine magnet status.2-4 These include quality of nursing leadership, organizational structure, management style, personnel policies and programs, professional models of care, quality of care, autonomy, and quality improvement.

Applying for magnet certification is an elaborate process that involves extensive and detailed documentation, site visits, and interviews. Staff participation includes nurses, administrators, and physicians—among others. The certification process can take a year or more, and facilities must recertify every four years.

Magnet-certified facilities are required to submit quality data for the ANCC to track. However, the agency states on its Web site that “independently sponsored research” has shown that magnet-certified facilities:

• Consistently outperform nonmagnet organizations;
• Deliver better patient outcomes;
• Have shorter lengths of patient stays;
• Enjoy increased nurse retention rates;
• Report higher rates of nursing job satisfaction; and
• Report higher patient satisfaction.5

To date more than 100 U.S. healthcare facilities have earned magnet certification, and the number is growing almost daily. In fact, Allen Kaiser, MD, chief of staff at Vanderbilt

University Hospital in Tennessee, wonders if the point will come where so many facilities are magnet-certified that that status will lose its significance. Or, perhaps, “people will wonder what is wrong if a facility isn’t certified,” he says.

HOSPITALISTS AND MAGNET

An academic hospitalist and Assistant Professor at Chicago’s Rush University Medical Center, Richard Abrams, MD, said that nursing-physician collaboration is key to a positive environment for hospitalist practice.

“To me, the strongest suit of the nurses I work with here is that they are collaborators,” he explains. “Everyone brings something—some unique skill set—to the table. This, along with our proclivity for collaboration and mutual trust—makes our facility successful.”

Magnet certification didn’t cause this collaborative atmosphere, Dr. Abrams is quick to stress. “Our facility was magnet before there was such a thing,” he explains. “Magnet status is nice, but nursing care was always fantastic here. Magnet just put a name to what we are and recognizes it nationally.”

Dr. Abrams encourages his residents to look for this quality at facilities with which they are considering employment. In fact, he even uses Rush’s magnet status as a selling point to attract hospitalists to his program.

“Sometimes they ask what that is and what it means,” he says. “You know the quality of the nursing staff at a magnet hospital. You know that there is a minimal level of quality you can expect.”

Dr. Abrams emphasizes the importance of trust between hospitalists and nurses. “If you can’t trust each other, it makes it so much harder to care for patients,” he says. “Our nurses spend much more time with patients than anyone else. I wouldn’t do anything without input from the nursing staff.

“We have a rule in the hospital. If a nurse thinks a patient needs to be transferred to intensive care, the patient is transferred,” continues Dr. Abrams. “We put this policy in place four to five years ago, and no one has ever questioned or disputed it.”

The biggest plus for nurses is that I’m on the floor eight or more hours a day. We have repeated interactions, and relationships develop more quickly. This probably breaks down some barriers that can exist between physicians and nurses.

—Richard Abrams, MD

PERFECT TOGETHER

Magnet status and hospitalists represent a good match. Just as magnet nursing status provides benefits for hospitalists, the presence of hospitalists helps create a positive environment for nurses.

“The biggest plus for nurses is that I’m on the floor eight or more hours a day. We have repeated interactions, and relationships develop more quickly,” notes Dr. Abrams. “This probably breaks down some barriers that can exist between physicians and nurses.”

When nurses have to whether to call an attending physician at 3 a.m., this often creates additional stress or worries for them. With hospitalists around, they almost always have a physician onsite. Even when the hospitalist isn’t right there, they know who to call and theyare likely to have a trusting relationship with this individual.

“I would feel bad if a nurse didn’t feel that she could pick up the phone and call me about any case,” says Dr. Abrams. “The more you work with people, the more trust you build.”

Magnet status is particularly important for hospitalists, explains Dr. Kaiser. “Because they spend so much time with nursing staff, the quality of nurses is especially important to hospitalists. Therefore, if we want to attract good hospitalists, we have to have good nurses. Because we have magnet status, we not only can say that we have a great nursing program; we can prove it.”

Sparger concurs. “Magnet validates a facility’s quality efforts and teamwork,” she says. “It makes you sit back and look at evidence-based practices for how you do things. You have to have evidence-based practices to write a policy. As hospitalists are more familiar and comfortable with hospital policies and procedures, this makes them the perfect match for magnet hospitals.”

At the same time when facilities put the hospitalist model together with magnet certification, the result is improved quality of life for both physicians and nurses.

While ANCC is still collecting data about magnet status and quality, Sparger and many individuals who work at magnet-certified facilities firmly believe that the characteristics that make they magnet also lead to reduced mortality and infections.

THE WORD SPREADS

If they don’t know about magnet certification already, hospitalists and other physicians likely will hear more about it in the near future.

“Magnet certification is a quality indicator at some level for hospitals,” says Dr. Abrams. “We will see a big push nationally for magnet at many more facilities.”

Nurses already see magnet status as an important sign that a hospital is a good place to work where quality care is high and nurses are respected. Increasingly, Dr. Abrams proposes, physicians will consider magnet status when choosing facilities at which to work. In fact this already is happening.

“I had one physicians say that he came here with confidence because he knew that we had a magnet staff,” says Beverly Hancock, MS, RN, education/quality and magnet project coordinator at Rush University Medical Center. “Also, I recently noticed on our Web site that several departments and programs mention our magnet status in their recruitment announcements.”

In fact, physicians themselves sometimes are the greatest advertisement for magnet hospitals. “If you talk to our physicians, they say that they tell everyone about the great nurses here,” says Hancock. “They say that they heard about it in their interviews and now they’re seeing it in person.”

At the same time, the word is spreading rapidly beyond practitioners. Just this year, U.S. News & World Report added magnet certification to its criteria for determining its annual list of the country’s best hospitals.

“There is no question that patients, insurers, and other healthcare groups will begin to place a lot of emphasis on magnet status as well,” concludes Dr. Abrams. TH

Contributor Joanne Kaldy is based in Maryland.

REFERENCES

1. McClure M, Poulin M, Sovie M, Wandelt M. Magnet Hospitals: Attraction and Retention of Professional Nurses. American Academy of Nursing Task Force and Nursing Practice in Hospitals. Kansas City, MO: American Nurses Association 1983.
2. Kramer M, Schmalenberg C. Magnet hospitals talk about the impact of DRGs on nursing care, part I. Nursing Management. 1987;18(9):38-42.
3. Kramer M, Schmalenberg C. Magnet hospitals talk about the impact of DRGs on nursing car, part II. Nursing Management. 1987; 18(10):33-40.
4. Kramer M, Schmalenberg C. Job satisfaction and retention. Insights for the ‘90s, part I. Nursing. 1991;3(3):50-55.
5. American Nurses Credentialing Center Web site. www.nursingworld.org/ancc/magnet/consumer/benefits.html. Benefits of magnet. Last accessed 8/16/05.

Magnet certification draws nurses to hospitals by documenting that these facilities are good places for them to work. But does magnet also suggest a positive environment for hospitalists and other physicians?

Ask Kathy Sparger, RN, MSN, chief nursing officer at South Miami Hospital in South Miami, Fla., who says her magnet facility perpetuates teamwork and collaboration in a way that creates a positive professional atmosphere for both nurses and physicians. She’s also emphatic that it enables high-quality care.

South Miami Nurses Kathleen Gori, RN, Melissa Korman, RN, and Zully Darby, RN, show off their magnet pride.

The mother of at least one patient likely agrees. Sparger tells the story of a baby born in the hospital with compromised circulation in his leg.

“When he was born, his leg was black,” she recalls. “We thought we would have to amputate.”

Devastated by the prospect of this decision, the physician-nurse team searched frantically for another solution. Then Sparger remembered an instance from years before when an elderly patient’s compromised circulation was resolved through the use of medicinal leeches. While the team had never heard of this procedure being used for an infant, they trusted Sparger and decided to follow her suggestion.

“We started therapy that night, and the baby went home with his leg intact,” she says, adding that she can recollect “hundreds of such scenarios” where the teamwork between physicians and nurses enabled positive outcomes. This is the essence of magnet, she notes: “Nurses know that their opinions are valued, so there is a better partnership with physicians.”

WHAT IS MAGNET?

Magnet certification is offered by the American Nurses Credentialing Center (ANCC) as a means of identifying hospitals that value nurses and provide optimal environments in which these professionals practice. According to ANCC, magnet designation is an important recognition of nurses’ work, the quality of a facility’s nursing program, and the importance of nurses to the entire organization’s success.

The concept of magnet dates back to the early 1980s. In 1981, the American Academy of Nurses developed the criteria for Magnet certification, which covered three broad areas:

• Administration: Participatory and supportive management style; well-prepared, decentralized organizational structure; “adequate” nurse staffing; deployment of opportunities;
• Professional practice: Professional practice models of care delivery; professional availability of specialist advice; emphasis on teaching staff responsibilities;
• Professional development: Planned staff orientation; emphasized in-service/competency-based clinical ladders; management development.1

A 1983 Magnet Hospital study identified variables found in a “magnet-like” environment, although these evolved over the next decade into 14 key forces used to determine magnet status.2-4 These include quality of nursing leadership, organizational structure, management style, personnel policies and programs, professional models of care, quality of care, autonomy, and quality improvement.

Applying for magnet certification is an elaborate process that involves extensive and detailed documentation, site visits, and interviews. Staff participation includes nurses, administrators, and physicians—among others. The certification process can take a year or more, and facilities must recertify every four years.

Magnet-certified facilities are required to submit quality data for the ANCC to track. However, the agency states on its Web site that “independently sponsored research” has shown that magnet-certified facilities:

• Consistently outperform nonmagnet organizations;
• Deliver better patient outcomes;
• Have shorter lengths of patient stays;
• Enjoy increased nurse retention rates;
• Report higher rates of nursing job satisfaction; and
• Report higher patient satisfaction.5

To date more than 100 U.S. healthcare facilities have earned magnet certification, and the number is growing almost daily. In fact, Allen Kaiser, MD, chief of staff at Vanderbilt

University Hospital in Tennessee, wonders if the point will come where so many facilities are magnet-certified that that status will lose its significance. Or, perhaps, “people will wonder what is wrong if a facility isn’t certified,” he says.

HOSPITALISTS AND MAGNET

An academic hospitalist and Assistant Professor at Chicago’s Rush University Medical Center, Richard Abrams, MD, said that nursing-physician collaboration is key to a positive environment for hospitalist practice.

“To me, the strongest suit of the nurses I work with here is that they are collaborators,” he explains. “Everyone brings something—some unique skill set—to the table. This, along with our proclivity for collaboration and mutual trust—makes our facility successful.”

Magnet certification didn’t cause this collaborative atmosphere, Dr. Abrams is quick to stress. “Our facility was magnet before there was such a thing,” he explains. “Magnet status is nice, but nursing care was always fantastic here. Magnet just put a name to what we are and recognizes it nationally.”

Dr. Abrams encourages his residents to look for this quality at facilities with which they are considering employment. In fact, he even uses Rush’s magnet status as a selling point to attract hospitalists to his program.

“Sometimes they ask what that is and what it means,” he says. “You know the quality of the nursing staff at a magnet hospital. You know that there is a minimal level of quality you can expect.”

Dr. Abrams emphasizes the importance of trust between hospitalists and nurses. “If you can’t trust each other, it makes it so much harder to care for patients,” he says. “Our nurses spend much more time with patients than anyone else. I wouldn’t do anything without input from the nursing staff.

“We have a rule in the hospital. If a nurse thinks a patient needs to be transferred to intensive care, the patient is transferred,” continues Dr. Abrams. “We put this policy in place four to five years ago, and no one has ever questioned or disputed it.”

The biggest plus for nurses is that I’m on the floor eight or more hours a day. We have repeated interactions, and relationships develop more quickly. This probably breaks down some barriers that can exist between physicians and nurses.

—Richard Abrams, MD

PERFECT TOGETHER

Magnet status and hospitalists represent a good match. Just as magnet nursing status provides benefits for hospitalists, the presence of hospitalists helps create a positive environment for nurses.

“The biggest plus for nurses is that I’m on the floor eight or more hours a day. We have repeated interactions, and relationships develop more quickly,” notes Dr. Abrams. “This probably breaks down some barriers that can exist between physicians and nurses.”

When nurses have to whether to call an attending physician at 3 a.m., this often creates additional stress or worries for them. With hospitalists around, they almost always have a physician onsite. Even when the hospitalist isn’t right there, they know who to call and theyare likely to have a trusting relationship with this individual.

“I would feel bad if a nurse didn’t feel that she could pick up the phone and call me about any case,” says Dr. Abrams. “The more you work with people, the more trust you build.”

Magnet status is particularly important for hospitalists, explains Dr. Kaiser. “Because they spend so much time with nursing staff, the quality of nurses is especially important to hospitalists. Therefore, if we want to attract good hospitalists, we have to have good nurses. Because we have magnet status, we not only can say that we have a great nursing program; we can prove it.”

Sparger concurs. “Magnet validates a facility’s quality efforts and teamwork,” she says. “It makes you sit back and look at evidence-based practices for how you do things. You have to have evidence-based practices to write a policy. As hospitalists are more familiar and comfortable with hospital policies and procedures, this makes them the perfect match for magnet hospitals.”

At the same time when facilities put the hospitalist model together with magnet certification, the result is improved quality of life for both physicians and nurses.

While ANCC is still collecting data about magnet status and quality, Sparger and many individuals who work at magnet-certified facilities firmly believe that the characteristics that make they magnet also lead to reduced mortality and infections.

THE WORD SPREADS

If they don’t know about magnet certification already, hospitalists and other physicians likely will hear more about it in the near future.

“Magnet certification is a quality indicator at some level for hospitals,” says Dr. Abrams. “We will see a big push nationally for magnet at many more facilities.”

Nurses already see magnet status as an important sign that a hospital is a good place to work where quality care is high and nurses are respected. Increasingly, Dr. Abrams proposes, physicians will consider magnet status when choosing facilities at which to work. In fact this already is happening.

“I had one physicians say that he came here with confidence because he knew that we had a magnet staff,” says Beverly Hancock, MS, RN, education/quality and magnet project coordinator at Rush University Medical Center. “Also, I recently noticed on our Web site that several departments and programs mention our magnet status in their recruitment announcements.”

In fact, physicians themselves sometimes are the greatest advertisement for magnet hospitals. “If you talk to our physicians, they say that they tell everyone about the great nurses here,” says Hancock. “They say that they heard about it in their interviews and now they’re seeing it in person.”

At the same time, the word is spreading rapidly beyond practitioners. Just this year, U.S. News & World Report added magnet certification to its criteria for determining its annual list of the country’s best hospitals.

“There is no question that patients, insurers, and other healthcare groups will begin to place a lot of emphasis on magnet status as well,” concludes Dr. Abrams. TH

Contributor Joanne Kaldy is based in Maryland.

REFERENCES

1. McClure M, Poulin M, Sovie M, Wandelt M. Magnet Hospitals: Attraction and Retention of Professional Nurses. American Academy of Nursing Task Force and Nursing Practice in Hospitals. Kansas City, MO: American Nurses Association 1983.
2. Kramer M, Schmalenberg C. Magnet hospitals talk about the impact of DRGs on nursing care, part I. Nursing Management. 1987;18(9):38-42.
3. Kramer M, Schmalenberg C. Magnet hospitals talk about the impact of DRGs on nursing car, part II. Nursing Management. 1987; 18(10):33-40.
4. Kramer M, Schmalenberg C. Job satisfaction and retention. Insights for the ‘90s, part I. Nursing. 1991;3(3):50-55.
5. American Nurses Credentialing Center Web site. www.nursingworld.org/ancc/magnet/consumer/benefits.html. Benefits of magnet. Last accessed 8/16/05.

While the idea of applying current knowledge to patient care dates back as far as medicine itself, the modern concept of evidence-based medicine (EBM) has developed in response to the ever-increasing need for clinicians to make patient care decisions in a reasoned and rational manner. It is the application of evidence gleaned from careful research, merged with clinical experience, patient values, and the unique features of every individual case, for the purpose of making the most effective patient care decisions.

It must be noted that the search for and use of the best evidence does not by itself constitute the appropriate practice of EBM: Patient care requires a more global balance of many factors, and true EBM attempts to address this. While there are general themes to an EBM approach to clinical problems, it would be a mistake to view EBM as a search for a “script” to follow in deciding how to handle a clinical presentation. EBM is not meant to exclude the individualized approach to medicine, but rather to enhance and refine it.

Perhaps the best way to think of EBM comes from McMaster University (Hamilton, Ontario, Canada), where in the 1970s the scholarly pursuit of EBM began to flourish. Researchers at McMaster describe EBM as the development of an attitude of enlightened skepticism toward the evidence behind daily clinical decisions. Clinical evidence should be viewed through the lens of epidemiologic principles, and rather than accepting all that we are told, we should require a careful evaluation of the evidence. Our patients demand the best possible care, and we owe it to ourselves, our patients, and our profession to determine the best possible care for each individual.

HOW IS EBM RELEVANT TO THE HOSPITALIST?

To make effective patient care decisions, hospitalists are no different than other clinicians. In fact, every practicing hospitalist asks and answers dozens of clinical questions each day, and many of these decisions immediately affect the well-being of patients.

For example, should an otherwise healthy 60-year-old patient receive perioperative beta-blocker therapy prior to laparoscopic cholecystectomy? What is the best way to evaluate this diabetic woman’s nonhealing leg ulcer for osteomyelitis? What is the prognosis for this young man newly diagnosed with glioblastoma multiforme?

Each of these is an example of a clinical question many of us may have already asked ourselves today. Hospital medicine moves quickly, and it is important to find the best answers to these questions as rapidly as possible. EBM provides a framework to help get to these answers and ultimately it helps us manage patients most effectively.

EBM is not meant to exclude the individualized approach to medicine, but rather to enhance and refine it.

An additional aspect of hospitalist practice that is somewhat unique is the central role the hospitalist plays in the complete care of patients. The hospitalist is often called upon to bring specialists together for a patient’s care, and EBM can be important in ensuring that these specialists make the best decisions for the patient.

For example, a careful review of the literature suggests that low molecular weight heparin is preferable to aspirin for postoperative deep vein thrombosis prophylaxis for most hip replacement patients. If an orthopedic service nevertheless writes orders for aspirin in such a patient, the informed hospitalist would want to clarify the rationale behind this choice and if appropriate recommend the use of low molecular weight heparin instead. Thus, hospitalists may need to anticipate not only their own clinical questions but also any clinical question relevant to the care of any of their patients.

THE ELEMENTS OF EBM?

At its essence, EBM means applying the best evidence available for the benefit of patients. In this series, we will review the basic elements of EBM:

• Constructing an answerable clinical question;
• Searching for the best evidence for the question at hand;
• Critically appraising the evidence for its validity, importance, and relevance to your patient; and
• Applying the best evidence to your clinical practice.

Each of these deserves a brief comment. To find the information most relevant to a clinical question, it is helpful to have a well-defined query of appropriately narrow scope. If we

want information on perioperative beta-blockade in the scenario outlined above, it may not be helpful to apply evidence derived from vascular surgery patients over age 65 with known coronary artery disease. If information were available on outcomes in younger patients undergoing lower-risk procedures, this might be more relevant to our question. Thus, an approach to constructing effective clinical questions is a critical skill for EBM.

The best clinical question cannot help us if we don’t know how to find the evidence relating to that question, however. Therefore, EBM requires some understanding of the relative benefits of sources such as Ovid MEDLINE (www.medscape.com) or UpToDate (www.uptodate.com), in addition to how to navigate through these sources to get to the evidence. Thankfully, these databases are becoming more powerful all the time, while also working to remain user-friendly. An approach to effective searches is clearly an important skill for EBM.

Once we have found the evidence for our question, we need to know how to evaluate the quality of the evidence. There are many guides available for individual types of clinical questions, but there are consistent themes across all types of questions, including assessment for potential bias, proper interpretation of study results, and deciding whether the results can be applied to your patient. Understanding these themes and then taking the evidence back to the bedside is the culmination of the EBM process for our patients.

SUMMARY

EBM is an approach to making patient care decisions incorporating the highest quality available evidence. This is of great relevance to hospitalists, especially given the central role hospitalists play in the care of patients across multiple disciplines. This series will serve as an introduction to the many facets of EBM, focused to a practicing hospitalist audience. TH

Dr. West practices in the Division of General Internal Medicine, Mayo Clinic College of Medicine, Rochester, Minn.

While the idea of applying current knowledge to patient care dates back as far as medicine itself, the modern concept of evidence-based medicine (EBM) has developed in response to the ever-increasing need for clinicians to make patient care decisions in a reasoned and rational manner. It is the application of evidence gleaned from careful research, merged with clinical experience, patient values, and the unique features of every individual case, for the purpose of making the most effective patient care decisions.

It must be noted that the search for and use of the best evidence does not by itself constitute the appropriate practice of EBM: Patient care requires a more global balance of many factors, and true EBM attempts to address this. While there are general themes to an EBM approach to clinical problems, it would be a mistake to view EBM as a search for a “script” to follow in deciding how to handle a clinical presentation. EBM is not meant to exclude the individualized approach to medicine, but rather to enhance and refine it.

Perhaps the best way to think of EBM comes from McMaster University (Hamilton, Ontario, Canada), where in the 1970s the scholarly pursuit of EBM began to flourish. Researchers at McMaster describe EBM as the development of an attitude of enlightened skepticism toward the evidence behind daily clinical decisions. Clinical evidence should be viewed through the lens of epidemiologic principles, and rather than accepting all that we are told, we should require a careful evaluation of the evidence. Our patients demand the best possible care, and we owe it to ourselves, our patients, and our profession to determine the best possible care for each individual.

HOW IS EBM RELEVANT TO THE HOSPITALIST?

To make effective patient care decisions, hospitalists are no different than other clinicians. In fact, every practicing hospitalist asks and answers dozens of clinical questions each day, and many of these decisions immediately affect the well-being of patients.

For example, should an otherwise healthy 60-year-old patient receive perioperative beta-blocker therapy prior to laparoscopic cholecystectomy? What is the best way to evaluate this diabetic woman’s nonhealing leg ulcer for osteomyelitis? What is the prognosis for this young man newly diagnosed with glioblastoma multiforme?

Each of these is an example of a clinical question many of us may have already asked ourselves today. Hospital medicine moves quickly, and it is important to find the best answers to these questions as rapidly as possible. EBM provides a framework to help get to these answers and ultimately it helps us manage patients most effectively.

EBM is not meant to exclude the individualized approach to medicine, but rather to enhance and refine it.

An additional aspect of hospitalist practice that is somewhat unique is the central role the hospitalist plays in the complete care of patients. The hospitalist is often called upon to bring specialists together for a patient’s care, and EBM can be important in ensuring that these specialists make the best decisions for the patient.

For example, a careful review of the literature suggests that low molecular weight heparin is preferable to aspirin for postoperative deep vein thrombosis prophylaxis for most hip replacement patients. If an orthopedic service nevertheless writes orders for aspirin in such a patient, the informed hospitalist would want to clarify the rationale behind this choice and if appropriate recommend the use of low molecular weight heparin instead. Thus, hospitalists may need to anticipate not only their own clinical questions but also any clinical question relevant to the care of any of their patients.

THE ELEMENTS OF EBM?

At its essence, EBM means applying the best evidence available for the benefit of patients. In this series, we will review the basic elements of EBM:

• Constructing an answerable clinical question;
• Searching for the best evidence for the question at hand;
• Critically appraising the evidence for its validity, importance, and relevance to your patient; and
• Applying the best evidence to your clinical practice.

Each of these deserves a brief comment. To find the information most relevant to a clinical question, it is helpful to have a well-defined query of appropriately narrow scope. If we

want information on perioperative beta-blockade in the scenario outlined above, it may not be helpful to apply evidence derived from vascular surgery patients over age 65 with known coronary artery disease. If information were available on outcomes in younger patients undergoing lower-risk procedures, this might be more relevant to our question. Thus, an approach to constructing effective clinical questions is a critical skill for EBM.

The best clinical question cannot help us if we don’t know how to find the evidence relating to that question, however. Therefore, EBM requires some understanding of the relative benefits of sources such as Ovid MEDLINE (www.medscape.com) or UpToDate (www.uptodate.com), in addition to how to navigate through these sources to get to the evidence. Thankfully, these databases are becoming more powerful all the time, while also working to remain user-friendly. An approach to effective searches is clearly an important skill for EBM.

Once we have found the evidence for our question, we need to know how to evaluate the quality of the evidence. There are many guides available for individual types of clinical questions, but there are consistent themes across all types of questions, including assessment for potential bias, proper interpretation of study results, and deciding whether the results can be applied to your patient. Understanding these themes and then taking the evidence back to the bedside is the culmination of the EBM process for our patients.

SUMMARY

EBM is an approach to making patient care decisions incorporating the highest quality available evidence. This is of great relevance to hospitalists, especially given the central role hospitalists play in the care of patients across multiple disciplines. This series will serve as an introduction to the many facets of EBM, focused to a practicing hospitalist audience. TH

Dr. West practices in the Division of General Internal Medicine, Mayo Clinic College of Medicine, Rochester, Minn.

While the idea of applying current knowledge to patient care dates back as far as medicine itself, the modern concept of evidence-based medicine (EBM) has developed in response to the ever-increasing need for clinicians to make patient care decisions in a reasoned and rational manner. It is the application of evidence gleaned from careful research, merged with clinical experience, patient values, and the unique features of every individual case, for the purpose of making the most effective patient care decisions.

It must be noted that the search for and use of the best evidence does not by itself constitute the appropriate practice of EBM: Patient care requires a more global balance of many factors, and true EBM attempts to address this. While there are general themes to an EBM approach to clinical problems, it would be a mistake to view EBM as a search for a “script” to follow in deciding how to handle a clinical presentation. EBM is not meant to exclude the individualized approach to medicine, but rather to enhance and refine it.

Perhaps the best way to think of EBM comes from McMaster University (Hamilton, Ontario, Canada), where in the 1970s the scholarly pursuit of EBM began to flourish. Researchers at McMaster describe EBM as the development of an attitude of enlightened skepticism toward the evidence behind daily clinical decisions. Clinical evidence should be viewed through the lens of epidemiologic principles, and rather than accepting all that we are told, we should require a careful evaluation of the evidence. Our patients demand the best possible care, and we owe it to ourselves, our patients, and our profession to determine the best possible care for each individual.

HOW IS EBM RELEVANT TO THE HOSPITALIST?

To make effective patient care decisions, hospitalists are no different than other clinicians. In fact, every practicing hospitalist asks and answers dozens of clinical questions each day, and many of these decisions immediately affect the well-being of patients.

For example, should an otherwise healthy 60-year-old patient receive perioperative beta-blocker therapy prior to laparoscopic cholecystectomy? What is the best way to evaluate this diabetic woman’s nonhealing leg ulcer for osteomyelitis? What is the prognosis for this young man newly diagnosed with glioblastoma multiforme?

Each of these is an example of a clinical question many of us may have already asked ourselves today. Hospital medicine moves quickly, and it is important to find the best answers to these questions as rapidly as possible. EBM provides a framework to help get to these answers and ultimately it helps us manage patients most effectively.

EBM is not meant to exclude the individualized approach to medicine, but rather to enhance and refine it.

An additional aspect of hospitalist practice that is somewhat unique is the central role the hospitalist plays in the complete care of patients. The hospitalist is often called upon to bring specialists together for a patient’s care, and EBM can be important in ensuring that these specialists make the best decisions for the patient.

For example, a careful review of the literature suggests that low molecular weight heparin is preferable to aspirin for postoperative deep vein thrombosis prophylaxis for most hip replacement patients. If an orthopedic service nevertheless writes orders for aspirin in such a patient, the informed hospitalist would want to clarify the rationale behind this choice and if appropriate recommend the use of low molecular weight heparin instead. Thus, hospitalists may need to anticipate not only their own clinical questions but also any clinical question relevant to the care of any of their patients.

THE ELEMENTS OF EBM?

At its essence, EBM means applying the best evidence available for the benefit of patients. In this series, we will review the basic elements of EBM:

• Constructing an answerable clinical question;
• Searching for the best evidence for the question at hand;
• Critically appraising the evidence for its validity, importance, and relevance to your patient; and
• Applying the best evidence to your clinical practice.

Each of these deserves a brief comment. To find the information most relevant to a clinical question, it is helpful to have a well-defined query of appropriately narrow scope. If we

want information on perioperative beta-blockade in the scenario outlined above, it may not be helpful to apply evidence derived from vascular surgery patients over age 65 with known coronary artery disease. If information were available on outcomes in younger patients undergoing lower-risk procedures, this might be more relevant to our question. Thus, an approach to constructing effective clinical questions is a critical skill for EBM.

The best clinical question cannot help us if we don’t know how to find the evidence relating to that question, however. Therefore, EBM requires some understanding of the relative benefits of sources such as Ovid MEDLINE (www.medscape.com) or UpToDate (www.uptodate.com), in addition to how to navigate through these sources to get to the evidence. Thankfully, these databases are becoming more powerful all the time, while also working to remain user-friendly. An approach to effective searches is clearly an important skill for EBM.

Once we have found the evidence for our question, we need to know how to evaluate the quality of the evidence. There are many guides available for individual types of clinical questions, but there are consistent themes across all types of questions, including assessment for potential bias, proper interpretation of study results, and deciding whether the results can be applied to your patient. Understanding these themes and then taking the evidence back to the bedside is the culmination of the EBM process for our patients.

SUMMARY

EBM is an approach to making patient care decisions incorporating the highest quality available evidence. This is of great relevance to hospitalists, especially given the central role hospitalists play in the care of patients across multiple disciplines. This series will serve as an introduction to the many facets of EBM, focused to a practicing hospitalist audience. TH

Dr. West practices in the Division of General Internal Medicine, Mayo Clinic College of Medicine, Rochester, Minn.

This article is the second in a series on the hospital of the future, designed to get our readers thinking and planning ahead for their own facilities.

Hospitals across the country wrestle with improving their discharge process, whether the goal is gaining a more time- and cost-effective outcome for the facility, or improving quality measures for patients upon departure, or both.

“A lot of people are attacking discharge problems from a lot of different angles,” says Vineet Arora, MD, academic hospitalist and researcher, University of Chicago Pritzker School of Medicine.

What will hospital discharge look like in the future? Based on current research, trials, and trends, it seems there are few surprises down the road in this area. The changes will come in the form of fine-tuning critical areas in the process rather than implementing new technology to radically change the way we release patients. Positive changes seem to be people-based rather than computer-based.

“Everybody’s on the technology bandwagon, but we have to understand the processes first,” says Lakshmi Halasyamani, MD, associate chair for the Department of Internal Medicine, St. Joseph Mercy Hospital, Ann Arbor, Mich. “Better technology won’t make care safer or more efficient. We have to examine how we organize care delivery, then look at technology. Otherwise it replicates the inefficiencies we have now.”

Here are some predictions for how the discharge process will be improved in the hospital of the future.

THE DISCHARGE PROCESS WILL BE SMOOTHER AND SAFER

Most hospital-based professionals agree that discharge is an area of care that needs more attention.

“Every day that you’re [in the hospital], we spend a little less time with you,” says Dr. Halasyamani. “We undervalue the risk of discharging patients; we need to focus on [the patients] more. The nurse calls us, and we get the discharge done as quickly as possible.”

In the hospital of the future, the discharge process will be driven by specific structured guidelines that ensure patients safety when they leave the hospital. Every discharge will involve a multidisciplinary team, with members signing off that the patient is not only ready to leave the hospital, but informed about their condition and any next steps, and has necessary medications or prescriptions in hand.

As for improving efficiency, minor changes can make a big difference. Chad Whelan, MD, assistant professor of medicine, University of Chicago Hospitals, is part of a task force working on how to move hospital discharges earlier in the day.

“An earlier discharge is better for everyone, including the patient—especially if they’re being transferred to another facility,” he points out. “One thing we’re looking at is the way diagnostic tests are categorized. Everything falls into two categories now: emergency diagnostics and everything else.”

Dr. Whelan and the taskforce have asked departments, including radiology and other labs, to create a third category: for patients waiting for a test before they can be discharged. All it takes is one question on the part of the service provider: “Is this patient waiting for these results before she can go home?” to move that patient to the front of the line.

Another recommendation Dr. Whelan’s task force will make involves staffing up. “Like we ramp nursing staff up and down depending on the census, we are looking at doing that with case managers and ward clerks to handle heavy discharge times,” he says.

David J. Rosenman, MD, senior associate consultant, Hospital Internal Medicine, Mayo Clinic in Rochester, Minn., suggests that paperwork might also be changed. “The discharge summary of the future will be more visual,” he predicts. “There are ways of displaying information that are more sophisticated and probably more helpful than static lists and linear prose alone.”

EMPOWERED PATIENTS

One change we are likely to see is patients taking on the responsibility of their own medical information. Ideally, the patients themselves will make caring for—and discharging—them easier and more efficient by sharing complete information on their current medications and other healthcare details that are often forgotten or overlooked by a provider or caregiver.

“The future of discharge lies with our ability to arm patients with their own information,” says Dr. Arora. “The more empowered the patient is, the better the outcome.” Personal health records (PHRs) are one solution. MyPHR is one online product, offered free by the American Health Information Management Association (AHIMA). Roughly 30 companies currently offer paid subscription PHR services to consumers. Peoplechart Corporation (San Francisco) is one of them and provides a single source of information controlled by the patient.

“We’re a pioneer of the PHR idea,” says Megan Mok, president and founder, Peoplechart Corporation. “There are not that many out there.”

Healthcare consumers can subscribe to a variety of Peoplechart tools and services (including initial collection of their records) that allow them to gain access to their comprehensive medical records via the Internet—or phone, if they choose—and to grant any given healthcare provider access to part or all of their records.

“Everything is patient-initiated and patient-controlled,” explains Mok. “There’s a big difference from systems controlled by providers, which may allow patients access, but not ownership.”

PHRs typically offer a comprehensive, integrated overview of an individual’s health data, including information that individuals add themselves on their symptoms and prescriptions, along with information such as diagnoses and lab results. Once a discharged patient updates her PHR, she can share her complete hospital records with her primary care physician, physical therapist, rehab facility, or whatever caregiver requires the information. This will save time and effort for all healthcare providers, and, more importantly, ensures that essential information is available.

Regardless of whether a patient has a PHR, physicians and other staff must ensure that the individual leaves the hospital with complete information on their care and medications.

“Discharge is a quality measure,” says Dr. Arora. “We need a multidisciplinary approach to address what each patient needs to go home.”

DEMYSTIFIED MEDICATIONS

In the very near future, the 2006 JCAHO standard for medication reconciliation will eliminate many problems with medications after discharge.

“This standard is extremely important,” says Dr. Rosenman. “Almost half of medication errors occur at transition points in a patient’s care. Reconciling medication lists—especially at these points—is critical to ensuring patient safety.”

The medication reconciliation form could conceivably morph into something broader in the future. “It would be nice for the medical record to be a living document that evolved with each encounter over the course of a patient’s life,” says Dr. Rosenman. “People may someday carry replaceable, updatable, credit-card-like medical cards or chips. In the meantime, we need to do our very best to keep medication lists and related data accurate and complete.”

While the patient will own his or her medical information, “the burden for ensuring the med list is accurate falls entirely on the healthcare organization,” insists Dr. Halasyamani. “This is a ripe opportunity to partner with the patients themselves. They and their families own the information. We have to help patients be stakeholders and give them the tools to manage their ever-changing medications and their healthcare.”

Many paper-based and computerized tools exist now, but there is no obvious standout product or method physicians can provide to patients that will ensure they take their prescriptions correctly on an ongoing basis.

“Health systems will have to develop a standard” for helping patients manage their medications, says Dr. Halasyamani. “Strategies must be low-tech but get the job done. They must resonate with things that patients already do, like paying bills.”

COMMUNICATION STILL CRITICAL

One step in the discharge process that ensures a smooth transition for inpatient to outpatient is communication with the professionals, facilities, or caregivers who will take over the patient’s care.

“The gap in care after discharge puts patients at risk for adverse events,” warns Dr. Arora. “One reason for this vulnerable gap is the flow of information between settings and teams of providers.” In the future, hospitals will better manage this essential transfer of information.

Typically, the patient’s primary care physician wants information from the hospital at admission and at discharge, and, if the primary care physician wishes, in between.

“We need to improve communications with primary care physicians in a way that respects their wishes for communication,” says Dr. Arora. The UCSF Hospitalist Group is already working on this.

“Until recently, we provided fax copies of our notes to primary care physicians. Now we have a new dictation system,” says Steven Pantilat, MD, FACP, SHM president. “We did a survey that found that most physicians want telephone contact at admission and at discharge, plus any major occurrences in between. The ability to exchange information in real time is important—and e-mail is not realtime.”

How does a hospitalist keep track of everyone’s communication preferences? “The hospitalist simply has to figure out what each primary care physician wants,” stresses Dr. Pantilat. “My sense is that in any hospital, there is a limited number of doctors or practices to deal with. How do you keep them all straight? Well, the same way a hospitalist keeps all the various nurses straight—you just do. It’s your business.”

PLANNED FOLLOW-UP

In the future, nearly every discharged patient will be contacted within two or three days by the hospitalist or another hospital medical staff. This may come in the form of a phone call to the patient to check on their overall health, symptoms, and medications. Or it may be a more hands-on approach.

The UCSF Medical Center has established a follow-up service to provide care to patients during the transition period immediately following discharge.

“This service was designed for patients who couldn’t otherwise be followed up on or those who would benefit from seeing the doctor who treated them in the hospital,” explains Dr. Pantilat, who initiated the idea for the service. “For example, if a patient with DVT was discharged, is the swelling smaller? The primary care physician can’t say—he didn’t see it.”

Out of more than 2,600 discharges during 1997-1998, the first year that the follow-up service existed, only 47 patients were prescribed with follow-up visits. “It was never meant to be a highly utilized service,” says Dr. Pantilat, “but to be a highly expandable, flexible service that addresses the needs of specific patients.” Of those 47 patients, four were readmitted to the hospital—one directly from the follow-up visit—compared with a national readmission average of 14%.

“We see these patients in the ED,” says Dr. Pantilat. “It’s the only department that’s open 24/7, and the ED has some extra bed capacity.”

When the hospitalist feels a follow-up is necessary, he or she schedules a visit with the patient before discharge for midmorning one or two days after discharge. (Midmorning is typically a slow time in the emergency department.) He then faxes the appointment information to the emergency department, so that when the patient shows up, she is preregistered. The emergency department telephones the hospitalist when the patient arrives, and that doctor then comes down to see the patient. The emergency department physicians have nothing to do with these follow-ups, though the nursing staff might be asked to help. Also, follow-up visits are considered an outpatient service and charged as such. “The follow-up service was established and run at virtually no cost,” says Dr. Pantilat.

Even if every hospital doesn’t arrange in-person follow-ups, there will be some form of contact after discharge. “Hospitals providing care in transition will expand a lot,” he explains, “whether it’s phone calls from a nurse or other healthcare professional or some other contact during that gap until a patient can re-establish with their primary care physician. Not every patient needs this, but a lot would benefit.”

THE HOSPITALIST ROLE IN DISCHARGE

As we move toward creating a better discharge process, hospitalists will be at the center of that change and the process itself.

“The hospitalist is the keeper of information,” says Dr. Arora. “They know why certain care decisions were made. This movement depends on the flow of information to help design systems to help implement communication.”

There are some barriers to a smooth discharge process that only hospitalists can eliminate. “The increased use of hospitalists means that patients are not familiar with their doctor” in the hospital, says Dr. Arora. “When they leave the hospital, some information stays behind. They don’t know who to call for that follow-up lab work prescribed in the hospital. … The hospitalist needs to do a better job of telling patients who they are and how to reach them after discharge. A systems-based solution, or solutions, is needed.”

It is up to hospitalists to ensure that their discharge system works, that each patient leaves with an understanding of next steps in their care and knows who to call for which specific follow-up step, and with contact information if they (or their primary care physician) need to reach their hospitalist.

Dr. Halasyamani believes that hospitalists are well positioned to implement change in general within their systems. “The hospitalist is in the trenches, in a position to see what changes have to take place,” she says. “It’s their role to inform their management of better processes.

Each of us needs to be a waver of the banner for new standards—it’s not good enough to just scribble prescriptions”

CONCLUSION

The future is coming fast, for improved hospital discharge as well as other everyday processes. “We’re learning that discharge should be a more structured, formal process,” says Dr. Whelan. “We’d like to move to a safer, more complete and more efficient way of handling it.”

Consider what your own facility is doing regarding discharging patients. If there is room for improvement, can you envision a way to bring that process into the future? TH

Jane Jerrard will continue writing the “Hospital of the Future” series this fall.

Flashback:

Colonial Hospitalists

250 years of admissions and discharge

The hospital-based physician must deal with many arcane and Byzantine criteria for admission, care, and discharge of patients. There are regulations for record-keeping and concerns about length of stay. Becoming a staff member may involve physician credentialing, and practitioners from other states or countries have to meet more rigorous standards.

This previous paragraph was not written about modern-day America. These issues are lifted from the “Rules and Regulations of the Pennsylvania Hospital” approved by the Board of Managers in 1752.1 The Pennsylvania Hospital was founded that year under the guidance of Benjamin Franklin. The facility was dedicated to care for the sick and poor. Among the biggest obstacles to its creation was fundraising. Franklin’s accounts of the early years of this institution included a final page with a useful form for donating money.

Hospitalists today face many of the same issues, including admission and discharge criteria, concerns about funding, and practice regulation, as their peers in 1752.

ADMISSION AND DISCHARGE CRITERIA

In 1752 there were 15 rules for admission and discharge of patients, as well as regulations for patients’ behavior while hospitalized. Among the most interesting:

1. No patients can be admitted if deemed incurable, lunaticks [sic] excepted, nor any case not requiring special services of a hospital.
2. No admits for smallpox, itch, or other infectious distempers unless proper apartments [isolation] available. Admits found to have the above will be discharged.
3. No admits of women with small children. Hospital will not maintain childcare facilities.
4. Persons admitted as above must provide funds for their own burial in case of their own demise.
5. 5. One bed to be held for a trauma case.
6. Patients will be discharged when cured or judged incurable
7. All cured patients must sign a release stating their cure and the benefit received from the hospital for use by the hospital managers.
8. No patient may leave the facility without a physician release. They may not swear or curse, get drunk, behave rudely or indecently, on pain of expulsion at first admonition.
9. No patient may gamble or beg.
10. Patients will aide in nursing other patients when able. This will include washing and ironing the linen and cleaning the rooms.

The Hospital Management Board was responsible for choosing a staff of six practitioners to manage these patients. There were guidelines for who could fill this job.

RULES FOR CHOICE OF PHYSICIANS AND SURGEONS

There were the rules in place in 1752 for choosing physicians and surgeons who could work in the hospital; the most interesting was that applying practitioners must be 27 years old, have served an apprenticeship in Philadelphia, have studied “physick” or surgery for seven years or more, and have undergone an exam by six hospital practitioners. Visiting practitioners had to reside in the city for three years before applying and then had to qualify under the same criteria.

LENGTH OF STAY

There was a significant interest in abstracting the admit diagnosis, length of stay, and outcome. The disposition of patients admitted during the first two years of the hospital’s existence, ending in April 1754 was presented in a modern format.

There were 117 admissions, with 60 cures. Eleven patients were relieved, though not cured. Seven were deemed incurable, 10 were taken away by friends, and 10 died. Three were discharged for irregular behavior, and 16 remained hospitalized.

The most common admission diagnosis was ulcers, representing almost a third of all admits, followed by lunacy. Other frequent diagnoses were dropsy (congestive heart disease), scrophulous and scorbutic diseases (extrapulmonary tuberculosis and scurvy) and rheumatism.

The highest mortality was for consumption, at 100%. The two patients admitted with flux (diarrhea) and prolapsus ani also died. Dropsy carried a 33% mortality rate, without the benefit of the latest medical innovation, foxglove (digitalis), which would be described a few decades later.2 Also notable is death from scurvy, the cure for which was described in 1753 by James Lind.3

The managers were pleased with the performance of the facility. They believed that their efforts had resulted in “good” for the 60 persons afflicted with “various distempers” who were cured and that many had received considerable relief. This was accomplished despite the limited amount of funds available, thanks to careful attendance afforded to the sick and poor, as well as proper diet and availability of medicines. Based on these favorable reports, the Board of Managers requested further funding.

Two hundred and fifty years later, physicians face many of the same issues, including admission and discharge criteria, concerns about funding, and practice regulation. Their actions continue to be monitored, and it is likely that the same will be true in the future. Hospital administrators remain frugal, and we are admonished, in the words of Benjamin Franklin, writing in Poor Richard’s Almanac, “A penny saved is a penny earned.”

—Jamie Newman, MD, FACP

REFERENCES

1. Franklin B. Some Account of the Pennsylvania Hospital 1754. (Facsimile Edition.) Baltimore: The Johns Hopkins Press; 1954.
2. Withering W. An Account of the Foxglove and Some of Its Medical Uses. Birmingham, England: M. Swinney; 1785.
3. Lind J. A Treatise of the Scurvy. Edinburgh, Scotland: Sands, Murray and Cochran; 1753.

This article is the second in a series on the hospital of the future, designed to get our readers thinking and planning ahead for their own facilities.

Hospitals across the country wrestle with improving their discharge process, whether the goal is gaining a more time- and cost-effective outcome for the facility, or improving quality measures for patients upon departure, or both.

“A lot of people are attacking discharge problems from a lot of different angles,” says Vineet Arora, MD, academic hospitalist and researcher, University of Chicago Pritzker School of Medicine.

What will hospital discharge look like in the future? Based on current research, trials, and trends, it seems there are few surprises down the road in this area. The changes will come in the form of fine-tuning critical areas in the process rather than implementing new technology to radically change the way we release patients. Positive changes seem to be people-based rather than computer-based.

“Everybody’s on the technology bandwagon, but we have to understand the processes first,” says Lakshmi Halasyamani, MD, associate chair for the Department of Internal Medicine, St. Joseph Mercy Hospital, Ann Arbor, Mich. “Better technology won’t make care safer or more efficient. We have to examine how we organize care delivery, then look at technology. Otherwise it replicates the inefficiencies we have now.”

Here are some predictions for how the discharge process will be improved in the hospital of the future.

THE DISCHARGE PROCESS WILL BE SMOOTHER AND SAFER

Most hospital-based professionals agree that discharge is an area of care that needs more attention.

“Every day that you’re [in the hospital], we spend a little less time with you,” says Dr. Halasyamani. “We undervalue the risk of discharging patients; we need to focus on [the patients] more. The nurse calls us, and we get the discharge done as quickly as possible.”

In the hospital of the future, the discharge process will be driven by specific structured guidelines that ensure patients safety when they leave the hospital. Every discharge will involve a multidisciplinary team, with members signing off that the patient is not only ready to leave the hospital, but informed about their condition and any next steps, and has necessary medications or prescriptions in hand.

As for improving efficiency, minor changes can make a big difference. Chad Whelan, MD, assistant professor of medicine, University of Chicago Hospitals, is part of a task force working on how to move hospital discharges earlier in the day.

“An earlier discharge is better for everyone, including the patient—especially if they’re being transferred to another facility,” he points out. “One thing we’re looking at is the way diagnostic tests are categorized. Everything falls into two categories now: emergency diagnostics and everything else.”

Dr. Whelan and the taskforce have asked departments, including radiology and other labs, to create a third category: for patients waiting for a test before they can be discharged. All it takes is one question on the part of the service provider: “Is this patient waiting for these results before she can go home?” to move that patient to the front of the line.

Another recommendation Dr. Whelan’s task force will make involves staffing up. “Like we ramp nursing staff up and down depending on the census, we are looking at doing that with case managers and ward clerks to handle heavy discharge times,” he says.

David J. Rosenman, MD, senior associate consultant, Hospital Internal Medicine, Mayo Clinic in Rochester, Minn., suggests that paperwork might also be changed. “The discharge summary of the future will be more visual,” he predicts. “There are ways of displaying information that are more sophisticated and probably more helpful than static lists and linear prose alone.”

EMPOWERED PATIENTS

One change we are likely to see is patients taking on the responsibility of their own medical information. Ideally, the patients themselves will make caring for—and discharging—them easier and more efficient by sharing complete information on their current medications and other healthcare details that are often forgotten or overlooked by a provider or caregiver.

“The future of discharge lies with our ability to arm patients with their own information,” says Dr. Arora. “The more empowered the patient is, the better the outcome.” Personal health records (PHRs) are one solution. MyPHR is one online product, offered free by the American Health Information Management Association (AHIMA). Roughly 30 companies currently offer paid subscription PHR services to consumers. Peoplechart Corporation (San Francisco) is one of them and provides a single source of information controlled by the patient.

“We’re a pioneer of the PHR idea,” says Megan Mok, president and founder, Peoplechart Corporation. “There are not that many out there.”

Healthcare consumers can subscribe to a variety of Peoplechart tools and services (including initial collection of their records) that allow them to gain access to their comprehensive medical records via the Internet—or phone, if they choose—and to grant any given healthcare provider access to part or all of their records.

“Everything is patient-initiated and patient-controlled,” explains Mok. “There’s a big difference from systems controlled by providers, which may allow patients access, but not ownership.”

PHRs typically offer a comprehensive, integrated overview of an individual’s health data, including information that individuals add themselves on their symptoms and prescriptions, along with information such as diagnoses and lab results. Once a discharged patient updates her PHR, she can share her complete hospital records with her primary care physician, physical therapist, rehab facility, or whatever caregiver requires the information. This will save time and effort for all healthcare providers, and, more importantly, ensures that essential information is available.

Regardless of whether a patient has a PHR, physicians and other staff must ensure that the individual leaves the hospital with complete information on their care and medications.

“Discharge is a quality measure,” says Dr. Arora. “We need a multidisciplinary approach to address what each patient needs to go home.”

DEMYSTIFIED MEDICATIONS

In the very near future, the 2006 JCAHO standard for medication reconciliation will eliminate many problems with medications after discharge.

“This standard is extremely important,” says Dr. Rosenman. “Almost half of medication errors occur at transition points in a patient’s care. Reconciling medication lists—especially at these points—is critical to ensuring patient safety.”

The medication reconciliation form could conceivably morph into something broader in the future. “It would be nice for the medical record to be a living document that evolved with each encounter over the course of a patient’s life,” says Dr. Rosenman. “People may someday carry replaceable, updatable, credit-card-like medical cards or chips. In the meantime, we need to do our very best to keep medication lists and related data accurate and complete.”

While the patient will own his or her medical information, “the burden for ensuring the med list is accurate falls entirely on the healthcare organization,” insists Dr. Halasyamani. “This is a ripe opportunity to partner with the patients themselves. They and their families own the information. We have to help patients be stakeholders and give them the tools to manage their ever-changing medications and their healthcare.”

Many paper-based and computerized tools exist now, but there is no obvious standout product or method physicians can provide to patients that will ensure they take their prescriptions correctly on an ongoing basis.

“Health systems will have to develop a standard” for helping patients manage their medications, says Dr. Halasyamani. “Strategies must be low-tech but get the job done. They must resonate with things that patients already do, like paying bills.”

COMMUNICATION STILL CRITICAL

One step in the discharge process that ensures a smooth transition for inpatient to outpatient is communication with the professionals, facilities, or caregivers who will take over the patient’s care.

“The gap in care after discharge puts patients at risk for adverse events,” warns Dr. Arora. “One reason for this vulnerable gap is the flow of information between settings and teams of providers.” In the future, hospitals will better manage this essential transfer of information.

Typically, the patient’s primary care physician wants information from the hospital at admission and at discharge, and, if the primary care physician wishes, in between.

“We need to improve communications with primary care physicians in a way that respects their wishes for communication,” says Dr. Arora. The UCSF Hospitalist Group is already working on this.

“Until recently, we provided fax copies of our notes to primary care physicians. Now we have a new dictation system,” says Steven Pantilat, MD, FACP, SHM president. “We did a survey that found that most physicians want telephone contact at admission and at discharge, plus any major occurrences in between. The ability to exchange information in real time is important—and e-mail is not realtime.”

How does a hospitalist keep track of everyone’s communication preferences? “The hospitalist simply has to figure out what each primary care physician wants,” stresses Dr. Pantilat. “My sense is that in any hospital, there is a limited number of doctors or practices to deal with. How do you keep them all straight? Well, the same way a hospitalist keeps all the various nurses straight—you just do. It’s your business.”

PLANNED FOLLOW-UP

In the future, nearly every discharged patient will be contacted within two or three days by the hospitalist or another hospital medical staff. This may come in the form of a phone call to the patient to check on their overall health, symptoms, and medications. Or it may be a more hands-on approach.

The UCSF Medical Center has established a follow-up service to provide care to patients during the transition period immediately following discharge.

“This service was designed for patients who couldn’t otherwise be followed up on or those who would benefit from seeing the doctor who treated them in the hospital,” explains Dr. Pantilat, who initiated the idea for the service. “For example, if a patient with DVT was discharged, is the swelling smaller? The primary care physician can’t say—he didn’t see it.”

Out of more than 2,600 discharges during 1997-1998, the first year that the follow-up service existed, only 47 patients were prescribed with follow-up visits. “It was never meant to be a highly utilized service,” says Dr. Pantilat, “but to be a highly expandable, flexible service that addresses the needs of specific patients.” Of those 47 patients, four were readmitted to the hospital—one directly from the follow-up visit—compared with a national readmission average of 14%.

“We see these patients in the ED,” says Dr. Pantilat. “It’s the only department that’s open 24/7, and the ED has some extra bed capacity.”

When the hospitalist feels a follow-up is necessary, he or she schedules a visit with the patient before discharge for midmorning one or two days after discharge. (Midmorning is typically a slow time in the emergency department.) He then faxes the appointment information to the emergency department, so that when the patient shows up, she is preregistered. The emergency department telephones the hospitalist when the patient arrives, and that doctor then comes down to see the patient. The emergency department physicians have nothing to do with these follow-ups, though the nursing staff might be asked to help. Also, follow-up visits are considered an outpatient service and charged as such. “The follow-up service was established and run at virtually no cost,” says Dr. Pantilat.

Even if every hospital doesn’t arrange in-person follow-ups, there will be some form of contact after discharge. “Hospitals providing care in transition will expand a lot,” he explains, “whether it’s phone calls from a nurse or other healthcare professional or some other contact during that gap until a patient can re-establish with their primary care physician. Not every patient needs this, but a lot would benefit.”

THE HOSPITALIST ROLE IN DISCHARGE

As we move toward creating a better discharge process, hospitalists will be at the center of that change and the process itself.

“The hospitalist is the keeper of information,” says Dr. Arora. “They know why certain care decisions were made. This movement depends on the flow of information to help design systems to help implement communication.”

There are some barriers to a smooth discharge process that only hospitalists can eliminate. “The increased use of hospitalists means that patients are not familiar with their doctor” in the hospital, says Dr. Arora. “When they leave the hospital, some information stays behind. They don’t know who to call for that follow-up lab work prescribed in the hospital. … The hospitalist needs to do a better job of telling patients who they are and how to reach them after discharge. A systems-based solution, or solutions, is needed.”

It is up to hospitalists to ensure that their discharge system works, that each patient leaves with an understanding of next steps in their care and knows who to call for which specific follow-up step, and with contact information if they (or their primary care physician) need to reach their hospitalist.

Dr. Halasyamani believes that hospitalists are well positioned to implement change in general within their systems. “The hospitalist is in the trenches, in a position to see what changes have to take place,” she says. “It’s their role to inform their management of better processes.

Each of us needs to be a waver of the banner for new standards—it’s not good enough to just scribble prescriptions”

CONCLUSION

The future is coming fast, for improved hospital discharge as well as other everyday processes. “We’re learning that discharge should be a more structured, formal process,” says Dr. Whelan. “We’d like to move to a safer, more complete and more efficient way of handling it.”

Consider what your own facility is doing regarding discharging patients. If there is room for improvement, can you envision a way to bring that process into the future? TH

Jane Jerrard will continue writing the “Hospital of the Future” series this fall.

Flashback:

Colonial Hospitalists

250 years of admissions and discharge

The hospital-based physician must deal with many arcane and Byzantine criteria for admission, care, and discharge of patients. There are regulations for record-keeping and concerns about length of stay. Becoming a staff member may involve physician credentialing, and practitioners from other states or countries have to meet more rigorous standards.

This previous paragraph was not written about modern-day America. These issues are lifted from the “Rules and Regulations of the Pennsylvania Hospital” approved by the Board of Managers in 1752.1 The Pennsylvania Hospital was founded that year under the guidance of Benjamin Franklin. The facility was dedicated to care for the sick and poor. Among the biggest obstacles to its creation was fundraising. Franklin’s accounts of the early years of this institution included a final page with a useful form for donating money.

Hospitalists today face many of the same issues, including admission and discharge criteria, concerns about funding, and practice regulation, as their peers in 1752.

ADMISSION AND DISCHARGE CRITERIA

In 1752 there were 15 rules for admission and discharge of patients, as well as regulations for patients’ behavior while hospitalized. Among the most interesting:

1. No patients can be admitted if deemed incurable, lunaticks [sic] excepted, nor any case not requiring special services of a hospital.
2. No admits for smallpox, itch, or other infectious distempers unless proper apartments [isolation] available. Admits found to have the above will be discharged.
3. No admits of women with small children. Hospital will not maintain childcare facilities.
4. Persons admitted as above must provide funds for their own burial in case of their own demise.
5. 5. One bed to be held for a trauma case.
6. Patients will be discharged when cured or judged incurable
7. All cured patients must sign a release stating their cure and the benefit received from the hospital for use by the hospital managers.
8. No patient may leave the facility without a physician release. They may not swear or curse, get drunk, behave rudely or indecently, on pain of expulsion at first admonition.
9. No patient may gamble or beg.
10. Patients will aide in nursing other patients when able. This will include washing and ironing the linen and cleaning the rooms.

The Hospital Management Board was responsible for choosing a staff of six practitioners to manage these patients. There were guidelines for who could fill this job.

RULES FOR CHOICE OF PHYSICIANS AND SURGEONS

There were the rules in place in 1752 for choosing physicians and surgeons who could work in the hospital; the most interesting was that applying practitioners must be 27 years old, have served an apprenticeship in Philadelphia, have studied “physick” or surgery for seven years or more, and have undergone an exam by six hospital practitioners. Visiting practitioners had to reside in the city for three years before applying and then had to qualify under the same criteria.

LENGTH OF STAY

There was a significant interest in abstracting the admit diagnosis, length of stay, and outcome. The disposition of patients admitted during the first two years of the hospital’s existence, ending in April 1754 was presented in a modern format.

There were 117 admissions, with 60 cures. Eleven patients were relieved, though not cured. Seven were deemed incurable, 10 were taken away by friends, and 10 died. Three were discharged for irregular behavior, and 16 remained hospitalized.

The most common admission diagnosis was ulcers, representing almost a third of all admits, followed by lunacy. Other frequent diagnoses were dropsy (congestive heart disease), scrophulous and scorbutic diseases (extrapulmonary tuberculosis and scurvy) and rheumatism.

The highest mortality was for consumption, at 100%. The two patients admitted with flux (diarrhea) and prolapsus ani also died. Dropsy carried a 33% mortality rate, without the benefit of the latest medical innovation, foxglove (digitalis), which would be described a few decades later.2 Also notable is death from scurvy, the cure for which was described in 1753 by James Lind.3

The managers were pleased with the performance of the facility. They believed that their efforts had resulted in “good” for the 60 persons afflicted with “various distempers” who were cured and that many had received considerable relief. This was accomplished despite the limited amount of funds available, thanks to careful attendance afforded to the sick and poor, as well as proper diet and availability of medicines. Based on these favorable reports, the Board of Managers requested further funding.

Two hundred and fifty years later, physicians face many of the same issues, including admission and discharge criteria, concerns about funding, and practice regulation. Their actions continue to be monitored, and it is likely that the same will be true in the future. Hospital administrators remain frugal, and we are admonished, in the words of Benjamin Franklin, writing in Poor Richard’s Almanac, “A penny saved is a penny earned.”

—Jamie Newman, MD, FACP

REFERENCES

1. Franklin B. Some Account of the Pennsylvania Hospital 1754. (Facsimile Edition.) Baltimore: The Johns Hopkins Press; 1954.
2. Withering W. An Account of the Foxglove and Some of Its Medical Uses. Birmingham, England: M. Swinney; 1785.
3. Lind J. A Treatise of the Scurvy. Edinburgh, Scotland: Sands, Murray and Cochran; 1753.

This article is the second in a series on the hospital of the future, designed to get our readers thinking and planning ahead for their own facilities.

Hospitals across the country wrestle with improving their discharge process, whether the goal is gaining a more time- and cost-effective outcome for the facility, or improving quality measures for patients upon departure, or both.

“A lot of people are attacking discharge problems from a lot of different angles,” says Vineet Arora, MD, academic hospitalist and researcher, University of Chicago Pritzker School of Medicine.

What will hospital discharge look like in the future? Based on current research, trials, and trends, it seems there are few surprises down the road in this area. The changes will come in the form of fine-tuning critical areas in the process rather than implementing new technology to radically change the way we release patients. Positive changes seem to be people-based rather than computer-based.

“Everybody’s on the technology bandwagon, but we have to understand the processes first,” says Lakshmi Halasyamani, MD, associate chair for the Department of Internal Medicine, St. Joseph Mercy Hospital, Ann Arbor, Mich. “Better technology won’t make care safer or more efficient. We have to examine how we organize care delivery, then look at technology. Otherwise it replicates the inefficiencies we have now.”

Here are some predictions for how the discharge process will be improved in the hospital of the future.

THE DISCHARGE PROCESS WILL BE SMOOTHER AND SAFER

Most hospital-based professionals agree that discharge is an area of care that needs more attention.

“Every day that you’re [in the hospital], we spend a little less time with you,” says Dr. Halasyamani. “We undervalue the risk of discharging patients; we need to focus on [the patients] more. The nurse calls us, and we get the discharge done as quickly as possible.”

In the hospital of the future, the discharge process will be driven by specific structured guidelines that ensure patients safety when they leave the hospital. Every discharge will involve a multidisciplinary team, with members signing off that the patient is not only ready to leave the hospital, but informed about their condition and any next steps, and has necessary medications or prescriptions in hand.

As for improving efficiency, minor changes can make a big difference. Chad Whelan, MD, assistant professor of medicine, University of Chicago Hospitals, is part of a task force working on how to move hospital discharges earlier in the day.

“An earlier discharge is better for everyone, including the patient—especially if they’re being transferred to another facility,” he points out. “One thing we’re looking at is the way diagnostic tests are categorized. Everything falls into two categories now: emergency diagnostics and everything else.”

Dr. Whelan and the taskforce have asked departments, including radiology and other labs, to create a third category: for patients waiting for a test before they can be discharged. All it takes is one question on the part of the service provider: “Is this patient waiting for these results before she can go home?” to move that patient to the front of the line.

Another recommendation Dr. Whelan’s task force will make involves staffing up. “Like we ramp nursing staff up and down depending on the census, we are looking at doing that with case managers and ward clerks to handle heavy discharge times,” he says.

David J. Rosenman, MD, senior associate consultant, Hospital Internal Medicine, Mayo Clinic in Rochester, Minn., suggests that paperwork might also be changed. “The discharge summary of the future will be more visual,” he predicts. “There are ways of displaying information that are more sophisticated and probably more helpful than static lists and linear prose alone.”

EMPOWERED PATIENTS

One change we are likely to see is patients taking on the responsibility of their own medical information. Ideally, the patients themselves will make caring for—and discharging—them easier and more efficient by sharing complete information on their current medications and other healthcare details that are often forgotten or overlooked by a provider or caregiver.

“The future of discharge lies with our ability to arm patients with their own information,” says Dr. Arora. “The more empowered the patient is, the better the outcome.” Personal health records (PHRs) are one solution. MyPHR is one online product, offered free by the American Health Information Management Association (AHIMA). Roughly 30 companies currently offer paid subscription PHR services to consumers. Peoplechart Corporation (San Francisco) is one of them and provides a single source of information controlled by the patient.

“We’re a pioneer of the PHR idea,” says Megan Mok, president and founder, Peoplechart Corporation. “There are not that many out there.”

Healthcare consumers can subscribe to a variety of Peoplechart tools and services (including initial collection of their records) that allow them to gain access to their comprehensive medical records via the Internet—or phone, if they choose—and to grant any given healthcare provider access to part or all of their records.

“Everything is patient-initiated and patient-controlled,” explains Mok. “There’s a big difference from systems controlled by providers, which may allow patients access, but not ownership.”

PHRs typically offer a comprehensive, integrated overview of an individual’s health data, including information that individuals add themselves on their symptoms and prescriptions, along with information such as diagnoses and lab results. Once a discharged patient updates her PHR, she can share her complete hospital records with her primary care physician, physical therapist, rehab facility, or whatever caregiver requires the information. This will save time and effort for all healthcare providers, and, more importantly, ensures that essential information is available.

Regardless of whether a patient has a PHR, physicians and other staff must ensure that the individual leaves the hospital with complete information on their care and medications.

“Discharge is a quality measure,” says Dr. Arora. “We need a multidisciplinary approach to address what each patient needs to go home.”

DEMYSTIFIED MEDICATIONS

In the very near future, the 2006 JCAHO standard for medication reconciliation will eliminate many problems with medications after discharge.

“This standard is extremely important,” says Dr. Rosenman. “Almost half of medication errors occur at transition points in a patient’s care. Reconciling medication lists—especially at these points—is critical to ensuring patient safety.”

The medication reconciliation form could conceivably morph into something broader in the future. “It would be nice for the medical record to be a living document that evolved with each encounter over the course of a patient’s life,” says Dr. Rosenman. “People may someday carry replaceable, updatable, credit-card-like medical cards or chips. In the meantime, we need to do our very best to keep medication lists and related data accurate and complete.”

While the patient will own his or her medical information, “the burden for ensuring the med list is accurate falls entirely on the healthcare organization,” insists Dr. Halasyamani. “This is a ripe opportunity to partner with the patients themselves. They and their families own the information. We have to help patients be stakeholders and give them the tools to manage their ever-changing medications and their healthcare.”

Many paper-based and computerized tools exist now, but there is no obvious standout product or method physicians can provide to patients that will ensure they take their prescriptions correctly on an ongoing basis.

“Health systems will have to develop a standard” for helping patients manage their medications, says Dr. Halasyamani. “Strategies must be low-tech but get the job done. They must resonate with things that patients already do, like paying bills.”

COMMUNICATION STILL CRITICAL

One step in the discharge process that ensures a smooth transition for inpatient to outpatient is communication with the professionals, facilities, or caregivers who will take over the patient’s care.

“The gap in care after discharge puts patients at risk for adverse events,” warns Dr. Arora. “One reason for this vulnerable gap is the flow of information between settings and teams of providers.” In the future, hospitals will better manage this essential transfer of information.

Typically, the patient’s primary care physician wants information from the hospital at admission and at discharge, and, if the primary care physician wishes, in between.

“We need to improve communications with primary care physicians in a way that respects their wishes for communication,” says Dr. Arora. The UCSF Hospitalist Group is already working on this.

“Until recently, we provided fax copies of our notes to primary care physicians. Now we have a new dictation system,” says Steven Pantilat, MD, FACP, SHM president. “We did a survey that found that most physicians want telephone contact at admission and at discharge, plus any major occurrences in between. The ability to exchange information in real time is important—and e-mail is not realtime.”

How does a hospitalist keep track of everyone’s communication preferences? “The hospitalist simply has to figure out what each primary care physician wants,” stresses Dr. Pantilat. “My sense is that in any hospital, there is a limited number of doctors or practices to deal with. How do you keep them all straight? Well, the same way a hospitalist keeps all the various nurses straight—you just do. It’s your business.”

PLANNED FOLLOW-UP

In the future, nearly every discharged patient will be contacted within two or three days by the hospitalist or another hospital medical staff. This may come in the form of a phone call to the patient to check on their overall health, symptoms, and medications. Or it may be a more hands-on approach.

The UCSF Medical Center has established a follow-up service to provide care to patients during the transition period immediately following discharge.

“This service was designed for patients who couldn’t otherwise be followed up on or those who would benefit from seeing the doctor who treated them in the hospital,” explains Dr. Pantilat, who initiated the idea for the service. “For example, if a patient with DVT was discharged, is the swelling smaller? The primary care physician can’t say—he didn’t see it.”

Out of more than 2,600 discharges during 1997-1998, the first year that the follow-up service existed, only 47 patients were prescribed with follow-up visits. “It was never meant to be a highly utilized service,” says Dr. Pantilat, “but to be a highly expandable, flexible service that addresses the needs of specific patients.” Of those 47 patients, four were readmitted to the hospital—one directly from the follow-up visit—compared with a national readmission average of 14%.

“We see these patients in the ED,” says Dr. Pantilat. “It’s the only department that’s open 24/7, and the ED has some extra bed capacity.”

When the hospitalist feels a follow-up is necessary, he or she schedules a visit with the patient before discharge for midmorning one or two days after discharge. (Midmorning is typically a slow time in the emergency department.) He then faxes the appointment information to the emergency department, so that when the patient shows up, she is preregistered. The emergency department telephones the hospitalist when the patient arrives, and that doctor then comes down to see the patient. The emergency department physicians have nothing to do with these follow-ups, though the nursing staff might be asked to help. Also, follow-up visits are considered an outpatient service and charged as such. “The follow-up service was established and run at virtually no cost,” says Dr. Pantilat.

Even if every hospital doesn’t arrange in-person follow-ups, there will be some form of contact after discharge. “Hospitals providing care in transition will expand a lot,” he explains, “whether it’s phone calls from a nurse or other healthcare professional or some other contact during that gap until a patient can re-establish with their primary care physician. Not every patient needs this, but a lot would benefit.”

THE HOSPITALIST ROLE IN DISCHARGE

As we move toward creating a better discharge process, hospitalists will be at the center of that change and the process itself.

“The hospitalist is the keeper of information,” says Dr. Arora. “They know why certain care decisions were made. This movement depends on the flow of information to help design systems to help implement communication.”

There are some barriers to a smooth discharge process that only hospitalists can eliminate. “The increased use of hospitalists means that patients are not familiar with their doctor” in the hospital, says Dr. Arora. “When they leave the hospital, some information stays behind. They don’t know who to call for that follow-up lab work prescribed in the hospital. … The hospitalist needs to do a better job of telling patients who they are and how to reach them after discharge. A systems-based solution, or solutions, is needed.”

It is up to hospitalists to ensure that their discharge system works, that each patient leaves with an understanding of next steps in their care and knows who to call for which specific follow-up step, and with contact information if they (or their primary care physician) need to reach their hospitalist.

Dr. Halasyamani believes that hospitalists are well positioned to implement change in general within their systems. “The hospitalist is in the trenches, in a position to see what changes have to take place,” she says. “It’s their role to inform their management of better processes.

Each of us needs to be a waver of the banner for new standards—it’s not good enough to just scribble prescriptions”

CONCLUSION

The future is coming fast, for improved hospital discharge as well as other everyday processes. “We’re learning that discharge should be a more structured, formal process,” says Dr. Whelan. “We’d like to move to a safer, more complete and more efficient way of handling it.”

Consider what your own facility is doing regarding discharging patients. If there is room for improvement, can you envision a way to bring that process into the future? TH

Jane Jerrard will continue writing the “Hospital of the Future” series this fall.

Flashback:

Colonial Hospitalists

250 years of admissions and discharge

The hospital-based physician must deal with many arcane and Byzantine criteria for admission, care, and discharge of patients. There are regulations for record-keeping and concerns about length of stay. Becoming a staff member may involve physician credentialing, and practitioners from other states or countries have to meet more rigorous standards.

This previous paragraph was not written about modern-day America. These issues are lifted from the “Rules and Regulations of the Pennsylvania Hospital” approved by the Board of Managers in 1752.1 The Pennsylvania Hospital was founded that year under the guidance of Benjamin Franklin. The facility was dedicated to care for the sick and poor. Among the biggest obstacles to its creation was fundraising. Franklin’s accounts of the early years of this institution included a final page with a useful form for donating money.

Hospitalists today face many of the same issues, including admission and discharge criteria, concerns about funding, and practice regulation, as their peers in 1752.

ADMISSION AND DISCHARGE CRITERIA

In 1752 there were 15 rules for admission and discharge of patients, as well as regulations for patients’ behavior while hospitalized. Among the most interesting:

1. No patients can be admitted if deemed incurable, lunaticks [sic] excepted, nor any case not requiring special services of a hospital.
2. No admits for smallpox, itch, or other infectious distempers unless proper apartments [isolation] available. Admits found to have the above will be discharged.
3. No admits of women with small children. Hospital will not maintain childcare facilities.
4. Persons admitted as above must provide funds for their own burial in case of their own demise.
5. 5. One bed to be held for a trauma case.
6. Patients will be discharged when cured or judged incurable
7. All cured patients must sign a release stating their cure and the benefit received from the hospital for use by the hospital managers.
8. No patient may leave the facility without a physician release. They may not swear or curse, get drunk, behave rudely or indecently, on pain of expulsion at first admonition.
9. No patient may gamble or beg.
10. Patients will aide in nursing other patients when able. This will include washing and ironing the linen and cleaning the rooms.

The Hospital Management Board was responsible for choosing a staff of six practitioners to manage these patients. There were guidelines for who could fill this job.

RULES FOR CHOICE OF PHYSICIANS AND SURGEONS

There were the rules in place in 1752 for choosing physicians and surgeons who could work in the hospital; the most interesting was that applying practitioners must be 27 years old, have served an apprenticeship in Philadelphia, have studied “physick” or surgery for seven years or more, and have undergone an exam by six hospital practitioners. Visiting practitioners had to reside in the city for three years before applying and then had to qualify under the same criteria.

LENGTH OF STAY

There was a significant interest in abstracting the admit diagnosis, length of stay, and outcome. The disposition of patients admitted during the first two years of the hospital’s existence, ending in April 1754 was presented in a modern format.

There were 117 admissions, with 60 cures. Eleven patients were relieved, though not cured. Seven were deemed incurable, 10 were taken away by friends, and 10 died. Three were discharged for irregular behavior, and 16 remained hospitalized.

The most common admission diagnosis was ulcers, representing almost a third of all admits, followed by lunacy. Other frequent diagnoses were dropsy (congestive heart disease), scrophulous and scorbutic diseases (extrapulmonary tuberculosis and scurvy) and rheumatism.

The highest mortality was for consumption, at 100%. The two patients admitted with flux (diarrhea) and prolapsus ani also died. Dropsy carried a 33% mortality rate, without the benefit of the latest medical innovation, foxglove (digitalis), which would be described a few decades later.2 Also notable is death from scurvy, the cure for which was described in 1753 by James Lind.3

The managers were pleased with the performance of the facility. They believed that their efforts had resulted in “good” for the 60 persons afflicted with “various distempers” who were cured and that many had received considerable relief. This was accomplished despite the limited amount of funds available, thanks to careful attendance afforded to the sick and poor, as well as proper diet and availability of medicines. Based on these favorable reports, the Board of Managers requested further funding.

Two hundred and fifty years later, physicians face many of the same issues, including admission and discharge criteria, concerns about funding, and practice regulation. Their actions continue to be monitored, and it is likely that the same will be true in the future. Hospital administrators remain frugal, and we are admonished, in the words of Benjamin Franklin, writing in Poor Richard’s Almanac, “A penny saved is a penny earned.”

—Jamie Newman, MD, FACP

REFERENCES

1. Franklin B. Some Account of the Pennsylvania Hospital 1754. (Facsimile Edition.) Baltimore: The Johns Hopkins Press; 1954.
2. Withering W. An Account of the Foxglove and Some of Its Medical Uses. Birmingham, England: M. Swinney; 1785.
3. Lind J. A Treatise of the Scurvy. Edinburgh, Scotland: Sands, Murray and Cochran; 1753.

SHM has established an aggressive goal of getting 400 respondents for its biannual Productivity and Compensation Survey. This would mean a 33% increase over the 300 respondents to the 2003 survey. SHM is tracking the number of respondents on its Web site homepage (www.hospitalmedicine.org). All surveys must be completed and returned by Nov. 25.

By now hospital medicine group leaders should have received a copy of the survey with instructions. SHM prefers that you complete the survey online. The response process for the online survey is simplified with built-in edits and a streamlined flow. In addition, you can stop in the middle of the questionnaire and return to complete it later.

WHY SHOULD YOU PARTICIPATE?

• Information: The survey questions represent the metrics most critical in benchmarking your hospital medicine program. You’ll be able to compare the characteristics and performance of your group with other hospital medicine programs across the country.
• Financial Incentive: There is a financial incentive to participate. Only survey respondents will receive the full survey report and analysis on a CD at no additional charge. Nonrespondents will pay as much as $495 for the results. The results will be available at the SHM Annual Meeting in Washington D.C., May 3-5, 2006.
• Potential Awards: Participants will be eligible to participate in a drawing to receive complimentary registrations to an upcoming Leadership Academy (valued at $1,500) or to the 2006 SHM Annual Meeting (valued at $525). If your group submits its completed questionnaires by Oct. 25 it will have two entries in the drawing. After that date, you’ll receive only one entry.
• Confidentiality: Survey responses will be completely confidential and data will be reported only in the aggregate. International Communications Research, an experienced survey research firm, is conducting the survey. SHM is not involved in collecting or processing the data.

SURVEY CONTENT

This year’s survey builds on the success of the 2003 survey, which is viewed by SHM members as the most accurate and useful source of hospitalist benchmark information. The 2005 survey features the following improvements: better definitions and instructions, and additional questions covering such topics as night coverage, hospitalist services, and the use of nurse practitioners and physician assistants.

The group questionnaire poses questions intended to characterize your hospital medicine program at the group and hospital level. To answer these questions you will need specific information about your hospital (e.g., number of beds, teaching status), the number of fulltime employees (including nonclinical staff), staff turnover, additional revenue received from the hospital or other sources, and the program’s average length-of-stay and case-mix index.

The individual questionnaire poses questions at individual hospitalist level. To answer these you will need information about demographics (age, gender, fulltime employees, specialty, years as a hospitalist, years with group), billing information (encounters, relative value units, charges, collections), hours and shifts worked, and compensation/ benefits for each hospitalist in the group.

CALL TO ACTION

If your hospital medicine group has not received a survey and you would like to participate, e-mail the following information to Marie Francois at mfrancois@hospitalmedicine.org: the name of your group, leader’s name, mailing address, e-mail, and telephone number. If you are completing the survey and you need clarification about any of the questions, contact SHM Customer Service at CustomerService@hospitalmedicine.org or call (800) 843-3360.

As hospital medicine continues to grow and emerge, SHM seeks to provide vital data characterizing the specialty to hospitalists, hospital and healthcare leaders, and policymakers. The 2005 Productivity and Compensation Survey is the key vehicle for providing that data. Help us achieve our goal of 400 hospital medicine group respondents.

Joe Miller is senior vice president for SHM.

NPs and PAs Help Shape SHM Initiatives

By Kevin Whitford, MD

The Nonphysician-Provider Task Force met at SHM’s Annual Meeting in Chicago in April. The meeting marked a significant transition as Mitchell Wilson, MD, concluded his term as chair of the committee. Dr. Wilson’s excellent leadership and organization greatly benefited the task force during its inaugural year. The task force is fortunate to have Dr. Wilson remain as a member.

During the April meeting, the group reviewed the SHM charge to the task force: the responsibility to develop initiatives and programs to promote and define the role of nurse practitioners, physician assistants, and other hospitalist nonphysician providers in hospital medicine. The task force must recommend an SHM nonphysicianprovider agenda to the SHM Board. The task force is looking for opportunities to encourage nonphysician providers to become active SHM members.

The group prepared a document, “Top Five Roles/Functions for Nonphysician Providers” to present to the SHM Board as a framework for the future.

At the annual meeting the task force pursued strategic planning for 2005 and 2006. The Web-based “Resource Center” development was at the top of the list. The task force has collected job descriptions that include acute care nurse practitioner, hospitalist physician assistant, clinical care coordinator, clinical nurse manager, hospitalist case manager, hospitalist program manager, and medical director.

Competency forms are also posted on the SHM Web site; the forms may be used as models to evaluate hospitalist clinical coordinator, hospitalist physician assistant, hospitalist program manager, and advanced nurse practitioner in hospital medicine. The task force plans to expand this resource area to include staffing models, billing and documentation, frequently asked questions, and a document on the value added by nonphysician providers.

The Nonphysician-Provider Task Force also has a “Hub and Spoke” initiative to broaden the input for nonphysician providers by linking members to the task force with hospitalist nonphysician providers across a broad representation of practices.

Other covered areas include plans for publishing articles in The Hospitalist, membership initiatives, and promoting the development of external relationships with national organizations such as the American Academy of Physician Assistants and American Association of Nurse Practitioners.

Task force members helped lead the forum on nonphysician providers at the SHM Annual Meeting. Participants’ questions ranged from specifics regarding the roles of nonphysician providers to filling in documentation issues and included a broad spectrum of practice types from small private to large academic medical centers. The Nonphysician-Provider Task Force is making plans for the program for the 2006 Annual Meeting.

We’ve also sought involvement across the spectrum of task forces and committees in the SHM to increase the representation and raise the awareness of nonphysician providers.

The SHM Board approved the list of top five roles for nonphysician providers in SHM. These include:

1. To foster hospital medicine nonphysician-provider educational and professional development;
2. To network with other nonphysician providers to share ideas concerning the integration of nonphysician providers in hospital medicine;
3. To provide input to SHM and SHM committees/task forces related to the role of the nonphysician provider on the hospital medicine team;
4. To serve as “ambassadors” for SHM recruitment of nonphysician-provider members; and
5. To share varied expertise in the educational offerings pertinent to nonphysician providers on the hospitalist team.

In the coming year, the task force will further refine this list and present a revised charge to the SHM Board. The original charge specifically mentions only nurse practitioners and physician assistants. We’ve been fortunate to have a clinical care coordinator and a health systems pharmacist join the task force. This broader perspective will benefit the task force and recognizes the broad range of professionals working with the hospitalist team.

If you’re interested in the issues being addressed by the Nonphysician-Provider Task Force, you have several avenues available to pursue those interests. The SHM listserv is an active forum for discussing issues and sharing solutions. If you’re interested in working with the Nonphysician Task Force directly, contact Jeanette Kalupa at kalupa.jeanette@cogenthealthcare.com or Scarlett Blue at sblue@firsthealth.org to be added to the Hub and Spoke initiative. You can also visit the resource center on the SHM Web site to view the nonphysician-provider resources, or you can submit documents for the task force to review for posting to the resource area.

Dr. Whitford is chair of SHM’s Nonphysician-Provider Task Force. Contact him at whitford.kevin@mayo.edu.

10 Tips for a Successful Compensation Negotiation

Here are some strategies that Linda Snelling, MD, presented at the Pediatric Hospital Medicine conference in Denver in July regarding how to best negotiate your compensation. These strategies apply to all hospitalists.

1. Start with value: describe what you’re doing, who benefits from your work.
2. Review your own billing and collections.
3. Evaluate your program costs.
4. Apply for grants (finding money allows your program to grow).
5. Determine synergy: Are you fulfilling your role in the institution/department? Are there other opportunities to explore?
6. Start from a position of strength. Determining how much the opponent is willing to pay or increase support based on your current success and the anticipated benefit from your continued efforts is the starting point from which you have to negotiate up. A better position is to determine the amount by which you want your support adjusted so you are at the starting point from which the opponent negotiates down.
7. Remember, you’re not going in there for a handout. You’re going in there with a promise of what you’ll deliver.
8. Think long term.
9. Leave room to negotiate. Never put all your cards on the table. You’ll have to make concessions; get something for that concession. “If you can’t do 8%, what can you do? 5%. OK, so what about 5% this year and 5% next year?”
10. Remain positive.

SHM’s Advocacy Efforts

Pay-for-performance legislation gains momentum on Capitol Hill

By Eric Siegal, MD

Washington policymakers are embracing a new approach to reforming the Medicare payment system: giving physicians and other providers financial incentives to meet certain quality standards. The so-called “pay-for-performance” or “value-based purchasing” model contained in various bills moving through Congress builds on recommendations made earlier this year by the Medicare Payment Advisory Commission (MedPAC) and mirrors initiatives that have proliferated in the private sector. In its March 2005 report to Congress, MedPAC officially recommended that Congress establish a pay-for-performance system for Medicare providers.

The Center for Medicare and Medicaid Services (CMS) is also developing and implementing a set of pay-for-performance initiatives to support quality improvement in the care of Medicare beneficiaries. CMS Administrator Mark McClellan, MD, an internist, has been a big proponent of this effort.

The basic thrust of pay-for-performance is to use Medicare’s purchasing power to reward and promote quality. This effort is also tied to legislation to accelerate the development of electronic medical records and to expand the use of information technology in the healthcare delivery system. The Public Policy Committee is examining the pay-for-performance bills introduced in Congress and their implications for hospital medicine.

SENATE LEGISLATION

In late June, Senate Finance Committee Chair Charles Grassley (R-IA) and Ranking Member Max Baucus (D-MT) introduced the Medicare Value Purchasing Act of 2005, S. 1356. This legislation would apply to physicians, acute care hospitals, Medicare Advantage plans, end-stage renal disease providers, home health agencies, and (to some extent) skilled nursing facilities.

In the first phase of implementation, Medicare reimbursement rates would be tied directly to reporting data on quality measures, while the second phase ties a portion of payment to provider performance. The Senate bill doesn’t makes changes to the sustainable growth rate formula that determines Medicare payments to physicians. That will likely be handled in separate legislation.

S. 1356 directs the Secretary of Health and Human Services to select quality measures through a multistakeholder, consensus-building process. Those quality measures already developed and accepted by the healthcare community would be taken into account. Under the legislation, the Secretary has the ability to vary measures used within types of providers. For example, the Secretary could differentiate hospital measures by the hospital’s size and scope of services. Or, the Secretary could vary physician measures based on physician specialty, type of practitioner, or the volume of services delivered. The legislation also specifies criteria for the selection of quality measures. For example, the measures should be evidence-based, reliable, and valid; relevant to rural areas; and relevant to the frail elderly and those with chronic conditions. They should include measures of over- and under use and measures of health information technology infrastructure.

HOUSE ACTION

House Ways and Means Health Subcommittee Chair Nancy Johnson (R-CT) was expected to introduce legislation before the August Congressional recess that would add pay-for-performance programs for physicians under Medicare and repeal the sustainable growth rate formula.

On July 12, Ways and Means Committee Chairman William M. Thomas (R-CA) and Johnson asked McClellan to make regulatory changes that could avert a 4.3% cut in the Medicare physician update in 2006. In particular, the lawmakers said that CMS should remove prescription drug expenditures from the sustainable growth rate, which are used to calculate yearly changes in reimbursements. Legislation to permanently fix the sustainable growth rate “would be prohibitively expensive given current interpretations of the formula,” they said.

In testimony before the Ways and Means Committee July 21, McClellan said eliminating the sustainable growth rate system in favor of an update that is similar to the current Medicare Economic Index, which measures the weighted average price change for various inputs involved with producing physicians’ services, would cost $183 billion over 10 years. CMS is currently reviewing the legal arguments regarding whether it can remove prescription drugs from the services included in the sustainable growth rate under existing authorities, he told the subcommittee.

The notion of linking a portion of Medicare payments to valid measures of quality, or paying for performance, is clearly here to stay. The concept has broad support from the Administration, Congress, CMS, and several specialty societies, even though many questions about its implementation must still be answered. The Public Policy Committee will work to position SHM to influence this important debate.

In the first phase of the Medicare Value Purchasing Act of 2005 implementation, Medicare reimbursement rates would be tied directly to reporting data on quality measures, while the second phase ties a portion of payment to provider performance.

SHM Partners with Patient Safety Leadership Fellowship Program

Focus on interdisciplinary leadership and patient safety proves invaluable

By Jeanne M. Huddleston, MD, FACP

SHM is now a partner in the Patient Safety Leadership Fellowship (PSLF) program, an intensive learning experience that develops leadership competencies and advances patient safety in healthcare through a dynamic, highly participatory, structured learning community.

The Health Forum-American Hospital Association and the National Patient Safety Foundation created the fellowship and now has several program partners. SHM has joined the list as a program partner in this PSLF with the Health Research and Education Trust (HRET), the American Organization of Nurse Executives (AONE), and the American Society for Healthcare Risk Management (ASHRM).

The ultimate objective of the PSLF is to provide multidisciplinary teams and individual providers with the opportunity to develop the leadership competencies necessary to make meaningful changes in healthcare safety. Through a combination of expert leadership and patient safety faculty, a specially designed curriculum, and field-based projects, PSLF Health Forum Fellowships offer an intensive educational opportunity.

Each fellowship experience is highly participatory and interdisciplinary. Participants from past fellowship classes include physicians, pharmacists, nurses, lawyers, risk managers, educators, administrators, and patients. This environment encourages the creation of new knowledge to advance the patient safety science and enhances interpersonal and professional effectiveness. Each fellowship is a yearlong journey that blends face-to-face leadership retreats, self-study educational curriculum, online computer conferencing, and site visits.

The heart of the fellowship program is an Action Learning Project (ALP) that fellows design and implement in their own organization/community/region. This allows for direct application of each participant’s knowledge and experience gained through the other curricular venues to be immediately applied with the added benefit of being able to draw on the experience of the fellowship faculty and staff to advance the participant’s progress. Fellows are required to provide a midyear and final report to their respective executives and/or boards, in addition to their learning community of fellows during the face-to-face leadership retreats. Examples of ALPs can be found at www.healthforumfellowships.com/healthforumfellowships/html/project.htm.

Through the course of the one-year learning experience, fellows are exposed to the following curricular components:

1. Knowledge of what creates safe healthcare systems;
2. Leadership, collaboration, and complexity;
3. The path to a culture of safety;
4. Lessons from inside and outside healthcare;
5. Disclosure, reporting, and transparency; and
6. The business case for creating a culture of safety.

Given the alignment of interests in quality, patient safety, and leadership between this fellowship and the developing core curriculum in hospital medicine, SHM became a program partner in mid2004. During 2005, SHM will become more involved by serving on the Fellowship’s Advisory and Curriculum Committees to help with oversight of the program concept and curricular development. In addition, SHM will provide one day of educational content drawing from the vast experience of hospitalists in the fields of leadership and patient safety.

I participated in the 2002-2003 PSLF inaugural class. The interdisciplinary nature of the education experience was rewarding and, I believe, was one of the core reasons the curricula benefited my effectiveness specifically in participating in quality and patient safety initiatives. My fellow alumni continue to serve as a community of quality and patient safety champions and assist each other by being a sounding board and advisory group to ongoing local activities. TH

Dr. Huddleston can be contacted via e-mail at huddleston.jeanne@mayo.edu.

SHM has established an aggressive goal of getting 400 respondents for its biannual Productivity and Compensation Survey. This would mean a 33% increase over the 300 respondents to the 2003 survey. SHM is tracking the number of respondents on its Web site homepage (www.hospitalmedicine.org). All surveys must be completed and returned by Nov. 25.

By now hospital medicine group leaders should have received a copy of the survey with instructions. SHM prefers that you complete the survey online. The response process for the online survey is simplified with built-in edits and a streamlined flow. In addition, you can stop in the middle of the questionnaire and return to complete it later.

WHY SHOULD YOU PARTICIPATE?

• Information: The survey questions represent the metrics most critical in benchmarking your hospital medicine program. You’ll be able to compare the characteristics and performance of your group with other hospital medicine programs across the country.
• Financial Incentive: There is a financial incentive to participate. Only survey respondents will receive the full survey report and analysis on a CD at no additional charge. Nonrespondents will pay as much as $495 for the results. The results will be available at the SHM Annual Meeting in Washington D.C., May 3-5, 2006.
• Potential Awards: Participants will be eligible to participate in a drawing to receive complimentary registrations to an upcoming Leadership Academy (valued at $1,500) or to the 2006 SHM Annual Meeting (valued at $525). If your group submits its completed questionnaires by Oct. 25 it will have two entries in the drawing. After that date, you’ll receive only one entry.
• Confidentiality: Survey responses will be completely confidential and data will be reported only in the aggregate. International Communications Research, an experienced survey research firm, is conducting the survey. SHM is not involved in collecting or processing the data.

SURVEY CONTENT

This year’s survey builds on the success of the 2003 survey, which is viewed by SHM members as the most accurate and useful source of hospitalist benchmark information. The 2005 survey features the following improvements: better definitions and instructions, and additional questions covering such topics as night coverage, hospitalist services, and the use of nurse practitioners and physician assistants.

The group questionnaire poses questions intended to characterize your hospital medicine program at the group and hospital level. To answer these questions you will need specific information about your hospital (e.g., number of beds, teaching status), the number of fulltime employees (including nonclinical staff), staff turnover, additional revenue received from the hospital or other sources, and the program’s average length-of-stay and case-mix index.

The individual questionnaire poses questions at individual hospitalist level. To answer these you will need information about demographics (age, gender, fulltime employees, specialty, years as a hospitalist, years with group), billing information (encounters, relative value units, charges, collections), hours and shifts worked, and compensation/ benefits for each hospitalist in the group.

CALL TO ACTION

If your hospital medicine group has not received a survey and you would like to participate, e-mail the following information to Marie Francois at mfrancois@hospitalmedicine.org: the name of your group, leader’s name, mailing address, e-mail, and telephone number. If you are completing the survey and you need clarification about any of the questions, contact SHM Customer Service at CustomerService@hospitalmedicine.org or call (800) 843-3360.

As hospital medicine continues to grow and emerge, SHM seeks to provide vital data characterizing the specialty to hospitalists, hospital and healthcare leaders, and policymakers. The 2005 Productivity and Compensation Survey is the key vehicle for providing that data. Help us achieve our goal of 400 hospital medicine group respondents.

Joe Miller is senior vice president for SHM.

NPs and PAs Help Shape SHM Initiatives

By Kevin Whitford, MD

The Nonphysician-Provider Task Force met at SHM’s Annual Meeting in Chicago in April. The meeting marked a significant transition as Mitchell Wilson, MD, concluded his term as chair of the committee. Dr. Wilson’s excellent leadership and organization greatly benefited the task force during its inaugural year. The task force is fortunate to have Dr. Wilson remain as a member.

During the April meeting, the group reviewed the SHM charge to the task force: the responsibility to develop initiatives and programs to promote and define the role of nurse practitioners, physician assistants, and other hospitalist nonphysician providers in hospital medicine. The task force must recommend an SHM nonphysicianprovider agenda to the SHM Board. The task force is looking for opportunities to encourage nonphysician providers to become active SHM members.

The group prepared a document, “Top Five Roles/Functions for Nonphysician Providers” to present to the SHM Board as a framework for the future.

At the annual meeting the task force pursued strategic planning for 2005 and 2006. The Web-based “Resource Center” development was at the top of the list. The task force has collected job descriptions that include acute care nurse practitioner, hospitalist physician assistant, clinical care coordinator, clinical nurse manager, hospitalist case manager, hospitalist program manager, and medical director.

Competency forms are also posted on the SHM Web site; the forms may be used as models to evaluate hospitalist clinical coordinator, hospitalist physician assistant, hospitalist program manager, and advanced nurse practitioner in hospital medicine. The task force plans to expand this resource area to include staffing models, billing and documentation, frequently asked questions, and a document on the value added by nonphysician providers.

The Nonphysician-Provider Task Force also has a “Hub and Spoke” initiative to broaden the input for nonphysician providers by linking members to the task force with hospitalist nonphysician providers across a broad representation of practices.

Other covered areas include plans for publishing articles in The Hospitalist, membership initiatives, and promoting the development of external relationships with national organizations such as the American Academy of Physician Assistants and American Association of Nurse Practitioners.

Task force members helped lead the forum on nonphysician providers at the SHM Annual Meeting. Participants’ questions ranged from specifics regarding the roles of nonphysician providers to filling in documentation issues and included a broad spectrum of practice types from small private to large academic medical centers. The Nonphysician-Provider Task Force is making plans for the program for the 2006 Annual Meeting.

We’ve also sought involvement across the spectrum of task forces and committees in the SHM to increase the representation and raise the awareness of nonphysician providers.

The SHM Board approved the list of top five roles for nonphysician providers in SHM. These include:

1. To foster hospital medicine nonphysician-provider educational and professional development;
2. To network with other nonphysician providers to share ideas concerning the integration of nonphysician providers in hospital medicine;
3. To provide input to SHM and SHM committees/task forces related to the role of the nonphysician provider on the hospital medicine team;
4. To serve as “ambassadors” for SHM recruitment of nonphysician-provider members; and
5. To share varied expertise in the educational offerings pertinent to nonphysician providers on the hospitalist team.

In the coming year, the task force will further refine this list and present a revised charge to the SHM Board. The original charge specifically mentions only nurse practitioners and physician assistants. We’ve been fortunate to have a clinical care coordinator and a health systems pharmacist join the task force. This broader perspective will benefit the task force and recognizes the broad range of professionals working with the hospitalist team.

If you’re interested in the issues being addressed by the Nonphysician-Provider Task Force, you have several avenues available to pursue those interests. The SHM listserv is an active forum for discussing issues and sharing solutions. If you’re interested in working with the Nonphysician Task Force directly, contact Jeanette Kalupa at kalupa.jeanette@cogenthealthcare.com or Scarlett Blue at sblue@firsthealth.org to be added to the Hub and Spoke initiative. You can also visit the resource center on the SHM Web site to view the nonphysician-provider resources, or you can submit documents for the task force to review for posting to the resource area.

Dr. Whitford is chair of SHM’s Nonphysician-Provider Task Force. Contact him at whitford.kevin@mayo.edu.

10 Tips for a Successful Compensation Negotiation

Here are some strategies that Linda Snelling, MD, presented at the Pediatric Hospital Medicine conference in Denver in July regarding how to best negotiate your compensation. These strategies apply to all hospitalists.

1. Start with value: describe what you’re doing, who benefits from your work.
2. Review your own billing and collections.
3. Evaluate your program costs.
4. Apply for grants (finding money allows your program to grow).
5. Determine synergy: Are you fulfilling your role in the institution/department? Are there other opportunities to explore?
6. Start from a position of strength. Determining how much the opponent is willing to pay or increase support based on your current success and the anticipated benefit from your continued efforts is the starting point from which you have to negotiate up. A better position is to determine the amount by which you want your support adjusted so you are at the starting point from which the opponent negotiates down.
7. Remember, you’re not going in there for a handout. You’re going in there with a promise of what you’ll deliver.
8. Think long term.
9. Leave room to negotiate. Never put all your cards on the table. You’ll have to make concessions; get something for that concession. “If you can’t do 8%, what can you do? 5%. OK, so what about 5% this year and 5% next year?”
10. Remain positive.

SHM’s Advocacy Efforts

Pay-for-performance legislation gains momentum on Capitol Hill

By Eric Siegal, MD

Washington policymakers are embracing a new approach to reforming the Medicare payment system: giving physicians and other providers financial incentives to meet certain quality standards. The so-called “pay-for-performance” or “value-based purchasing” model contained in various bills moving through Congress builds on recommendations made earlier this year by the Medicare Payment Advisory Commission (MedPAC) and mirrors initiatives that have proliferated in the private sector. In its March 2005 report to Congress, MedPAC officially recommended that Congress establish a pay-for-performance system for Medicare providers.

The Center for Medicare and Medicaid Services (CMS) is also developing and implementing a set of pay-for-performance initiatives to support quality improvement in the care of Medicare beneficiaries. CMS Administrator Mark McClellan, MD, an internist, has been a big proponent of this effort.

The basic thrust of pay-for-performance is to use Medicare’s purchasing power to reward and promote quality. This effort is also tied to legislation to accelerate the development of electronic medical records and to expand the use of information technology in the healthcare delivery system. The Public Policy Committee is examining the pay-for-performance bills introduced in Congress and their implications for hospital medicine.

SENATE LEGISLATION

In late June, Senate Finance Committee Chair Charles Grassley (R-IA) and Ranking Member Max Baucus (D-MT) introduced the Medicare Value Purchasing Act of 2005, S. 1356. This legislation would apply to physicians, acute care hospitals, Medicare Advantage plans, end-stage renal disease providers, home health agencies, and (to some extent) skilled nursing facilities.

In the first phase of implementation, Medicare reimbursement rates would be tied directly to reporting data on quality measures, while the second phase ties a portion of payment to provider performance. The Senate bill doesn’t makes changes to the sustainable growth rate formula that determines Medicare payments to physicians. That will likely be handled in separate legislation.

S. 1356 directs the Secretary of Health and Human Services to select quality measures through a multistakeholder, consensus-building process. Those quality measures already developed and accepted by the healthcare community would be taken into account. Under the legislation, the Secretary has the ability to vary measures used within types of providers. For example, the Secretary could differentiate hospital measures by the hospital’s size and scope of services. Or, the Secretary could vary physician measures based on physician specialty, type of practitioner, or the volume of services delivered. The legislation also specifies criteria for the selection of quality measures. For example, the measures should be evidence-based, reliable, and valid; relevant to rural areas; and relevant to the frail elderly and those with chronic conditions. They should include measures of over- and under use and measures of health information technology infrastructure.

HOUSE ACTION

House Ways and Means Health Subcommittee Chair Nancy Johnson (R-CT) was expected to introduce legislation before the August Congressional recess that would add pay-for-performance programs for physicians under Medicare and repeal the sustainable growth rate formula.

On July 12, Ways and Means Committee Chairman William M. Thomas (R-CA) and Johnson asked McClellan to make regulatory changes that could avert a 4.3% cut in the Medicare physician update in 2006. In particular, the lawmakers said that CMS should remove prescription drug expenditures from the sustainable growth rate, which are used to calculate yearly changes in reimbursements. Legislation to permanently fix the sustainable growth rate “would be prohibitively expensive given current interpretations of the formula,” they said.

In testimony before the Ways and Means Committee July 21, McClellan said eliminating the sustainable growth rate system in favor of an update that is similar to the current Medicare Economic Index, which measures the weighted average price change for various inputs involved with producing physicians’ services, would cost $183 billion over 10 years. CMS is currently reviewing the legal arguments regarding whether it can remove prescription drugs from the services included in the sustainable growth rate under existing authorities, he told the subcommittee.

The notion of linking a portion of Medicare payments to valid measures of quality, or paying for performance, is clearly here to stay. The concept has broad support from the Administration, Congress, CMS, and several specialty societies, even though many questions about its implementation must still be answered. The Public Policy Committee will work to position SHM to influence this important debate.

In the first phase of the Medicare Value Purchasing Act of 2005 implementation, Medicare reimbursement rates would be tied directly to reporting data on quality measures, while the second phase ties a portion of payment to provider performance.

SHM Partners with Patient Safety Leadership Fellowship Program

Focus on interdisciplinary leadership and patient safety proves invaluable

By Jeanne M. Huddleston, MD, FACP

SHM is now a partner in the Patient Safety Leadership Fellowship (PSLF) program, an intensive learning experience that develops leadership competencies and advances patient safety in healthcare through a dynamic, highly participatory, structured learning community.

The Health Forum-American Hospital Association and the National Patient Safety Foundation created the fellowship and now has several program partners. SHM has joined the list as a program partner in this PSLF with the Health Research and Education Trust (HRET), the American Organization of Nurse Executives (AONE), and the American Society for Healthcare Risk Management (ASHRM).

The ultimate objective of the PSLF is to provide multidisciplinary teams and individual providers with the opportunity to develop the leadership competencies necessary to make meaningful changes in healthcare safety. Through a combination of expert leadership and patient safety faculty, a specially designed curriculum, and field-based projects, PSLF Health Forum Fellowships offer an intensive educational opportunity.

Each fellowship experience is highly participatory and interdisciplinary. Participants from past fellowship classes include physicians, pharmacists, nurses, lawyers, risk managers, educators, administrators, and patients. This environment encourages the creation of new knowledge to advance the patient safety science and enhances interpersonal and professional effectiveness. Each fellowship is a yearlong journey that blends face-to-face leadership retreats, self-study educational curriculum, online computer conferencing, and site visits.

The heart of the fellowship program is an Action Learning Project (ALP) that fellows design and implement in their own organization/community/region. This allows for direct application of each participant’s knowledge and experience gained through the other curricular venues to be immediately applied with the added benefit of being able to draw on the experience of the fellowship faculty and staff to advance the participant’s progress. Fellows are required to provide a midyear and final report to their respective executives and/or boards, in addition to their learning community of fellows during the face-to-face leadership retreats. Examples of ALPs can be found at www.healthforumfellowships.com/healthforumfellowships/html/project.htm.

Through the course of the one-year learning experience, fellows are exposed to the following curricular components:

1. Knowledge of what creates safe healthcare systems;
2. Leadership, collaboration, and complexity;
3. The path to a culture of safety;
4. Lessons from inside and outside healthcare;
5. Disclosure, reporting, and transparency; and
6. The business case for creating a culture of safety.

Given the alignment of interests in quality, patient safety, and leadership between this fellowship and the developing core curriculum in hospital medicine, SHM became a program partner in mid2004. During 2005, SHM will become more involved by serving on the Fellowship’s Advisory and Curriculum Committees to help with oversight of the program concept and curricular development. In addition, SHM will provide one day of educational content drawing from the vast experience of hospitalists in the fields of leadership and patient safety.

I participated in the 2002-2003 PSLF inaugural class. The interdisciplinary nature of the education experience was rewarding and, I believe, was one of the core reasons the curricula benefited my effectiveness specifically in participating in quality and patient safety initiatives. My fellow alumni continue to serve as a community of quality and patient safety champions and assist each other by being a sounding board and advisory group to ongoing local activities. TH

Dr. Huddleston can be contacted via e-mail at huddleston.jeanne@mayo.edu.

SHM has established an aggressive goal of getting 400 respondents for its biannual Productivity and Compensation Survey. This would mean a 33% increase over the 300 respondents to the 2003 survey. SHM is tracking the number of respondents on its Web site homepage (www.hospitalmedicine.org). All surveys must be completed and returned by Nov. 25.

By now hospital medicine group leaders should have received a copy of the survey with instructions. SHM prefers that you complete the survey online. The response process for the online survey is simplified with built-in edits and a streamlined flow. In addition, you can stop in the middle of the questionnaire and return to complete it later.

WHY SHOULD YOU PARTICIPATE?

• Information: The survey questions represent the metrics most critical in benchmarking your hospital medicine program. You’ll be able to compare the characteristics and performance of your group with other hospital medicine programs across the country.
• Financial Incentive: There is a financial incentive to participate. Only survey respondents will receive the full survey report and analysis on a CD at no additional charge. Nonrespondents will pay as much as $495 for the results. The results will be available at the SHM Annual Meeting in Washington D.C., May 3-5, 2006.
• Potential Awards: Participants will be eligible to participate in a drawing to receive complimentary registrations to an upcoming Leadership Academy (valued at $1,500) or to the 2006 SHM Annual Meeting (valued at $525). If your group submits its completed questionnaires by Oct. 25 it will have two entries in the drawing. After that date, you’ll receive only one entry.
• Confidentiality: Survey responses will be completely confidential and data will be reported only in the aggregate. International Communications Research, an experienced survey research firm, is conducting the survey. SHM is not involved in collecting or processing the data.

SURVEY CONTENT

This year’s survey builds on the success of the 2003 survey, which is viewed by SHM members as the most accurate and useful source of hospitalist benchmark information. The 2005 survey features the following improvements: better definitions and instructions, and additional questions covering such topics as night coverage, hospitalist services, and the use of nurse practitioners and physician assistants.

The group questionnaire poses questions intended to characterize your hospital medicine program at the group and hospital level. To answer these questions you will need specific information about your hospital (e.g., number of beds, teaching status), the number of fulltime employees (including nonclinical staff), staff turnover, additional revenue received from the hospital or other sources, and the program’s average length-of-stay and case-mix index.

The individual questionnaire poses questions at individual hospitalist level. To answer these you will need information about demographics (age, gender, fulltime employees, specialty, years as a hospitalist, years with group), billing information (encounters, relative value units, charges, collections), hours and shifts worked, and compensation/ benefits for each hospitalist in the group.

CALL TO ACTION

If your hospital medicine group has not received a survey and you would like to participate, e-mail the following information to Marie Francois at mfrancois@hospitalmedicine.org: the name of your group, leader’s name, mailing address, e-mail, and telephone number. If you are completing the survey and you need clarification about any of the questions, contact SHM Customer Service at CustomerService@hospitalmedicine.org or call (800) 843-3360.

As hospital medicine continues to grow and emerge, SHM seeks to provide vital data characterizing the specialty to hospitalists, hospital and healthcare leaders, and policymakers. The 2005 Productivity and Compensation Survey is the key vehicle for providing that data. Help us achieve our goal of 400 hospital medicine group respondents.

Joe Miller is senior vice president for SHM.

NPs and PAs Help Shape SHM Initiatives

By Kevin Whitford, MD

The Nonphysician-Provider Task Force met at SHM’s Annual Meeting in Chicago in April. The meeting marked a significant transition as Mitchell Wilson, MD, concluded his term as chair of the committee. Dr. Wilson’s excellent leadership and organization greatly benefited the task force during its inaugural year. The task force is fortunate to have Dr. Wilson remain as a member.

During the April meeting, the group reviewed the SHM charge to the task force: the responsibility to develop initiatives and programs to promote and define the role of nurse practitioners, physician assistants, and other hospitalist nonphysician providers in hospital medicine. The task force must recommend an SHM nonphysicianprovider agenda to the SHM Board. The task force is looking for opportunities to encourage nonphysician providers to become active SHM members.

The group prepared a document, “Top Five Roles/Functions for Nonphysician Providers” to present to the SHM Board as a framework for the future.

At the annual meeting the task force pursued strategic planning for 2005 and 2006. The Web-based “Resource Center” development was at the top of the list. The task force has collected job descriptions that include acute care nurse practitioner, hospitalist physician assistant, clinical care coordinator, clinical nurse manager, hospitalist case manager, hospitalist program manager, and medical director.

Competency forms are also posted on the SHM Web site; the forms may be used as models to evaluate hospitalist clinical coordinator, hospitalist physician assistant, hospitalist program manager, and advanced nurse practitioner in hospital medicine. The task force plans to expand this resource area to include staffing models, billing and documentation, frequently asked questions, and a document on the value added by nonphysician providers.

The Nonphysician-Provider Task Force also has a “Hub and Spoke” initiative to broaden the input for nonphysician providers by linking members to the task force with hospitalist nonphysician providers across a broad representation of practices.

Other covered areas include plans for publishing articles in The Hospitalist, membership initiatives, and promoting the development of external relationships with national organizations such as the American Academy of Physician Assistants and American Association of Nurse Practitioners.

Task force members helped lead the forum on nonphysician providers at the SHM Annual Meeting. Participants’ questions ranged from specifics regarding the roles of nonphysician providers to filling in documentation issues and included a broad spectrum of practice types from small private to large academic medical centers. The Nonphysician-Provider Task Force is making plans for the program for the 2006 Annual Meeting.

We’ve also sought involvement across the spectrum of task forces and committees in the SHM to increase the representation and raise the awareness of nonphysician providers.

The SHM Board approved the list of top five roles for nonphysician providers in SHM. These include:

1. To foster hospital medicine nonphysician-provider educational and professional development;
2. To network with other nonphysician providers to share ideas concerning the integration of nonphysician providers in hospital medicine;
3. To provide input to SHM and SHM committees/task forces related to the role of the nonphysician provider on the hospital medicine team;
4. To serve as “ambassadors” for SHM recruitment of nonphysician-provider members; and
5. To share varied expertise in the educational offerings pertinent to nonphysician providers on the hospitalist team.

In the coming year, the task force will further refine this list and present a revised charge to the SHM Board. The original charge specifically mentions only nurse practitioners and physician assistants. We’ve been fortunate to have a clinical care coordinator and a health systems pharmacist join the task force. This broader perspective will benefit the task force and recognizes the broad range of professionals working with the hospitalist team.

If you’re interested in the issues being addressed by the Nonphysician-Provider Task Force, you have several avenues available to pursue those interests. The SHM listserv is an active forum for discussing issues and sharing solutions. If you’re interested in working with the Nonphysician Task Force directly, contact Jeanette Kalupa at kalupa.jeanette@cogenthealthcare.com or Scarlett Blue at sblue@firsthealth.org to be added to the Hub and Spoke initiative. You can also visit the resource center on the SHM Web site to view the nonphysician-provider resources, or you can submit documents for the task force to review for posting to the resource area.

Dr. Whitford is chair of SHM’s Nonphysician-Provider Task Force. Contact him at whitford.kevin@mayo.edu.

10 Tips for a Successful Compensation Negotiation

Here are some strategies that Linda Snelling, MD, presented at the Pediatric Hospital Medicine conference in Denver in July regarding how to best negotiate your compensation. These strategies apply to all hospitalists.

1. Start with value: describe what you’re doing, who benefits from your work.
2. Review your own billing and collections.
3. Evaluate your program costs.
4. Apply for grants (finding money allows your program to grow).
5. Determine synergy: Are you fulfilling your role in the institution/department? Are there other opportunities to explore?
6. Start from a position of strength. Determining how much the opponent is willing to pay or increase support based on your current success and the anticipated benefit from your continued efforts is the starting point from which you have to negotiate up. A better position is to determine the amount by which you want your support adjusted so you are at the starting point from which the opponent negotiates down.
7. Remember, you’re not going in there for a handout. You’re going in there with a promise of what you’ll deliver.
8. Think long term.
9. Leave room to negotiate. Never put all your cards on the table. You’ll have to make concessions; get something for that concession. “If you can’t do 8%, what can you do? 5%. OK, so what about 5% this year and 5% next year?”
10. Remain positive.

SHM’s Advocacy Efforts

Pay-for-performance legislation gains momentum on Capitol Hill

By Eric Siegal, MD

Washington policymakers are embracing a new approach to reforming the Medicare payment system: giving physicians and other providers financial incentives to meet certain quality standards. The so-called “pay-for-performance” or “value-based purchasing” model contained in various bills moving through Congress builds on recommendations made earlier this year by the Medicare Payment Advisory Commission (MedPAC) and mirrors initiatives that have proliferated in the private sector. In its March 2005 report to Congress, MedPAC officially recommended that Congress establish a pay-for-performance system for Medicare providers.

The Center for Medicare and Medicaid Services (CMS) is also developing and implementing a set of pay-for-performance initiatives to support quality improvement in the care of Medicare beneficiaries. CMS Administrator Mark McClellan, MD, an internist, has been a big proponent of this effort.

The basic thrust of pay-for-performance is to use Medicare’s purchasing power to reward and promote quality. This effort is also tied to legislation to accelerate the development of electronic medical records and to expand the use of information technology in the healthcare delivery system. The Public Policy Committee is examining the pay-for-performance bills introduced in Congress and their implications for hospital medicine.

SENATE LEGISLATION

In late June, Senate Finance Committee Chair Charles Grassley (R-IA) and Ranking Member Max Baucus (D-MT) introduced the Medicare Value Purchasing Act of 2005, S. 1356. This legislation would apply to physicians, acute care hospitals, Medicare Advantage plans, end-stage renal disease providers, home health agencies, and (to some extent) skilled nursing facilities.

In the first phase of implementation, Medicare reimbursement rates would be tied directly to reporting data on quality measures, while the second phase ties a portion of payment to provider performance. The Senate bill doesn’t makes changes to the sustainable growth rate formula that determines Medicare payments to physicians. That will likely be handled in separate legislation.

S. 1356 directs the Secretary of Health and Human Services to select quality measures through a multistakeholder, consensus-building process. Those quality measures already developed and accepted by the healthcare community would be taken into account. Under the legislation, the Secretary has the ability to vary measures used within types of providers. For example, the Secretary could differentiate hospital measures by the hospital’s size and scope of services. Or, the Secretary could vary physician measures based on physician specialty, type of practitioner, or the volume of services delivered. The legislation also specifies criteria for the selection of quality measures. For example, the measures should be evidence-based, reliable, and valid; relevant to rural areas; and relevant to the frail elderly and those with chronic conditions. They should include measures of over- and under use and measures of health information technology infrastructure.

HOUSE ACTION

House Ways and Means Health Subcommittee Chair Nancy Johnson (R-CT) was expected to introduce legislation before the August Congressional recess that would add pay-for-performance programs for physicians under Medicare and repeal the sustainable growth rate formula.

On July 12, Ways and Means Committee Chairman William M. Thomas (R-CA) and Johnson asked McClellan to make regulatory changes that could avert a 4.3% cut in the Medicare physician update in 2006. In particular, the lawmakers said that CMS should remove prescription drug expenditures from the sustainable growth rate, which are used to calculate yearly changes in reimbursements. Legislation to permanently fix the sustainable growth rate “would be prohibitively expensive given current interpretations of the formula,” they said.

In testimony before the Ways and Means Committee July 21, McClellan said eliminating the sustainable growth rate system in favor of an update that is similar to the current Medicare Economic Index, which measures the weighted average price change for various inputs involved with producing physicians’ services, would cost $183 billion over 10 years. CMS is currently reviewing the legal arguments regarding whether it can remove prescription drugs from the services included in the sustainable growth rate under existing authorities, he told the subcommittee.

The notion of linking a portion of Medicare payments to valid measures of quality, or paying for performance, is clearly here to stay. The concept has broad support from the Administration, Congress, CMS, and several specialty societies, even though many questions about its implementation must still be answered. The Public Policy Committee will work to position SHM to influence this important debate.

In the first phase of the Medicare Value Purchasing Act of 2005 implementation, Medicare reimbursement rates would be tied directly to reporting data on quality measures, while the second phase ties a portion of payment to provider performance.

SHM Partners with Patient Safety Leadership Fellowship Program

Focus on interdisciplinary leadership and patient safety proves invaluable

By Jeanne M. Huddleston, MD, FACP

SHM is now a partner in the Patient Safety Leadership Fellowship (PSLF) program, an intensive learning experience that develops leadership competencies and advances patient safety in healthcare through a dynamic, highly participatory, structured learning community.

The Health Forum-American Hospital Association and the National Patient Safety Foundation created the fellowship and now has several program partners. SHM has joined the list as a program partner in this PSLF with the Health Research and Education Trust (HRET), the American Organization of Nurse Executives (AONE), and the American Society for Healthcare Risk Management (ASHRM).

The ultimate objective of the PSLF is to provide multidisciplinary teams and individual providers with the opportunity to develop the leadership competencies necessary to make meaningful changes in healthcare safety. Through a combination of expert leadership and patient safety faculty, a specially designed curriculum, and field-based projects, PSLF Health Forum Fellowships offer an intensive educational opportunity.

Each fellowship experience is highly participatory and interdisciplinary. Participants from past fellowship classes include physicians, pharmacists, nurses, lawyers, risk managers, educators, administrators, and patients. This environment encourages the creation of new knowledge to advance the patient safety science and enhances interpersonal and professional effectiveness. Each fellowship is a yearlong journey that blends face-to-face leadership retreats, self-study educational curriculum, online computer conferencing, and site visits.

The heart of the fellowship program is an Action Learning Project (ALP) that fellows design and implement in their own organization/community/region. This allows for direct application of each participant’s knowledge and experience gained through the other curricular venues to be immediately applied with the added benefit of being able to draw on the experience of the fellowship faculty and staff to advance the participant’s progress. Fellows are required to provide a midyear and final report to their respective executives and/or boards, in addition to their learning community of fellows during the face-to-face leadership retreats. Examples of ALPs can be found at www.healthforumfellowships.com/healthforumfellowships/html/project.htm.

Through the course of the one-year learning experience, fellows are exposed to the following curricular components:

1. Knowledge of what creates safe healthcare systems;
2. Leadership, collaboration, and complexity;
3. The path to a culture of safety;
4. Lessons from inside and outside healthcare;
5. Disclosure, reporting, and transparency; and
6. The business case for creating a culture of safety.

Given the alignment of interests in quality, patient safety, and leadership between this fellowship and the developing core curriculum in hospital medicine, SHM became a program partner in mid2004. During 2005, SHM will become more involved by serving on the Fellowship’s Advisory and Curriculum Committees to help with oversight of the program concept and curricular development. In addition, SHM will provide one day of educational content drawing from the vast experience of hospitalists in the fields of leadership and patient safety.

I participated in the 2002-2003 PSLF inaugural class. The interdisciplinary nature of the education experience was rewarding and, I believe, was one of the core reasons the curricula benefited my effectiveness specifically in participating in quality and patient safety initiatives. My fellow alumni continue to serve as a community of quality and patient safety champions and assist each other by being a sounding board and advisory group to ongoing local activities. TH

Dr. Huddleston can be contacted via e-mail at huddleston.jeanne@mayo.edu.

An 84-year-old woman with history of coronary artery disease, hypertension, and hyperlipidemia presented with six months of anorexia, nausea, a five-pound weight loss, weakness, and nonbloody diarrhea. Over the past one to two weeks, she noticed decreased urine output despite her use of furosemide.

She was found to have a serum creatinine of 3.5 mg/dL on admission, increased from 1.5 mg/dL five days previously. She had no rash, dyspnea, cough, or abdominal pain. Urinalysis revealed >100 red blood cells (RBC), >100 white blood cells (WBC), occasional hyaline casts, and many gramnegative bacilli. Ciprofloxacin was started for her urinary tract infection. A renal biopsy was performed. The images shown are photomicrographs of light microscopy and immunofluorescence of the renal biopsy specimen. TH

Kidney biopsy: Immunofluorescence

Which of the following would be the most appropriate initial therapy for this condition?

1. Increase dose of furosemide;
2. Start fish oil;
3. Initiate Low-dose dopamine;
4. Discontinue ACE inhibitor; or
5. Begin emergent plasmapheresis.

Discussion

The correct answer is e: plasmapheresis. The renal biopsy, as shown in the image at left, reveals crescents involving glomeruli on light microscopy and linear IgG staining on immunofluorescence. This patient has antiglomerular basement membrane (anti-GBM) glomerulonephritis (GN), which accounts for 10% to 20% of crescentic glomerulonephritides. It is characterized by circulating antibodies to the glomerular basement membrane with deposition of IgG or, rarely, IgA along the GBM.

The pulmonary-renal vasculitic syndrome is called Goodpasture’s syndrome, in which pulmonary hemorrhage occurs concurrently with GN. Anti-GBM disease has a bimodal distribution, with peaks in the second to third decades and the sixth to seventh decades of life.

Kidney biopsy: Immunofluorescence

Etiology is usually idiopathic, but hydrocarbon exposure has also been associated with the disease. Clinical presentation of renal anti-GBM disease is characterized by an acute onset of GN with severe oliguria or anuria. Urinalysis typically shows hematuria, dysmorphic red blood cells, and red blood cell casts. The diagnostic laboratory finding is circulating antibodies to GBM, specifically to the alpha-3 chain of type IV collagen; these are detected by radioimmunoassay or enzyme immunoassay in approximately 90% of patients.

The standard treatment for anti-GBM disease includes intensive plasmapheresis combined with corticosteroids and cyclophosphamide or azathioprine. Plasmapheresis consists of removal of two to four liters of plasma and replacement with fresh frozen plasma or a 5% albumin solution on a daily basis until circulating antibody levels become undetectable (usually two to three weeks). Steroids should be administered initially as pulse methylprednisolone (30 mg/kg or 1,000 mg intravenously over 20 minutes) for three doses (daily or every other day) followed by daily oral prednisone (1 mg/kg per day) for at least the first month, followed by a gradual taper. The initial cyclophosphamide dose is 2 mg/kg per day either orally or intravenously (0.5 g/m2 body surface area).

Selecting patients for treatment is based primarily on severity at presentation. Based on a large retrospective review of 71 patients treated with plasma exchange, prednisolone, and cyclophosphamide, those who presented with plasma creatinine (Cr) concentration of less than 5.7 mg/dL or those who had Cr greater than 5.7 mg/dL but did not require immediate dialysis had a favorable long-term patient and renal survival (approximately 70% to 80% at 90 months). Patients who required immediate dialysis had poor survival (approximately 35% at 90 months). Patients who had crescents in all glomeruli on renal biopsy required long-term maintenance dialysis. Therefore, plasma exchange, prednisone, and cyclophosphamide should be administered in the following settings:

1. Pulmonary hemorrhage;
2. Renal failure (Cr above 5-7 mg/dL) but not requiring immediate renal replacement therapy; and
3. Less severe disease on renal biopsy (less than 30% to 50% crescents). Therapy is unlikely to be effective in patients who present with dialysisdependent renal failure without hemoptysis or if 100% of glomeruli have crescents on renal biopsy. In these settings, the risk of therapy may exceed the likelihood of benefit.

Fish oil is a potential therapy for IgA nephropathy, not anti-GBM disease. ACE inhibition may be useful in patients with nephrotic syndrome. IV hydration would be likely to cause volume overload and precipitate the need for acute dialysis. Low-dose dopamine has not proven effective in reversing acute renal failure. TH

REFERENCES

1. Clarkson MR, Brenner BM. Pocket Companion to Brenner & Rector’s The Kidney, 7th ed. Philadelphia, Pa: Elsevier Inc; 2005:198-199.
2. Rose BD, Kaplan AA, Appel GB. Treatment of anti-GBM antibody disease (Goodpasture’s syndrome). UpToDate Online. Available at: www.uptodate.com/physicians/pulmonology_toclist.asp. Last accessed August 18, 2005.
3. Levy JB, Turner AN, Rees AJ, et al. Long-term outcome of anti-glomerular basement membrane antibody disease treated with plasma exchange and immunosuppression. Ann Intern Med. 2001;134:1033.
4. Bolton WK. Goodpasture’s syndrome. Kidney Int. 1996;50:1753.
5. Jennette JC. Rapidly progressive crescentic glomerulonephritis. Kidney Int. 2003;63:1164.

An 84-year-old woman with history of coronary artery disease, hypertension, and hyperlipidemia presented with six months of anorexia, nausea, a five-pound weight loss, weakness, and nonbloody diarrhea. Over the past one to two weeks, she noticed decreased urine output despite her use of furosemide.

She was found to have a serum creatinine of 3.5 mg/dL on admission, increased from 1.5 mg/dL five days previously. She had no rash, dyspnea, cough, or abdominal pain. Urinalysis revealed >100 red blood cells (RBC), >100 white blood cells (WBC), occasional hyaline casts, and many gramnegative bacilli. Ciprofloxacin was started for her urinary tract infection. A renal biopsy was performed. The images shown are photomicrographs of light microscopy and immunofluorescence of the renal biopsy specimen. TH

Kidney biopsy: Immunofluorescence

Which of the following would be the most appropriate initial therapy for this condition?

1. Increase dose of furosemide;
2. Start fish oil;
3. Initiate Low-dose dopamine;
4. Discontinue ACE inhibitor; or
5. Begin emergent plasmapheresis.

Discussion

The correct answer is e: plasmapheresis. The renal biopsy, as shown in the image at left, reveals crescents involving glomeruli on light microscopy and linear IgG staining on immunofluorescence. This patient has antiglomerular basement membrane (anti-GBM) glomerulonephritis (GN), which accounts for 10% to 20% of crescentic glomerulonephritides. It is characterized by circulating antibodies to the glomerular basement membrane with deposition of IgG or, rarely, IgA along the GBM.

The pulmonary-renal vasculitic syndrome is called Goodpasture’s syndrome, in which pulmonary hemorrhage occurs concurrently with GN. Anti-GBM disease has a bimodal distribution, with peaks in the second to third decades and the sixth to seventh decades of life.

Kidney biopsy: Immunofluorescence

Etiology is usually idiopathic, but hydrocarbon exposure has also been associated with the disease. Clinical presentation of renal anti-GBM disease is characterized by an acute onset of GN with severe oliguria or anuria. Urinalysis typically shows hematuria, dysmorphic red blood cells, and red blood cell casts. The diagnostic laboratory finding is circulating antibodies to GBM, specifically to the alpha-3 chain of type IV collagen; these are detected by radioimmunoassay or enzyme immunoassay in approximately 90% of patients.

The standard treatment for anti-GBM disease includes intensive plasmapheresis combined with corticosteroids and cyclophosphamide or azathioprine. Plasmapheresis consists of removal of two to four liters of plasma and replacement with fresh frozen plasma or a 5% albumin solution on a daily basis until circulating antibody levels become undetectable (usually two to three weeks). Steroids should be administered initially as pulse methylprednisolone (30 mg/kg or 1,000 mg intravenously over 20 minutes) for three doses (daily or every other day) followed by daily oral prednisone (1 mg/kg per day) for at least the first month, followed by a gradual taper. The initial cyclophosphamide dose is 2 mg/kg per day either orally or intravenously (0.5 g/m2 body surface area).

Selecting patients for treatment is based primarily on severity at presentation. Based on a large retrospective review of 71 patients treated with plasma exchange, prednisolone, and cyclophosphamide, those who presented with plasma creatinine (Cr) concentration of less than 5.7 mg/dL or those who had Cr greater than 5.7 mg/dL but did not require immediate dialysis had a favorable long-term patient and renal survival (approximately 70% to 80% at 90 months). Patients who required immediate dialysis had poor survival (approximately 35% at 90 months). Patients who had crescents in all glomeruli on renal biopsy required long-term maintenance dialysis. Therefore, plasma exchange, prednisone, and cyclophosphamide should be administered in the following settings:

1. Pulmonary hemorrhage;
2. Renal failure (Cr above 5-7 mg/dL) but not requiring immediate renal replacement therapy; and
3. Less severe disease on renal biopsy (less than 30% to 50% crescents). Therapy is unlikely to be effective in patients who present with dialysisdependent renal failure without hemoptysis or if 100% of glomeruli have crescents on renal biopsy. In these settings, the risk of therapy may exceed the likelihood of benefit.

Fish oil is a potential therapy for IgA nephropathy, not anti-GBM disease. ACE inhibition may be useful in patients with nephrotic syndrome. IV hydration would be likely to cause volume overload and precipitate the need for acute dialysis. Low-dose dopamine has not proven effective in reversing acute renal failure. TH

REFERENCES

1. Clarkson MR, Brenner BM. Pocket Companion to Brenner & Rector’s The Kidney, 7th ed. Philadelphia, Pa: Elsevier Inc; 2005:198-199.
2. Rose BD, Kaplan AA, Appel GB. Treatment of anti-GBM antibody disease (Goodpasture’s syndrome). UpToDate Online. Available at: www.uptodate.com/physicians/pulmonology_toclist.asp. Last accessed August 18, 2005.
3. Levy JB, Turner AN, Rees AJ, et al. Long-term outcome of anti-glomerular basement membrane antibody disease treated with plasma exchange and immunosuppression. Ann Intern Med. 2001;134:1033.
4. Bolton WK. Goodpasture’s syndrome. Kidney Int. 1996;50:1753.
5. Jennette JC. Rapidly progressive crescentic glomerulonephritis. Kidney Int. 2003;63:1164.

An 84-year-old woman with history of coronary artery disease, hypertension, and hyperlipidemia presented with six months of anorexia, nausea, a five-pound weight loss, weakness, and nonbloody diarrhea. Over the past one to two weeks, she noticed decreased urine output despite her use of furosemide.

She was found to have a serum creatinine of 3.5 mg/dL on admission, increased from 1.5 mg/dL five days previously. She had no rash, dyspnea, cough, or abdominal pain. Urinalysis revealed >100 red blood cells (RBC), >100 white blood cells (WBC), occasional hyaline casts, and many gramnegative bacilli. Ciprofloxacin was started for her urinary tract infection. A renal biopsy was performed. The images shown are photomicrographs of light microscopy and immunofluorescence of the renal biopsy specimen. TH

Kidney biopsy: Immunofluorescence

Which of the following would be the most appropriate initial therapy for this condition?

1. Increase dose of furosemide;
2. Start fish oil;
3. Initiate Low-dose dopamine;
4. Discontinue ACE inhibitor; or
5. Begin emergent plasmapheresis.

Discussion

The correct answer is e: plasmapheresis. The renal biopsy, as shown in the image at left, reveals crescents involving glomeruli on light microscopy and linear IgG staining on immunofluorescence. This patient has antiglomerular basement membrane (anti-GBM) glomerulonephritis (GN), which accounts for 10% to 20% of crescentic glomerulonephritides. It is characterized by circulating antibodies to the glomerular basement membrane with deposition of IgG or, rarely, IgA along the GBM.

The pulmonary-renal vasculitic syndrome is called Goodpasture’s syndrome, in which pulmonary hemorrhage occurs concurrently with GN. Anti-GBM disease has a bimodal distribution, with peaks in the second to third decades and the sixth to seventh decades of life.

Kidney biopsy: Immunofluorescence

Etiology is usually idiopathic, but hydrocarbon exposure has also been associated with the disease. Clinical presentation of renal anti-GBM disease is characterized by an acute onset of GN with severe oliguria or anuria. Urinalysis typically shows hematuria, dysmorphic red blood cells, and red blood cell casts. The diagnostic laboratory finding is circulating antibodies to GBM, specifically to the alpha-3 chain of type IV collagen; these are detected by radioimmunoassay or enzyme immunoassay in approximately 90% of patients.

The standard treatment for anti-GBM disease includes intensive plasmapheresis combined with corticosteroids and cyclophosphamide or azathioprine. Plasmapheresis consists of removal of two to four liters of plasma and replacement with fresh frozen plasma or a 5% albumin solution on a daily basis until circulating antibody levels become undetectable (usually two to three weeks). Steroids should be administered initially as pulse methylprednisolone (30 mg/kg or 1,000 mg intravenously over 20 minutes) for three doses (daily or every other day) followed by daily oral prednisone (1 mg/kg per day) for at least the first month, followed by a gradual taper. The initial cyclophosphamide dose is 2 mg/kg per day either orally or intravenously (0.5 g/m2 body surface area).

Selecting patients for treatment is based primarily on severity at presentation. Based on a large retrospective review of 71 patients treated with plasma exchange, prednisolone, and cyclophosphamide, those who presented with plasma creatinine (Cr) concentration of less than 5.7 mg/dL or those who had Cr greater than 5.7 mg/dL but did not require immediate dialysis had a favorable long-term patient and renal survival (approximately 70% to 80% at 90 months). Patients who required immediate dialysis had poor survival (approximately 35% at 90 months). Patients who had crescents in all glomeruli on renal biopsy required long-term maintenance dialysis. Therefore, plasma exchange, prednisone, and cyclophosphamide should be administered in the following settings:

1. Pulmonary hemorrhage;
2. Renal failure (Cr above 5-7 mg/dL) but not requiring immediate renal replacement therapy; and
3. Less severe disease on renal biopsy (less than 30% to 50% crescents). Therapy is unlikely to be effective in patients who present with dialysisdependent renal failure without hemoptysis or if 100% of glomeruli have crescents on renal biopsy. In these settings, the risk of therapy may exceed the likelihood of benefit.

Fish oil is a potential therapy for IgA nephropathy, not anti-GBM disease. ACE inhibition may be useful in patients with nephrotic syndrome. IV hydration would be likely to cause volume overload and precipitate the need for acute dialysis. Low-dose dopamine has not proven effective in reversing acute renal failure. TH

REFERENCES

1. Clarkson MR, Brenner BM. Pocket Companion to Brenner & Rector’s The Kidney, 7th ed. Philadelphia, Pa: Elsevier Inc; 2005:198-199.
2. Rose BD, Kaplan AA, Appel GB. Treatment of anti-GBM antibody disease (Goodpasture’s syndrome). UpToDate Online. Available at: www.uptodate.com/physicians/pulmonology_toclist.asp. Last accessed August 18, 2005.
3. Levy JB, Turner AN, Rees AJ, et al. Long-term outcome of anti-glomerular basement membrane antibody disease treated with plasma exchange and immunosuppression. Ann Intern Med. 2001;134:1033.
4. Bolton WK. Goodpasture’s syndrome. Kidney Int. 1996;50:1753.
5. Jennette JC. Rapidly progressive crescentic glomerulonephritis. Kidney Int. 2003;63:1164.

At times it seems as though the solution to every problem in the medical center is for the hospitalists to do it. At the University of California at San Francisco, my hospitalist colleagues lead efforts in information technology, quality improvement, perioperative care, transfers of patients to the medical center, and chair countless medical staff committees.

SHM published a supplement (2005; vol. 9, supp. 1) to The Hospitalist detailing the ways hospitalists add value. The supplement contained articles about treating unassigned patients, leading medical staffs, providing extraordinary availability, improving resource utilization, maximizing throughput and improving patient flow, educating staff and colleagues, and improving patient safety and quality of care.

Given all these activities, it’s no wonder life as a hospitalist is busy. But these activities also add a richness and variety to work and place us at the center of the life of the hospital. As our field continues to grow, our responsibilities will continue to grow. In the years ahead, one challenge for our field will be to know when to say “no.”

At an increasing number of hospitals across the country hospitalists add value in another important way by becoming involved with starting, staffing, and using palliative care services. Hospitalists already play a central role in caring for patients with life-threatening illness by providing expert symptom management and talking with them and their families frankly and compassionately about their illness, prognosis, and preferences for care. While this opportunity to affect the care of individual patients and their families is critical, we can better improve the care of these patients by participating in and leading efforts to establish palliative care services within our institutions.

For hospitalists, the arguments that support starting a palliative care service will be familiar because they involve many of the same issues as when starting a hospitalist program. It is helpful to consider why a hospitalist would want to undertake such an endeavor and why a hospital would support it. Here are the key issues:

1) Need: Many hospitalist programs are started to care for patients for whom there was not a doctor available. While inpatients who need palliative care may already have a doctor, the same argument about need applies. Simply put, the hospital is where half of Americans die and where others with serious, chronic, and life-threatening illness spend time. If for no other reason, palliative care services, like hospitalist programs, are necessary because so many patients need this care.

2) Quality: One of the most important drivers of hospitalist programs is quality. Because hospitalists focus on the care of hospitalized patients they can develop expertise and deliver higher quality. The same holds for palliative care. Studies demonstrate widespread shortfalls in

the quality of care that seriously ill and dying patients receive.1 In addition to doing a poor job managing pain, we typically fail to elicit and respect patient preferences. Just as a hospitalist program provides clinicians focused on the care of inpatients, a palliative care team consisting of physicians, nurses, a social worker, pharmacist, and chaplain provides expertise to address the broad range of issues that arise for patients and their families in a comprehensive and high-quality way.

3) Economics: Studies show that hospitalist programs can reduce length of stay and costs at similar quality.2 While cost-cutting is never the sole reason and often not the most important reason for starting a hospitalist program, the fact that these programs can reduce costs makes them financially attractive to hospitals. Palliative care programs provide the same financial advantages, usually with improved quality.

When given a choice, patients faced with a terminal illness will often choose care focused on symptom management and quality of life rather than longevity. Most often this care requires administering simple medications such as opioids, avoiding invasive procedures, and dedicating clinicians’ time to ensure that symptoms are well-managed, and the broad range of concerns are addressed. At UCSF and elsewhere palliative care programs consistently demonstrate cost savings.3 As our chief operating officer says, “We support palliative care because it’s the right thing to do. It helps that it reduces costs, but that’s not why we do it.”

4) Mission alignment: Hospitalist programs align beautifully with the mission of hospitals to provide high-quality, safe patient care at lower cost and with higher satisfaction. Many hospitals have other concerns that hospitalists help with, such as increasing throughput, managing unassigned patients, and improving care processes. Similarly palliative care programs improve the quality of care for patients with life-threatening illness, reduce costs, and increase patient and family satisfaction. Palliative care services also help with throughput by helping to transition patients to less intensive levels of care consistent with their preferences and expediting discharge to home and hospice.

5) Interdisciplinary skills: No hospitalist is an island. The effective hospitalist understands the benefits and necessity of working closely with colleagues from other disciplines to provide high-quality care. In the same way it requires an interdisciplinary palliative care team to address the range of issues facing patients from pain and symptom management to depression and anxiety to spiritual concerns to practical questions about how to get help at home and who will pay for it. The skills that hospitalists develop working with colleagues in the hospital are identical to those needed to provide palliative care.

WHY HOSPITALISTS MUST GET INVOLVED

The parallels between hospitalist programs and palliative care programs support the role of hospitalists in providing palliative care. But there are other important reasons for hospitalists to become involved with palliative care teams.

First, palliative care adds variety to work. Although it may seem that any given day already has too much variety, focusing on palliative care issues, and visiting with patients about their hopes and fears can be a welcome change from general hospitalist work. Second, palliative care can provide incredible personal rewards. Third, palliative care can add diversification to a hospitalist’s income stream through professional fees and hospital support directed at palliative care. Fourth, for the vast majority of us hospitalists who are generalists, palliative care offers the opportunity to develop special expertise and even board certification. Finally, a palliative care service in the hospital can increase the status of the institution, improving family satisfaction, addressing many JCAHO requirements, and supporting the bottom line.

As hospitalists we have many ways to get involved with a palliative care service. Those who are really motivated can lead the implementation of a palliative care service. Because only a minority of hospitals have palliative care programs, this opportunity will be available at many institutions.4,5 But even if you don’t want to lead the effort, you can still play a key role by joining an existing palliative care team or joining a team that is planning to start a program.

Palliative care programs can improve the care of seriously ill and dying patients. They address an important and unmet patient care need and mesh well with the mission and goals of nearly all hospitals. Hospitalists are perfectly positioned to participate in, lead, and use palliative care services. Such work not only helps our patients but benefits us as well by providing the rewards of helping patients and families in need. In the end, we gain not only from easing the suffering of our fellow human beings but from remembering how precious life is, how limited our time is, and how important our choices are about how we spend our time. TH

SHM President Dr. Pantilat is an associate professor of clinical medicine at UCSF.

REFERENCES

1. A controlled trial to improve care for seriously ill hospitalized patients. The study to understand prognoses and preferences for outcomes and risks of treatments (SUPPORT). The SUPPORT Principal Investigators. JAMA. 1995;274(20):1591-1598.
2. Wachter RM, Goldman L. The hospitalist movement 5 years later. JAMA. 2002;287(4):487-494.
3. Smith TJ, Coyne PJ, Cassel B, et al. A high-volume specialist palliative care unit and team may reduce in-hospital end-of-life care costs. J Palliat Med. 2003;6(5):699-705.
4. Pan CX, Morrison RS, Meier DE, et al. How prevalent are hospital-based palliative care programs? Status report and future directions. J Palliat Med. 2001;4(3):315-324.
5. Pantilat SZ, Billings JA. Prevalence and structure of palliative care services in California hospitals. Arch Intern Med. May 12 2003;163(9):1084-1088.

At times it seems as though the solution to every problem in the medical center is for the hospitalists to do it. At the University of California at San Francisco, my hospitalist colleagues lead efforts in information technology, quality improvement, perioperative care, transfers of patients to the medical center, and chair countless medical staff committees.

SHM published a supplement (2005; vol. 9, supp. 1) to The Hospitalist detailing the ways hospitalists add value. The supplement contained articles about treating unassigned patients, leading medical staffs, providing extraordinary availability, improving resource utilization, maximizing throughput and improving patient flow, educating staff and colleagues, and improving patient safety and quality of care.

Given all these activities, it’s no wonder life as a hospitalist is busy. But these activities also add a richness and variety to work and place us at the center of the life of the hospital. As our field continues to grow, our responsibilities will continue to grow. In the years ahead, one challenge for our field will be to know when to say “no.”

At an increasing number of hospitals across the country hospitalists add value in another important way by becoming involved with starting, staffing, and using palliative care services. Hospitalists already play a central role in caring for patients with life-threatening illness by providing expert symptom management and talking with them and their families frankly and compassionately about their illness, prognosis, and preferences for care. While this opportunity to affect the care of individual patients and their families is critical, we can better improve the care of these patients by participating in and leading efforts to establish palliative care services within our institutions.

For hospitalists, the arguments that support starting a palliative care service will be familiar because they involve many of the same issues as when starting a hospitalist program. It is helpful to consider why a hospitalist would want to undertake such an endeavor and why a hospital would support it. Here are the key issues:

1) Need: Many hospitalist programs are started to care for patients for whom there was not a doctor available. While inpatients who need palliative care may already have a doctor, the same argument about need applies. Simply put, the hospital is where half of Americans die and where others with serious, chronic, and life-threatening illness spend time. If for no other reason, palliative care services, like hospitalist programs, are necessary because so many patients need this care.

2) Quality: One of the most important drivers of hospitalist programs is quality. Because hospitalists focus on the care of hospitalized patients they can develop expertise and deliver higher quality. The same holds for palliative care. Studies demonstrate widespread shortfalls in

the quality of care that seriously ill and dying patients receive.1 In addition to doing a poor job managing pain, we typically fail to elicit and respect patient preferences. Just as a hospitalist program provides clinicians focused on the care of inpatients, a palliative care team consisting of physicians, nurses, a social worker, pharmacist, and chaplain provides expertise to address the broad range of issues that arise for patients and their families in a comprehensive and high-quality way.

3) Economics: Studies show that hospitalist programs can reduce length of stay and costs at similar quality.2 While cost-cutting is never the sole reason and often not the most important reason for starting a hospitalist program, the fact that these programs can reduce costs makes them financially attractive to hospitals. Palliative care programs provide the same financial advantages, usually with improved quality.

When given a choice, patients faced with a terminal illness will often choose care focused on symptom management and quality of life rather than longevity. Most often this care requires administering simple medications such as opioids, avoiding invasive procedures, and dedicating clinicians’ time to ensure that symptoms are well-managed, and the broad range of concerns are addressed. At UCSF and elsewhere palliative care programs consistently demonstrate cost savings.3 As our chief operating officer says, “We support palliative care because it’s the right thing to do. It helps that it reduces costs, but that’s not why we do it.”

4) Mission alignment: Hospitalist programs align beautifully with the mission of hospitals to provide high-quality, safe patient care at lower cost and with higher satisfaction. Many hospitals have other concerns that hospitalists help with, such as increasing throughput, managing unassigned patients, and improving care processes. Similarly palliative care programs improve the quality of care for patients with life-threatening illness, reduce costs, and increase patient and family satisfaction. Palliative care services also help with throughput by helping to transition patients to less intensive levels of care consistent with their preferences and expediting discharge to home and hospice.

5) Interdisciplinary skills: No hospitalist is an island. The effective hospitalist understands the benefits and necessity of working closely with colleagues from other disciplines to provide high-quality care. In the same way it requires an interdisciplinary palliative care team to address the range of issues facing patients from pain and symptom management to depression and anxiety to spiritual concerns to practical questions about how to get help at home and who will pay for it. The skills that hospitalists develop working with colleagues in the hospital are identical to those needed to provide palliative care.

WHY HOSPITALISTS MUST GET INVOLVED

The parallels between hospitalist programs and palliative care programs support the role of hospitalists in providing palliative care. But there are other important reasons for hospitalists to become involved with palliative care teams.

First, palliative care adds variety to work. Although it may seem that any given day already has too much variety, focusing on palliative care issues, and visiting with patients about their hopes and fears can be a welcome change from general hospitalist work. Second, palliative care can provide incredible personal rewards. Third, palliative care can add diversification to a hospitalist’s income stream through professional fees and hospital support directed at palliative care. Fourth, for the vast majority of us hospitalists who are generalists, palliative care offers the opportunity to develop special expertise and even board certification. Finally, a palliative care service in the hospital can increase the status of the institution, improving family satisfaction, addressing many JCAHO requirements, and supporting the bottom line.

As hospitalists we have many ways to get involved with a palliative care service. Those who are really motivated can lead the implementation of a palliative care service. Because only a minority of hospitals have palliative care programs, this opportunity will be available at many institutions.4,5 But even if you don’t want to lead the effort, you can still play a key role by joining an existing palliative care team or joining a team that is planning to start a program.

Palliative care programs can improve the care of seriously ill and dying patients. They address an important and unmet patient care need and mesh well with the mission and goals of nearly all hospitals. Hospitalists are perfectly positioned to participate in, lead, and use palliative care services. Such work not only helps our patients but benefits us as well by providing the rewards of helping patients and families in need. In the end, we gain not only from easing the suffering of our fellow human beings but from remembering how precious life is, how limited our time is, and how important our choices are about how we spend our time. TH

SHM President Dr. Pantilat is an associate professor of clinical medicine at UCSF.

REFERENCES

1. A controlled trial to improve care for seriously ill hospitalized patients. The study to understand prognoses and preferences for outcomes and risks of treatments (SUPPORT). The SUPPORT Principal Investigators. JAMA. 1995;274(20):1591-1598.
2. Wachter RM, Goldman L. The hospitalist movement 5 years later. JAMA. 2002;287(4):487-494.
3. Smith TJ, Coyne PJ, Cassel B, et al. A high-volume specialist palliative care unit and team may reduce in-hospital end-of-life care costs. J Palliat Med. 2003;6(5):699-705.
4. Pan CX, Morrison RS, Meier DE, et al. How prevalent are hospital-based palliative care programs? Status report and future directions. J Palliat Med. 2001;4(3):315-324.
5. Pantilat SZ, Billings JA. Prevalence and structure of palliative care services in California hospitals. Arch Intern Med. May 12 2003;163(9):1084-1088.

At times it seems as though the solution to every problem in the medical center is for the hospitalists to do it. At the University of California at San Francisco, my hospitalist colleagues lead efforts in information technology, quality improvement, perioperative care, transfers of patients to the medical center, and chair countless medical staff committees.

SHM published a supplement (2005; vol. 9, supp. 1) to The Hospitalist detailing the ways hospitalists add value. The supplement contained articles about treating unassigned patients, leading medical staffs, providing extraordinary availability, improving resource utilization, maximizing throughput and improving patient flow, educating staff and colleagues, and improving patient safety and quality of care.

Given all these activities, it’s no wonder life as a hospitalist is busy. But these activities also add a richness and variety to work and place us at the center of the life of the hospital. As our field continues to grow, our responsibilities will continue to grow. In the years ahead, one challenge for our field will be to know when to say “no.”

At an increasing number of hospitals across the country hospitalists add value in another important way by becoming involved with starting, staffing, and using palliative care services. Hospitalists already play a central role in caring for patients with life-threatening illness by providing expert symptom management and talking with them and their families frankly and compassionately about their illness, prognosis, and preferences for care. While this opportunity to affect the care of individual patients and their families is critical, we can better improve the care of these patients by participating in and leading efforts to establish palliative care services within our institutions.

For hospitalists, the arguments that support starting a palliative care service will be familiar because they involve many of the same issues as when starting a hospitalist program. It is helpful to consider why a hospitalist would want to undertake such an endeavor and why a hospital would support it. Here are the key issues:

1) Need: Many hospitalist programs are started to care for patients for whom there was not a doctor available. While inpatients who need palliative care may already have a doctor, the same argument about need applies. Simply put, the hospital is where half of Americans die and where others with serious, chronic, and life-threatening illness spend time. If for no other reason, palliative care services, like hospitalist programs, are necessary because so many patients need this care.

2) Quality: One of the most important drivers of hospitalist programs is quality. Because hospitalists focus on the care of hospitalized patients they can develop expertise and deliver higher quality. The same holds for palliative care. Studies demonstrate widespread shortfalls in

the quality of care that seriously ill and dying patients receive.1 In addition to doing a poor job managing pain, we typically fail to elicit and respect patient preferences. Just as a hospitalist program provides clinicians focused on the care of inpatients, a palliative care team consisting of physicians, nurses, a social worker, pharmacist, and chaplain provides expertise to address the broad range of issues that arise for patients and their families in a comprehensive and high-quality way.

3) Economics: Studies show that hospitalist programs can reduce length of stay and costs at similar quality.2 While cost-cutting is never the sole reason and often not the most important reason for starting a hospitalist program, the fact that these programs can reduce costs makes them financially attractive to hospitals. Palliative care programs provide the same financial advantages, usually with improved quality.

When given a choice, patients faced with a terminal illness will often choose care focused on symptom management and quality of life rather than longevity. Most often this care requires administering simple medications such as opioids, avoiding invasive procedures, and dedicating clinicians’ time to ensure that symptoms are well-managed, and the broad range of concerns are addressed. At UCSF and elsewhere palliative care programs consistently demonstrate cost savings.3 As our chief operating officer says, “We support palliative care because it’s the right thing to do. It helps that it reduces costs, but that’s not why we do it.”

4) Mission alignment: Hospitalist programs align beautifully with the mission of hospitals to provide high-quality, safe patient care at lower cost and with higher satisfaction. Many hospitals have other concerns that hospitalists help with, such as increasing throughput, managing unassigned patients, and improving care processes. Similarly palliative care programs improve the quality of care for patients with life-threatening illness, reduce costs, and increase patient and family satisfaction. Palliative care services also help with throughput by helping to transition patients to less intensive levels of care consistent with their preferences and expediting discharge to home and hospice.

5) Interdisciplinary skills: No hospitalist is an island. The effective hospitalist understands the benefits and necessity of working closely with colleagues from other disciplines to provide high-quality care. In the same way it requires an interdisciplinary palliative care team to address the range of issues facing patients from pain and symptom management to depression and anxiety to spiritual concerns to practical questions about how to get help at home and who will pay for it. The skills that hospitalists develop working with colleagues in the hospital are identical to those needed to provide palliative care.

WHY HOSPITALISTS MUST GET INVOLVED

The parallels between hospitalist programs and palliative care programs support the role of hospitalists in providing palliative care. But there are other important reasons for hospitalists to become involved with palliative care teams.

First, palliative care adds variety to work. Although it may seem that any given day already has too much variety, focusing on palliative care issues, and visiting with patients about their hopes and fears can be a welcome change from general hospitalist work. Second, palliative care can provide incredible personal rewards. Third, palliative care can add diversification to a hospitalist’s income stream through professional fees and hospital support directed at palliative care. Fourth, for the vast majority of us hospitalists who are generalists, palliative care offers the opportunity to develop special expertise and even board certification. Finally, a palliative care service in the hospital can increase the status of the institution, improving family satisfaction, addressing many JCAHO requirements, and supporting the bottom line.

As hospitalists we have many ways to get involved with a palliative care service. Those who are really motivated can lead the implementation of a palliative care service. Because only a minority of hospitals have palliative care programs, this opportunity will be available at many institutions.4,5 But even if you don’t want to lead the effort, you can still play a key role by joining an existing palliative care team or joining a team that is planning to start a program.

Palliative care programs can improve the care of seriously ill and dying patients. They address an important and unmet patient care need and mesh well with the mission and goals of nearly all hospitals. Hospitalists are perfectly positioned to participate in, lead, and use palliative care services. Such work not only helps our patients but benefits us as well by providing the rewards of helping patients and families in need. In the end, we gain not only from easing the suffering of our fellow human beings but from remembering how precious life is, how limited our time is, and how important our choices are about how we spend our time. TH

SHM President Dr. Pantilat is an associate professor of clinical medicine at UCSF.

REFERENCES

1. A controlled trial to improve care for seriously ill hospitalized patients. The study to understand prognoses and preferences for outcomes and risks of treatments (SUPPORT). The SUPPORT Principal Investigators. JAMA. 1995;274(20):1591-1598.
2. Wachter RM, Goldman L. The hospitalist movement 5 years later. JAMA. 2002;287(4):487-494.
3. Smith TJ, Coyne PJ, Cassel B, et al. A high-volume specialist palliative care unit and team may reduce in-hospital end-of-life care costs. J Palliat Med. 2003;6(5):699-705.
4. Pan CX, Morrison RS, Meier DE, et al. How prevalent are hospital-based palliative care programs? Status report and future directions. J Palliat Med. 2001;4(3):315-324.
5. Pantilat SZ, Billings JA. Prevalence and structure of palliative care services in California hospitals. Arch Intern Med. May 12 2003;163(9):1084-1088.

Editors’ note: When a disaster strikes—whether manmade or natural—we are wrenched from our normal existence into another realm entirely. The petty concerns of daily life fade from sight in the wake of destruction and death.

For the practitioner of medicine, this is a time of great challenge to demonstrate the highest ideals of medicine. The people of the Gulf Coast must now face a dawn where the life they knew is gone and must be built anew. In this issue we’re proud to include the memoirs of two New Orleans physicians who worked through this catastrophe.

For more information on how you can help with the recovery effort, visit www.hospitalmedicine.org.

Despite the best preparations and planning, many aspects of managing a physician practice change rapidly, and many new problems arise immediately following a disaster. Below, we present our experiences as a large hospitalist program in a tertiary-care referral center during the days before and the seven days after Hurricane Katrina, a category IV storm, devastated New Orleans.

PREPARATION

Ochsner Clinic Foundation (OCF) is an integrated medical institution with more than 700 physicians and 24 clinics throughout Southeast Louisiana, including Northshore and Baton Rouge. For nearly 60 years, Ochsner has cared for residents in the greater New Orleans communities at the Ochsner Main Campus, which includes a multispecialty clinic, a 500-bed hospital, and residency training programs. The Main Campus is located by the Mississippi River at the parish line between Orleans Parish and Jefferson Parish—areas protected from flooding under the levee system.

The Hospitalist Program at the Ochsner Main Campus has 18 physicians and four nurse practitioners. Approximately 60% of our patients are managed by Internal Medicine Residency teaching services and the rest by staff physicians. Prior to the landing of Hurricane Katrina, we cared for 60% of the hospitalized patients. Our past hurricane experience led us to develop a two-team system for disasters. Team A has four hospitalists who are required to stay on campus;

Team B is available within a week later to relieve Team A.

We tracked Hurricane Katrina following its exit from the Florida area. The decision analysis for our essential medical team was based on the category of the hurricane, staff location, and projected path. On Saturday, August 27, we were informed that Hurricane Katrina was reaching category V status and expected to hit New Orleans early Monday morning. This unexpected arrival required us to mobilize the hurricane emergency preparedness team rapidly. Hence both teams A and B were requested to remain on premise—preferably without family and pets. On the facility side, we had four generators on site and started to request other generators from around the country on the news of changing course of the hurricane.

SUNDAY, AUGUST 28:

The Day before Katrina Landed

New Orleans Mayor Ray Nagin ordered a mandatory evacuation of the city for the first time in history. At Ochsner, all essential personnel were expected to report to their stations by 7 p.m. The arrival of the hurricane gave little time to our staff to arrange alternative living arrangements for their significant others and pets. Consequently many non-medical dependents and pets arrived at the facility even though we didn’t have adequate supplies to be self-sufficient for more than a few days. Many expected our organization to have ample resources to accommodate all needs—food, shelter, and support. A hurricane disaster phone line was created to update the status of OCF following the hurricane.

MONDAY, AUGUST 29:

Katrina Lands in New Orleans

OCF lost power in the early morning of August 29. Our facility sustained water and roof damage on the top floors of the hospital and unexpected ceiling glass breaks in the walkways. The howling of the intense wind created an ominous feeling among all of those sheltered in the facility. Fortunately, only minor flooding occurred around the institution.

In contrast, major flooding was reported throughout metropolitan New Orleans—especially in New Orleans East and surrounding low-lying parishes. Major wind damage was seen in buildings in the central business district, and 100% of the power was out in that area.

Downtown New Orleans and the French Quarter were dry thanks to the pumping system. Disturbingly, though, breaches in the levee system protecting New Orleans were reported in the 17th Street Canal.

By Monday afternoon, our entire facility was running on emergency generators, which provided energy only for essential equipment and left the institution with no air-conditioning, minimal lighting, and no plumbing. Physicians used flashlights to see patients, and the rooms became unbearably hot and humid; the heat index outside was 105 degrees Fahrenheit.

All regular communications went off service, including telephone lines, cell phones, and outside pagers. Fortunately OCF had invested in Spectralink phones in the past few years; this internal, antenna-based phone system continued to function. We were even able to dial long-distance intermittently. Our information system also went down, but we kept generator power for intermittent use of the Internet and Intranet to allow our employees to access information and contact with the outside world. At night—from the towers of our hospital—it was strange to see our former city of lights in total darkness.

TUESDAY, AUGUST 30:

Hurricane Aftermath Day 1

Reports of catastrophic flooding and heroic rooftop rescues in New Orleans East and other parishes were announced on the radio and via the Internet. Unfortunately the levee breach at the 17th Street Canal became uncontrolled, and water began flowing from Lake Pontchartrain into New Orleans, ultimately flooding 80% of the city of New Orleans. The Superdome and the Convention Center began to fill with thousands of refugees.

The lack of electricity, inadequate food and water supplies, overcrowding, lack of adequate sanitary conditions, and—later—security concerns exponentially created a humanitarian crisis. We were devastated by the plight of our fellow New Orleans residents, whose only crime was, largely, being too poor to evacuate. Approximately 300,000 people never evacuated, and this posed an interminable challenge for city, state, and federal governments. Unfortunately the acts of a few heartless gangs tarnished the beautiful and friendly image of the Big Easy.

At Ochsner we began to conserve our resources because of the commitment to care for more than 500 people onsite. Our dietary department provided approximately 1,600 meals daily, working in hot and sweaty conditions. In the hospital the heat began to take a physical toll on everyone. We also suffered the psychological toll of not knowing what had happened to our families, friends, and belongings. We lost the ability to run most laboratory studies. We concentrated our efforts in preserving human lives with only basic means.

With no working elevators, navigating 11 floors of the hospital was a challenge for all. Our survival tactics included not just adequate fluid hydration, but electrolyte replacement. Unexpectedly, we discovered that OCF had invested in a deep-well water system separate

from the county water supply in the hospital. Thus the hospital continued to have water for at least the first three floors. The cool well water provided much-needed refreshing showers and maintained adequate sanitary conditions.

One of our hospitalists evacuated from OCF (along with several of our team’s family members) to Houston. On their way, they passed downed power-lines, a daiquiri shop in flames, and cars carrying boats on their roofs into New Orleans to help rescue stranded people.

WEDNESDAY, AUGUST 31:

Hurricane Aftermath Day 2

Conditions in downtown New Orleans became increasing dire with rising floodwater, hunger, thirst, and reports of looting and unrest. Rumors started to spread about the status and safety of OCF. One stated that OCF had looted a nearby Wal-Mart for food and supplies even though, in fact, senior executives of Wal-Mart personally inventoried the items and generously donated them to our institution.

There were also rumors about looters approaching from downtown. Family members outside the city were urging our employees to leave because of the danger of continued flooding and civil unrest. OCF administrators (under the leadership of the CEO Patrick Quinlan, MD, President and COO Warner Thomas, MD, and Medical Director Richard Guthrie, MD) actively addressed these issues to stop the rumors with scheduled and mandatory open forums. During the next few days, OCF was in a lock-down mode with the National Guard and our own security department providing security.

Not knowing the capability of our facility in this time of extreme uncertainly, we proceeded to discharge and move patients to other centers, such as Memorial Hermann Hospital in Houston and Summit Hospital in Baton Rouge via both helicopter and ambulance.

Simultaneously we focused on patients who were stable and ready for discharge to increase our organization capacity to create a plan for providing resource for both the east and west banks of the Mississippi River.

THURSDAY, SEPTEMBER 1:

Hurricane Aftermath Day 3

With the city of New Orleans under marshal law, OCF continued in lock-down mode. During the aftermath, a high priority was to contact all the evacuated employees. An employee outreach program was implemented in which each department accounted for the whereabouts of all personnel. As for our hospitalist program, we started to meet twice daily immediately after the hurricane to address concerns of emergency department volumes, maintain open communications, provide mutual psychological support, and foster a spirit of teamwork. During these meetings we believed that our department had cemented a bond that could not be created in normal circumstances. Our efforts through the storm and the unimaginable adversity were nothing short of extraordinary.

Our medical colleagues in Charity Hospital in downtown New Orleans faced unprecedented challenges caring for patients with minimal supplies. We heard reports of doctors giving each other IV hydration and medical personnel bagging ventilator patients in shifts. With no communication except the Internet, they resorted to e-mailing CNN for help.

FRIDAY, SEPTEMBER 2:

Hurricane Aftermath Day 4

President Bush arrived to visit New Orleans and other devastated areas in the Gulf region. With the National Guard moving in to provide security and relief efforts, Mayor Nagin declared the day a turning point for the city. After the hurricane, it was uncertain how many patients would require medical care in the community. From the Hurricane Ivan experience in Pensacola, Fla., we were advised that 10 days after the disaster, one could anticipate a doubling of the highest emergency department volume for several weeks.

We were uncertain that the evacuation of the whole city could provide such volume. To offer quality clinical care and remain in sound mind under such conditions, we hospitalists unanimously agreed to care for our patients 24/7 in weekly rotation. Our hospital census during this period was at 60% of usual and the admission was running at 40% of normal. We decreased the residents from three members per team to two in order to provide a five-day rotation of three teams. We utilized the staging center of Ochsner Baton Rouge to organize our employees and provide transportation to and from New Orleans. Employees were discouraged from driving in

their own vehicles due to gasoline shortage and safety concerns.

SATURDAY, SEPTEMBER 3:

Hurricane Aftermath Day 5

Conditions in New Orleans improved rapidly with better security. Evacuees were steadily transported out of the Superdome and Convention Center. Hurricane Katrina disasters posed new challenges in providing care. We saw patients with

• Severe dehydration;
• Exhaustion caused by the lack of use or incorrect use of their medications for days resulting in exacerbation of chronic conditions such as COPD;
• Water-borne illnesses from prolonged immersion in toxic water;
• Reactive airway diseases from environmental allergens;
• Cellulitis from cuts and bruises in evacuees, as well as people attempting home repairs;
• Carbon monoxide poisoning from generators used incorrectly inside homes; and
• Withdrawals from illicit drug uses.

SUNDAY, SEPTEMBER 4:

Hurricane Aftermath Day 6

During the Sunday ad-hoc church service at Ochsner, doctors, nurses, employees, patients, and families came together in spiritual healing. We sang praises of hope and optimism for our community. We were grateful for our status in this unbelievable disaster and offered prayers and hope for those who had lost so much. We had never been so proud of the efforts of every individual in our institution for maintaining this facility for patient care in such dire situations and promised to be optimistic about our future.

Fortunately, with the help of the Jefferson Parish emergency utility crews, power was restored to our institution. We became fully functional to take on the challenges of the community.

MONDAY, SEPTEMBER 5:

Hurricane Aftermath Day 7

The 17th Street Canal breach was controlled and the water pump back in operation. Residents of Jefferson Parish were allowed to return to take their personal items from their houses but were still under voluntary evacuation, while Orleans Parish was still closed. To plan the demand for medical care in the wake of gradual recovery, OCF began to maintain all of our employees through strategic deployments in various satellite clinics and hospitals according to the needs of the population in New Orleans and other areas.

LESSONS LEARNED

We have learned so much from this disaster. The key to overcome such adverse conditions entails strong psychosocial support from colleagues and family. Strong leadership is crucial to maintain a sense of serenity and an optimistic outlook in times of uncertainty. We experienced a sense of camaraderie after seeing all medical personnel participating in activities beyond of the boundary of usual roles.

The expansion of the essential personnel team list to include social workers and discharge planners is crucial to focus on the unique and nonconventional logistical challenges post-disaster. Intense focus on group dynamics was essential to avoid physical and emotional burnout. Frequent and predictably scheduled face-to-face communication was also important in disseminating accurate, unadulterated information because our decision-making changed hour-to-hour immediately after Hurricane Katrina, day-to-day in the few days afterward, and week-to-week just one week post-disaster.

Obviously the financial implications are immense for our city and our institution. We are developing financial plans, a relief fund, and other resources to assist our employees who have been severely affected by the hurricane. TH

Dr. Deitelzweig and Dr. Lee work at the Ochsner Clinic Foundation, Department of Hospital-Based Internal Medicine, New Orleans. You can contact Dr. Deitelzweig by phone at (504) 842-5766; his e-mail is sdeiteilzweig@ochsner.org

Editors’ note: When a disaster strikes—whether manmade or natural—we are wrenched from our normal existence into another realm entirely. The petty concerns of daily life fade from sight in the wake of destruction and death.

For the practitioner of medicine, this is a time of great challenge to demonstrate the highest ideals of medicine. The people of the Gulf Coast must now face a dawn where the life they knew is gone and must be built anew. In this issue we’re proud to include the memoirs of two New Orleans physicians who worked through this catastrophe.

For more information on how you can help with the recovery effort, visit www.hospitalmedicine.org.

Despite the best preparations and planning, many aspects of managing a physician practice change rapidly, and many new problems arise immediately following a disaster. Below, we present our experiences as a large hospitalist program in a tertiary-care referral center during the days before and the seven days after Hurricane Katrina, a category IV storm, devastated New Orleans.

PREPARATION

Ochsner Clinic Foundation (OCF) is an integrated medical institution with more than 700 physicians and 24 clinics throughout Southeast Louisiana, including Northshore and Baton Rouge. For nearly 60 years, Ochsner has cared for residents in the greater New Orleans communities at the Ochsner Main Campus, which includes a multispecialty clinic, a 500-bed hospital, and residency training programs. The Main Campus is located by the Mississippi River at the parish line between Orleans Parish and Jefferson Parish—areas protected from flooding under the levee system.

The Hospitalist Program at the Ochsner Main Campus has 18 physicians and four nurse practitioners. Approximately 60% of our patients are managed by Internal Medicine Residency teaching services and the rest by staff physicians. Prior to the landing of Hurricane Katrina, we cared for 60% of the hospitalized patients. Our past hurricane experience led us to develop a two-team system for disasters. Team A has four hospitalists who are required to stay on campus;

Team B is available within a week later to relieve Team A.

We tracked Hurricane Katrina following its exit from the Florida area. The decision analysis for our essential medical team was based on the category of the hurricane, staff location, and projected path. On Saturday, August 27, we were informed that Hurricane Katrina was reaching category V status and expected to hit New Orleans early Monday morning. This unexpected arrival required us to mobilize the hurricane emergency preparedness team rapidly. Hence both teams A and B were requested to remain on premise—preferably without family and pets. On the facility side, we had four generators on site and started to request other generators from around the country on the news of changing course of the hurricane.

SUNDAY, AUGUST 28:

The Day before Katrina Landed

New Orleans Mayor Ray Nagin ordered a mandatory evacuation of the city for the first time in history. At Ochsner, all essential personnel were expected to report to their stations by 7 p.m. The arrival of the hurricane gave little time to our staff to arrange alternative living arrangements for their significant others and pets. Consequently many non-medical dependents and pets arrived at the facility even though we didn’t have adequate supplies to be self-sufficient for more than a few days. Many expected our organization to have ample resources to accommodate all needs—food, shelter, and support. A hurricane disaster phone line was created to update the status of OCF following the hurricane.

MONDAY, AUGUST 29:

Katrina Lands in New Orleans

OCF lost power in the early morning of August 29. Our facility sustained water and roof damage on the top floors of the hospital and unexpected ceiling glass breaks in the walkways. The howling of the intense wind created an ominous feeling among all of those sheltered in the facility. Fortunately, only minor flooding occurred around the institution.

In contrast, major flooding was reported throughout metropolitan New Orleans—especially in New Orleans East and surrounding low-lying parishes. Major wind damage was seen in buildings in the central business district, and 100% of the power was out in that area.

Downtown New Orleans and the French Quarter were dry thanks to the pumping system. Disturbingly, though, breaches in the levee system protecting New Orleans were reported in the 17th Street Canal.

By Monday afternoon, our entire facility was running on emergency generators, which provided energy only for essential equipment and left the institution with no air-conditioning, minimal lighting, and no plumbing. Physicians used flashlights to see patients, and the rooms became unbearably hot and humid; the heat index outside was 105 degrees Fahrenheit.

All regular communications went off service, including telephone lines, cell phones, and outside pagers. Fortunately OCF had invested in Spectralink phones in the past few years; this internal, antenna-based phone system continued to function. We were even able to dial long-distance intermittently. Our information system also went down, but we kept generator power for intermittent use of the Internet and Intranet to allow our employees to access information and contact with the outside world. At night—from the towers of our hospital—it was strange to see our former city of lights in total darkness.

TUESDAY, AUGUST 30:

Hurricane Aftermath Day 1

Reports of catastrophic flooding and heroic rooftop rescues in New Orleans East and other parishes were announced on the radio and via the Internet. Unfortunately the levee breach at the 17th Street Canal became uncontrolled, and water began flowing from Lake Pontchartrain into New Orleans, ultimately flooding 80% of the city of New Orleans. The Superdome and the Convention Center began to fill with thousands of refugees.

The lack of electricity, inadequate food and water supplies, overcrowding, lack of adequate sanitary conditions, and—later—security concerns exponentially created a humanitarian crisis. We were devastated by the plight of our fellow New Orleans residents, whose only crime was, largely, being too poor to evacuate. Approximately 300,000 people never evacuated, and this posed an interminable challenge for city, state, and federal governments. Unfortunately the acts of a few heartless gangs tarnished the beautiful and friendly image of the Big Easy.

At Ochsner we began to conserve our resources because of the commitment to care for more than 500 people onsite. Our dietary department provided approximately 1,600 meals daily, working in hot and sweaty conditions. In the hospital the heat began to take a physical toll on everyone. We also suffered the psychological toll of not knowing what had happened to our families, friends, and belongings. We lost the ability to run most laboratory studies. We concentrated our efforts in preserving human lives with only basic means.

With no working elevators, navigating 11 floors of the hospital was a challenge for all. Our survival tactics included not just adequate fluid hydration, but electrolyte replacement. Unexpectedly, we discovered that OCF had invested in a deep-well water system separate

from the county water supply in the hospital. Thus the hospital continued to have water for at least the first three floors. The cool well water provided much-needed refreshing showers and maintained adequate sanitary conditions.

One of our hospitalists evacuated from OCF (along with several of our team’s family members) to Houston. On their way, they passed downed power-lines, a daiquiri shop in flames, and cars carrying boats on their roofs into New Orleans to help rescue stranded people.

WEDNESDAY, AUGUST 31:

Hurricane Aftermath Day 2

Conditions in downtown New Orleans became increasing dire with rising floodwater, hunger, thirst, and reports of looting and unrest. Rumors started to spread about the status and safety of OCF. One stated that OCF had looted a nearby Wal-Mart for food and supplies even though, in fact, senior executives of Wal-Mart personally inventoried the items and generously donated them to our institution.

There were also rumors about looters approaching from downtown. Family members outside the city were urging our employees to leave because of the danger of continued flooding and civil unrest. OCF administrators (under the leadership of the CEO Patrick Quinlan, MD, President and COO Warner Thomas, MD, and Medical Director Richard Guthrie, MD) actively addressed these issues to stop the rumors with scheduled and mandatory open forums. During the next few days, OCF was in a lock-down mode with the National Guard and our own security department providing security.

Not knowing the capability of our facility in this time of extreme uncertainly, we proceeded to discharge and move patients to other centers, such as Memorial Hermann Hospital in Houston and Summit Hospital in Baton Rouge via both helicopter and ambulance.

Simultaneously we focused on patients who were stable and ready for discharge to increase our organization capacity to create a plan for providing resource for both the east and west banks of the Mississippi River.

THURSDAY, SEPTEMBER 1:

Hurricane Aftermath Day 3

With the city of New Orleans under marshal law, OCF continued in lock-down mode. During the aftermath, a high priority was to contact all the evacuated employees. An employee outreach program was implemented in which each department accounted for the whereabouts of all personnel. As for our hospitalist program, we started to meet twice daily immediately after the hurricane to address concerns of emergency department volumes, maintain open communications, provide mutual psychological support, and foster a spirit of teamwork. During these meetings we believed that our department had cemented a bond that could not be created in normal circumstances. Our efforts through the storm and the unimaginable adversity were nothing short of extraordinary.

Our medical colleagues in Charity Hospital in downtown New Orleans faced unprecedented challenges caring for patients with minimal supplies. We heard reports of doctors giving each other IV hydration and medical personnel bagging ventilator patients in shifts. With no communication except the Internet, they resorted to e-mailing CNN for help.

FRIDAY, SEPTEMBER 2:

Hurricane Aftermath Day 4

President Bush arrived to visit New Orleans and other devastated areas in the Gulf region. With the National Guard moving in to provide security and relief efforts, Mayor Nagin declared the day a turning point for the city. After the hurricane, it was uncertain how many patients would require medical care in the community. From the Hurricane Ivan experience in Pensacola, Fla., we were advised that 10 days after the disaster, one could anticipate a doubling of the highest emergency department volume for several weeks.

We were uncertain that the evacuation of the whole city could provide such volume. To offer quality clinical care and remain in sound mind under such conditions, we hospitalists unanimously agreed to care for our patients 24/7 in weekly rotation. Our hospital census during this period was at 60% of usual and the admission was running at 40% of normal. We decreased the residents from three members per team to two in order to provide a five-day rotation of three teams. We utilized the staging center of Ochsner Baton Rouge to organize our employees and provide transportation to and from New Orleans. Employees were discouraged from driving in

their own vehicles due to gasoline shortage and safety concerns.

SATURDAY, SEPTEMBER 3:

Hurricane Aftermath Day 5

Conditions in New Orleans improved rapidly with better security. Evacuees were steadily transported out of the Superdome and Convention Center. Hurricane Katrina disasters posed new challenges in providing care. We saw patients with

• Severe dehydration;
• Exhaustion caused by the lack of use or incorrect use of their medications for days resulting in exacerbation of chronic conditions such as COPD;
• Water-borne illnesses from prolonged immersion in toxic water;
• Reactive airway diseases from environmental allergens;
• Cellulitis from cuts and bruises in evacuees, as well as people attempting home repairs;
• Carbon monoxide poisoning from generators used incorrectly inside homes; and
• Withdrawals from illicit drug uses.

SUNDAY, SEPTEMBER 4:

Hurricane Aftermath Day 6

During the Sunday ad-hoc church service at Ochsner, doctors, nurses, employees, patients, and families came together in spiritual healing. We sang praises of hope and optimism for our community. We were grateful for our status in this unbelievable disaster and offered prayers and hope for those who had lost so much. We had never been so proud of the efforts of every individual in our institution for maintaining this facility for patient care in such dire situations and promised to be optimistic about our future.

Fortunately, with the help of the Jefferson Parish emergency utility crews, power was restored to our institution. We became fully functional to take on the challenges of the community.

MONDAY, SEPTEMBER 5:

Hurricane Aftermath Day 7

The 17th Street Canal breach was controlled and the water pump back in operation. Residents of Jefferson Parish were allowed to return to take their personal items from their houses but were still under voluntary evacuation, while Orleans Parish was still closed. To plan the demand for medical care in the wake of gradual recovery, OCF began to maintain all of our employees through strategic deployments in various satellite clinics and hospitals according to the needs of the population in New Orleans and other areas.

LESSONS LEARNED

We have learned so much from this disaster. The key to overcome such adverse conditions entails strong psychosocial support from colleagues and family. Strong leadership is crucial to maintain a sense of serenity and an optimistic outlook in times of uncertainty. We experienced a sense of camaraderie after seeing all medical personnel participating in activities beyond of the boundary of usual roles.

The expansion of the essential personnel team list to include social workers and discharge planners is crucial to focus on the unique and nonconventional logistical challenges post-disaster. Intense focus on group dynamics was essential to avoid physical and emotional burnout. Frequent and predictably scheduled face-to-face communication was also important in disseminating accurate, unadulterated information because our decision-making changed hour-to-hour immediately after Hurricane Katrina, day-to-day in the few days afterward, and week-to-week just one week post-disaster.

Obviously the financial implications are immense for our city and our institution. We are developing financial plans, a relief fund, and other resources to assist our employees who have been severely affected by the hurricane. TH

Dr. Deitelzweig and Dr. Lee work at the Ochsner Clinic Foundation, Department of Hospital-Based Internal Medicine, New Orleans. You can contact Dr. Deitelzweig by phone at (504) 842-5766; his e-mail is sdeiteilzweig@ochsner.org

Editors’ note: When a disaster strikes—whether manmade or natural—we are wrenched from our normal existence into another realm entirely. The petty concerns of daily life fade from sight in the wake of destruction and death.

For the practitioner of medicine, this is a time of great challenge to demonstrate the highest ideals of medicine. The people of the Gulf Coast must now face a dawn where the life they knew is gone and must be built anew. In this issue we’re proud to include the memoirs of two New Orleans physicians who worked through this catastrophe.

For more information on how you can help with the recovery effort, visit www.hospitalmedicine.org.

Despite the best preparations and planning, many aspects of managing a physician practice change rapidly, and many new problems arise immediately following a disaster. Below, we present our experiences as a large hospitalist program in a tertiary-care referral center during the days before and the seven days after Hurricane Katrina, a category IV storm, devastated New Orleans.

PREPARATION

Ochsner Clinic Foundation (OCF) is an integrated medical institution with more than 700 physicians and 24 clinics throughout Southeast Louisiana, including Northshore and Baton Rouge. For nearly 60 years, Ochsner has cared for residents in the greater New Orleans communities at the Ochsner Main Campus, which includes a multispecialty clinic, a 500-bed hospital, and residency training programs. The Main Campus is located by the Mississippi River at the parish line between Orleans Parish and Jefferson Parish—areas protected from flooding under the levee system.

The Hospitalist Program at the Ochsner Main Campus has 18 physicians and four nurse practitioners. Approximately 60% of our patients are managed by Internal Medicine Residency teaching services and the rest by staff physicians. Prior to the landing of Hurricane Katrina, we cared for 60% of the hospitalized patients. Our past hurricane experience led us to develop a two-team system for disasters. Team A has four hospitalists who are required to stay on campus;

Team B is available within a week later to relieve Team A.

We tracked Hurricane Katrina following its exit from the Florida area. The decision analysis for our essential medical team was based on the category of the hurricane, staff location, and projected path. On Saturday, August 27, we were informed that Hurricane Katrina was reaching category V status and expected to hit New Orleans early Monday morning. This unexpected arrival required us to mobilize the hurricane emergency preparedness team rapidly. Hence both teams A and B were requested to remain on premise—preferably without family and pets. On the facility side, we had four generators on site and started to request other generators from around the country on the news of changing course of the hurricane.

SUNDAY, AUGUST 28:

The Day before Katrina Landed

New Orleans Mayor Ray Nagin ordered a mandatory evacuation of the city for the first time in history. At Ochsner, all essential personnel were expected to report to their stations by 7 p.m. The arrival of the hurricane gave little time to our staff to arrange alternative living arrangements for their significant others and pets. Consequently many non-medical dependents and pets arrived at the facility even though we didn’t have adequate supplies to be self-sufficient for more than a few days. Many expected our organization to have ample resources to accommodate all needs—food, shelter, and support. A hurricane disaster phone line was created to update the status of OCF following the hurricane.

MONDAY, AUGUST 29:

Katrina Lands in New Orleans

OCF lost power in the early morning of August 29. Our facility sustained water and roof damage on the top floors of the hospital and unexpected ceiling glass breaks in the walkways. The howling of the intense wind created an ominous feeling among all of those sheltered in the facility. Fortunately, only minor flooding occurred around the institution.

In contrast, major flooding was reported throughout metropolitan New Orleans—especially in New Orleans East and surrounding low-lying parishes. Major wind damage was seen in buildings in the central business district, and 100% of the power was out in that area.

Downtown New Orleans and the French Quarter were dry thanks to the pumping system. Disturbingly, though, breaches in the levee system protecting New Orleans were reported in the 17th Street Canal.

By Monday afternoon, our entire facility was running on emergency generators, which provided energy only for essential equipment and left the institution with no air-conditioning, minimal lighting, and no plumbing. Physicians used flashlights to see patients, and the rooms became unbearably hot and humid; the heat index outside was 105 degrees Fahrenheit.

All regular communications went off service, including telephone lines, cell phones, and outside pagers. Fortunately OCF had invested in Spectralink phones in the past few years; this internal, antenna-based phone system continued to function. We were even able to dial long-distance intermittently. Our information system also went down, but we kept generator power for intermittent use of the Internet and Intranet to allow our employees to access information and contact with the outside world. At night—from the towers of our hospital—it was strange to see our former city of lights in total darkness.

TUESDAY, AUGUST 30:

Hurricane Aftermath Day 1

Reports of catastrophic flooding and heroic rooftop rescues in New Orleans East and other parishes were announced on the radio and via the Internet. Unfortunately the levee breach at the 17th Street Canal became uncontrolled, and water began flowing from Lake Pontchartrain into New Orleans, ultimately flooding 80% of the city of New Orleans. The Superdome and the Convention Center began to fill with thousands of refugees.

The lack of electricity, inadequate food and water supplies, overcrowding, lack of adequate sanitary conditions, and—later—security concerns exponentially created a humanitarian crisis. We were devastated by the plight of our fellow New Orleans residents, whose only crime was, largely, being too poor to evacuate. Approximately 300,000 people never evacuated, and this posed an interminable challenge for city, state, and federal governments. Unfortunately the acts of a few heartless gangs tarnished the beautiful and friendly image of the Big Easy.

At Ochsner we began to conserve our resources because of the commitment to care for more than 500 people onsite. Our dietary department provided approximately 1,600 meals daily, working in hot and sweaty conditions. In the hospital the heat began to take a physical toll on everyone. We also suffered the psychological toll of not knowing what had happened to our families, friends, and belongings. We lost the ability to run most laboratory studies. We concentrated our efforts in preserving human lives with only basic means.

With no working elevators, navigating 11 floors of the hospital was a challenge for all. Our survival tactics included not just adequate fluid hydration, but electrolyte replacement. Unexpectedly, we discovered that OCF had invested in a deep-well water system separate

from the county water supply in the hospital. Thus the hospital continued to have water for at least the first three floors. The cool well water provided much-needed refreshing showers and maintained adequate sanitary conditions.

One of our hospitalists evacuated from OCF (along with several of our team’s family members) to Houston. On their way, they passed downed power-lines, a daiquiri shop in flames, and cars carrying boats on their roofs into New Orleans to help rescue stranded people.

WEDNESDAY, AUGUST 31:

Hurricane Aftermath Day 2

Conditions in downtown New Orleans became increasing dire with rising floodwater, hunger, thirst, and reports of looting and unrest. Rumors started to spread about the status and safety of OCF. One stated that OCF had looted a nearby Wal-Mart for food and supplies even though, in fact, senior executives of Wal-Mart personally inventoried the items and generously donated them to our institution.

There were also rumors about looters approaching from downtown. Family members outside the city were urging our employees to leave because of the danger of continued flooding and civil unrest. OCF administrators (under the leadership of the CEO Patrick Quinlan, MD, President and COO Warner Thomas, MD, and Medical Director Richard Guthrie, MD) actively addressed these issues to stop the rumors with scheduled and mandatory open forums. During the next few days, OCF was in a lock-down mode with the National Guard and our own security department providing security.

Not knowing the capability of our facility in this time of extreme uncertainly, we proceeded to discharge and move patients to other centers, such as Memorial Hermann Hospital in Houston and Summit Hospital in Baton Rouge via both helicopter and ambulance.

Simultaneously we focused on patients who were stable and ready for discharge to increase our organization capacity to create a plan for providing resource for both the east and west banks of the Mississippi River.

THURSDAY, SEPTEMBER 1:

Hurricane Aftermath Day 3

With the city of New Orleans under marshal law, OCF continued in lock-down mode. During the aftermath, a high priority was to contact all the evacuated employees. An employee outreach program was implemented in which each department accounted for the whereabouts of all personnel. As for our hospitalist program, we started to meet twice daily immediately after the hurricane to address concerns of emergency department volumes, maintain open communications, provide mutual psychological support, and foster a spirit of teamwork. During these meetings we believed that our department had cemented a bond that could not be created in normal circumstances. Our efforts through the storm and the unimaginable adversity were nothing short of extraordinary.

Our medical colleagues in Charity Hospital in downtown New Orleans faced unprecedented challenges caring for patients with minimal supplies. We heard reports of doctors giving each other IV hydration and medical personnel bagging ventilator patients in shifts. With no communication except the Internet, they resorted to e-mailing CNN for help.

FRIDAY, SEPTEMBER 2:

Hurricane Aftermath Day 4

President Bush arrived to visit New Orleans and other devastated areas in the Gulf region. With the National Guard moving in to provide security and relief efforts, Mayor Nagin declared the day a turning point for the city. After the hurricane, it was uncertain how many patients would require medical care in the community. From the Hurricane Ivan experience in Pensacola, Fla., we were advised that 10 days after the disaster, one could anticipate a doubling of the highest emergency department volume for several weeks.

We were uncertain that the evacuation of the whole city could provide such volume. To offer quality clinical care and remain in sound mind under such conditions, we hospitalists unanimously agreed to care for our patients 24/7 in weekly rotation. Our hospital census during this period was at 60% of usual and the admission was running at 40% of normal. We decreased the residents from three members per team to two in order to provide a five-day rotation of three teams. We utilized the staging center of Ochsner Baton Rouge to organize our employees and provide transportation to and from New Orleans. Employees were discouraged from driving in

their own vehicles due to gasoline shortage and safety concerns.

SATURDAY, SEPTEMBER 3:

Hurricane Aftermath Day 5

Conditions in New Orleans improved rapidly with better security. Evacuees were steadily transported out of the Superdome and Convention Center. Hurricane Katrina disasters posed new challenges in providing care. We saw patients with

• Severe dehydration;
• Exhaustion caused by the lack of use or incorrect use of their medications for days resulting in exacerbation of chronic conditions such as COPD;
• Water-borne illnesses from prolonged immersion in toxic water;
• Reactive airway diseases from environmental allergens;
• Cellulitis from cuts and bruises in evacuees, as well as people attempting home repairs;
• Carbon monoxide poisoning from generators used incorrectly inside homes; and
• Withdrawals from illicit drug uses.

SUNDAY, SEPTEMBER 4:

Hurricane Aftermath Day 6

During the Sunday ad-hoc church service at Ochsner, doctors, nurses, employees, patients, and families came together in spiritual healing. We sang praises of hope and optimism for our community. We were grateful for our status in this unbelievable disaster and offered prayers and hope for those who had lost so much. We had never been so proud of the efforts of every individual in our institution for maintaining this facility for patient care in such dire situations and promised to be optimistic about our future.

Fortunately, with the help of the Jefferson Parish emergency utility crews, power was restored to our institution. We became fully functional to take on the challenges of the community.

MONDAY, SEPTEMBER 5:

Hurricane Aftermath Day 7

The 17th Street Canal breach was controlled and the water pump back in operation. Residents of Jefferson Parish were allowed to return to take their personal items from their houses but were still under voluntary evacuation, while Orleans Parish was still closed. To plan the demand for medical care in the wake of gradual recovery, OCF began to maintain all of our employees through strategic deployments in various satellite clinics and hospitals according to the needs of the population in New Orleans and other areas.

LESSONS LEARNED

We have learned so much from this disaster. The key to overcome such adverse conditions entails strong psychosocial support from colleagues and family. Strong leadership is crucial to maintain a sense of serenity and an optimistic outlook in times of uncertainty. We experienced a sense of camaraderie after seeing all medical personnel participating in activities beyond of the boundary of usual roles.

The expansion of the essential personnel team list to include social workers and discharge planners is crucial to focus on the unique and nonconventional logistical challenges post-disaster. Intense focus on group dynamics was essential to avoid physical and emotional burnout. Frequent and predictably scheduled face-to-face communication was also important in disseminating accurate, unadulterated information because our decision-making changed hour-to-hour immediately after Hurricane Katrina, day-to-day in the few days afterward, and week-to-week just one week post-disaster.

Obviously the financial implications are immense for our city and our institution. We are developing financial plans, a relief fund, and other resources to assist our employees who have been severely affected by the hurricane. TH

Dr. Deitelzweig and Dr. Lee work at the Ochsner Clinic Foundation, Department of Hospital-Based Internal Medicine, New Orleans. You can contact Dr. Deitelzweig by phone at (504) 842-5766; his e-mail is sdeiteilzweig@ochsner.org

Supplement Editors:
Robert M. Palmer, MD, MPH, and Richard J. Lederman, MD, PhD

Contents

Preface: Internists and the older patient with neurologic illness
Robert M. Palmer, MD, MPH, and Richard J. Lederman, MD, PhD

The art of managing dementia in the elderly
Adam Rosenblatt, MD

Preventing ischemic stroke in the older adult
Geoffrey S.F. Ling, MD, PhD, and Shari M. Ling, MD

Seizures in the elderly: Nuances in presentation and treatment
Elizabeth Waterhouse, MD, and Alan Towne, MD

Movement disorders in the older patient: Differential diagnosis and general management
Mark S. Baron, MD

Depression in older patients with neurologic illness: Causes, recognition, management
Alan Carson, MBChB, MPhil, MD, and Richard Margolin, MD

Supplement Editors:
Robert M. Palmer, MD, MPH, and Richard J. Lederman, MD, PhD

Contents

Preface: Internists and the older patient with neurologic illness
Robert M. Palmer, MD, MPH, and Richard J. Lederman, MD, PhD

The art of managing dementia in the elderly
Adam Rosenblatt, MD

Preventing ischemic stroke in the older adult
Geoffrey S.F. Ling, MD, PhD, and Shari M. Ling, MD

Seizures in the elderly: Nuances in presentation and treatment
Elizabeth Waterhouse, MD, and Alan Towne, MD

Movement disorders in the older patient: Differential diagnosis and general management
Mark S. Baron, MD

Depression in older patients with neurologic illness: Causes, recognition, management
Alan Carson, MBChB, MPhil, MD, and Richard Margolin, MD

Supplement Editors:
Robert M. Palmer, MD, MPH, and Richard J. Lederman, MD, PhD

Contents

Preface: Internists and the older patient with neurologic illness
Robert M. Palmer, MD, MPH, and Richard J. Lederman, MD, PhD

The art of managing dementia in the elderly
Adam Rosenblatt, MD

Preventing ischemic stroke in the older adult
Geoffrey S.F. Ling, MD, PhD, and Shari M. Ling, MD

Seizures in the elderly: Nuances in presentation and treatment
Elizabeth Waterhouse, MD, and Alan Towne, MD

Movement disorders in the older patient: Differential diagnosis and general management
Mark S. Baron, MD

Depression in older patients with neurologic illness: Causes, recognition, management
Alan Carson, MBChB, MPhil, MD, and Richard Margolin, MD