Practice Economics

As a hospitalist, caring for critically ill or injured patients can be stressful and demanding. Working with difficult doctors, those who exhibit intimidating and disruptive behaviors such as verbal outbursts and physical threats as well as passive activities such as refusing to perform assigned tasks, can make the work environment even more challenging.1 Some docs are routinely reluctant—or refuse—to answer questions or return phone calls or pages. Some communicate in condescending language or voice intonation; some are brutally impatient.1

difficultdoctors.jpg

The most difficult doctors to work with are those who are not aligned with the hospital’s or treatment team’s goals and those who aren’t open to feedback and coaching, says Rob Zipper, MD, MMM, SFHM, regional chief medical officer of Sound Physicians, based in Tacoma, Wash.

“If physicians are aware of a practice’s guidelines and goals but simply won’t comply with them, it makes it harder on everyone else who is pulling the ship in the same direction,” he says.

Unruly physicians don’t just annoy their coworkers. According to a sentinel event alert from The Joint Commission, they can:

• foster medical errors;
• contribute to poor patient satisfaction;
• contribute to preventable adverse outcomes;
• increase the cost of care;
• undermine team effectiveness; and
• cause qualified clinicians, administrators, and managers to seek new positions in more professional environments.1

“These issues are all connected,” says Stephen R. Nichols, MD, chief of clinical operations performance at the Schumacher Group in Brownwood, Texas. “Disruptive behaviors create mitigated communications and dissatisfaction among staff, which bleeds over into other aspects that are involved secondarily.”

Stephen M. Paskoff, Esq., president and CEO of ELI in Atlanta, can attest to the most severe consequences of bad behavior on patient care.

At one institution, a surgeon’s disruptive behavior lead to a coworker forgetting to perform a procedure and a patient dying.2 In another incident, the emergency department stopped calling on a medical subspecialist who was predictably abusive. The subspecialist knew how to treat a specific patient with an unusual intervention. Since the specialist was not consulted initially, the patient ended up in the intensive care unit.2

One bad hospitalist can bring down the reputation of an entire team.

“Many programs are incentivized based on medical staff and primary-care physicians’ perceptions of their care, so there are direct and indirect consequences,” Dr. Zipper says.

The bottom line, says Felix Aguirre, MD, SFHM, vice president of medical affairs at IPC Healthcare in North Hollywood, Calif., is that it only takes one bad experience to tarnish a group, but it takes many positive experiences to erase the damage.

The Roots of Evil

Intimidating and disruptive behavior stems from both individual and systemic factors. Care providers who exhibit characteristics such as self-centeredness, immaturity, or defensiveness can be more prone to unprofessional behavior. They can lack interpersonal, coping, or conflict-management skills.1

Systemic factors are marked by pressures related to increased productivity demands, cost-containment requirements, embedded hierarchies, and fear of litigation in the healthcare environment. These pressures can be further exacerbated by changes to or differences in the authority, autonomy, empowerment, and roles or values of professionals on the healthcare team as well as by the continual daily changes in shifts, rotations, and interdepartmental support staff. This dynamic creates challenges for interprofessional communication and development of trust among team members.1

According to The Joint Commission, intimidating and disruptive behaviors are often manifested by healthcare professionals in positions of power.1 But other members of the care team can be problematic as well.

“In my experience, conflicts usually revolve around different perspectives and objectives, even if both parties are acting respectfully,” Dr. Zipper says. “Sometimes, however, providers or other care team members are tired or stressed and don’t behave professionally.”

Paskoff, who has more than 40 years of experience in healthcare-related workplace issues, including serving as an investigator for the U.S. Equal Employment Opportunity Commission, says some doctors learn bad behaviors from their mentors and that behaviors can be passed down through generations because they are tolerated.

“When I asked one physician who had outstanding training and an outstanding technical reputation how he became abusive, he said, ‘I learned from the best.’” Paskoff was actually able to track the doctor’s training to the late 1800s and physicians who were known for similar behaviors.

Confronting Those Who Misbehave

Dr. Zipper says physicians should confront behavioral issues directly.

“I will typically discuss a complaint with a doctor privately, and ask him or her what happened without being accusatory,” he says. “I try to provide as much concrete and objective information as I can. The doctor needs to know that you are trying to help him or her succeed. That said, if something is clearly bad behavior, feedback should be direct and include a statement such as, ‘This is not how we behave in this practice.’”

At times, it may not be possible to discuss an emergent matter, such as during a code blue.

“However, I will often ask if anyone on the code team has any ideas or concerns before ending the code,” Dr. Nichols says. “Then after the critical time has passed, it is important to debrief and reconnect with the team, especially the less-experienced members who may have lingering concerns.”

For many employees, however, it is difficult to report disruptive behaviors. This is due to a fear of retaliation and the stigma associated with “blowing the whistle” on a colleague as well as a general reluctance to confront an intimidator.1

If an employee cannot muster the courage to confront a disruptive coworker or if the issue isn’t resolved by talking with the difficult individual, an employee should be a good citizen and report bad behavior to the appropriate hospital authority in a timely manner, says A. Kevin Troutman, Esq., a partner at Fisher Phillips in Houston and a former healthcare human resources executive.

Hospitals accredited by The Joint Commission are required to create a code of conduct that defines disruptive and inappropriate behaviors. In addition, leaders must create and implement a process for managing these behaviors.1

Helping Difficult Doctors

After a physician or another employee has been called out for bad behavior, steps need to be taken to correct the problem. Robert Fuller, Esq., an attorney with Nelson Hardiman, LLP, in Los Angeles, has found a positive-oriented intervention called “the 3-Ds”—which stands for diagnose, design, and do—that has been a successful tool for achieving positive change. The strategy involves a supervisor and employee mutually developing a worksheet to diagnose the problem. Next, they design a remediation and improvement plan. Finally, they implement the plan and specify dates to achieve certain milestones. Coworkers should be informed of the plan and be urged to support it.

“Make it clear that the positive aspect of this plan turns to progressive discipline, including termination, if the employee doesn’t improve or abandons the plan of action,” Fuller says. In most cases, troublemakers will make a sincere effort to control disruptive tendencies.

Troutman suggests enlisting the assistance of a respected peer.

“Have a senior-level doctor help the noncompliant physician understand why his or her behavior creates problems for everyone, including the doctor himself,” he says. “Also, consider connecting compensation and other rewards to job performance, which encompasses good behavior and good citizenship within the organization. Make expectations and consequences clear.”

If an employee has a recent change in behavior, ask if there is a reason.

“It is my experience that sudden changes in behaviors are often the result of a personal or clinical issue, so it is important and humane to make certain that there is not some other cause for the change before assuming someone is simply being disruptive or difficult,” Dr. Nichols says.

Many healthcare institutions are now setting up centers of professionalism. Paskoff reports that The Center for Professionalism and Peer Support (CPPS) was created in 2008 at Brigham and Women’s Hospital in Boston to educate the hospital community regarding professionalism and manage unprofessional behavior.3 CPPS has established standards of behavior and a framework to deal with difficult behaviors.

“An employee is told what he or she is doing wrong, receives counseling, and is given resources to improve,” he explains. “If an employee doesn’t improve, he or she is told that the behavior won’t be tolerated.”

Dismissing Bad Employees

After addressing the specifics of unacceptable behavior and explaining the consequences of repeating it, leadership should monitor subsequent conduct and provide feedback.

“If the employee commits other violations or behaves badly, promptly address the misconduct again and make it clear that further such actions will not be tolerated,” Troutman says. “Expect immediate and sustained improvement and compliance. Be consistent, and if bad conduct continues after an opportunity to improve, do not prolong anyone’s suffering. Instead, terminate the disruptive employee. When you do, make the reasons clear.”

Karen Appold is a medical writer in Pennsylvania.

References

1. Behaviors that undermine a culture of safety. The Joint Commission website. Accessed April 17, 2015.
2. Whittemore AD, New England Society for Vascular Surgery. The impact of professionalism on safe surgical care. J Vasc Surg. 2007;45(2):415-419.
3. Shapiro J, Whittemore A, Tsen LC. Instituting a culture of professionalism: the establishment of a center for professionalism and peer support. Jt Comm J Qual Patient Saf. 2014;40(4):168-177.

Are Behaviors Getting Better or Worse?

Wyatt.jpg

The Joint Commission issued a sentinel event alert1 on July 9, 2008, as a result of continuous reports to the commission’s Office of Quality and Patient Safety about disruptive behavior. Despite efforts to prevent employees from behaving badly, Ronald Wyatt, MD, MHA, medical director of the Division of Healthcare Improvement, says there is no evidence that the number of instances of bad behavior is decreasing.

According to a 2013 Institute for Safe Medication Practices survey with 4,884 respondents:2

• 73% reported encountering negative comments about colleagues or leaders during the previous year.
• 68% reported condescending language or demeaning comments or insults.
• 77% said they had encountered reluctance or refusal to answer questions or return calls.
• 69% reported they had encountered impatience with questions or hanging up the phone.

In addition, in a 2011 survey of more than 500 physician leaders and more than 300 staff physicians, 71 percent of respondents stated they had witnessed some type of disruptive behavior within the previous month, while 26 percent stated that they had been disruptive at one point in their career.3

Despite the gloomy news, Dr. Wyatt says, “There is increased awareness of disruptive behaviors, and they are being reported more often than in the past.”

As a former chief of medicine at a hospital, Dr. Wyatt says the lack of improvement could be due to hospital leadership.

“This is a critical piece to having a sound patient safety system,” he says.

In order for bad behaviors to improve, hospital leadership needs to be committed to creating a culture of safety. This would involve answering “yes” to the following questions:

• Does staff feel safe to report disruptive behaviors, and will leadership act on those reports?
• Is leadership committed to decreasing these types of behaviors?
• Is there a reporting system in place, and is it being used, monitored, and acted on?
• Can leadership step in and enforce the process if physicians aren’t complying?
• Is a model in place if intervention is necessary?

According to Dr. Wyatt, data show that one intervention is usually enough for most physicians to cease bad behaviors, but a small portion will persist.4

Hospitals accredited by The Joint Commission can contact the organization for a template regarding a policy for disruptive behaviors. Some consultants can also provide this.

—Karen Appold

References

1. Behaviors that undermine a culture of safety. The Joint Commission website. Accessed April 17, 2015.
2. Patient safety systems. Comprehensive Accreditation Manual for Hospitals. The Joint Commission. January 1, 2015:7-8.
3. MacDonald O. Disruptive physician behavior. Quantia Communications, Inc.: Waltham, MA. May 15, 2011.
4. Pichert JW, Moore IN, Karrass J, et al. An intervention model that promotes accountability: peer messengers and patient/family complaints. Jt Comm J Qual Patient Saf. 2013;39(10):435-446.

Proceed with Caution When Hiring Staff

Troutman.jpg

Ideally, an institution won’t hire someone with intimidating and disruptive behavior in the first place. But this is always easier said than done.

In an effort to select and hire the best employees, it is important during the interview process to ask many questions about a candidate’s prior experiences and previous bosses as well as what the employee perceives to be good behavior and reasonable expectations.

“Listen for victim-like responses and criticisms of prior supervisors or employers,” says A. Kevin Troutman, Esq., a partner at Fisher Phillips in Houston and a former healthcare human resources executive. “Such responses are red flags that may help predict how the applicant will work out in your organization.”

Stephen M. Paskoff, Esq., president and CEO of ELI in Atlanta, says it’s best for the candidate to have interviews with multiple staff members in different ranks.

“Sometimes people will show a different side if he or she perceives someone as unimportant or someone that he or she could boss around,” he says. “The interview can be very telling if the applicant is a cultural fit or not.”

Carefully check a candidate’s previous training and employment records. It can be difficult, however, to decipher whether a potential employee will indeed be a good choice because prior employers almost uniformly refuse to provide more than someone’s position and dates of employment when references are checked, says Robert Fuller, Esq., an attorney with Nelson Hardiman, LLP, in Los Angeles.

Consequently, Fuller recommends that hospitals have very specific probation policies, allowing for termination for any reason within the first 90 days of employment and active supervision of new employees to ensure that no red flags are raised within that time frame.

If someone was fired from a previous job, use extra caution in making a hiring decision. Paskoff advises considering the facts: What was the person fired for? What do his or her records look like?

“Just because someone was fired, you shouldn’t dismiss him or her, but know what he or she was fired for and how well the firing was documented and investigated,” he says.

Fuller advises differently.

“If proper policies were followed and the employee failed to comport with improvement recommendations, he or she is not going to be any different the second time around,” he says.

Although the job interview process can be lengthy, “don’t take any shortcuts,” Paskoff says. You may end up costing an organization a lot more than time if you do.

—Karen Appold

As a hospitalist, caring for critically ill or injured patients can be stressful and demanding. Working with difficult doctors, those who exhibit intimidating and disruptive behaviors such as verbal outbursts and physical threats as well as passive activities such as refusing to perform assigned tasks, can make the work environment even more challenging.1 Some docs are routinely reluctant—or refuse—to answer questions or return phone calls or pages. Some communicate in condescending language or voice intonation; some are brutally impatient.1

difficultdoctors.jpg

The most difficult doctors to work with are those who are not aligned with the hospital’s or treatment team’s goals and those who aren’t open to feedback and coaching, says Rob Zipper, MD, MMM, SFHM, regional chief medical officer of Sound Physicians, based in Tacoma, Wash.

“If physicians are aware of a practice’s guidelines and goals but simply won’t comply with them, it makes it harder on everyone else who is pulling the ship in the same direction,” he says.

Unruly physicians don’t just annoy their coworkers. According to a sentinel event alert from The Joint Commission, they can:

• foster medical errors;
• contribute to poor patient satisfaction;
• contribute to preventable adverse outcomes;
• increase the cost of care;
• undermine team effectiveness; and
• cause qualified clinicians, administrators, and managers to seek new positions in more professional environments.1

“These issues are all connected,” says Stephen R. Nichols, MD, chief of clinical operations performance at the Schumacher Group in Brownwood, Texas. “Disruptive behaviors create mitigated communications and dissatisfaction among staff, which bleeds over into other aspects that are involved secondarily.”

Stephen M. Paskoff, Esq., president and CEO of ELI in Atlanta, can attest to the most severe consequences of bad behavior on patient care.

At one institution, a surgeon’s disruptive behavior lead to a coworker forgetting to perform a procedure and a patient dying.2 In another incident, the emergency department stopped calling on a medical subspecialist who was predictably abusive. The subspecialist knew how to treat a specific patient with an unusual intervention. Since the specialist was not consulted initially, the patient ended up in the intensive care unit.2

One bad hospitalist can bring down the reputation of an entire team.

“Many programs are incentivized based on medical staff and primary-care physicians’ perceptions of their care, so there are direct and indirect consequences,” Dr. Zipper says.

The bottom line, says Felix Aguirre, MD, SFHM, vice president of medical affairs at IPC Healthcare in North Hollywood, Calif., is that it only takes one bad experience to tarnish a group, but it takes many positive experiences to erase the damage.

The Roots of Evil

Intimidating and disruptive behavior stems from both individual and systemic factors. Care providers who exhibit characteristics such as self-centeredness, immaturity, or defensiveness can be more prone to unprofessional behavior. They can lack interpersonal, coping, or conflict-management skills.1

Systemic factors are marked by pressures related to increased productivity demands, cost-containment requirements, embedded hierarchies, and fear of litigation in the healthcare environment. These pressures can be further exacerbated by changes to or differences in the authority, autonomy, empowerment, and roles or values of professionals on the healthcare team as well as by the continual daily changes in shifts, rotations, and interdepartmental support staff. This dynamic creates challenges for interprofessional communication and development of trust among team members.1

According to The Joint Commission, intimidating and disruptive behaviors are often manifested by healthcare professionals in positions of power.1 But other members of the care team can be problematic as well.

“In my experience, conflicts usually revolve around different perspectives and objectives, even if both parties are acting respectfully,” Dr. Zipper says. “Sometimes, however, providers or other care team members are tired or stressed and don’t behave professionally.”

Paskoff, who has more than 40 years of experience in healthcare-related workplace issues, including serving as an investigator for the U.S. Equal Employment Opportunity Commission, says some doctors learn bad behaviors from their mentors and that behaviors can be passed down through generations because they are tolerated.

“When I asked one physician who had outstanding training and an outstanding technical reputation how he became abusive, he said, ‘I learned from the best.’” Paskoff was actually able to track the doctor’s training to the late 1800s and physicians who were known for similar behaviors.

Confronting Those Who Misbehave

Dr. Zipper says physicians should confront behavioral issues directly.

“I will typically discuss a complaint with a doctor privately, and ask him or her what happened without being accusatory,” he says. “I try to provide as much concrete and objective information as I can. The doctor needs to know that you are trying to help him or her succeed. That said, if something is clearly bad behavior, feedback should be direct and include a statement such as, ‘This is not how we behave in this practice.’”

At times, it may not be possible to discuss an emergent matter, such as during a code blue.

“However, I will often ask if anyone on the code team has any ideas or concerns before ending the code,” Dr. Nichols says. “Then after the critical time has passed, it is important to debrief and reconnect with the team, especially the less-experienced members who may have lingering concerns.”

For many employees, however, it is difficult to report disruptive behaviors. This is due to a fear of retaliation and the stigma associated with “blowing the whistle” on a colleague as well as a general reluctance to confront an intimidator.1

If an employee cannot muster the courage to confront a disruptive coworker or if the issue isn’t resolved by talking with the difficult individual, an employee should be a good citizen and report bad behavior to the appropriate hospital authority in a timely manner, says A. Kevin Troutman, Esq., a partner at Fisher Phillips in Houston and a former healthcare human resources executive.

Hospitals accredited by The Joint Commission are required to create a code of conduct that defines disruptive and inappropriate behaviors. In addition, leaders must create and implement a process for managing these behaviors.1

Helping Difficult Doctors

After a physician or another employee has been called out for bad behavior, steps need to be taken to correct the problem. Robert Fuller, Esq., an attorney with Nelson Hardiman, LLP, in Los Angeles, has found a positive-oriented intervention called “the 3-Ds”—which stands for diagnose, design, and do—that has been a successful tool for achieving positive change. The strategy involves a supervisor and employee mutually developing a worksheet to diagnose the problem. Next, they design a remediation and improvement plan. Finally, they implement the plan and specify dates to achieve certain milestones. Coworkers should be informed of the plan and be urged to support it.

“Make it clear that the positive aspect of this plan turns to progressive discipline, including termination, if the employee doesn’t improve or abandons the plan of action,” Fuller says. In most cases, troublemakers will make a sincere effort to control disruptive tendencies.

Troutman suggests enlisting the assistance of a respected peer.

“Have a senior-level doctor help the noncompliant physician understand why his or her behavior creates problems for everyone, including the doctor himself,” he says. “Also, consider connecting compensation and other rewards to job performance, which encompasses good behavior and good citizenship within the organization. Make expectations and consequences clear.”

If an employee has a recent change in behavior, ask if there is a reason.

“It is my experience that sudden changes in behaviors are often the result of a personal or clinical issue, so it is important and humane to make certain that there is not some other cause for the change before assuming someone is simply being disruptive or difficult,” Dr. Nichols says.

Many healthcare institutions are now setting up centers of professionalism. Paskoff reports that The Center for Professionalism and Peer Support (CPPS) was created in 2008 at Brigham and Women’s Hospital in Boston to educate the hospital community regarding professionalism and manage unprofessional behavior.3 CPPS has established standards of behavior and a framework to deal with difficult behaviors.

“An employee is told what he or she is doing wrong, receives counseling, and is given resources to improve,” he explains. “If an employee doesn’t improve, he or she is told that the behavior won’t be tolerated.”

Dismissing Bad Employees

After addressing the specifics of unacceptable behavior and explaining the consequences of repeating it, leadership should monitor subsequent conduct and provide feedback.

“If the employee commits other violations or behaves badly, promptly address the misconduct again and make it clear that further such actions will not be tolerated,” Troutman says. “Expect immediate and sustained improvement and compliance. Be consistent, and if bad conduct continues after an opportunity to improve, do not prolong anyone’s suffering. Instead, terminate the disruptive employee. When you do, make the reasons clear.”

Karen Appold is a medical writer in Pennsylvania.

References

1. Behaviors that undermine a culture of safety. The Joint Commission website. Accessed April 17, 2015.
2. Whittemore AD, New England Society for Vascular Surgery. The impact of professionalism on safe surgical care. J Vasc Surg. 2007;45(2):415-419.
3. Shapiro J, Whittemore A, Tsen LC. Instituting a culture of professionalism: the establishment of a center for professionalism and peer support. Jt Comm J Qual Patient Saf. 2014;40(4):168-177.

Are Behaviors Getting Better or Worse?

Wyatt.jpg

The Joint Commission issued a sentinel event alert1 on July 9, 2008, as a result of continuous reports to the commission’s Office of Quality and Patient Safety about disruptive behavior. Despite efforts to prevent employees from behaving badly, Ronald Wyatt, MD, MHA, medical director of the Division of Healthcare Improvement, says there is no evidence that the number of instances of bad behavior is decreasing.

According to a 2013 Institute for Safe Medication Practices survey with 4,884 respondents:2

• 73% reported encountering negative comments about colleagues or leaders during the previous year.
• 68% reported condescending language or demeaning comments or insults.
• 77% said they had encountered reluctance or refusal to answer questions or return calls.
• 69% reported they had encountered impatience with questions or hanging up the phone.

In addition, in a 2011 survey of more than 500 physician leaders and more than 300 staff physicians, 71 percent of respondents stated they had witnessed some type of disruptive behavior within the previous month, while 26 percent stated that they had been disruptive at one point in their career.3

Despite the gloomy news, Dr. Wyatt says, “There is increased awareness of disruptive behaviors, and they are being reported more often than in the past.”

As a former chief of medicine at a hospital, Dr. Wyatt says the lack of improvement could be due to hospital leadership.

“This is a critical piece to having a sound patient safety system,” he says.

In order for bad behaviors to improve, hospital leadership needs to be committed to creating a culture of safety. This would involve answering “yes” to the following questions:

• Does staff feel safe to report disruptive behaviors, and will leadership act on those reports?
• Is leadership committed to decreasing these types of behaviors?
• Is there a reporting system in place, and is it being used, monitored, and acted on?
• Can leadership step in and enforce the process if physicians aren’t complying?
• Is a model in place if intervention is necessary?

According to Dr. Wyatt, data show that one intervention is usually enough for most physicians to cease bad behaviors, but a small portion will persist.4

Hospitals accredited by The Joint Commission can contact the organization for a template regarding a policy for disruptive behaviors. Some consultants can also provide this.

—Karen Appold

References

1. Behaviors that undermine a culture of safety. The Joint Commission website. Accessed April 17, 2015.
2. Patient safety systems. Comprehensive Accreditation Manual for Hospitals. The Joint Commission. January 1, 2015:7-8.
3. MacDonald O. Disruptive physician behavior. Quantia Communications, Inc.: Waltham, MA. May 15, 2011.
4. Pichert JW, Moore IN, Karrass J, et al. An intervention model that promotes accountability: peer messengers and patient/family complaints. Jt Comm J Qual Patient Saf. 2013;39(10):435-446.

Proceed with Caution When Hiring Staff

Troutman.jpg

Ideally, an institution won’t hire someone with intimidating and disruptive behavior in the first place. But this is always easier said than done.

In an effort to select and hire the best employees, it is important during the interview process to ask many questions about a candidate’s prior experiences and previous bosses as well as what the employee perceives to be good behavior and reasonable expectations.

“Listen for victim-like responses and criticisms of prior supervisors or employers,” says A. Kevin Troutman, Esq., a partner at Fisher Phillips in Houston and a former healthcare human resources executive. “Such responses are red flags that may help predict how the applicant will work out in your organization.”

Stephen M. Paskoff, Esq., president and CEO of ELI in Atlanta, says it’s best for the candidate to have interviews with multiple staff members in different ranks.

“Sometimes people will show a different side if he or she perceives someone as unimportant or someone that he or she could boss around,” he says. “The interview can be very telling if the applicant is a cultural fit or not.”

Carefully check a candidate’s previous training and employment records. It can be difficult, however, to decipher whether a potential employee will indeed be a good choice because prior employers almost uniformly refuse to provide more than someone’s position and dates of employment when references are checked, says Robert Fuller, Esq., an attorney with Nelson Hardiman, LLP, in Los Angeles.

Consequently, Fuller recommends that hospitals have very specific probation policies, allowing for termination for any reason within the first 90 days of employment and active supervision of new employees to ensure that no red flags are raised within that time frame.

If someone was fired from a previous job, use extra caution in making a hiring decision. Paskoff advises considering the facts: What was the person fired for? What do his or her records look like?

“Just because someone was fired, you shouldn’t dismiss him or her, but know what he or she was fired for and how well the firing was documented and investigated,” he says.

Fuller advises differently.

“If proper policies were followed and the employee failed to comport with improvement recommendations, he or she is not going to be any different the second time around,” he says.

Although the job interview process can be lengthy, “don’t take any shortcuts,” Paskoff says. You may end up costing an organization a lot more than time if you do.

—Karen Appold

As a hospitalist, caring for critically ill or injured patients can be stressful and demanding. Working with difficult doctors, those who exhibit intimidating and disruptive behaviors such as verbal outbursts and physical threats as well as passive activities such as refusing to perform assigned tasks, can make the work environment even more challenging.1 Some docs are routinely reluctant—or refuse—to answer questions or return phone calls or pages. Some communicate in condescending language or voice intonation; some are brutally impatient.1

difficultdoctors.jpg

The most difficult doctors to work with are those who are not aligned with the hospital’s or treatment team’s goals and those who aren’t open to feedback and coaching, says Rob Zipper, MD, MMM, SFHM, regional chief medical officer of Sound Physicians, based in Tacoma, Wash.

“If physicians are aware of a practice’s guidelines and goals but simply won’t comply with them, it makes it harder on everyone else who is pulling the ship in the same direction,” he says.

Unruly physicians don’t just annoy their coworkers. According to a sentinel event alert from The Joint Commission, they can:

• foster medical errors;
• contribute to poor patient satisfaction;
• contribute to preventable adverse outcomes;
• increase the cost of care;
• undermine team effectiveness; and
• cause qualified clinicians, administrators, and managers to seek new positions in more professional environments.1

“These issues are all connected,” says Stephen R. Nichols, MD, chief of clinical operations performance at the Schumacher Group in Brownwood, Texas. “Disruptive behaviors create mitigated communications and dissatisfaction among staff, which bleeds over into other aspects that are involved secondarily.”

Stephen M. Paskoff, Esq., president and CEO of ELI in Atlanta, can attest to the most severe consequences of bad behavior on patient care.

At one institution, a surgeon’s disruptive behavior lead to a coworker forgetting to perform a procedure and a patient dying.2 In another incident, the emergency department stopped calling on a medical subspecialist who was predictably abusive. The subspecialist knew how to treat a specific patient with an unusual intervention. Since the specialist was not consulted initially, the patient ended up in the intensive care unit.2

One bad hospitalist can bring down the reputation of an entire team.

“Many programs are incentivized based on medical staff and primary-care physicians’ perceptions of their care, so there are direct and indirect consequences,” Dr. Zipper says.

The bottom line, says Felix Aguirre, MD, SFHM, vice president of medical affairs at IPC Healthcare in North Hollywood, Calif., is that it only takes one bad experience to tarnish a group, but it takes many positive experiences to erase the damage.

The Roots of Evil

Intimidating and disruptive behavior stems from both individual and systemic factors. Care providers who exhibit characteristics such as self-centeredness, immaturity, or defensiveness can be more prone to unprofessional behavior. They can lack interpersonal, coping, or conflict-management skills.1

Systemic factors are marked by pressures related to increased productivity demands, cost-containment requirements, embedded hierarchies, and fear of litigation in the healthcare environment. These pressures can be further exacerbated by changes to or differences in the authority, autonomy, empowerment, and roles or values of professionals on the healthcare team as well as by the continual daily changes in shifts, rotations, and interdepartmental support staff. This dynamic creates challenges for interprofessional communication and development of trust among team members.1

According to The Joint Commission, intimidating and disruptive behaviors are often manifested by healthcare professionals in positions of power.1 But other members of the care team can be problematic as well.

“In my experience, conflicts usually revolve around different perspectives and objectives, even if both parties are acting respectfully,” Dr. Zipper says. “Sometimes, however, providers or other care team members are tired or stressed and don’t behave professionally.”

Paskoff, who has more than 40 years of experience in healthcare-related workplace issues, including serving as an investigator for the U.S. Equal Employment Opportunity Commission, says some doctors learn bad behaviors from their mentors and that behaviors can be passed down through generations because they are tolerated.

“When I asked one physician who had outstanding training and an outstanding technical reputation how he became abusive, he said, ‘I learned from the best.’” Paskoff was actually able to track the doctor’s training to the late 1800s and physicians who were known for similar behaviors.

Confronting Those Who Misbehave

Dr. Zipper says physicians should confront behavioral issues directly.

“I will typically discuss a complaint with a doctor privately, and ask him or her what happened without being accusatory,” he says. “I try to provide as much concrete and objective information as I can. The doctor needs to know that you are trying to help him or her succeed. That said, if something is clearly bad behavior, feedback should be direct and include a statement such as, ‘This is not how we behave in this practice.’”

At times, it may not be possible to discuss an emergent matter, such as during a code blue.

“However, I will often ask if anyone on the code team has any ideas or concerns before ending the code,” Dr. Nichols says. “Then after the critical time has passed, it is important to debrief and reconnect with the team, especially the less-experienced members who may have lingering concerns.”

For many employees, however, it is difficult to report disruptive behaviors. This is due to a fear of retaliation and the stigma associated with “blowing the whistle” on a colleague as well as a general reluctance to confront an intimidator.1

If an employee cannot muster the courage to confront a disruptive coworker or if the issue isn’t resolved by talking with the difficult individual, an employee should be a good citizen and report bad behavior to the appropriate hospital authority in a timely manner, says A. Kevin Troutman, Esq., a partner at Fisher Phillips in Houston and a former healthcare human resources executive.

Hospitals accredited by The Joint Commission are required to create a code of conduct that defines disruptive and inappropriate behaviors. In addition, leaders must create and implement a process for managing these behaviors.1

Helping Difficult Doctors

After a physician or another employee has been called out for bad behavior, steps need to be taken to correct the problem. Robert Fuller, Esq., an attorney with Nelson Hardiman, LLP, in Los Angeles, has found a positive-oriented intervention called “the 3-Ds”—which stands for diagnose, design, and do—that has been a successful tool for achieving positive change. The strategy involves a supervisor and employee mutually developing a worksheet to diagnose the problem. Next, they design a remediation and improvement plan. Finally, they implement the plan and specify dates to achieve certain milestones. Coworkers should be informed of the plan and be urged to support it.

“Make it clear that the positive aspect of this plan turns to progressive discipline, including termination, if the employee doesn’t improve or abandons the plan of action,” Fuller says. In most cases, troublemakers will make a sincere effort to control disruptive tendencies.

Troutman suggests enlisting the assistance of a respected peer.

“Have a senior-level doctor help the noncompliant physician understand why his or her behavior creates problems for everyone, including the doctor himself,” he says. “Also, consider connecting compensation and other rewards to job performance, which encompasses good behavior and good citizenship within the organization. Make expectations and consequences clear.”

If an employee has a recent change in behavior, ask if there is a reason.

“It is my experience that sudden changes in behaviors are often the result of a personal or clinical issue, so it is important and humane to make certain that there is not some other cause for the change before assuming someone is simply being disruptive or difficult,” Dr. Nichols says.

Many healthcare institutions are now setting up centers of professionalism. Paskoff reports that The Center for Professionalism and Peer Support (CPPS) was created in 2008 at Brigham and Women’s Hospital in Boston to educate the hospital community regarding professionalism and manage unprofessional behavior.3 CPPS has established standards of behavior and a framework to deal with difficult behaviors.

“An employee is told what he or she is doing wrong, receives counseling, and is given resources to improve,” he explains. “If an employee doesn’t improve, he or she is told that the behavior won’t be tolerated.”

Dismissing Bad Employees

After addressing the specifics of unacceptable behavior and explaining the consequences of repeating it, leadership should monitor subsequent conduct and provide feedback.

“If the employee commits other violations or behaves badly, promptly address the misconduct again and make it clear that further such actions will not be tolerated,” Troutman says. “Expect immediate and sustained improvement and compliance. Be consistent, and if bad conduct continues after an opportunity to improve, do not prolong anyone’s suffering. Instead, terminate the disruptive employee. When you do, make the reasons clear.”

Karen Appold is a medical writer in Pennsylvania.

References

1. Behaviors that undermine a culture of safety. The Joint Commission website. Accessed April 17, 2015.
2. Whittemore AD, New England Society for Vascular Surgery. The impact of professionalism on safe surgical care. J Vasc Surg. 2007;45(2):415-419.
3. Shapiro J, Whittemore A, Tsen LC. Instituting a culture of professionalism: the establishment of a center for professionalism and peer support. Jt Comm J Qual Patient Saf. 2014;40(4):168-177.

Are Behaviors Getting Better or Worse?

Wyatt.jpg

The Joint Commission issued a sentinel event alert1 on July 9, 2008, as a result of continuous reports to the commission’s Office of Quality and Patient Safety about disruptive behavior. Despite efforts to prevent employees from behaving badly, Ronald Wyatt, MD, MHA, medical director of the Division of Healthcare Improvement, says there is no evidence that the number of instances of bad behavior is decreasing.

According to a 2013 Institute for Safe Medication Practices survey with 4,884 respondents:2

• 73% reported encountering negative comments about colleagues or leaders during the previous year.
• 68% reported condescending language or demeaning comments or insults.
• 77% said they had encountered reluctance or refusal to answer questions or return calls.
• 69% reported they had encountered impatience with questions or hanging up the phone.

In addition, in a 2011 survey of more than 500 physician leaders and more than 300 staff physicians, 71 percent of respondents stated they had witnessed some type of disruptive behavior within the previous month, while 26 percent stated that they had been disruptive at one point in their career.3

Despite the gloomy news, Dr. Wyatt says, “There is increased awareness of disruptive behaviors, and they are being reported more often than in the past.”

As a former chief of medicine at a hospital, Dr. Wyatt says the lack of improvement could be due to hospital leadership.

“This is a critical piece to having a sound patient safety system,” he says.

In order for bad behaviors to improve, hospital leadership needs to be committed to creating a culture of safety. This would involve answering “yes” to the following questions:

• Does staff feel safe to report disruptive behaviors, and will leadership act on those reports?
• Is leadership committed to decreasing these types of behaviors?
• Is there a reporting system in place, and is it being used, monitored, and acted on?
• Can leadership step in and enforce the process if physicians aren’t complying?
• Is a model in place if intervention is necessary?

According to Dr. Wyatt, data show that one intervention is usually enough for most physicians to cease bad behaviors, but a small portion will persist.4

Hospitals accredited by The Joint Commission can contact the organization for a template regarding a policy for disruptive behaviors. Some consultants can also provide this.

—Karen Appold

References

1. Behaviors that undermine a culture of safety. The Joint Commission website. Accessed April 17, 2015.
2. Patient safety systems. Comprehensive Accreditation Manual for Hospitals. The Joint Commission. January 1, 2015:7-8.
3. MacDonald O. Disruptive physician behavior. Quantia Communications, Inc.: Waltham, MA. May 15, 2011.
4. Pichert JW, Moore IN, Karrass J, et al. An intervention model that promotes accountability: peer messengers and patient/family complaints. Jt Comm J Qual Patient Saf. 2013;39(10):435-446.

Proceed with Caution When Hiring Staff

Troutman.jpg

Ideally, an institution won’t hire someone with intimidating and disruptive behavior in the first place. But this is always easier said than done.

In an effort to select and hire the best employees, it is important during the interview process to ask many questions about a candidate’s prior experiences and previous bosses as well as what the employee perceives to be good behavior and reasonable expectations.

“Listen for victim-like responses and criticisms of prior supervisors or employers,” says A. Kevin Troutman, Esq., a partner at Fisher Phillips in Houston and a former healthcare human resources executive. “Such responses are red flags that may help predict how the applicant will work out in your organization.”

Stephen M. Paskoff, Esq., president and CEO of ELI in Atlanta, says it’s best for the candidate to have interviews with multiple staff members in different ranks.

“Sometimes people will show a different side if he or she perceives someone as unimportant or someone that he or she could boss around,” he says. “The interview can be very telling if the applicant is a cultural fit or not.”

Carefully check a candidate’s previous training and employment records. It can be difficult, however, to decipher whether a potential employee will indeed be a good choice because prior employers almost uniformly refuse to provide more than someone’s position and dates of employment when references are checked, says Robert Fuller, Esq., an attorney with Nelson Hardiman, LLP, in Los Angeles.

Consequently, Fuller recommends that hospitals have very specific probation policies, allowing for termination for any reason within the first 90 days of employment and active supervision of new employees to ensure that no red flags are raised within that time frame.

If someone was fired from a previous job, use extra caution in making a hiring decision. Paskoff advises considering the facts: What was the person fired for? What do his or her records look like?

“Just because someone was fired, you shouldn’t dismiss him or her, but know what he or she was fired for and how well the firing was documented and investigated,” he says.

Fuller advises differently.

“If proper policies were followed and the employee failed to comport with improvement recommendations, he or she is not going to be any different the second time around,” he says.

Although the job interview process can be lengthy, “don’t take any shortcuts,” Paskoff says. You may end up costing an organization a lot more than time if you do.

—Karen Appold

Inpatient hospitalization can be a key time for patients to quit smoking, according to an abstract called “No More Butts: An Automated System for Inpatient Smoking Cessation Team Consults.”1

“Tobacco smoking continues to be one of the most important public health threats that we face,” says lead author Sujatha Sankaran, MD, assistant clinical professor in the division of hospital medicine and medical director of smoking cessation at the University of California, San Francisco. “Hospitalization is an extremely important moment and provides an excellent opportunity to counsel and provide cessation resources for people who are concerned about their health.”

Inpatients who receive smoking cessation counseling, nicotine replacement, and referral to outpatient resources have increased quit rates six weeks after hospital discharge, their research showed.

However, according to the abstract, in 2014:

• 34.5% of tobacco users admitted to one 600-bed academic hospital were documented as having received and accepted tobacco cessation counseling
• 45.7% of tobacco users received nicotine replacement therapy
• 1.35% of tobacco users received after-discharge consultations to outpatient smoking cessation resources

Researchers piloted a system in which a dedicated respiratory therapist–staffed smoking cessation consult service was trained to provide targeted tobacco cessation services to all inpatients who use tobacco. Of 1944 patients identified as using tobacco, 1545 received and accepted cessation counseling from a trained member of the Smoking Cessation Team, 1526 received nicotine replacement therapy, and 464 received an electronic referral to either a telephone or in-person quit line

“Hospitalists know firsthand the serious harm that tobacco use causes to patients but often are overwhelmed by the acute issues of patients and are unable to fully address tobacco use with hospitalized patients,” Dr. Sankaran says. “An automated cessation service can help lessen this burden by providing automatic cessation resources to all tobacco users.”

Reference

1. Sankaran S, Burke R, O’Keefe S. No more butts: an automated system for inpatient smoking cessation team consults [abstract]. J Hosp Med. 2016;11(suppl 1). Accessed November 9, 2016.

Inpatient hospitalization can be a key time for patients to quit smoking, according to an abstract called “No More Butts: An Automated System for Inpatient Smoking Cessation Team Consults.”1

“Tobacco smoking continues to be one of the most important public health threats that we face,” says lead author Sujatha Sankaran, MD, assistant clinical professor in the division of hospital medicine and medical director of smoking cessation at the University of California, San Francisco. “Hospitalization is an extremely important moment and provides an excellent opportunity to counsel and provide cessation resources for people who are concerned about their health.”

Inpatients who receive smoking cessation counseling, nicotine replacement, and referral to outpatient resources have increased quit rates six weeks after hospital discharge, their research showed.

However, according to the abstract, in 2014:

• 34.5% of tobacco users admitted to one 600-bed academic hospital were documented as having received and accepted tobacco cessation counseling
• 45.7% of tobacco users received nicotine replacement therapy
• 1.35% of tobacco users received after-discharge consultations to outpatient smoking cessation resources

Researchers piloted a system in which a dedicated respiratory therapist–staffed smoking cessation consult service was trained to provide targeted tobacco cessation services to all inpatients who use tobacco. Of 1944 patients identified as using tobacco, 1545 received and accepted cessation counseling from a trained member of the Smoking Cessation Team, 1526 received nicotine replacement therapy, and 464 received an electronic referral to either a telephone or in-person quit line

“Hospitalists know firsthand the serious harm that tobacco use causes to patients but often are overwhelmed by the acute issues of patients and are unable to fully address tobacco use with hospitalized patients,” Dr. Sankaran says. “An automated cessation service can help lessen this burden by providing automatic cessation resources to all tobacco users.”

Reference

1. Sankaran S, Burke R, O’Keefe S. No more butts: an automated system for inpatient smoking cessation team consults [abstract]. J Hosp Med. 2016;11(suppl 1). Accessed November 9, 2016.

Inpatient hospitalization can be a key time for patients to quit smoking, according to an abstract called “No More Butts: An Automated System for Inpatient Smoking Cessation Team Consults.”1

“Tobacco smoking continues to be one of the most important public health threats that we face,” says lead author Sujatha Sankaran, MD, assistant clinical professor in the division of hospital medicine and medical director of smoking cessation at the University of California, San Francisco. “Hospitalization is an extremely important moment and provides an excellent opportunity to counsel and provide cessation resources for people who are concerned about their health.”

Inpatients who receive smoking cessation counseling, nicotine replacement, and referral to outpatient resources have increased quit rates six weeks after hospital discharge, their research showed.

However, according to the abstract, in 2014:

• 34.5% of tobacco users admitted to one 600-bed academic hospital were documented as having received and accepted tobacco cessation counseling
• 45.7% of tobacco users received nicotine replacement therapy
• 1.35% of tobacco users received after-discharge consultations to outpatient smoking cessation resources

Researchers piloted a system in which a dedicated respiratory therapist–staffed smoking cessation consult service was trained to provide targeted tobacco cessation services to all inpatients who use tobacco. Of 1944 patients identified as using tobacco, 1545 received and accepted cessation counseling from a trained member of the Smoking Cessation Team, 1526 received nicotine replacement therapy, and 464 received an electronic referral to either a telephone or in-person quit line

“Hospitalists know firsthand the serious harm that tobacco use causes to patients but often are overwhelmed by the acute issues of patients and are unable to fully address tobacco use with hospitalized patients,” Dr. Sankaran says. “An automated cessation service can help lessen this burden by providing automatic cessation resources to all tobacco users.”

Reference

1. Sankaran S, Burke R, O’Keefe S. No more butts: an automated system for inpatient smoking cessation team consults [abstract]. J Hosp Med. 2016;11(suppl 1). Accessed November 9, 2016.

Collaborate_topper-300x134.jpg

Time was critical. He needed surgery right away to remove his gallbladder. But for that, he needed a surgeon.

“There was a surgeon on call, but the surgeon was not picking up the phone,” Dr. Singh says. “I’m scratching my head. Why is the surgeon not calling back? Where is the surgeon? Did the pager get lost? What if the patient has a bad outcome?”

Eventually, Dr. Singh had to give up on the on-call surgeon, and the patient was flown to a hospital 45 miles away in downtown Sacramento. His surgery had been delayed for almost 12 hours.

The man lived largely due to good luck, Dr. Singh says. The unresponsive surgeon had disciplinary proceedings started against his license but retired rather than face the consequences.

Today, hospitalists at Sutter Amador no longer have to anxiously wait for those responses to emergency pages. It’s one of many hospitals that have turned to a “surgicalist” model, with a surgeon always on hand at the hospital. Surgicalists perform both emergency procedures and procedures that are tied to a hospital admission, without which a patient can’t be discharged. Although it is growing in popularity, the model is still only seen in a small fraction of hospitals.

The model is widely supported by hospitalists because it brings several advantages, mainly a greater availability of the surgeon for consult.

“We don’t have to hunt them down, trying to call their office, trying to see if they’re available to call back,” says Dr. Singh, who is now also the chair of medical staff performance at Sutter Amador and adds that the change has helped with his job satisfaction.

A Clear Delineation

Arrangements between hospitalists and surgicalists vary depending on the hospital, but there typically are clearly delineated criteria on who cares for whom, with the more urgent surgical cases tending to fall under the surgicalists’ care and those with less urgent problems, even though surgery might be involved, tending to go to hospitalists.

When a surgery-related question or the need for actual surgery arises, the model calls for a quick response time from the surgicalist. Hospitalists and surgicalists collaborate on ways to reduce length of stay and prevent readmissions since they share the same institutional goals. Hospitalists are also more in tune with the needs of the surgeons, for instance, not feeding a patient who is going to need quick surgery and not administering blood thinners when a surgery is imminent unless there’s an overriding reason not to do so.

One advantage of this collaboration is that a hospitalist working alongside a surgicalist can get extra surgery-related guidance even when surgery probably isn’t needed, says John Nelson, MD, MHM, a hospitalist at Overlake Medical Center in Bellevue, Wash., a hospitalist management consultant, and a past president of SHM.

“Maybe the opinion of a general surgeon could be useful, but maybe I can get along without it because the general surgeons are busy. It’s going to be hard for them to find time to see this patient, and they’re not going to be very interested in it,” he says. “But if instead I have a surgical hospitalist who’s there all day, it’s much less of a bother for them to come by and take a look at my patient.”

Remaining Challenges

The model is not without its hurdles. When surgicalists are on a 24-hour shift, the patients will see a new one each day, sometimes prompting them to ask, “Who’s my doctor?” Also, complex cases can pose a challenge as they move from one surgicalist to another day to day.

John Maa, MD, who wrote a seminal paper on surgicalists in 2007 based on an early surgicalist model he started at San Mateo Medical Center in California,1 says he is now concerned that the principles he helped make popular—the absorption of surgeons into a system as they work hand in hand with other hospital staff all the time—might be eroding. Some small staffing companies are calling themselves surgicalists, promising fast response times, but are actually locum tenens surgeons under a surgicalist guise, he says.

Properly rolled out, surgicalist programs mean a much better working relationship between hospitalists and surgeons, says Lynette Scherer, MD, FACS, chief medical officer at Surgical Affiliates Management Group in Sacramento. The company, founded in 1996, employs about 200 surgeons, twice as many as three years ago, Dr. Scherer says, but the company declined to share what that amounts to in full-time equivalent positions.

“The hospitalists know all of our algorithms, and they know when to call us,” Dr. Scherer says. “We share the patients on the inpatient side as we need to. We keep the ones that are appropriate for us, and they keep the ones that are appropriate for them.”

The details depend on the hospital, she says.

“Whenever we go to a new site, we sit down with the hospitalist team and say, ‘What do you need here?’ And our admitting grids are different based on what the different needs of the hospitals are.”

To stay on top of complex cases with very sick patients, the medical director rounds with the team nearly every day to help guide that care, Dr. Scherer says.

At Sutter Amador, the arrival of the surgicalist model has helped shorten the length of stay by almost one day for surgery admissions, Dr. Singh says.

Reported outcomes, however, seem to be mixed.

In 2008, Sutter Medical Center in Sacramento switched from a nine-surgeon call panel to four surgeons who covered the acute-care surgery service in 24-hour shifts. Researchers looked at outcomes from 2007, before the new model was adopted, and from the four subsequent years. The results were published in 2014 in the Journal of the American College of Surgeons.2

The total number of operations rose significantly, with 497 performed in 2007 and 640 in 2011. The percentage of cases with complications also fell significantly, from 21% in 2007 to 12% in 2011, with a low of 11% in 2010.

But the mortality rate rose significantly, from 1.4% in 2007 to 2.2% in 2011, with a high of 4.1% in 2008. The study authors note that the mortality rate ultimately fell back to levels not statistically significantly higher than the rate before the service. They suggested the spike could have been due to a greater willingness by the service to treat severely ill patients and due to the “immaturity” of the service in its earlier years. The percentage of cases with a readmission fell from 6.4% in 2007 to 4.7% in 2011, with a low of 3% in 2009, but that change wasn’t quite statistically significant.

“The data’s really bearing out that emergency patients are different in terms of the care they demand,” Dr. Scherer says. “So the patient with alcoholic cirrhosis who presents with a hole in his colon is very different than somebody who presents for an elective colon resection. And you can really reduce complications when you have a team of educated people taking care of these patients.”

Dr. Nelson says adopting the model “just means you’re a smoother operator and you can provide better service to people.” He adds that for any hospital that is getting poor surgical coverage and is paying for it, “it might make sense to consider it.”

Thomas R. Collins is a freelance medical writer based in Florida.

References

1. Maa J, Carter JT, Gosnell JE, Wachter R, Harris HW. The surgical hospitalist: a new model for emergency surgical care. J Am Coll Surg. 2007;205(5):704-711.
2. O’Mara MS, Scherer L, Wisner D, Owens LJ. Sustainability and success of the acute care surgery model in the nontrauma setting. J Am Coll Surg. 2014;219(1):90-98.

 

For a Model That Many Say Makes Sense, Why Not More Growth?

Collaborate-300x167.jpg

Surgicalists and hospitalists say that collaboration between the two groups of specialists brings a smoother process, generates better outcomes, and offers greater job satisfaction.

 

So why hasn’t the surgicalist field exploded? About 10 years ago, that’s what was predicted. In 2007, John Nelson, MD, MHM, a hospitalist at Overlake Medical Center in Bellevue, Wash., a hospitalist management consultant, and a past president of SHM, wrote an article saying the field could be close to a “surge” similar to the medical hospitalist explosion.1

 

It’s not known how many of the nation’s roughly 5,600 hospitals use a surgicalist model. There is no association for surgicalists, who are also sometimes called “surgical hospitalists.”

 

But according to Dr. Nelson’s anecdotal impressions, the number could range from 300 to 800 hospitals, he says. That would mean it is in place only in roughly 10% of U.S. hospitals.

 

Expansion of the field has been slowed by cost and politics.

 

Most hospitals don’t have enough surgeons to pull off a surgicalist program, and adding the right number of surgeons costs money, Dr. Nelson says.

 

And at smaller community hospitals that have used on-call surgeons for years, it’s a thorny issue. Those surgeons often get a call stipend for being on call. If surgeons don’t have a full slate of elective surgeries, they could rely on that on-call pay and resist the adoption of the surgicalist model, which would mean losing that pay, Dr. Nelson says.

 

“Some of the surgeons in the community might say, ‘I don’t really like ED call, but I have to keep doing it because of the stipend. I depend on it for my income,’” he says.

 

Even those who wouldn’t mind losing that on-call pay might not be enthusiastic about a move to a surgicalist model because it would bring more general surgeons into the region.

 

Some, Dr. Nelson says, might say, “How do I know that in two years they aren’t stealing my referrals? The new surgical hospitalist is also a potential competitor for referrals I depend on.”

 

And other surgeons might resist simply because they like the professional gratification of emergency surgery work, he says.

 

According to John Maa, MD, who wrote a seminal paper on surgicalists in 2007 based on an early surgicalist model he started at San Mateo Medical Center in California,2 “In a lot of academic centers that didn’t pay call stipend, this was just very simple for them to implement some model of this. … Once you try to send someone to an established group where there was already someone taking call, that became very controversial, and I’ve seen litigation result from that.”

 

Trauma surgeons resisted the model, at least in part, because of semantics: The term “surgical hospitalist” was too similar to “medical hospitalist,” and they worried it might imply a lack of surgical training, says Dr. Maa.

 

For now, the typical assessment of the model that Dr. Nelson hears is: “They’ve thought about it, they may in the future, but no, they don’t have one.”

 

“It’s not growing as fast as the medical hospitalist idea did,” he says. “But it is growing. It’s not going to go away, but it’s still relatively small.”

 

—Thomas R. Collins

 

References

 

 

 

 

1. Nelson J. The surgical surge. The Hospitalist website. Accessed October 25, 2016.
2. Maa J, Carter JT, Gosnell JE, Wachter R, Harris HW. The surgical hospitalist: a new model for emergency surgical care. J Am Coll Surg. 2007 ;205(5):704-711.

 

Collaborate_topper-300x134.jpg

Time was critical. He needed surgery right away to remove his gallbladder. But for that, he needed a surgeon.

“There was a surgeon on call, but the surgeon was not picking up the phone,” Dr. Singh says. “I’m scratching my head. Why is the surgeon not calling back? Where is the surgeon? Did the pager get lost? What if the patient has a bad outcome?”

Eventually, Dr. Singh had to give up on the on-call surgeon, and the patient was flown to a hospital 45 miles away in downtown Sacramento. His surgery had been delayed for almost 12 hours.

The man lived largely due to good luck, Dr. Singh says. The unresponsive surgeon had disciplinary proceedings started against his license but retired rather than face the consequences.

Today, hospitalists at Sutter Amador no longer have to anxiously wait for those responses to emergency pages. It’s one of many hospitals that have turned to a “surgicalist” model, with a surgeon always on hand at the hospital. Surgicalists perform both emergency procedures and procedures that are tied to a hospital admission, without which a patient can’t be discharged. Although it is growing in popularity, the model is still only seen in a small fraction of hospitals.

The model is widely supported by hospitalists because it brings several advantages, mainly a greater availability of the surgeon for consult.

“We don’t have to hunt them down, trying to call their office, trying to see if they’re available to call back,” says Dr. Singh, who is now also the chair of medical staff performance at Sutter Amador and adds that the change has helped with his job satisfaction.

A Clear Delineation

Arrangements between hospitalists and surgicalists vary depending on the hospital, but there typically are clearly delineated criteria on who cares for whom, with the more urgent surgical cases tending to fall under the surgicalists’ care and those with less urgent problems, even though surgery might be involved, tending to go to hospitalists.

When a surgery-related question or the need for actual surgery arises, the model calls for a quick response time from the surgicalist. Hospitalists and surgicalists collaborate on ways to reduce length of stay and prevent readmissions since they share the same institutional goals. Hospitalists are also more in tune with the needs of the surgeons, for instance, not feeding a patient who is going to need quick surgery and not administering blood thinners when a surgery is imminent unless there’s an overriding reason not to do so.

One advantage of this collaboration is that a hospitalist working alongside a surgicalist can get extra surgery-related guidance even when surgery probably isn’t needed, says John Nelson, MD, MHM, a hospitalist at Overlake Medical Center in Bellevue, Wash., a hospitalist management consultant, and a past president of SHM.

“Maybe the opinion of a general surgeon could be useful, but maybe I can get along without it because the general surgeons are busy. It’s going to be hard for them to find time to see this patient, and they’re not going to be very interested in it,” he says. “But if instead I have a surgical hospitalist who’s there all day, it’s much less of a bother for them to come by and take a look at my patient.”

Remaining Challenges

The model is not without its hurdles. When surgicalists are on a 24-hour shift, the patients will see a new one each day, sometimes prompting them to ask, “Who’s my doctor?” Also, complex cases can pose a challenge as they move from one surgicalist to another day to day.

John Maa, MD, who wrote a seminal paper on surgicalists in 2007 based on an early surgicalist model he started at San Mateo Medical Center in California,1 says he is now concerned that the principles he helped make popular—the absorption of surgeons into a system as they work hand in hand with other hospital staff all the time—might be eroding. Some small staffing companies are calling themselves surgicalists, promising fast response times, but are actually locum tenens surgeons under a surgicalist guise, he says.

Properly rolled out, surgicalist programs mean a much better working relationship between hospitalists and surgeons, says Lynette Scherer, MD, FACS, chief medical officer at Surgical Affiliates Management Group in Sacramento. The company, founded in 1996, employs about 200 surgeons, twice as many as three years ago, Dr. Scherer says, but the company declined to share what that amounts to in full-time equivalent positions.

“The hospitalists know all of our algorithms, and they know when to call us,” Dr. Scherer says. “We share the patients on the inpatient side as we need to. We keep the ones that are appropriate for us, and they keep the ones that are appropriate for them.”

The details depend on the hospital, she says.

“Whenever we go to a new site, we sit down with the hospitalist team and say, ‘What do you need here?’ And our admitting grids are different based on what the different needs of the hospitals are.”

To stay on top of complex cases with very sick patients, the medical director rounds with the team nearly every day to help guide that care, Dr. Scherer says.

At Sutter Amador, the arrival of the surgicalist model has helped shorten the length of stay by almost one day for surgery admissions, Dr. Singh says.

Reported outcomes, however, seem to be mixed.

In 2008, Sutter Medical Center in Sacramento switched from a nine-surgeon call panel to four surgeons who covered the acute-care surgery service in 24-hour shifts. Researchers looked at outcomes from 2007, before the new model was adopted, and from the four subsequent years. The results were published in 2014 in the Journal of the American College of Surgeons.2

The total number of operations rose significantly, with 497 performed in 2007 and 640 in 2011. The percentage of cases with complications also fell significantly, from 21% in 2007 to 12% in 2011, with a low of 11% in 2010.

But the mortality rate rose significantly, from 1.4% in 2007 to 2.2% in 2011, with a high of 4.1% in 2008. The study authors note that the mortality rate ultimately fell back to levels not statistically significantly higher than the rate before the service. They suggested the spike could have been due to a greater willingness by the service to treat severely ill patients and due to the “immaturity” of the service in its earlier years. The percentage of cases with a readmission fell from 6.4% in 2007 to 4.7% in 2011, with a low of 3% in 2009, but that change wasn’t quite statistically significant.

“The data’s really bearing out that emergency patients are different in terms of the care they demand,” Dr. Scherer says. “So the patient with alcoholic cirrhosis who presents with a hole in his colon is very different than somebody who presents for an elective colon resection. And you can really reduce complications when you have a team of educated people taking care of these patients.”

Dr. Nelson says adopting the model “just means you’re a smoother operator and you can provide better service to people.” He adds that for any hospital that is getting poor surgical coverage and is paying for it, “it might make sense to consider it.”

Thomas R. Collins is a freelance medical writer based in Florida.

References

1. Maa J, Carter JT, Gosnell JE, Wachter R, Harris HW. The surgical hospitalist: a new model for emergency surgical care. J Am Coll Surg. 2007;205(5):704-711.
2. O’Mara MS, Scherer L, Wisner D, Owens LJ. Sustainability and success of the acute care surgery model in the nontrauma setting. J Am Coll Surg. 2014;219(1):90-98.

 

For a Model That Many Say Makes Sense, Why Not More Growth?

Collaborate-300x167.jpg

Surgicalists and hospitalists say that collaboration between the two groups of specialists brings a smoother process, generates better outcomes, and offers greater job satisfaction.

 

So why hasn’t the surgicalist field exploded? About 10 years ago, that’s what was predicted. In 2007, John Nelson, MD, MHM, a hospitalist at Overlake Medical Center in Bellevue, Wash., a hospitalist management consultant, and a past president of SHM, wrote an article saying the field could be close to a “surge” similar to the medical hospitalist explosion.1

 

It’s not known how many of the nation’s roughly 5,600 hospitals use a surgicalist model. There is no association for surgicalists, who are also sometimes called “surgical hospitalists.”

 

But according to Dr. Nelson’s anecdotal impressions, the number could range from 300 to 800 hospitals, he says. That would mean it is in place only in roughly 10% of U.S. hospitals.

 

Expansion of the field has been slowed by cost and politics.

 

Most hospitals don’t have enough surgeons to pull off a surgicalist program, and adding the right number of surgeons costs money, Dr. Nelson says.

 

And at smaller community hospitals that have used on-call surgeons for years, it’s a thorny issue. Those surgeons often get a call stipend for being on call. If surgeons don’t have a full slate of elective surgeries, they could rely on that on-call pay and resist the adoption of the surgicalist model, which would mean losing that pay, Dr. Nelson says.

 

“Some of the surgeons in the community might say, ‘I don’t really like ED call, but I have to keep doing it because of the stipend. I depend on it for my income,’” he says.

 

Even those who wouldn’t mind losing that on-call pay might not be enthusiastic about a move to a surgicalist model because it would bring more general surgeons into the region.

 

Some, Dr. Nelson says, might say, “How do I know that in two years they aren’t stealing my referrals? The new surgical hospitalist is also a potential competitor for referrals I depend on.”

 

And other surgeons might resist simply because they like the professional gratification of emergency surgery work, he says.

 

According to John Maa, MD, who wrote a seminal paper on surgicalists in 2007 based on an early surgicalist model he started at San Mateo Medical Center in California,2 “In a lot of academic centers that didn’t pay call stipend, this was just very simple for them to implement some model of this. … Once you try to send someone to an established group where there was already someone taking call, that became very controversial, and I’ve seen litigation result from that.”

 

Trauma surgeons resisted the model, at least in part, because of semantics: The term “surgical hospitalist” was too similar to “medical hospitalist,” and they worried it might imply a lack of surgical training, says Dr. Maa.

 

For now, the typical assessment of the model that Dr. Nelson hears is: “They’ve thought about it, they may in the future, but no, they don’t have one.”

 

“It’s not growing as fast as the medical hospitalist idea did,” he says. “But it is growing. It’s not going to go away, but it’s still relatively small.”

 

—Thomas R. Collins

 

References

 

 

 

 

1. Nelson J. The surgical surge. The Hospitalist website. Accessed October 25, 2016.
2. Maa J, Carter JT, Gosnell JE, Wachter R, Harris HW. The surgical hospitalist: a new model for emergency surgical care. J Am Coll Surg. 2007 ;205(5):704-711.

 

Collaborate_topper-300x134.jpg

Time was critical. He needed surgery right away to remove his gallbladder. But for that, he needed a surgeon.

“There was a surgeon on call, but the surgeon was not picking up the phone,” Dr. Singh says. “I’m scratching my head. Why is the surgeon not calling back? Where is the surgeon? Did the pager get lost? What if the patient has a bad outcome?”

Eventually, Dr. Singh had to give up on the on-call surgeon, and the patient was flown to a hospital 45 miles away in downtown Sacramento. His surgery had been delayed for almost 12 hours.

The man lived largely due to good luck, Dr. Singh says. The unresponsive surgeon had disciplinary proceedings started against his license but retired rather than face the consequences.

Today, hospitalists at Sutter Amador no longer have to anxiously wait for those responses to emergency pages. It’s one of many hospitals that have turned to a “surgicalist” model, with a surgeon always on hand at the hospital. Surgicalists perform both emergency procedures and procedures that are tied to a hospital admission, without which a patient can’t be discharged. Although it is growing in popularity, the model is still only seen in a small fraction of hospitals.

The model is widely supported by hospitalists because it brings several advantages, mainly a greater availability of the surgeon for consult.

“We don’t have to hunt them down, trying to call their office, trying to see if they’re available to call back,” says Dr. Singh, who is now also the chair of medical staff performance at Sutter Amador and adds that the change has helped with his job satisfaction.

A Clear Delineation

Arrangements between hospitalists and surgicalists vary depending on the hospital, but there typically are clearly delineated criteria on who cares for whom, with the more urgent surgical cases tending to fall under the surgicalists’ care and those with less urgent problems, even though surgery might be involved, tending to go to hospitalists.

When a surgery-related question or the need for actual surgery arises, the model calls for a quick response time from the surgicalist. Hospitalists and surgicalists collaborate on ways to reduce length of stay and prevent readmissions since they share the same institutional goals. Hospitalists are also more in tune with the needs of the surgeons, for instance, not feeding a patient who is going to need quick surgery and not administering blood thinners when a surgery is imminent unless there’s an overriding reason not to do so.

One advantage of this collaboration is that a hospitalist working alongside a surgicalist can get extra surgery-related guidance even when surgery probably isn’t needed, says John Nelson, MD, MHM, a hospitalist at Overlake Medical Center in Bellevue, Wash., a hospitalist management consultant, and a past president of SHM.

“Maybe the opinion of a general surgeon could be useful, but maybe I can get along without it because the general surgeons are busy. It’s going to be hard for them to find time to see this patient, and they’re not going to be very interested in it,” he says. “But if instead I have a surgical hospitalist who’s there all day, it’s much less of a bother for them to come by and take a look at my patient.”

Remaining Challenges

The model is not without its hurdles. When surgicalists are on a 24-hour shift, the patients will see a new one each day, sometimes prompting them to ask, “Who’s my doctor?” Also, complex cases can pose a challenge as they move from one surgicalist to another day to day.

John Maa, MD, who wrote a seminal paper on surgicalists in 2007 based on an early surgicalist model he started at San Mateo Medical Center in California,1 says he is now concerned that the principles he helped make popular—the absorption of surgeons into a system as they work hand in hand with other hospital staff all the time—might be eroding. Some small staffing companies are calling themselves surgicalists, promising fast response times, but are actually locum tenens surgeons under a surgicalist guise, he says.

Properly rolled out, surgicalist programs mean a much better working relationship between hospitalists and surgeons, says Lynette Scherer, MD, FACS, chief medical officer at Surgical Affiliates Management Group in Sacramento. The company, founded in 1996, employs about 200 surgeons, twice as many as three years ago, Dr. Scherer says, but the company declined to share what that amounts to in full-time equivalent positions.

“The hospitalists know all of our algorithms, and they know when to call us,” Dr. Scherer says. “We share the patients on the inpatient side as we need to. We keep the ones that are appropriate for us, and they keep the ones that are appropriate for them.”

The details depend on the hospital, she says.

“Whenever we go to a new site, we sit down with the hospitalist team and say, ‘What do you need here?’ And our admitting grids are different based on what the different needs of the hospitals are.”

To stay on top of complex cases with very sick patients, the medical director rounds with the team nearly every day to help guide that care, Dr. Scherer says.

At Sutter Amador, the arrival of the surgicalist model has helped shorten the length of stay by almost one day for surgery admissions, Dr. Singh says.

Reported outcomes, however, seem to be mixed.

In 2008, Sutter Medical Center in Sacramento switched from a nine-surgeon call panel to four surgeons who covered the acute-care surgery service in 24-hour shifts. Researchers looked at outcomes from 2007, before the new model was adopted, and from the four subsequent years. The results were published in 2014 in the Journal of the American College of Surgeons.2

The total number of operations rose significantly, with 497 performed in 2007 and 640 in 2011. The percentage of cases with complications also fell significantly, from 21% in 2007 to 12% in 2011, with a low of 11% in 2010.

But the mortality rate rose significantly, from 1.4% in 2007 to 2.2% in 2011, with a high of 4.1% in 2008. The study authors note that the mortality rate ultimately fell back to levels not statistically significantly higher than the rate before the service. They suggested the spike could have been due to a greater willingness by the service to treat severely ill patients and due to the “immaturity” of the service in its earlier years. The percentage of cases with a readmission fell from 6.4% in 2007 to 4.7% in 2011, with a low of 3% in 2009, but that change wasn’t quite statistically significant.

“The data’s really bearing out that emergency patients are different in terms of the care they demand,” Dr. Scherer says. “So the patient with alcoholic cirrhosis who presents with a hole in his colon is very different than somebody who presents for an elective colon resection. And you can really reduce complications when you have a team of educated people taking care of these patients.”

Dr. Nelson says adopting the model “just means you’re a smoother operator and you can provide better service to people.” He adds that for any hospital that is getting poor surgical coverage and is paying for it, “it might make sense to consider it.”

Thomas R. Collins is a freelance medical writer based in Florida.

References

1. Maa J, Carter JT, Gosnell JE, Wachter R, Harris HW. The surgical hospitalist: a new model for emergency surgical care. J Am Coll Surg. 2007;205(5):704-711.
2. O’Mara MS, Scherer L, Wisner D, Owens LJ. Sustainability and success of the acute care surgery model in the nontrauma setting. J Am Coll Surg. 2014;219(1):90-98.

 

For a Model That Many Say Makes Sense, Why Not More Growth?

Collaborate-300x167.jpg

Surgicalists and hospitalists say that collaboration between the two groups of specialists brings a smoother process, generates better outcomes, and offers greater job satisfaction.

 

So why hasn’t the surgicalist field exploded? About 10 years ago, that’s what was predicted. In 2007, John Nelson, MD, MHM, a hospitalist at Overlake Medical Center in Bellevue, Wash., a hospitalist management consultant, and a past president of SHM, wrote an article saying the field could be close to a “surge” similar to the medical hospitalist explosion.1

 

It’s not known how many of the nation’s roughly 5,600 hospitals use a surgicalist model. There is no association for surgicalists, who are also sometimes called “surgical hospitalists.”

 

But according to Dr. Nelson’s anecdotal impressions, the number could range from 300 to 800 hospitals, he says. That would mean it is in place only in roughly 10% of U.S. hospitals.

 

Expansion of the field has been slowed by cost and politics.

 

Most hospitals don’t have enough surgeons to pull off a surgicalist program, and adding the right number of surgeons costs money, Dr. Nelson says.

 

And at smaller community hospitals that have used on-call surgeons for years, it’s a thorny issue. Those surgeons often get a call stipend for being on call. If surgeons don’t have a full slate of elective surgeries, they could rely on that on-call pay and resist the adoption of the surgicalist model, which would mean losing that pay, Dr. Nelson says.

 

“Some of the surgeons in the community might say, ‘I don’t really like ED call, but I have to keep doing it because of the stipend. I depend on it for my income,’” he says.

 

Even those who wouldn’t mind losing that on-call pay might not be enthusiastic about a move to a surgicalist model because it would bring more general surgeons into the region.

 

Some, Dr. Nelson says, might say, “How do I know that in two years they aren’t stealing my referrals? The new surgical hospitalist is also a potential competitor for referrals I depend on.”

 

And other surgeons might resist simply because they like the professional gratification of emergency surgery work, he says.

 

According to John Maa, MD, who wrote a seminal paper on surgicalists in 2007 based on an early surgicalist model he started at San Mateo Medical Center in California,2 “In a lot of academic centers that didn’t pay call stipend, this was just very simple for them to implement some model of this. … Once you try to send someone to an established group where there was already someone taking call, that became very controversial, and I’ve seen litigation result from that.”

 

Trauma surgeons resisted the model, at least in part, because of semantics: The term “surgical hospitalist” was too similar to “medical hospitalist,” and they worried it might imply a lack of surgical training, says Dr. Maa.

 

For now, the typical assessment of the model that Dr. Nelson hears is: “They’ve thought about it, they may in the future, but no, they don’t have one.”

 

“It’s not growing as fast as the medical hospitalist idea did,” he says. “But it is growing. It’s not going to go away, but it’s still relatively small.”

 

—Thomas R. Collins

 

References

 

 

 

 

1. Nelson J. The surgical surge. The Hospitalist website. Accessed October 25, 2016.
2. Maa J, Carter JT, Gosnell JE, Wachter R, Harris HW. The surgical hospitalist: a new model for emergency surgical care. J Am Coll Surg. 2007 ;205(5):704-711.

 

MIPS.jpg

While in medical school, I learned about what was then called GRID (gay-related immune deficiency) and we now know as HIV/AIDS. I thought this condition would become so central to practice in nearly any specialty that I decided to try to keep up with all of the literature on it. It wasn’t yet in textbooks, so I thought it would be very important to keep up with all the new research studies and review articles about it.

I kept in my apartment a growing file of articles photocopied and torn out of journals. But I had badly misjudged the enormity of the task, and within a few years, there were far too many articles for me to read or keep up with in any fashion. Before long, HIV medicine became its own specialty, and while it has always been something I, like any hospitalist, need to know something about, I’ve left it to others to be the real HIV experts.

I was naive to have embarked on the quest. What seemed manageable at first became overwhelming very quickly. The same could be said for trying to keep up with new payment models.

New Professional Fee Reimbursement Models

For decades, most physicians could understand the general concept of how their professional activities generated revenue. But it’s gotten a lot more complicated lately.

The growing prevalence of capitation and other managed-care reimbursement models in the ’80s and ’90s might have been when reimbursement complexity began to increase significantly. But while nearly every doctor in the country heard about managed care, for many, it was something happening elsewhere that never made its way to them.

But for hospitalists, I think the arrival of the Physician Quality Reporting System (PQRS, originally Physician Quality Reporting Initiative, or PQRI) marks the swerve in reimbursement complexity. Some years ago I wrote in these pages about the importance of hospitalists understanding PQRS and described key features of the program.

Like HIV/AIDS medicine literature, the breadth and complexity of reimbursement programs from the Centers for Medicare & Medicaid Services (and other payors) seem to have grown logarithmically since PQRS. The still relatively new bundled payment and MACRA-related models are far more complicated than PQRS. And they change often. Calendar milestones come and go with changes in relevant metrics and performance thresholds, etc. Even the terminology changes frequently. Did you know, for example, that under MIPSi “Advancing Care Information” is essentially a new name for EHR Meaningful Use?

Bundled payments and MACRA are only a small portion of new models implemented over the last few years. There are many others, and dedicated effort is required just to keep track of whether each model influences only physicians (and other providers), only hospitals, or both.

Clinicians’ Responsibility for Keeping Up

My thinking about most hospitalists, or doctors in any specialty, keeping up with all of these models has evolved the same way it did with HIV/AIDS. I think it’s pretty clear that it’s folly to expect most clinicians to know more than the broad outlines of these programs.

Payment models are important. Someone needs to know them in detail, but clinicians should reserve brain cells for clinical knowledge base and focus only on the big picture of payment models. Think how well you’ve done learning and keeping up with CPT coding, observation versus inpatient status determinations, and clinical documentation. You probably still aren’t an expert at these things, so is it wise to set about becoming an expert in new payment models?

Instead, most hospitalists should rely on others to keep up with the precise details of these programs. Most commonly that will mean our employer will appoint or hire one or more people, or engage an outside party, to do this.

Don’t Feel Guilty

It’s common to leave a presentation or doctor’s lounge conversation on payment models feeling like you need to study up on the details of this or that payment model since good performance under that model will be important for your paycheck and to remain a viable “player.” And speakers sometimes intentionally or unintentionally enhance your anxiety about this. Maybe they love to show off what they know, and it’s easy for them to think only about their topic and not keep in mind all of the other stuff you need to know.

It’s terrific if someone in your practice is particularly interested in payment models and chooses to stay on top of them. Just make sure that doesn’t come at the expense of keeping up with changes in clinical practice. Most groups won’t have such a person and should rely on others, including SHM, without feeling the smallest bit of guilt.

SHM is advocating on behalf of hospitalists and working diligently to distill the impact MACRA and its various alternative payment frameworks will have on hospital medicine. With webinars, Q&As, and additional online and print resources, SHM will continue to provide digestible updates for hospitalists and their practices.

The End of Small-Group Physician Practice?

While the intent of these programs is to encourage and reward improvements in clinical practice, keeping up with and managing them is a tax that takes resources away from clinical practice. This is an especially difficult burden for small private practices and may prove to be a significant factor in nearly extinguishing them. There are relatively few small private hospitalist groups,ii but all of them should carefully consider how they will keep up with new reimbursement models.

MIPS.jpg

While in medical school, I learned about what was then called GRID (gay-related immune deficiency) and we now know as HIV/AIDS. I thought this condition would become so central to practice in nearly any specialty that I decided to try to keep up with all of the literature on it. It wasn’t yet in textbooks, so I thought it would be very important to keep up with all the new research studies and review articles about it.

I kept in my apartment a growing file of articles photocopied and torn out of journals. But I had badly misjudged the enormity of the task, and within a few years, there were far too many articles for me to read or keep up with in any fashion. Before long, HIV medicine became its own specialty, and while it has always been something I, like any hospitalist, need to know something about, I’ve left it to others to be the real HIV experts.

I was naive to have embarked on the quest. What seemed manageable at first became overwhelming very quickly. The same could be said for trying to keep up with new payment models.

New Professional Fee Reimbursement Models

For decades, most physicians could understand the general concept of how their professional activities generated revenue. But it’s gotten a lot more complicated lately.

The growing prevalence of capitation and other managed-care reimbursement models in the ’80s and ’90s might have been when reimbursement complexity began to increase significantly. But while nearly every doctor in the country heard about managed care, for many, it was something happening elsewhere that never made its way to them.

But for hospitalists, I think the arrival of the Physician Quality Reporting System (PQRS, originally Physician Quality Reporting Initiative, or PQRI) marks the swerve in reimbursement complexity. Some years ago I wrote in these pages about the importance of hospitalists understanding PQRS and described key features of the program.

Like HIV/AIDS medicine literature, the breadth and complexity of reimbursement programs from the Centers for Medicare & Medicaid Services (and other payors) seem to have grown logarithmically since PQRS. The still relatively new bundled payment and MACRA-related models are far more complicated than PQRS. And they change often. Calendar milestones come and go with changes in relevant metrics and performance thresholds, etc. Even the terminology changes frequently. Did you know, for example, that under MIPSi “Advancing Care Information” is essentially a new name for EHR Meaningful Use?

Bundled payments and MACRA are only a small portion of new models implemented over the last few years. There are many others, and dedicated effort is required just to keep track of whether each model influences only physicians (and other providers), only hospitals, or both.

Clinicians’ Responsibility for Keeping Up

My thinking about most hospitalists, or doctors in any specialty, keeping up with all of these models has evolved the same way it did with HIV/AIDS. I think it’s pretty clear that it’s folly to expect most clinicians to know more than the broad outlines of these programs.

Payment models are important. Someone needs to know them in detail, but clinicians should reserve brain cells for clinical knowledge base and focus only on the big picture of payment models. Think how well you’ve done learning and keeping up with CPT coding, observation versus inpatient status determinations, and clinical documentation. You probably still aren’t an expert at these things, so is it wise to set about becoming an expert in new payment models?

Instead, most hospitalists should rely on others to keep up with the precise details of these programs. Most commonly that will mean our employer will appoint or hire one or more people, or engage an outside party, to do this.

Don’t Feel Guilty

It’s common to leave a presentation or doctor’s lounge conversation on payment models feeling like you need to study up on the details of this or that payment model since good performance under that model will be important for your paycheck and to remain a viable “player.” And speakers sometimes intentionally or unintentionally enhance your anxiety about this. Maybe they love to show off what they know, and it’s easy for them to think only about their topic and not keep in mind all of the other stuff you need to know.

It’s terrific if someone in your practice is particularly interested in payment models and chooses to stay on top of them. Just make sure that doesn’t come at the expense of keeping up with changes in clinical practice. Most groups won’t have such a person and should rely on others, including SHM, without feeling the smallest bit of guilt.

SHM is advocating on behalf of hospitalists and working diligently to distill the impact MACRA and its various alternative payment frameworks will have on hospital medicine. With webinars, Q&As, and additional online and print resources, SHM will continue to provide digestible updates for hospitalists and their practices.

The End of Small-Group Physician Practice?

While the intent of these programs is to encourage and reward improvements in clinical practice, keeping up with and managing them is a tax that takes resources away from clinical practice. This is an especially difficult burden for small private practices and may prove to be a significant factor in nearly extinguishing them. There are relatively few small private hospitalist groups,ii but all of them should carefully consider how they will keep up with new reimbursement models.

MIPS.jpg

While in medical school, I learned about what was then called GRID (gay-related immune deficiency) and we now know as HIV/AIDS. I thought this condition would become so central to practice in nearly any specialty that I decided to try to keep up with all of the literature on it. It wasn’t yet in textbooks, so I thought it would be very important to keep up with all the new research studies and review articles about it.

I kept in my apartment a growing file of articles photocopied and torn out of journals. But I had badly misjudged the enormity of the task, and within a few years, there were far too many articles for me to read or keep up with in any fashion. Before long, HIV medicine became its own specialty, and while it has always been something I, like any hospitalist, need to know something about, I’ve left it to others to be the real HIV experts.

I was naive to have embarked on the quest. What seemed manageable at first became overwhelming very quickly. The same could be said for trying to keep up with new payment models.

New Professional Fee Reimbursement Models

For decades, most physicians could understand the general concept of how their professional activities generated revenue. But it’s gotten a lot more complicated lately.

The growing prevalence of capitation and other managed-care reimbursement models in the ’80s and ’90s might have been when reimbursement complexity began to increase significantly. But while nearly every doctor in the country heard about managed care, for many, it was something happening elsewhere that never made its way to them.

But for hospitalists, I think the arrival of the Physician Quality Reporting System (PQRS, originally Physician Quality Reporting Initiative, or PQRI) marks the swerve in reimbursement complexity. Some years ago I wrote in these pages about the importance of hospitalists understanding PQRS and described key features of the program.

Like HIV/AIDS medicine literature, the breadth and complexity of reimbursement programs from the Centers for Medicare & Medicaid Services (and other payors) seem to have grown logarithmically since PQRS. The still relatively new bundled payment and MACRA-related models are far more complicated than PQRS. And they change often. Calendar milestones come and go with changes in relevant metrics and performance thresholds, etc. Even the terminology changes frequently. Did you know, for example, that under MIPSi “Advancing Care Information” is essentially a new name for EHR Meaningful Use?

Bundled payments and MACRA are only a small portion of new models implemented over the last few years. There are many others, and dedicated effort is required just to keep track of whether each model influences only physicians (and other providers), only hospitals, or both.

Clinicians’ Responsibility for Keeping Up

My thinking about most hospitalists, or doctors in any specialty, keeping up with all of these models has evolved the same way it did with HIV/AIDS. I think it’s pretty clear that it’s folly to expect most clinicians to know more than the broad outlines of these programs.

Payment models are important. Someone needs to know them in detail, but clinicians should reserve brain cells for clinical knowledge base and focus only on the big picture of payment models. Think how well you’ve done learning and keeping up with CPT coding, observation versus inpatient status determinations, and clinical documentation. You probably still aren’t an expert at these things, so is it wise to set about becoming an expert in new payment models?

Instead, most hospitalists should rely on others to keep up with the precise details of these programs. Most commonly that will mean our employer will appoint or hire one or more people, or engage an outside party, to do this.

Don’t Feel Guilty

It’s common to leave a presentation or doctor’s lounge conversation on payment models feeling like you need to study up on the details of this or that payment model since good performance under that model will be important for your paycheck and to remain a viable “player.” And speakers sometimes intentionally or unintentionally enhance your anxiety about this. Maybe they love to show off what they know, and it’s easy for them to think only about their topic and not keep in mind all of the other stuff you need to know.

It’s terrific if someone in your practice is particularly interested in payment models and chooses to stay on top of them. Just make sure that doesn’t come at the expense of keeping up with changes in clinical practice. Most groups won’t have such a person and should rely on others, including SHM, without feeling the smallest bit of guilt.

SHM is advocating on behalf of hospitalists and working diligently to distill the impact MACRA and its various alternative payment frameworks will have on hospital medicine. With webinars, Q&As, and additional online and print resources, SHM will continue to provide digestible updates for hospitalists and their practices.

The End of Small-Group Physician Practice?

While the intent of these programs is to encourage and reward improvements in clinical practice, keeping up with and managing them is a tax that takes resources away from clinical practice. This is an especially difficult burden for small private practices and may prove to be a significant factor in nearly extinguishing them. There are relatively few small private hospitalist groups,ii but all of them should carefully consider how they will keep up with new reimbursement models.

The very nature of America’s hospitals is changing. At one time in the not too distant past, hospitals could charge “cost-plus,” tacking on a profit above their actual expenses. Hospitals generated most of their revenue from procedures on horizontal patients with long stays in house. Physicians viewed the hospital as a swap meet, with each physician having an autonomous booth and not caring much what went on elsewhere in the facility.

Wellikson.jpg

Today, hospitals are under tough cost pressures, with changes in payments from Medicare, Medicaid, and private insurers. Many hospitals now get more than 50% of their revenue from vertical patients from what was previously considered the outpatient segment of healthcare. Physicians have moved from being revenue providers to being potential competitors or, in the best-case scenario, active partners and teammates with their hospital.

And hospitalists are right in the middle of this changing dynamic.

Because the hospital and the healthcare system are rapidly evolving, it should not surprise anyone that the very nature of hospital medicine is changing rapidly. Some would say too rapidly.

At a strategic planning session I led almost 20 years when the National Association of Inpatient Physicians (NAIP), the precursor to SHM, was just starting out, the prevailing consensus was that hospitalists might take over inpatient services for 50% of family physicians and 25% of internists. Obviously, the penetrance of hospital medicine into almost every hospital in the U.S. and the transfer of the acute-care management of most of the inpatients previously handled by family physicians and internists are just part of the growth in hospital medicine.

Even more innovative and disruptive has been the almost relentless scope creep as hospitalists now actively comanage many surgical and subspecialty patients. As the neurologists have given up most of their acute-care duties, hospitalists are now the de facto inpatient neurologists. Hospitalists also now manage the majority of inpatient senior citizens and have become the inpatient geriatricians without the formal training. In-hospital procedures (e.g., central line, ultrasound, intubation, etc.) previously done by surgeons or critical-care or primary-care physicians now are done by default by hospitalists.

But these expansions of hospitalist scope pale in comparison with the continued broadening of responsibilities that continues to stretch even the most well-trained hospitalists beyond their training or capacity.

Palliative Care

There are not enough trained and certified palliative-care physicians to allocate one of them to each hospital. Yet treatment and survival of cancer and other serious diseases as well as the aging of the population demand that hospitals be prepared to provide the most compassionate and up-to-date palliative approach possible. Palliative care is more than just end-of-life care. It involves hospice as well as pain and symptom management. It is aimed at improvement in quality of life and is used in the presence or absence of curative strategies.

Hospitalists have been thrust into the breach and are being asked more and more to provide palliative-care services. SHM has recognized the gap between the increasing demand on hospitalists and the inadequate training we all receive in residency. That’s why we’re working with palliative-care societies and experts to develop educational and training initiatives to close these gaps.

Critical Care

Our hospitals are becoming increasingly critical care intensive as simpler cases are treated as outpatients and only the very ill come to be admitted to hospital. This has created an increasing demand for more physicians trained in critical care at a time when older intensivists are retiring or going into sleep medicine and younger physicians, who might have chosen a career in critical care, are becoming hospitalists. The shortage of trained critical-care providers is reaching a crisis point in many American hospitals, with hospitalists being asked to be the critical-care extender.

Over the years, SHM has partnered with the Society of Critical Care Medicine (SCCM) to propose innovative training options (e.g., one-year critical-care fellowship obtained midcareer), but the boards and others in the critical-care establishment have not been supportive. SHM plans to continue to work with open-minded critical-care thought leaders to develop and promote additional training in critical-care skills for hospitalists, who continue to be thrust into this role at their local hospitals.

Post-Acute Care

For many of hospital medicine’s larger national and regional companies, the management of the care in the post-acute-care space of skilled nursing facilities, long-term acute-care facilities, and the like has been the fastest-growing part of their business in the last few years. Skills and process improvement that have helped improve effectiveness and efficiency in our nation’s hospitals are being applied to post-acute-care facilities. Once again, hospitalists are finding themselves being asked to perform at a high level in environments that are new to them.

In this arena, the hospitalist’s ability to impact care is evident in managing transfers and information as well as providing leadership in patient safety. Determining the correct postdischarge disposition is the largest driver of costs in the acute-care and post-acute-care setting. Hospitalists and the hospital medicine organizations are providing key direction.

Preoperative Care

Many may not know that bundled into the anesthesia fee is the funding to cover pre-op assessment and post-op management as well as the intraoperative oversight of anesthesia and vital signs for the surgical patient. In reality, the role of perioperative management has fallen for many years initially to internists and more recently to hospitalists.

Hospitalists have been active in optimizing the patient for surgery and medically clearing the patient. Hospitalists work with surgeons to manage comorbidities; prevent complications, such as infections, DVTs, and pulmonary emboli; and help with pain management and transitions to discharge from the hospital. Hospitalists have worked with surgeons to create efficiencies like reduced length of stay and prevention of readmission as well as to help the patient return to function postoperatively.

SHM’s Perioperative Care Work Group is publishing a set of Perioperative Care Guidelines in the Journal of Hospital Medicine. SHM is actively working with the American College of Surgeons on a teamwork approach to the surgical patient as well as innovative alternative payment models with bundling at the level of the individual surgical patients, which the Centers for Medicare & Medicaid Services is currently evaluating.

Working through a Dilemma

The one thing all these expansions of scope have in common is that there is an unfilled need and hospitalists are being thrust onto the front lines, thrown into the deep water without the benefit of thorough training that should be requisite with the responsibilities. This is not a turf battle where we have stolen someone’s cheese. This is pure and simple where need is trumping training, and if not done properly, the patient may suffer, and hospitalists will bear the uncomfortable feeling of being asked to do more than we should.

SHM and our national hospitalist thought leaders see this dilemma. We are working diligently with other professional medical societies and key specialty educators and thought leaders to create training pathways to support the expansion of the hospitalist’s scope. This is building the boat while you are going down a rapidly moving river. It is not easy stuff. But our patients and our hospitalists demand this, and SHM will step up. Help is on the way.

Larry Wellikson, MD, MHM, is CEO of the Society of Hospital Medicine.

The very nature of America’s hospitals is changing. At one time in the not too distant past, hospitals could charge “cost-plus,” tacking on a profit above their actual expenses. Hospitals generated most of their revenue from procedures on horizontal patients with long stays in house. Physicians viewed the hospital as a swap meet, with each physician having an autonomous booth and not caring much what went on elsewhere in the facility.

Wellikson.jpg

Today, hospitals are under tough cost pressures, with changes in payments from Medicare, Medicaid, and private insurers. Many hospitals now get more than 50% of their revenue from vertical patients from what was previously considered the outpatient segment of healthcare. Physicians have moved from being revenue providers to being potential competitors or, in the best-case scenario, active partners and teammates with their hospital.

And hospitalists are right in the middle of this changing dynamic.

Because the hospital and the healthcare system are rapidly evolving, it should not surprise anyone that the very nature of hospital medicine is changing rapidly. Some would say too rapidly.

At a strategic planning session I led almost 20 years when the National Association of Inpatient Physicians (NAIP), the precursor to SHM, was just starting out, the prevailing consensus was that hospitalists might take over inpatient services for 50% of family physicians and 25% of internists. Obviously, the penetrance of hospital medicine into almost every hospital in the U.S. and the transfer of the acute-care management of most of the inpatients previously handled by family physicians and internists are just part of the growth in hospital medicine.

Even more innovative and disruptive has been the almost relentless scope creep as hospitalists now actively comanage many surgical and subspecialty patients. As the neurologists have given up most of their acute-care duties, hospitalists are now the de facto inpatient neurologists. Hospitalists also now manage the majority of inpatient senior citizens and have become the inpatient geriatricians without the formal training. In-hospital procedures (e.g., central line, ultrasound, intubation, etc.) previously done by surgeons or critical-care or primary-care physicians now are done by default by hospitalists.

But these expansions of hospitalist scope pale in comparison with the continued broadening of responsibilities that continues to stretch even the most well-trained hospitalists beyond their training or capacity.

Palliative Care

There are not enough trained and certified palliative-care physicians to allocate one of them to each hospital. Yet treatment and survival of cancer and other serious diseases as well as the aging of the population demand that hospitals be prepared to provide the most compassionate and up-to-date palliative approach possible. Palliative care is more than just end-of-life care. It involves hospice as well as pain and symptom management. It is aimed at improvement in quality of life and is used in the presence or absence of curative strategies.

Hospitalists have been thrust into the breach and are being asked more and more to provide palliative-care services. SHM has recognized the gap between the increasing demand on hospitalists and the inadequate training we all receive in residency. That’s why we’re working with palliative-care societies and experts to develop educational and training initiatives to close these gaps.

Critical Care

Our hospitals are becoming increasingly critical care intensive as simpler cases are treated as outpatients and only the very ill come to be admitted to hospital. This has created an increasing demand for more physicians trained in critical care at a time when older intensivists are retiring or going into sleep medicine and younger physicians, who might have chosen a career in critical care, are becoming hospitalists. The shortage of trained critical-care providers is reaching a crisis point in many American hospitals, with hospitalists being asked to be the critical-care extender.

Over the years, SHM has partnered with the Society of Critical Care Medicine (SCCM) to propose innovative training options (e.g., one-year critical-care fellowship obtained midcareer), but the boards and others in the critical-care establishment have not been supportive. SHM plans to continue to work with open-minded critical-care thought leaders to develop and promote additional training in critical-care skills for hospitalists, who continue to be thrust into this role at their local hospitals.

Post-Acute Care

For many of hospital medicine’s larger national and regional companies, the management of the care in the post-acute-care space of skilled nursing facilities, long-term acute-care facilities, and the like has been the fastest-growing part of their business in the last few years. Skills and process improvement that have helped improve effectiveness and efficiency in our nation’s hospitals are being applied to post-acute-care facilities. Once again, hospitalists are finding themselves being asked to perform at a high level in environments that are new to them.

In this arena, the hospitalist’s ability to impact care is evident in managing transfers and information as well as providing leadership in patient safety. Determining the correct postdischarge disposition is the largest driver of costs in the acute-care and post-acute-care setting. Hospitalists and the hospital medicine organizations are providing key direction.

Preoperative Care

Many may not know that bundled into the anesthesia fee is the funding to cover pre-op assessment and post-op management as well as the intraoperative oversight of anesthesia and vital signs for the surgical patient. In reality, the role of perioperative management has fallen for many years initially to internists and more recently to hospitalists.

Hospitalists have been active in optimizing the patient for surgery and medically clearing the patient. Hospitalists work with surgeons to manage comorbidities; prevent complications, such as infections, DVTs, and pulmonary emboli; and help with pain management and transitions to discharge from the hospital. Hospitalists have worked with surgeons to create efficiencies like reduced length of stay and prevention of readmission as well as to help the patient return to function postoperatively.

SHM’s Perioperative Care Work Group is publishing a set of Perioperative Care Guidelines in the Journal of Hospital Medicine. SHM is actively working with the American College of Surgeons on a teamwork approach to the surgical patient as well as innovative alternative payment models with bundling at the level of the individual surgical patients, which the Centers for Medicare & Medicaid Services is currently evaluating.

Working through a Dilemma

The one thing all these expansions of scope have in common is that there is an unfilled need and hospitalists are being thrust onto the front lines, thrown into the deep water without the benefit of thorough training that should be requisite with the responsibilities. This is not a turf battle where we have stolen someone’s cheese. This is pure and simple where need is trumping training, and if not done properly, the patient may suffer, and hospitalists will bear the uncomfortable feeling of being asked to do more than we should.

SHM and our national hospitalist thought leaders see this dilemma. We are working diligently with other professional medical societies and key specialty educators and thought leaders to create training pathways to support the expansion of the hospitalist’s scope. This is building the boat while you are going down a rapidly moving river. It is not easy stuff. But our patients and our hospitalists demand this, and SHM will step up. Help is on the way.

Larry Wellikson, MD, MHM, is CEO of the Society of Hospital Medicine.

The very nature of America’s hospitals is changing. At one time in the not too distant past, hospitals could charge “cost-plus,” tacking on a profit above their actual expenses. Hospitals generated most of their revenue from procedures on horizontal patients with long stays in house. Physicians viewed the hospital as a swap meet, with each physician having an autonomous booth and not caring much what went on elsewhere in the facility.

Wellikson.jpg

Today, hospitals are under tough cost pressures, with changes in payments from Medicare, Medicaid, and private insurers. Many hospitals now get more than 50% of their revenue from vertical patients from what was previously considered the outpatient segment of healthcare. Physicians have moved from being revenue providers to being potential competitors or, in the best-case scenario, active partners and teammates with their hospital.

And hospitalists are right in the middle of this changing dynamic.

Because the hospital and the healthcare system are rapidly evolving, it should not surprise anyone that the very nature of hospital medicine is changing rapidly. Some would say too rapidly.

At a strategic planning session I led almost 20 years when the National Association of Inpatient Physicians (NAIP), the precursor to SHM, was just starting out, the prevailing consensus was that hospitalists might take over inpatient services for 50% of family physicians and 25% of internists. Obviously, the penetrance of hospital medicine into almost every hospital in the U.S. and the transfer of the acute-care management of most of the inpatients previously handled by family physicians and internists are just part of the growth in hospital medicine.

Even more innovative and disruptive has been the almost relentless scope creep as hospitalists now actively comanage many surgical and subspecialty patients. As the neurologists have given up most of their acute-care duties, hospitalists are now the de facto inpatient neurologists. Hospitalists also now manage the majority of inpatient senior citizens and have become the inpatient geriatricians without the formal training. In-hospital procedures (e.g., central line, ultrasound, intubation, etc.) previously done by surgeons or critical-care or primary-care physicians now are done by default by hospitalists.

But these expansions of hospitalist scope pale in comparison with the continued broadening of responsibilities that continues to stretch even the most well-trained hospitalists beyond their training or capacity.

Palliative Care

There are not enough trained and certified palliative-care physicians to allocate one of them to each hospital. Yet treatment and survival of cancer and other serious diseases as well as the aging of the population demand that hospitals be prepared to provide the most compassionate and up-to-date palliative approach possible. Palliative care is more than just end-of-life care. It involves hospice as well as pain and symptom management. It is aimed at improvement in quality of life and is used in the presence or absence of curative strategies.

Hospitalists have been thrust into the breach and are being asked more and more to provide palliative-care services. SHM has recognized the gap between the increasing demand on hospitalists and the inadequate training we all receive in residency. That’s why we’re working with palliative-care societies and experts to develop educational and training initiatives to close these gaps.

Critical Care

Our hospitals are becoming increasingly critical care intensive as simpler cases are treated as outpatients and only the very ill come to be admitted to hospital. This has created an increasing demand for more physicians trained in critical care at a time when older intensivists are retiring or going into sleep medicine and younger physicians, who might have chosen a career in critical care, are becoming hospitalists. The shortage of trained critical-care providers is reaching a crisis point in many American hospitals, with hospitalists being asked to be the critical-care extender.

Over the years, SHM has partnered with the Society of Critical Care Medicine (SCCM) to propose innovative training options (e.g., one-year critical-care fellowship obtained midcareer), but the boards and others in the critical-care establishment have not been supportive. SHM plans to continue to work with open-minded critical-care thought leaders to develop and promote additional training in critical-care skills for hospitalists, who continue to be thrust into this role at their local hospitals.

Post-Acute Care

For many of hospital medicine’s larger national and regional companies, the management of the care in the post-acute-care space of skilled nursing facilities, long-term acute-care facilities, and the like has been the fastest-growing part of their business in the last few years. Skills and process improvement that have helped improve effectiveness and efficiency in our nation’s hospitals are being applied to post-acute-care facilities. Once again, hospitalists are finding themselves being asked to perform at a high level in environments that are new to them.

In this arena, the hospitalist’s ability to impact care is evident in managing transfers and information as well as providing leadership in patient safety. Determining the correct postdischarge disposition is the largest driver of costs in the acute-care and post-acute-care setting. Hospitalists and the hospital medicine organizations are providing key direction.

Preoperative Care

Many may not know that bundled into the anesthesia fee is the funding to cover pre-op assessment and post-op management as well as the intraoperative oversight of anesthesia and vital signs for the surgical patient. In reality, the role of perioperative management has fallen for many years initially to internists and more recently to hospitalists.

Hospitalists have been active in optimizing the patient for surgery and medically clearing the patient. Hospitalists work with surgeons to manage comorbidities; prevent complications, such as infections, DVTs, and pulmonary emboli; and help with pain management and transitions to discharge from the hospital. Hospitalists have worked with surgeons to create efficiencies like reduced length of stay and prevention of readmission as well as to help the patient return to function postoperatively.

SHM’s Perioperative Care Work Group is publishing a set of Perioperative Care Guidelines in the Journal of Hospital Medicine. SHM is actively working with the American College of Surgeons on a teamwork approach to the surgical patient as well as innovative alternative payment models with bundling at the level of the individual surgical patients, which the Centers for Medicare & Medicaid Services is currently evaluating.

Working through a Dilemma

The one thing all these expansions of scope have in common is that there is an unfilled need and hospitalists are being thrust onto the front lines, thrown into the deep water without the benefit of thorough training that should be requisite with the responsibilities. This is not a turf battle where we have stolen someone’s cheese. This is pure and simple where need is trumping training, and if not done properly, the patient may suffer, and hospitalists will bear the uncomfortable feeling of being asked to do more than we should.

SHM and our national hospitalist thought leaders see this dilemma. We are working diligently with other professional medical societies and key specialty educators and thought leaders to create training pathways to support the expansion of the hospitalist’s scope. This is building the boat while you are going down a rapidly moving river. It is not easy stuff. But our patients and our hospitalists demand this, and SHM will step up. Help is on the way.

Larry Wellikson, MD, MHM, is CEO of the Society of Hospital Medicine.

At Bay Area Medical Center in Marinette, Wis., the time had come to start talking about an elderly woman’s end-of-life care.

Difficult.jpg

Her hospitalist thought that those discussions should take place with the patient present, but the woman’s family felt otherwise and made this known to the hospitalist, who stood his ground.

Eventually, the family told a nurse that they wanted to fire the physician. But the only other hospitalist on shift didn’t want to take the patient.

As case managers and hospital administrators tried to wrap their heads around the situation, it became clear: They didn’t really know what to do.

Could the patient fire a physician? Was the second physician obligated to take what he knew from the outset would be a difficult case? What if nobody wanted to take care of this patient?

“There was no black-and-white to this,” says Robin Dequaine, director of medical staff services at the hospital, who was involved in the case.

Some “difficult patient” scenarios are fairly straightforward. A patient is violent? Enact your security measures. An addict wants narcotics? Don’t give them.

But there are other situations that enter murkier territory: What if a patient makes inappropriate or abusive remarks? How much should a hospitalist put up with? What if a patient’s request for treatment might not be the hospitalist’s first choice but could be seen as reasonable? Is the patient’s request accommodated? And what about those firings?

Hospitalists, administrators, and patient advocates say these tense situations with patients involving firings, or would-be firings, while not a daily occurrence, are actually fairly common.¹ Getting to the root of the problem is essential. And as with so much in healthcare, good communication is the absolute crux of it all, they say.

“These are almost all communication issues,” says John Bulger, DO, MBA, FACP, SFHM, chief medical officer at Geisinger Health Plan in Danville, Pa., who has had a long career as a hospitalist and administrator handling and trying to resolve these situations. “They’re all [about] the way the hospitalist and the team is relating to the patient.”

Jackie O’Doherty, a private patient advocate who practices in New Jersey and New York across a gamut of hospital types, has a similar view.

“For me, the biggest problem, period, against hospitalists, doctors, everybody in the hospital, is communication—the lack of it,” she says. “Their communication skills are really poor.”

Patients accustomed to choice in the outpatient setting might not handle it well when they don’t have an established relationship with their hospitalist, says John Vazquez, MD, associate director for the Emory University School of Medicine’s Division of Hospital Medicine in Atlanta.

But the system, he says, “does not allow for, unfortunately, that much patient choice.”

End-of-life Discussion at a Small Hospital

Dequaine says the staff at Bay Area Medical Center was caught flat-footed with the case of the family not wanting end-of-life care discussed with their elderly mother.

“The doctor felt very confident that he was in a position that he could have that discussion in front of the patient,” she says.

At the 99-bed center, there were just two hospitalists, who were also employees of the hospital, on shift. And the communication channels involving the medical director of hospital medicine, a case manager, and the chief nursing executive were not well-controlled, Dequaine says.

“It didn’t go up the ladder correctly,” she says. “Too many people got involved, not knowing that somebody else was already involved.”

The second hospitalist at first said he would take the case, but later Dequaine learned that he changed his mind.

“He knew his care would be no different, and we were very, very busy, so they both had a high census already,” Dequaine says.

A third physician reluctantly took over until the issue subsided. And the family still brings the patient to the hospital for care.

Ultimately, the center adopted a new policy that doesn’t guarantee a patient a new doctor, only that the hospital will have frank discussions to try to resolve the issue and then try to arrange for a transfer if the situation can’t be resolved.

“The goal is not to get rid of the patient or to force them to keep the provider,” Dequaine says. “The goal is to resolve it in a mutually satisfactory way.”

A Patient Demands a Contraindicated Medication

A middle-aged woman with Crohn’s disease was hospitalized at Emory with an infection. The woman, worried about her disease flaring, wanted to keep getting her immunosuppressant, but the hospitalist suspended it because she needed to fight off the infection. The patient became upset. At a point when the hospitalist wasn’t in the room, the woman insisted to a nurse that she get her medication. The nurse called a doctor who was on call, but that doctor wouldn’t give the immunosuppressant either.

The patient began to think she wasn’t being listened to. Dr. Vazquez went in to see the patient and apologized for the misunderstanding.

“I went back into the room and explained here’s why I’m doing it: ‘I totally understand where you’re coming from; you don’t want your disease to be out of control. I appreciate that. What I’m worried about is killing you if we give you an immunosuppressant at the wrong time,’” Dr. Vazquez says.

Dr. Vazquez has underscored at his center how important it is for the physicians to be consulted and go back into the room when patients want to fire them, even though the expedient step might be to just bring in a new doctor. At previous centers, he says, it wouldn’t be unusual for the director to get a call from a nurse, who would say, “Yeah, they want to fire this physician, so let me know who’s going to see the patient.”

But simply switching doctors, he cautions, is like saying, “I agree with you we have incompetent doctors here, so we’re going to remove that doctor and I’m going to put a doctor on who actually knows what they’re doing.”

When doctors try to resolve the issues, good things tend to happen, Dr. Vazquez says.

“There’s generally a large amount of appreciation that someone comes back into the room and says, ‘We want to do this right.’”

Of course, there are times when, if tension remains after such discussions, patient care might be better served by a swap. At large centers, that might be possible, Dr. Bulger of Geisinger says.

“If the patient doesn’t tell the doctor something because he or she doesn’t like the doctor, then the doctor’s decisions are made on partial information—that’s the issue,” he says.

O’Doherty, the patient advocate, says that if patients frustrated with poor communication actually fired physicians as often as they would like, there would be more firings.

“Patients don’t like firing the doctors because they don’t want to be the patient who everybody doesn’t like,” she says. “They’re afraid that if they argue or disagree or ask too many questions, that they’re not going to get the care they need. And the family is afraid of that as well, especially in the older population. They think doctors are like God, they hold your life in their hands. So they don’t want to really question doctors.”

She says patients don’t necessarily need a particular finesse or expert bedside manner. In many cases, she says, it’s “just giving the information.”

A Patient Demands Pain Medication

Martin Austin, MD, SFHM, recently cared for a patient with chronic headaches. The patient asked for higher doses of pain medication, insinuating that she might turn to heroin if denied.

“I was trying to make the argument that I kind of disagreed with that but, ‘I respect your opinion,’” says Dr. Austin, medical director at the Gwinnett Medical Center Inpatient Medical Group in Georgia. “We came to a negotiation about how long we would use narcotics acutely until her other acute issues were over, but then we would try to get her away from narcotics.”

A good approach, he says, is to “outline to the patient why you’re doing what you’re doing. We try not to pick battles and give the patient some degree of control if it’s not contraindicated.”

But sometimes there can be no negotiating these kinds of requests, he says.

“Sometimes we’ll just say, ‘Look, it’s not a good thing for you to continue on this medication. You’re showing side effects, you’re sedated. … We think that the risk outweighs the benefit in this case,” he says.

A Patient Feels Left in the Dark

One patient at Emory wanted to fire his hospitalist because he wouldn’t tell him what was on his CT scan.

Dr. Vazquez held a discussion between the patient and the doctor. If not for the seriousness of the patient’s condition (he had tremors and neurological concerns), it would have been almost comical.

The patient had asked, “What’s on my scan?” The patient interpreted the doctor’s response, “It’s negative,” to mean that he wasn’t being told something about the scan.

Dr. Vazquez realized that the patient had felt dismissed.

“He was a sick gentleman,” Dr. Vazquez says. “And what he wanted to hear was, ‘Look, the great news is your CT scan looks good. There’s not an anatomical abnormality. It’s not a tumor. It’s not a big bleed. … That’s great news, but I, as a physician, I am concerned about you. You’re sick. We’ve got to really figure out what’s going on with you.’… He wanted a pat on the back, and that’s all it took.”

After that, the patient no longer wanted to fire the hospitalist.

Verbal Abuse

One case at Gwinnett involves a hospitalist who was quite shy and easily intimidated and was not comfortable with a patient.

“They were struggling with a patient who was very difficult and very angry and a little abusive,” Dr. Austin says. “This doctor was really suffering psychically from this whole thing, and we switched.” Another doctor, who would not be thrown by the situation, took over the case. And Dr. Austin says he had great respect for the first doctor’s request to hand over the case.

“They needed a different personality,” he says. “It worked out beautifully. The patient and the doctor got along much better. The doctor was firm with the patient but respectful, and the other doctor felt relieved. And the [original] doctor is great with patients who need a lot of emotional support, probably better than the other doctor. So that worked out really well.”

It might be a challenge during a busy day, but it’s helpful to step back and see the situation as a whole, Dr. Bulger says. Sometimes, hospitalists can get flustered when patients are not acting rationally. But there’s usually a good reason they’re acting that way, he says.

“The patient is sick. And if it’s the patient’s family, they’re stressed by the fact that the patient’s sick. So you really need to take a step back and understand that.” TH

Thomas R. Collins is a freelance writer based in West Palm Beach, Fla.

Reference

1. Centor R. Can I fire my hospitalist? SGIM Forum. 32(5):112-13.

Physician Communication Often Abysmal, Patient Advocate Says

communication2.jpg

Hospitalists, no doubt, encounter many challenging patient situations that have a lot to do with inappropriate behavior on the part of patients.

But from patient advocate Jackie O’Doherty’s point of view, many tough situations involving the patient-physician dynamic evolve from hospitalists who seem almost incapable of communicating well.

“I’m not saying they’re bad; their communication is not as great as it should be,” she says. “It has to be just giving the information. People get really frustrated when they’re in the hospital and they don’t know what’s going on.”

O’Doherty, a private patient advocate who represents patients in their efforts to get good healthcare at hospitals in New York and New Jersey, says sometimes the communication gaps are staggering.

For example, she represents a patient who had a heart attack and was transferred to a larger center to have open-heart surgery. The surgery went well, but when a Swan catheter was pulled, a plaque was hit and the man had a stroke. Suddenly, his care became a lot more complicated.

A series of specialists came in to see him. One told him that he would be sitting at home at the dinner table and watching football on Thanksgiving. Others gave him a far less rosy outlook. Some told him to drink water; others said not to.

The patient became frustrated, and O’Doherty demanded a meeting to sort out the mess. Eventually, all five of the patient’s doctors, a social worker, and the director of nursing met.

If the hospitalist is supposed to be a unifying force, that hadn’t happened in that case, O’Doherty says. Such cases, while not the norm, are frequent enough to cause concern.

“They’re the quarterbacks, supposedly, of the whole hospital experience, and I haven’t really seen that happen,” she says.

In another case, a patient getting suspect care—O’Doherty had pictures of the patient with a tracheostomy almost falling out of the bed—got a good response.

“They want to do whatever they can to make this work, and that’s a great response,” she says. “The question is, would that have been the response had I not been there?”

She understands the pressures that hospitalists can feel. And she says the system in which the hospitalist is working can matter as much as the hospitalist’s own communication skills.

“If you have a hospital that’s crazy busy, understaffed, and there’s not time,” she says, “that’s what goes first is the communication.”

At Bay Area Medical Center in Marinette, Wis., the time had come to start talking about an elderly woman’s end-of-life care.

Difficult.jpg

Her hospitalist thought that those discussions should take place with the patient present, but the woman’s family felt otherwise and made this known to the hospitalist, who stood his ground.

Eventually, the family told a nurse that they wanted to fire the physician. But the only other hospitalist on shift didn’t want to take the patient.

As case managers and hospital administrators tried to wrap their heads around the situation, it became clear: They didn’t really know what to do.

Could the patient fire a physician? Was the second physician obligated to take what he knew from the outset would be a difficult case? What if nobody wanted to take care of this patient?

“There was no black-and-white to this,” says Robin Dequaine, director of medical staff services at the hospital, who was involved in the case.

Some “difficult patient” scenarios are fairly straightforward. A patient is violent? Enact your security measures. An addict wants narcotics? Don’t give them.

But there are other situations that enter murkier territory: What if a patient makes inappropriate or abusive remarks? How much should a hospitalist put up with? What if a patient’s request for treatment might not be the hospitalist’s first choice but could be seen as reasonable? Is the patient’s request accommodated? And what about those firings?

Hospitalists, administrators, and patient advocates say these tense situations with patients involving firings, or would-be firings, while not a daily occurrence, are actually fairly common.¹ Getting to the root of the problem is essential. And as with so much in healthcare, good communication is the absolute crux of it all, they say.

“These are almost all communication issues,” says John Bulger, DO, MBA, FACP, SFHM, chief medical officer at Geisinger Health Plan in Danville, Pa., who has had a long career as a hospitalist and administrator handling and trying to resolve these situations. “They’re all [about] the way the hospitalist and the team is relating to the patient.”

Jackie O’Doherty, a private patient advocate who practices in New Jersey and New York across a gamut of hospital types, has a similar view.

“For me, the biggest problem, period, against hospitalists, doctors, everybody in the hospital, is communication—the lack of it,” she says. “Their communication skills are really poor.”

Patients accustomed to choice in the outpatient setting might not handle it well when they don’t have an established relationship with their hospitalist, says John Vazquez, MD, associate director for the Emory University School of Medicine’s Division of Hospital Medicine in Atlanta.

But the system, he says, “does not allow for, unfortunately, that much patient choice.”

End-of-life Discussion at a Small Hospital

Dequaine says the staff at Bay Area Medical Center was caught flat-footed with the case of the family not wanting end-of-life care discussed with their elderly mother.

“The doctor felt very confident that he was in a position that he could have that discussion in front of the patient,” she says.

At the 99-bed center, there were just two hospitalists, who were also employees of the hospital, on shift. And the communication channels involving the medical director of hospital medicine, a case manager, and the chief nursing executive were not well-controlled, Dequaine says.

“It didn’t go up the ladder correctly,” she says. “Too many people got involved, not knowing that somebody else was already involved.”

The second hospitalist at first said he would take the case, but later Dequaine learned that he changed his mind.

“He knew his care would be no different, and we were very, very busy, so they both had a high census already,” Dequaine says.

A third physician reluctantly took over until the issue subsided. And the family still brings the patient to the hospital for care.

Ultimately, the center adopted a new policy that doesn’t guarantee a patient a new doctor, only that the hospital will have frank discussions to try to resolve the issue and then try to arrange for a transfer if the situation can’t be resolved.

“The goal is not to get rid of the patient or to force them to keep the provider,” Dequaine says. “The goal is to resolve it in a mutually satisfactory way.”

A Patient Demands a Contraindicated Medication

A middle-aged woman with Crohn’s disease was hospitalized at Emory with an infection. The woman, worried about her disease flaring, wanted to keep getting her immunosuppressant, but the hospitalist suspended it because she needed to fight off the infection. The patient became upset. At a point when the hospitalist wasn’t in the room, the woman insisted to a nurse that she get her medication. The nurse called a doctor who was on call, but that doctor wouldn’t give the immunosuppressant either.

The patient began to think she wasn’t being listened to. Dr. Vazquez went in to see the patient and apologized for the misunderstanding.

“I went back into the room and explained here’s why I’m doing it: ‘I totally understand where you’re coming from; you don’t want your disease to be out of control. I appreciate that. What I’m worried about is killing you if we give you an immunosuppressant at the wrong time,’” Dr. Vazquez says.

Dr. Vazquez has underscored at his center how important it is for the physicians to be consulted and go back into the room when patients want to fire them, even though the expedient step might be to just bring in a new doctor. At previous centers, he says, it wouldn’t be unusual for the director to get a call from a nurse, who would say, “Yeah, they want to fire this physician, so let me know who’s going to see the patient.”

But simply switching doctors, he cautions, is like saying, “I agree with you we have incompetent doctors here, so we’re going to remove that doctor and I’m going to put a doctor on who actually knows what they’re doing.”

When doctors try to resolve the issues, good things tend to happen, Dr. Vazquez says.

“There’s generally a large amount of appreciation that someone comes back into the room and says, ‘We want to do this right.’”

Of course, there are times when, if tension remains after such discussions, patient care might be better served by a swap. At large centers, that might be possible, Dr. Bulger of Geisinger says.

“If the patient doesn’t tell the doctor something because he or she doesn’t like the doctor, then the doctor’s decisions are made on partial information—that’s the issue,” he says.

O’Doherty, the patient advocate, says that if patients frustrated with poor communication actually fired physicians as often as they would like, there would be more firings.

“Patients don’t like firing the doctors because they don’t want to be the patient who everybody doesn’t like,” she says. “They’re afraid that if they argue or disagree or ask too many questions, that they’re not going to get the care they need. And the family is afraid of that as well, especially in the older population. They think doctors are like God, they hold your life in their hands. So they don’t want to really question doctors.”

She says patients don’t necessarily need a particular finesse or expert bedside manner. In many cases, she says, it’s “just giving the information.”

A Patient Demands Pain Medication

Martin Austin, MD, SFHM, recently cared for a patient with chronic headaches. The patient asked for higher doses of pain medication, insinuating that she might turn to heroin if denied.

“I was trying to make the argument that I kind of disagreed with that but, ‘I respect your opinion,’” says Dr. Austin, medical director at the Gwinnett Medical Center Inpatient Medical Group in Georgia. “We came to a negotiation about how long we would use narcotics acutely until her other acute issues were over, but then we would try to get her away from narcotics.”

A good approach, he says, is to “outline to the patient why you’re doing what you’re doing. We try not to pick battles and give the patient some degree of control if it’s not contraindicated.”

But sometimes there can be no negotiating these kinds of requests, he says.

“Sometimes we’ll just say, ‘Look, it’s not a good thing for you to continue on this medication. You’re showing side effects, you’re sedated. … We think that the risk outweighs the benefit in this case,” he says.

A Patient Feels Left in the Dark

One patient at Emory wanted to fire his hospitalist because he wouldn’t tell him what was on his CT scan.

Dr. Vazquez held a discussion between the patient and the doctor. If not for the seriousness of the patient’s condition (he had tremors and neurological concerns), it would have been almost comical.

The patient had asked, “What’s on my scan?” The patient interpreted the doctor’s response, “It’s negative,” to mean that he wasn’t being told something about the scan.

Dr. Vazquez realized that the patient had felt dismissed.

“He was a sick gentleman,” Dr. Vazquez says. “And what he wanted to hear was, ‘Look, the great news is your CT scan looks good. There’s not an anatomical abnormality. It’s not a tumor. It’s not a big bleed. … That’s great news, but I, as a physician, I am concerned about you. You’re sick. We’ve got to really figure out what’s going on with you.’… He wanted a pat on the back, and that’s all it took.”

After that, the patient no longer wanted to fire the hospitalist.

Verbal Abuse

One case at Gwinnett involves a hospitalist who was quite shy and easily intimidated and was not comfortable with a patient.

“They were struggling with a patient who was very difficult and very angry and a little abusive,” Dr. Austin says. “This doctor was really suffering psychically from this whole thing, and we switched.” Another doctor, who would not be thrown by the situation, took over the case. And Dr. Austin says he had great respect for the first doctor’s request to hand over the case.

“They needed a different personality,” he says. “It worked out beautifully. The patient and the doctor got along much better. The doctor was firm with the patient but respectful, and the other doctor felt relieved. And the [original] doctor is great with patients who need a lot of emotional support, probably better than the other doctor. So that worked out really well.”

It might be a challenge during a busy day, but it’s helpful to step back and see the situation as a whole, Dr. Bulger says. Sometimes, hospitalists can get flustered when patients are not acting rationally. But there’s usually a good reason they’re acting that way, he says.

“The patient is sick. And if it’s the patient’s family, they’re stressed by the fact that the patient’s sick. So you really need to take a step back and understand that.” TH

Thomas R. Collins is a freelance writer based in West Palm Beach, Fla.

Reference

1. Centor R. Can I fire my hospitalist? SGIM Forum. 32(5):112-13.

Physician Communication Often Abysmal, Patient Advocate Says

communication2.jpg

Hospitalists, no doubt, encounter many challenging patient situations that have a lot to do with inappropriate behavior on the part of patients.

But from patient advocate Jackie O’Doherty’s point of view, many tough situations involving the patient-physician dynamic evolve from hospitalists who seem almost incapable of communicating well.

“I’m not saying they’re bad; their communication is not as great as it should be,” she says. “It has to be just giving the information. People get really frustrated when they’re in the hospital and they don’t know what’s going on.”

O’Doherty, a private patient advocate who represents patients in their efforts to get good healthcare at hospitals in New York and New Jersey, says sometimes the communication gaps are staggering.

For example, she represents a patient who had a heart attack and was transferred to a larger center to have open-heart surgery. The surgery went well, but when a Swan catheter was pulled, a plaque was hit and the man had a stroke. Suddenly, his care became a lot more complicated.

A series of specialists came in to see him. One told him that he would be sitting at home at the dinner table and watching football on Thanksgiving. Others gave him a far less rosy outlook. Some told him to drink water; others said not to.

The patient became frustrated, and O’Doherty demanded a meeting to sort out the mess. Eventually, all five of the patient’s doctors, a social worker, and the director of nursing met.

If the hospitalist is supposed to be a unifying force, that hadn’t happened in that case, O’Doherty says. Such cases, while not the norm, are frequent enough to cause concern.

“They’re the quarterbacks, supposedly, of the whole hospital experience, and I haven’t really seen that happen,” she says.

In another case, a patient getting suspect care—O’Doherty had pictures of the patient with a tracheostomy almost falling out of the bed—got a good response.

“They want to do whatever they can to make this work, and that’s a great response,” she says. “The question is, would that have been the response had I not been there?”

She understands the pressures that hospitalists can feel. And she says the system in which the hospitalist is working can matter as much as the hospitalist’s own communication skills.

“If you have a hospital that’s crazy busy, understaffed, and there’s not time,” she says, “that’s what goes first is the communication.”

At Bay Area Medical Center in Marinette, Wis., the time had come to start talking about an elderly woman’s end-of-life care.

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Her hospitalist thought that those discussions should take place with the patient present, but the woman’s family felt otherwise and made this known to the hospitalist, who stood his ground.

Eventually, the family told a nurse that they wanted to fire the physician. But the only other hospitalist on shift didn’t want to take the patient.

As case managers and hospital administrators tried to wrap their heads around the situation, it became clear: They didn’t really know what to do.

Could the patient fire a physician? Was the second physician obligated to take what he knew from the outset would be a difficult case? What if nobody wanted to take care of this patient?

“There was no black-and-white to this,” says Robin Dequaine, director of medical staff services at the hospital, who was involved in the case.

Some “difficult patient” scenarios are fairly straightforward. A patient is violent? Enact your security measures. An addict wants narcotics? Don’t give them.

But there are other situations that enter murkier territory: What if a patient makes inappropriate or abusive remarks? How much should a hospitalist put up with? What if a patient’s request for treatment might not be the hospitalist’s first choice but could be seen as reasonable? Is the patient’s request accommodated? And what about those firings?

Hospitalists, administrators, and patient advocates say these tense situations with patients involving firings, or would-be firings, while not a daily occurrence, are actually fairly common.¹ Getting to the root of the problem is essential. And as with so much in healthcare, good communication is the absolute crux of it all, they say.

“These are almost all communication issues,” says John Bulger, DO, MBA, FACP, SFHM, chief medical officer at Geisinger Health Plan in Danville, Pa., who has had a long career as a hospitalist and administrator handling and trying to resolve these situations. “They’re all [about] the way the hospitalist and the team is relating to the patient.”

Jackie O’Doherty, a private patient advocate who practices in New Jersey and New York across a gamut of hospital types, has a similar view.

“For me, the biggest problem, period, against hospitalists, doctors, everybody in the hospital, is communication—the lack of it,” she says. “Their communication skills are really poor.”

Patients accustomed to choice in the outpatient setting might not handle it well when they don’t have an established relationship with their hospitalist, says John Vazquez, MD, associate director for the Emory University School of Medicine’s Division of Hospital Medicine in Atlanta.

But the system, he says, “does not allow for, unfortunately, that much patient choice.”

End-of-life Discussion at a Small Hospital

Dequaine says the staff at Bay Area Medical Center was caught flat-footed with the case of the family not wanting end-of-life care discussed with their elderly mother.

“The doctor felt very confident that he was in a position that he could have that discussion in front of the patient,” she says.

At the 99-bed center, there were just two hospitalists, who were also employees of the hospital, on shift. And the communication channels involving the medical director of hospital medicine, a case manager, and the chief nursing executive were not well-controlled, Dequaine says.

“It didn’t go up the ladder correctly,” she says. “Too many people got involved, not knowing that somebody else was already involved.”

The second hospitalist at first said he would take the case, but later Dequaine learned that he changed his mind.

“He knew his care would be no different, and we were very, very busy, so they both had a high census already,” Dequaine says.

A third physician reluctantly took over until the issue subsided. And the family still brings the patient to the hospital for care.

Ultimately, the center adopted a new policy that doesn’t guarantee a patient a new doctor, only that the hospital will have frank discussions to try to resolve the issue and then try to arrange for a transfer if the situation can’t be resolved.

“The goal is not to get rid of the patient or to force them to keep the provider,” Dequaine says. “The goal is to resolve it in a mutually satisfactory way.”

A Patient Demands a Contraindicated Medication

A middle-aged woman with Crohn’s disease was hospitalized at Emory with an infection. The woman, worried about her disease flaring, wanted to keep getting her immunosuppressant, but the hospitalist suspended it because she needed to fight off the infection. The patient became upset. At a point when the hospitalist wasn’t in the room, the woman insisted to a nurse that she get her medication. The nurse called a doctor who was on call, but that doctor wouldn’t give the immunosuppressant either.

The patient began to think she wasn’t being listened to. Dr. Vazquez went in to see the patient and apologized for the misunderstanding.

“I went back into the room and explained here’s why I’m doing it: ‘I totally understand where you’re coming from; you don’t want your disease to be out of control. I appreciate that. What I’m worried about is killing you if we give you an immunosuppressant at the wrong time,’” Dr. Vazquez says.

Dr. Vazquez has underscored at his center how important it is for the physicians to be consulted and go back into the room when patients want to fire them, even though the expedient step might be to just bring in a new doctor. At previous centers, he says, it wouldn’t be unusual for the director to get a call from a nurse, who would say, “Yeah, they want to fire this physician, so let me know who’s going to see the patient.”

But simply switching doctors, he cautions, is like saying, “I agree with you we have incompetent doctors here, so we’re going to remove that doctor and I’m going to put a doctor on who actually knows what they’re doing.”

When doctors try to resolve the issues, good things tend to happen, Dr. Vazquez says.

“There’s generally a large amount of appreciation that someone comes back into the room and says, ‘We want to do this right.’”

Of course, there are times when, if tension remains after such discussions, patient care might be better served by a swap. At large centers, that might be possible, Dr. Bulger of Geisinger says.

“If the patient doesn’t tell the doctor something because he or she doesn’t like the doctor, then the doctor’s decisions are made on partial information—that’s the issue,” he says.

O’Doherty, the patient advocate, says that if patients frustrated with poor communication actually fired physicians as often as they would like, there would be more firings.

“Patients don’t like firing the doctors because they don’t want to be the patient who everybody doesn’t like,” she says. “They’re afraid that if they argue or disagree or ask too many questions, that they’re not going to get the care they need. And the family is afraid of that as well, especially in the older population. They think doctors are like God, they hold your life in their hands. So they don’t want to really question doctors.”

She says patients don’t necessarily need a particular finesse or expert bedside manner. In many cases, she says, it’s “just giving the information.”

A Patient Demands Pain Medication

Martin Austin, MD, SFHM, recently cared for a patient with chronic headaches. The patient asked for higher doses of pain medication, insinuating that she might turn to heroin if denied.

“I was trying to make the argument that I kind of disagreed with that but, ‘I respect your opinion,’” says Dr. Austin, medical director at the Gwinnett Medical Center Inpatient Medical Group in Georgia. “We came to a negotiation about how long we would use narcotics acutely until her other acute issues were over, but then we would try to get her away from narcotics.”

A good approach, he says, is to “outline to the patient why you’re doing what you’re doing. We try not to pick battles and give the patient some degree of control if it’s not contraindicated.”

But sometimes there can be no negotiating these kinds of requests, he says.

“Sometimes we’ll just say, ‘Look, it’s not a good thing for you to continue on this medication. You’re showing side effects, you’re sedated. … We think that the risk outweighs the benefit in this case,” he says.

A Patient Feels Left in the Dark

One patient at Emory wanted to fire his hospitalist because he wouldn’t tell him what was on his CT scan.

Dr. Vazquez held a discussion between the patient and the doctor. If not for the seriousness of the patient’s condition (he had tremors and neurological concerns), it would have been almost comical.

The patient had asked, “What’s on my scan?” The patient interpreted the doctor’s response, “It’s negative,” to mean that he wasn’t being told something about the scan.

Dr. Vazquez realized that the patient had felt dismissed.

“He was a sick gentleman,” Dr. Vazquez says. “And what he wanted to hear was, ‘Look, the great news is your CT scan looks good. There’s not an anatomical abnormality. It’s not a tumor. It’s not a big bleed. … That’s great news, but I, as a physician, I am concerned about you. You’re sick. We’ve got to really figure out what’s going on with you.’… He wanted a pat on the back, and that’s all it took.”

After that, the patient no longer wanted to fire the hospitalist.

Verbal Abuse

One case at Gwinnett involves a hospitalist who was quite shy and easily intimidated and was not comfortable with a patient.

“They were struggling with a patient who was very difficult and very angry and a little abusive,” Dr. Austin says. “This doctor was really suffering psychically from this whole thing, and we switched.” Another doctor, who would not be thrown by the situation, took over the case. And Dr. Austin says he had great respect for the first doctor’s request to hand over the case.

“They needed a different personality,” he says. “It worked out beautifully. The patient and the doctor got along much better. The doctor was firm with the patient but respectful, and the other doctor felt relieved. And the [original] doctor is great with patients who need a lot of emotional support, probably better than the other doctor. So that worked out really well.”

It might be a challenge during a busy day, but it’s helpful to step back and see the situation as a whole, Dr. Bulger says. Sometimes, hospitalists can get flustered when patients are not acting rationally. But there’s usually a good reason they’re acting that way, he says.

“The patient is sick. And if it’s the patient’s family, they’re stressed by the fact that the patient’s sick. So you really need to take a step back and understand that.” TH

Thomas R. Collins is a freelance writer based in West Palm Beach, Fla.

Reference

1. Centor R. Can I fire my hospitalist? SGIM Forum. 32(5):112-13.

Physician Communication Often Abysmal, Patient Advocate Says

communication2.jpg

Hospitalists, no doubt, encounter many challenging patient situations that have a lot to do with inappropriate behavior on the part of patients.

But from patient advocate Jackie O’Doherty’s point of view, many tough situations involving the patient-physician dynamic evolve from hospitalists who seem almost incapable of communicating well.

“I’m not saying they’re bad; their communication is not as great as it should be,” she says. “It has to be just giving the information. People get really frustrated when they’re in the hospital and they don’t know what’s going on.”

O’Doherty, a private patient advocate who represents patients in their efforts to get good healthcare at hospitals in New York and New Jersey, says sometimes the communication gaps are staggering.

For example, she represents a patient who had a heart attack and was transferred to a larger center to have open-heart surgery. The surgery went well, but when a Swan catheter was pulled, a plaque was hit and the man had a stroke. Suddenly, his care became a lot more complicated.

A series of specialists came in to see him. One told him that he would be sitting at home at the dinner table and watching football on Thanksgiving. Others gave him a far less rosy outlook. Some told him to drink water; others said not to.

The patient became frustrated, and O’Doherty demanded a meeting to sort out the mess. Eventually, all five of the patient’s doctors, a social worker, and the director of nursing met.

If the hospitalist is supposed to be a unifying force, that hadn’t happened in that case, O’Doherty says. Such cases, while not the norm, are frequent enough to cause concern.

“They’re the quarterbacks, supposedly, of the whole hospital experience, and I haven’t really seen that happen,” she says.

In another case, a patient getting suspect care—O’Doherty had pictures of the patient with a tracheostomy almost falling out of the bed—got a good response.

“They want to do whatever they can to make this work, and that’s a great response,” she says. “The question is, would that have been the response had I not been there?”

She understands the pressures that hospitalists can feel. And she says the system in which the hospitalist is working can matter as much as the hospitalist’s own communication skills.

“If you have a hospital that’s crazy busy, understaffed, and there’s not time,” she says, “that’s what goes first is the communication.”

bundled-300x221.jpg

As far back as 1983 —13 years before the birth of HM—Medicare created what was then called an “inpatient prospective payment system,” which essentially let Medicare pay a fixed amount for the entirety of a hospital stay, based on diagnosis. Then in 1991, the Centers for Medicare & Medicaid Services (CMS) introduced one payment for coronary artery bypass graft surgery, and even included 90-day readmission in the check.

Fast forward to the past 10 years when accountable care organizations (ACOs) and value-based purchasing (VBP) have been the focus of HM executives looking to take the lead in how to make bundled payments work for them.

The Bundled Payments for Care Improvement (BPCI) initiative was introduced by CMS’s Center for Medicare & Medicaid Innovation (CMMI) in 2011 and is now compiling its first data sets for the next frontier of payments for episodic care.

For rank-and-file hospitalists who have felt inundated by the regulations and promised payment reforms from ACOs and VBPs, why is this program so important?

“The reason this is so special is that it is one of the few CMS programs that allows providers to be in the driver’s seat,” says Kerry Weiner, MD, chief medical officer of acute and post-acute services at TeamHealth-‎IPC The Hospitalist Company. “They have the opportunity to be accountable and to actually be the designers of reengineering care. The other programs that you just mentioned, like value-based purchasing, largely originate from health systems or the federal government and dictate the principles and the metrics that as a provider you’re going to be evaluated upon.

“This model, the bundled model, gives us the flexibility, scale and brackets of risk that we want to accept and thereby gives us a lot more control over what physicians and physician groups can manage successfully.”

BPCI might be a game-changer for HM because it’s the first of the bundled-payment initiatives that truly falls direct to the care provided by hospitalists. In short, the plan covers 48 defined episodes of care and would parse out payments for those episodes in a holistic—and some say more appropriate—way. Currently, a hospitalist would get paid for a patient’s stay in the hospital and a primary-care physician (PCP) could be paid for some follow-up. If the patient ends up back in the hospital quickly, the hospitalist could get paid again and, upon discharge, a PCP could, too.

But under BPCI, pay would be determined based on the episode of care. The details of who gets paid what and the rules that apply are all likely to evolve, of course, but it’s hoped the basic premise of bundled payments would lower the overall cost of healthcare.

How It Works

Under the Patient Protection and Affordable Care Act (ACA) of 2009, it was mandated that the government establish a five-year pilot program by 2013 that bundled payments for inpatient care, according to the American Hospital Association.

The program has now ramped up to include more than 650 participating organization, not including thousands of physicians that then partner with those groups, over four models. The initiative covers defined episodes of care, both medical and surgical, that begin at the time of inpatient admission and stretch 30, 60 or 90 days post-discharge.

And hospitalists are poised to take the lead on how payment models, especially bundled payments, are shaped over the next few years, says John Nelson, MD, MHM, a co-founder and past president of SHM and and principal in Nelson Flores Hospital Medicine Consultants in Bellevue, Wash. Nelson says his consulting firm has seen an uptick in calls over the past two years dealing with alternative payment models (APMs).

“Hospitalists find themselves at a vitally important nexus of performance and success on new payment models,” he adds.

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Win Whitcomb, MD, MHM, chief medical officer of Remedy Partners in Darien, Conn., agrees that BPCI and future iterations of bundled payment programs “are likely to be a potent driver of an evolving hospitalist specialty.” His hypothesis is that APMs such as BPCI are an important way for Medicare to reach its stated goal of having 50% of its fee-for-service payments running through APMs by the end of 2018. To further entice that process, physicians who document at least 25% of their revenue as coming through APMs will get a 5% bonus.

“The stakes are high now,” says Dr. Whitcomb, a past SHM president whose employer is an Awardee Convener in the BPCI initiative, meaning it administers the program. “Medicare [has] laid out the

course for the next two and a half, three years and beyond… It will be crucial for hospitalists to have a path to participate broadly in APMs..”

Dr. Whitcomb says BPCI is the program that should excite hospitalists most because it is more applicable to them moving forward than ACOs, heralded by many healthcare executives several years ago as the future of payment reform.

“With a focus on ambulatory care, ACOs have not broadly involved hospitalists,” he says. “If you look at the State of Hospital Medicine surveys, you look at how many hospitalists are meaningfully working at a system level on ACOs and committees and so forth to improve the performance of the ACO, and it’s very low.”

In fact, just 13.9% of HM groups serving adults only had formed or were participating in a functioning ACO, according to SHM’s 2014 State of Hospital Medicine report. Another 6% were in the process of forming or participating, the paper reported.

“ACOs have not yet widely worked alongside hospitalist teams to optimize where patients go after hospitalization, which is arguably the most important way to deal with post-acute-care utilization” Dr. Whitcomb adds. “whereas nearly all hospitalists working in bundle payments are focusing on a ‘high-value’ transition out of the hospital.”

Improving Care

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While BPCI is focused on payment structure, the program could breed process improvements as well as improve care, says hospitalist Patrick Conway, MD, MHM, MSc, CMS’s chief medical officer and deputy administrator for innovation and quality.

“In addition to assessing the quality of patient outcomes and patient experience, CMS is also monitoring for unintended consequences, including whether there is an increase in the number of specific clinical episodes [such as specific elective surgeries] that would not have been expected in the absence of BPCI,” Dr. Conway says. “CMS can audit and intervene if it detects unintended negative consequences for beneficiaries.”

Dr. Whitcomb says two main ways that hospitalists can use BPCI to calculate value is by having better metrics on post-acute facility utilization and reduced readmission.

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Immediate past SHM President Robert Harrington Jr., MD, SFHM, says that BPCI is a major stepping stone to merging quality and payment, along the lines of using Physician Quality Reporting System (PQRS) data in the value-based payment modifier.

“CMS is saying to all of us in the provider world, ‘We want to get out of the business of unit economics, and we want to start paying for episodes of care and providers should be at risk for quality outcomes,” he says. “BPCI, to me, is one of the rungs in the ladder.”

Dr. Harrington, chief medical officer at Reliant Post-Acute Care Solutions in Atlanta, says that the program’s inclusion of acute-care hospitals, skilled nursing facilities (SNFs), physician group practices, long-term care hospitals, inpatient rehabilitation facilities, and home health agencies working together is what differentiates it from past attempts at payment reform.

“Population health is sort of where this is headed,” he adds. “You sit in a CFO seat at a hospital or healthcare system right now, and five years ago, they’d buy an MRI machine and they wanted throughput through that MRI machine and they wanted as many people run through that MRI machine in the fee-for-service world as they could get to go through that machine. Nowadays, you start to look at it from a population health standpoint and the CFO is going to say to you, ‘I don’t want anybody going through that MRI machine unless they have to.’

“So it’s a total reversal of perspective when hospitals either become joined at the hip with the payors or become the payors and they start taking risk on population health and I think BPCI is one way that Medicare has allowed all of us to test the waters and get comfortable with that.”

Getting Involved

Dr. Weiner is aware that some hospitalists are nervous about bundled payments because their reimbursement is, in part based on care provided outside of their control. Take a surgical procedure where a hospitalist managing the post-surgery care is left to deal with any potential mistakes made. Or the process works fine until there is poor management by ambulatory care once the patient is discharged.

“That is the reason this program exists,” he says. “It poses the question, who is going to be accountable for the care outside of the traditional site of care that providers have been practicing in, your traditional boundaries? I would argue that physicians are more or are just as valuable as any other segment of the healthcare system in managing the transitions of care and in managing the gaps in the system.”

Given how HM has moved into post-discharge care via SNFs and other post-acute care facilities in recent years, Dr. Weiner says that while hospitalists can’t actually deliver all of the care in an “episode,” they can shepherd that process.

Hospitalists “have control over where the patient goes after they leave the acute-care facility, for example,” he says. “They write the orders on what level of care is needed, and they should have the intimate knowledge about what’s available in their community to ensure the patient gets the best care possible. As long as they have the accountability and the power to direct care, then they have the ability to negotiate and recommend care that is best for the patient, so they can select the better facilities in the community, the better agencies in the community, the better resources in the community to ensure that there is better care once the patient leaves the hospital.”

Dr. Conway suggests HM practitioners view BPCI as a model based on “quality and value.” He says early participants helped define clinical episodes, length of episode, and risk track, making the program better suited to address the actual needs of hospitalists.

“I would encourage hospital medicine physicians and care teams to view bundled payment models as an opportunity for them and their patients for better care and smarter spending,” he adds. “CMS continues to explore ways to pay for value and not just volume. Many of the organizations that are participating in BPCI have partnered with their physician communities and established gainsharing agreement. …Most importantly, this model focuses on care coordination for patients across episodes of care.

And that’s the key for Dr. Weiner.

Hospitalists who embrace BPCI can shape it as the predominant inpatient funding model for hospitals over the next five or 10 years. HM administrators and practitioners who don’t seize the opportunity to flesh out the program tacitly cede control to people outside the hospital who may not tailor the program nearly as well, he says.

“Those who have accountability in the end, the systems, the people, the entities, the providers that have the ability, the accountability for it will ultimately design it,” Dr. Weiner adds. “I think physicians, especially hospitalists, should be at that table. We should play an active role in designing the system.” TH

Richard Quinn is a freelance writer in New Jersey.

The ABCs of $$$s

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Hospitalists whoaren’t in leadership, administrative or committee positions may not be familiar with the latest round of alphabet soup that is tied to payment reform and Medicare’s announced push to have 50% of its payments not by fee-for-service by 2018. Here are the most important ones:

• APM: Alternative payment models. The catch-all phrase for a variety of programs and initiatives that are outside the traditional fee-for-service model.
• MACRA: Medicare Access & CHIP Reauthorization Act of 2015. The act ended the hated sustainable growth rate (SGR) formula and combined CMS’s existing quality reporting programs under one system.
• MIPS: Merit-Based Incentive Payment System. The new program combines parts of the Physician Quality Reporting System (PQRS), the value modifier (VM, or value-based payment modifier/VBPM), and the Medicare electronic health record (EHR) incentive program into a single program.

Source: Centers for Medicare & Medicaid Services

—By Richard Quinn

bundled-300x221.jpg

As far back as 1983 —13 years before the birth of HM—Medicare created what was then called an “inpatient prospective payment system,” which essentially let Medicare pay a fixed amount for the entirety of a hospital stay, based on diagnosis. Then in 1991, the Centers for Medicare & Medicaid Services (CMS) introduced one payment for coronary artery bypass graft surgery, and even included 90-day readmission in the check.

Fast forward to the past 10 years when accountable care organizations (ACOs) and value-based purchasing (VBP) have been the focus of HM executives looking to take the lead in how to make bundled payments work for them.

The Bundled Payments for Care Improvement (BPCI) initiative was introduced by CMS’s Center for Medicare & Medicaid Innovation (CMMI) in 2011 and is now compiling its first data sets for the next frontier of payments for episodic care.

For rank-and-file hospitalists who have felt inundated by the regulations and promised payment reforms from ACOs and VBPs, why is this program so important?

“The reason this is so special is that it is one of the few CMS programs that allows providers to be in the driver’s seat,” says Kerry Weiner, MD, chief medical officer of acute and post-acute services at TeamHealth-‎IPC The Hospitalist Company. “They have the opportunity to be accountable and to actually be the designers of reengineering care. The other programs that you just mentioned, like value-based purchasing, largely originate from health systems or the federal government and dictate the principles and the metrics that as a provider you’re going to be evaluated upon.

“This model, the bundled model, gives us the flexibility, scale and brackets of risk that we want to accept and thereby gives us a lot more control over what physicians and physician groups can manage successfully.”

BPCI might be a game-changer for HM because it’s the first of the bundled-payment initiatives that truly falls direct to the care provided by hospitalists. In short, the plan covers 48 defined episodes of care and would parse out payments for those episodes in a holistic—and some say more appropriate—way. Currently, a hospitalist would get paid for a patient’s stay in the hospital and a primary-care physician (PCP) could be paid for some follow-up. If the patient ends up back in the hospital quickly, the hospitalist could get paid again and, upon discharge, a PCP could, too.

But under BPCI, pay would be determined based on the episode of care. The details of who gets paid what and the rules that apply are all likely to evolve, of course, but it’s hoped the basic premise of bundled payments would lower the overall cost of healthcare.

How It Works

Under the Patient Protection and Affordable Care Act (ACA) of 2009, it was mandated that the government establish a five-year pilot program by 2013 that bundled payments for inpatient care, according to the American Hospital Association.

The program has now ramped up to include more than 650 participating organization, not including thousands of physicians that then partner with those groups, over four models. The initiative covers defined episodes of care, both medical and surgical, that begin at the time of inpatient admission and stretch 30, 60 or 90 days post-discharge.

And hospitalists are poised to take the lead on how payment models, especially bundled payments, are shaped over the next few years, says John Nelson, MD, MHM, a co-founder and past president of SHM and and principal in Nelson Flores Hospital Medicine Consultants in Bellevue, Wash. Nelson says his consulting firm has seen an uptick in calls over the past two years dealing with alternative payment models (APMs).

“Hospitalists find themselves at a vitally important nexus of performance and success on new payment models,” he adds.

TH_08_pg17a.jpg

Win Whitcomb, MD, MHM, chief medical officer of Remedy Partners in Darien, Conn., agrees that BPCI and future iterations of bundled payment programs “are likely to be a potent driver of an evolving hospitalist specialty.” His hypothesis is that APMs such as BPCI are an important way for Medicare to reach its stated goal of having 50% of its fee-for-service payments running through APMs by the end of 2018. To further entice that process, physicians who document at least 25% of their revenue as coming through APMs will get a 5% bonus.

“The stakes are high now,” says Dr. Whitcomb, a past SHM president whose employer is an Awardee Convener in the BPCI initiative, meaning it administers the program. “Medicare [has] laid out the

course for the next two and a half, three years and beyond… It will be crucial for hospitalists to have a path to participate broadly in APMs..”

Dr. Whitcomb says BPCI is the program that should excite hospitalists most because it is more applicable to them moving forward than ACOs, heralded by many healthcare executives several years ago as the future of payment reform.

“With a focus on ambulatory care, ACOs have not broadly involved hospitalists,” he says. “If you look at the State of Hospital Medicine surveys, you look at how many hospitalists are meaningfully working at a system level on ACOs and committees and so forth to improve the performance of the ACO, and it’s very low.”

In fact, just 13.9% of HM groups serving adults only had formed or were participating in a functioning ACO, according to SHM’s 2014 State of Hospital Medicine report. Another 6% were in the process of forming or participating, the paper reported.

“ACOs have not yet widely worked alongside hospitalist teams to optimize where patients go after hospitalization, which is arguably the most important way to deal with post-acute-care utilization” Dr. Whitcomb adds. “whereas nearly all hospitalists working in bundle payments are focusing on a ‘high-value’ transition out of the hospital.”

Improving Care

conway.jpg

While BPCI is focused on payment structure, the program could breed process improvements as well as improve care, says hospitalist Patrick Conway, MD, MHM, MSc, CMS’s chief medical officer and deputy administrator for innovation and quality.

“In addition to assessing the quality of patient outcomes and patient experience, CMS is also monitoring for unintended consequences, including whether there is an increase in the number of specific clinical episodes [such as specific elective surgeries] that would not have been expected in the absence of BPCI,” Dr. Conway says. “CMS can audit and intervene if it detects unintended negative consequences for beneficiaries.”

Dr. Whitcomb says two main ways that hospitalists can use BPCI to calculate value is by having better metrics on post-acute facility utilization and reduced readmission.

TH_0915_pg42.png

Immediate past SHM President Robert Harrington Jr., MD, SFHM, says that BPCI is a major stepping stone to merging quality and payment, along the lines of using Physician Quality Reporting System (PQRS) data in the value-based payment modifier.

“CMS is saying to all of us in the provider world, ‘We want to get out of the business of unit economics, and we want to start paying for episodes of care and providers should be at risk for quality outcomes,” he says. “BPCI, to me, is one of the rungs in the ladder.”

Dr. Harrington, chief medical officer at Reliant Post-Acute Care Solutions in Atlanta, says that the program’s inclusion of acute-care hospitals, skilled nursing facilities (SNFs), physician group practices, long-term care hospitals, inpatient rehabilitation facilities, and home health agencies working together is what differentiates it from past attempts at payment reform.

“Population health is sort of where this is headed,” he adds. “You sit in a CFO seat at a hospital or healthcare system right now, and five years ago, they’d buy an MRI machine and they wanted throughput through that MRI machine and they wanted as many people run through that MRI machine in the fee-for-service world as they could get to go through that machine. Nowadays, you start to look at it from a population health standpoint and the CFO is going to say to you, ‘I don’t want anybody going through that MRI machine unless they have to.’

“So it’s a total reversal of perspective when hospitals either become joined at the hip with the payors or become the payors and they start taking risk on population health and I think BPCI is one way that Medicare has allowed all of us to test the waters and get comfortable with that.”

Getting Involved

Dr. Weiner is aware that some hospitalists are nervous about bundled payments because their reimbursement is, in part based on care provided outside of their control. Take a surgical procedure where a hospitalist managing the post-surgery care is left to deal with any potential mistakes made. Or the process works fine until there is poor management by ambulatory care once the patient is discharged.

“That is the reason this program exists,” he says. “It poses the question, who is going to be accountable for the care outside of the traditional site of care that providers have been practicing in, your traditional boundaries? I would argue that physicians are more or are just as valuable as any other segment of the healthcare system in managing the transitions of care and in managing the gaps in the system.”

Given how HM has moved into post-discharge care via SNFs and other post-acute care facilities in recent years, Dr. Weiner says that while hospitalists can’t actually deliver all of the care in an “episode,” they can shepherd that process.

Hospitalists “have control over where the patient goes after they leave the acute-care facility, for example,” he says. “They write the orders on what level of care is needed, and they should have the intimate knowledge about what’s available in their community to ensure the patient gets the best care possible. As long as they have the accountability and the power to direct care, then they have the ability to negotiate and recommend care that is best for the patient, so they can select the better facilities in the community, the better agencies in the community, the better resources in the community to ensure that there is better care once the patient leaves the hospital.”

Dr. Conway suggests HM practitioners view BPCI as a model based on “quality and value.” He says early participants helped define clinical episodes, length of episode, and risk track, making the program better suited to address the actual needs of hospitalists.

“I would encourage hospital medicine physicians and care teams to view bundled payment models as an opportunity for them and their patients for better care and smarter spending,” he adds. “CMS continues to explore ways to pay for value and not just volume. Many of the organizations that are participating in BPCI have partnered with their physician communities and established gainsharing agreement. …Most importantly, this model focuses on care coordination for patients across episodes of care.

And that’s the key for Dr. Weiner.

Hospitalists who embrace BPCI can shape it as the predominant inpatient funding model for hospitals over the next five or 10 years. HM administrators and practitioners who don’t seize the opportunity to flesh out the program tacitly cede control to people outside the hospital who may not tailor the program nearly as well, he says.

“Those who have accountability in the end, the systems, the people, the entities, the providers that have the ability, the accountability for it will ultimately design it,” Dr. Weiner adds. “I think physicians, especially hospitalists, should be at that table. We should play an active role in designing the system.” TH

Richard Quinn is a freelance writer in New Jersey.

The ABCs of $$$s

soupsidebar-300x300.jpg

Hospitalists whoaren’t in leadership, administrative or committee positions may not be familiar with the latest round of alphabet soup that is tied to payment reform and Medicare’s announced push to have 50% of its payments not by fee-for-service by 2018. Here are the most important ones:

• APM: Alternative payment models. The catch-all phrase for a variety of programs and initiatives that are outside the traditional fee-for-service model.
• MACRA: Medicare Access & CHIP Reauthorization Act of 2015. The act ended the hated sustainable growth rate (SGR) formula and combined CMS’s existing quality reporting programs under one system.
• MIPS: Merit-Based Incentive Payment System. The new program combines parts of the Physician Quality Reporting System (PQRS), the value modifier (VM, or value-based payment modifier/VBPM), and the Medicare electronic health record (EHR) incentive program into a single program.

Source: Centers for Medicare & Medicaid Services

—By Richard Quinn

bundled-300x221.jpg

As far back as 1983 —13 years before the birth of HM—Medicare created what was then called an “inpatient prospective payment system,” which essentially let Medicare pay a fixed amount for the entirety of a hospital stay, based on diagnosis. Then in 1991, the Centers for Medicare & Medicaid Services (CMS) introduced one payment for coronary artery bypass graft surgery, and even included 90-day readmission in the check.

Fast forward to the past 10 years when accountable care organizations (ACOs) and value-based purchasing (VBP) have been the focus of HM executives looking to take the lead in how to make bundled payments work for them.

The Bundled Payments for Care Improvement (BPCI) initiative was introduced by CMS’s Center for Medicare & Medicaid Innovation (CMMI) in 2011 and is now compiling its first data sets for the next frontier of payments for episodic care.

For rank-and-file hospitalists who have felt inundated by the regulations and promised payment reforms from ACOs and VBPs, why is this program so important?

“The reason this is so special is that it is one of the few CMS programs that allows providers to be in the driver’s seat,” says Kerry Weiner, MD, chief medical officer of acute and post-acute services at TeamHealth-‎IPC The Hospitalist Company. “They have the opportunity to be accountable and to actually be the designers of reengineering care. The other programs that you just mentioned, like value-based purchasing, largely originate from health systems or the federal government and dictate the principles and the metrics that as a provider you’re going to be evaluated upon.

“This model, the bundled model, gives us the flexibility, scale and brackets of risk that we want to accept and thereby gives us a lot more control over what physicians and physician groups can manage successfully.”

BPCI might be a game-changer for HM because it’s the first of the bundled-payment initiatives that truly falls direct to the care provided by hospitalists. In short, the plan covers 48 defined episodes of care and would parse out payments for those episodes in a holistic—and some say more appropriate—way. Currently, a hospitalist would get paid for a patient’s stay in the hospital and a primary-care physician (PCP) could be paid for some follow-up. If the patient ends up back in the hospital quickly, the hospitalist could get paid again and, upon discharge, a PCP could, too.

But under BPCI, pay would be determined based on the episode of care. The details of who gets paid what and the rules that apply are all likely to evolve, of course, but it’s hoped the basic premise of bundled payments would lower the overall cost of healthcare.

How It Works

Under the Patient Protection and Affordable Care Act (ACA) of 2009, it was mandated that the government establish a five-year pilot program by 2013 that bundled payments for inpatient care, according to the American Hospital Association.

The program has now ramped up to include more than 650 participating organization, not including thousands of physicians that then partner with those groups, over four models. The initiative covers defined episodes of care, both medical and surgical, that begin at the time of inpatient admission and stretch 30, 60 or 90 days post-discharge.

And hospitalists are poised to take the lead on how payment models, especially bundled payments, are shaped over the next few years, says John Nelson, MD, MHM, a co-founder and past president of SHM and and principal in Nelson Flores Hospital Medicine Consultants in Bellevue, Wash. Nelson says his consulting firm has seen an uptick in calls over the past two years dealing with alternative payment models (APMs).

“Hospitalists find themselves at a vitally important nexus of performance and success on new payment models,” he adds.

TH_08_pg17a.jpg

Win Whitcomb, MD, MHM, chief medical officer of Remedy Partners in Darien, Conn., agrees that BPCI and future iterations of bundled payment programs “are likely to be a potent driver of an evolving hospitalist specialty.” His hypothesis is that APMs such as BPCI are an important way for Medicare to reach its stated goal of having 50% of its fee-for-service payments running through APMs by the end of 2018. To further entice that process, physicians who document at least 25% of their revenue as coming through APMs will get a 5% bonus.

“The stakes are high now,” says Dr. Whitcomb, a past SHM president whose employer is an Awardee Convener in the BPCI initiative, meaning it administers the program. “Medicare [has] laid out the

course for the next two and a half, three years and beyond… It will be crucial for hospitalists to have a path to participate broadly in APMs..”

Dr. Whitcomb says BPCI is the program that should excite hospitalists most because it is more applicable to them moving forward than ACOs, heralded by many healthcare executives several years ago as the future of payment reform.

“With a focus on ambulatory care, ACOs have not broadly involved hospitalists,” he says. “If you look at the State of Hospital Medicine surveys, you look at how many hospitalists are meaningfully working at a system level on ACOs and committees and so forth to improve the performance of the ACO, and it’s very low.”

In fact, just 13.9% of HM groups serving adults only had formed or were participating in a functioning ACO, according to SHM’s 2014 State of Hospital Medicine report. Another 6% were in the process of forming or participating, the paper reported.

“ACOs have not yet widely worked alongside hospitalist teams to optimize where patients go after hospitalization, which is arguably the most important way to deal with post-acute-care utilization” Dr. Whitcomb adds. “whereas nearly all hospitalists working in bundle payments are focusing on a ‘high-value’ transition out of the hospital.”

Improving Care

conway.jpg

While BPCI is focused on payment structure, the program could breed process improvements as well as improve care, says hospitalist Patrick Conway, MD, MHM, MSc, CMS’s chief medical officer and deputy administrator for innovation and quality.

“In addition to assessing the quality of patient outcomes and patient experience, CMS is also monitoring for unintended consequences, including whether there is an increase in the number of specific clinical episodes [such as specific elective surgeries] that would not have been expected in the absence of BPCI,” Dr. Conway says. “CMS can audit and intervene if it detects unintended negative consequences for beneficiaries.”

Dr. Whitcomb says two main ways that hospitalists can use BPCI to calculate value is by having better metrics on post-acute facility utilization and reduced readmission.

TH_0915_pg42.png

Immediate past SHM President Robert Harrington Jr., MD, SFHM, says that BPCI is a major stepping stone to merging quality and payment, along the lines of using Physician Quality Reporting System (PQRS) data in the value-based payment modifier.

“CMS is saying to all of us in the provider world, ‘We want to get out of the business of unit economics, and we want to start paying for episodes of care and providers should be at risk for quality outcomes,” he says. “BPCI, to me, is one of the rungs in the ladder.”

Dr. Harrington, chief medical officer at Reliant Post-Acute Care Solutions in Atlanta, says that the program’s inclusion of acute-care hospitals, skilled nursing facilities (SNFs), physician group practices, long-term care hospitals, inpatient rehabilitation facilities, and home health agencies working together is what differentiates it from past attempts at payment reform.

“Population health is sort of where this is headed,” he adds. “You sit in a CFO seat at a hospital or healthcare system right now, and five years ago, they’d buy an MRI machine and they wanted throughput through that MRI machine and they wanted as many people run through that MRI machine in the fee-for-service world as they could get to go through that machine. Nowadays, you start to look at it from a population health standpoint and the CFO is going to say to you, ‘I don’t want anybody going through that MRI machine unless they have to.’

“So it’s a total reversal of perspective when hospitals either become joined at the hip with the payors or become the payors and they start taking risk on population health and I think BPCI is one way that Medicare has allowed all of us to test the waters and get comfortable with that.”

Getting Involved

Dr. Weiner is aware that some hospitalists are nervous about bundled payments because their reimbursement is, in part based on care provided outside of their control. Take a surgical procedure where a hospitalist managing the post-surgery care is left to deal with any potential mistakes made. Or the process works fine until there is poor management by ambulatory care once the patient is discharged.

“That is the reason this program exists,” he says. “It poses the question, who is going to be accountable for the care outside of the traditional site of care that providers have been practicing in, your traditional boundaries? I would argue that physicians are more or are just as valuable as any other segment of the healthcare system in managing the transitions of care and in managing the gaps in the system.”

Given how HM has moved into post-discharge care via SNFs and other post-acute care facilities in recent years, Dr. Weiner says that while hospitalists can’t actually deliver all of the care in an “episode,” they can shepherd that process.

Hospitalists “have control over where the patient goes after they leave the acute-care facility, for example,” he says. “They write the orders on what level of care is needed, and they should have the intimate knowledge about what’s available in their community to ensure the patient gets the best care possible. As long as they have the accountability and the power to direct care, then they have the ability to negotiate and recommend care that is best for the patient, so they can select the better facilities in the community, the better agencies in the community, the better resources in the community to ensure that there is better care once the patient leaves the hospital.”

Dr. Conway suggests HM practitioners view BPCI as a model based on “quality and value.” He says early participants helped define clinical episodes, length of episode, and risk track, making the program better suited to address the actual needs of hospitalists.

“I would encourage hospital medicine physicians and care teams to view bundled payment models as an opportunity for them and their patients for better care and smarter spending,” he adds. “CMS continues to explore ways to pay for value and not just volume. Many of the organizations that are participating in BPCI have partnered with their physician communities and established gainsharing agreement. …Most importantly, this model focuses on care coordination for patients across episodes of care.

And that’s the key for Dr. Weiner.

Hospitalists who embrace BPCI can shape it as the predominant inpatient funding model for hospitals over the next five or 10 years. HM administrators and practitioners who don’t seize the opportunity to flesh out the program tacitly cede control to people outside the hospital who may not tailor the program nearly as well, he says.

“Those who have accountability in the end, the systems, the people, the entities, the providers that have the ability, the accountability for it will ultimately design it,” Dr. Weiner adds. “I think physicians, especially hospitalists, should be at that table. We should play an active role in designing the system.” TH

Richard Quinn is a freelance writer in New Jersey.

The ABCs of $$$s

soupsidebar-300x300.jpg

Hospitalists whoaren’t in leadership, administrative or committee positions may not be familiar with the latest round of alphabet soup that is tied to payment reform and Medicare’s announced push to have 50% of its payments not by fee-for-service by 2018. Here are the most important ones:

• APM: Alternative payment models. The catch-all phrase for a variety of programs and initiatives that are outside the traditional fee-for-service model.
• MACRA: Medicare Access & CHIP Reauthorization Act of 2015. The act ended the hated sustainable growth rate (SGR) formula and combined CMS’s existing quality reporting programs under one system.
• MIPS: Merit-Based Incentive Payment System. The new program combines parts of the Physician Quality Reporting System (PQRS), the value modifier (VM, or value-based payment modifier/VBPM), and the Medicare electronic health record (EHR) incentive program into a single program.

Source: Centers for Medicare & Medicaid Services

—By Richard Quinn

Hospitalists often rely on inpatient telemetry monitoring to identify arrhythmias, ischemia, and QT prolongation, but research has shown that its inappropriate usage increases costs to the healthcare system. An abstract presented at the 2016 meeting of the Society of Hospital Medicine looked at one hospital’s telemetry usage and how it might be improved.

Telemedicine.jpg

The study revolved around a progress note template the authors developed, which incorporated documentation for telemetry use indications and need for telemetry continuation on non-ICU internal medicine services. The authors also provided an educational session describing American College of Cardiology and American Heart Association (ACC/AHA) telemetry use guidelines for internal medicine residents with a pretest and posttest.

Application of ACA/AHA guidelines was assessed with five scenarios before and after instruction on the guidelines. On pretest, only 29% of trainees answered all five questions correctly; on posttest, 63% did. A comparison between charts of admitted patients with telemetry orders from 2015 with charts from 2013 indicated that the appropriate initiation of telemetry improved significantly as did telemetry documentation. Inappropriate continuation rates were cut in half.

The success of the study suggests further work.

“We plan expansion of telemetry utilization education to internal medicine faculty and nursing to encourage daily review of telemetry usage,” the authors write. “We are also working to develop telemetry orders that end during standard work hours to prevent inadvertent continuation by overnight providers.”

Reference

1. Kuehn C, Steyers CM III, Glenn K, Fang M. Resident-based telemetry utilization innovations lead to improved outcomes [abstract]. J Hosp Med. 2016;11(suppl 1). Accessed October 17, 2016.

Hospitalists often rely on inpatient telemetry monitoring to identify arrhythmias, ischemia, and QT prolongation, but research has shown that its inappropriate usage increases costs to the healthcare system. An abstract presented at the 2016 meeting of the Society of Hospital Medicine looked at one hospital’s telemetry usage and how it might be improved.

Telemedicine.jpg

The study revolved around a progress note template the authors developed, which incorporated documentation for telemetry use indications and need for telemetry continuation on non-ICU internal medicine services. The authors also provided an educational session describing American College of Cardiology and American Heart Association (ACC/AHA) telemetry use guidelines for internal medicine residents with a pretest and posttest.

Application of ACA/AHA guidelines was assessed with five scenarios before and after instruction on the guidelines. On pretest, only 29% of trainees answered all five questions correctly; on posttest, 63% did. A comparison between charts of admitted patients with telemetry orders from 2015 with charts from 2013 indicated that the appropriate initiation of telemetry improved significantly as did telemetry documentation. Inappropriate continuation rates were cut in half.

The success of the study suggests further work.

“We plan expansion of telemetry utilization education to internal medicine faculty and nursing to encourage daily review of telemetry usage,” the authors write. “We are also working to develop telemetry orders that end during standard work hours to prevent inadvertent continuation by overnight providers.”

Reference

1. Kuehn C, Steyers CM III, Glenn K, Fang M. Resident-based telemetry utilization innovations lead to improved outcomes [abstract]. J Hosp Med. 2016;11(suppl 1). Accessed October 17, 2016.

Hospitalists often rely on inpatient telemetry monitoring to identify arrhythmias, ischemia, and QT prolongation, but research has shown that its inappropriate usage increases costs to the healthcare system. An abstract presented at the 2016 meeting of the Society of Hospital Medicine looked at one hospital’s telemetry usage and how it might be improved.

Telemedicine.jpg

The study revolved around a progress note template the authors developed, which incorporated documentation for telemetry use indications and need for telemetry continuation on non-ICU internal medicine services. The authors also provided an educational session describing American College of Cardiology and American Heart Association (ACC/AHA) telemetry use guidelines for internal medicine residents with a pretest and posttest.

Application of ACA/AHA guidelines was assessed with five scenarios before and after instruction on the guidelines. On pretest, only 29% of trainees answered all five questions correctly; on posttest, 63% did. A comparison between charts of admitted patients with telemetry orders from 2015 with charts from 2013 indicated that the appropriate initiation of telemetry improved significantly as did telemetry documentation. Inappropriate continuation rates were cut in half.

The success of the study suggests further work.

“We plan expansion of telemetry utilization education to internal medicine faculty and nursing to encourage daily review of telemetry usage,” the authors write. “We are also working to develop telemetry orders that end during standard work hours to prevent inadvertent continuation by overnight providers.”

Reference

1. Kuehn C, Steyers CM III, Glenn K, Fang M. Resident-based telemetry utilization innovations lead to improved outcomes [abstract]. J Hosp Med. 2016;11(suppl 1). Accessed October 17, 2016.

Algorithm-300x172.jpg

One recent paper in Clinical Pediatrics, for example, chronicled low adherence to the 2011 National Heart, Lung, and Blood Institute lipid screening guidelines in primary-care settings.1 Another cautioned providers to “mind the (implementation) gap” in venous thromboembolism prevention guidelines for medical inpatients.2 A third found that lower adherence to guidelines issued by the American College of Cardiology/American Heart Association for acute coronary syndrome patients was significantly associated with higher bleeding and mortality rates.3

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Both clinical trials and real-world studies have demonstrated that when guidelines are applied, patients do better, says William Lewis, MD, professor of medicine at Case Western Reserve University and director of the Heart & Vascular Center at MetroHealth in Cleveland. So why aren’t they followed more consistently?

Experts in both HM and other disciplines cite multiple obstacles. Lack of evidence, conflicting evidence, or lack of awareness about evidence can all conspire against the main goal of helping providers deliver consistent high-value care, says Christopher Moriates, MD, assistant clinical professor in the Division of Hospital Medicine at the University of California, San Francisco.

Christopher-Moriates.jpg

“In our day-to-day lives as hospitalists, for the vast majority probably of what we do there’s no clear guideline or there’s a guideline that doesn’t necessarily apply to the patient standing in front of me,” he says.

Even when a guideline is clear and relevant, other doctors say inadequate dissemination and implementation can still derail quality improvement efforts.

“A lot of what we do as physicians is what we learned in residency, and to incorporate the new data is difficult,” says Leonard Feldman, MD, SFHM, a hospitalist and associate professor of internal medicine and pediatrics at Johns Hopkins School of Medicine in Baltimore.

Lenny-Feldman.jpg

Dr. Feldman believes many doctors have yet to integrate recently revised hypertension and cholesterol guidelines into their practice, for example. Some guidelines have proven more complex or controversial, limiting their adoption.

“I know I struggle to keep up with all of the guidelines, and I’m in a big academic center where people are talking about them all the time, and I’m working with residents who are talking about them all the time,” Dr. Feldman says.

Despite the remaining gaps, however, many researchers agree that momentum has built steadily over the past two decades toward a more systematic approach to creating solid evidence-based guidelines and integrating them into real-world decision making.

Emphasis on Evidence and Transparency

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The term “evidence-based medicine” was coined in 1990 by Gordon Guyatt, MD, MSc, FRCPC, distinguished professor of medicine and clinical epidemiology at McMaster University in Hamilton, Ontario. It’s played an active role in formulating guidelines for multiple organizations. The guideline-writing process, Dr. Guyatt says, once consisted of little more than self-selected clinicians sitting around a table.

“It used to be that a bunch of experts got together and decided and made the recommendations with very little in the way of a systematic process and certainly not evidence based,” he says.

Cincinnati Children’s Hospital Medical Center was among the pioneers pushing for a more systematic approach; the hospital began working on its own guidelines in 1995 and published the first of many the following year.

Wendy-Gerhardt.jpg

“We started evidence-based guidelines when the docs were still saying, ‘This is cookbook medicine. I don’t know if I want to do this or not,’” says Wendy Gerhardt, MSN, director of evidence-based decision making in the James M. Anderson Center for Health Systems Excellence at Cincinnati Children’s.

Some doctors also argued that clinical guidelines would stifle innovation, cramp their individual style, or intrude on their relationships with patients. Despite some lingering misgivings among clinicians, however, the process has gained considerable support. In 2000, an organization called the GRADE Working Group (Grading of Recommendations, Assessment, Development and Evaluation) began developing a new approach to raise the quality of evidence and strength of recommendations.

The group’s work led to a 2004 article in BMJ, and the journal subsequently published a six-part series about GRADE for clinicians.4 More recently, the Journal of Clinical Epidemiology also delved into the issue with a 15-part series detailing the GRADE methodology.5 Together, Dr. Guyatt says, the articles have become a go-to guide for guidelines and have helped solidify the focus on evidence.

Cincinnati Children’s and other institutions also have developed tools, and the Institute of Medicine has published guideline-writing standards.

“So it’s easier than it’s ever been to know whether or not you have a decent guideline in your hand,” Gerhardt says.

Likewise, medical organizations are more clearly explaining how they came up with different kinds of guidelines. Evidence-based and consensus guidelines aren’t necessarily mutually exclusive, though consensus building is often used in the absence of high-quality evidence. Some organizations have limited the pool of evidence for guidelines to randomized controlled trial data.

“Unfortunately, for us in the real world, we actually have to make decisions even when there’s not enough data,” Dr. Feldman says.

Sometimes, the best available evidence may be observational studies, and some committees still try to reach a consensus based on that evidence and on the panelists’ professional opinions.

Dr. Guyatt agrees that it’s “absolutely not” true that evidence-based guidelines require randomized controlled trials. “What you need for any recommendation is a thorough review and summary of the best available evidence,” he says.

As part of each final document, Cincinnati Children’s details how it created the guideline, when the literature searches occurred, how the committee reached a consensus, and which panelists participated in the deliberations. The information, Gerhardt says, allows anyone else to “make some sensible decisions about whether or not it’s a guideline you want to use.”

Guideline-crafting institutions are also focusing more on the proper makeup of their panels. In general, Dr. Guyatt says, a panel with more than 10 people can be unwieldy. Guidelines that include many specific recommendations, however, may require multiple subsections, each with its own committee.

Dr. Guyatt is careful to note that, like many other experts, he has multiple potential conflicts of interest, such as working on the anti-thrombotic guidelines issued by the American College of Chest Physicians. Committees, he says, have become increasingly aware of how properly handling conflicts (financial or otherwise) can be critical in building and maintaining trust among clinicians and patients. One technique is to ensure that a diversity of opinions is reflected among a committee whose experts have various conflicts. If one expert’s company makes drug A, for example, then the committee also includes experts involved with drugs B or C. As an alternative, some committees have explicitly barred anyone with a conflict of interest from participating at all.

But experts often provide crucial input, Dr. Guyatt says, and several committees have adopted variations of a middle-ground approach. In an approach that he favors, all guideline-formulating panelists are conflict-free but begin their work by meeting with a separate group of experts who may have some conflicts but can help point out the main issues. The panelists then deliberate and write a draft of the recommendations, after which they meet again with the experts to receive feedback before finalizing the draft.

In a related approach, experts sit on the panel and discuss the evidence, but those with conflicts recuse themselves before the group votes on any recommendations. Delineating between discussions of the evidence and discussions of recommendations can be tricky, though, increasing the risk that a conflict of interest may influence the outcome. Even so, Dr. Guyatt says the model is still preferable to other alternatives.

Getting the Word Out

Once guidelines have been crafted and vetted, how can hospitalists get up to speed on them? Dr. Feldman’s favorite go-to source is Guideline.gov, a national guideline clearinghouse that he calls one of the best compendiums of available information. Especially helpful, he adds, are details such as how the guidelines were created.

To help maximize his time, he also uses tools like NEJM Journal Watch, which sends daily emails on noteworthy articles and weekend roundups of the most important studies.

“It is a way of at least trying to keep up with what’s going on,” he says. Similarly, he adds, ACP Journal Club provides summaries of important new articles, The Hospitalist can help highlight important guidelines that affect HM, and CME meetings or online modules like SHMconsults.com can help doctors keep pace.

For the past decade, Dr. Guyatt has worked with another popular tool, a guideline-disseminating service called UpToDate. Many alternatives exist, such as DynaMed Plus.

“I think you just need to pick away,” Dr. Feldman says. “You need to decide that as a physician, as a lifelong learner, that you are going to do something that is going to keep you up-to-date. There are many ways of doing it. You just have to decide what you’re going to do and commit to it.”

Lisa-Shieh.jpg

Researchers are helping out by studying how to present new guidelines in ways that engage doctors and improve patient outcomes. Another trend is to make guidelines routinely accessible not only in electronic medical records but also on tablets and smartphones. Lisa Shieh, MD, PhD, FHM, a hospitalist and clinical professor of medicine at Stanford University Medical Center, has studied how best-practice alerts, or BPAs, impact adherence to guidelines covering the appropriate use of blood products. Dr. Shieh, who splits her time between quality improvement and hospital medicine, says getting new information and guidelines into clinicians’ hands can be a logistical challenge.

“At Stanford, we had a huge official campaign around the guidelines, and that did make some impact, but it wasn’t huge in improving appropriate blood use,” she says. When the medial center set up a BPA through the electronic medical record system, however, both overall and inappropriate blood use declined significantly. In fact, the percentage of providers ordering blood products for patients with a hemoglobin count above 8 g/dL dropped from 60% to 25%.6

One difference maker, Dr. Shieh says, was providing education at the moment a doctor actually ordered blood. To avoid alert fatigue, the “smart BPA” fires only if a doctor tries to order blood and the patient’s hemoglobin is greater than 7 or 8 g/dL, depending on the diagnosis. If the doctor still wants to transfuse, the system requests a clinical indication for the exception.

Despite the clear improvement in appropriate use, the team wanted to understand why 25% of providers were still ordering blood products for patients with a hemoglobin count greater than 8 despite the triggered BPA and whether additional interventions could yield further improvements. Through their study, the researchers documented several reasons for the continued ordering. In some cases, the system failed to properly document actual or potential bleeding as an indicator. In other cases, the ordering reflected a lack of consensus on the guidelines in fields like hematology and oncology.

One of the most intriguing reasons, though, was that residents often did the ordering at the behest of an attending who might have never seen the BPA.

“It’s not actually reaching the audience making the decision; it might be reaching the audience that’s just carrying out the order,” Dr. Shieh says.

The insight, she says, may provide an opportunity to talk with attending physicians who may not have completely bought into the guidelines and to involve the entire team in the decision-making process.

Hospitalists, she says, can play a vital role in guideline development and implementation, especially for strategies that include BPAs.

“I think they’re the perfect group to help use this technology wisely because they are at the front lines taking care of patients so they’ll know the best workflow of when these alerts fire and maybe which ones happen the most often,” Dr. Shieh says. “I think this is a fantastic opportunity to get more hospitalists involved in designing these alerts and collaborating with the IT folks.”

Even with widespread buy-in from providers, guidelines may not reach their full potential without a careful consideration of patients’ values and concerns. Experts say joint deliberations and discussions are especially important for guidelines that are complicated, controversial, or carrying potential risks that must be weighed against the benefits.

Some of the conversations are easy, with well-defined risks and benefits and clear patient preferences, but others must traverse vast tracts of gray area. Fortunately, Dr. Feldman says, more tools also are becoming available for this kind of shared decision making. Some use pictorial representations to help patients understand the potential outcomes of alternative courses of action or inaction.

“Sometimes, that pictorial representation is worth the 1,000 words that we wouldn’t be able to adequately describe otherwise,” he says.

Similarly, Cincinnati Children’s has developed tools to help to ease the shared decision-making process.

“We look where there’s equivocal evidence or no evidence and have developed tools that help the clinician have that conversation with the family and then have them informed enough that they can actually weigh in on what they want,” Gerhardt says. One end product is a card or trifold pamphlet that might help parents understand the benefits and side effects of alternate strategies.

“Typically, in medicine, we’re used to telling people what needs to be done,” she says. “So shared decision making is kind of a different thing for clinicians to engage in.” TH

Bryn Nelson, PhD, is a freelance writer in Seattle.

References

1. Valle CW, Binns HJ, Quadri-Sheriff M, Benuck I, Patel A. Physicians’ lack of adherence to National Heart, Lung, and Blood Institute guidelines for pediatric lipid screening. Clin Pediatr. 2015;54(12):1200-1205.
2. Maynard G, Jenkins IH, Merli GJ. Venous thromboembolism prevention guidelines for medical inpatients: mind the (implementation) gap. J Hosp Med. 2013;8(10):582-588.
3. Mehta RH, Chen AY, Alexander KP, Ohman EM, Roe MT, Peterson ED. Doing the right things and doing them the right way: association between hospital guideline adherence, dosing safety, and outcomes among patients with acute coronary syndrome. Circulation. 2015;131(11):980-987.
4. GRADE Working Group. Grading quality of evidence and strength of recommendations. BMJ. 2004;328:1490
5. Andrews JC, Schünemann HJ, Oxman AD, et al. GRADE guidelines: 15. Going from evidence to recommendation—determinants of a recommendation’s direction and strength. J Clin Epidemiol. 2013;66(7):726-735.
6. 6. Chen JH, Fang DZ, Tim Goodnough L, Evans KH, Lee Porter M, Shieh L. Why providers transfuse blood products outside recommended guidelines in spite of integrated electronic best practice alerts. J Hosp Med. 2015;10(1):1-7.

Algorithm-300x172.jpg

One recent paper in Clinical Pediatrics, for example, chronicled low adherence to the 2011 National Heart, Lung, and Blood Institute lipid screening guidelines in primary-care settings.1 Another cautioned providers to “mind the (implementation) gap” in venous thromboembolism prevention guidelines for medical inpatients.2 A third found that lower adherence to guidelines issued by the American College of Cardiology/American Heart Association for acute coronary syndrome patients was significantly associated with higher bleeding and mortality rates.3

William-Lewis.jpg

Both clinical trials and real-world studies have demonstrated that when guidelines are applied, patients do better, says William Lewis, MD, professor of medicine at Case Western Reserve University and director of the Heart & Vascular Center at MetroHealth in Cleveland. So why aren’t they followed more consistently?

Experts in both HM and other disciplines cite multiple obstacles. Lack of evidence, conflicting evidence, or lack of awareness about evidence can all conspire against the main goal of helping providers deliver consistent high-value care, says Christopher Moriates, MD, assistant clinical professor in the Division of Hospital Medicine at the University of California, San Francisco.

Christopher-Moriates.jpg

“In our day-to-day lives as hospitalists, for the vast majority probably of what we do there’s no clear guideline or there’s a guideline that doesn’t necessarily apply to the patient standing in front of me,” he says.

Even when a guideline is clear and relevant, other doctors say inadequate dissemination and implementation can still derail quality improvement efforts.

“A lot of what we do as physicians is what we learned in residency, and to incorporate the new data is difficult,” says Leonard Feldman, MD, SFHM, a hospitalist and associate professor of internal medicine and pediatrics at Johns Hopkins School of Medicine in Baltimore.

Lenny-Feldman.jpg

Dr. Feldman believes many doctors have yet to integrate recently revised hypertension and cholesterol guidelines into their practice, for example. Some guidelines have proven more complex or controversial, limiting their adoption.

“I know I struggle to keep up with all of the guidelines, and I’m in a big academic center where people are talking about them all the time, and I’m working with residents who are talking about them all the time,” Dr. Feldman says.

Despite the remaining gaps, however, many researchers agree that momentum has built steadily over the past two decades toward a more systematic approach to creating solid evidence-based guidelines and integrating them into real-world decision making.

Emphasis on Evidence and Transparency

Gordon-Guyatt.jpg

The term “evidence-based medicine” was coined in 1990 by Gordon Guyatt, MD, MSc, FRCPC, distinguished professor of medicine and clinical epidemiology at McMaster University in Hamilton, Ontario. It’s played an active role in formulating guidelines for multiple organizations. The guideline-writing process, Dr. Guyatt says, once consisted of little more than self-selected clinicians sitting around a table.

“It used to be that a bunch of experts got together and decided and made the recommendations with very little in the way of a systematic process and certainly not evidence based,” he says.

Cincinnati Children’s Hospital Medical Center was among the pioneers pushing for a more systematic approach; the hospital began working on its own guidelines in 1995 and published the first of many the following year.

Wendy-Gerhardt.jpg

“We started evidence-based guidelines when the docs were still saying, ‘This is cookbook medicine. I don’t know if I want to do this or not,’” says Wendy Gerhardt, MSN, director of evidence-based decision making in the James M. Anderson Center for Health Systems Excellence at Cincinnati Children’s.

Some doctors also argued that clinical guidelines would stifle innovation, cramp their individual style, or intrude on their relationships with patients. Despite some lingering misgivings among clinicians, however, the process has gained considerable support. In 2000, an organization called the GRADE Working Group (Grading of Recommendations, Assessment, Development and Evaluation) began developing a new approach to raise the quality of evidence and strength of recommendations.

The group’s work led to a 2004 article in BMJ, and the journal subsequently published a six-part series about GRADE for clinicians.4 More recently, the Journal of Clinical Epidemiology also delved into the issue with a 15-part series detailing the GRADE methodology.5 Together, Dr. Guyatt says, the articles have become a go-to guide for guidelines and have helped solidify the focus on evidence.

Cincinnati Children’s and other institutions also have developed tools, and the Institute of Medicine has published guideline-writing standards.

“So it’s easier than it’s ever been to know whether or not you have a decent guideline in your hand,” Gerhardt says.

Likewise, medical organizations are more clearly explaining how they came up with different kinds of guidelines. Evidence-based and consensus guidelines aren’t necessarily mutually exclusive, though consensus building is often used in the absence of high-quality evidence. Some organizations have limited the pool of evidence for guidelines to randomized controlled trial data.

“Unfortunately, for us in the real world, we actually have to make decisions even when there’s not enough data,” Dr. Feldman says.

Sometimes, the best available evidence may be observational studies, and some committees still try to reach a consensus based on that evidence and on the panelists’ professional opinions.

Dr. Guyatt agrees that it’s “absolutely not” true that evidence-based guidelines require randomized controlled trials. “What you need for any recommendation is a thorough review and summary of the best available evidence,” he says.

As part of each final document, Cincinnati Children’s details how it created the guideline, when the literature searches occurred, how the committee reached a consensus, and which panelists participated in the deliberations. The information, Gerhardt says, allows anyone else to “make some sensible decisions about whether or not it’s a guideline you want to use.”

Guideline-crafting institutions are also focusing more on the proper makeup of their panels. In general, Dr. Guyatt says, a panel with more than 10 people can be unwieldy. Guidelines that include many specific recommendations, however, may require multiple subsections, each with its own committee.

Dr. Guyatt is careful to note that, like many other experts, he has multiple potential conflicts of interest, such as working on the anti-thrombotic guidelines issued by the American College of Chest Physicians. Committees, he says, have become increasingly aware of how properly handling conflicts (financial or otherwise) can be critical in building and maintaining trust among clinicians and patients. One technique is to ensure that a diversity of opinions is reflected among a committee whose experts have various conflicts. If one expert’s company makes drug A, for example, then the committee also includes experts involved with drugs B or C. As an alternative, some committees have explicitly barred anyone with a conflict of interest from participating at all.

But experts often provide crucial input, Dr. Guyatt says, and several committees have adopted variations of a middle-ground approach. In an approach that he favors, all guideline-formulating panelists are conflict-free but begin their work by meeting with a separate group of experts who may have some conflicts but can help point out the main issues. The panelists then deliberate and write a draft of the recommendations, after which they meet again with the experts to receive feedback before finalizing the draft.

In a related approach, experts sit on the panel and discuss the evidence, but those with conflicts recuse themselves before the group votes on any recommendations. Delineating between discussions of the evidence and discussions of recommendations can be tricky, though, increasing the risk that a conflict of interest may influence the outcome. Even so, Dr. Guyatt says the model is still preferable to other alternatives.

Getting the Word Out

Once guidelines have been crafted and vetted, how can hospitalists get up to speed on them? Dr. Feldman’s favorite go-to source is Guideline.gov, a national guideline clearinghouse that he calls one of the best compendiums of available information. Especially helpful, he adds, are details such as how the guidelines were created.

To help maximize his time, he also uses tools like NEJM Journal Watch, which sends daily emails on noteworthy articles and weekend roundups of the most important studies.

“It is a way of at least trying to keep up with what’s going on,” he says. Similarly, he adds, ACP Journal Club provides summaries of important new articles, The Hospitalist can help highlight important guidelines that affect HM, and CME meetings or online modules like SHMconsults.com can help doctors keep pace.

For the past decade, Dr. Guyatt has worked with another popular tool, a guideline-disseminating service called UpToDate. Many alternatives exist, such as DynaMed Plus.

“I think you just need to pick away,” Dr. Feldman says. “You need to decide that as a physician, as a lifelong learner, that you are going to do something that is going to keep you up-to-date. There are many ways of doing it. You just have to decide what you’re going to do and commit to it.”

Lisa-Shieh.jpg

Researchers are helping out by studying how to present new guidelines in ways that engage doctors and improve patient outcomes. Another trend is to make guidelines routinely accessible not only in electronic medical records but also on tablets and smartphones. Lisa Shieh, MD, PhD, FHM, a hospitalist and clinical professor of medicine at Stanford University Medical Center, has studied how best-practice alerts, or BPAs, impact adherence to guidelines covering the appropriate use of blood products. Dr. Shieh, who splits her time between quality improvement and hospital medicine, says getting new information and guidelines into clinicians’ hands can be a logistical challenge.

“At Stanford, we had a huge official campaign around the guidelines, and that did make some impact, but it wasn’t huge in improving appropriate blood use,” she says. When the medial center set up a BPA through the electronic medical record system, however, both overall and inappropriate blood use declined significantly. In fact, the percentage of providers ordering blood products for patients with a hemoglobin count above 8 g/dL dropped from 60% to 25%.6

One difference maker, Dr. Shieh says, was providing education at the moment a doctor actually ordered blood. To avoid alert fatigue, the “smart BPA” fires only if a doctor tries to order blood and the patient’s hemoglobin is greater than 7 or 8 g/dL, depending on the diagnosis. If the doctor still wants to transfuse, the system requests a clinical indication for the exception.

Despite the clear improvement in appropriate use, the team wanted to understand why 25% of providers were still ordering blood products for patients with a hemoglobin count greater than 8 despite the triggered BPA and whether additional interventions could yield further improvements. Through their study, the researchers documented several reasons for the continued ordering. In some cases, the system failed to properly document actual or potential bleeding as an indicator. In other cases, the ordering reflected a lack of consensus on the guidelines in fields like hematology and oncology.

One of the most intriguing reasons, though, was that residents often did the ordering at the behest of an attending who might have never seen the BPA.

“It’s not actually reaching the audience making the decision; it might be reaching the audience that’s just carrying out the order,” Dr. Shieh says.

The insight, she says, may provide an opportunity to talk with attending physicians who may not have completely bought into the guidelines and to involve the entire team in the decision-making process.

Hospitalists, she says, can play a vital role in guideline development and implementation, especially for strategies that include BPAs.

“I think they’re the perfect group to help use this technology wisely because they are at the front lines taking care of patients so they’ll know the best workflow of when these alerts fire and maybe which ones happen the most often,” Dr. Shieh says. “I think this is a fantastic opportunity to get more hospitalists involved in designing these alerts and collaborating with the IT folks.”

Even with widespread buy-in from providers, guidelines may not reach their full potential without a careful consideration of patients’ values and concerns. Experts say joint deliberations and discussions are especially important for guidelines that are complicated, controversial, or carrying potential risks that must be weighed against the benefits.

Some of the conversations are easy, with well-defined risks and benefits and clear patient preferences, but others must traverse vast tracts of gray area. Fortunately, Dr. Feldman says, more tools also are becoming available for this kind of shared decision making. Some use pictorial representations to help patients understand the potential outcomes of alternative courses of action or inaction.

“Sometimes, that pictorial representation is worth the 1,000 words that we wouldn’t be able to adequately describe otherwise,” he says.

Similarly, Cincinnati Children’s has developed tools to help to ease the shared decision-making process.

“We look where there’s equivocal evidence or no evidence and have developed tools that help the clinician have that conversation with the family and then have them informed enough that they can actually weigh in on what they want,” Gerhardt says. One end product is a card or trifold pamphlet that might help parents understand the benefits and side effects of alternate strategies.

“Typically, in medicine, we’re used to telling people what needs to be done,” she says. “So shared decision making is kind of a different thing for clinicians to engage in.” TH

Bryn Nelson, PhD, is a freelance writer in Seattle.

References

1. Valle CW, Binns HJ, Quadri-Sheriff M, Benuck I, Patel A. Physicians’ lack of adherence to National Heart, Lung, and Blood Institute guidelines for pediatric lipid screening. Clin Pediatr. 2015;54(12):1200-1205.
2. Maynard G, Jenkins IH, Merli GJ. Venous thromboembolism prevention guidelines for medical inpatients: mind the (implementation) gap. J Hosp Med. 2013;8(10):582-588.
3. Mehta RH, Chen AY, Alexander KP, Ohman EM, Roe MT, Peterson ED. Doing the right things and doing them the right way: association between hospital guideline adherence, dosing safety, and outcomes among patients with acute coronary syndrome. Circulation. 2015;131(11):980-987.
4. GRADE Working Group. Grading quality of evidence and strength of recommendations. BMJ. 2004;328:1490
5. Andrews JC, Schünemann HJ, Oxman AD, et al. GRADE guidelines: 15. Going from evidence to recommendation—determinants of a recommendation’s direction and strength. J Clin Epidemiol. 2013;66(7):726-735.
6. 6. Chen JH, Fang DZ, Tim Goodnough L, Evans KH, Lee Porter M, Shieh L. Why providers transfuse blood products outside recommended guidelines in spite of integrated electronic best practice alerts. J Hosp Med. 2015;10(1):1-7.

Algorithm-300x172.jpg

One recent paper in Clinical Pediatrics, for example, chronicled low adherence to the 2011 National Heart, Lung, and Blood Institute lipid screening guidelines in primary-care settings.1 Another cautioned providers to “mind the (implementation) gap” in venous thromboembolism prevention guidelines for medical inpatients.2 A third found that lower adherence to guidelines issued by the American College of Cardiology/American Heart Association for acute coronary syndrome patients was significantly associated with higher bleeding and mortality rates.3

William-Lewis.jpg

Both clinical trials and real-world studies have demonstrated that when guidelines are applied, patients do better, says William Lewis, MD, professor of medicine at Case Western Reserve University and director of the Heart & Vascular Center at MetroHealth in Cleveland. So why aren’t they followed more consistently?

Experts in both HM and other disciplines cite multiple obstacles. Lack of evidence, conflicting evidence, or lack of awareness about evidence can all conspire against the main goal of helping providers deliver consistent high-value care, says Christopher Moriates, MD, assistant clinical professor in the Division of Hospital Medicine at the University of California, San Francisco.

Christopher-Moriates.jpg

“In our day-to-day lives as hospitalists, for the vast majority probably of what we do there’s no clear guideline or there’s a guideline that doesn’t necessarily apply to the patient standing in front of me,” he says.

Even when a guideline is clear and relevant, other doctors say inadequate dissemination and implementation can still derail quality improvement efforts.

“A lot of what we do as physicians is what we learned in residency, and to incorporate the new data is difficult,” says Leonard Feldman, MD, SFHM, a hospitalist and associate professor of internal medicine and pediatrics at Johns Hopkins School of Medicine in Baltimore.

Lenny-Feldman.jpg

Dr. Feldman believes many doctors have yet to integrate recently revised hypertension and cholesterol guidelines into their practice, for example. Some guidelines have proven more complex or controversial, limiting their adoption.

“I know I struggle to keep up with all of the guidelines, and I’m in a big academic center where people are talking about them all the time, and I’m working with residents who are talking about them all the time,” Dr. Feldman says.

Despite the remaining gaps, however, many researchers agree that momentum has built steadily over the past two decades toward a more systematic approach to creating solid evidence-based guidelines and integrating them into real-world decision making.

Emphasis on Evidence and Transparency

Gordon-Guyatt.jpg

The term “evidence-based medicine” was coined in 1990 by Gordon Guyatt, MD, MSc, FRCPC, distinguished professor of medicine and clinical epidemiology at McMaster University in Hamilton, Ontario. It’s played an active role in formulating guidelines for multiple organizations. The guideline-writing process, Dr. Guyatt says, once consisted of little more than self-selected clinicians sitting around a table.

“It used to be that a bunch of experts got together and decided and made the recommendations with very little in the way of a systematic process and certainly not evidence based,” he says.

Cincinnati Children’s Hospital Medical Center was among the pioneers pushing for a more systematic approach; the hospital began working on its own guidelines in 1995 and published the first of many the following year.

Wendy-Gerhardt.jpg

“We started evidence-based guidelines when the docs were still saying, ‘This is cookbook medicine. I don’t know if I want to do this or not,’” says Wendy Gerhardt, MSN, director of evidence-based decision making in the James M. Anderson Center for Health Systems Excellence at Cincinnati Children’s.

Some doctors also argued that clinical guidelines would stifle innovation, cramp their individual style, or intrude on their relationships with patients. Despite some lingering misgivings among clinicians, however, the process has gained considerable support. In 2000, an organization called the GRADE Working Group (Grading of Recommendations, Assessment, Development and Evaluation) began developing a new approach to raise the quality of evidence and strength of recommendations.

The group’s work led to a 2004 article in BMJ, and the journal subsequently published a six-part series about GRADE for clinicians.4 More recently, the Journal of Clinical Epidemiology also delved into the issue with a 15-part series detailing the GRADE methodology.5 Together, Dr. Guyatt says, the articles have become a go-to guide for guidelines and have helped solidify the focus on evidence.

Cincinnati Children’s and other institutions also have developed tools, and the Institute of Medicine has published guideline-writing standards.

“So it’s easier than it’s ever been to know whether or not you have a decent guideline in your hand,” Gerhardt says.

Likewise, medical organizations are more clearly explaining how they came up with different kinds of guidelines. Evidence-based and consensus guidelines aren’t necessarily mutually exclusive, though consensus building is often used in the absence of high-quality evidence. Some organizations have limited the pool of evidence for guidelines to randomized controlled trial data.

“Unfortunately, for us in the real world, we actually have to make decisions even when there’s not enough data,” Dr. Feldman says.

Sometimes, the best available evidence may be observational studies, and some committees still try to reach a consensus based on that evidence and on the panelists’ professional opinions.

Dr. Guyatt agrees that it’s “absolutely not” true that evidence-based guidelines require randomized controlled trials. “What you need for any recommendation is a thorough review and summary of the best available evidence,” he says.

As part of each final document, Cincinnati Children’s details how it created the guideline, when the literature searches occurred, how the committee reached a consensus, and which panelists participated in the deliberations. The information, Gerhardt says, allows anyone else to “make some sensible decisions about whether or not it’s a guideline you want to use.”

Guideline-crafting institutions are also focusing more on the proper makeup of their panels. In general, Dr. Guyatt says, a panel with more than 10 people can be unwieldy. Guidelines that include many specific recommendations, however, may require multiple subsections, each with its own committee.

Dr. Guyatt is careful to note that, like many other experts, he has multiple potential conflicts of interest, such as working on the anti-thrombotic guidelines issued by the American College of Chest Physicians. Committees, he says, have become increasingly aware of how properly handling conflicts (financial or otherwise) can be critical in building and maintaining trust among clinicians and patients. One technique is to ensure that a diversity of opinions is reflected among a committee whose experts have various conflicts. If one expert’s company makes drug A, for example, then the committee also includes experts involved with drugs B or C. As an alternative, some committees have explicitly barred anyone with a conflict of interest from participating at all.

But experts often provide crucial input, Dr. Guyatt says, and several committees have adopted variations of a middle-ground approach. In an approach that he favors, all guideline-formulating panelists are conflict-free but begin their work by meeting with a separate group of experts who may have some conflicts but can help point out the main issues. The panelists then deliberate and write a draft of the recommendations, after which they meet again with the experts to receive feedback before finalizing the draft.

In a related approach, experts sit on the panel and discuss the evidence, but those with conflicts recuse themselves before the group votes on any recommendations. Delineating between discussions of the evidence and discussions of recommendations can be tricky, though, increasing the risk that a conflict of interest may influence the outcome. Even so, Dr. Guyatt says the model is still preferable to other alternatives.

Getting the Word Out

Once guidelines have been crafted and vetted, how can hospitalists get up to speed on them? Dr. Feldman’s favorite go-to source is Guideline.gov, a national guideline clearinghouse that he calls one of the best compendiums of available information. Especially helpful, he adds, are details such as how the guidelines were created.

To help maximize his time, he also uses tools like NEJM Journal Watch, which sends daily emails on noteworthy articles and weekend roundups of the most important studies.

“It is a way of at least trying to keep up with what’s going on,” he says. Similarly, he adds, ACP Journal Club provides summaries of important new articles, The Hospitalist can help highlight important guidelines that affect HM, and CME meetings or online modules like SHMconsults.com can help doctors keep pace.

For the past decade, Dr. Guyatt has worked with another popular tool, a guideline-disseminating service called UpToDate. Many alternatives exist, such as DynaMed Plus.

“I think you just need to pick away,” Dr. Feldman says. “You need to decide that as a physician, as a lifelong learner, that you are going to do something that is going to keep you up-to-date. There are many ways of doing it. You just have to decide what you’re going to do and commit to it.”

Lisa-Shieh.jpg

Researchers are helping out by studying how to present new guidelines in ways that engage doctors and improve patient outcomes. Another trend is to make guidelines routinely accessible not only in electronic medical records but also on tablets and smartphones. Lisa Shieh, MD, PhD, FHM, a hospitalist and clinical professor of medicine at Stanford University Medical Center, has studied how best-practice alerts, or BPAs, impact adherence to guidelines covering the appropriate use of blood products. Dr. Shieh, who splits her time between quality improvement and hospital medicine, says getting new information and guidelines into clinicians’ hands can be a logistical challenge.

“At Stanford, we had a huge official campaign around the guidelines, and that did make some impact, but it wasn’t huge in improving appropriate blood use,” she says. When the medial center set up a BPA through the electronic medical record system, however, both overall and inappropriate blood use declined significantly. In fact, the percentage of providers ordering blood products for patients with a hemoglobin count above 8 g/dL dropped from 60% to 25%.6

One difference maker, Dr. Shieh says, was providing education at the moment a doctor actually ordered blood. To avoid alert fatigue, the “smart BPA” fires only if a doctor tries to order blood and the patient’s hemoglobin is greater than 7 or 8 g/dL, depending on the diagnosis. If the doctor still wants to transfuse, the system requests a clinical indication for the exception.

Despite the clear improvement in appropriate use, the team wanted to understand why 25% of providers were still ordering blood products for patients with a hemoglobin count greater than 8 despite the triggered BPA and whether additional interventions could yield further improvements. Through their study, the researchers documented several reasons for the continued ordering. In some cases, the system failed to properly document actual or potential bleeding as an indicator. In other cases, the ordering reflected a lack of consensus on the guidelines in fields like hematology and oncology.

One of the most intriguing reasons, though, was that residents often did the ordering at the behest of an attending who might have never seen the BPA.

“It’s not actually reaching the audience making the decision; it might be reaching the audience that’s just carrying out the order,” Dr. Shieh says.

The insight, she says, may provide an opportunity to talk with attending physicians who may not have completely bought into the guidelines and to involve the entire team in the decision-making process.

Hospitalists, she says, can play a vital role in guideline development and implementation, especially for strategies that include BPAs.

“I think they’re the perfect group to help use this technology wisely because they are at the front lines taking care of patients so they’ll know the best workflow of when these alerts fire and maybe which ones happen the most often,” Dr. Shieh says. “I think this is a fantastic opportunity to get more hospitalists involved in designing these alerts and collaborating with the IT folks.”

Even with widespread buy-in from providers, guidelines may not reach their full potential without a careful consideration of patients’ values and concerns. Experts say joint deliberations and discussions are especially important for guidelines that are complicated, controversial, or carrying potential risks that must be weighed against the benefits.

Some of the conversations are easy, with well-defined risks and benefits and clear patient preferences, but others must traverse vast tracts of gray area. Fortunately, Dr. Feldman says, more tools also are becoming available for this kind of shared decision making. Some use pictorial representations to help patients understand the potential outcomes of alternative courses of action or inaction.

“Sometimes, that pictorial representation is worth the 1,000 words that we wouldn’t be able to adequately describe otherwise,” he says.

Similarly, Cincinnati Children’s has developed tools to help to ease the shared decision-making process.

“We look where there’s equivocal evidence or no evidence and have developed tools that help the clinician have that conversation with the family and then have them informed enough that they can actually weigh in on what they want,” Gerhardt says. One end product is a card or trifold pamphlet that might help parents understand the benefits and side effects of alternate strategies.

“Typically, in medicine, we’re used to telling people what needs to be done,” she says. “So shared decision making is kind of a different thing for clinicians to engage in.” TH

Bryn Nelson, PhD, is a freelance writer in Seattle.

References

1. Valle CW, Binns HJ, Quadri-Sheriff M, Benuck I, Patel A. Physicians’ lack of adherence to National Heart, Lung, and Blood Institute guidelines for pediatric lipid screening. Clin Pediatr. 2015;54(12):1200-1205.
2. Maynard G, Jenkins IH, Merli GJ. Venous thromboembolism prevention guidelines for medical inpatients: mind the (implementation) gap. J Hosp Med. 2013;8(10):582-588.
3. Mehta RH, Chen AY, Alexander KP, Ohman EM, Roe MT, Peterson ED. Doing the right things and doing them the right way: association between hospital guideline adherence, dosing safety, and outcomes among patients with acute coronary syndrome. Circulation. 2015;131(11):980-987.
4. GRADE Working Group. Grading quality of evidence and strength of recommendations. BMJ. 2004;328:1490
5. Andrews JC, Schünemann HJ, Oxman AD, et al. GRADE guidelines: 15. Going from evidence to recommendation—determinants of a recommendation’s direction and strength. J Clin Epidemiol. 2013;66(7):726-735.
6. 6. Chen JH, Fang DZ, Tim Goodnough L, Evans KH, Lee Porter M, Shieh L. Why providers transfuse blood products outside recommended guidelines in spite of integrated electronic best practice alerts. J Hosp Med. 2015;10(1):1-7.