Perspectives in Hospital Medicine

In 2010, the Journal of Hospital Medicine published an article proposing a “talent facilitation” framework for addressing physician workforce challenges.¹ Since then, continuous changes in healthcare work environments and shifts in relevant policies have intensified a sense of clinician workforce crisis in the United States,^2,3 often described as an epidemic of burnout. Unfortunately, hospital medicine remains among the specialties most impacted by high burnout rates and related turnover.^4-6

Despite efforts to address the sustainability of careers in hospital medicine, common approaches remain mostly reactive. Existing research on burnout is largely descriptive, focusing on the magnitude of the problem,³ the links between burnout and diminished productivity or turnover,⁷ and the negative impact of burnout on patient care.^8.9 Improvement efforts often focus on rescuing individuals from burnout, rather than prevention.¹⁰ While evidence exists that both individually targeted interventions (eg, mindfulness-based stress reduction) and institutional changes (eg, improvements in the operation of care teams) can reduce burnout, efforts to promote individuals’ resilience appear to have limited impact.^11,12

Given our field’s reputation for innovation, we believe hospitalist groups must lead the way in developing practical solutions that enhance the well-being of their members, by doing more than exhorting clinicians to “heal themselves” or imploring executives to fix care delivery systems. In this article, we describe an approach to increase resilience and well-being in a large, academic hospital medicine practice and offer an emerging list of best practices.

Maslach et al. demonstrated that burnout reflects an individual’s experience of emotional exhaustion, depersonalization of human interactions, and decreased sense of accomplishment at work.¹³ Updated frameworks emphasize that well-being and lower burnout arise from workflow efficiency, a surrounding culture of wellness, and attention to individual resilience.¹⁴ Emerging evidence suggests that burnout and well-being are, in part, a collective experience.¹⁵ As outlined in the recently published “Charter on Physician Well-being,”¹⁶ this realization creates an opportunity for clinical groups to enhance collective well-being—or thriving—rather than asking individuals to take personal responsibility for resilience or waiting for a top-down system redesign to fix drivers of burnout.

In 2013, our academic hospital medicine group set a new vision: To become the best in the nation by being an outstanding place to work. We held an inclusive divisional strategic planning retreat, which focused on clarifying the group’s six core values and exploring how to translate the values into structures, processes, and behaviors that reinforced, rather than undermined, a positive work environment. We used these initial themes to create 16 novel interventions from 2014-2017 (Figure).

Notably, we pursued this work without explicit support or interference from senior leaders in our institution. There were no competing organizational efforts addressing hospitalist efficiency, turnover, or burnout until 2017 (Excellence in Communication, described below). Furthermore, we avoided individually targeted resilience efforts based on feedback from our group that “requiring resilience activities is like blaming the victim.” Intervention participation was not mandatory, out of respect for individual choice and to avoid impeding hospitalists’ daily work.

Before designing interventions, we created a measurement tool to assess our existing culture and track evolution over time (available upon request). We utilized the instrument to provoke emotional responses, surface paradoxes, uncover assumptions, and engage the group in iterative dialog that informed and calibrated interventions. The instrument itself drew from validated elements of existing tools to quantify perceptions across nine domains: meaningful work, autonomy, professional development, logistical support, health, fulfillment outside of work, collegiality, organizational learning, and safety culture.

Several subsequent interventions focused on the emotional experience of work. For example, we developed a formal mechanism (Something Awesome) for members to share the experience of positive emotions during daily work (eg, gratitude and awe) for five minutes at monthly group meetings. We created a Collaborative Case Review process, allowing members to submit concerning cases for nonpunitive discussion and coaching among peers. Finally, we created Above and Beyond Awards, through which members’ written praise of peers’ extraordinary efforts were distributed to the entire group.

We also pursued interventions designed to increase empathy and translate it to action. These included leader rounding on our clinical units, which sought to recognize and thank individuals for daily work and to uncover exigent needs, such as food or assistance with conflict resolution between services. We created “Flash Mobs” or group conversations, which are facilitated by a leader and convened in the hospital, in order to hear from people and discuss topics of concern in real time, such as increased patient volumes. Likewise, we established “The Incubator,” a half-day meeting held four to six times annually when selected clinical faculty applied design thinking techniques to create, test, and implement ideas to enhance workplace experience (eg, supplying healthy food to our common work space at low cost).

Another key focus was professional development for group members. Examples included a three-year development program for new faculty (LaunchPad), increasing the number of available leadership roles for aspiring leaders, modifying annual reviews to focus on increasing individuals’ strengths-based work rather than solely grading performance, and creating a peer-support coaching program for newly hired members. In 2017, we began offering members a full shift credit to attend the hospital’s four-hour Excellence in Communication course, which covers six high-yield skills that increase efficiency, efficacy, and joy in practice.

Finally, we revised a number of structures and operational processes within our group’s control. We created a task force to address the needs of new parents and acquired a lactation room in the hospital. Instead of only covering offsite conference attendance (our old policy), we enhanced autonomy regarding use of continuing education dollars to allow faculty to fund any activity supporting their clinical practice. Finally, we applied quality improvement methodology to redesign the clinical schedule. This included blending value-stream mapping, software solutions, and a values-based framework to analyze proposed changes through the lens of waste elimination, IT feasibility, and whether the proposed changes aligned with the group’s core values.

We examined the impact of these tactics on workplace experience over a four-year period (Figure). In 2014, 30% of group members reported psychological safety, 24% had become more callous toward people in their current job, and 45% were experiencing burnout. By 2017, 59% felt a sense of psychological safety (69% increase), 15% had become more callous toward people (38% decrease), and 33% were experiencing burnout (27% decrease). Average annual turnover in the five years before the first survey was 13.2%; turnover declined during the intervention period to 6.6% (adjusted for increased number of positions). While few comprehensive models exist for calculating well-being program return on investment, the American Medical Association’s calculator¹⁷ demonstrated our group’s cost of burnout plus turnover in 2013 was $464,385 per year (assumptions in Appendix 1). We spent $343,517 on the 16 interventions between 2013 and 2017, representing an average annual cost of $86,000: $190,094 to buy-down clinical time for new leadership roles, $133,023 to fund time for the Incubator, $2,500 on gifts and awards, $4,900 on program supplies, and $10,000 on leadership training.

Based on the current literature and our experience, hospital medicine groups seeking to improve culture, resilience, and well-being should:

• Collaborate to define the group’s sense of purpose. Mission and vision are important, but most of the focus should be on surfacing, naming, and agreeing upon the group’s essential core values—the beliefs that inform whether hospitalists see the workplace as attractive, fair, and sustainable. Utilizing an expert, neutral facilitator is helpful.
• Assess culture—including, but not limited to, individual burnout and well-being—using preexisting questions from validated instruments. As culture is a product of systems, team climate, and leadership, measurement should include these domains.
• Monitor and share anonymous data from the assessment regularly (at least annually) as soon as possible after survey results are available. The data should drive inclusive, open, nonjudgmental dialog among group members and leaders in order to clarify, explore, and refine what the data mean.
• Undertake improvement efforts that emerge from the steps above, with a balanced focus on the three domains of well-being: efficiency of practice, culture of wellness, and personal resilience. Modify the number and intensity of interventions based on the group’s readiness and ability to control change in these domains. For example, some groups may have more excitement and ability to work on factors impacting the efficiency of practice, such as electronic health record templates, while others may wish to enhance opportunities for collegial interaction during the workday.
• Strive for codesign. Group members must be an integral part of the solution, rather than simply raise complaints with the expectation that leaders will devise solutions. Ideally, group members should have time, funding, or titles to lead improvement efforts.
• Opportunities to improve resilience and well-being should be widely available to all group members, but should not be mandatory.

The healthcare industry will continue to grapple with high rates of burnout and rapid change for the foreseeable future. We believe significant improvements in burnout rates and workplace experience can result from hospitalist-led interventions designed to improve experience of work among hospitalist clinicians, even as we await broader and necessary systematic efforts to address structural drivers of professional satisfaction. This work is vital if we are to honor our field’s history of productive innovation and navigate dynamic change in healthcare by attracting, engaging, developing, and retaining our most valuable asset: our people.

Disclosures

The authors declare they have no conflicts of interest/competing interests.

In 2010, the Journal of Hospital Medicine published an article proposing a “talent facilitation” framework for addressing physician workforce challenges.¹ Since then, continuous changes in healthcare work environments and shifts in relevant policies have intensified a sense of clinician workforce crisis in the United States,^2,3 often described as an epidemic of burnout. Unfortunately, hospital medicine remains among the specialties most impacted by high burnout rates and related turnover.^4-6

Despite efforts to address the sustainability of careers in hospital medicine, common approaches remain mostly reactive. Existing research on burnout is largely descriptive, focusing on the magnitude of the problem,³ the links between burnout and diminished productivity or turnover,⁷ and the negative impact of burnout on patient care.^8.9 Improvement efforts often focus on rescuing individuals from burnout, rather than prevention.¹⁰ While evidence exists that both individually targeted interventions (eg, mindfulness-based stress reduction) and institutional changes (eg, improvements in the operation of care teams) can reduce burnout, efforts to promote individuals’ resilience appear to have limited impact.^11,12

Given our field’s reputation for innovation, we believe hospitalist groups must lead the way in developing practical solutions that enhance the well-being of their members, by doing more than exhorting clinicians to “heal themselves” or imploring executives to fix care delivery systems. In this article, we describe an approach to increase resilience and well-being in a large, academic hospital medicine practice and offer an emerging list of best practices.

Maslach et al. demonstrated that burnout reflects an individual’s experience of emotional exhaustion, depersonalization of human interactions, and decreased sense of accomplishment at work.¹³ Updated frameworks emphasize that well-being and lower burnout arise from workflow efficiency, a surrounding culture of wellness, and attention to individual resilience.¹⁴ Emerging evidence suggests that burnout and well-being are, in part, a collective experience.¹⁵ As outlined in the recently published “Charter on Physician Well-being,”¹⁶ this realization creates an opportunity for clinical groups to enhance collective well-being—or thriving—rather than asking individuals to take personal responsibility for resilience or waiting for a top-down system redesign to fix drivers of burnout.

In 2013, our academic hospital medicine group set a new vision: To become the best in the nation by being an outstanding place to work. We held an inclusive divisional strategic planning retreat, which focused on clarifying the group’s six core values and exploring how to translate the values into structures, processes, and behaviors that reinforced, rather than undermined, a positive work environment. We used these initial themes to create 16 novel interventions from 2014-2017 (Figure).

Notably, we pursued this work without explicit support or interference from senior leaders in our institution. There were no competing organizational efforts addressing hospitalist efficiency, turnover, or burnout until 2017 (Excellence in Communication, described below). Furthermore, we avoided individually targeted resilience efforts based on feedback from our group that “requiring resilience activities is like blaming the victim.” Intervention participation was not mandatory, out of respect for individual choice and to avoid impeding hospitalists’ daily work.

Before designing interventions, we created a measurement tool to assess our existing culture and track evolution over time (available upon request). We utilized the instrument to provoke emotional responses, surface paradoxes, uncover assumptions, and engage the group in iterative dialog that informed and calibrated interventions. The instrument itself drew from validated elements of existing tools to quantify perceptions across nine domains: meaningful work, autonomy, professional development, logistical support, health, fulfillment outside of work, collegiality, organizational learning, and safety culture.

Several subsequent interventions focused on the emotional experience of work. For example, we developed a formal mechanism (Something Awesome) for members to share the experience of positive emotions during daily work (eg, gratitude and awe) for five minutes at monthly group meetings. We created a Collaborative Case Review process, allowing members to submit concerning cases for nonpunitive discussion and coaching among peers. Finally, we created Above and Beyond Awards, through which members’ written praise of peers’ extraordinary efforts were distributed to the entire group.

We also pursued interventions designed to increase empathy and translate it to action. These included leader rounding on our clinical units, which sought to recognize and thank individuals for daily work and to uncover exigent needs, such as food or assistance with conflict resolution between services. We created “Flash Mobs” or group conversations, which are facilitated by a leader and convened in the hospital, in order to hear from people and discuss topics of concern in real time, such as increased patient volumes. Likewise, we established “The Incubator,” a half-day meeting held four to six times annually when selected clinical faculty applied design thinking techniques to create, test, and implement ideas to enhance workplace experience (eg, supplying healthy food to our common work space at low cost).

Another key focus was professional development for group members. Examples included a three-year development program for new faculty (LaunchPad), increasing the number of available leadership roles for aspiring leaders, modifying annual reviews to focus on increasing individuals’ strengths-based work rather than solely grading performance, and creating a peer-support coaching program for newly hired members. In 2017, we began offering members a full shift credit to attend the hospital’s four-hour Excellence in Communication course, which covers six high-yield skills that increase efficiency, efficacy, and joy in practice.

Finally, we revised a number of structures and operational processes within our group’s control. We created a task force to address the needs of new parents and acquired a lactation room in the hospital. Instead of only covering offsite conference attendance (our old policy), we enhanced autonomy regarding use of continuing education dollars to allow faculty to fund any activity supporting their clinical practice. Finally, we applied quality improvement methodology to redesign the clinical schedule. This included blending value-stream mapping, software solutions, and a values-based framework to analyze proposed changes through the lens of waste elimination, IT feasibility, and whether the proposed changes aligned with the group’s core values.

We examined the impact of these tactics on workplace experience over a four-year period (Figure). In 2014, 30% of group members reported psychological safety, 24% had become more callous toward people in their current job, and 45% were experiencing burnout. By 2017, 59% felt a sense of psychological safety (69% increase), 15% had become more callous toward people (38% decrease), and 33% were experiencing burnout (27% decrease). Average annual turnover in the five years before the first survey was 13.2%; turnover declined during the intervention period to 6.6% (adjusted for increased number of positions). While few comprehensive models exist for calculating well-being program return on investment, the American Medical Association’s calculator¹⁷ demonstrated our group’s cost of burnout plus turnover in 2013 was $464,385 per year (assumptions in Appendix 1). We spent $343,517 on the 16 interventions between 2013 and 2017, representing an average annual cost of $86,000: $190,094 to buy-down clinical time for new leadership roles, $133,023 to fund time for the Incubator, $2,500 on gifts and awards, $4,900 on program supplies, and $10,000 on leadership training.

Based on the current literature and our experience, hospital medicine groups seeking to improve culture, resilience, and well-being should:

• Collaborate to define the group’s sense of purpose. Mission and vision are important, but most of the focus should be on surfacing, naming, and agreeing upon the group’s essential core values—the beliefs that inform whether hospitalists see the workplace as attractive, fair, and sustainable. Utilizing an expert, neutral facilitator is helpful.
• Assess culture—including, but not limited to, individual burnout and well-being—using preexisting questions from validated instruments. As culture is a product of systems, team climate, and leadership, measurement should include these domains.
• Monitor and share anonymous data from the assessment regularly (at least annually) as soon as possible after survey results are available. The data should drive inclusive, open, nonjudgmental dialog among group members and leaders in order to clarify, explore, and refine what the data mean.
• Undertake improvement efforts that emerge from the steps above, with a balanced focus on the three domains of well-being: efficiency of practice, culture of wellness, and personal resilience. Modify the number and intensity of interventions based on the group’s readiness and ability to control change in these domains. For example, some groups may have more excitement and ability to work on factors impacting the efficiency of practice, such as electronic health record templates, while others may wish to enhance opportunities for collegial interaction during the workday.
• Strive for codesign. Group members must be an integral part of the solution, rather than simply raise complaints with the expectation that leaders will devise solutions. Ideally, group members should have time, funding, or titles to lead improvement efforts.
• Opportunities to improve resilience and well-being should be widely available to all group members, but should not be mandatory.

The healthcare industry will continue to grapple with high rates of burnout and rapid change for the foreseeable future. We believe significant improvements in burnout rates and workplace experience can result from hospitalist-led interventions designed to improve experience of work among hospitalist clinicians, even as we await broader and necessary systematic efforts to address structural drivers of professional satisfaction. This work is vital if we are to honor our field’s history of productive innovation and navigate dynamic change in healthcare by attracting, engaging, developing, and retaining our most valuable asset: our people.

Disclosures

The authors declare they have no conflicts of interest/competing interests.

In 2010, the Journal of Hospital Medicine published an article proposing a “talent facilitation” framework for addressing physician workforce challenges.¹ Since then, continuous changes in healthcare work environments and shifts in relevant policies have intensified a sense of clinician workforce crisis in the United States,^2,3 often described as an epidemic of burnout. Unfortunately, hospital medicine remains among the specialties most impacted by high burnout rates and related turnover.^4-6

Despite efforts to address the sustainability of careers in hospital medicine, common approaches remain mostly reactive. Existing research on burnout is largely descriptive, focusing on the magnitude of the problem,³ the links between burnout and diminished productivity or turnover,⁷ and the negative impact of burnout on patient care.^8.9 Improvement efforts often focus on rescuing individuals from burnout, rather than prevention.¹⁰ While evidence exists that both individually targeted interventions (eg, mindfulness-based stress reduction) and institutional changes (eg, improvements in the operation of care teams) can reduce burnout, efforts to promote individuals’ resilience appear to have limited impact.^11,12

Given our field’s reputation for innovation, we believe hospitalist groups must lead the way in developing practical solutions that enhance the well-being of their members, by doing more than exhorting clinicians to “heal themselves” or imploring executives to fix care delivery systems. In this article, we describe an approach to increase resilience and well-being in a large, academic hospital medicine practice and offer an emerging list of best practices.

Maslach et al. demonstrated that burnout reflects an individual’s experience of emotional exhaustion, depersonalization of human interactions, and decreased sense of accomplishment at work.¹³ Updated frameworks emphasize that well-being and lower burnout arise from workflow efficiency, a surrounding culture of wellness, and attention to individual resilience.¹⁴ Emerging evidence suggests that burnout and well-being are, in part, a collective experience.¹⁵ As outlined in the recently published “Charter on Physician Well-being,”¹⁶ this realization creates an opportunity for clinical groups to enhance collective well-being—or thriving—rather than asking individuals to take personal responsibility for resilience or waiting for a top-down system redesign to fix drivers of burnout.

In 2013, our academic hospital medicine group set a new vision: To become the best in the nation by being an outstanding place to work. We held an inclusive divisional strategic planning retreat, which focused on clarifying the group’s six core values and exploring how to translate the values into structures, processes, and behaviors that reinforced, rather than undermined, a positive work environment. We used these initial themes to create 16 novel interventions from 2014-2017 (Figure).

Notably, we pursued this work without explicit support or interference from senior leaders in our institution. There were no competing organizational efforts addressing hospitalist efficiency, turnover, or burnout until 2017 (Excellence in Communication, described below). Furthermore, we avoided individually targeted resilience efforts based on feedback from our group that “requiring resilience activities is like blaming the victim.” Intervention participation was not mandatory, out of respect for individual choice and to avoid impeding hospitalists’ daily work.

Before designing interventions, we created a measurement tool to assess our existing culture and track evolution over time (available upon request). We utilized the instrument to provoke emotional responses, surface paradoxes, uncover assumptions, and engage the group in iterative dialog that informed and calibrated interventions. The instrument itself drew from validated elements of existing tools to quantify perceptions across nine domains: meaningful work, autonomy, professional development, logistical support, health, fulfillment outside of work, collegiality, organizational learning, and safety culture.

Several subsequent interventions focused on the emotional experience of work. For example, we developed a formal mechanism (Something Awesome) for members to share the experience of positive emotions during daily work (eg, gratitude and awe) for five minutes at monthly group meetings. We created a Collaborative Case Review process, allowing members to submit concerning cases for nonpunitive discussion and coaching among peers. Finally, we created Above and Beyond Awards, through which members’ written praise of peers’ extraordinary efforts were distributed to the entire group.

We also pursued interventions designed to increase empathy and translate it to action. These included leader rounding on our clinical units, which sought to recognize and thank individuals for daily work and to uncover exigent needs, such as food or assistance with conflict resolution between services. We created “Flash Mobs” or group conversations, which are facilitated by a leader and convened in the hospital, in order to hear from people and discuss topics of concern in real time, such as increased patient volumes. Likewise, we established “The Incubator,” a half-day meeting held four to six times annually when selected clinical faculty applied design thinking techniques to create, test, and implement ideas to enhance workplace experience (eg, supplying healthy food to our common work space at low cost).

Another key focus was professional development for group members. Examples included a three-year development program for new faculty (LaunchPad), increasing the number of available leadership roles for aspiring leaders, modifying annual reviews to focus on increasing individuals’ strengths-based work rather than solely grading performance, and creating a peer-support coaching program for newly hired members. In 2017, we began offering members a full shift credit to attend the hospital’s four-hour Excellence in Communication course, which covers six high-yield skills that increase efficiency, efficacy, and joy in practice.

Finally, we revised a number of structures and operational processes within our group’s control. We created a task force to address the needs of new parents and acquired a lactation room in the hospital. Instead of only covering offsite conference attendance (our old policy), we enhanced autonomy regarding use of continuing education dollars to allow faculty to fund any activity supporting their clinical practice. Finally, we applied quality improvement methodology to redesign the clinical schedule. This included blending value-stream mapping, software solutions, and a values-based framework to analyze proposed changes through the lens of waste elimination, IT feasibility, and whether the proposed changes aligned with the group’s core values.

We examined the impact of these tactics on workplace experience over a four-year period (Figure). In 2014, 30% of group members reported psychological safety, 24% had become more callous toward people in their current job, and 45% were experiencing burnout. By 2017, 59% felt a sense of psychological safety (69% increase), 15% had become more callous toward people (38% decrease), and 33% were experiencing burnout (27% decrease). Average annual turnover in the five years before the first survey was 13.2%; turnover declined during the intervention period to 6.6% (adjusted for increased number of positions). While few comprehensive models exist for calculating well-being program return on investment, the American Medical Association’s calculator¹⁷ demonstrated our group’s cost of burnout plus turnover in 2013 was $464,385 per year (assumptions in Appendix 1). We spent $343,517 on the 16 interventions between 2013 and 2017, representing an average annual cost of $86,000: $190,094 to buy-down clinical time for new leadership roles, $133,023 to fund time for the Incubator, $2,500 on gifts and awards, $4,900 on program supplies, and $10,000 on leadership training.

Based on the current literature and our experience, hospital medicine groups seeking to improve culture, resilience, and well-being should:

• Collaborate to define the group’s sense of purpose. Mission and vision are important, but most of the focus should be on surfacing, naming, and agreeing upon the group’s essential core values—the beliefs that inform whether hospitalists see the workplace as attractive, fair, and sustainable. Utilizing an expert, neutral facilitator is helpful.
• Assess culture—including, but not limited to, individual burnout and well-being—using preexisting questions from validated instruments. As culture is a product of systems, team climate, and leadership, measurement should include these domains.
• Monitor and share anonymous data from the assessment regularly (at least annually) as soon as possible after survey results are available. The data should drive inclusive, open, nonjudgmental dialog among group members and leaders in order to clarify, explore, and refine what the data mean.
• Undertake improvement efforts that emerge from the steps above, with a balanced focus on the three domains of well-being: efficiency of practice, culture of wellness, and personal resilience. Modify the number and intensity of interventions based on the group’s readiness and ability to control change in these domains. For example, some groups may have more excitement and ability to work on factors impacting the efficiency of practice, such as electronic health record templates, while others may wish to enhance opportunities for collegial interaction during the workday.
• Strive for codesign. Group members must be an integral part of the solution, rather than simply raise complaints with the expectation that leaders will devise solutions. Ideally, group members should have time, funding, or titles to lead improvement efforts.
• Opportunities to improve resilience and well-being should be widely available to all group members, but should not be mandatory.

The healthcare industry will continue to grapple with high rates of burnout and rapid change for the foreseeable future. We believe significant improvements in burnout rates and workplace experience can result from hospitalist-led interventions designed to improve experience of work among hospitalist clinicians, even as we await broader and necessary systematic efforts to address structural drivers of professional satisfaction. This work is vital if we are to honor our field’s history of productive innovation and navigate dynamic change in healthcare by attracting, engaging, developing, and retaining our most valuable asset: our people.

Disclosures

The authors declare they have no conflicts of interest/competing interests.

“Lord have mercy on me, was the kneeling drunkard’s plea.”

—Johnny Cash

The Diagnostic and Statistical Manual of the American Psychiatric Association defines opioid-use disorder (OUD) as a problematic pattern of prescription and/or illicit opioid medication use leading to clinically significant impairment or distress.¹ Compared with their non-OUD counterparts, patients with OUD have poorer overall health and worse health service outcomes, including higher rates of morbidity, mortality, HIV and HCV transmission, and 30-day readmissions.² With the rate of fatal overdoses from opioids at crisis levels, leading scientific and professional organizations have declared OUD to be a public health emergency in the United States.³

The opioid epidemic affects hospitalists through the rising incidence of hospitalization, not only as a result of OUD’s indirect complications, but also its direct effects of intoxication and withdrawal.⁴ In caring for patients with OUD, hospitalists are often presented with many ethical dilemmas. Whether the dilemma involves timing and circumstances of discharge or the permission to leave the hospital floor, they often involve elements of mutual mistrust. In qualitative ethnographic studies, patients with OUD report not trusting that the medical staff will take their concerns of inadequately treated pain and other needs seriously. Providers may mistrust the patient’s report of pain and withhold treatment for OUD for nonclinical reasons.⁵ Here, we examine two ethical dilemmas specific to OUD in hospitalized patients. Our aim in describing these dilemmas is to help hospitalists recognize that targeting issues of mistrust may assist them to deliver better care to hospitalized patients with OUD.

In the inpatient setting, ethical dilemmas surrounding discharge are common among people who inject drugs (PWID). These patients have disproportionately high rates of soft tissue and systemic infections, such as endocarditis and osteomyelitis, and subsequently often require long-term, outpatient parenteral antibiotic therapy (OPAT).⁶ From both the clinical and ethical perspectives, discharging PWID requiring OPAT to an unsupervised setting or continuing inpatient hospitalization to prevent a potential adverse event are equally imperfect solutions.

These patients may be clinically stable, suitable for discharge, and prefer to be discharged, but the practitioner’s concerns regarding untoward complications frequently override the patient’s wishes. Valid reasons for this exercise of what could be considered soft-paternalism are considered when physicians unilaterally decide what is best for patients, including refusal of community agencies to provide OPAT to PWID, inadequate social support and/or health literacy to administer the therapy, or varying degrees of homelessness that can affect timely follow-up. However, surveys of both hospitalists and infectious disease specialists also indicate that they may avoid discharge because of concerns the PWID will tamper with the intravenous (IV) catheter to inject drugs.⁷ This reluctance to discharge otherwise socially and medically suitable patients increases length of stay,⁷ decreases patient satisfaction, and could lead to misuse of limited hospital resources.

Both patient mistrust and stigmatization may contribute to this dilemma. Healthcare professionals have been shown to share and reflect a long-standing bias in their attitudes toward patients with substance-use disorders and OUD, in particular.⁸ Studies of providers’ attitudes are limited but suggest that legal concerns over liability and professional sanctions,⁹ reluctance to contribute to the development or relapse of addiction,¹⁰ and a strong psychological investment in not being deceived by the patient¹¹ may influence physicians’ decisions about care.

Closely supervising IV antibiotic therapy for all PWID may not reflect current medical knowledge and may imply a moral assessment of patients’ culpability and lack of will power to resist using drugs.¹² No evidence is available to suggest that inpatient parenteral antibiotic treatment offers superior adherence, and emerging evidence showing that carefully selected patients with an injection drug-use history can be safely and effectively treated as outpatients has been obtained.^13,14 Ho et al. found high rates of treatment success in patients with adequate housing, a reliable guardian, and willingness to comply with appropriate IV catheter use.¹³ Although the study by Buehrle et al. found higher rates of OPAT failure among PWIDs, 25% of these failures were due to adverse drug reactions and only 2% were due to documented line manipulations.¹⁴ This research suggests that disposition to alternative settings for OPAT in PWID may be feasible, reasonable, and deserving of further study. Rather than treating PWIDs as a homogenous group of increased risk, contextualizing care based on individual risk stratification promotes more patient-centered care that is medically appropriate and potentially more cost efficient. A thorough risk assessment includes medical evaluation of remote versus recent drug use, other psychiatric comorbidities, and a current willingness to avoid drug use and initiate treatment for it.

Patient-centered approaches that respond to the individual needs of patients have altered the care delivery model in order to improve health services outcomes. In developing an alternative care model to inpatient treatment in PWID who required OPAT, Jafari et al.¹⁵ evaluated a community model of care that provided a home-like residence as an alternative to hospitalization where patients could receive OPAT in a medically and socially supportive environment. This environment, which included RN and mental health staff for substance-use counseling, wound care, medication management, and IV therapy, demonstrated lower rates of against medical advice (AMA) discharge and higher patient satisfaction compared with hospitalization.¹⁵

Ethical dilemmas may also arise when patients with OUD desire greater mobility in the hospital. Although some inpatients may be permitted to leave the floor, some treatment teams may believe that patients with OUD leave the floor to use drugs and that the patient’s IV will facilitate such behavior. Nursing and medical staff may also believe that, if they agree to a request to leave the floor, they are complicit in any potential drug use or harmful consequences resulting from this use. For their part, patients may have a desire for more mobility because of the sometimes unpleasant constraints of hospitalization, which are not unique to these patients¹⁶ or to distract them from their cravings. Patients, unable to tolerate the restriction emotionally or believing they are being treated unfairly, even punitively, may leave AMA rather than complete needed medical care. Once more, distrust of the patient and fear of liability may lead hospital staff to respond in counterproductive ways.

Addressing this dilemma depends, in part on creating an environment where PWID and patients with OUD are treated fairly and appropriately for their underlying illness. Such treatment includes ensuring withdrawal symptoms and pain are adequately treated, building trust by empathically addressing patients’ needs and preferences,¹⁷ and having a systematic (ie, policy-based) approach for requests to leave the floor. The latter intervention assures a transparent, referable standard that providers can apply and refer to as needed.

Efforts to adequately treat withdrawal symptoms in the hospital setting have shown promise in maintaining patient engagement, reducing the rate of AMA discharges, and improving follow up with outpatient medical and substance-use treatment.¹⁸ Because physicians consistently cite the lack of advanced training in addiction medicine as a treatment limitation,¹² training may go a long way in closing this knowledge and skill gap. Furthermore, systematic efforts to better educate and train hospitalists in the care of patients with addiction can improve both knowledge and attitudes about caring for this vulnerable population,¹⁹ thereby enhancing therapeutic relationships and patient centeredness. Finally, institutional policies promoting fair, systematic, and transparent guidance are needed for front-line practitioners to manage the legal, clinical, and ethical ambiguities involved when PWID wish to leave the hospital floor.

In addressing the mistrust some staff may have toward the patients described in the preceding ethical dilemmas, the use of universal precautions is an ethical and efficacious approach that balances reliance on patients’ veracity with due diligence in objective clinical assessments.²⁰ These universal precautions, which are grounded in mutual respect and responsibility between physician and patient, include a set of strategies originally established in infectious disease practice and adapted to the management of chronic pain particularly when opioids are used.²¹ They are based on the recognition that identifying which patients prescribed opioids will develop an OUD or misuse opioids is difficult. Hence, the safest and least-stigmatizing approach is to treat all patients as individuals who could potentially be at risk. This is an ethically strong approach that seeks to balance the competing values of patent safety and patient centeredness, and involves taking a substance-use history from all patients admitted to the hospital and routinely checking state prescription-drug monitoring programs among other steps. Although self-reporting, at least of prescription-drug misuse, is fairly reliable,²² establishing expectations for mutual respect when working with patients with OUD and other addictive disorders is more likely to garner valid reports and a positive alliance. Once this relationship is established, the practitioner can respond to problematic behaviors with clear, compassionate limit setting.

From a broader perspective, a hospital system and culture that is unable to promote trust and adequately treat pain and withdrawal can create a “risk environment” for PWID.²³ When providers are inadequately trained in the management of pain and addiction, or there is a shortage of addiction specialists, or inadequate policy guidance for managing the care of these patients, this can result in AMA discharges and reduced willingness to seek future care. Viewing this problem more expansively may persuade healthcare professionals that patients alone are not entirely responsible for the outcomes related to their illness but that modifying practices and structure at the hospital level has the potential to mitigate harm to this vulnerable population.

As inpatient team leaders, hospitalists have the unique opportunity to address the opioid crisis by enhancing the quality of care provided to hospitalized patients with OUD. This enhancement can be accomplished by destigmatizing substance-use disorders, establishing relationships of trust, and promoting remedies to structural deficiencies in the healthcare system that contribute to the problem. These approaches have the potential to enhance not only the care of patients with OUD but also the satisfaction of the treatment team caring for these patients.²⁴ Such changes will ideally allow physicians to better treat the illness, address ethical and clinical concerns when they arise, and promote enhanced participation in treatment planning.

Disclosures

The authors have no conflicts of interest to disclose, financial or otherwise. The views expressed in this article are those of the authors and do not necessarily reflect the position or policy of the U.S. Department of Veterans Affairs, the U.S. Government, or the VA National Center for Ethics in Health Care.

“Lord have mercy on me, was the kneeling drunkard’s plea.”

—Johnny Cash

The Diagnostic and Statistical Manual of the American Psychiatric Association defines opioid-use disorder (OUD) as a problematic pattern of prescription and/or illicit opioid medication use leading to clinically significant impairment or distress.¹ Compared with their non-OUD counterparts, patients with OUD have poorer overall health and worse health service outcomes, including higher rates of morbidity, mortality, HIV and HCV transmission, and 30-day readmissions.² With the rate of fatal overdoses from opioids at crisis levels, leading scientific and professional organizations have declared OUD to be a public health emergency in the United States.³

The opioid epidemic affects hospitalists through the rising incidence of hospitalization, not only as a result of OUD’s indirect complications, but also its direct effects of intoxication and withdrawal.⁴ In caring for patients with OUD, hospitalists are often presented with many ethical dilemmas. Whether the dilemma involves timing and circumstances of discharge or the permission to leave the hospital floor, they often involve elements of mutual mistrust. In qualitative ethnographic studies, patients with OUD report not trusting that the medical staff will take their concerns of inadequately treated pain and other needs seriously. Providers may mistrust the patient’s report of pain and withhold treatment for OUD for nonclinical reasons.⁵ Here, we examine two ethical dilemmas specific to OUD in hospitalized patients. Our aim in describing these dilemmas is to help hospitalists recognize that targeting issues of mistrust may assist them to deliver better care to hospitalized patients with OUD.

In the inpatient setting, ethical dilemmas surrounding discharge are common among people who inject drugs (PWID). These patients have disproportionately high rates of soft tissue and systemic infections, such as endocarditis and osteomyelitis, and subsequently often require long-term, outpatient parenteral antibiotic therapy (OPAT).⁶ From both the clinical and ethical perspectives, discharging PWID requiring OPAT to an unsupervised setting or continuing inpatient hospitalization to prevent a potential adverse event are equally imperfect solutions.

These patients may be clinically stable, suitable for discharge, and prefer to be discharged, but the practitioner’s concerns regarding untoward complications frequently override the patient’s wishes. Valid reasons for this exercise of what could be considered soft-paternalism are considered when physicians unilaterally decide what is best for patients, including refusal of community agencies to provide OPAT to PWID, inadequate social support and/or health literacy to administer the therapy, or varying degrees of homelessness that can affect timely follow-up. However, surveys of both hospitalists and infectious disease specialists also indicate that they may avoid discharge because of concerns the PWID will tamper with the intravenous (IV) catheter to inject drugs.⁷ This reluctance to discharge otherwise socially and medically suitable patients increases length of stay,⁷ decreases patient satisfaction, and could lead to misuse of limited hospital resources.

Both patient mistrust and stigmatization may contribute to this dilemma. Healthcare professionals have been shown to share and reflect a long-standing bias in their attitudes toward patients with substance-use disorders and OUD, in particular.⁸ Studies of providers’ attitudes are limited but suggest that legal concerns over liability and professional sanctions,⁹ reluctance to contribute to the development or relapse of addiction,¹⁰ and a strong psychological investment in not being deceived by the patient¹¹ may influence physicians’ decisions about care.

Closely supervising IV antibiotic therapy for all PWID may not reflect current medical knowledge and may imply a moral assessment of patients’ culpability and lack of will power to resist using drugs.¹² No evidence is available to suggest that inpatient parenteral antibiotic treatment offers superior adherence, and emerging evidence showing that carefully selected patients with an injection drug-use history can be safely and effectively treated as outpatients has been obtained.^13,14 Ho et al. found high rates of treatment success in patients with adequate housing, a reliable guardian, and willingness to comply with appropriate IV catheter use.¹³ Although the study by Buehrle et al. found higher rates of OPAT failure among PWIDs, 25% of these failures were due to adverse drug reactions and only 2% were due to documented line manipulations.¹⁴ This research suggests that disposition to alternative settings for OPAT in PWID may be feasible, reasonable, and deserving of further study. Rather than treating PWIDs as a homogenous group of increased risk, contextualizing care based on individual risk stratification promotes more patient-centered care that is medically appropriate and potentially more cost efficient. A thorough risk assessment includes medical evaluation of remote versus recent drug use, other psychiatric comorbidities, and a current willingness to avoid drug use and initiate treatment for it.

Patient-centered approaches that respond to the individual needs of patients have altered the care delivery model in order to improve health services outcomes. In developing an alternative care model to inpatient treatment in PWID who required OPAT, Jafari et al.¹⁵ evaluated a community model of care that provided a home-like residence as an alternative to hospitalization where patients could receive OPAT in a medically and socially supportive environment. This environment, which included RN and mental health staff for substance-use counseling, wound care, medication management, and IV therapy, demonstrated lower rates of against medical advice (AMA) discharge and higher patient satisfaction compared with hospitalization.¹⁵

Ethical dilemmas may also arise when patients with OUD desire greater mobility in the hospital. Although some inpatients may be permitted to leave the floor, some treatment teams may believe that patients with OUD leave the floor to use drugs and that the patient’s IV will facilitate such behavior. Nursing and medical staff may also believe that, if they agree to a request to leave the floor, they are complicit in any potential drug use or harmful consequences resulting from this use. For their part, patients may have a desire for more mobility because of the sometimes unpleasant constraints of hospitalization, which are not unique to these patients¹⁶ or to distract them from their cravings. Patients, unable to tolerate the restriction emotionally or believing they are being treated unfairly, even punitively, may leave AMA rather than complete needed medical care. Once more, distrust of the patient and fear of liability may lead hospital staff to respond in counterproductive ways.

Addressing this dilemma depends, in part on creating an environment where PWID and patients with OUD are treated fairly and appropriately for their underlying illness. Such treatment includes ensuring withdrawal symptoms and pain are adequately treated, building trust by empathically addressing patients’ needs and preferences,¹⁷ and having a systematic (ie, policy-based) approach for requests to leave the floor. The latter intervention assures a transparent, referable standard that providers can apply and refer to as needed.

Efforts to adequately treat withdrawal symptoms in the hospital setting have shown promise in maintaining patient engagement, reducing the rate of AMA discharges, and improving follow up with outpatient medical and substance-use treatment.¹⁸ Because physicians consistently cite the lack of advanced training in addiction medicine as a treatment limitation,¹² training may go a long way in closing this knowledge and skill gap. Furthermore, systematic efforts to better educate and train hospitalists in the care of patients with addiction can improve both knowledge and attitudes about caring for this vulnerable population,¹⁹ thereby enhancing therapeutic relationships and patient centeredness. Finally, institutional policies promoting fair, systematic, and transparent guidance are needed for front-line practitioners to manage the legal, clinical, and ethical ambiguities involved when PWID wish to leave the hospital floor.

In addressing the mistrust some staff may have toward the patients described in the preceding ethical dilemmas, the use of universal precautions is an ethical and efficacious approach that balances reliance on patients’ veracity with due diligence in objective clinical assessments.²⁰ These universal precautions, which are grounded in mutual respect and responsibility between physician and patient, include a set of strategies originally established in infectious disease practice and adapted to the management of chronic pain particularly when opioids are used.²¹ They are based on the recognition that identifying which patients prescribed opioids will develop an OUD or misuse opioids is difficult. Hence, the safest and least-stigmatizing approach is to treat all patients as individuals who could potentially be at risk. This is an ethically strong approach that seeks to balance the competing values of patent safety and patient centeredness, and involves taking a substance-use history from all patients admitted to the hospital and routinely checking state prescription-drug monitoring programs among other steps. Although self-reporting, at least of prescription-drug misuse, is fairly reliable,²² establishing expectations for mutual respect when working with patients with OUD and other addictive disorders is more likely to garner valid reports and a positive alliance. Once this relationship is established, the practitioner can respond to problematic behaviors with clear, compassionate limit setting.

From a broader perspective, a hospital system and culture that is unable to promote trust and adequately treat pain and withdrawal can create a “risk environment” for PWID.²³ When providers are inadequately trained in the management of pain and addiction, or there is a shortage of addiction specialists, or inadequate policy guidance for managing the care of these patients, this can result in AMA discharges and reduced willingness to seek future care. Viewing this problem more expansively may persuade healthcare professionals that patients alone are not entirely responsible for the outcomes related to their illness but that modifying practices and structure at the hospital level has the potential to mitigate harm to this vulnerable population.

As inpatient team leaders, hospitalists have the unique opportunity to address the opioid crisis by enhancing the quality of care provided to hospitalized patients with OUD. This enhancement can be accomplished by destigmatizing substance-use disorders, establishing relationships of trust, and promoting remedies to structural deficiencies in the healthcare system that contribute to the problem. These approaches have the potential to enhance not only the care of patients with OUD but also the satisfaction of the treatment team caring for these patients.²⁴ Such changes will ideally allow physicians to better treat the illness, address ethical and clinical concerns when they arise, and promote enhanced participation in treatment planning.

Disclosures

The authors have no conflicts of interest to disclose, financial or otherwise. The views expressed in this article are those of the authors and do not necessarily reflect the position or policy of the U.S. Department of Veterans Affairs, the U.S. Government, or the VA National Center for Ethics in Health Care.

“Lord have mercy on me, was the kneeling drunkard’s plea.”

—Johnny Cash

The Diagnostic and Statistical Manual of the American Psychiatric Association defines opioid-use disorder (OUD) as a problematic pattern of prescription and/or illicit opioid medication use leading to clinically significant impairment or distress.¹ Compared with their non-OUD counterparts, patients with OUD have poorer overall health and worse health service outcomes, including higher rates of morbidity, mortality, HIV and HCV transmission, and 30-day readmissions.² With the rate of fatal overdoses from opioids at crisis levels, leading scientific and professional organizations have declared OUD to be a public health emergency in the United States.³

The opioid epidemic affects hospitalists through the rising incidence of hospitalization, not only as a result of OUD’s indirect complications, but also its direct effects of intoxication and withdrawal.⁴ In caring for patients with OUD, hospitalists are often presented with many ethical dilemmas. Whether the dilemma involves timing and circumstances of discharge or the permission to leave the hospital floor, they often involve elements of mutual mistrust. In qualitative ethnographic studies, patients with OUD report not trusting that the medical staff will take their concerns of inadequately treated pain and other needs seriously. Providers may mistrust the patient’s report of pain and withhold treatment for OUD for nonclinical reasons.⁵ Here, we examine two ethical dilemmas specific to OUD in hospitalized patients. Our aim in describing these dilemmas is to help hospitalists recognize that targeting issues of mistrust may assist them to deliver better care to hospitalized patients with OUD.

In the inpatient setting, ethical dilemmas surrounding discharge are common among people who inject drugs (PWID). These patients have disproportionately high rates of soft tissue and systemic infections, such as endocarditis and osteomyelitis, and subsequently often require long-term, outpatient parenteral antibiotic therapy (OPAT).⁶ From both the clinical and ethical perspectives, discharging PWID requiring OPAT to an unsupervised setting or continuing inpatient hospitalization to prevent a potential adverse event are equally imperfect solutions.

These patients may be clinically stable, suitable for discharge, and prefer to be discharged, but the practitioner’s concerns regarding untoward complications frequently override the patient’s wishes. Valid reasons for this exercise of what could be considered soft-paternalism are considered when physicians unilaterally decide what is best for patients, including refusal of community agencies to provide OPAT to PWID, inadequate social support and/or health literacy to administer the therapy, or varying degrees of homelessness that can affect timely follow-up. However, surveys of both hospitalists and infectious disease specialists also indicate that they may avoid discharge because of concerns the PWID will tamper with the intravenous (IV) catheter to inject drugs.⁷ This reluctance to discharge otherwise socially and medically suitable patients increases length of stay,⁷ decreases patient satisfaction, and could lead to misuse of limited hospital resources.

Both patient mistrust and stigmatization may contribute to this dilemma. Healthcare professionals have been shown to share and reflect a long-standing bias in their attitudes toward patients with substance-use disorders and OUD, in particular.⁸ Studies of providers’ attitudes are limited but suggest that legal concerns over liability and professional sanctions,⁹ reluctance to contribute to the development or relapse of addiction,¹⁰ and a strong psychological investment in not being deceived by the patient¹¹ may influence physicians’ decisions about care.

Closely supervising IV antibiotic therapy for all PWID may not reflect current medical knowledge and may imply a moral assessment of patients’ culpability and lack of will power to resist using drugs.¹² No evidence is available to suggest that inpatient parenteral antibiotic treatment offers superior adherence, and emerging evidence showing that carefully selected patients with an injection drug-use history can be safely and effectively treated as outpatients has been obtained.^13,14 Ho et al. found high rates of treatment success in patients with adequate housing, a reliable guardian, and willingness to comply with appropriate IV catheter use.¹³ Although the study by Buehrle et al. found higher rates of OPAT failure among PWIDs, 25% of these failures were due to adverse drug reactions and only 2% were due to documented line manipulations.¹⁴ This research suggests that disposition to alternative settings for OPAT in PWID may be feasible, reasonable, and deserving of further study. Rather than treating PWIDs as a homogenous group of increased risk, contextualizing care based on individual risk stratification promotes more patient-centered care that is medically appropriate and potentially more cost efficient. A thorough risk assessment includes medical evaluation of remote versus recent drug use, other psychiatric comorbidities, and a current willingness to avoid drug use and initiate treatment for it.

Patient-centered approaches that respond to the individual needs of patients have altered the care delivery model in order to improve health services outcomes. In developing an alternative care model to inpatient treatment in PWID who required OPAT, Jafari et al.¹⁵ evaluated a community model of care that provided a home-like residence as an alternative to hospitalization where patients could receive OPAT in a medically and socially supportive environment. This environment, which included RN and mental health staff for substance-use counseling, wound care, medication management, and IV therapy, demonstrated lower rates of against medical advice (AMA) discharge and higher patient satisfaction compared with hospitalization.¹⁵

Ethical dilemmas may also arise when patients with OUD desire greater mobility in the hospital. Although some inpatients may be permitted to leave the floor, some treatment teams may believe that patients with OUD leave the floor to use drugs and that the patient’s IV will facilitate such behavior. Nursing and medical staff may also believe that, if they agree to a request to leave the floor, they are complicit in any potential drug use or harmful consequences resulting from this use. For their part, patients may have a desire for more mobility because of the sometimes unpleasant constraints of hospitalization, which are not unique to these patients¹⁶ or to distract them from their cravings. Patients, unable to tolerate the restriction emotionally or believing they are being treated unfairly, even punitively, may leave AMA rather than complete needed medical care. Once more, distrust of the patient and fear of liability may lead hospital staff to respond in counterproductive ways.

Addressing this dilemma depends, in part on creating an environment where PWID and patients with OUD are treated fairly and appropriately for their underlying illness. Such treatment includes ensuring withdrawal symptoms and pain are adequately treated, building trust by empathically addressing patients’ needs and preferences,¹⁷ and having a systematic (ie, policy-based) approach for requests to leave the floor. The latter intervention assures a transparent, referable standard that providers can apply and refer to as needed.

Efforts to adequately treat withdrawal symptoms in the hospital setting have shown promise in maintaining patient engagement, reducing the rate of AMA discharges, and improving follow up with outpatient medical and substance-use treatment.¹⁸ Because physicians consistently cite the lack of advanced training in addiction medicine as a treatment limitation,¹² training may go a long way in closing this knowledge and skill gap. Furthermore, systematic efforts to better educate and train hospitalists in the care of patients with addiction can improve both knowledge and attitudes about caring for this vulnerable population,¹⁹ thereby enhancing therapeutic relationships and patient centeredness. Finally, institutional policies promoting fair, systematic, and transparent guidance are needed for front-line practitioners to manage the legal, clinical, and ethical ambiguities involved when PWID wish to leave the hospital floor.

In addressing the mistrust some staff may have toward the patients described in the preceding ethical dilemmas, the use of universal precautions is an ethical and efficacious approach that balances reliance on patients’ veracity with due diligence in objective clinical assessments.²⁰ These universal precautions, which are grounded in mutual respect and responsibility between physician and patient, include a set of strategies originally established in infectious disease practice and adapted to the management of chronic pain particularly when opioids are used.²¹ They are based on the recognition that identifying which patients prescribed opioids will develop an OUD or misuse opioids is difficult. Hence, the safest and least-stigmatizing approach is to treat all patients as individuals who could potentially be at risk. This is an ethically strong approach that seeks to balance the competing values of patent safety and patient centeredness, and involves taking a substance-use history from all patients admitted to the hospital and routinely checking state prescription-drug monitoring programs among other steps. Although self-reporting, at least of prescription-drug misuse, is fairly reliable,²² establishing expectations for mutual respect when working with patients with OUD and other addictive disorders is more likely to garner valid reports and a positive alliance. Once this relationship is established, the practitioner can respond to problematic behaviors with clear, compassionate limit setting.

From a broader perspective, a hospital system and culture that is unable to promote trust and adequately treat pain and withdrawal can create a “risk environment” for PWID.²³ When providers are inadequately trained in the management of pain and addiction, or there is a shortage of addiction specialists, or inadequate policy guidance for managing the care of these patients, this can result in AMA discharges and reduced willingness to seek future care. Viewing this problem more expansively may persuade healthcare professionals that patients alone are not entirely responsible for the outcomes related to their illness but that modifying practices and structure at the hospital level has the potential to mitigate harm to this vulnerable population.

As inpatient team leaders, hospitalists have the unique opportunity to address the opioid crisis by enhancing the quality of care provided to hospitalized patients with OUD. This enhancement can be accomplished by destigmatizing substance-use disorders, establishing relationships of trust, and promoting remedies to structural deficiencies in the healthcare system that contribute to the problem. These approaches have the potential to enhance not only the care of patients with OUD but also the satisfaction of the treatment team caring for these patients.²⁴ Such changes will ideally allow physicians to better treat the illness, address ethical and clinical concerns when they arise, and promote enhanced participation in treatment planning.

Disclosures

The authors have no conflicts of interest to disclose, financial or otherwise. The views expressed in this article are those of the authors and do not necessarily reflect the position or policy of the U.S. Department of Veterans Affairs, the U.S. Government, or the VA National Center for Ethics in Health Care.

Should physicians be subject to random drug testing? It’s a controversial topic. One in 10 Americans suffer from a drug use disorder at some point in their lives.¹ Although physicians engaging in drug diversion is very rare, we recognize, in the context of rising rates of opiate use, that drug misuse and addiction can involve physicians.^2,3 When it occurs, addiction can drive behaviors that endanger both clinicians and patients. Media reports on drug diversion describe an anesthesiologist who died of overdose from diverted fentanyl and a surgical technician with HIV who used and replaced opioids in the operating room, resulting in thousands of patients needing to be tested for infection.⁴ Multiple outbreaks of hepatitis C involving more than a dozen hospitals in eight states were traced to a single health care provider diverting narcotics.⁵ An investigation of outbreaks at various medical centers in the United States over a 10-year period identified nearly 30,000 patients that were potentially exposed and more than 100 iatrogenic infections.⁶

The profession of medicine holds a special place in the esteem of the public, with healthcare providers being among the most trusted professions. Patients rely on us to keep them safe when they are at their most vulnerable. This trust is predicated on the belief that the profession of medicine will self-regulate. Drug diversion by clinicians is a violation of this trust.

Our hospital utilizes existing structures to address substance use disorder; such structures include regular education on recognizing impairment for the medical staff, an impaired clinician policy for suspicion of impairment, and a state physician health program that provides nonpunitive evaluation and treatment for substance use by clinicians. In response to the imperative to mitigate the potential for drug diversion, our health system undertook a number of additional initiatives. These initiatives, included inventory control and tracking of controlled substances, and random testing and trigger-based audits of returned medications to ensure the entire amount had been accounted for. As part of this system-wide initiative, UCHealth began random drug testing of employees in safety-sensitive positions (for whom impairment would represent the potential for harm to others). Medical staff are not employees of the health system and were not initially subject to testing. The key questions at the time included the following:

• Is our organization doing everything possible to prevent drug diversion?
• If nurses and other staff are subject to random drug testing, why would physicians be exempt?

The University of Colorado Hospital (UCH) is the academic medical center within UCHealth. The structure of the relationship between the hospital and its medical staff requires the question of drug testing for physicians to be addressed by the UCH Medical Board (Medical Executive Committee). Medical staff leadership and key opinion leaders were engaged in the process of considering random drug testing of the medical staff. In the process, medical staff leadership raised additional questions about the process of decision making:

• “How should this issue be handled in the context of physician autonomy?”
• “How do we assure the concerns of the medical staff are heard and addressed?”

The guiding principles considered by the medical staff leadership in the implementation of random drug testing included the following: (1) as a matter of medical professionalism, for random drug testing to be implemented, the medical staff must elect to submit to mandatory testing; (2) the random drug testing program must be designed to minimize harm; and (3) the process for random drug testing program design needs to engage front-line clinicians. This resulted in a series of communications, meetings, and outreach to groups within the medical staff.

From front-line medical staff members, we heard overwhelming consensus for the moral case to prevent patient harm resulting from drug diversion, our professional duty to address the issue, and the need to maintain public trust in the institution of medicine. At the same time, medical staff members often expressed skepticism regarding the efficacy of random drug testing as a tactic, concerns about operational implementation, and fears regarding the unintended consequences:

• How strong is the evidence that random drug testing prevents drug diversion?
• How can we be confident that false-positive tests will not cause innocent clinicians to be incorrectly accused of drug use?

The efficacy of random drug testing in preventing drug diversion is not settled. The discussion of how to proceed in the absence of well-designed studies on the tactic was robust. One common principle we heard from members of the medical staff was that our response be driven by an authentic organizational desire to reduce patient harm. They expressed that the process of testing needs to respect the boundaries between work and home life and to avoid the disruption of clinical responsibilities. Whether targeting testing to “higher risk” groups of clinicians is appropriate and whether or not alcohol and/or marijuana would be tested came up often.

Other concerns expressed also included the intrusion of the institution into the private medical conditions of the medical staff members, breach of confidentiality, or accessibility of the information obtained as a result of the program for unrelated legal proceedings. One of the most prominent fears expressed was the possible impact of false-positive tests on the clinicians’ careers.

Following the listening tour by the medical staff and hospital leadership and extensive discussions, the Medical Board voted to approve a policy to implement random drug testing. The deliberative process lasted for approximately eight months. We sought input from other healthcare systems, such as the Veterans Administration and Cleveland Clinic, that conduct random drug tests on employed physicians. A physician from Massachusetts General Hospital who led the 2004 implementation of random drug testing for anesthesiologists was invited to come to Colorado to give grand rounds about the experience in his department and answer questions about the implementation of random drug testing at a Medical Board meeting.⁷ The policy went into effect January 2017.

The design of the program sought to explicitly address the issues raised by the front-line clinicians. In the interest of equity, all specialties, including Radiology and Pathology, are subject to testing. Medical staff are selected for testing using a random number generator and retained in the random selection pool at all times, regardless of previous selection for testing. Consistent with the underlying objective of identifying drug diversion, testing is limited to drugs at higher risk for diversion (eg, amphetamine, barbiturate, benzodiazepine, butorphanol, cocaine metabolite, fentanyl, ketamine, meperidine, methadone, nalbuphine, opiates, oxycodone, and tramadol). Although alcohol and marijuana are substances of abuse, they are not substances of healthcare diversion and thus are excluded from random drug testing (although included in testing for impairment). Random drug testing is conducted only for medical staff who are onsite and providing clinical services. The individuals selected for random drug testing are notified by Employee Health, or their clinical supervisor, to present to Employee Health that day to provide a urine sample. The involvement of the clinical supervisor in specific departments and the flexibility in time of presentation was implemented to address the concerns of the medical staff regarding harm from the disruption of acute patient care.

To address the concern regarding false-positive tests, an external medical laboratory that performs testing compliant with Substance Abuse and Mental Health Services and governmental standards is used. Samples are split providing the ability to perform independent testing of two samples. The thresholds are set to minimize false-positive tests. Positive results are sent to an independent medical review officer who confidentially contacts the medical staff member to assess for valid prescriptions to explain the test results. Unexplained positive test results trigger the testing of the second half of the split sample.

To address issues of dignity, privacy, and confidentiality, Employee Health discretely oversees the urine collection. The test results are not part of the individual’s medical record. Only the coordinator for random drug testing in Human Resources compliance can access the test results, which are stored in a separate, secure database. The medical review officer shares no information about the medical staff members’ medical conditions. A positive drug assay attributable to a valid medical explanation is reported as a negative test.

Positive test results, which would be reported to the President of the Medical Staff, would trigger further investigation, potential Medical Board action consistent with medical staff bylaws, and reporting to licensing bodies as appropriate. We recognize that most addiction is not associated with diversion, and all individuals struggling with substance use need support. The medical staff and hospital leadership committed through this process to connecting medical staff members who are identified by random drug testing to help for substance use disorder, starting with the State Physician Health Program.

The Medical Executive Committees of all hospitals within UCHealth have also approved random drug testing of medical staff. We are not the first healthcare organization to tackle the potential for drug diversion by healthcare workers. To our knowledge, we are the largest health system to have nonemployed medical staff leadership vote for the entire medical staff to be subject to random drug testing. Along the journey, the approach of random drug testing for physicians was vigorously debated. In this regard, we proffer one final question:

• How would you have voted?

Disclosures

The authors have nothing to disclose.

Should physicians be subject to random drug testing? It’s a controversial topic. One in 10 Americans suffer from a drug use disorder at some point in their lives.¹ Although physicians engaging in drug diversion is very rare, we recognize, in the context of rising rates of opiate use, that drug misuse and addiction can involve physicians.^2,3 When it occurs, addiction can drive behaviors that endanger both clinicians and patients. Media reports on drug diversion describe an anesthesiologist who died of overdose from diverted fentanyl and a surgical technician with HIV who used and replaced opioids in the operating room, resulting in thousands of patients needing to be tested for infection.⁴ Multiple outbreaks of hepatitis C involving more than a dozen hospitals in eight states were traced to a single health care provider diverting narcotics.⁵ An investigation of outbreaks at various medical centers in the United States over a 10-year period identified nearly 30,000 patients that were potentially exposed and more than 100 iatrogenic infections.⁶

The profession of medicine holds a special place in the esteem of the public, with healthcare providers being among the most trusted professions. Patients rely on us to keep them safe when they are at their most vulnerable. This trust is predicated on the belief that the profession of medicine will self-regulate. Drug diversion by clinicians is a violation of this trust.

Our hospital utilizes existing structures to address substance use disorder; such structures include regular education on recognizing impairment for the medical staff, an impaired clinician policy for suspicion of impairment, and a state physician health program that provides nonpunitive evaluation and treatment for substance use by clinicians. In response to the imperative to mitigate the potential for drug diversion, our health system undertook a number of additional initiatives. These initiatives, included inventory control and tracking of controlled substances, and random testing and trigger-based audits of returned medications to ensure the entire amount had been accounted for. As part of this system-wide initiative, UCHealth began random drug testing of employees in safety-sensitive positions (for whom impairment would represent the potential for harm to others). Medical staff are not employees of the health system and were not initially subject to testing. The key questions at the time included the following:

• Is our organization doing everything possible to prevent drug diversion?
• If nurses and other staff are subject to random drug testing, why would physicians be exempt?

The University of Colorado Hospital (UCH) is the academic medical center within UCHealth. The structure of the relationship between the hospital and its medical staff requires the question of drug testing for physicians to be addressed by the UCH Medical Board (Medical Executive Committee). Medical staff leadership and key opinion leaders were engaged in the process of considering random drug testing of the medical staff. In the process, medical staff leadership raised additional questions about the process of decision making:

• “How should this issue be handled in the context of physician autonomy?”
• “How do we assure the concerns of the medical staff are heard and addressed?”

The guiding principles considered by the medical staff leadership in the implementation of random drug testing included the following: (1) as a matter of medical professionalism, for random drug testing to be implemented, the medical staff must elect to submit to mandatory testing; (2) the random drug testing program must be designed to minimize harm; and (3) the process for random drug testing program design needs to engage front-line clinicians. This resulted in a series of communications, meetings, and outreach to groups within the medical staff.

From front-line medical staff members, we heard overwhelming consensus for the moral case to prevent patient harm resulting from drug diversion, our professional duty to address the issue, and the need to maintain public trust in the institution of medicine. At the same time, medical staff members often expressed skepticism regarding the efficacy of random drug testing as a tactic, concerns about operational implementation, and fears regarding the unintended consequences:

• How strong is the evidence that random drug testing prevents drug diversion?
• How can we be confident that false-positive tests will not cause innocent clinicians to be incorrectly accused of drug use?

The efficacy of random drug testing in preventing drug diversion is not settled. The discussion of how to proceed in the absence of well-designed studies on the tactic was robust. One common principle we heard from members of the medical staff was that our response be driven by an authentic organizational desire to reduce patient harm. They expressed that the process of testing needs to respect the boundaries between work and home life and to avoid the disruption of clinical responsibilities. Whether targeting testing to “higher risk” groups of clinicians is appropriate and whether or not alcohol and/or marijuana would be tested came up often.

Other concerns expressed also included the intrusion of the institution into the private medical conditions of the medical staff members, breach of confidentiality, or accessibility of the information obtained as a result of the program for unrelated legal proceedings. One of the most prominent fears expressed was the possible impact of false-positive tests on the clinicians’ careers.

Following the listening tour by the medical staff and hospital leadership and extensive discussions, the Medical Board voted to approve a policy to implement random drug testing. The deliberative process lasted for approximately eight months. We sought input from other healthcare systems, such as the Veterans Administration and Cleveland Clinic, that conduct random drug tests on employed physicians. A physician from Massachusetts General Hospital who led the 2004 implementation of random drug testing for anesthesiologists was invited to come to Colorado to give grand rounds about the experience in his department and answer questions about the implementation of random drug testing at a Medical Board meeting.⁷ The policy went into effect January 2017.

The design of the program sought to explicitly address the issues raised by the front-line clinicians. In the interest of equity, all specialties, including Radiology and Pathology, are subject to testing. Medical staff are selected for testing using a random number generator and retained in the random selection pool at all times, regardless of previous selection for testing. Consistent with the underlying objective of identifying drug diversion, testing is limited to drugs at higher risk for diversion (eg, amphetamine, barbiturate, benzodiazepine, butorphanol, cocaine metabolite, fentanyl, ketamine, meperidine, methadone, nalbuphine, opiates, oxycodone, and tramadol). Although alcohol and marijuana are substances of abuse, they are not substances of healthcare diversion and thus are excluded from random drug testing (although included in testing for impairment). Random drug testing is conducted only for medical staff who are onsite and providing clinical services. The individuals selected for random drug testing are notified by Employee Health, or their clinical supervisor, to present to Employee Health that day to provide a urine sample. The involvement of the clinical supervisor in specific departments and the flexibility in time of presentation was implemented to address the concerns of the medical staff regarding harm from the disruption of acute patient care.

To address the concern regarding false-positive tests, an external medical laboratory that performs testing compliant with Substance Abuse and Mental Health Services and governmental standards is used. Samples are split providing the ability to perform independent testing of two samples. The thresholds are set to minimize false-positive tests. Positive results are sent to an independent medical review officer who confidentially contacts the medical staff member to assess for valid prescriptions to explain the test results. Unexplained positive test results trigger the testing of the second half of the split sample.

To address issues of dignity, privacy, and confidentiality, Employee Health discretely oversees the urine collection. The test results are not part of the individual’s medical record. Only the coordinator for random drug testing in Human Resources compliance can access the test results, which are stored in a separate, secure database. The medical review officer shares no information about the medical staff members’ medical conditions. A positive drug assay attributable to a valid medical explanation is reported as a negative test.

Positive test results, which would be reported to the President of the Medical Staff, would trigger further investigation, potential Medical Board action consistent with medical staff bylaws, and reporting to licensing bodies as appropriate. We recognize that most addiction is not associated with diversion, and all individuals struggling with substance use need support. The medical staff and hospital leadership committed through this process to connecting medical staff members who are identified by random drug testing to help for substance use disorder, starting with the State Physician Health Program.

The Medical Executive Committees of all hospitals within UCHealth have also approved random drug testing of medical staff. We are not the first healthcare organization to tackle the potential for drug diversion by healthcare workers. To our knowledge, we are the largest health system to have nonemployed medical staff leadership vote for the entire medical staff to be subject to random drug testing. Along the journey, the approach of random drug testing for physicians was vigorously debated. In this regard, we proffer one final question:

• How would you have voted?

Disclosures

The authors have nothing to disclose.

Should physicians be subject to random drug testing? It’s a controversial topic. One in 10 Americans suffer from a drug use disorder at some point in their lives.¹ Although physicians engaging in drug diversion is very rare, we recognize, in the context of rising rates of opiate use, that drug misuse and addiction can involve physicians.^2,3 When it occurs, addiction can drive behaviors that endanger both clinicians and patients. Media reports on drug diversion describe an anesthesiologist who died of overdose from diverted fentanyl and a surgical technician with HIV who used and replaced opioids in the operating room, resulting in thousands of patients needing to be tested for infection.⁴ Multiple outbreaks of hepatitis C involving more than a dozen hospitals in eight states were traced to a single health care provider diverting narcotics.⁵ An investigation of outbreaks at various medical centers in the United States over a 10-year period identified nearly 30,000 patients that were potentially exposed and more than 100 iatrogenic infections.⁶

The profession of medicine holds a special place in the esteem of the public, with healthcare providers being among the most trusted professions. Patients rely on us to keep them safe when they are at their most vulnerable. This trust is predicated on the belief that the profession of medicine will self-regulate. Drug diversion by clinicians is a violation of this trust.

Our hospital utilizes existing structures to address substance use disorder; such structures include regular education on recognizing impairment for the medical staff, an impaired clinician policy for suspicion of impairment, and a state physician health program that provides nonpunitive evaluation and treatment for substance use by clinicians. In response to the imperative to mitigate the potential for drug diversion, our health system undertook a number of additional initiatives. These initiatives, included inventory control and tracking of controlled substances, and random testing and trigger-based audits of returned medications to ensure the entire amount had been accounted for. As part of this system-wide initiative, UCHealth began random drug testing of employees in safety-sensitive positions (for whom impairment would represent the potential for harm to others). Medical staff are not employees of the health system and were not initially subject to testing. The key questions at the time included the following:

• Is our organization doing everything possible to prevent drug diversion?
• If nurses and other staff are subject to random drug testing, why would physicians be exempt?

The University of Colorado Hospital (UCH) is the academic medical center within UCHealth. The structure of the relationship between the hospital and its medical staff requires the question of drug testing for physicians to be addressed by the UCH Medical Board (Medical Executive Committee). Medical staff leadership and key opinion leaders were engaged in the process of considering random drug testing of the medical staff. In the process, medical staff leadership raised additional questions about the process of decision making:

• “How should this issue be handled in the context of physician autonomy?”
• “How do we assure the concerns of the medical staff are heard and addressed?”

The guiding principles considered by the medical staff leadership in the implementation of random drug testing included the following: (1) as a matter of medical professionalism, for random drug testing to be implemented, the medical staff must elect to submit to mandatory testing; (2) the random drug testing program must be designed to minimize harm; and (3) the process for random drug testing program design needs to engage front-line clinicians. This resulted in a series of communications, meetings, and outreach to groups within the medical staff.

From front-line medical staff members, we heard overwhelming consensus for the moral case to prevent patient harm resulting from drug diversion, our professional duty to address the issue, and the need to maintain public trust in the institution of medicine. At the same time, medical staff members often expressed skepticism regarding the efficacy of random drug testing as a tactic, concerns about operational implementation, and fears regarding the unintended consequences:

• How strong is the evidence that random drug testing prevents drug diversion?
• How can we be confident that false-positive tests will not cause innocent clinicians to be incorrectly accused of drug use?

The efficacy of random drug testing in preventing drug diversion is not settled. The discussion of how to proceed in the absence of well-designed studies on the tactic was robust. One common principle we heard from members of the medical staff was that our response be driven by an authentic organizational desire to reduce patient harm. They expressed that the process of testing needs to respect the boundaries between work and home life and to avoid the disruption of clinical responsibilities. Whether targeting testing to “higher risk” groups of clinicians is appropriate and whether or not alcohol and/or marijuana would be tested came up often.

Other concerns expressed also included the intrusion of the institution into the private medical conditions of the medical staff members, breach of confidentiality, or accessibility of the information obtained as a result of the program for unrelated legal proceedings. One of the most prominent fears expressed was the possible impact of false-positive tests on the clinicians’ careers.

Following the listening tour by the medical staff and hospital leadership and extensive discussions, the Medical Board voted to approve a policy to implement random drug testing. The deliberative process lasted for approximately eight months. We sought input from other healthcare systems, such as the Veterans Administration and Cleveland Clinic, that conduct random drug tests on employed physicians. A physician from Massachusetts General Hospital who led the 2004 implementation of random drug testing for anesthesiologists was invited to come to Colorado to give grand rounds about the experience in his department and answer questions about the implementation of random drug testing at a Medical Board meeting.⁷ The policy went into effect January 2017.

The design of the program sought to explicitly address the issues raised by the front-line clinicians. In the interest of equity, all specialties, including Radiology and Pathology, are subject to testing. Medical staff are selected for testing using a random number generator and retained in the random selection pool at all times, regardless of previous selection for testing. Consistent with the underlying objective of identifying drug diversion, testing is limited to drugs at higher risk for diversion (eg, amphetamine, barbiturate, benzodiazepine, butorphanol, cocaine metabolite, fentanyl, ketamine, meperidine, methadone, nalbuphine, opiates, oxycodone, and tramadol). Although alcohol and marijuana are substances of abuse, they are not substances of healthcare diversion and thus are excluded from random drug testing (although included in testing for impairment). Random drug testing is conducted only for medical staff who are onsite and providing clinical services. The individuals selected for random drug testing are notified by Employee Health, or their clinical supervisor, to present to Employee Health that day to provide a urine sample. The involvement of the clinical supervisor in specific departments and the flexibility in time of presentation was implemented to address the concerns of the medical staff regarding harm from the disruption of acute patient care.

To address the concern regarding false-positive tests, an external medical laboratory that performs testing compliant with Substance Abuse and Mental Health Services and governmental standards is used. Samples are split providing the ability to perform independent testing of two samples. The thresholds are set to minimize false-positive tests. Positive results are sent to an independent medical review officer who confidentially contacts the medical staff member to assess for valid prescriptions to explain the test results. Unexplained positive test results trigger the testing of the second half of the split sample.

To address issues of dignity, privacy, and confidentiality, Employee Health discretely oversees the urine collection. The test results are not part of the individual’s medical record. Only the coordinator for random drug testing in Human Resources compliance can access the test results, which are stored in a separate, secure database. The medical review officer shares no information about the medical staff members’ medical conditions. A positive drug assay attributable to a valid medical explanation is reported as a negative test.

Positive test results, which would be reported to the President of the Medical Staff, would trigger further investigation, potential Medical Board action consistent with medical staff bylaws, and reporting to licensing bodies as appropriate. We recognize that most addiction is not associated with diversion, and all individuals struggling with substance use need support. The medical staff and hospital leadership committed through this process to connecting medical staff members who are identified by random drug testing to help for substance use disorder, starting with the State Physician Health Program.

The Medical Executive Committees of all hospitals within UCHealth have also approved random drug testing of medical staff. We are not the first healthcare organization to tackle the potential for drug diversion by healthcare workers. To our knowledge, we are the largest health system to have nonemployed medical staff leadership vote for the entire medical staff to be subject to random drug testing. Along the journey, the approach of random drug testing for physicians was vigorously debated. In this regard, we proffer one final question:

• How would you have voted?

Disclosures

The authors have nothing to disclose.

Palliative care is an essential component of inpatient medicine. At its core, it is an interdisciplinary philosophy of care aiming to achieve the best quality of life for patients and families in the physical, psychosocial, and spiritual domains. With the aging population and growing complexity of hospitalized patients, inpatient palliative care needs are only projected to rise. However, a mismatch exists between the number of palliative care–trained physicians and the demand for such physicians. Currently, only 6,600 US physicians are board certified in palliative care – just 37% of the projected need.¹ These workforce shortages have serious implications. In fact, it is estimated that nearly 40% of all hospitalized patients who need palliative care go without it.²

Existing efforts to improve access to palliative care have largely focused on bolstering the palliative care workforce. One tactic particularly relevant to hospitalists centers on frontline physicians providing “primary” palliative care: basic symptom management, patient-centered communication, and goals of care assessment, regardless of the disease state.³ Such physicians constitute the base of today’s palliative care workforce model – a three-tiered pyramid built on clinician availability and skills. In this model, the second tier (“secondary” palliative care) includes physicians supported by a palliative care consultant or referral. The third level (“tertiary” palliative care) encompasses care provided directly by specialized palliative care teams, usually within academic medical centers (Figure).⁴

To better address the current palliative care access problem, we propose a new model: “The Palliative care Redistribution Integrated Service Model (PRISM; Figure 1).” Using the industrial engineering principle of “task shifting,” this approach leverages disciplinary diversity and shifts specific activities from more specialized to less specialized members.⁹ In this way, PRISM integrates hospital-based interdisciplinary teams across all tiers of palliative care delivery.

PRISM sheds a tier-based approach in favor of flexible, skill-based verticals that span all physician and nonphysician providers. By dividing the original pyramid into three domains – physical, psychosocial, and spiritual – providers with various spheres of expertise may serve patients on multiple tiers. For example, a bedside nurse may perform basic psychosocial assessment consistent with his or her training, while physicians may focus on code status or prescribe antiemetics or low-dose opiate monotherapy – skills they have refined during medical school. Analogously, secondary palliative care may be delivered by any provider with more advanced skills in communication or symptom management. In this way, we expand the pool of clinicians available to provide palliative care to include nurses, hospitalists, oncologists, intensivists, social workers, and chaplains and also recognize the diversity of skill sets within and between disciplines. Thus, a hospitalist may clarify the goals of care but may ask a social worker trained in psychosocial assessment for assistance with difficult family dynamics or a chaplain for spiritual needs. Interdisciplinary teamwork and cross-disciplinary communication – hallmarks of palliative care – are encouraged and valued. Furthermore, if providers feel uncomfortable providing a certain type of care, they can ask for assistance from more experienced providers within their discipline or outside of it. In rare cases, the most complex patients may be referred to specialist palliative care teams.

Inherent within PRISM is a recognition that all providers must have a basic palliative care skillset obtained through educational initiatives.⁷ Yet focusing solely on training the workforce as a strategy has and will continue to miss the mark. Rather, structural changes to the means of providing care are also needed. Within hospitals, these changes often rely heavily on hospitalists due to their central position in care delivery. In this way, hospitalists are well primed to be the agents of change in this model.

Since many hospitalized patients have unrecognized and underserved palliative care needs, a formal approach to assessment is needed. Lin et al. proposed criteria for a “sentinel hospitalization,” marking a major illness or transition in high-risk patients necessitating palliative interventions.¹⁰ Similar screening criteria have been validated among hospitalized oncology patients¹¹ and in critical care.¹² While checklists have been shown to help identify hospitalized patients with palliative care needs,¹³ their implementation has been slow, presumably because they are burdensome for busy providers to complete.

Technological automation may be a solution to the checklist conundrum. For example, if palliative care screening criteria could be automatically extracted from electronic health records, scoring systems could trigger hospitalists to consider the goals of care discussions or engage an interdisciplinary care team to fulfill a variety of needs. Frameworks for such scoring systems already exist and are familiar to most hospitalists. For example, admission order sets routinely calculate the Padua or Caprini score to facilitate decision-making for prophylaxis of deep vein thrombosis. An admission order set that screens and prompts decision-making around palliative care needs is thus feasible. One example is a hard stop for entering code status in the admission order set; in turn, this hard stop could also trigger providers to complete a “check-box” palliative care screening checklist. Automatic extraction of certain data from the record – such as age, prior code status, recent hospitalizations, or mobility scores – could auto-populate to facilitate decision-making. In turn, measuring the influence of such tools on access to palliative care, workflow, and capacity will be important, as most tools may not have quality or value intended.¹⁴

It is common for hospitalists to oversee care for 15-20 patients at a time. Thus, they may not have the time to meaningfully engage patients to assess palliative care needs. Creating designated hospitalist palliative care teams with enhanced interdisciplinary support for patients identified using sentinel hospitalization or checklist-based tools may help to solve this dilemma. These teams may also employ lower “caps,” freeing up time for critical discussions and planning around end of life. At the University of Michigan, we are planning just such an approach, a strategy which has the additional benefit of bypassing the binary “care versus no care” dilemma faced by patients choosing palliation. Rather, patients may continue to receive treatments congruent with the goals of care in such teams.

A call for health systems to develop and implement palliative care quality metrics has emerged. Given their role in quality improvement and health system reform, hospitalists are well positioned to shepherd this imperative. Creating incentives to screen inpatients for palliative care needs and develop new homes in which to care for these patients are but a few ways to help set the tone. Additionally, developing and sharing quality metrics and benchmarks currently captured in repositories such as the Palliative Care Quality Network, Global Palliative Care Quality Alliance, and Center to Advance Palliative Care can help to assess and continually improve care delivery. Creating and sharing dashboards from these metrics with all providers, regardless of discipline or training, will ensure accountability to deliver quality palliative care.

Many hospitalized patients do not receive appropriate attention to their palliative care needs. A new interdisciplinary workforce model that task shifts to physician and nonphysician providers and pairs system-level innovations and quality may solve this problem. Input and endorsement from a wide variety of disciplines (particularly our nonphysician colleagues) are needed to make PRISM operational. The proof of concept will lie in testing feasibility among key stakeholders and rigorously studying the proposed interventions. Through innovation in technology, workflow, and quality improvement, hospitalists are well poised to lead this change. After all, our patients deserve nothing less.

Disclosures

The authors have nothing to disclose.Funding: Dr. Abedini’s work is supported by the University of Michigan National Clinician Scholars Program at the Institute for Healthcare Policy and Innovation, as well as the Un

Palliative care is an essential component of inpatient medicine. At its core, it is an interdisciplinary philosophy of care aiming to achieve the best quality of life for patients and families in the physical, psychosocial, and spiritual domains. With the aging population and growing complexity of hospitalized patients, inpatient palliative care needs are only projected to rise. However, a mismatch exists between the number of palliative care–trained physicians and the demand for such physicians. Currently, only 6,600 US physicians are board certified in palliative care – just 37% of the projected need.¹ These workforce shortages have serious implications. In fact, it is estimated that nearly 40% of all hospitalized patients who need palliative care go without it.²

Existing efforts to improve access to palliative care have largely focused on bolstering the palliative care workforce. One tactic particularly relevant to hospitalists centers on frontline physicians providing “primary” palliative care: basic symptom management, patient-centered communication, and goals of care assessment, regardless of the disease state.³ Such physicians constitute the base of today’s palliative care workforce model – a three-tiered pyramid built on clinician availability and skills. In this model, the second tier (“secondary” palliative care) includes physicians supported by a palliative care consultant or referral. The third level (“tertiary” palliative care) encompasses care provided directly by specialized palliative care teams, usually within academic medical centers (Figure).⁴

To better address the current palliative care access problem, we propose a new model: “The Palliative care Redistribution Integrated Service Model (PRISM; Figure 1).” Using the industrial engineering principle of “task shifting,” this approach leverages disciplinary diversity and shifts specific activities from more specialized to less specialized members.⁹ In this way, PRISM integrates hospital-based interdisciplinary teams across all tiers of palliative care delivery.

PRISM sheds a tier-based approach in favor of flexible, skill-based verticals that span all physician and nonphysician providers. By dividing the original pyramid into three domains – physical, psychosocial, and spiritual – providers with various spheres of expertise may serve patients on multiple tiers. For example, a bedside nurse may perform basic psychosocial assessment consistent with his or her training, while physicians may focus on code status or prescribe antiemetics or low-dose opiate monotherapy – skills they have refined during medical school. Analogously, secondary palliative care may be delivered by any provider with more advanced skills in communication or symptom management. In this way, we expand the pool of clinicians available to provide palliative care to include nurses, hospitalists, oncologists, intensivists, social workers, and chaplains and also recognize the diversity of skill sets within and between disciplines. Thus, a hospitalist may clarify the goals of care but may ask a social worker trained in psychosocial assessment for assistance with difficult family dynamics or a chaplain for spiritual needs. Interdisciplinary teamwork and cross-disciplinary communication – hallmarks of palliative care – are encouraged and valued. Furthermore, if providers feel uncomfortable providing a certain type of care, they can ask for assistance from more experienced providers within their discipline or outside of it. In rare cases, the most complex patients may be referred to specialist palliative care teams.

Inherent within PRISM is a recognition that all providers must have a basic palliative care skillset obtained through educational initiatives.⁷ Yet focusing solely on training the workforce as a strategy has and will continue to miss the mark. Rather, structural changes to the means of providing care are also needed. Within hospitals, these changes often rely heavily on hospitalists due to their central position in care delivery. In this way, hospitalists are well primed to be the agents of change in this model.

Since many hospitalized patients have unrecognized and underserved palliative care needs, a formal approach to assessment is needed. Lin et al. proposed criteria for a “sentinel hospitalization,” marking a major illness or transition in high-risk patients necessitating palliative interventions.¹⁰ Similar screening criteria have been validated among hospitalized oncology patients¹¹ and in critical care.¹² While checklists have been shown to help identify hospitalized patients with palliative care needs,¹³ their implementation has been slow, presumably because they are burdensome for busy providers to complete.

Technological automation may be a solution to the checklist conundrum. For example, if palliative care screening criteria could be automatically extracted from electronic health records, scoring systems could trigger hospitalists to consider the goals of care discussions or engage an interdisciplinary care team to fulfill a variety of needs. Frameworks for such scoring systems already exist and are familiar to most hospitalists. For example, admission order sets routinely calculate the Padua or Caprini score to facilitate decision-making for prophylaxis of deep vein thrombosis. An admission order set that screens and prompts decision-making around palliative care needs is thus feasible. One example is a hard stop for entering code status in the admission order set; in turn, this hard stop could also trigger providers to complete a “check-box” palliative care screening checklist. Automatic extraction of certain data from the record – such as age, prior code status, recent hospitalizations, or mobility scores – could auto-populate to facilitate decision-making. In turn, measuring the influence of such tools on access to palliative care, workflow, and capacity will be important, as most tools may not have quality or value intended.¹⁴

It is common for hospitalists to oversee care for 15-20 patients at a time. Thus, they may not have the time to meaningfully engage patients to assess palliative care needs. Creating designated hospitalist palliative care teams with enhanced interdisciplinary support for patients identified using sentinel hospitalization or checklist-based tools may help to solve this dilemma. These teams may also employ lower “caps,” freeing up time for critical discussions and planning around end of life. At the University of Michigan, we are planning just such an approach, a strategy which has the additional benefit of bypassing the binary “care versus no care” dilemma faced by patients choosing palliation. Rather, patients may continue to receive treatments congruent with the goals of care in such teams.

A call for health systems to develop and implement palliative care quality metrics has emerged. Given their role in quality improvement and health system reform, hospitalists are well positioned to shepherd this imperative. Creating incentives to screen inpatients for palliative care needs and develop new homes in which to care for these patients are but a few ways to help set the tone. Additionally, developing and sharing quality metrics and benchmarks currently captured in repositories such as the Palliative Care Quality Network, Global Palliative Care Quality Alliance, and Center to Advance Palliative Care can help to assess and continually improve care delivery. Creating and sharing dashboards from these metrics with all providers, regardless of discipline or training, will ensure accountability to deliver quality palliative care.

Many hospitalized patients do not receive appropriate attention to their palliative care needs. A new interdisciplinary workforce model that task shifts to physician and nonphysician providers and pairs system-level innovations and quality may solve this problem. Input and endorsement from a wide variety of disciplines (particularly our nonphysician colleagues) are needed to make PRISM operational. The proof of concept will lie in testing feasibility among key stakeholders and rigorously studying the proposed interventions. Through innovation in technology, workflow, and quality improvement, hospitalists are well poised to lead this change. After all, our patients deserve nothing less.

Disclosures

The authors have nothing to disclose.Funding: Dr. Abedini’s work is supported by the University of Michigan National Clinician Scholars Program at the Institute for Healthcare Policy and Innovation, as well as the Un

Palliative care is an essential component of inpatient medicine. At its core, it is an interdisciplinary philosophy of care aiming to achieve the best quality of life for patients and families in the physical, psychosocial, and spiritual domains. With the aging population and growing complexity of hospitalized patients, inpatient palliative care needs are only projected to rise. However, a mismatch exists between the number of palliative care–trained physicians and the demand for such physicians. Currently, only 6,600 US physicians are board certified in palliative care – just 37% of the projected need.¹ These workforce shortages have serious implications. In fact, it is estimated that nearly 40% of all hospitalized patients who need palliative care go without it.²

Existing efforts to improve access to palliative care have largely focused on bolstering the palliative care workforce. One tactic particularly relevant to hospitalists centers on frontline physicians providing “primary” palliative care: basic symptom management, patient-centered communication, and goals of care assessment, regardless of the disease state.³ Such physicians constitute the base of today’s palliative care workforce model – a three-tiered pyramid built on clinician availability and skills. In this model, the second tier (“secondary” palliative care) includes physicians supported by a palliative care consultant or referral. The third level (“tertiary” palliative care) encompasses care provided directly by specialized palliative care teams, usually within academic medical centers (Figure).⁴

To better address the current palliative care access problem, we propose a new model: “The Palliative care Redistribution Integrated Service Model (PRISM; Figure 1).” Using the industrial engineering principle of “task shifting,” this approach leverages disciplinary diversity and shifts specific activities from more specialized to less specialized members.⁹ In this way, PRISM integrates hospital-based interdisciplinary teams across all tiers of palliative care delivery.

PRISM sheds a tier-based approach in favor of flexible, skill-based verticals that span all physician and nonphysician providers. By dividing the original pyramid into three domains – physical, psychosocial, and spiritual – providers with various spheres of expertise may serve patients on multiple tiers. For example, a bedside nurse may perform basic psychosocial assessment consistent with his or her training, while physicians may focus on code status or prescribe antiemetics or low-dose opiate monotherapy – skills they have refined during medical school. Analogously, secondary palliative care may be delivered by any provider with more advanced skills in communication or symptom management. In this way, we expand the pool of clinicians available to provide palliative care to include nurses, hospitalists, oncologists, intensivists, social workers, and chaplains and also recognize the diversity of skill sets within and between disciplines. Thus, a hospitalist may clarify the goals of care but may ask a social worker trained in psychosocial assessment for assistance with difficult family dynamics or a chaplain for spiritual needs. Interdisciplinary teamwork and cross-disciplinary communication – hallmarks of palliative care – are encouraged and valued. Furthermore, if providers feel uncomfortable providing a certain type of care, they can ask for assistance from more experienced providers within their discipline or outside of it. In rare cases, the most complex patients may be referred to specialist palliative care teams.

Inherent within PRISM is a recognition that all providers must have a basic palliative care skillset obtained through educational initiatives.⁷ Yet focusing solely on training the workforce as a strategy has and will continue to miss the mark. Rather, structural changes to the means of providing care are also needed. Within hospitals, these changes often rely heavily on hospitalists due to their central position in care delivery. In this way, hospitalists are well primed to be the agents of change in this model.

Since many hospitalized patients have unrecognized and underserved palliative care needs, a formal approach to assessment is needed. Lin et al. proposed criteria for a “sentinel hospitalization,” marking a major illness or transition in high-risk patients necessitating palliative interventions.¹⁰ Similar screening criteria have been validated among hospitalized oncology patients¹¹ and in critical care.¹² While checklists have been shown to help identify hospitalized patients with palliative care needs,¹³ their implementation has been slow, presumably because they are burdensome for busy providers to complete.

Technological automation may be a solution to the checklist conundrum. For example, if palliative care screening criteria could be automatically extracted from electronic health records, scoring systems could trigger hospitalists to consider the goals of care discussions or engage an interdisciplinary care team to fulfill a variety of needs. Frameworks for such scoring systems already exist and are familiar to most hospitalists. For example, admission order sets routinely calculate the Padua or Caprini score to facilitate decision-making for prophylaxis of deep vein thrombosis. An admission order set that screens and prompts decision-making around palliative care needs is thus feasible. One example is a hard stop for entering code status in the admission order set; in turn, this hard stop could also trigger providers to complete a “check-box” palliative care screening checklist. Automatic extraction of certain data from the record – such as age, prior code status, recent hospitalizations, or mobility scores – could auto-populate to facilitate decision-making. In turn, measuring the influence of such tools on access to palliative care, workflow, and capacity will be important, as most tools may not have quality or value intended.¹⁴

It is common for hospitalists to oversee care for 15-20 patients at a time. Thus, they may not have the time to meaningfully engage patients to assess palliative care needs. Creating designated hospitalist palliative care teams with enhanced interdisciplinary support for patients identified using sentinel hospitalization or checklist-based tools may help to solve this dilemma. These teams may also employ lower “caps,” freeing up time for critical discussions and planning around end of life. At the University of Michigan, we are planning just such an approach, a strategy which has the additional benefit of bypassing the binary “care versus no care” dilemma faced by patients choosing palliation. Rather, patients may continue to receive treatments congruent with the goals of care in such teams.

A call for health systems to develop and implement palliative care quality metrics has emerged. Given their role in quality improvement and health system reform, hospitalists are well positioned to shepherd this imperative. Creating incentives to screen inpatients for palliative care needs and develop new homes in which to care for these patients are but a few ways to help set the tone. Additionally, developing and sharing quality metrics and benchmarks currently captured in repositories such as the Palliative Care Quality Network, Global Palliative Care Quality Alliance, and Center to Advance Palliative Care can help to assess and continually improve care delivery. Creating and sharing dashboards from these metrics with all providers, regardless of discipline or training, will ensure accountability to deliver quality palliative care.

Many hospitalized patients do not receive appropriate attention to their palliative care needs. A new interdisciplinary workforce model that task shifts to physician and nonphysician providers and pairs system-level innovations and quality may solve this problem. Input and endorsement from a wide variety of disciplines (particularly our nonphysician colleagues) are needed to make PRISM operational. The proof of concept will lie in testing feasibility among key stakeholders and rigorously studying the proposed interventions. Through innovation in technology, workflow, and quality improvement, hospitalists are well poised to lead this change. After all, our patients deserve nothing less.

Disclosures

The authors have nothing to disclose.Funding: Dr. Abedini’s work is supported by the University of Michigan National Clinician Scholars Program at the Institute for Healthcare Policy and Innovation, as well as the Un

“Every system is perfectly designed to get the results it gets.”
—W. Edwards Deming inspired quote¹

The timing of patient discharge represents a Gordian knot in hospital operations. Moving the time of discharge to earlier in the day is a complex challenge that defies replicable solutions and is often a barrier to optimal throughput and patient experience. In this issue of the Journal of Hospital Medicine, Zoucha et al. identify that discharge orders are frequently delayed due to physicians caring for other patients, heterogeneity in physician rounding styles, and other intrinsic factors such as census size, rounding style, and teaching versus nonteaching services.² Some of these factors and their negative impact are consistent with the effect of higher hospitalist workload (census) when increasing length of stay that was identified by Elliott et al.³ Others, such as rounding style and balancing teaching and education, are a part of many hospitalist service operations. Other intrinsic factors identified by the authors include awaiting consultant recommendations, care completion by social workers, procedures, labs, radiology, therapy services, and home oxygen.

The authors, however, recognize hospitalist behaviors and hospital operations as intrinsic factors. This is significant because intrinsic factors are theoretically under the control of the hospital’s physicians, administration, and support services. They lend themselves to continuous improvement, re-engineering, and change management. They are a direct result of the people, processes, structure, and supporting information technology (IT).

The findings of this study contrast with the perceived dominance of extrinsic factors such as awaiting a ride, insurance authorization issues, or placement as the cause for discharge delays. Anecdotally, physicians and nurses in organizations often identify such extrinsic factors as causes of discharge delays before they call out intrinsic factors.

Frequently, the first reaction to managing complex intrinsic constraints is to add resources and complexity. Continuous improvement often reveals the culprit is poor design and waste found throughout the system. Zoucha et al. refer to LEAN successes by others⁴ as an example of how to approach these complex intrinsic issues. Increasing early discharge with improvement in length of stay and reducing or maintaining the readmission rate has been achieved using the Institute for Healthcare Improvement Model for Improvement,⁵ the Red/Yellow/Green Discharge Tool within the electronic medical record,⁶ and a comprehensive management plan.⁷ These examples were often accomplished through improving the deployment of existing resources and reducing wasted activity. New predictive tools using supervised machine learning can help identify appropriate patients for discharge earlier in the day.⁸ This approach is built on the concepts of “efficiency and communication as components of quality healthcare delivery.”⁶

Perhaps a practical reductionist approach is to start with the end in mind, and ask the question “what matters most?” Three key times occur in each discharge and the authors capture two of these: the discharge order time and discharge time. Not captured is the time the patient and family are told they are being discharged. It is against this backdrop that we can look at four perspectives: caregiver, organization, community, and the patient and family. “What matters most?” depends on the perspective of each one of the parties involved.

From the perspective of the caregivers (physicians and residents), the conclusions support prioritizing rounding on patients ready to discharge, lowering team census, and restructuring teaching rounds to drive earlier discharges. But only 7% of encounters prioritized patients ready for discharge first. Seventy-six percent prioritized sickest patients first (33%), room-by-room (27%), and newest patients (16%).² The authors emphasize that such an approach needs to be balanced against the needs of the entire team census to ensure optimal care for all patients. Team and individual hospitalist census and processes must be optimized to improve the efficiency and effectiveness of the work. For teaching services, the goal is to accomplish effective teaching while maintaining or improving throughput. When addressing optimal census, Wachter concludes “the right census number will be the one in a given setting that maximizes patient outcomes (and in a teaching hospital, educational outcomes as well), efficiency, and the satisfaction of both patients and clinicians, and does so in an economical way.”⁹

Healthcare is delivered by teams. As we look at supporting and structuring our hospitalist teams’ inpatient rounding we need to include the contributions of advanced practice professionals, pharmacists, nurses, care managers, social workers, and others. Achieving a team focus on a goal can be supported by number-by-time (n-by-T) target initiatives, which have been used successfully.^10,11 Team-based solutions must be developed to address these complex issues and in recognition of the need to distribute this responsibility across the system, not just depending on physician changes to ensure optimal outcomes.

The perspectives of organization and community have the common goals of delivering healthcare value (outcomes, quality, safety, and sustainability) and ensuring access. To achieve these, it is important to separate the discharge curve (by shifting these patients’ time of discharge to the left) from the arrival curve, which is more fixed. The organization and community benefit from reduced cost of care, improved value delivery, and better access to services. For hospitals and health systems facing high occupancy, this becomes important for access and serving the community, especially during the peak hours for admissions and discharges.

Against this backdrop is the most important perspective, which is that of the patients and families. What matters most to them? When does their clock start? For patients and families, we believe that their expectations begin when the physician or APP says, “you are doing well and we can get you home today.” In the current study, the median time to discharge from the discharge order for four of the five hospitals was about three hours.² It is reasonable to assume the time interval is on the order of four to six hours or more for many patients. Is this acceptable? We have little data to answer this question directly, and while the Hospital Consumers Assessment of Healthcare Providers and Systems (HCAHPS) survey asks select questions regarding the effectiveness of discharge information, it is silent on matters of discharge timeliness and expectations. While on the administrative side we often use readmission rates as a proxy for a safe and “effective” discharge, in reality, we lack meaningful patient-reported outcome measures to assess our effectiveness, which is a necessity for performance improvement.

The opportunities for improvement suggested by this study include restructuring rounding to prioritize discharges, managing census per provider, and rethinking resident education to accommodate both education and service. The authors’ approach includes identifying ways to improve the efficiency of the work through other team members (such as pharmacy techs for medication reconciliation) and balancing ancillary services support for all inpatient care and the outpatients they serve. Alternatively, tying incentives to the goal could be a convenient leadership response. The 2016 Society of Hospital Medicine State of Hospital Medicine Report notes that more than half (54%) of nonacademic hospitalist groups that treat adults have an incentive tied to early morning discharge orders or times. We believe that by keeping the patients and families at the center of this discussion, we are more likely to accomplish the goal of improved safety, efficiency, effectiveness, and patient experience.

The literature supports discharge delays as an international challenge with research on the topic in healthcare systems across the world.¹² This may be related to an aging population, improvements, and access to advanced healthcare, and the challenges of occupancy and capacity mismatches in many healthcare systems worldwide. The authors have identified important intrinsic factors for these throughput and discharge delays. The results beg the question, are we willing to do the redesign and behavior change in our delivery of healthcare and healthcare education to achieve a more optimized system of care delivery?

A now-retired Cleveland Clinic performance improvement engineer frequently referenced W. Edwards Deming on “what makes the biggest difference in improving internal service quality?” He distilled this to two axioms based on Deming’s work: reducing cycle time and reducing defects. Both must be accomplished from the customer’s (patient’s) perspective without tradeoffs between the two. Cycle time is the time to accomplish a completed process or action, such as patient discharge or LOS. Defects are all the waste or “impossible” challenges that contribute to the feeling of resignation that lead to people dismissing the possibility of improvement, stating “it is what it is.” The challenge in the service of our patients and families, organizations, and communities is to move this dialog forward to “it is what we make it.”¹³

When we tell the patient and family they are being discharged it should happen safely, efficiently, predictably, and with empathy. From the perspective of clinicians, it should be as easy as possible to consistently do the right thing and do the work to which they have dedicated themselves. For communities and organizations struggling with access, improving throughput is vital.

Disclosures

Neither author has any conflicts to disclose. There are no external funding sources for this manuscript.

“Every system is perfectly designed to get the results it gets.”
—W. Edwards Deming inspired quote¹

The timing of patient discharge represents a Gordian knot in hospital operations. Moving the time of discharge to earlier in the day is a complex challenge that defies replicable solutions and is often a barrier to optimal throughput and patient experience. In this issue of the Journal of Hospital Medicine, Zoucha et al. identify that discharge orders are frequently delayed due to physicians caring for other patients, heterogeneity in physician rounding styles, and other intrinsic factors such as census size, rounding style, and teaching versus nonteaching services.² Some of these factors and their negative impact are consistent with the effect of higher hospitalist workload (census) when increasing length of stay that was identified by Elliott et al.³ Others, such as rounding style and balancing teaching and education, are a part of many hospitalist service operations. Other intrinsic factors identified by the authors include awaiting consultant recommendations, care completion by social workers, procedures, labs, radiology, therapy services, and home oxygen.

The authors, however, recognize hospitalist behaviors and hospital operations as intrinsic factors. This is significant because intrinsic factors are theoretically under the control of the hospital’s physicians, administration, and support services. They lend themselves to continuous improvement, re-engineering, and change management. They are a direct result of the people, processes, structure, and supporting information technology (IT).

The findings of this study contrast with the perceived dominance of extrinsic factors such as awaiting a ride, insurance authorization issues, or placement as the cause for discharge delays. Anecdotally, physicians and nurses in organizations often identify such extrinsic factors as causes of discharge delays before they call out intrinsic factors.

Frequently, the first reaction to managing complex intrinsic constraints is to add resources and complexity. Continuous improvement often reveals the culprit is poor design and waste found throughout the system. Zoucha et al. refer to LEAN successes by others⁴ as an example of how to approach these complex intrinsic issues. Increasing early discharge with improvement in length of stay and reducing or maintaining the readmission rate has been achieved using the Institute for Healthcare Improvement Model for Improvement,⁵ the Red/Yellow/Green Discharge Tool within the electronic medical record,⁶ and a comprehensive management plan.⁷ These examples were often accomplished through improving the deployment of existing resources and reducing wasted activity. New predictive tools using supervised machine learning can help identify appropriate patients for discharge earlier in the day.⁸ This approach is built on the concepts of “efficiency and communication as components of quality healthcare delivery.”⁶

Perhaps a practical reductionist approach is to start with the end in mind, and ask the question “what matters most?” Three key times occur in each discharge and the authors capture two of these: the discharge order time and discharge time. Not captured is the time the patient and family are told they are being discharged. It is against this backdrop that we can look at four perspectives: caregiver, organization, community, and the patient and family. “What matters most?” depends on the perspective of each one of the parties involved.

From the perspective of the caregivers (physicians and residents), the conclusions support prioritizing rounding on patients ready to discharge, lowering team census, and restructuring teaching rounds to drive earlier discharges. But only 7% of encounters prioritized patients ready for discharge first. Seventy-six percent prioritized sickest patients first (33%), room-by-room (27%), and newest patients (16%).² The authors emphasize that such an approach needs to be balanced against the needs of the entire team census to ensure optimal care for all patients. Team and individual hospitalist census and processes must be optimized to improve the efficiency and effectiveness of the work. For teaching services, the goal is to accomplish effective teaching while maintaining or improving throughput. When addressing optimal census, Wachter concludes “the right census number will be the one in a given setting that maximizes patient outcomes (and in a teaching hospital, educational outcomes as well), efficiency, and the satisfaction of both patients and clinicians, and does so in an economical way.”⁹

Healthcare is delivered by teams. As we look at supporting and structuring our hospitalist teams’ inpatient rounding we need to include the contributions of advanced practice professionals, pharmacists, nurses, care managers, social workers, and others. Achieving a team focus on a goal can be supported by number-by-time (n-by-T) target initiatives, which have been used successfully.^10,11 Team-based solutions must be developed to address these complex issues and in recognition of the need to distribute this responsibility across the system, not just depending on physician changes to ensure optimal outcomes.

The perspectives of organization and community have the common goals of delivering healthcare value (outcomes, quality, safety, and sustainability) and ensuring access. To achieve these, it is important to separate the discharge curve (by shifting these patients’ time of discharge to the left) from the arrival curve, which is more fixed. The organization and community benefit from reduced cost of care, improved value delivery, and better access to services. For hospitals and health systems facing high occupancy, this becomes important for access and serving the community, especially during the peak hours for admissions and discharges.

Against this backdrop is the most important perspective, which is that of the patients and families. What matters most to them? When does their clock start? For patients and families, we believe that their expectations begin when the physician or APP says, “you are doing well and we can get you home today.” In the current study, the median time to discharge from the discharge order for four of the five hospitals was about three hours.² It is reasonable to assume the time interval is on the order of four to six hours or more for many patients. Is this acceptable? We have little data to answer this question directly, and while the Hospital Consumers Assessment of Healthcare Providers and Systems (HCAHPS) survey asks select questions regarding the effectiveness of discharge information, it is silent on matters of discharge timeliness and expectations. While on the administrative side we often use readmission rates as a proxy for a safe and “effective” discharge, in reality, we lack meaningful patient-reported outcome measures to assess our effectiveness, which is a necessity for performance improvement.

The opportunities for improvement suggested by this study include restructuring rounding to prioritize discharges, managing census per provider, and rethinking resident education to accommodate both education and service. The authors’ approach includes identifying ways to improve the efficiency of the work through other team members (such as pharmacy techs for medication reconciliation) and balancing ancillary services support for all inpatient care and the outpatients they serve. Alternatively, tying incentives to the goal could be a convenient leadership response. The 2016 Society of Hospital Medicine State of Hospital Medicine Report notes that more than half (54%) of nonacademic hospitalist groups that treat adults have an incentive tied to early morning discharge orders or times. We believe that by keeping the patients and families at the center of this discussion, we are more likely to accomplish the goal of improved safety, efficiency, effectiveness, and patient experience.

The literature supports discharge delays as an international challenge with research on the topic in healthcare systems across the world.¹² This may be related to an aging population, improvements, and access to advanced healthcare, and the challenges of occupancy and capacity mismatches in many healthcare systems worldwide. The authors have identified important intrinsic factors for these throughput and discharge delays. The results beg the question, are we willing to do the redesign and behavior change in our delivery of healthcare and healthcare education to achieve a more optimized system of care delivery?

A now-retired Cleveland Clinic performance improvement engineer frequently referenced W. Edwards Deming on “what makes the biggest difference in improving internal service quality?” He distilled this to two axioms based on Deming’s work: reducing cycle time and reducing defects. Both must be accomplished from the customer’s (patient’s) perspective without tradeoffs between the two. Cycle time is the time to accomplish a completed process or action, such as patient discharge or LOS. Defects are all the waste or “impossible” challenges that contribute to the feeling of resignation that lead to people dismissing the possibility of improvement, stating “it is what it is.” The challenge in the service of our patients and families, organizations, and communities is to move this dialog forward to “it is what we make it.”¹³

When we tell the patient and family they are being discharged it should happen safely, efficiently, predictably, and with empathy. From the perspective of clinicians, it should be as easy as possible to consistently do the right thing and do the work to which they have dedicated themselves. For communities and organizations struggling with access, improving throughput is vital.

Disclosures

Neither author has any conflicts to disclose. There are no external funding sources for this manuscript.

“Every system is perfectly designed to get the results it gets.”
—W. Edwards Deming inspired quote¹

The timing of patient discharge represents a Gordian knot in hospital operations. Moving the time of discharge to earlier in the day is a complex challenge that defies replicable solutions and is often a barrier to optimal throughput and patient experience. In this issue of the Journal of Hospital Medicine, Zoucha et al. identify that discharge orders are frequently delayed due to physicians caring for other patients, heterogeneity in physician rounding styles, and other intrinsic factors such as census size, rounding style, and teaching versus nonteaching services.² Some of these factors and their negative impact are consistent with the effect of higher hospitalist workload (census) when increasing length of stay that was identified by Elliott et al.³ Others, such as rounding style and balancing teaching and education, are a part of many hospitalist service operations. Other intrinsic factors identified by the authors include awaiting consultant recommendations, care completion by social workers, procedures, labs, radiology, therapy services, and home oxygen.

The authors, however, recognize hospitalist behaviors and hospital operations as intrinsic factors. This is significant because intrinsic factors are theoretically under the control of the hospital’s physicians, administration, and support services. They lend themselves to continuous improvement, re-engineering, and change management. They are a direct result of the people, processes, structure, and supporting information technology (IT).

The findings of this study contrast with the perceived dominance of extrinsic factors such as awaiting a ride, insurance authorization issues, or placement as the cause for discharge delays. Anecdotally, physicians and nurses in organizations often identify such extrinsic factors as causes of discharge delays before they call out intrinsic factors.

Frequently, the first reaction to managing complex intrinsic constraints is to add resources and complexity. Continuous improvement often reveals the culprit is poor design and waste found throughout the system. Zoucha et al. refer to LEAN successes by others⁴ as an example of how to approach these complex intrinsic issues. Increasing early discharge with improvement in length of stay and reducing or maintaining the readmission rate has been achieved using the Institute for Healthcare Improvement Model for Improvement,⁵ the Red/Yellow/Green Discharge Tool within the electronic medical record,⁶ and a comprehensive management plan.⁷ These examples were often accomplished through improving the deployment of existing resources and reducing wasted activity. New predictive tools using supervised machine learning can help identify appropriate patients for discharge earlier in the day.⁸ This approach is built on the concepts of “efficiency and communication as components of quality healthcare delivery.”⁶

Perhaps a practical reductionist approach is to start with the end in mind, and ask the question “what matters most?” Three key times occur in each discharge and the authors capture two of these: the discharge order time and discharge time. Not captured is the time the patient and family are told they are being discharged. It is against this backdrop that we can look at four perspectives: caregiver, organization, community, and the patient and family. “What matters most?” depends on the perspective of each one of the parties involved.

From the perspective of the caregivers (physicians and residents), the conclusions support prioritizing rounding on patients ready to discharge, lowering team census, and restructuring teaching rounds to drive earlier discharges. But only 7% of encounters prioritized patients ready for discharge first. Seventy-six percent prioritized sickest patients first (33%), room-by-room (27%), and newest patients (16%).² The authors emphasize that such an approach needs to be balanced against the needs of the entire team census to ensure optimal care for all patients. Team and individual hospitalist census and processes must be optimized to improve the efficiency and effectiveness of the work. For teaching services, the goal is to accomplish effective teaching while maintaining or improving throughput. When addressing optimal census, Wachter concludes “the right census number will be the one in a given setting that maximizes patient outcomes (and in a teaching hospital, educational outcomes as well), efficiency, and the satisfaction of both patients and clinicians, and does so in an economical way.”⁹

Healthcare is delivered by teams. As we look at supporting and structuring our hospitalist teams’ inpatient rounding we need to include the contributions of advanced practice professionals, pharmacists, nurses, care managers, social workers, and others. Achieving a team focus on a goal can be supported by number-by-time (n-by-T) target initiatives, which have been used successfully.^10,11 Team-based solutions must be developed to address these complex issues and in recognition of the need to distribute this responsibility across the system, not just depending on physician changes to ensure optimal outcomes.

The perspectives of organization and community have the common goals of delivering healthcare value (outcomes, quality, safety, and sustainability) and ensuring access. To achieve these, it is important to separate the discharge curve (by shifting these patients’ time of discharge to the left) from the arrival curve, which is more fixed. The organization and community benefit from reduced cost of care, improved value delivery, and better access to services. For hospitals and health systems facing high occupancy, this becomes important for access and serving the community, especially during the peak hours for admissions and discharges.

Against this backdrop is the most important perspective, which is that of the patients and families. What matters most to them? When does their clock start? For patients and families, we believe that their expectations begin when the physician or APP says, “you are doing well and we can get you home today.” In the current study, the median time to discharge from the discharge order for four of the five hospitals was about three hours.² It is reasonable to assume the time interval is on the order of four to six hours or more for many patients. Is this acceptable? We have little data to answer this question directly, and while the Hospital Consumers Assessment of Healthcare Providers and Systems (HCAHPS) survey asks select questions regarding the effectiveness of discharge information, it is silent on matters of discharge timeliness and expectations. While on the administrative side we often use readmission rates as a proxy for a safe and “effective” discharge, in reality, we lack meaningful patient-reported outcome measures to assess our effectiveness, which is a necessity for performance improvement.

The opportunities for improvement suggested by this study include restructuring rounding to prioritize discharges, managing census per provider, and rethinking resident education to accommodate both education and service. The authors’ approach includes identifying ways to improve the efficiency of the work through other team members (such as pharmacy techs for medication reconciliation) and balancing ancillary services support for all inpatient care and the outpatients they serve. Alternatively, tying incentives to the goal could be a convenient leadership response. The 2016 Society of Hospital Medicine State of Hospital Medicine Report notes that more than half (54%) of nonacademic hospitalist groups that treat adults have an incentive tied to early morning discharge orders or times. We believe that by keeping the patients and families at the center of this discussion, we are more likely to accomplish the goal of improved safety, efficiency, effectiveness, and patient experience.

The literature supports discharge delays as an international challenge with research on the topic in healthcare systems across the world.¹² This may be related to an aging population, improvements, and access to advanced healthcare, and the challenges of occupancy and capacity mismatches in many healthcare systems worldwide. The authors have identified important intrinsic factors for these throughput and discharge delays. The results beg the question, are we willing to do the redesign and behavior change in our delivery of healthcare and healthcare education to achieve a more optimized system of care delivery?

A now-retired Cleveland Clinic performance improvement engineer frequently referenced W. Edwards Deming on “what makes the biggest difference in improving internal service quality?” He distilled this to two axioms based on Deming’s work: reducing cycle time and reducing defects. Both must be accomplished from the customer’s (patient’s) perspective without tradeoffs between the two. Cycle time is the time to accomplish a completed process or action, such as patient discharge or LOS. Defects are all the waste or “impossible” challenges that contribute to the feeling of resignation that lead to people dismissing the possibility of improvement, stating “it is what it is.” The challenge in the service of our patients and families, organizations, and communities is to move this dialog forward to “it is what we make it.”¹³

When we tell the patient and family they are being discharged it should happen safely, efficiently, predictably, and with empathy. From the perspective of clinicians, it should be as easy as possible to consistently do the right thing and do the work to which they have dedicated themselves. For communities and organizations struggling with access, improving throughput is vital.

Disclosures

Neither author has any conflicts to disclose. There are no external funding sources for this manuscript.

On September 12, 2017, a son walked into his mother’s room in the surgical intensive care unit (ICU) of Dartmouth-Hitchcock Medical Center (DHMC) in Lebanon, New Hampshire, and shot her with a handgun. As an actively practicing hospitalist and the Chief Clinical Officer for DHMC, I immediately became involved with our hospitals’ response to domestic violence, a homicide, and an issue that to this point we felt lived outside our walls.

Several hospital systems are struggling with violence entering their institutions, particularly in their psychiatry and emergency service areas, fueled in part by untreated mental health and the rising opioid epidemic. Although gun violence in hospitals is indeed rare, inside the hospital, it occurs often in the emergency department.¹ In New Hampshire, we suffer from a woefully underfunded state mental health infrastructure and one of the highest opioid death rates in the United States.²

DHMC is a 400-bed academic medical center, level 1 trauma center, and a National Cancer Institute (NCI)-designated cancer center that serves New Hampshire and eastern Vermont with its community and critical access hospitals and community group practices across the two states. With a wide geographic catchment area, our academic hospital at DHMC has one of the highest case-mix indices in the northeastern United States and is in the top 30 among hospitals of >300 beds in the United States.

After the shooting, the patient’s son left the ICU without targeting anyone else, and despite video surveillance systems, he was not seen leaving the hospital. At the same time, a Code Blue was called to address the victim and her needs. The Critical Care staff struggled to attend to and resuscitate the victim, and my Medicine team, on call that day, was paged and rushed to the ICU to assist. In a unit trained to manage the sequelae of trauma, this event was painfully surreal. Ultimately, the surgical critical-care physician, attending to the patient, ended the resuscitation efforts when it was clear that the patient, now a homicide victim, could not be saved.

With the shooter’s whereabouts unknown, a Code Silver (Active Shooter alert) was called. Then, following our “Run-Hide-Fight” training protocol, staff, patients, and visitors exited the building in large numbers and those that could not, sheltered in place. The operating room and the emergency department were secured and continued to function.

More than 160 law enforcement officers, including trained tactical and SWAT teams, from 13 different agencies arrived on scene. Ninety minutes after the shooting, the son was apprehended at a police traffic checkpoint, attempting to leave the hospital campus.

Our involvement in this event did not end at this point. Concerned about the possibility of other suspects or devices left in the hospital, the law enforcement officers swept our hospital. With a 1.2 million square foot campus, this would take another two hours, during which we still provided care to our patients and asked the staff and families to continue to seek safe shelter.

The shock of this terrible day was immediate and profound, leading to a thorough debrief and systematic analysis of how we might improve our processes and in turn help other organizations that might unfortunately face similar situations.

We reflected on how to better secure our hospital and to strengthen our coordination and collaboration with law enforcement. We increased our security presence not only in the ICU but also in our emergency department and developed individual unit-based security measures. We fast-tracked a unit-based shutdown plan that was already in process and increased our commitments to plan and drill for larger scenarios in conjunction with law enforcement agencies.

The physical location of our hospital was important in how our response unfolded. DHMC’s unique rural location in northern New England added challenges specific to our location, which may provide an opportunity for other hospitals to consider. Although we were able to provide care, water, and transport during this tragedy on a warm day in September, caring for thousands of people outside a hospital during a typical subzero February would be a different story.

Communication during the event and how specifically to ask people to act were identified as a key area of improvement. We realized that our language and training around the various codes lacked clarity and specificity. As is familiar to many, in our hospital with Red, Blue, Black, Purple, and White codes, some staff (and certainly families and visitors) were not sure what to do in a “Code Silver.” We worked to better define our language so that in a future event or in a drill, we would state in plain language that we have “an active shooter” or a “violence with weapons” event in progress with clear instructions on next steps. Our term “Run-Hide-Fight” was changed to “Avoid-Hide-Fight” to better reflect updated training and best practice for a future event. We revised our teaching and training materials and protocols, so that in the event of a similar situation, we could provide information in plain language, across numerous formats, and with some frequency to keep people apprised, even if the situation is not changing.

Our methods of ongoing communications were also reassessed. In our reviews, it became clear that the notification systems and the computer-based alerts seen on the computers of hospital staff were different from those at the medical school. Communication protocols on pagers and mobile phones and across social media such as Facebook and Twitter were redesigned. Though our institution has long had the ability to provide cell phone notifications during emergencies, not all employees and staff had elected to activate this feature. We also improved our speaker systems so that overhead paging and alerts could be heard outside the building.

Having improved personal reference materials on hand is important. We updated the cards attached to our ID badges with clear instructions about “active shooter” or “violence with weapon” situations. We also developed different response scenarios dependent on the campus location. An event in the ICU, for example, might require leaving the scene, although sheltering-in-place might be more appropriate for an offsite administrative building.

A significant challenge to our active-shooter situation was making sure that our staff, patients, visitors, and their families were adequately supported following the event. Learning from the experiences of other hospitals and communities, we undertook a deliberate process of preparedness and healing.³ From our surgical ICU to our distant community group practices, we provided communication and avenues for personal support. Our Employee Assistance Program provided 24/7 support in a conference room in the surgical ICU and in other areas, on and off site, for all staff at Dartmouth-Hitchcock. The shooting affected those in the vicinity, as well as far away. Staff who had experienced domestic and other violence in their past were impacted in ways that required special care and attention. Some who were in adjacent rooms during the event were able to return to work immediately, whereas other staff, in separate units and more distant clinics, struggled and required leaves of absence. Through this event, we witnessed the personal and deep psychological impact of such violence. We held town halls, updated daily communications from our Incident Command Team, and maintained an open dialog across the organization.

In reflection, it is challenging to face this experience without the greater context of what we unfortunately experience all too often in America today. We have seen the spectrum from the shootings at Marjory Stoneman Douglas High School in Parkland, Florida, to the isolated events that rarely reach our national news and collective consciousness. It seems that we have already experienced a shooting at a school every week in the US.

There is even an overlap seen in domestic and mass shootings as we saw in the Sandy Hook Elementary School shootings in 2012, in which the tragic event was preceded by the shooter murdering his mother in her home.⁴ Today, in the US, women are disproportionally the subject of domestic violence, and more than half of all killed are done so by a male family member. The presence of a gun in domestic violence situations increases the risk for homicide for women by 500%.^{5- 7} Our experience indeed mirrored this reality.

Many readers of this piece will recognize how similar their situation is to that of our hospital, that this happens elsewhere, not here. Although my institution has faced this as a tragedy that has tested our organization, one cannot also be deeply troubled by the greater impact of domestic and gun violence on healthcare and the American society today. Our staff and physicians have been witness and at times subject to such violence, and this experience has now made it even more poignant. Ultimately, and sadly, we feel that we are more prepared.

Disclosures

The author has nothing to disclose.

On September 12, 2017, a son walked into his mother’s room in the surgical intensive care unit (ICU) of Dartmouth-Hitchcock Medical Center (DHMC) in Lebanon, New Hampshire, and shot her with a handgun. As an actively practicing hospitalist and the Chief Clinical Officer for DHMC, I immediately became involved with our hospitals’ response to domestic violence, a homicide, and an issue that to this point we felt lived outside our walls.

Several hospital systems are struggling with violence entering their institutions, particularly in their psychiatry and emergency service areas, fueled in part by untreated mental health and the rising opioid epidemic. Although gun violence in hospitals is indeed rare, inside the hospital, it occurs often in the emergency department.¹ In New Hampshire, we suffer from a woefully underfunded state mental health infrastructure and one of the highest opioid death rates in the United States.²

DHMC is a 400-bed academic medical center, level 1 trauma center, and a National Cancer Institute (NCI)-designated cancer center that serves New Hampshire and eastern Vermont with its community and critical access hospitals and community group practices across the two states. With a wide geographic catchment area, our academic hospital at DHMC has one of the highest case-mix indices in the northeastern United States and is in the top 30 among hospitals of >300 beds in the United States.

After the shooting, the patient’s son left the ICU without targeting anyone else, and despite video surveillance systems, he was not seen leaving the hospital. At the same time, a Code Blue was called to address the victim and her needs. The Critical Care staff struggled to attend to and resuscitate the victim, and my Medicine team, on call that day, was paged and rushed to the ICU to assist. In a unit trained to manage the sequelae of trauma, this event was painfully surreal. Ultimately, the surgical critical-care physician, attending to the patient, ended the resuscitation efforts when it was clear that the patient, now a homicide victim, could not be saved.

With the shooter’s whereabouts unknown, a Code Silver (Active Shooter alert) was called. Then, following our “Run-Hide-Fight” training protocol, staff, patients, and visitors exited the building in large numbers and those that could not, sheltered in place. The operating room and the emergency department were secured and continued to function.

More than 160 law enforcement officers, including trained tactical and SWAT teams, from 13 different agencies arrived on scene. Ninety minutes after the shooting, the son was apprehended at a police traffic checkpoint, attempting to leave the hospital campus.

Our involvement in this event did not end at this point. Concerned about the possibility of other suspects or devices left in the hospital, the law enforcement officers swept our hospital. With a 1.2 million square foot campus, this would take another two hours, during which we still provided care to our patients and asked the staff and families to continue to seek safe shelter.

The shock of this terrible day was immediate and profound, leading to a thorough debrief and systematic analysis of how we might improve our processes and in turn help other organizations that might unfortunately face similar situations.

We reflected on how to better secure our hospital and to strengthen our coordination and collaboration with law enforcement. We increased our security presence not only in the ICU but also in our emergency department and developed individual unit-based security measures. We fast-tracked a unit-based shutdown plan that was already in process and increased our commitments to plan and drill for larger scenarios in conjunction with law enforcement agencies.

The physical location of our hospital was important in how our response unfolded. DHMC’s unique rural location in northern New England added challenges specific to our location, which may provide an opportunity for other hospitals to consider. Although we were able to provide care, water, and transport during this tragedy on a warm day in September, caring for thousands of people outside a hospital during a typical subzero February would be a different story.

Communication during the event and how specifically to ask people to act were identified as a key area of improvement. We realized that our language and training around the various codes lacked clarity and specificity. As is familiar to many, in our hospital with Red, Blue, Black, Purple, and White codes, some staff (and certainly families and visitors) were not sure what to do in a “Code Silver.” We worked to better define our language so that in a future event or in a drill, we would state in plain language that we have “an active shooter” or a “violence with weapons” event in progress with clear instructions on next steps. Our term “Run-Hide-Fight” was changed to “Avoid-Hide-Fight” to better reflect updated training and best practice for a future event. We revised our teaching and training materials and protocols, so that in the event of a similar situation, we could provide information in plain language, across numerous formats, and with some frequency to keep people apprised, even if the situation is not changing.

Our methods of ongoing communications were also reassessed. In our reviews, it became clear that the notification systems and the computer-based alerts seen on the computers of hospital staff were different from those at the medical school. Communication protocols on pagers and mobile phones and across social media such as Facebook and Twitter were redesigned. Though our institution has long had the ability to provide cell phone notifications during emergencies, not all employees and staff had elected to activate this feature. We also improved our speaker systems so that overhead paging and alerts could be heard outside the building.

Having improved personal reference materials on hand is important. We updated the cards attached to our ID badges with clear instructions about “active shooter” or “violence with weapon” situations. We also developed different response scenarios dependent on the campus location. An event in the ICU, for example, might require leaving the scene, although sheltering-in-place might be more appropriate for an offsite administrative building.

A significant challenge to our active-shooter situation was making sure that our staff, patients, visitors, and their families were adequately supported following the event. Learning from the experiences of other hospitals and communities, we undertook a deliberate process of preparedness and healing.³ From our surgical ICU to our distant community group practices, we provided communication and avenues for personal support. Our Employee Assistance Program provided 24/7 support in a conference room in the surgical ICU and in other areas, on and off site, for all staff at Dartmouth-Hitchcock. The shooting affected those in the vicinity, as well as far away. Staff who had experienced domestic and other violence in their past were impacted in ways that required special care and attention. Some who were in adjacent rooms during the event were able to return to work immediately, whereas other staff, in separate units and more distant clinics, struggled and required leaves of absence. Through this event, we witnessed the personal and deep psychological impact of such violence. We held town halls, updated daily communications from our Incident Command Team, and maintained an open dialog across the organization.

In reflection, it is challenging to face this experience without the greater context of what we unfortunately experience all too often in America today. We have seen the spectrum from the shootings at Marjory Stoneman Douglas High School in Parkland, Florida, to the isolated events that rarely reach our national news and collective consciousness. It seems that we have already experienced a shooting at a school every week in the US.

There is even an overlap seen in domestic and mass shootings as we saw in the Sandy Hook Elementary School shootings in 2012, in which the tragic event was preceded by the shooter murdering his mother in her home.⁴ Today, in the US, women are disproportionally the subject of domestic violence, and more than half of all killed are done so by a male family member. The presence of a gun in domestic violence situations increases the risk for homicide for women by 500%.^{5- 7} Our experience indeed mirrored this reality.

Many readers of this piece will recognize how similar their situation is to that of our hospital, that this happens elsewhere, not here. Although my institution has faced this as a tragedy that has tested our organization, one cannot also be deeply troubled by the greater impact of domestic and gun violence on healthcare and the American society today. Our staff and physicians have been witness and at times subject to such violence, and this experience has now made it even more poignant. Ultimately, and sadly, we feel that we are more prepared.

Disclosures

The author has nothing to disclose.

On September 12, 2017, a son walked into his mother’s room in the surgical intensive care unit (ICU) of Dartmouth-Hitchcock Medical Center (DHMC) in Lebanon, New Hampshire, and shot her with a handgun. As an actively practicing hospitalist and the Chief Clinical Officer for DHMC, I immediately became involved with our hospitals’ response to domestic violence, a homicide, and an issue that to this point we felt lived outside our walls.

Several hospital systems are struggling with violence entering their institutions, particularly in their psychiatry and emergency service areas, fueled in part by untreated mental health and the rising opioid epidemic. Although gun violence in hospitals is indeed rare, inside the hospital, it occurs often in the emergency department.¹ In New Hampshire, we suffer from a woefully underfunded state mental health infrastructure and one of the highest opioid death rates in the United States.²

DHMC is a 400-bed academic medical center, level 1 trauma center, and a National Cancer Institute (NCI)-designated cancer center that serves New Hampshire and eastern Vermont with its community and critical access hospitals and community group practices across the two states. With a wide geographic catchment area, our academic hospital at DHMC has one of the highest case-mix indices in the northeastern United States and is in the top 30 among hospitals of >300 beds in the United States.

After the shooting, the patient’s son left the ICU without targeting anyone else, and despite video surveillance systems, he was not seen leaving the hospital. At the same time, a Code Blue was called to address the victim and her needs. The Critical Care staff struggled to attend to and resuscitate the victim, and my Medicine team, on call that day, was paged and rushed to the ICU to assist. In a unit trained to manage the sequelae of trauma, this event was painfully surreal. Ultimately, the surgical critical-care physician, attending to the patient, ended the resuscitation efforts when it was clear that the patient, now a homicide victim, could not be saved.

With the shooter’s whereabouts unknown, a Code Silver (Active Shooter alert) was called. Then, following our “Run-Hide-Fight” training protocol, staff, patients, and visitors exited the building in large numbers and those that could not, sheltered in place. The operating room and the emergency department were secured and continued to function.

More than 160 law enforcement officers, including trained tactical and SWAT teams, from 13 different agencies arrived on scene. Ninety minutes after the shooting, the son was apprehended at a police traffic checkpoint, attempting to leave the hospital campus.

Our involvement in this event did not end at this point. Concerned about the possibility of other suspects or devices left in the hospital, the law enforcement officers swept our hospital. With a 1.2 million square foot campus, this would take another two hours, during which we still provided care to our patients and asked the staff and families to continue to seek safe shelter.

The shock of this terrible day was immediate and profound, leading to a thorough debrief and systematic analysis of how we might improve our processes and in turn help other organizations that might unfortunately face similar situations.

We reflected on how to better secure our hospital and to strengthen our coordination and collaboration with law enforcement. We increased our security presence not only in the ICU but also in our emergency department and developed individual unit-based security measures. We fast-tracked a unit-based shutdown plan that was already in process and increased our commitments to plan and drill for larger scenarios in conjunction with law enforcement agencies.

The physical location of our hospital was important in how our response unfolded. DHMC’s unique rural location in northern New England added challenges specific to our location, which may provide an opportunity for other hospitals to consider. Although we were able to provide care, water, and transport during this tragedy on a warm day in September, caring for thousands of people outside a hospital during a typical subzero February would be a different story.

Communication during the event and how specifically to ask people to act were identified as a key area of improvement. We realized that our language and training around the various codes lacked clarity and specificity. As is familiar to many, in our hospital with Red, Blue, Black, Purple, and White codes, some staff (and certainly families and visitors) were not sure what to do in a “Code Silver.” We worked to better define our language so that in a future event or in a drill, we would state in plain language that we have “an active shooter” or a “violence with weapons” event in progress with clear instructions on next steps. Our term “Run-Hide-Fight” was changed to “Avoid-Hide-Fight” to better reflect updated training and best practice for a future event. We revised our teaching and training materials and protocols, so that in the event of a similar situation, we could provide information in plain language, across numerous formats, and with some frequency to keep people apprised, even if the situation is not changing.

Our methods of ongoing communications were also reassessed. In our reviews, it became clear that the notification systems and the computer-based alerts seen on the computers of hospital staff were different from those at the medical school. Communication protocols on pagers and mobile phones and across social media such as Facebook and Twitter were redesigned. Though our institution has long had the ability to provide cell phone notifications during emergencies, not all employees and staff had elected to activate this feature. We also improved our speaker systems so that overhead paging and alerts could be heard outside the building.

Having improved personal reference materials on hand is important. We updated the cards attached to our ID badges with clear instructions about “active shooter” or “violence with weapon” situations. We also developed different response scenarios dependent on the campus location. An event in the ICU, for example, might require leaving the scene, although sheltering-in-place might be more appropriate for an offsite administrative building.

A significant challenge to our active-shooter situation was making sure that our staff, patients, visitors, and their families were adequately supported following the event. Learning from the experiences of other hospitals and communities, we undertook a deliberate process of preparedness and healing.³ From our surgical ICU to our distant community group practices, we provided communication and avenues for personal support. Our Employee Assistance Program provided 24/7 support in a conference room in the surgical ICU and in other areas, on and off site, for all staff at Dartmouth-Hitchcock. The shooting affected those in the vicinity, as well as far away. Staff who had experienced domestic and other violence in their past were impacted in ways that required special care and attention. Some who were in adjacent rooms during the event were able to return to work immediately, whereas other staff, in separate units and more distant clinics, struggled and required leaves of absence. Through this event, we witnessed the personal and deep psychological impact of such violence. We held town halls, updated daily communications from our Incident Command Team, and maintained an open dialog across the organization.

In reflection, it is challenging to face this experience without the greater context of what we unfortunately experience all too often in America today. We have seen the spectrum from the shootings at Marjory Stoneman Douglas High School in Parkland, Florida, to the isolated events that rarely reach our national news and collective consciousness. It seems that we have already experienced a shooting at a school every week in the US.

There is even an overlap seen in domestic and mass shootings as we saw in the Sandy Hook Elementary School shootings in 2012, in which the tragic event was preceded by the shooter murdering his mother in her home.⁴ Today, in the US, women are disproportionally the subject of domestic violence, and more than half of all killed are done so by a male family member. The presence of a gun in domestic violence situations increases the risk for homicide for women by 500%.^{5- 7} Our experience indeed mirrored this reality.

Many readers of this piece will recognize how similar their situation is to that of our hospital, that this happens elsewhere, not here. Although my institution has faced this as a tragedy that has tested our organization, one cannot also be deeply troubled by the greater impact of domestic and gun violence on healthcare and the American society today. Our staff and physicians have been witness and at times subject to such violence, and this experience has now made it even more poignant. Ultimately, and sadly, we feel that we are more prepared.

Disclosures

The author has nothing to disclose.

As a hospital-acquired condition responsible for a significant share of preventable deaths in the United States,¹ venous thromboembolism (VTE) prevention should remain a high priority for healthcare organizations. Pursuant to the goal of reducing the frequency of this and other hospital-acquired conditions, several performance measures have been developed by third-party payers in the United States to provide incentives for inpatients to receive prophylaxis measures appropriate to their specific level of risk. Perhaps the best known of these is the Hospital Value-Based Purchasing Program, initiated by the Center for Medicare and Medicaid Studies (CMS) in 2013 as a provision of the Affordable Care Act.² The Joint Commission, as steward of the 6 VTE-related measures,³ dictates the criteria for assessing performance. However, recent adjustments to one of these measures have been performed in such a way that neglects real-world considerations faced by providers and threatens to delegitimize the important role that value-based purchasing should have in reimbursement.

Effective in 2017, the guidelines pertaining to abstraction-based reporting added a new component to the VTE-6 measure, which applies to those inpatients not ordered to receive mechanical or pharmacologic prophylaxis who go on to suffer VTE. Specifically, it is concerned with how accurately hospitals stratify such patients as low risk before the decision is made to not order either method of prophylaxis. With the update, to satisfy the measure, a formal assessment confirming a patient’s low-risk status must have been documented between arrival and the time the VTE diagnostic test was performed. The guidelines explicitly note that only 3 risk assessment models (RAMs) are accepted, including the Caprini DVT Prediction Score, Padua Prediction Score, and IMPROVE VTE Risk Score.⁴ The rationale for this addition to the measure clearly is to protect patients from being incorrectly designated as low risk and subsequently receiving inadequate prophylaxis that could increase their likelihood of developing preventable VTE. Unfortunately, in its current form, it imposes a substantial burden on providers and healthcare organizations, without much promise of significantly reducing rates of this pervasive threat to patient safety.

Although the aim of reducing the incidence of VTE is laudable, this updated requirement for VTE-6 is problematic on several levels. First, there is considerable uncertainty regarding how to implement the RAMs clinically in a user-friendly way that is conducive to their intended use. Due to limitations in most computerized physician order entry systems, it is not feasible to mandate the RAMs for only those patients not ordered for VTE prophylaxis (nor would it be sensible to restrict performing the assessment to low-risk patients, as the point of RAMs is to help risk stratify and not simply validate whatever determinations were already made by other means). As virtually every class of inpatient has some risk of VTE development, these factors effectively require that a score be tabulated on all admitted patients, giving the measure an enormous footprint on clinical operations. This is important because the permissible RAMs can sometimes be quite burdensome to complete faithfully. For instance, the Caprini Score necessitates the fairly prodigious collection and input of up to 26 data points. Some of the questions require exceedingly granular data, such as whether there is any “history of unexplained stillborn infant, recurrent spontaneous abortion (more than 3), premature birth with toxemia or growth restricted infant.”⁵ This clearly is far outside the scope of most focused admission assessments. Already deluged with the number of clicks inherent to the workflow of most electronic health records,⁶ it seems likely that some providers default to selecting “no” for such prompts as a time-saving measure, potentially sabotaging the goal of linking patients with a risk-appropriate method of prophylaxis. Meanwhile, those who are diligent about completing the assessment honestly will find themselves rewarded with less time to dedicate to other critical aspects of patient care.⁷

The small number of RAMs accepted under the measure also fails to account for the breadth of clinical circumstances providers faced. Although the permitted models are validated in certain patient populations, they exclude some that might be better suited for many practice environments. The University of California San Diego “3 bucket” design, for instance, has been shown to result in high levels of risk-appropriate prophylaxis, has high inter-user agreement, and perhaps most importantly, is relatively quick and easy to use.⁸ Also critical, it is easier to integrate into the admission workflow for under-resourced hospitals that might not have the ability to incorporate a point-based risk score calculator into their electronic health records.

Finally, the relative abruptness with which the changes were made complicated the task for institutions to integrate the RAMs into their applicable order sets in a user-friendly fashion. The new guidelines were released only 6 months before taking effect,⁹ and the RAM requirement was not widely advertised. This left a fairly short window that does not seem to reflect an understanding by the Joint Commission of the process required by hospitals to make such a transition responsibly. This should involve obtaining inputs from multiple specialty stakeholders on which RAM to employ, working with information system specialists on how to restructure key order sets, and education of end-users on how to apply them correctly.¹⁰

For these reasons, the rollout of the VTE-6 update falls well short of its ambitions. Satisfying the measure necessitates a substantial investment of time and effort by providers and yet forcing the use of such decidedly imperfect RAMs could paradoxically worsen accurate risk stratification and appropriate use of prophylaxis. Also, while it represents only a small slice of pay-for-performance initiatives, its broader impact should not be underestimated. Unlike many of the more specific items, the VTE measures affect the workflow related to virtually all hospitalized patients. Therefore, it is imperative that regulators “get it right,” as it might only take one poorly conceived mandate of this type to risk permanently souring providers and hospitals on the idea of value-based purchasing. The Joint Commission and CMS ought to seriously consider retracting the new provisions until the role of RAMs for VTE prevention is better understood. This would buy time to reconfigure the measure in a way that is compatible with actual clinical care and for hospitals to thoughtfully design how new requirements can best be implemented.

Disclosurses

The author has nothing to disclose.

As a hospital-acquired condition responsible for a significant share of preventable deaths in the United States,¹ venous thromboembolism (VTE) prevention should remain a high priority for healthcare organizations. Pursuant to the goal of reducing the frequency of this and other hospital-acquired conditions, several performance measures have been developed by third-party payers in the United States to provide incentives for inpatients to receive prophylaxis measures appropriate to their specific level of risk. Perhaps the best known of these is the Hospital Value-Based Purchasing Program, initiated by the Center for Medicare and Medicaid Studies (CMS) in 2013 as a provision of the Affordable Care Act.² The Joint Commission, as steward of the 6 VTE-related measures,³ dictates the criteria for assessing performance. However, recent adjustments to one of these measures have been performed in such a way that neglects real-world considerations faced by providers and threatens to delegitimize the important role that value-based purchasing should have in reimbursement.

Effective in 2017, the guidelines pertaining to abstraction-based reporting added a new component to the VTE-6 measure, which applies to those inpatients not ordered to receive mechanical or pharmacologic prophylaxis who go on to suffer VTE. Specifically, it is concerned with how accurately hospitals stratify such patients as low risk before the decision is made to not order either method of prophylaxis. With the update, to satisfy the measure, a formal assessment confirming a patient’s low-risk status must have been documented between arrival and the time the VTE diagnostic test was performed. The guidelines explicitly note that only 3 risk assessment models (RAMs) are accepted, including the Caprini DVT Prediction Score, Padua Prediction Score, and IMPROVE VTE Risk Score.⁴ The rationale for this addition to the measure clearly is to protect patients from being incorrectly designated as low risk and subsequently receiving inadequate prophylaxis that could increase their likelihood of developing preventable VTE. Unfortunately, in its current form, it imposes a substantial burden on providers and healthcare organizations, without much promise of significantly reducing rates of this pervasive threat to patient safety.

Although the aim of reducing the incidence of VTE is laudable, this updated requirement for VTE-6 is problematic on several levels. First, there is considerable uncertainty regarding how to implement the RAMs clinically in a user-friendly way that is conducive to their intended use. Due to limitations in most computerized physician order entry systems, it is not feasible to mandate the RAMs for only those patients not ordered for VTE prophylaxis (nor would it be sensible to restrict performing the assessment to low-risk patients, as the point of RAMs is to help risk stratify and not simply validate whatever determinations were already made by other means). As virtually every class of inpatient has some risk of VTE development, these factors effectively require that a score be tabulated on all admitted patients, giving the measure an enormous footprint on clinical operations. This is important because the permissible RAMs can sometimes be quite burdensome to complete faithfully. For instance, the Caprini Score necessitates the fairly prodigious collection and input of up to 26 data points. Some of the questions require exceedingly granular data, such as whether there is any “history of unexplained stillborn infant, recurrent spontaneous abortion (more than 3), premature birth with toxemia or growth restricted infant.”⁵ This clearly is far outside the scope of most focused admission assessments. Already deluged with the number of clicks inherent to the workflow of most electronic health records,⁶ it seems likely that some providers default to selecting “no” for such prompts as a time-saving measure, potentially sabotaging the goal of linking patients with a risk-appropriate method of prophylaxis. Meanwhile, those who are diligent about completing the assessment honestly will find themselves rewarded with less time to dedicate to other critical aspects of patient care.⁷

The small number of RAMs accepted under the measure also fails to account for the breadth of clinical circumstances providers faced. Although the permitted models are validated in certain patient populations, they exclude some that might be better suited for many practice environments. The University of California San Diego “3 bucket” design, for instance, has been shown to result in high levels of risk-appropriate prophylaxis, has high inter-user agreement, and perhaps most importantly, is relatively quick and easy to use.⁸ Also critical, it is easier to integrate into the admission workflow for under-resourced hospitals that might not have the ability to incorporate a point-based risk score calculator into their electronic health records.

Finally, the relative abruptness with which the changes were made complicated the task for institutions to integrate the RAMs into their applicable order sets in a user-friendly fashion. The new guidelines were released only 6 months before taking effect,⁹ and the RAM requirement was not widely advertised. This left a fairly short window that does not seem to reflect an understanding by the Joint Commission of the process required by hospitals to make such a transition responsibly. This should involve obtaining inputs from multiple specialty stakeholders on which RAM to employ, working with information system specialists on how to restructure key order sets, and education of end-users on how to apply them correctly.¹⁰

For these reasons, the rollout of the VTE-6 update falls well short of its ambitions. Satisfying the measure necessitates a substantial investment of time and effort by providers and yet forcing the use of such decidedly imperfect RAMs could paradoxically worsen accurate risk stratification and appropriate use of prophylaxis. Also, while it represents only a small slice of pay-for-performance initiatives, its broader impact should not be underestimated. Unlike many of the more specific items, the VTE measures affect the workflow related to virtually all hospitalized patients. Therefore, it is imperative that regulators “get it right,” as it might only take one poorly conceived mandate of this type to risk permanently souring providers and hospitals on the idea of value-based purchasing. The Joint Commission and CMS ought to seriously consider retracting the new provisions until the role of RAMs for VTE prevention is better understood. This would buy time to reconfigure the measure in a way that is compatible with actual clinical care and for hospitals to thoughtfully design how new requirements can best be implemented.

Disclosurses

The author has nothing to disclose.

As a hospital-acquired condition responsible for a significant share of preventable deaths in the United States,¹ venous thromboembolism (VTE) prevention should remain a high priority for healthcare organizations. Pursuant to the goal of reducing the frequency of this and other hospital-acquired conditions, several performance measures have been developed by third-party payers in the United States to provide incentives for inpatients to receive prophylaxis measures appropriate to their specific level of risk. Perhaps the best known of these is the Hospital Value-Based Purchasing Program, initiated by the Center for Medicare and Medicaid Studies (CMS) in 2013 as a provision of the Affordable Care Act.² The Joint Commission, as steward of the 6 VTE-related measures,³ dictates the criteria for assessing performance. However, recent adjustments to one of these measures have been performed in such a way that neglects real-world considerations faced by providers and threatens to delegitimize the important role that value-based purchasing should have in reimbursement.

Effective in 2017, the guidelines pertaining to abstraction-based reporting added a new component to the VTE-6 measure, which applies to those inpatients not ordered to receive mechanical or pharmacologic prophylaxis who go on to suffer VTE. Specifically, it is concerned with how accurately hospitals stratify such patients as low risk before the decision is made to not order either method of prophylaxis. With the update, to satisfy the measure, a formal assessment confirming a patient’s low-risk status must have been documented between arrival and the time the VTE diagnostic test was performed. The guidelines explicitly note that only 3 risk assessment models (RAMs) are accepted, including the Caprini DVT Prediction Score, Padua Prediction Score, and IMPROVE VTE Risk Score.⁴ The rationale for this addition to the measure clearly is to protect patients from being incorrectly designated as low risk and subsequently receiving inadequate prophylaxis that could increase their likelihood of developing preventable VTE. Unfortunately, in its current form, it imposes a substantial burden on providers and healthcare organizations, without much promise of significantly reducing rates of this pervasive threat to patient safety.

Although the aim of reducing the incidence of VTE is laudable, this updated requirement for VTE-6 is problematic on several levels. First, there is considerable uncertainty regarding how to implement the RAMs clinically in a user-friendly way that is conducive to their intended use. Due to limitations in most computerized physician order entry systems, it is not feasible to mandate the RAMs for only those patients not ordered for VTE prophylaxis (nor would it be sensible to restrict performing the assessment to low-risk patients, as the point of RAMs is to help risk stratify and not simply validate whatever determinations were already made by other means). As virtually every class of inpatient has some risk of VTE development, these factors effectively require that a score be tabulated on all admitted patients, giving the measure an enormous footprint on clinical operations. This is important because the permissible RAMs can sometimes be quite burdensome to complete faithfully. For instance, the Caprini Score necessitates the fairly prodigious collection and input of up to 26 data points. Some of the questions require exceedingly granular data, such as whether there is any “history of unexplained stillborn infant, recurrent spontaneous abortion (more than 3), premature birth with toxemia or growth restricted infant.”⁵ This clearly is far outside the scope of most focused admission assessments. Already deluged with the number of clicks inherent to the workflow of most electronic health records,⁶ it seems likely that some providers default to selecting “no” for such prompts as a time-saving measure, potentially sabotaging the goal of linking patients with a risk-appropriate method of prophylaxis. Meanwhile, those who are diligent about completing the assessment honestly will find themselves rewarded with less time to dedicate to other critical aspects of patient care.⁷

The small number of RAMs accepted under the measure also fails to account for the breadth of clinical circumstances providers faced. Although the permitted models are validated in certain patient populations, they exclude some that might be better suited for many practice environments. The University of California San Diego “3 bucket” design, for instance, has been shown to result in high levels of risk-appropriate prophylaxis, has high inter-user agreement, and perhaps most importantly, is relatively quick and easy to use.⁸ Also critical, it is easier to integrate into the admission workflow for under-resourced hospitals that might not have the ability to incorporate a point-based risk score calculator into their electronic health records.

Finally, the relative abruptness with which the changes were made complicated the task for institutions to integrate the RAMs into their applicable order sets in a user-friendly fashion. The new guidelines were released only 6 months before taking effect,⁹ and the RAM requirement was not widely advertised. This left a fairly short window that does not seem to reflect an understanding by the Joint Commission of the process required by hospitals to make such a transition responsibly. This should involve obtaining inputs from multiple specialty stakeholders on which RAM to employ, working with information system specialists on how to restructure key order sets, and education of end-users on how to apply them correctly.¹⁰

For these reasons, the rollout of the VTE-6 update falls well short of its ambitions. Satisfying the measure necessitates a substantial investment of time and effort by providers and yet forcing the use of such decidedly imperfect RAMs could paradoxically worsen accurate risk stratification and appropriate use of prophylaxis. Also, while it represents only a small slice of pay-for-performance initiatives, its broader impact should not be underestimated. Unlike many of the more specific items, the VTE measures affect the workflow related to virtually all hospitalized patients. Therefore, it is imperative that regulators “get it right,” as it might only take one poorly conceived mandate of this type to risk permanently souring providers and hospitals on the idea of value-based purchasing. The Joint Commission and CMS ought to seriously consider retracting the new provisions until the role of RAMs for VTE prevention is better understood. This would buy time to reconfigure the measure in a way that is compatible with actual clinical care and for hospitals to thoughtfully design how new requirements can best be implemented.

Disclosurses

The author has nothing to disclose.