Innovations in Healthcare

A recent study published in the Journal of Hospital Medicine reports on an early warning and response system (EWRS) for sepsis used in all three hospitals within the Philadelphia-based University of Pennsylvania Health System (UPHS) for three-month spans in 2012 and 2013. The system integrates laboratory values and vital signs into patients EHRs and establishes a threshold for triggering the alert.

After implementing the EWRS, at-risk patients received faster care for sepsis and/or were transferred to the ICU more quickly, says lead author Craig A. Umscheid, MD, MSCE, director of the Center for Evidence-Based Practice at the University of Pennsylvania in Philadelphia. Study authors also note that quicker care suggested reduced mortality from sepsis as well.

"Whenever a patient triggered the alert, their probability of mortality was much higher than patients who didn't trigger the alert," Dr. Umscheid says. "I think what makes our study unique compared to other studies that have tried to predict sepsis is that beyond just creating a prediction rule for sepsis, we actually implemented it into a clinical care setting, alerted providers in real time, and then those providers changed their care based on the prediction."

More than 90% of care teams arrived at the bedside when they received an alert. "Meaning that they saw some value in the alert, and the infrastructure that we put in place was able to mobilize the team and get them to the bedside within 30 minutes," Dr. Umscheid adds. "We saw an increase in sepsis antibiotics used, and we saw an increase in fluid boluses within six hours.”

As many as 3 million cases of severe sepsis occur in the U.S. annually, and 750,000 result in deaths, according to the study. The high number of cases has led to several efforts to create better clinical practices for sepsis patients.

"Sepsis is arguably one of the most, if not the most important, causes of preventable mortality in the inpatient setting," Dr. Umscheid says. "One thing that we thought we could do better was identify sepsis cases earlier so that we could provide early antibiotics and fluids."

Visit our website for more information on identifying and treating sepsis.

A recent study published in the Journal of Hospital Medicine reports on an early warning and response system (EWRS) for sepsis used in all three hospitals within the Philadelphia-based University of Pennsylvania Health System (UPHS) for three-month spans in 2012 and 2013. The system integrates laboratory values and vital signs into patients EHRs and establishes a threshold for triggering the alert.

After implementing the EWRS, at-risk patients received faster care for sepsis and/or were transferred to the ICU more quickly, says lead author Craig A. Umscheid, MD, MSCE, director of the Center for Evidence-Based Practice at the University of Pennsylvania in Philadelphia. Study authors also note that quicker care suggested reduced mortality from sepsis as well.

"Whenever a patient triggered the alert, their probability of mortality was much higher than patients who didn't trigger the alert," Dr. Umscheid says. "I think what makes our study unique compared to other studies that have tried to predict sepsis is that beyond just creating a prediction rule for sepsis, we actually implemented it into a clinical care setting, alerted providers in real time, and then those providers changed their care based on the prediction."

More than 90% of care teams arrived at the bedside when they received an alert. "Meaning that they saw some value in the alert, and the infrastructure that we put in place was able to mobilize the team and get them to the bedside within 30 minutes," Dr. Umscheid adds. "We saw an increase in sepsis antibiotics used, and we saw an increase in fluid boluses within six hours.”

As many as 3 million cases of severe sepsis occur in the U.S. annually, and 750,000 result in deaths, according to the study. The high number of cases has led to several efforts to create better clinical practices for sepsis patients.

"Sepsis is arguably one of the most, if not the most important, causes of preventable mortality in the inpatient setting," Dr. Umscheid says. "One thing that we thought we could do better was identify sepsis cases earlier so that we could provide early antibiotics and fluids."

Visit our website for more information on identifying and treating sepsis.

A recent study published in the Journal of Hospital Medicine reports on an early warning and response system (EWRS) for sepsis used in all three hospitals within the Philadelphia-based University of Pennsylvania Health System (UPHS) for three-month spans in 2012 and 2013. The system integrates laboratory values and vital signs into patients EHRs and establishes a threshold for triggering the alert.

After implementing the EWRS, at-risk patients received faster care for sepsis and/or were transferred to the ICU more quickly, says lead author Craig A. Umscheid, MD, MSCE, director of the Center for Evidence-Based Practice at the University of Pennsylvania in Philadelphia. Study authors also note that quicker care suggested reduced mortality from sepsis as well.

"Whenever a patient triggered the alert, their probability of mortality was much higher than patients who didn't trigger the alert," Dr. Umscheid says. "I think what makes our study unique compared to other studies that have tried to predict sepsis is that beyond just creating a prediction rule for sepsis, we actually implemented it into a clinical care setting, alerted providers in real time, and then those providers changed their care based on the prediction."

More than 90% of care teams arrived at the bedside when they received an alert. "Meaning that they saw some value in the alert, and the infrastructure that we put in place was able to mobilize the team and get them to the bedside within 30 minutes," Dr. Umscheid adds. "We saw an increase in sepsis antibiotics used, and we saw an increase in fluid boluses within six hours.”

As many as 3 million cases of severe sepsis occur in the U.S. annually, and 750,000 result in deaths, according to the study. The high number of cases has led to several efforts to create better clinical practices for sepsis patients.

"Sepsis is arguably one of the most, if not the most important, causes of preventable mortality in the inpatient setting," Dr. Umscheid says. "One thing that we thought we could do better was identify sepsis cases earlier so that we could provide early antibiotics and fluids."

Visit our website for more information on identifying and treating sepsis.

Clinical question: Do signouts vary in the quality and quantity of information, and what are the various factors affecting signout quality?

Background: Miscommunication during transfers of responsibility for hospitalized patients is common and can result in harm. Recommendations for safe and effective handoffs emphasize key content, clear communication, senior staff supervision, and adequate time for questions. Still, little is known about adherence to these recommendations in clinical practice.

Study design: Prospective, observational cohort.

Setting: Medical unit of an acute-care teaching hospital.

Synopsis: Oral signouts were audiotaped among IM house staff teams and the accompanying written signouts were collected for review of content. Signout sessions (n=88) included eight IM teams at one hospital and contained 503 patient signouts.

The median signout duration was 35 seconds (IQR 19-62) per patient. Key clinical information was present in just 62% of combined written or oral signouts. Most signouts included no questions from the recipient. Factors associated with higher rate of content inclusion included: familiarity with the patient, sense of responsibility (primary team vs. covering team), only one signout per day (as compared to sequential signout), presence of a senior resident, and comprehensive, written signouts.

Study limitations include the Hawthorne effect, as several participants mentioned that the presence of audiotape led to more comprehensive signouts than are typical. Also, the signout quality assessment in this study has not been validated with patient-safety outcomes.

Bottom line: Signouts among internal-medicine residents at this one hospital showed variability in terms of quantitative and qualitative information and often missed crucial information about patient care.

Citation: Horwitz LI, Moin T, Krumholz HM, Wang L, Bradley EH. What are covering doctors told about their patients? Analysis of sign-out among internal medicine house staff. Qual Saf Health Care. 2009;18(4):248-255.

Clinical question: Do signouts vary in the quality and quantity of information, and what are the various factors affecting signout quality?

Background: Miscommunication during transfers of responsibility for hospitalized patients is common and can result in harm. Recommendations for safe and effective handoffs emphasize key content, clear communication, senior staff supervision, and adequate time for questions. Still, little is known about adherence to these recommendations in clinical practice.

Study design: Prospective, observational cohort.

Setting: Medical unit of an acute-care teaching hospital.

Synopsis: Oral signouts were audiotaped among IM house staff teams and the accompanying written signouts were collected for review of content. Signout sessions (n=88) included eight IM teams at one hospital and contained 503 patient signouts.

The median signout duration was 35 seconds (IQR 19-62) per patient. Key clinical information was present in just 62% of combined written or oral signouts. Most signouts included no questions from the recipient. Factors associated with higher rate of content inclusion included: familiarity with the patient, sense of responsibility (primary team vs. covering team), only one signout per day (as compared to sequential signout), presence of a senior resident, and comprehensive, written signouts.

Study limitations include the Hawthorne effect, as several participants mentioned that the presence of audiotape led to more comprehensive signouts than are typical. Also, the signout quality assessment in this study has not been validated with patient-safety outcomes.

Bottom line: Signouts among internal-medicine residents at this one hospital showed variability in terms of quantitative and qualitative information and often missed crucial information about patient care.

Citation: Horwitz LI, Moin T, Krumholz HM, Wang L, Bradley EH. What are covering doctors told about their patients? Analysis of sign-out among internal medicine house staff. Qual Saf Health Care. 2009;18(4):248-255.

Clinical question: Do signouts vary in the quality and quantity of information, and what are the various factors affecting signout quality?

Background: Miscommunication during transfers of responsibility for hospitalized patients is common and can result in harm. Recommendations for safe and effective handoffs emphasize key content, clear communication, senior staff supervision, and adequate time for questions. Still, little is known about adherence to these recommendations in clinical practice.

Study design: Prospective, observational cohort.

Setting: Medical unit of an acute-care teaching hospital.

Synopsis: Oral signouts were audiotaped among IM house staff teams and the accompanying written signouts were collected for review of content. Signout sessions (n=88) included eight IM teams at one hospital and contained 503 patient signouts.

The median signout duration was 35 seconds (IQR 19-62) per patient. Key clinical information was present in just 62% of combined written or oral signouts. Most signouts included no questions from the recipient. Factors associated with higher rate of content inclusion included: familiarity with the patient, sense of responsibility (primary team vs. covering team), only one signout per day (as compared to sequential signout), presence of a senior resident, and comprehensive, written signouts.

Study limitations include the Hawthorne effect, as several participants mentioned that the presence of audiotape led to more comprehensive signouts than are typical. Also, the signout quality assessment in this study has not been validated with patient-safety outcomes.

Bottom line: Signouts among internal-medicine residents at this one hospital showed variability in terms of quantitative and qualitative information and often missed crucial information about patient care.

Citation: Horwitz LI, Moin T, Krumholz HM, Wang L, Bradley EH. What are covering doctors told about their patients? Analysis of sign-out among internal medicine house staff. Qual Saf Health Care. 2009;18(4):248-255.

Clinical question: How does traditional, oral signout from emergency providers to inpatient medicine physicians compare to dictated, voicemail signout?

Background: Communication failures contribute to errors in care transition from ED to inpatient medicine units. Signout between ED providers and internal medicine (IM) physicians is typically oral (“synchronous communication”). It is not known how dictated signout to a voicemail system (“asynchronous communication”) affects the quality and safety of handoff communications.

Study design: Prospective, pre-post analysis.

Setting: A 944-bed urban academic medical center in Connecticut.

Synopsis: Surveys were administered to all IM and ED providers before and after the implementation of a voicemail signout system. In the new system, ED providers dictated signout for stable patients, rather than giving traditional synchronous telephone signout. It was the responsibility of the admitting IM physician to listen to the voicemail after receiving a text notification that a patient was being admitted.

ED providers recorded signouts in 89.5% of medicine admissions. However, voicemails were accessed only 58.5% of the time by receiving physicians. All ED providers and 56% of IM physicians believed signout was easier following the voicemail intervention. Overall, ED providers gave the quality, content, and accuracy of their signout communication higher ratings than IM physicians did; 69% of all providers felt the interaction among participants was worse following the intervention. There was no change in the rate of perceived adverse events or ICU transfers within 24 hours after admission.

This intervention was a QI initiative at a single center. Mixed results and small sample size limit generalizability of the study.

Bottom line: Asynchronous signout by voicemail increased efficiency, particularly among ED providers but decreased perceived quality of interaction between medical providers without obviously affecting patient safety.

Citation: Horwitz LI, Parwani V, Shah NR, et al. Evaluation of an asynchronous physician voicemail sign-out for emergency department admissions. Ann Emerg Med. 2009;54:368-378.

Clinical question: How does traditional, oral signout from emergency providers to inpatient medicine physicians compare to dictated, voicemail signout?

Background: Communication failures contribute to errors in care transition from ED to inpatient medicine units. Signout between ED providers and internal medicine (IM) physicians is typically oral (“synchronous communication”). It is not known how dictated signout to a voicemail system (“asynchronous communication”) affects the quality and safety of handoff communications.

Study design: Prospective, pre-post analysis.

Setting: A 944-bed urban academic medical center in Connecticut.

Synopsis: Surveys were administered to all IM and ED providers before and after the implementation of a voicemail signout system. In the new system, ED providers dictated signout for stable patients, rather than giving traditional synchronous telephone signout. It was the responsibility of the admitting IM physician to listen to the voicemail after receiving a text notification that a patient was being admitted.

ED providers recorded signouts in 89.5% of medicine admissions. However, voicemails were accessed only 58.5% of the time by receiving physicians. All ED providers and 56% of IM physicians believed signout was easier following the voicemail intervention. Overall, ED providers gave the quality, content, and accuracy of their signout communication higher ratings than IM physicians did; 69% of all providers felt the interaction among participants was worse following the intervention. There was no change in the rate of perceived adverse events or ICU transfers within 24 hours after admission.

This intervention was a QI initiative at a single center. Mixed results and small sample size limit generalizability of the study.

Bottom line: Asynchronous signout by voicemail increased efficiency, particularly among ED providers but decreased perceived quality of interaction between medical providers without obviously affecting patient safety.

Citation: Horwitz LI, Parwani V, Shah NR, et al. Evaluation of an asynchronous physician voicemail sign-out for emergency department admissions. Ann Emerg Med. 2009;54:368-378.

Clinical question: How does traditional, oral signout from emergency providers to inpatient medicine physicians compare to dictated, voicemail signout?

Background: Communication failures contribute to errors in care transition from ED to inpatient medicine units. Signout between ED providers and internal medicine (IM) physicians is typically oral (“synchronous communication”). It is not known how dictated signout to a voicemail system (“asynchronous communication”) affects the quality and safety of handoff communications.

Study design: Prospective, pre-post analysis.

Setting: A 944-bed urban academic medical center in Connecticut.

Synopsis: Surveys were administered to all IM and ED providers before and after the implementation of a voicemail signout system. In the new system, ED providers dictated signout for stable patients, rather than giving traditional synchronous telephone signout. It was the responsibility of the admitting IM physician to listen to the voicemail after receiving a text notification that a patient was being admitted.

ED providers recorded signouts in 89.5% of medicine admissions. However, voicemails were accessed only 58.5% of the time by receiving physicians. All ED providers and 56% of IM physicians believed signout was easier following the voicemail intervention. Overall, ED providers gave the quality, content, and accuracy of their signout communication higher ratings than IM physicians did; 69% of all providers felt the interaction among participants was worse following the intervention. There was no change in the rate of perceived adverse events or ICU transfers within 24 hours after admission.

This intervention was a QI initiative at a single center. Mixed results and small sample size limit generalizability of the study.

Bottom line: Asynchronous signout by voicemail increased efficiency, particularly among ED providers but decreased perceived quality of interaction between medical providers without obviously affecting patient safety.

Citation: Horwitz LI, Parwani V, Shah NR, et al. Evaluation of an asynchronous physician voicemail sign-out for emergency department admissions. Ann Emerg Med. 2009;54:368-378.

The Institute for Healthcare Improvement (IHI) released its Triple Aim Initiative in 2008, challenging the healthcare industry to undergo extensive systematic change, with the following goals:¹

• Reduce the per capita cost of healthcare;
• Improve the patient experience of care, including quality and satisfaction; and
• Improve the health of populations.

The first two aims are difficult enough, but the third involves engaging and empowering patients and their families to take ownership of their own health and wellness. This is much more than just understanding what your diagnoses are and which medications to take; it is about getting and staying well. Keeping patients and their families well is a goal that has eluded the healthcare industry since before Hippocrates and is an extremely challenging one for hospitalists, whose time with patients is usually limited to an acute care hospital stay.

Naturally, when one industry cannot figure out how to do something well, another industry will develop a breakthrough innovation. Enter Apple Inc., which has officially moved into the health and wellness business. Apple Health is a new app that will share multiple inputs of patient information in a cloud platform called “HealthKit.” HealthKit will allow a user to view a personalized dashboard of health and fitness metrics, which conglomerates information from a myriad of different health and wellness apps, helping them “communicate” with one another.²

The breadth and choice of health and wellness apps available to users is astounding. In a five-minute browse through the app store on my iPhone, I found the following free options to help patients track and understand their health and wellness:

• MyPlate Calorie Tracker, Calorie Counter, and Fooducate help educate and monitor caloric intake.
• iTriage, WebMD, and Mango Health Medication Manager, which can answer questions about symptoms you may be experiencing, will save a list of medications, conditions, procedures, physicians, appointments, and more, and can help you manage your medications.
• Nexercise, MapMyRun, MapMyRide, MapMyFitness, Pacer, and Health Mate track physical activity.
• Fitness Buddy and Daily Workout allow users to view daily workout options and target muscle groups for appropriate exercises.
• ShopWell allows you to scan food labels and evaluate ingredients, calories, gluten, and so on in most store-bought food products.

What Apple proposes to do with its new HealthKit is coordinate the input of these types of apps to synthesize a patient’s health and wellness onto a single platform, which can be shared with caretakers and healthcare providers as needed. The company, as only Apple can, actually declared that its app might be “the beginning of a health revolution.”

A New Day

What HealthKit offers is truly unique from a data security standpoint, which will appeal to Orwellian paranoids. Traditionally, when customers use services such as Google or Yahoo, these services use your personal identity—gathered in pieces of data such as your location and your browsing histories—and then use that data to collect, store, or sell such information on their terms. But Apple promises to help manage health and wellness data on the users’ terms. The purpose is to enable easy but secure sharing of complex health information, which can be updated by users or by other devices. Apple has coordinated with other developers to import information to HealthKit from multiple platforms and devices (such as Nike+, Withings Scale, and Fitbit Flex), acting as a central repository of personalized information.

With this technology, it’s easy to envision hospitals, clinics, pharmacies, laboratories, and even insurers integrating bilaterally with any patient information housed on HealthKit, at the discretion of the user. Mayo Clinic, Cleveland Clinic, Kaiser Permanente, Stanford, UCLA, and Mount Sinai Hospital are all rumored to be working with Apple to figure out how to exchange relevant patient information to enhance the continuity of a patient’s care. In addition to these potential collaborators, electronic health record providers Epic Systems and Allscripts are rumored to be working with Apple in some sort of partnership.^3,4

Not only will HealthKit be a secure repository of information, but it will constantly monitor all the metrics and can be programmed to send alerts to key stakeholders, such as family members or healthcare providers, when any of the metrics veer outside predetermined boundaries.⁴

This “new revolution” in healthcare and wellness should prove extremely helpful to hospitalists, who are often caught in the crosshairs of disjointed patient care delivery systems, and patients who need someone (or something) to track their health and wellness. Imagine a late afternoon admission of a patient who knows exactly what medications she is taking, who can outline several months’ history of caloric intake, physical activity, and basic vital signs, who has an accurate and updated inventory of laboratory exams from other medical centers, and who has a list of all recent physicians and appointments. Although this may seem too good to be true, such an admission may not be too far in the future.

What would be even better is if a patient’s health and wellness tracking keeps him out of the hospital altogether. After all, an Apple a day keeps the doctors away.

Dr. Scheurer is a hospitalist and chief quality officer at the Medical University of South Carolina in Charleston. She is physician editor of The Hospitalist. Email her at scheured@musc.edu.

References

1. Institute for Healthcare Improvement. IHI Triple Aim Initiative. Available at: http://www.ihi.org/Engage/Initiatives/TripleAim/Pages/default.aspx. Accessed August 31, 2014.
2. Apple Inc. Healthkit information page. Available at: https://developer.apple.com/healthkit/. Accessed August 31, 2014.
3. The Advisory Board Company. Daily Briefing: Apple in talks with top hospitals to become ‘hub of health data.’ Available at: http://www.advisory.com/daily-briefing/2014/08/12/apple-in-talks-with-top-hospitals-to-become-hub-of-health-data. Accessed August 31, 2014.
4. Sullivan M. VentureBeat News. Apple announces HealthKit platform and new health app. Available at: http://venturebeat.com/2014/06/02/apple-announces-heath-kit-platform-and-health-app/. Accessed August 31, 2014.

The Institute for Healthcare Improvement (IHI) released its Triple Aim Initiative in 2008, challenging the healthcare industry to undergo extensive systematic change, with the following goals:¹

• Reduce the per capita cost of healthcare;
• Improve the patient experience of care, including quality and satisfaction; and
• Improve the health of populations.

The first two aims are difficult enough, but the third involves engaging and empowering patients and their families to take ownership of their own health and wellness. This is much more than just understanding what your diagnoses are and which medications to take; it is about getting and staying well. Keeping patients and their families well is a goal that has eluded the healthcare industry since before Hippocrates and is an extremely challenging one for hospitalists, whose time with patients is usually limited to an acute care hospital stay.

Naturally, when one industry cannot figure out how to do something well, another industry will develop a breakthrough innovation. Enter Apple Inc., which has officially moved into the health and wellness business. Apple Health is a new app that will share multiple inputs of patient information in a cloud platform called “HealthKit.” HealthKit will allow a user to view a personalized dashboard of health and fitness metrics, which conglomerates information from a myriad of different health and wellness apps, helping them “communicate” with one another.²

The breadth and choice of health and wellness apps available to users is astounding. In a five-minute browse through the app store on my iPhone, I found the following free options to help patients track and understand their health and wellness:

• MyPlate Calorie Tracker, Calorie Counter, and Fooducate help educate and monitor caloric intake.
• iTriage, WebMD, and Mango Health Medication Manager, which can answer questions about symptoms you may be experiencing, will save a list of medications, conditions, procedures, physicians, appointments, and more, and can help you manage your medications.
• Nexercise, MapMyRun, MapMyRide, MapMyFitness, Pacer, and Health Mate track physical activity.
• Fitness Buddy and Daily Workout allow users to view daily workout options and target muscle groups for appropriate exercises.
• ShopWell allows you to scan food labels and evaluate ingredients, calories, gluten, and so on in most store-bought food products.

What Apple proposes to do with its new HealthKit is coordinate the input of these types of apps to synthesize a patient’s health and wellness onto a single platform, which can be shared with caretakers and healthcare providers as needed. The company, as only Apple can, actually declared that its app might be “the beginning of a health revolution.”

A New Day

What HealthKit offers is truly unique from a data security standpoint, which will appeal to Orwellian paranoids. Traditionally, when customers use services such as Google or Yahoo, these services use your personal identity—gathered in pieces of data such as your location and your browsing histories—and then use that data to collect, store, or sell such information on their terms. But Apple promises to help manage health and wellness data on the users’ terms. The purpose is to enable easy but secure sharing of complex health information, which can be updated by users or by other devices. Apple has coordinated with other developers to import information to HealthKit from multiple platforms and devices (such as Nike+, Withings Scale, and Fitbit Flex), acting as a central repository of personalized information.

With this technology, it’s easy to envision hospitals, clinics, pharmacies, laboratories, and even insurers integrating bilaterally with any patient information housed on HealthKit, at the discretion of the user. Mayo Clinic, Cleveland Clinic, Kaiser Permanente, Stanford, UCLA, and Mount Sinai Hospital are all rumored to be working with Apple to figure out how to exchange relevant patient information to enhance the continuity of a patient’s care. In addition to these potential collaborators, electronic health record providers Epic Systems and Allscripts are rumored to be working with Apple in some sort of partnership.^3,4

Not only will HealthKit be a secure repository of information, but it will constantly monitor all the metrics and can be programmed to send alerts to key stakeholders, such as family members or healthcare providers, when any of the metrics veer outside predetermined boundaries.⁴

This “new revolution” in healthcare and wellness should prove extremely helpful to hospitalists, who are often caught in the crosshairs of disjointed patient care delivery systems, and patients who need someone (or something) to track their health and wellness. Imagine a late afternoon admission of a patient who knows exactly what medications she is taking, who can outline several months’ history of caloric intake, physical activity, and basic vital signs, who has an accurate and updated inventory of laboratory exams from other medical centers, and who has a list of all recent physicians and appointments. Although this may seem too good to be true, such an admission may not be too far in the future.

What would be even better is if a patient’s health and wellness tracking keeps him out of the hospital altogether. After all, an Apple a day keeps the doctors away.

Dr. Scheurer is a hospitalist and chief quality officer at the Medical University of South Carolina in Charleston. She is physician editor of The Hospitalist. Email her at scheured@musc.edu.

References

1. Institute for Healthcare Improvement. IHI Triple Aim Initiative. Available at: http://www.ihi.org/Engage/Initiatives/TripleAim/Pages/default.aspx. Accessed August 31, 2014.
2. Apple Inc. Healthkit information page. Available at: https://developer.apple.com/healthkit/. Accessed August 31, 2014.
3. The Advisory Board Company. Daily Briefing: Apple in talks with top hospitals to become ‘hub of health data.’ Available at: http://www.advisory.com/daily-briefing/2014/08/12/apple-in-talks-with-top-hospitals-to-become-hub-of-health-data. Accessed August 31, 2014.
4. Sullivan M. VentureBeat News. Apple announces HealthKit platform and new health app. Available at: http://venturebeat.com/2014/06/02/apple-announces-heath-kit-platform-and-health-app/. Accessed August 31, 2014.

The Institute for Healthcare Improvement (IHI) released its Triple Aim Initiative in 2008, challenging the healthcare industry to undergo extensive systematic change, with the following goals:¹

• Reduce the per capita cost of healthcare;
• Improve the patient experience of care, including quality and satisfaction; and
• Improve the health of populations.

The first two aims are difficult enough, but the third involves engaging and empowering patients and their families to take ownership of their own health and wellness. This is much more than just understanding what your diagnoses are and which medications to take; it is about getting and staying well. Keeping patients and their families well is a goal that has eluded the healthcare industry since before Hippocrates and is an extremely challenging one for hospitalists, whose time with patients is usually limited to an acute care hospital stay.

Naturally, when one industry cannot figure out how to do something well, another industry will develop a breakthrough innovation. Enter Apple Inc., which has officially moved into the health and wellness business. Apple Health is a new app that will share multiple inputs of patient information in a cloud platform called “HealthKit.” HealthKit will allow a user to view a personalized dashboard of health and fitness metrics, which conglomerates information from a myriad of different health and wellness apps, helping them “communicate” with one another.²

The breadth and choice of health and wellness apps available to users is astounding. In a five-minute browse through the app store on my iPhone, I found the following free options to help patients track and understand their health and wellness:

• MyPlate Calorie Tracker, Calorie Counter, and Fooducate help educate and monitor caloric intake.
• iTriage, WebMD, and Mango Health Medication Manager, which can answer questions about symptoms you may be experiencing, will save a list of medications, conditions, procedures, physicians, appointments, and more, and can help you manage your medications.
• Nexercise, MapMyRun, MapMyRide, MapMyFitness, Pacer, and Health Mate track physical activity.
• Fitness Buddy and Daily Workout allow users to view daily workout options and target muscle groups for appropriate exercises.
• ShopWell allows you to scan food labels and evaluate ingredients, calories, gluten, and so on in most store-bought food products.

What Apple proposes to do with its new HealthKit is coordinate the input of these types of apps to synthesize a patient’s health and wellness onto a single platform, which can be shared with caretakers and healthcare providers as needed. The company, as only Apple can, actually declared that its app might be “the beginning of a health revolution.”

A New Day

What HealthKit offers is truly unique from a data security standpoint, which will appeal to Orwellian paranoids. Traditionally, when customers use services such as Google or Yahoo, these services use your personal identity—gathered in pieces of data such as your location and your browsing histories—and then use that data to collect, store, or sell such information on their terms. But Apple promises to help manage health and wellness data on the users’ terms. The purpose is to enable easy but secure sharing of complex health information, which can be updated by users or by other devices. Apple has coordinated with other developers to import information to HealthKit from multiple platforms and devices (such as Nike+, Withings Scale, and Fitbit Flex), acting as a central repository of personalized information.

With this technology, it’s easy to envision hospitals, clinics, pharmacies, laboratories, and even insurers integrating bilaterally with any patient information housed on HealthKit, at the discretion of the user. Mayo Clinic, Cleveland Clinic, Kaiser Permanente, Stanford, UCLA, and Mount Sinai Hospital are all rumored to be working with Apple to figure out how to exchange relevant patient information to enhance the continuity of a patient’s care. In addition to these potential collaborators, electronic health record providers Epic Systems and Allscripts are rumored to be working with Apple in some sort of partnership.^3,4

Not only will HealthKit be a secure repository of information, but it will constantly monitor all the metrics and can be programmed to send alerts to key stakeholders, such as family members or healthcare providers, when any of the metrics veer outside predetermined boundaries.⁴

This “new revolution” in healthcare and wellness should prove extremely helpful to hospitalists, who are often caught in the crosshairs of disjointed patient care delivery systems, and patients who need someone (or something) to track their health and wellness. Imagine a late afternoon admission of a patient who knows exactly what medications she is taking, who can outline several months’ history of caloric intake, physical activity, and basic vital signs, who has an accurate and updated inventory of laboratory exams from other medical centers, and who has a list of all recent physicians and appointments. Although this may seem too good to be true, such an admission may not be too far in the future.

What would be even better is if a patient’s health and wellness tracking keeps him out of the hospital altogether. After all, an Apple a day keeps the doctors away.

Dr. Scheurer is a hospitalist and chief quality officer at the Medical University of South Carolina in Charleston. She is physician editor of The Hospitalist. Email her at scheured@musc.edu.

References

1. Institute for Healthcare Improvement. IHI Triple Aim Initiative. Available at: http://www.ihi.org/Engage/Initiatives/TripleAim/Pages/default.aspx. Accessed August 31, 2014.
2. Apple Inc. Healthkit information page. Available at: https://developer.apple.com/healthkit/. Accessed August 31, 2014.
3. The Advisory Board Company. Daily Briefing: Apple in talks with top hospitals to become ‘hub of health data.’ Available at: http://www.advisory.com/daily-briefing/2014/08/12/apple-in-talks-with-top-hospitals-to-become-hub-of-health-data. Accessed August 31, 2014.
4. Sullivan M. VentureBeat News. Apple announces HealthKit platform and new health app. Available at: http://venturebeat.com/2014/06/02/apple-announces-heath-kit-platform-and-health-app/. Accessed August 31, 2014.

Costs of Care (www.costsofcare.org), a nonprofit dedicated to empowering patients and their caregivers to deflate medical bills, and the American Board of Internal Medicine (ABIM) Foundation plan to launch their second annual Teaching Value and Choosing Wisely Competition this fall to highlight healthcare innovations promoting value. The submission deadline is Feb. 1, 2015.

The Teaching Value Project, the main educational arm of Costs of Care, has developed web-based video training modules based on actual cases, along with other educational materials to help residents and medical students learn to make clinical decisions optimizing quality and cost, says Christopher Moriates, MD, hospitalist and co-chair of the University of California-San Francisco’s High-Value Care Committee.

Details of the contest will be posted at www.teachingvalue.org. For more information, send an e-mail to TeachingValue@CostsofCare.org.

Larry Beresford is a freelance writer in Alameda, Calif.

Costs of Care (www.costsofcare.org), a nonprofit dedicated to empowering patients and their caregivers to deflate medical bills, and the American Board of Internal Medicine (ABIM) Foundation plan to launch their second annual Teaching Value and Choosing Wisely Competition this fall to highlight healthcare innovations promoting value. The submission deadline is Feb. 1, 2015.

The Teaching Value Project, the main educational arm of Costs of Care, has developed web-based video training modules based on actual cases, along with other educational materials to help residents and medical students learn to make clinical decisions optimizing quality and cost, says Christopher Moriates, MD, hospitalist and co-chair of the University of California-San Francisco’s High-Value Care Committee.

Details of the contest will be posted at www.teachingvalue.org. For more information, send an e-mail to TeachingValue@CostsofCare.org.

Larry Beresford is a freelance writer in Alameda, Calif.

Costs of Care (www.costsofcare.org), a nonprofit dedicated to empowering patients and their caregivers to deflate medical bills, and the American Board of Internal Medicine (ABIM) Foundation plan to launch their second annual Teaching Value and Choosing Wisely Competition this fall to highlight healthcare innovations promoting value. The submission deadline is Feb. 1, 2015.

The Teaching Value Project, the main educational arm of Costs of Care, has developed web-based video training modules based on actual cases, along with other educational materials to help residents and medical students learn to make clinical decisions optimizing quality and cost, says Christopher Moriates, MD, hospitalist and co-chair of the University of California-San Francisco’s High-Value Care Committee.

Details of the contest will be posted at www.teachingvalue.org. For more information, send an e-mail to TeachingValue@CostsofCare.org.

Larry Beresford is a freelance writer in Alameda, Calif.

Editor’s note: This is the first of two articles from SHM’s Health Information Technology committee offering practical recommendations for improving electronic health records (EHRs) to reduce readmissions, along with practice-based vignettes to support the recommendations.

Despite limited support from the medical literature, hospital teams know that technology, specifically electronic health record (EHR) technology, can improve healthcare quality. Given 2009’s Health Information Technology for Economic and Clinical Health (HITECH) Act, the federal government is betting on this as well. These hospital teams, often led by hospitalists, are charged with creating workflows and EHR build that will affect measurable quality indicators. Hospital finances, tied to Medicare pay-for-performance incentives, hang in the balance.

As a hospitalist and chairperson of SHM’s IT Quality Subcommittee, I helped lead an effort to examine how technology and EHRs could be used to reduce readmissions. The subcommittee was composed of eight hospitalists from around the country and two mentors, Jerome Osheroff, MD, FACMI, of TMIT Consulting, and Kendall Rogers, MD, CPE, FACP, FHM, of the University of New Mexico. The goal of this effort was to create reproducible models of how EHR and technology in general could be leveraged to reduce readmissions.

Members of the committee initially were asked to evaluate all-cause, 30-day readmissions at their respective institutions. Any hospital with a readmissions rate less than 16% over the previous year was considered “high performing.” Members were asked to advocate for one technology/EHR intervention that had the most impact locally. Interventions were vetted within the committee and based on literature review.

Specific categories evaluated included:

• Readmission risk assessment;
• Communication with referring physicians;
• Medication reconciliation;
• Multidisciplinary rounds;
• Patient education;
• Discharge coaches;
• Patient-centric discharge paperwork;
• Post-discharge coordination of care; and
• Medication compliance.

These site-specific experiences could be considered “springboards” for randomized trials of likely successful interventions.

Recommendation: Use readmission risk assessment to apply resources to most appropriate patients.

Ned Jaleel, DO, MMM, CPE, a hospitalist and informaticist for Meditech Corp., and Maruf Haider, MD, a hospitalist and informaticist for INOVA Healthcare, have mapped implemented processes for real-time assessment of readmission risk stratification and “measurevention” based on this data.

Augusta Health in Fishersville, Va., uses Meditech EHR to extract relevant data about risk assessment and display this data to case managers using the LACE model (length of stay, acuity, comorbidities, ER visits). The modified LACE model included medication information to create a readmission risk score. Case managers can then determine which patients require the most care and attention from the multidisciplinary team.

Dr. Haider has taken this process a step further by using the LACE score to determine the need for specific tiered intervention based on established risk. Average risk patients are simply set up with a follow-up appointment within seven days. Higher risk patients are set up with health coaching, home nursing, or more intense inpatient multidisciplinary rounds based on four tiers of risk stratification. Risk stratification is discussed on rounds, and providers are requested to order the additional services. Patients referred to transitional services had a 6.5% readmission rate compared to the hospitalist groups overall at 15.6%.

Recommendation: Use electronic communication to increase reliability of contact with primary care physicians.

At Lahey Health System in Burlington, Mass., I knew that hospitalists needed to improve communication with PCPs. Telephone communication was unreliable, and discharge summaries were not being delivered to referring physicians in a timely fashion.

The hospitalists already were using a homegrown “patient handoff report” to track currently admitted patients, along with clinical summaries. A decision was made that secure e-mail, driven by data in the handoff reports, could provide the solution. Because the system was between inpatient EHR vendors, it would need to be developed by in-house IT services. A specific challenge would be referring physicians with no attachment to the health system.

Using a secure messaging vendor (ZixCorp), we were able to create e-mail messages to referring physicians using data already in the handoff system to avoid duplication of data entry. The benefit to referring physicians was the brevity and timeliness of the data and the ability to ask questions directly via return e-mail. Fortunately, we were able to request enough e-mails to ensure that the majority of patients with non-system physicians would allow this type of communication. This and other interventions have allowed Lahey to reduce 30-day readmissions to less than 15%.

Recommendation: Use pharmacy resources to improve quality of medication reconciliation.

Rupesh Prasad, MD, MPH, of Aurora Healthcare in Milwaukee, Wisconsin, has spent part of his professional career optimizing medication reconciliation. The key has been incorporating EHR workflows that allow pharmacy to take an active role in medication reconciliation.

Initially, pharmacy technicians collect the home medication list using information from pharmacy, patient and family, and primary physician and enter into the system. This allows the admitting provider to perform the most accurate medication reconciliation possible. The EHR has allowed more accurate sharing of medication lists across inpatient and outpatient care areas and helped to prevent dosing errors and duplication via decision support. The discharge materials provide information in a patient-centric manner that helps reduce medication errors at home. These and other interventions have helped reduce readmission at Aurora to less than 16% at 30 days.

Recommendation: Use EHR resources to support BOOST rounds to improve collaboration.

Gaurav Chaturvedi, MD, of Northwestern Lake Forest Hospital in Lake Forest, Ill., has used his Cerner EHR in collaboration with SHM’s Project BOOST to reduce readmission in 2013 to a very impressive 11% at 30 days.

The key to success is daily multidisciplinary rounds at the bedside involving all members of the care team, including physicians, nurses, case managers, pharmacy, physical therapy, and social work. This ensures that all members of the care team, including the patient and family, are up to date on the care plan at the same time. The EHR has supported this process through creation of templates that pull in critical information for rounds such as ambulation, central lines, VTE prophylaxis, Foley, and medication reconciliation.

With all of the information readily available in the same template for rounds, the team can focus efficiently on the goals of care and discharge needs required to prevent readmissions.

Recommendation: Improve patient education by integrating with discharge workflows.

Dr. Chaturvedi also has experience integrating patient education into EHR workflows. His initial efforts involved heart failure education and resulted in reduction over 48 months in heart failure readmission rates to 8.3% from 27% at 30 days. Prior to discharge, heart failure patients received a guidebook with the medication summary, appointments, diet, and EHR-integrated educational materials from the Krames StayWell database. This highly successful, partially EHR-based intervention included a scale to promote daily weights.

After EHR implementation in 2012, Lake Forest Hospital needed to leverage similar successful functionality into their Cerner EHR. The hospital worked with Cerner to develop Mpages that allowed seamless multi-provider entry on discharge paperwork. This would include primary and secondary diagnoses and warning signs. These entries would “suggest” Krames’ patient-centric educational materials that would discuss diagnosis and treatment, along with warning signs specific to the diagnosis. TH

Dr. Finkel is a hospitalist at Lahey Hospital and Medical Center in Burlington, Mass. Email questions and comments to noah.j.finkel@gmail.com.

Editor’s note: This is the first of two articles from SHM’s Health Information Technology committee offering practical recommendations for improving electronic health records (EHRs) to reduce readmissions, along with practice-based vignettes to support the recommendations.

Despite limited support from the medical literature, hospital teams know that technology, specifically electronic health record (EHR) technology, can improve healthcare quality. Given 2009’s Health Information Technology for Economic and Clinical Health (HITECH) Act, the federal government is betting on this as well. These hospital teams, often led by hospitalists, are charged with creating workflows and EHR build that will affect measurable quality indicators. Hospital finances, tied to Medicare pay-for-performance incentives, hang in the balance.

As a hospitalist and chairperson of SHM’s IT Quality Subcommittee, I helped lead an effort to examine how technology and EHRs could be used to reduce readmissions. The subcommittee was composed of eight hospitalists from around the country and two mentors, Jerome Osheroff, MD, FACMI, of TMIT Consulting, and Kendall Rogers, MD, CPE, FACP, FHM, of the University of New Mexico. The goal of this effort was to create reproducible models of how EHR and technology in general could be leveraged to reduce readmissions.

Members of the committee initially were asked to evaluate all-cause, 30-day readmissions at their respective institutions. Any hospital with a readmissions rate less than 16% over the previous year was considered “high performing.” Members were asked to advocate for one technology/EHR intervention that had the most impact locally. Interventions were vetted within the committee and based on literature review.

Specific categories evaluated included:

• Readmission risk assessment;
• Communication with referring physicians;
• Medication reconciliation;
• Multidisciplinary rounds;
• Patient education;
• Discharge coaches;
• Patient-centric discharge paperwork;
• Post-discharge coordination of care; and
• Medication compliance.

These site-specific experiences could be considered “springboards” for randomized trials of likely successful interventions.

Recommendation: Use readmission risk assessment to apply resources to most appropriate patients.

Ned Jaleel, DO, MMM, CPE, a hospitalist and informaticist for Meditech Corp., and Maruf Haider, MD, a hospitalist and informaticist for INOVA Healthcare, have mapped implemented processes for real-time assessment of readmission risk stratification and “measurevention” based on this data.

Augusta Health in Fishersville, Va., uses Meditech EHR to extract relevant data about risk assessment and display this data to case managers using the LACE model (length of stay, acuity, comorbidities, ER visits). The modified LACE model included medication information to create a readmission risk score. Case managers can then determine which patients require the most care and attention from the multidisciplinary team.

Dr. Haider has taken this process a step further by using the LACE score to determine the need for specific tiered intervention based on established risk. Average risk patients are simply set up with a follow-up appointment within seven days. Higher risk patients are set up with health coaching, home nursing, or more intense inpatient multidisciplinary rounds based on four tiers of risk stratification. Risk stratification is discussed on rounds, and providers are requested to order the additional services. Patients referred to transitional services had a 6.5% readmission rate compared to the hospitalist groups overall at 15.6%.

Recommendation: Use electronic communication to increase reliability of contact with primary care physicians.

At Lahey Health System in Burlington, Mass., I knew that hospitalists needed to improve communication with PCPs. Telephone communication was unreliable, and discharge summaries were not being delivered to referring physicians in a timely fashion.

The hospitalists already were using a homegrown “patient handoff report” to track currently admitted patients, along with clinical summaries. A decision was made that secure e-mail, driven by data in the handoff reports, could provide the solution. Because the system was between inpatient EHR vendors, it would need to be developed by in-house IT services. A specific challenge would be referring physicians with no attachment to the health system.

Using a secure messaging vendor (ZixCorp), we were able to create e-mail messages to referring physicians using data already in the handoff system to avoid duplication of data entry. The benefit to referring physicians was the brevity and timeliness of the data and the ability to ask questions directly via return e-mail. Fortunately, we were able to request enough e-mails to ensure that the majority of patients with non-system physicians would allow this type of communication. This and other interventions have allowed Lahey to reduce 30-day readmissions to less than 15%.

Recommendation: Use pharmacy resources to improve quality of medication reconciliation.

Rupesh Prasad, MD, MPH, of Aurora Healthcare in Milwaukee, Wisconsin, has spent part of his professional career optimizing medication reconciliation. The key has been incorporating EHR workflows that allow pharmacy to take an active role in medication reconciliation.

Initially, pharmacy technicians collect the home medication list using information from pharmacy, patient and family, and primary physician and enter into the system. This allows the admitting provider to perform the most accurate medication reconciliation possible. The EHR has allowed more accurate sharing of medication lists across inpatient and outpatient care areas and helped to prevent dosing errors and duplication via decision support. The discharge materials provide information in a patient-centric manner that helps reduce medication errors at home. These and other interventions have helped reduce readmission at Aurora to less than 16% at 30 days.

Recommendation: Use EHR resources to support BOOST rounds to improve collaboration.

Gaurav Chaturvedi, MD, of Northwestern Lake Forest Hospital in Lake Forest, Ill., has used his Cerner EHR in collaboration with SHM’s Project BOOST to reduce readmission in 2013 to a very impressive 11% at 30 days.

The key to success is daily multidisciplinary rounds at the bedside involving all members of the care team, including physicians, nurses, case managers, pharmacy, physical therapy, and social work. This ensures that all members of the care team, including the patient and family, are up to date on the care plan at the same time. The EHR has supported this process through creation of templates that pull in critical information for rounds such as ambulation, central lines, VTE prophylaxis, Foley, and medication reconciliation.

With all of the information readily available in the same template for rounds, the team can focus efficiently on the goals of care and discharge needs required to prevent readmissions.

Recommendation: Improve patient education by integrating with discharge workflows.

Dr. Chaturvedi also has experience integrating patient education into EHR workflows. His initial efforts involved heart failure education and resulted in reduction over 48 months in heart failure readmission rates to 8.3% from 27% at 30 days. Prior to discharge, heart failure patients received a guidebook with the medication summary, appointments, diet, and EHR-integrated educational materials from the Krames StayWell database. This highly successful, partially EHR-based intervention included a scale to promote daily weights.

After EHR implementation in 2012, Lake Forest Hospital needed to leverage similar successful functionality into their Cerner EHR. The hospital worked with Cerner to develop Mpages that allowed seamless multi-provider entry on discharge paperwork. This would include primary and secondary diagnoses and warning signs. These entries would “suggest” Krames’ patient-centric educational materials that would discuss diagnosis and treatment, along with warning signs specific to the diagnosis. TH

Dr. Finkel is a hospitalist at Lahey Hospital and Medical Center in Burlington, Mass. Email questions and comments to noah.j.finkel@gmail.com.

Editor’s note: This is the first of two articles from SHM’s Health Information Technology committee offering practical recommendations for improving electronic health records (EHRs) to reduce readmissions, along with practice-based vignettes to support the recommendations.

Despite limited support from the medical literature, hospital teams know that technology, specifically electronic health record (EHR) technology, can improve healthcare quality. Given 2009’s Health Information Technology for Economic and Clinical Health (HITECH) Act, the federal government is betting on this as well. These hospital teams, often led by hospitalists, are charged with creating workflows and EHR build that will affect measurable quality indicators. Hospital finances, tied to Medicare pay-for-performance incentives, hang in the balance.

As a hospitalist and chairperson of SHM’s IT Quality Subcommittee, I helped lead an effort to examine how technology and EHRs could be used to reduce readmissions. The subcommittee was composed of eight hospitalists from around the country and two mentors, Jerome Osheroff, MD, FACMI, of TMIT Consulting, and Kendall Rogers, MD, CPE, FACP, FHM, of the University of New Mexico. The goal of this effort was to create reproducible models of how EHR and technology in general could be leveraged to reduce readmissions.

Members of the committee initially were asked to evaluate all-cause, 30-day readmissions at their respective institutions. Any hospital with a readmissions rate less than 16% over the previous year was considered “high performing.” Members were asked to advocate for one technology/EHR intervention that had the most impact locally. Interventions were vetted within the committee and based on literature review.

Specific categories evaluated included:

• Readmission risk assessment;
• Communication with referring physicians;
• Medication reconciliation;
• Multidisciplinary rounds;
• Patient education;
• Discharge coaches;
• Patient-centric discharge paperwork;
• Post-discharge coordination of care; and
• Medication compliance.

These site-specific experiences could be considered “springboards” for randomized trials of likely successful interventions.

Recommendation: Use readmission risk assessment to apply resources to most appropriate patients.

Ned Jaleel, DO, MMM, CPE, a hospitalist and informaticist for Meditech Corp., and Maruf Haider, MD, a hospitalist and informaticist for INOVA Healthcare, have mapped implemented processes for real-time assessment of readmission risk stratification and “measurevention” based on this data.

Augusta Health in Fishersville, Va., uses Meditech EHR to extract relevant data about risk assessment and display this data to case managers using the LACE model (length of stay, acuity, comorbidities, ER visits). The modified LACE model included medication information to create a readmission risk score. Case managers can then determine which patients require the most care and attention from the multidisciplinary team.

Dr. Haider has taken this process a step further by using the LACE score to determine the need for specific tiered intervention based on established risk. Average risk patients are simply set up with a follow-up appointment within seven days. Higher risk patients are set up with health coaching, home nursing, or more intense inpatient multidisciplinary rounds based on four tiers of risk stratification. Risk stratification is discussed on rounds, and providers are requested to order the additional services. Patients referred to transitional services had a 6.5% readmission rate compared to the hospitalist groups overall at 15.6%.

Recommendation: Use electronic communication to increase reliability of contact with primary care physicians.

At Lahey Health System in Burlington, Mass., I knew that hospitalists needed to improve communication with PCPs. Telephone communication was unreliable, and discharge summaries were not being delivered to referring physicians in a timely fashion.

The hospitalists already were using a homegrown “patient handoff report” to track currently admitted patients, along with clinical summaries. A decision was made that secure e-mail, driven by data in the handoff reports, could provide the solution. Because the system was between inpatient EHR vendors, it would need to be developed by in-house IT services. A specific challenge would be referring physicians with no attachment to the health system.

Using a secure messaging vendor (ZixCorp), we were able to create e-mail messages to referring physicians using data already in the handoff system to avoid duplication of data entry. The benefit to referring physicians was the brevity and timeliness of the data and the ability to ask questions directly via return e-mail. Fortunately, we were able to request enough e-mails to ensure that the majority of patients with non-system physicians would allow this type of communication. This and other interventions have allowed Lahey to reduce 30-day readmissions to less than 15%.

Recommendation: Use pharmacy resources to improve quality of medication reconciliation.

Rupesh Prasad, MD, MPH, of Aurora Healthcare in Milwaukee, Wisconsin, has spent part of his professional career optimizing medication reconciliation. The key has been incorporating EHR workflows that allow pharmacy to take an active role in medication reconciliation.

Initially, pharmacy technicians collect the home medication list using information from pharmacy, patient and family, and primary physician and enter into the system. This allows the admitting provider to perform the most accurate medication reconciliation possible. The EHR has allowed more accurate sharing of medication lists across inpatient and outpatient care areas and helped to prevent dosing errors and duplication via decision support. The discharge materials provide information in a patient-centric manner that helps reduce medication errors at home. These and other interventions have helped reduce readmission at Aurora to less than 16% at 30 days.

Recommendation: Use EHR resources to support BOOST rounds to improve collaboration.

Gaurav Chaturvedi, MD, of Northwestern Lake Forest Hospital in Lake Forest, Ill., has used his Cerner EHR in collaboration with SHM’s Project BOOST to reduce readmission in 2013 to a very impressive 11% at 30 days.

The key to success is daily multidisciplinary rounds at the bedside involving all members of the care team, including physicians, nurses, case managers, pharmacy, physical therapy, and social work. This ensures that all members of the care team, including the patient and family, are up to date on the care plan at the same time. The EHR has supported this process through creation of templates that pull in critical information for rounds such as ambulation, central lines, VTE prophylaxis, Foley, and medication reconciliation.

With all of the information readily available in the same template for rounds, the team can focus efficiently on the goals of care and discharge needs required to prevent readmissions.

Recommendation: Improve patient education by integrating with discharge workflows.

Dr. Chaturvedi also has experience integrating patient education into EHR workflows. His initial efforts involved heart failure education and resulted in reduction over 48 months in heart failure readmission rates to 8.3% from 27% at 30 days. Prior to discharge, heart failure patients received a guidebook with the medication summary, appointments, diet, and EHR-integrated educational materials from the Krames StayWell database. This highly successful, partially EHR-based intervention included a scale to promote daily weights.

After EHR implementation in 2012, Lake Forest Hospital needed to leverage similar successful functionality into their Cerner EHR. The hospital worked with Cerner to develop Mpages that allowed seamless multi-provider entry on discharge paperwork. This would include primary and secondary diagnoses and warning signs. These entries would “suggest” Krames’ patient-centric educational materials that would discuss diagnosis and treatment, along with warning signs specific to the diagnosis. TH

Dr. Finkel is a hospitalist at Lahey Hospital and Medical Center in Burlington, Mass. Email questions and comments to noah.j.finkel@gmail.com.

Christine Lum Lung, MD, SFHM

When SHM received the Joint Commission’s John M. Eisenberg Patient Safety and Quality Award for 2011 for innovation in patient safety and quality at the national level, the award represented national recognition for the society’s three major hospital quality improvement initiatives. Moreover, it highlighted the integral role mentors play in each of the programs, helping physicians and hospitals make accelerated progress on important patient safety and quality issues.

Mentored implementation assigns a physician expert to train, guide, and work with the participating facilities’ hospitalist-led, multidisciplinary team through the life cycle of a QI initiative. The three programs focus on VTE prevention, glycemic control, and transitions of care. The first hospital cohort for VTE prevention—the VTE Prevention Collaborative—was in 2007. The care transitions program, known as Project BOOST, started in 2008. The Glycemic Control Mentored Implementation (GCMI) Program began in 2009. A fourth SHM mentored implementation program is MARQUIS, the Multi-Center Medication Reconciliation Quality Improvement Study.

In basic terms, mentoring is “coaching from a physician who has expertise both in the clinical subject matter and in implementing the processes and tools of quality improvement—usually because they’ve done it themselves,” says Gregory Maynard, MD, MSc, SFHM, senior vice president of SHM’s Center for Hospital Innovation and Improvement and a co-founder of two of its mentored implementation programs.

Mentors typically are paired with one or two participating hospitals for 12 to 18 months, conducting monthly conference calls with the team, sharing tools and resources from SHM’s online library, and offering advice on how to navigate the treacherous currents of culture change within a hospital. BOOST mentors also make in-person site visits. They are well versed in protocol and order set design and quality measurement strategies, and they know how to engage frontline professionals and institutional leadership, Dr. Maynard says.

Some mentors have received formal QI training, and many have attended Mentor University, a 1-1/2 day intensive training course offered by SHM that reinforces the nuances of coaching, the contents of SHM’s quality toolkits, and ideas for overcoming common barriers to improvement. SHM’s mentor support provides continuous professional development for the mentors, pairing new mentors with senior mentors to coach them in the process and hosting an online community with other mentors.

“What’s telling to me is that many of the people who have been mentored by SHM’s programs in one topic go on to become mentors in another topic, taking those portable skills and principles and applying them in other quality areas,” Dr. Maynard says. “We’re fostering leadership and quality improvement skills among hospitalists; that’s really one of our main goals. People learn the skill and then spread it within their system.”

Mark Williams, MD, FACP, MHM, Project BOOST principal investigator and a veteran SHM mentor, says that just providing educational materials to health professionals often isn’t enough for them to overcome the barriers to change.

“I’ve seen many large-scale quality projects that didn’t work, as they were simply disseminating information, content, or knowledge,” he says. Mentored implementation as practiced by SHM is “a model for disseminating quality improvement nationally,” he adds. “Pretty much any quality improvement project can be done this way.”

Key to the mentored implementation program’s success is the personalized approach and customized solutions.

“You directly meet with the team in their own setting and begin to see what’s going on,” Dr. Williams says. “You also meet with the hospital’s senior leadership. That’s when you start to see change.”

The Hospitalist connected with eight SHM mentors. The following are snapshots of their work in the mentorship program and some of the lessons they taught—and learned—from the program.

Christine Lum Lung, MD, SFHM

Christine Lum Lung, MD, SFHM

Title: Medical director, Northern Colorado Hospitalists, Fort Collins

Program: VTE Prevention Collaborative

Background: As a practicing hospitalist and medical director of the HM group for a two-hospital system, Dr. Lum Lung chaired its quality committee for VTE protocol development. “It was obvious at our hospitals that we needed to do better at VTE prevention,” she explains.

Dr. Lum Lung’s team received VTE mentorship from Dr. Maynard, who later asked her to become a VTE mentor. She also attended all three levels of SHM’s Leadership Academy and has since become a mentor for the new HP3 (Hospitalist Program Peak Performance) mentored implementation program, a one-year collaboration among SHM, Northwestern University, Blue Cross/Blue Shield of Illinois, and the Illinois Hospital Association that is designed to help hospitalist groups optimize their programs and build healthy group culture.

Teachable moment: The essential qualities of a good mentee, Dr. Lum Lung says, are drive and dedication. “You believe strongly about it, so you can sell it to others. You also need a thick skin to face the adversities that come up. When my mentor gave me tasks and deadlines, I met those deadlines.”

Success story: “I’ve been impressed with how hard groups and individuals can work.” Most of the teams she has worked with were facing significant external stressors—starting a new program, moving into a new hospital, rolling out a new EHR, becoming part of a growing medical group. “Yet each of them has been incredibly engaged in the process and dedicated to completing their projects.”

Lessons learned: “That we all have something to learn from each other. While I am officially the mentor, I have learned a lot about processes, teamwork, and flow issues from the sites that could potentially be incorporated in our program.”

Advice: Working on a project as a team can be very powerful, she says. Even seemingly ‘small’ projects have allowed teams to learn how to work better together on day-to-day issues. With the victory of a small project behind them, they make lists of the next thing that they want to tackle.

“Our profession is constantly changing. We need to be thinking ahead for how we will face those challenges,” Dr. Lum Lung says. “A team that works well together will have an advantage in this new environment. Even if you have people who are new to quality improvement, their participation can still be important.”

Jordan Messler, MD, SFHM

Jordan Messler, MD, SFHM

Title: Medical director, Morton Plant Hospitalists, Clearwater, Fla.

Program: GCMI; Project BOOST

Background: Dr. Messler’s interest in QI led him to work with colleagues in SHM who are national leaders in quality. “A couple of years ago, I enrolled in Emory’s Quality Academy, a sister course to Intermountain Health’s course on quality. Then I enrolled our hospital in both the GCMI Program and Project BOOST. My mentors for those programs were terrific guides, which led to my interest in seeing their side of the program as a mentor myself.”

Teachable moment: One program had difficulty implementing a VTE prevention tool and couldn’t get nursing support as it had expected, largely due to lack of nursing engagement on the project team, he says. “We started talking about the history of the projects, and prior interventions. In addition, we talked to the different disciplines separately. It seems there used to be an excellent system where nursing helped out on the project team for risk assessment.”

As VTE prevention became more of a priority, some physicians separately created a new tool to replace the nursing tool without involving the whole team. “And they couldn’t understand why nursing wasn’t buying into the new process.”

Success story: There are similar themes to success and failure. Sites that have strong administrative support (i.e., C-suite representation on the QI team), that have “accountability structure and stick to the basics of QI, with clear goals, ability to gather and report data, and use of a QI model [such as PDSA or Six Sigma] are the ones that succeed,” Dr. Messler says. “And the reverse is consistently true. Sustainable QI needs to be multidisciplinary, involving every voice, considering prior interventions and understanding of the culture.”

Lessons learned: “As mentors, we all continue to say we learn as much or more from these sites as they, hopefully, are learning from us. This collaboration and sharing of ideas has been instrumental to the success of the program.”

Advice: Get started today, and don’t give up. Follow the road map of QI projects, gather support, and get started. You will learn as much from your failures as your successes.

Dr. Messler says hospitals are looking for physician leaders to improve quality, and hospitalists are perfectly positioned to be those QI leaders. These big projects can last for years, so quality teams and hospitals need to be prepared to take the long view.

Stephanie Rennke, MD

Stephanie Rennke, MD

Title: Associate clinical professor of medicine, co-director of faculty development, division of hospital medicine, University of California San Francisco Medical Center.

Program: Project BOOST

Background: “When I started as a hospitalist right out of residency, QI had not been part of my training. But I noticed that quality was at the forefront of the academic interests of all the hospitalists at UCSF. I was personally interested in transitions of care. I still do home visits after hours for at-risk patients when they leave the hospital.”

Dr. Rennke started in QI as a member of UCSF’s BOOST team in 2008. “I worked with other faculty in the division who had previous experience in quality improvement and transitions in care. One of the co-principal investigators for BOOST, Dr. Arpana Vidyarthi, suggested that it would be a really rewarding experience to mentor—and it was.”

Teachable moment: “I’ve been so impressed by the diversity of what’s out there. No hospitalist program or hospital is the same. There is no one-size-fits-all for quality improvement or transitions of care, so it is incredibly important that the mentor takes the time to get to know both the team and the hospital.”

Success story: “During a site visit, I had an opportunity to watch one of the nurses, who had received training from a competency-based Teach Back program, practice Teach Back with a patient at the bedside,” Dr. Rennke says. “I was doing a tour of the floor and went into the room of a patient about to be discharged. A young float nurse, not long out of school, sat down with the patient and went through the medications and discharge plan using Teach Back. It didn’t take more time, but the time was spent more constructively, with interaction back and forth. I remember that ‘aha’ moment for the patient and the look in her eyes. For me, as a mentor, it was exciting to think that something I had tried to bring to them had been incorporated by the site and was really working.”

Lessons learned: “I have learned that, while at a large institution like UCSF we tend to work in silos, smaller sites are often more integrated with the various disciplines. You can walk down the hall to the clinical pharmacist or have lunch with the charge nurse. So I’ve tried to bring back home a commitment to really get to know professional colleagues and have them feel that I’m interested in their perspectives.”

Advice: “Work in teams. You cannot do this alone. Include frontline staff. And don’t forget to advertise to others that the program exists. Get the word out—let people know.”

Jennifer Quartarolo, MD, SFHM

Jennifer Quartarolo, MD, SFHM

Title: Medical director, clinical resource management; associate clinical professor, division of hospital medicine, University of California San Diego Health System

Program: Project BOOST

Background: Dr. Quartarolo has 11 years of clinical experience as an academic hospitalist at two different medical centers, and she completed a training program in healthcare delivery and improvement through the Institute for Health Care Delivery Research in Salt Lake City, Utah. “At my own institution, I had been involved in multiple QI projects,” she says. “Since joining the faculty, I worked with our care transitions team for five years before becoming a mentor. We incorporated many elements from Project BOOST as we worked to improve our care transitions process,” which led to an invitation to be a mentor.

Teachable moment: “I had one site that I worked with that had a great new form they had developed to incorporate into their transition process; however, when they decided to implement the form, they got a lot of pushback from nursing,” she says. “Then they realized that they had not involved any frontline nurses in their planning. This example points out how important it is to have all the key players involved on your team, as improving transitions of care is a complex process requiring multidisciplinary collaboration.”

Success story: Dr. Quartarolo says she has worked with several hospitals that have seen significant improvement in their readmission rates after participating in Project BOOST and implementing its tools.

Lessons learned: “I am constantly impressed by the innovative ideas that teams come up with to deal with the challenges that their hospitals face,” she says. Every hospital is unique and needs to do self-evaluation before deciding what to focus on. “I have also worked with many sites that have challenges getting physicians engaged in their efforts, particularly if they do not have a hospitalist program.”

Advice: “We are in a unique role as hospitalists to identify systems issues and improve quality of care in the inpatient setting, and this is particularly useful in improving care transitions and decreasing readmissions rates.”

Rich Balaban, MD

Rich Balaban, MD

Title: Medical director, Hospital-to-Home Community Collaboration Program, Cambridge Health Alliance; assistant professor of medicine, Harvard Medical School, Boston

Program: Project BOOST

Background: Dr. Balaban has worked clinically in both the inpatient setting as a hospitalist and the outpatient setting as a primary care doctor. “I have seen hospital discharges as both a receiver and a sender, so [I] have been able to appreciate the challenges facing doctors, nurses, case managers, and patients involved in the care transition process,” he says.

Dr. Balaban also conducted a randomized controlled trial that demonstrated the benefits of engaging nurses at a patient’s primary care site to make outreach phone calls immediately after hospital discharge. Dr. Williams asked him to present on the study.

“It was a great opportunity for me to share the results of our work and for Mark to see my presentation skills,” he says. “When I asked if there were opportunities to get more involved in care transitions work, he invited me to consider becoming a BOOST mentor.”

Teachable moment: “Wearing my primary care hat, I believe that while it is very important to structure an effective discharge for the patient while in the hospital, success or failure ultimately is determined by what happens in the outpatient setting,” Dr. Balaban says. Even if a ‘perfect discharge’ occurs in the hospital, it can all quickly unravel once the patient arrives at home.

Success story: “At several sites, I have encouraged the inpatient care team to invite the outpatient care team to become part of the care transitions team. This has frequently brought an important viewpoint and voice to the care transitions table. While hospitalists have initiated the discussion about care transitions, they need an effective outpatient partner to create a truly effective process.”

Lessons learned: “I have learned to hold judgment until seeing with my own eyes,” Dr. Balaban says. “One of the first sites I visited had developed a post-discharge clinic, which they were excited to show me. From my point of view, I thought that after discharge, patient care should be assumed by the primary care office as soon as possible, and a post-discharge clinic would only delay that process.

“To my great surprise, their post-discharge clinic provided an ideal bridge between the hospital and primary care. The post-discharge clinic really worked and provided patients with a wonderful resource. … I’ve learned that there are many ways to solve problems, often based on the available resources at a specific site.”

Advice: In order to best understand the challenges of hospital discharge, it is critical that you understand what happens to patients after they leave the hospital. Make a home visit to a recently discharged patient to really understand the challenges that patients face when they return home.

Amitkumar R. Patel, MD, MBA, FACP, SFHM

Amitkumar R. Patel, MD, MBA, FACP, SFHM

Title: Clinical instructor in hospital medicine, Feinberg School of Medicine, Northwestern University, Chicago

Program: Project BOOST; also working with critical access hospitals in Illinois through PREP (Preventing Readmissions through Effective Partnerships)

Background: Although he now works in an urban teaching hospital, Dr. Patel also did private practice as a community hospitalist and has pursued formal healthcare management-focused training.

“I became a mentor because my experience and interest in quality improvement fit well with Project BOOST,” he says. “I enjoy coaching teams as they face challenges in quality improvement, especially in relation to readmissions reduction. My work with critical access hospitals is the result of my first year as a mentor with the PREP collaborative in Illinois.”

PREP, a collaborative initiative of SHM and the Illinois Hospital Association that is funded by Blue Cross/Blue Shield of Illinois, aims to help hospitals focus on quality initiatives, including BOOST.

Teachable moment/success story: One of Dr. Patel’s BOOST sites believed the team included all appropriate personnel to obtain discharge appointments prior to patients’ discharges. But as they began to work through the process of making sure each appointment was appropriately documented, the various team members assigned to this process could not consistently complete the task within their workflow.

The pilot unit secretaries were not part of the BOOST team initially but saw that they could fulfill this role quickly and easily. They knew who to call at the physicians’ offices to avoid getting stuck in the phone menu trees, and they used this knowledge to reach the schedulers directly. The BOOST team quickly realized the unit secretaries were the most appropriate personnel to capture this information and work with the patients or their families/caregivers to obtain the most convenient appointments. This role was added to the team, and the unit secretaries took ownership of this process. Other teams may also want to look beyond the customary team members to roles that may not be thought of as quality team members.

Lessons learned: “The biggest take-away for me involves the unique culture that exists in many of our urban and rural communities,” he says. Every BOOST site implements the project’s elements in its own unique way, and what works well in one location may not fit the needs of another. The role of the mentor is to balance the need for community-specific advice with unique attributes of the facility and the elements of Project BOOST. “Often, we use our mentor calls to brainstorm solutions, and the teams are teaching me what will work best in their environment.”

Advice: “Responsibility for hospital change management should not be abdicated to administrators or quality improvement staff members,” he says. “QI is not a sometime thing for some staff; it’s an all-the-time process for every staff member, including physicians, to participate in and actively manage.”

Cheryl O’Malley, MD, FHM

Cheryl O’Malley, MD, FHM

Title: Internal medicine residency program director, Banner Good Samaritan Medical Center, Phoenix

Program: GCMI

Background: Banner Good Samaritan has participated in the BOOST, VTE, and GCMI programs. Dr. O’Malley brought her experience from developing, implementing, and leading local glycemic control efforts to mentoring others.

“When I first started working on our hospital’s process, I had so many questions and asked one of my mentors from residency, Dr. Greg Maynard,” she says. “He helped me to see that people around the country were asking the same questions and invited me to join SHM’s glycemic control work group. When the GCMI program started, I was asked to be a mentor.”

Teachable moment: “When I was a new attending on the wards after residency, my patients would ask me why their blood sugars were so much better controlled at home than in the hospital. Usually, the answer was that they were put on a sliding scale when they came into the hospital,” she says, noting that what was done at home wasn’t going to work in the hospital. Patients needed a different regimen—a more proactive approach than just the customary sliding scale.

“I started to learn more about basal rates, nutrition, and correction insulin regimens in the hospital, but I realized that to really have adequate safety and direction for the nursing staff, it would require a formal order set and systematic approach,” she says.

Success story: “One of my sites invited me to come and present grand rounds at the hospital, and the local physician team leader invited the whole quality team to her home. It was a very exciting team and had achieved a lot. Fifteen or 20 of us spent the evening talking about the project but also just enjoying the collegiality,” Dr. O’Malley says. “Even though we had never seen one another, I instantly knew everyone by voice from spending so much time on the phone. And we knew a lot about one another’s personal lives and careers.”

Lessons learned: “Hearing a program describe what they are doing and knowing that they were far ahead of my own hospital in many ways but still being able to provide an insight or a perspective to help them achieve their own next steps. Everyone has something to learn from another hospital or another discipline. We can all leverage our experiences to improve patient care.”

Advice: “Be patient. This is a really long process of constant improvements. I have been working on glycemic control for 10 years now and still feel like we have many opportunities to further improve.”

Cheryl O’Malley, MD, FHM

Christopher Kim, MD, MBA, SFHM

Title: Clinical associate professor of internal medicine and assistant professor of pediatrics, University of Michigan Health System, Ann Arbor

Program: Project BOOST; Michigan Transitions of Care Collaborative (M-TC2)

Background: Dr. Kim brings clinical, quality improvement, leadership, collaborative learning, and discussion facilitation skills to his work as program director of M-TC2 and as mentor to the sites he works with.

The collaborative is part of a set of state collaborative quality initiatives funded by Blue Cross Blue Shield of Michigan. One of those initiatives is focused on improving care transitions between the hospital setting and ambulatory care providers, using Project BOOST tools—expanded to integrate more closely with primary care providers, physician organizations, and ambulatory care. The eight Michigan-based mentors for M-TC2 have all attended SHM’s Mentor University.

Teachable moment: There are local challenges and there are general challenges—those that are commonly shared by most hospitals, Dr. Kim explains. Both need to be overcome when working on an improvement project such as transitions of care. The local hospitalist brings expertise about the former—which are often more difficult to understand and overcome. The mentor brings knowledge and experience of the universal challenges, as well as the benefit of having seen or heard about what other programs have done. Together, they can work to help the organization become better equipped to improve the initiative at hand.

Success story: “One hospital in the collaborative realized that it could roll out the Teach Back concept to both nurses and physicians,” he says. They started to teach residents how to interact with patients and began using this approach in physician-nurse teams. Subsequently, the team shared with the collaborative how physicians have embraced the concept.

Lessons learned: Every site has its successes and challenges, he says. Sharing both sides of the story can only advance the mission of the collaborative, as each organization learns from the successes and failures of the others.

Mentored implementation really does what it’s intended to do—helping to support the sites and keeping an organization on track and accountable for the work it does, because someone external to the organization is working with it and providing information about what other sites are doing.

Advice: Talk with different disciplines and find out how much they long to work with other care providers, and then have discussions about how to make interdisciplinary practice happen. “At our collaborative meetings over time, many of the 24 participating sites have shared their progress—the good things and the struggles,” Dr. Kim says.

Larry Beresford is a freelance writer in Alameda, Calif.

Christine Lum Lung, MD, SFHM

When SHM received the Joint Commission’s John M. Eisenberg Patient Safety and Quality Award for 2011 for innovation in patient safety and quality at the national level, the award represented national recognition for the society’s three major hospital quality improvement initiatives. Moreover, it highlighted the integral role mentors play in each of the programs, helping physicians and hospitals make accelerated progress on important patient safety and quality issues.

Mentored implementation assigns a physician expert to train, guide, and work with the participating facilities’ hospitalist-led, multidisciplinary team through the life cycle of a QI initiative. The three programs focus on VTE prevention, glycemic control, and transitions of care. The first hospital cohort for VTE prevention—the VTE Prevention Collaborative—was in 2007. The care transitions program, known as Project BOOST, started in 2008. The Glycemic Control Mentored Implementation (GCMI) Program began in 2009. A fourth SHM mentored implementation program is MARQUIS, the Multi-Center Medication Reconciliation Quality Improvement Study.

In basic terms, mentoring is “coaching from a physician who has expertise both in the clinical subject matter and in implementing the processes and tools of quality improvement—usually because they’ve done it themselves,” says Gregory Maynard, MD, MSc, SFHM, senior vice president of SHM’s Center for Hospital Innovation and Improvement and a co-founder of two of its mentored implementation programs.

Mentors typically are paired with one or two participating hospitals for 12 to 18 months, conducting monthly conference calls with the team, sharing tools and resources from SHM’s online library, and offering advice on how to navigate the treacherous currents of culture change within a hospital. BOOST mentors also make in-person site visits. They are well versed in protocol and order set design and quality measurement strategies, and they know how to engage frontline professionals and institutional leadership, Dr. Maynard says.

Some mentors have received formal QI training, and many have attended Mentor University, a 1-1/2 day intensive training course offered by SHM that reinforces the nuances of coaching, the contents of SHM’s quality toolkits, and ideas for overcoming common barriers to improvement. SHM’s mentor support provides continuous professional development for the mentors, pairing new mentors with senior mentors to coach them in the process and hosting an online community with other mentors.

“What’s telling to me is that many of the people who have been mentored by SHM’s programs in one topic go on to become mentors in another topic, taking those portable skills and principles and applying them in other quality areas,” Dr. Maynard says. “We’re fostering leadership and quality improvement skills among hospitalists; that’s really one of our main goals. People learn the skill and then spread it within their system.”

Mark Williams, MD, FACP, MHM, Project BOOST principal investigator and a veteran SHM mentor, says that just providing educational materials to health professionals often isn’t enough for them to overcome the barriers to change.

“I’ve seen many large-scale quality projects that didn’t work, as they were simply disseminating information, content, or knowledge,” he says. Mentored implementation as practiced by SHM is “a model for disseminating quality improvement nationally,” he adds. “Pretty much any quality improvement project can be done this way.”

Key to the mentored implementation program’s success is the personalized approach and customized solutions.

“You directly meet with the team in their own setting and begin to see what’s going on,” Dr. Williams says. “You also meet with the hospital’s senior leadership. That’s when you start to see change.”

The Hospitalist connected with eight SHM mentors. The following are snapshots of their work in the mentorship program and some of the lessons they taught—and learned—from the program.

Christine Lum Lung, MD, SFHM

Christine Lum Lung, MD, SFHM

Title: Medical director, Northern Colorado Hospitalists, Fort Collins

Program: VTE Prevention Collaborative

Background: As a practicing hospitalist and medical director of the HM group for a two-hospital system, Dr. Lum Lung chaired its quality committee for VTE protocol development. “It was obvious at our hospitals that we needed to do better at VTE prevention,” she explains.

Dr. Lum Lung’s team received VTE mentorship from Dr. Maynard, who later asked her to become a VTE mentor. She also attended all three levels of SHM’s Leadership Academy and has since become a mentor for the new HP3 (Hospitalist Program Peak Performance) mentored implementation program, a one-year collaboration among SHM, Northwestern University, Blue Cross/Blue Shield of Illinois, and the Illinois Hospital Association that is designed to help hospitalist groups optimize their programs and build healthy group culture.

Teachable moment: The essential qualities of a good mentee, Dr. Lum Lung says, are drive and dedication. “You believe strongly about it, so you can sell it to others. You also need a thick skin to face the adversities that come up. When my mentor gave me tasks and deadlines, I met those deadlines.”

Success story: “I’ve been impressed with how hard groups and individuals can work.” Most of the teams she has worked with were facing significant external stressors—starting a new program, moving into a new hospital, rolling out a new EHR, becoming part of a growing medical group. “Yet each of them has been incredibly engaged in the process and dedicated to completing their projects.”

Lessons learned: “That we all have something to learn from each other. While I am officially the mentor, I have learned a lot about processes, teamwork, and flow issues from the sites that could potentially be incorporated in our program.”

Advice: Working on a project as a team can be very powerful, she says. Even seemingly ‘small’ projects have allowed teams to learn how to work better together on day-to-day issues. With the victory of a small project behind them, they make lists of the next thing that they want to tackle.

“Our profession is constantly changing. We need to be thinking ahead for how we will face those challenges,” Dr. Lum Lung says. “A team that works well together will have an advantage in this new environment. Even if you have people who are new to quality improvement, their participation can still be important.”

Jordan Messler, MD, SFHM

Jordan Messler, MD, SFHM

Title: Medical director, Morton Plant Hospitalists, Clearwater, Fla.

Program: GCMI; Project BOOST

Background: Dr. Messler’s interest in QI led him to work with colleagues in SHM who are national leaders in quality. “A couple of years ago, I enrolled in Emory’s Quality Academy, a sister course to Intermountain Health’s course on quality. Then I enrolled our hospital in both the GCMI Program and Project BOOST. My mentors for those programs were terrific guides, which led to my interest in seeing their side of the program as a mentor myself.”

Teachable moment: One program had difficulty implementing a VTE prevention tool and couldn’t get nursing support as it had expected, largely due to lack of nursing engagement on the project team, he says. “We started talking about the history of the projects, and prior interventions. In addition, we talked to the different disciplines separately. It seems there used to be an excellent system where nursing helped out on the project team for risk assessment.”

As VTE prevention became more of a priority, some physicians separately created a new tool to replace the nursing tool without involving the whole team. “And they couldn’t understand why nursing wasn’t buying into the new process.”

Success story: There are similar themes to success and failure. Sites that have strong administrative support (i.e., C-suite representation on the QI team), that have “accountability structure and stick to the basics of QI, with clear goals, ability to gather and report data, and use of a QI model [such as PDSA or Six Sigma] are the ones that succeed,” Dr. Messler says. “And the reverse is consistently true. Sustainable QI needs to be multidisciplinary, involving every voice, considering prior interventions and understanding of the culture.”

Lessons learned: “As mentors, we all continue to say we learn as much or more from these sites as they, hopefully, are learning from us. This collaboration and sharing of ideas has been instrumental to the success of the program.”

Advice: Get started today, and don’t give up. Follow the road map of QI projects, gather support, and get started. You will learn as much from your failures as your successes.

Dr. Messler says hospitals are looking for physician leaders to improve quality, and hospitalists are perfectly positioned to be those QI leaders. These big projects can last for years, so quality teams and hospitals need to be prepared to take the long view.

Stephanie Rennke, MD

Stephanie Rennke, MD

Title: Associate clinical professor of medicine, co-director of faculty development, division of hospital medicine, University of California San Francisco Medical Center.

Program: Project BOOST

Background: “When I started as a hospitalist right out of residency, QI had not been part of my training. But I noticed that quality was at the forefront of the academic interests of all the hospitalists at UCSF. I was personally interested in transitions of care. I still do home visits after hours for at-risk patients when they leave the hospital.”

Dr. Rennke started in QI as a member of UCSF’s BOOST team in 2008. “I worked with other faculty in the division who had previous experience in quality improvement and transitions in care. One of the co-principal investigators for BOOST, Dr. Arpana Vidyarthi, suggested that it would be a really rewarding experience to mentor—and it was.”

Teachable moment: “I’ve been so impressed by the diversity of what’s out there. No hospitalist program or hospital is the same. There is no one-size-fits-all for quality improvement or transitions of care, so it is incredibly important that the mentor takes the time to get to know both the team and the hospital.”

Success story: “During a site visit, I had an opportunity to watch one of the nurses, who had received training from a competency-based Teach Back program, practice Teach Back with a patient at the bedside,” Dr. Rennke says. “I was doing a tour of the floor and went into the room of a patient about to be discharged. A young float nurse, not long out of school, sat down with the patient and went through the medications and discharge plan using Teach Back. It didn’t take more time, but the time was spent more constructively, with interaction back and forth. I remember that ‘aha’ moment for the patient and the look in her eyes. For me, as a mentor, it was exciting to think that something I had tried to bring to them had been incorporated by the site and was really working.”

Lessons learned: “I have learned that, while at a large institution like UCSF we tend to work in silos, smaller sites are often more integrated with the various disciplines. You can walk down the hall to the clinical pharmacist or have lunch with the charge nurse. So I’ve tried to bring back home a commitment to really get to know professional colleagues and have them feel that I’m interested in their perspectives.”

Advice: “Work in teams. You cannot do this alone. Include frontline staff. And don’t forget to advertise to others that the program exists. Get the word out—let people know.”

Jennifer Quartarolo, MD, SFHM

Jennifer Quartarolo, MD, SFHM

Title: Medical director, clinical resource management; associate clinical professor, division of hospital medicine, University of California San Diego Health System

Program: Project BOOST

Background: Dr. Quartarolo has 11 years of clinical experience as an academic hospitalist at two different medical centers, and she completed a training program in healthcare delivery and improvement through the Institute for Health Care Delivery Research in Salt Lake City, Utah. “At my own institution, I had been involved in multiple QI projects,” she says. “Since joining the faculty, I worked with our care transitions team for five years before becoming a mentor. We incorporated many elements from Project BOOST as we worked to improve our care transitions process,” which led to an invitation to be a mentor.

Teachable moment: “I had one site that I worked with that had a great new form they had developed to incorporate into their transition process; however, when they decided to implement the form, they got a lot of pushback from nursing,” she says. “Then they realized that they had not involved any frontline nurses in their planning. This example points out how important it is to have all the key players involved on your team, as improving transitions of care is a complex process requiring multidisciplinary collaboration.”

Success story: Dr. Quartarolo says she has worked with several hospitals that have seen significant improvement in their readmission rates after participating in Project BOOST and implementing its tools.

Lessons learned: “I am constantly impressed by the innovative ideas that teams come up with to deal with the challenges that their hospitals face,” she says. Every hospital is unique and needs to do self-evaluation before deciding what to focus on. “I have also worked with many sites that have challenges getting physicians engaged in their efforts, particularly if they do not have a hospitalist program.”

Advice: “We are in a unique role as hospitalists to identify systems issues and improve quality of care in the inpatient setting, and this is particularly useful in improving care transitions and decreasing readmissions rates.”

Rich Balaban, MD

Rich Balaban, MD

Title: Medical director, Hospital-to-Home Community Collaboration Program, Cambridge Health Alliance; assistant professor of medicine, Harvard Medical School, Boston

Program: Project BOOST

Background: Dr. Balaban has worked clinically in both the inpatient setting as a hospitalist and the outpatient setting as a primary care doctor. “I have seen hospital discharges as both a receiver and a sender, so [I] have been able to appreciate the challenges facing doctors, nurses, case managers, and patients involved in the care transition process,” he says.

Dr. Balaban also conducted a randomized controlled trial that demonstrated the benefits of engaging nurses at a patient’s primary care site to make outreach phone calls immediately after hospital discharge. Dr. Williams asked him to present on the study.

“It was a great opportunity for me to share the results of our work and for Mark to see my presentation skills,” he says. “When I asked if there were opportunities to get more involved in care transitions work, he invited me to consider becoming a BOOST mentor.”

Teachable moment: “Wearing my primary care hat, I believe that while it is very important to structure an effective discharge for the patient while in the hospital, success or failure ultimately is determined by what happens in the outpatient setting,” Dr. Balaban says. Even if a ‘perfect discharge’ occurs in the hospital, it can all quickly unravel once the patient arrives at home.

Success story: “At several sites, I have encouraged the inpatient care team to invite the outpatient care team to become part of the care transitions team. This has frequently brought an important viewpoint and voice to the care transitions table. While hospitalists have initiated the discussion about care transitions, they need an effective outpatient partner to create a truly effective process.”

Lessons learned: “I have learned to hold judgment until seeing with my own eyes,” Dr. Balaban says. “One of the first sites I visited had developed a post-discharge clinic, which they were excited to show me. From my point of view, I thought that after discharge, patient care should be assumed by the primary care office as soon as possible, and a post-discharge clinic would only delay that process.

“To my great surprise, their post-discharge clinic provided an ideal bridge between the hospital and primary care. The post-discharge clinic really worked and provided patients with a wonderful resource. … I’ve learned that there are many ways to solve problems, often based on the available resources at a specific site.”

Advice: In order to best understand the challenges of hospital discharge, it is critical that you understand what happens to patients after they leave the hospital. Make a home visit to a recently discharged patient to really understand the challenges that patients face when they return home.

Amitkumar R. Patel, MD, MBA, FACP, SFHM

Amitkumar R. Patel, MD, MBA, FACP, SFHM

Title: Clinical instructor in hospital medicine, Feinberg School of Medicine, Northwestern University, Chicago

Program: Project BOOST; also working with critical access hospitals in Illinois through PREP (Preventing Readmissions through Effective Partnerships)

Background: Although he now works in an urban teaching hospital, Dr. Patel also did private practice as a community hospitalist and has pursued formal healthcare management-focused training.

“I became a mentor because my experience and interest in quality improvement fit well with Project BOOST,” he says. “I enjoy coaching teams as they face challenges in quality improvement, especially in relation to readmissions reduction. My work with critical access hospitals is the result of my first year as a mentor with the PREP collaborative in Illinois.”

PREP, a collaborative initiative of SHM and the Illinois Hospital Association that is funded by Blue Cross/Blue Shield of Illinois, aims to help hospitals focus on quality initiatives, including BOOST.

Teachable moment/success story: One of Dr. Patel’s BOOST sites believed the team included all appropriate personnel to obtain discharge appointments prior to patients’ discharges. But as they began to work through the process of making sure each appointment was appropriately documented, the various team members assigned to this process could not consistently complete the task within their workflow.

The pilot unit secretaries were not part of the BOOST team initially but saw that they could fulfill this role quickly and easily. They knew who to call at the physicians’ offices to avoid getting stuck in the phone menu trees, and they used this knowledge to reach the schedulers directly. The BOOST team quickly realized the unit secretaries were the most appropriate personnel to capture this information and work with the patients or their families/caregivers to obtain the most convenient appointments. This role was added to the team, and the unit secretaries took ownership of this process. Other teams may also want to look beyond the customary team members to roles that may not be thought of as quality team members.

Lessons learned: “The biggest take-away for me involves the unique culture that exists in many of our urban and rural communities,” he says. Every BOOST site implements the project’s elements in its own unique way, and what works well in one location may not fit the needs of another. The role of the mentor is to balance the need for community-specific advice with unique attributes of the facility and the elements of Project BOOST. “Often, we use our mentor calls to brainstorm solutions, and the teams are teaching me what will work best in their environment.”

Advice: “Responsibility for hospital change management should not be abdicated to administrators or quality improvement staff members,” he says. “QI is not a sometime thing for some staff; it’s an all-the-time process for every staff member, including physicians, to participate in and actively manage.”

Cheryl O’Malley, MD, FHM

Cheryl O’Malley, MD, FHM

Title: Internal medicine residency program director, Banner Good Samaritan Medical Center, Phoenix

Program: GCMI

Background: Banner Good Samaritan has participated in the BOOST, VTE, and GCMI programs. Dr. O’Malley brought her experience from developing, implementing, and leading local glycemic control efforts to mentoring others.

“When I first started working on our hospital’s process, I had so many questions and asked one of my mentors from residency, Dr. Greg Maynard,” she says. “He helped me to see that people around the country were asking the same questions and invited me to join SHM’s glycemic control work group. When the GCMI program started, I was asked to be a mentor.”

Teachable moment: “When I was a new attending on the wards after residency, my patients would ask me why their blood sugars were so much better controlled at home than in the hospital. Usually, the answer was that they were put on a sliding scale when they came into the hospital,” she says, noting that what was done at home wasn’t going to work in the hospital. Patients needed a different regimen—a more proactive approach than just the customary sliding scale.

“I started to learn more about basal rates, nutrition, and correction insulin regimens in the hospital, but I realized that to really have adequate safety and direction for the nursing staff, it would require a formal order set and systematic approach,” she says.

Success story: “One of my sites invited me to come and present grand rounds at the hospital, and the local physician team leader invited the whole quality team to her home. It was a very exciting team and had achieved a lot. Fifteen or 20 of us spent the evening talking about the project but also just enjoying the collegiality,” Dr. O’Malley says. “Even though we had never seen one another, I instantly knew everyone by voice from spending so much time on the phone. And we knew a lot about one another’s personal lives and careers.”

Lessons learned: “Hearing a program describe what they are doing and knowing that they were far ahead of my own hospital in many ways but still being able to provide an insight or a perspective to help them achieve their own next steps. Everyone has something to learn from another hospital or another discipline. We can all leverage our experiences to improve patient care.”

Advice: “Be patient. This is a really long process of constant improvements. I have been working on glycemic control for 10 years now and still feel like we have many opportunities to further improve.”

Cheryl O’Malley, MD, FHM

Christopher Kim, MD, MBA, SFHM

Title: Clinical associate professor of internal medicine and assistant professor of pediatrics, University of Michigan Health System, Ann Arbor

Program: Project BOOST; Michigan Transitions of Care Collaborative (M-TC2)

Background: Dr. Kim brings clinical, quality improvement, leadership, collaborative learning, and discussion facilitation skills to his work as program director of M-TC2 and as mentor to the sites he works with.

The collaborative is part of a set of state collaborative quality initiatives funded by Blue Cross Blue Shield of Michigan. One of those initiatives is focused on improving care transitions between the hospital setting and ambulatory care providers, using Project BOOST tools—expanded to integrate more closely with primary care providers, physician organizations, and ambulatory care. The eight Michigan-based mentors for M-TC2 have all attended SHM’s Mentor University.

Teachable moment: There are local challenges and there are general challenges—those that are commonly shared by most hospitals, Dr. Kim explains. Both need to be overcome when working on an improvement project such as transitions of care. The local hospitalist brings expertise about the former—which are often more difficult to understand and overcome. The mentor brings knowledge and experience of the universal challenges, as well as the benefit of having seen or heard about what other programs have done. Together, they can work to help the organization become better equipped to improve the initiative at hand.

Success story: “One hospital in the collaborative realized that it could roll out the Teach Back concept to both nurses and physicians,” he says. They started to teach residents how to interact with patients and began using this approach in physician-nurse teams. Subsequently, the team shared with the collaborative how physicians have embraced the concept.

Lessons learned: Every site has its successes and challenges, he says. Sharing both sides of the story can only advance the mission of the collaborative, as each organization learns from the successes and failures of the others.

Mentored implementation really does what it’s intended to do—helping to support the sites and keeping an organization on track and accountable for the work it does, because someone external to the organization is working with it and providing information about what other sites are doing.

Advice: Talk with different disciplines and find out how much they long to work with other care providers, and then have discussions about how to make interdisciplinary practice happen. “At our collaborative meetings over time, many of the 24 participating sites have shared their progress—the good things and the struggles,” Dr. Kim says.

Larry Beresford is a freelance writer in Alameda, Calif.

Christine Lum Lung, MD, SFHM

When SHM received the Joint Commission’s John M. Eisenberg Patient Safety and Quality Award for 2011 for innovation in patient safety and quality at the national level, the award represented national recognition for the society’s three major hospital quality improvement initiatives. Moreover, it highlighted the integral role mentors play in each of the programs, helping physicians and hospitals make accelerated progress on important patient safety and quality issues.

Mentored implementation assigns a physician expert to train, guide, and work with the participating facilities’ hospitalist-led, multidisciplinary team through the life cycle of a QI initiative. The three programs focus on VTE prevention, glycemic control, and transitions of care. The first hospital cohort for VTE prevention—the VTE Prevention Collaborative—was in 2007. The care transitions program, known as Project BOOST, started in 2008. The Glycemic Control Mentored Implementation (GCMI) Program began in 2009. A fourth SHM mentored implementation program is MARQUIS, the Multi-Center Medication Reconciliation Quality Improvement Study.

In basic terms, mentoring is “coaching from a physician who has expertise both in the clinical subject matter and in implementing the processes and tools of quality improvement—usually because they’ve done it themselves,” says Gregory Maynard, MD, MSc, SFHM, senior vice president of SHM’s Center for Hospital Innovation and Improvement and a co-founder of two of its mentored implementation programs.

Mentors typically are paired with one or two participating hospitals for 12 to 18 months, conducting monthly conference calls with the team, sharing tools and resources from SHM’s online library, and offering advice on how to navigate the treacherous currents of culture change within a hospital. BOOST mentors also make in-person site visits. They are well versed in protocol and order set design and quality measurement strategies, and they know how to engage frontline professionals and institutional leadership, Dr. Maynard says.

Some mentors have received formal QI training, and many have attended Mentor University, a 1-1/2 day intensive training course offered by SHM that reinforces the nuances of coaching, the contents of SHM’s quality toolkits, and ideas for overcoming common barriers to improvement. SHM’s mentor support provides continuous professional development for the mentors, pairing new mentors with senior mentors to coach them in the process and hosting an online community with other mentors.

“What’s telling to me is that many of the people who have been mentored by SHM’s programs in one topic go on to become mentors in another topic, taking those portable skills and principles and applying them in other quality areas,” Dr. Maynard says. “We’re fostering leadership and quality improvement skills among hospitalists; that’s really one of our main goals. People learn the skill and then spread it within their system.”

Mark Williams, MD, FACP, MHM, Project BOOST principal investigator and a veteran SHM mentor, says that just providing educational materials to health professionals often isn’t enough for them to overcome the barriers to change.

“I’ve seen many large-scale quality projects that didn’t work, as they were simply disseminating information, content, or knowledge,” he says. Mentored implementation as practiced by SHM is “a model for disseminating quality improvement nationally,” he adds. “Pretty much any quality improvement project can be done this way.”

Key to the mentored implementation program’s success is the personalized approach and customized solutions.

“You directly meet with the team in their own setting and begin to see what’s going on,” Dr. Williams says. “You also meet with the hospital’s senior leadership. That’s when you start to see change.”

The Hospitalist connected with eight SHM mentors. The following are snapshots of their work in the mentorship program and some of the lessons they taught—and learned—from the program.

Christine Lum Lung, MD, SFHM

Christine Lum Lung, MD, SFHM

Title: Medical director, Northern Colorado Hospitalists, Fort Collins

Program: VTE Prevention Collaborative

Background: As a practicing hospitalist and medical director of the HM group for a two-hospital system, Dr. Lum Lung chaired its quality committee for VTE protocol development. “It was obvious at our hospitals that we needed to do better at VTE prevention,” she explains.

Dr. Lum Lung’s team received VTE mentorship from Dr. Maynard, who later asked her to become a VTE mentor. She also attended all three levels of SHM’s Leadership Academy and has since become a mentor for the new HP3 (Hospitalist Program Peak Performance) mentored implementation program, a one-year collaboration among SHM, Northwestern University, Blue Cross/Blue Shield of Illinois, and the Illinois Hospital Association that is designed to help hospitalist groups optimize their programs and build healthy group culture.

Teachable moment: The essential qualities of a good mentee, Dr. Lum Lung says, are drive and dedication. “You believe strongly about it, so you can sell it to others. You also need a thick skin to face the adversities that come up. When my mentor gave me tasks and deadlines, I met those deadlines.”

Success story: “I’ve been impressed with how hard groups and individuals can work.” Most of the teams she has worked with were facing significant external stressors—starting a new program, moving into a new hospital, rolling out a new EHR, becoming part of a growing medical group. “Yet each of them has been incredibly engaged in the process and dedicated to completing their projects.”

Lessons learned: “That we all have something to learn from each other. While I am officially the mentor, I have learned a lot about processes, teamwork, and flow issues from the sites that could potentially be incorporated in our program.”

Advice: Working on a project as a team can be very powerful, she says. Even seemingly ‘small’ projects have allowed teams to learn how to work better together on day-to-day issues. With the victory of a small project behind them, they make lists of the next thing that they want to tackle.

“Our profession is constantly changing. We need to be thinking ahead for how we will face those challenges,” Dr. Lum Lung says. “A team that works well together will have an advantage in this new environment. Even if you have people who are new to quality improvement, their participation can still be important.”

Jordan Messler, MD, SFHM

Jordan Messler, MD, SFHM

Title: Medical director, Morton Plant Hospitalists, Clearwater, Fla.

Program: GCMI; Project BOOST

Background: Dr. Messler’s interest in QI led him to work with colleagues in SHM who are national leaders in quality. “A couple of years ago, I enrolled in Emory’s Quality Academy, a sister course to Intermountain Health’s course on quality. Then I enrolled our hospital in both the GCMI Program and Project BOOST. My mentors for those programs were terrific guides, which led to my interest in seeing their side of the program as a mentor myself.”

Teachable moment: One program had difficulty implementing a VTE prevention tool and couldn’t get nursing support as it had expected, largely due to lack of nursing engagement on the project team, he says. “We started talking about the history of the projects, and prior interventions. In addition, we talked to the different disciplines separately. It seems there used to be an excellent system where nursing helped out on the project team for risk assessment.”

As VTE prevention became more of a priority, some physicians separately created a new tool to replace the nursing tool without involving the whole team. “And they couldn’t understand why nursing wasn’t buying into the new process.”

Success story: There are similar themes to success and failure. Sites that have strong administrative support (i.e., C-suite representation on the QI team), that have “accountability structure and stick to the basics of QI, with clear goals, ability to gather and report data, and use of a QI model [such as PDSA or Six Sigma] are the ones that succeed,” Dr. Messler says. “And the reverse is consistently true. Sustainable QI needs to be multidisciplinary, involving every voice, considering prior interventions and understanding of the culture.”

Lessons learned: “As mentors, we all continue to say we learn as much or more from these sites as they, hopefully, are learning from us. This collaboration and sharing of ideas has been instrumental to the success of the program.”

Advice: Get started today, and don’t give up. Follow the road map of QI projects, gather support, and get started. You will learn as much from your failures as your successes.

Dr. Messler says hospitals are looking for physician leaders to improve quality, and hospitalists are perfectly positioned to be those QI leaders. These big projects can last for years, so quality teams and hospitals need to be prepared to take the long view.

Stephanie Rennke, MD

Stephanie Rennke, MD

Title: Associate clinical professor of medicine, co-director of faculty development, division of hospital medicine, University of California San Francisco Medical Center.

Program: Project BOOST

Background: “When I started as a hospitalist right out of residency, QI had not been part of my training. But I noticed that quality was at the forefront of the academic interests of all the hospitalists at UCSF. I was personally interested in transitions of care. I still do home visits after hours for at-risk patients when they leave the hospital.”

Dr. Rennke started in QI as a member of UCSF’s BOOST team in 2008. “I worked with other faculty in the division who had previous experience in quality improvement and transitions in care. One of the co-principal investigators for BOOST, Dr. Arpana Vidyarthi, suggested that it would be a really rewarding experience to mentor—and it was.”

Teachable moment: “I’ve been so impressed by the diversity of what’s out there. No hospitalist program or hospital is the same. There is no one-size-fits-all for quality improvement or transitions of care, so it is incredibly important that the mentor takes the time to get to know both the team and the hospital.”

Success story: “During a site visit, I had an opportunity to watch one of the nurses, who had received training from a competency-based Teach Back program, practice Teach Back with a patient at the bedside,” Dr. Rennke says. “I was doing a tour of the floor and went into the room of a patient about to be discharged. A young float nurse, not long out of school, sat down with the patient and went through the medications and discharge plan using Teach Back. It didn’t take more time, but the time was spent more constructively, with interaction back and forth. I remember that ‘aha’ moment for the patient and the look in her eyes. For me, as a mentor, it was exciting to think that something I had tried to bring to them had been incorporated by the site and was really working.”

Lessons learned: “I have learned that, while at a large institution like UCSF we tend to work in silos, smaller sites are often more integrated with the various disciplines. You can walk down the hall to the clinical pharmacist or have lunch with the charge nurse. So I’ve tried to bring back home a commitment to really get to know professional colleagues and have them feel that I’m interested in their perspectives.”

Advice: “Work in teams. You cannot do this alone. Include frontline staff. And don’t forget to advertise to others that the program exists. Get the word out—let people know.”

Jennifer Quartarolo, MD, SFHM

Jennifer Quartarolo, MD, SFHM

Title: Medical director, clinical resource management; associate clinical professor, division of hospital medicine, University of California San Diego Health System

Program: Project BOOST

Background: Dr. Quartarolo has 11 years of clinical experience as an academic hospitalist at two different medical centers, and she completed a training program in healthcare delivery and improvement through the Institute for Health Care Delivery Research in Salt Lake City, Utah. “At my own institution, I had been involved in multiple QI projects,” she says. “Since joining the faculty, I worked with our care transitions team for five years before becoming a mentor. We incorporated many elements from Project BOOST as we worked to improve our care transitions process,” which led to an invitation to be a mentor.

Teachable moment: “I had one site that I worked with that had a great new form they had developed to incorporate into their transition process; however, when they decided to implement the form, they got a lot of pushback from nursing,” she says. “Then they realized that they had not involved any frontline nurses in their planning. This example points out how important it is to have all the key players involved on your team, as improving transitions of care is a complex process requiring multidisciplinary collaboration.”

Success story: Dr. Quartarolo says she has worked with several hospitals that have seen significant improvement in their readmission rates after participating in Project BOOST and implementing its tools.

Lessons learned: “I am constantly impressed by the innovative ideas that teams come up with to deal with the challenges that their hospitals face,” she says. Every hospital is unique and needs to do self-evaluation before deciding what to focus on. “I have also worked with many sites that have challenges getting physicians engaged in their efforts, particularly if they do not have a hospitalist program.”

Advice: “We are in a unique role as hospitalists to identify systems issues and improve quality of care in the inpatient setting, and this is particularly useful in improving care transitions and decreasing readmissions rates.”

Rich Balaban, MD

Rich Balaban, MD

Title: Medical director, Hospital-to-Home Community Collaboration Program, Cambridge Health Alliance; assistant professor of medicine, Harvard Medical School, Boston

Program: Project BOOST

Background: Dr. Balaban has worked clinically in both the inpatient setting as a hospitalist and the outpatient setting as a primary care doctor. “I have seen hospital discharges as both a receiver and a sender, so [I] have been able to appreciate the challenges facing doctors, nurses, case managers, and patients involved in the care transition process,” he says.

Dr. Balaban also conducted a randomized controlled trial that demonstrated the benefits of engaging nurses at a patient’s primary care site to make outreach phone calls immediately after hospital discharge. Dr. Williams asked him to present on the study.

“It was a great opportunity for me to share the results of our work and for Mark to see my presentation skills,” he says. “When I asked if there were opportunities to get more involved in care transitions work, he invited me to consider becoming a BOOST mentor.”

Teachable moment: “Wearing my primary care hat, I believe that while it is very important to structure an effective discharge for the patient while in the hospital, success or failure ultimately is determined by what happens in the outpatient setting,” Dr. Balaban says. Even if a ‘perfect discharge’ occurs in the hospital, it can all quickly unravel once the patient arrives at home.

Success story: “At several sites, I have encouraged the inpatient care team to invite the outpatient care team to become part of the care transitions team. This has frequently brought an important viewpoint and voice to the care transitions table. While hospitalists have initiated the discussion about care transitions, they need an effective outpatient partner to create a truly effective process.”

Lessons learned: “I have learned to hold judgment until seeing with my own eyes,” Dr. Balaban says. “One of the first sites I visited had developed a post-discharge clinic, which they were excited to show me. From my point of view, I thought that after discharge, patient care should be assumed by the primary care office as soon as possible, and a post-discharge clinic would only delay that process.

“To my great surprise, their post-discharge clinic provided an ideal bridge between the hospital and primary care. The post-discharge clinic really worked and provided patients with a wonderful resource. … I’ve learned that there are many ways to solve problems, often based on the available resources at a specific site.”

Advice: In order to best understand the challenges of hospital discharge, it is critical that you understand what happens to patients after they leave the hospital. Make a home visit to a recently discharged patient to really understand the challenges that patients face when they return home.

Amitkumar R. Patel, MD, MBA, FACP, SFHM

Amitkumar R. Patel, MD, MBA, FACP, SFHM

Title: Clinical instructor in hospital medicine, Feinberg School of Medicine, Northwestern University, Chicago

Program: Project BOOST; also working with critical access hospitals in Illinois through PREP (Preventing Readmissions through Effective Partnerships)

Background: Although he now works in an urban teaching hospital, Dr. Patel also did private practice as a community hospitalist and has pursued formal healthcare management-focused training.

“I became a mentor because my experience and interest in quality improvement fit well with Project BOOST,” he says. “I enjoy coaching teams as they face challenges in quality improvement, especially in relation to readmissions reduction. My work with critical access hospitals is the result of my first year as a mentor with the PREP collaborative in Illinois.”

PREP, a collaborative initiative of SHM and the Illinois Hospital Association that is funded by Blue Cross/Blue Shield of Illinois, aims to help hospitals focus on quality initiatives, including BOOST.

Teachable moment/success story: One of Dr. Patel’s BOOST sites believed the team included all appropriate personnel to obtain discharge appointments prior to patients’ discharges. But as they began to work through the process of making sure each appointment was appropriately documented, the various team members assigned to this process could not consistently complete the task within their workflow.

The pilot unit secretaries were not part of the BOOST team initially but saw that they could fulfill this role quickly and easily. They knew who to call at the physicians’ offices to avoid getting stuck in the phone menu trees, and they used this knowledge to reach the schedulers directly. The BOOST team quickly realized the unit secretaries were the most appropriate personnel to capture this information and work with the patients or their families/caregivers to obtain the most convenient appointments. This role was added to the team, and the unit secretaries took ownership of this process. Other teams may also want to look beyond the customary team members to roles that may not be thought of as quality team members.

Lessons learned: “The biggest take-away for me involves the unique culture that exists in many of our urban and rural communities,” he says. Every BOOST site implements the project’s elements in its own unique way, and what works well in one location may not fit the needs of another. The role of the mentor is to balance the need for community-specific advice with unique attributes of the facility and the elements of Project BOOST. “Often, we use our mentor calls to brainstorm solutions, and the teams are teaching me what will work best in their environment.”

Advice: “Responsibility for hospital change management should not be abdicated to administrators or quality improvement staff members,” he says. “QI is not a sometime thing for some staff; it’s an all-the-time process for every staff member, including physicians, to participate in and actively manage.”

Cheryl O’Malley, MD, FHM

Cheryl O’Malley, MD, FHM

Title: Internal medicine residency program director, Banner Good Samaritan Medical Center, Phoenix

Program: GCMI

Background: Banner Good Samaritan has participated in the BOOST, VTE, and GCMI programs. Dr. O’Malley brought her experience from developing, implementing, and leading local glycemic control efforts to mentoring others.

“When I first started working on our hospital’s process, I had so many questions and asked one of my mentors from residency, Dr. Greg Maynard,” she says. “He helped me to see that people around the country were asking the same questions and invited me to join SHM’s glycemic control work group. When the GCMI program started, I was asked to be a mentor.”

Teachable moment: “When I was a new attending on the wards after residency, my patients would ask me why their blood sugars were so much better controlled at home than in the hospital. Usually, the answer was that they were put on a sliding scale when they came into the hospital,” she says, noting that what was done at home wasn’t going to work in the hospital. Patients needed a different regimen—a more proactive approach than just the customary sliding scale.

“I started to learn more about basal rates, nutrition, and correction insulin regimens in the hospital, but I realized that to really have adequate safety and direction for the nursing staff, it would require a formal order set and systematic approach,” she says.

Success story: “One of my sites invited me to come and present grand rounds at the hospital, and the local physician team leader invited the whole quality team to her home. It was a very exciting team and had achieved a lot. Fifteen or 20 of us spent the evening talking about the project but also just enjoying the collegiality,” Dr. O’Malley says. “Even though we had never seen one another, I instantly knew everyone by voice from spending so much time on the phone. And we knew a lot about one another’s personal lives and careers.”

Lessons learned: “Hearing a program describe what they are doing and knowing that they were far ahead of my own hospital in many ways but still being able to provide an insight or a perspective to help them achieve their own next steps. Everyone has something to learn from another hospital or another discipline. We can all leverage our experiences to improve patient care.”

Advice: “Be patient. This is a really long process of constant improvements. I have been working on glycemic control for 10 years now and still feel like we have many opportunities to further improve.”

Cheryl O’Malley, MD, FHM

Christopher Kim, MD, MBA, SFHM

Title: Clinical associate professor of internal medicine and assistant professor of pediatrics, University of Michigan Health System, Ann Arbor

Program: Project BOOST; Michigan Transitions of Care Collaborative (M-TC2)

Background: Dr. Kim brings clinical, quality improvement, leadership, collaborative learning, and discussion facilitation skills to his work as program director of M-TC2 and as mentor to the sites he works with.

The collaborative is part of a set of state collaborative quality initiatives funded by Blue Cross Blue Shield of Michigan. One of those initiatives is focused on improving care transitions between the hospital setting and ambulatory care providers, using Project BOOST tools—expanded to integrate more closely with primary care providers, physician organizations, and ambulatory care. The eight Michigan-based mentors for M-TC2 have all attended SHM’s Mentor University.

Teachable moment: There are local challenges and there are general challenges—those that are commonly shared by most hospitals, Dr. Kim explains. Both need to be overcome when working on an improvement project such as transitions of care. The local hospitalist brings expertise about the former—which are often more difficult to understand and overcome. The mentor brings knowledge and experience of the universal challenges, as well as the benefit of having seen or heard about what other programs have done. Together, they can work to help the organization become better equipped to improve the initiative at hand.

Success story: “One hospital in the collaborative realized that it could roll out the Teach Back concept to both nurses and physicians,” he says. They started to teach residents how to interact with patients and began using this approach in physician-nurse teams. Subsequently, the team shared with the collaborative how physicians have embraced the concept.

Lessons learned: Every site has its successes and challenges, he says. Sharing both sides of the story can only advance the mission of the collaborative, as each organization learns from the successes and failures of the others.

Mentored implementation really does what it’s intended to do—helping to support the sites and keeping an organization on track and accountable for the work it does, because someone external to the organization is working with it and providing information about what other sites are doing.

Advice: Talk with different disciplines and find out how much they long to work with other care providers, and then have discussions about how to make interdisciplinary practice happen. “At our collaborative meetings over time, many of the 24 participating sites have shared their progress—the good things and the struggles,” Dr. Kim says.

Larry Beresford is a freelance writer in Alameda, Calif.

Click here to listen to excerpts of our interview with Dr. Williams

Click here to listen to excerpts of our interview with Dr. Williams

Click here to listen to excerpts of our interview with Dr. Williams

Financial pressures to reduce 30-day hospital readmissions and improve discharge processes continue to grow. The Centers for Medicare and Medicaid Services started by penalizing hospitals for up to 1% of their Medicare reimbursement via the Hospital Readmissions Reduction Program. By 2015, the program will penalize hospitals up to 3%.

This is no longer news to the hospital C-suite. A 2013 survey reported that 85% of hospital leaders had addressed the readmissions penalty in their business plan (http://content.hcpro.com/pdf/content/296905.pdf); however, the same survey revealed that only 62% of hospital leaders reported changes to clinical protocols and practices during acute care, and even fewer were providing care navigators or coaches for high-risk patients.

That’s where hospitalists can help. Through SHM’s Project BOOST, hospitalists and hospital-based care teams improve transition from hospital to home. Project BOOST also helps hospitals identify high-risk patients and target risk-specific interventions, a critical part of reducing readmissions.

Beyond the immediate financial implications, implementing programs like Project BOOST to reduce readmissions can position hospitals as leaders for better healthcare in their communities.

“I recommend Project BOOST enthusiastically and unequivocally,” says Manasi Kekan, MD, MS, FACP, medical director for Houston Methodist Hospital. “If implemented efficiently, it could result in a ‘win-win’ situation for patients, the hospital, and the healthcare providers.”

SHM is accepting applications for the 2014 Project BOOST cohort through August 30. For details and application, visit www.hospitalmedicine.org/boost.

Financial pressures to reduce 30-day hospital readmissions and improve discharge processes continue to grow. The Centers for Medicare and Medicaid Services started by penalizing hospitals for up to 1% of their Medicare reimbursement via the Hospital Readmissions Reduction Program. By 2015, the program will penalize hospitals up to 3%.

This is no longer news to the hospital C-suite. A 2013 survey reported that 85% of hospital leaders had addressed the readmissions penalty in their business plan (http://content.hcpro.com/pdf/content/296905.pdf); however, the same survey revealed that only 62% of hospital leaders reported changes to clinical protocols and practices during acute care, and even fewer were providing care navigators or coaches for high-risk patients.

That’s where hospitalists can help. Through SHM’s Project BOOST, hospitalists and hospital-based care teams improve transition from hospital to home. Project BOOST also helps hospitals identify high-risk patients and target risk-specific interventions, a critical part of reducing readmissions.

Beyond the immediate financial implications, implementing programs like Project BOOST to reduce readmissions can position hospitals as leaders for better healthcare in their communities.

“I recommend Project BOOST enthusiastically and unequivocally,” says Manasi Kekan, MD, MS, FACP, medical director for Houston Methodist Hospital. “If implemented efficiently, it could result in a ‘win-win’ situation for patients, the hospital, and the healthcare providers.”

SHM is accepting applications for the 2014 Project BOOST cohort through August 30. For details and application, visit www.hospitalmedicine.org/boost.

Financial pressures to reduce 30-day hospital readmissions and improve discharge processes continue to grow. The Centers for Medicare and Medicaid Services started by penalizing hospitals for up to 1% of their Medicare reimbursement via the Hospital Readmissions Reduction Program. By 2015, the program will penalize hospitals up to 3%.

This is no longer news to the hospital C-suite. A 2013 survey reported that 85% of hospital leaders had addressed the readmissions penalty in their business plan (http://content.hcpro.com/pdf/content/296905.pdf); however, the same survey revealed that only 62% of hospital leaders reported changes to clinical protocols and practices during acute care, and even fewer were providing care navigators or coaches for high-risk patients.

That’s where hospitalists can help. Through SHM’s Project BOOST, hospitalists and hospital-based care teams improve transition from hospital to home. Project BOOST also helps hospitals identify high-risk patients and target risk-specific interventions, a critical part of reducing readmissions.

Beyond the immediate financial implications, implementing programs like Project BOOST to reduce readmissions can position hospitals as leaders for better healthcare in their communities.

“I recommend Project BOOST enthusiastically and unequivocally,” says Manasi Kekan, MD, MS, FACP, medical director for Houston Methodist Hospital. “If implemented efficiently, it could result in a ‘win-win’ situation for patients, the hospital, and the healthcare providers.”

SHM is accepting applications for the 2014 Project BOOST cohort through August 30. For details and application, visit www.hospitalmedicine.org/boost.

Are you helping your hospital choose wisely? You could receive thousands of dollars in return for your good work in providing high-value care to hospitalized patients through SHM’s Choosing Wisely case study competition.

SHM will be awarding a total of $20,000 to hospitalists who submit winning case studies illustrating their implementation of the Choosing Wisely principles published by SHM in 2013. Grand prize winners for both adult and pediatric HM will receive $4,000 each, and three honorable mention winners in both categories will each receive $2,000.

But don’t wait long. The deadline for submissions is September 9. For information and submission forms, visit www.hospitalmedicine.org/choosingwisely.

Are you helping your hospital choose wisely? You could receive thousands of dollars in return for your good work in providing high-value care to hospitalized patients through SHM’s Choosing Wisely case study competition.

SHM will be awarding a total of $20,000 to hospitalists who submit winning case studies illustrating their implementation of the Choosing Wisely principles published by SHM in 2013. Grand prize winners for both adult and pediatric HM will receive $4,000 each, and three honorable mention winners in both categories will each receive $2,000.

But don’t wait long. The deadline for submissions is September 9. For information and submission forms, visit www.hospitalmedicine.org/choosingwisely.

Are you helping your hospital choose wisely? You could receive thousands of dollars in return for your good work in providing high-value care to hospitalized patients through SHM’s Choosing Wisely case study competition.

SHM will be awarding a total of $20,000 to hospitalists who submit winning case studies illustrating their implementation of the Choosing Wisely principles published by SHM in 2013. Grand prize winners for both adult and pediatric HM will receive $4,000 each, and three honorable mention winners in both categories will each receive $2,000.

But don’t wait long. The deadline for submissions is September 9. For information and submission forms, visit www.hospitalmedicine.org/choosingwisely.