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Using “design thinking” to improve health care
Health care workers creating innovations by applying “design thinking” – “a human-centered approach to innovation” that comes from the business world – is a growing trend, according to a recent New York Times article.
“With design thinking, the innovations come from those who actually work there, providing feedback to designers to improve the final product,” wrote author Amitha Kalaichandran, MD, MHS.
“Health providers ... are uniquely positioned to come up with fresh solutions to health care problems,” Dr. Kalaichandran wrote. An example at her own hospital: The leader of the trauma team now wears an orange vest, clearly identifying who’s in charge in a potentially chaotic situation. It was an idea created by a hospital nurse.
“A 2016 report that looked at ways in which a health system can implement design thinking identified three principles behind the approach: empathy for the user, in this case a patient, doctor or other health care provider; the involvement of an interdisciplinary team; and rapid prototyping of the idea,” she wrote. “To develop a truly useful product, a comprehensive understanding of the problem the innovation aims to solve is paramount.”
In design thinking, described as creative, multidisciplinary thinking around a problem, groups naturally coalesce to find such solutions. The article cites examples such as Clinicians for Design, an international group of providers focused on improving hospital layouts, and Health Design by Us, a collaborative group that supports health care innovations such as a mobile system for diabetes management, designed by a patient.
Reference
Kalaichandran A. Design thinking for doctors and nurses. The New York Times. Aug. 3, 2017. Accessed Aug. 7, 2017.
Health care workers creating innovations by applying “design thinking” – “a human-centered approach to innovation” that comes from the business world – is a growing trend, according to a recent New York Times article.
“With design thinking, the innovations come from those who actually work there, providing feedback to designers to improve the final product,” wrote author Amitha Kalaichandran, MD, MHS.
“Health providers ... are uniquely positioned to come up with fresh solutions to health care problems,” Dr. Kalaichandran wrote. An example at her own hospital: The leader of the trauma team now wears an orange vest, clearly identifying who’s in charge in a potentially chaotic situation. It was an idea created by a hospital nurse.
“A 2016 report that looked at ways in which a health system can implement design thinking identified three principles behind the approach: empathy for the user, in this case a patient, doctor or other health care provider; the involvement of an interdisciplinary team; and rapid prototyping of the idea,” she wrote. “To develop a truly useful product, a comprehensive understanding of the problem the innovation aims to solve is paramount.”
In design thinking, described as creative, multidisciplinary thinking around a problem, groups naturally coalesce to find such solutions. The article cites examples such as Clinicians for Design, an international group of providers focused on improving hospital layouts, and Health Design by Us, a collaborative group that supports health care innovations such as a mobile system for diabetes management, designed by a patient.
Reference
Kalaichandran A. Design thinking for doctors and nurses. The New York Times. Aug. 3, 2017. Accessed Aug. 7, 2017.
Health care workers creating innovations by applying “design thinking” – “a human-centered approach to innovation” that comes from the business world – is a growing trend, according to a recent New York Times article.
“With design thinking, the innovations come from those who actually work there, providing feedback to designers to improve the final product,” wrote author Amitha Kalaichandran, MD, MHS.
“Health providers ... are uniquely positioned to come up with fresh solutions to health care problems,” Dr. Kalaichandran wrote. An example at her own hospital: The leader of the trauma team now wears an orange vest, clearly identifying who’s in charge in a potentially chaotic situation. It was an idea created by a hospital nurse.
“A 2016 report that looked at ways in which a health system can implement design thinking identified three principles behind the approach: empathy for the user, in this case a patient, doctor or other health care provider; the involvement of an interdisciplinary team; and rapid prototyping of the idea,” she wrote. “To develop a truly useful product, a comprehensive understanding of the problem the innovation aims to solve is paramount.”
In design thinking, described as creative, multidisciplinary thinking around a problem, groups naturally coalesce to find such solutions. The article cites examples such as Clinicians for Design, an international group of providers focused on improving hospital layouts, and Health Design by Us, a collaborative group that supports health care innovations such as a mobile system for diabetes management, designed by a patient.
Reference
Kalaichandran A. Design thinking for doctors and nurses. The New York Times. Aug. 3, 2017. Accessed Aug. 7, 2017.
New curriculum teaches value-based health care
While value has become an imperative in both training and health care delivery, few tools exist to teach hospitalists and other providers the basic concepts of value.
“Hospitalists are on the front lines of health care value delivery, and it is critical that we understand and embrace the concepts of value; however, we also need to be able to deliver upon these ideals,” said Christopher Moriates, MD, assistant dean for health care value at the University of Texas at Austin.
“As a hospitalist, I ensured that the content would be specifically applicable to our day-to-day world and experience,” Dr. Moriates said. “Using the modules, hospitalists can better understand how emerging tools, such as the University of Utah’s Value-Drive Outcome tool, can be used by hospitalists to improve value. The modules also dig into thorny subjects like understanding health care costs – for example, what really is the difference between costs and charges?”
The course is adaptive and interactive, using the latest in instructional technology, he said. Hospitalists can take the course independently and earn free CME credits; those who complete all three modules in this first collection will receive a certificate of completion and CME credit.
The goal is to release 10 modules over the course of this academic year, Dr. Moriates said. Future collections will cover “value-based health care delivery,” “how to deliver high-value care at the bedside,” and “how to deliver high-value care in systems.”
“As value-based health care is increasingly taught in medical schools and residency training, it is important for hospitalists – especially any of us that work with trainees – to be able to speak the same language and understand what our trainees now will know,” he said.
While value has become an imperative in both training and health care delivery, few tools exist to teach hospitalists and other providers the basic concepts of value.
“Hospitalists are on the front lines of health care value delivery, and it is critical that we understand and embrace the concepts of value; however, we also need to be able to deliver upon these ideals,” said Christopher Moriates, MD, assistant dean for health care value at the University of Texas at Austin.
“As a hospitalist, I ensured that the content would be specifically applicable to our day-to-day world and experience,” Dr. Moriates said. “Using the modules, hospitalists can better understand how emerging tools, such as the University of Utah’s Value-Drive Outcome tool, can be used by hospitalists to improve value. The modules also dig into thorny subjects like understanding health care costs – for example, what really is the difference between costs and charges?”
The course is adaptive and interactive, using the latest in instructional technology, he said. Hospitalists can take the course independently and earn free CME credits; those who complete all three modules in this first collection will receive a certificate of completion and CME credit.
The goal is to release 10 modules over the course of this academic year, Dr. Moriates said. Future collections will cover “value-based health care delivery,” “how to deliver high-value care at the bedside,” and “how to deliver high-value care in systems.”
“As value-based health care is increasingly taught in medical schools and residency training, it is important for hospitalists – especially any of us that work with trainees – to be able to speak the same language and understand what our trainees now will know,” he said.
While value has become an imperative in both training and health care delivery, few tools exist to teach hospitalists and other providers the basic concepts of value.
“Hospitalists are on the front lines of health care value delivery, and it is critical that we understand and embrace the concepts of value; however, we also need to be able to deliver upon these ideals,” said Christopher Moriates, MD, assistant dean for health care value at the University of Texas at Austin.
“As a hospitalist, I ensured that the content would be specifically applicable to our day-to-day world and experience,” Dr. Moriates said. “Using the modules, hospitalists can better understand how emerging tools, such as the University of Utah’s Value-Drive Outcome tool, can be used by hospitalists to improve value. The modules also dig into thorny subjects like understanding health care costs – for example, what really is the difference between costs and charges?”
The course is adaptive and interactive, using the latest in instructional technology, he said. Hospitalists can take the course independently and earn free CME credits; those who complete all three modules in this first collection will receive a certificate of completion and CME credit.
The goal is to release 10 modules over the course of this academic year, Dr. Moriates said. Future collections will cover “value-based health care delivery,” “how to deliver high-value care at the bedside,” and “how to deliver high-value care in systems.”
“As value-based health care is increasingly taught in medical schools and residency training, it is important for hospitalists – especially any of us that work with trainees – to be able to speak the same language and understand what our trainees now will know,” he said.
Using post-acute and long-term care quality report cards
The challenges of hospital discharge planning are well known and yet have not been adequately addressed by hospitalists and discharge teams. As the complexity of patient care needs has grown, so has the difficulty in developing appropriate discharge goals for post-acute and long term care (LTC), choosing the appropriate setting(s), and selecting appropriate providers. Post-acute and LTC needs may include rehabilitation, nursing care, home health, supportive services, and/or palliative care1 in an institutional setting or at home from a wide array of providers with varying levels of quality.
Even though 52% of U.S. hospitals received penalties for having higher-than-expected readmissions between 2013 and 2017,2 inadequate discharge planning for post-acute and LTC continues to contribute to high rates of all-cause 30-day rehospitalization. The discharge process sometimes is deficient in: discussion of goals; assessment of discharge needs; appropriate choice of discharge locations; and the provision of additional or different home services.3 Discharge decisions are complicated by the stressful circumstances of hospitalization and discharge deadlines.
Hospital discharge planning decisions fall heavily on patients, families, and caregivers, often with inadequate information about choices and options. More than 30 states have passed the Caregiver Advise, Record, and Enable (CARE) Act into law to require hospitals to provide resources for family caregiver education and instruction,7 but hospitals do not have to provide information on all LTC options and provider quality ratings.
Quality report cards about LTC providers – a major innovation for consumer education and choice – are often not used in the discharge process for a number of reasons. A significant concern is that using report cards will extend the length of stay. Rather than extending the decision-making time and the length of stay, the use of report cards can reduce length of stay.9 A focus on identifying the first available nursing home bed or LTC provider often ignores the need to identify the most appropriate high-quality providers.
Hospitals and health plans often have established networks of post-acute and LTC providers and these networks must be taken into account in the discharge process. Most hospital and health plan networks have providers with a wide range of ratings, allowing for choices within networks.
The Centers for Medicare and Medicaid Services (CMS) established a web-based nursing home report card called Nursing Home Compare in 1998 that includes information on facility characteristics, deficiencies, staffing information (since 2000), and resident quality indicators (since 2002). In 2008, the website added a “five-star” rating system for all U.S. nursing homes and all-cause 30-day readmission rates and successful discharge rates from nursing homes were incorporated into the ratings in 2016.
CMS also established a web-based home health website, which provides quality ratings. This website has general information, quality measures, and patient surveys with information on readmission rates from home health agency services.
After establishment of the CMS Nursing Home Compare rating system in 2008, nursing homes improved their scores on certain quality measures and consumer demand significantly increased for the best (5-star) facilities and decreased for 1-star facilities.10 More recently, a clinical trial of the use of a personalized version of Nursing Home Compare in the hospital discharge planning process found greater patient satisfaction, patients being more likely to go to higher ranked nursing homes, patients traveling further to nursing homes, and patients having shorter hospital stays, compared with the control group.9
Quality report cards show wide variations within and across states ranging from one star (poorest quality) to five stars (highest quality). More than one-third of nursing homes had relatively low overall star ratings (1 or 2 stars) serving 39 percent of residents in 2015.11 Federal nursing home regulatory violations range from zero to more than 40 deficiencies (average of 7) with a scope and severity ranging from minor to widespread harm or jeopardy (including deaths).12 Total nurse staffing hours (average, 4.1 hours per resident day) range from less than 3 hours to more than 5.5 hours per resident day and RN hours are 3.5 times higher in some nursing homes than in the lowest staffed homes.13 Hospital readmission rates for short-stay residents from nursing homes also vary widely (4%-52%; average, 21%).12,14
Hospitalists and discharge planners should inform patients, families, and caregivers about the federal and state LTC quality report cards, provide education and choices, and engage and assist them in the decision making process. Hospitals, health plans, and accountable care organizations also need to be more informed about the availability of and benefits of using quality report cards for developing post-acute and LTC provider networks. The use of high quality LTC network providers should be able to reduce hospital length of stay and hospital readmission rates, and improve patient and caregiver satisfaction.
Charlene Harrington, PhD, RN, is professor of sociology and nursing; Leslie Ross, PhD, is a research specialist and principal investigator of the Calqualitycare.org website project; and Jeffrey Newman, MD, MPH, is a professor at the Institute for Health and Aging, all at the University of California, San Francisco.
References
1. Mor V et al. The revolving door of rehospitalization from skilled nursing facilities. Health Aff (Millwood). 2010;29(1):57-64.
2. Thompson, MP, Waters, TM, Kaplan et al. Most hospitals received annual penalties for excess readmissions, but some fared better than others. Health Aff (Millwood). 36(5):893-901.
3. Auerbach AD et al. Preventability and causes of readmissions in a national cohort of general medicine patients. JAMA Intern Med. 2016;176(4):484-93.
4. Jack B et al. A reengineered hospital discharge program to decrease rehospitalization: a randomized trial. Ann Intern Med. 2009;150(3):178-87.
5. Hansen LO et al. Project BOOST: effectiveness of a multihospital effort to reduce rehospitalization. J Hosp Med. 2013;8(8)421-7.
6. Naylor MD et al. The care span: The importance of transitional care in achieving health reform. Health Aff (Millwood). 2011;30(4):746-54.
7. Coleman EA. Family caregivers as partners in care transitions: The caregiver advise record and enable act. J Hosp Med. 2016 Dec;11(12):883-5.
8. Leppin AL et al. Preventing 30-day hospital readmissions: a systematic review and meta-analysis of randomized trials. JAMA Internal Med. 2014;174(7):1095-107.
9. Mukamel DB et al. Personalizing nursing home compare and the discharge from hospitals to nursing homes. Health Serv Res. 2016;1(6):2076-2094.
10. Werner RM et al. Changes in consumer demand following public reporting of summary quality ratings: An evaluation in nursing homes. Health Serv Res. 2016;51 Suppl 2:1291-309.
11. Boccuti C et al. Reading the stars: nursing home quality star ratings, nationally and by state. Kaiser Family Foundation Issue Brief. May 2015.
12. Centers for Medicare and Medicaid Services. Nursing home compare data archives. May 2017 monthly files. Quality MSR Claims data. https://data.medicare.gov/data/archives/nursing-home-compare. Accessed July 15, 2017.
13. Harrington C et al. The need for higher minimum staffing standards in U.S. nursing homes. Health Serv Insights. 2016;9:13-9.
14. Mor V et al. The revolving door of rehospitalization from skilled nursing facilities. Health Aff (Millwood). 2010;29(1):57-64.
The challenges of hospital discharge planning are well known and yet have not been adequately addressed by hospitalists and discharge teams. As the complexity of patient care needs has grown, so has the difficulty in developing appropriate discharge goals for post-acute and long term care (LTC), choosing the appropriate setting(s), and selecting appropriate providers. Post-acute and LTC needs may include rehabilitation, nursing care, home health, supportive services, and/or palliative care1 in an institutional setting or at home from a wide array of providers with varying levels of quality.
Even though 52% of U.S. hospitals received penalties for having higher-than-expected readmissions between 2013 and 2017,2 inadequate discharge planning for post-acute and LTC continues to contribute to high rates of all-cause 30-day rehospitalization. The discharge process sometimes is deficient in: discussion of goals; assessment of discharge needs; appropriate choice of discharge locations; and the provision of additional or different home services.3 Discharge decisions are complicated by the stressful circumstances of hospitalization and discharge deadlines.
Hospital discharge planning decisions fall heavily on patients, families, and caregivers, often with inadequate information about choices and options. More than 30 states have passed the Caregiver Advise, Record, and Enable (CARE) Act into law to require hospitals to provide resources for family caregiver education and instruction,7 but hospitals do not have to provide information on all LTC options and provider quality ratings.
Quality report cards about LTC providers – a major innovation for consumer education and choice – are often not used in the discharge process for a number of reasons. A significant concern is that using report cards will extend the length of stay. Rather than extending the decision-making time and the length of stay, the use of report cards can reduce length of stay.9 A focus on identifying the first available nursing home bed or LTC provider often ignores the need to identify the most appropriate high-quality providers.
Hospitals and health plans often have established networks of post-acute and LTC providers and these networks must be taken into account in the discharge process. Most hospital and health plan networks have providers with a wide range of ratings, allowing for choices within networks.
The Centers for Medicare and Medicaid Services (CMS) established a web-based nursing home report card called Nursing Home Compare in 1998 that includes information on facility characteristics, deficiencies, staffing information (since 2000), and resident quality indicators (since 2002). In 2008, the website added a “five-star” rating system for all U.S. nursing homes and all-cause 30-day readmission rates and successful discharge rates from nursing homes were incorporated into the ratings in 2016.
CMS also established a web-based home health website, which provides quality ratings. This website has general information, quality measures, and patient surveys with information on readmission rates from home health agency services.
After establishment of the CMS Nursing Home Compare rating system in 2008, nursing homes improved their scores on certain quality measures and consumer demand significantly increased for the best (5-star) facilities and decreased for 1-star facilities.10 More recently, a clinical trial of the use of a personalized version of Nursing Home Compare in the hospital discharge planning process found greater patient satisfaction, patients being more likely to go to higher ranked nursing homes, patients traveling further to nursing homes, and patients having shorter hospital stays, compared with the control group.9
Quality report cards show wide variations within and across states ranging from one star (poorest quality) to five stars (highest quality). More than one-third of nursing homes had relatively low overall star ratings (1 or 2 stars) serving 39 percent of residents in 2015.11 Federal nursing home regulatory violations range from zero to more than 40 deficiencies (average of 7) with a scope and severity ranging from minor to widespread harm or jeopardy (including deaths).12 Total nurse staffing hours (average, 4.1 hours per resident day) range from less than 3 hours to more than 5.5 hours per resident day and RN hours are 3.5 times higher in some nursing homes than in the lowest staffed homes.13 Hospital readmission rates for short-stay residents from nursing homes also vary widely (4%-52%; average, 21%).12,14
Hospitalists and discharge planners should inform patients, families, and caregivers about the federal and state LTC quality report cards, provide education and choices, and engage and assist them in the decision making process. Hospitals, health plans, and accountable care organizations also need to be more informed about the availability of and benefits of using quality report cards for developing post-acute and LTC provider networks. The use of high quality LTC network providers should be able to reduce hospital length of stay and hospital readmission rates, and improve patient and caregiver satisfaction.
Charlene Harrington, PhD, RN, is professor of sociology and nursing; Leslie Ross, PhD, is a research specialist and principal investigator of the Calqualitycare.org website project; and Jeffrey Newman, MD, MPH, is a professor at the Institute for Health and Aging, all at the University of California, San Francisco.
References
1. Mor V et al. The revolving door of rehospitalization from skilled nursing facilities. Health Aff (Millwood). 2010;29(1):57-64.
2. Thompson, MP, Waters, TM, Kaplan et al. Most hospitals received annual penalties for excess readmissions, but some fared better than others. Health Aff (Millwood). 36(5):893-901.
3. Auerbach AD et al. Preventability and causes of readmissions in a national cohort of general medicine patients. JAMA Intern Med. 2016;176(4):484-93.
4. Jack B et al. A reengineered hospital discharge program to decrease rehospitalization: a randomized trial. Ann Intern Med. 2009;150(3):178-87.
5. Hansen LO et al. Project BOOST: effectiveness of a multihospital effort to reduce rehospitalization. J Hosp Med. 2013;8(8)421-7.
6. Naylor MD et al. The care span: The importance of transitional care in achieving health reform. Health Aff (Millwood). 2011;30(4):746-54.
7. Coleman EA. Family caregivers as partners in care transitions: The caregiver advise record and enable act. J Hosp Med. 2016 Dec;11(12):883-5.
8. Leppin AL et al. Preventing 30-day hospital readmissions: a systematic review and meta-analysis of randomized trials. JAMA Internal Med. 2014;174(7):1095-107.
9. Mukamel DB et al. Personalizing nursing home compare and the discharge from hospitals to nursing homes. Health Serv Res. 2016;1(6):2076-2094.
10. Werner RM et al. Changes in consumer demand following public reporting of summary quality ratings: An evaluation in nursing homes. Health Serv Res. 2016;51 Suppl 2:1291-309.
11. Boccuti C et al. Reading the stars: nursing home quality star ratings, nationally and by state. Kaiser Family Foundation Issue Brief. May 2015.
12. Centers for Medicare and Medicaid Services. Nursing home compare data archives. May 2017 monthly files. Quality MSR Claims data. https://data.medicare.gov/data/archives/nursing-home-compare. Accessed July 15, 2017.
13. Harrington C et al. The need for higher minimum staffing standards in U.S. nursing homes. Health Serv Insights. 2016;9:13-9.
14. Mor V et al. The revolving door of rehospitalization from skilled nursing facilities. Health Aff (Millwood). 2010;29(1):57-64.
The challenges of hospital discharge planning are well known and yet have not been adequately addressed by hospitalists and discharge teams. As the complexity of patient care needs has grown, so has the difficulty in developing appropriate discharge goals for post-acute and long term care (LTC), choosing the appropriate setting(s), and selecting appropriate providers. Post-acute and LTC needs may include rehabilitation, nursing care, home health, supportive services, and/or palliative care1 in an institutional setting or at home from a wide array of providers with varying levels of quality.
Even though 52% of U.S. hospitals received penalties for having higher-than-expected readmissions between 2013 and 2017,2 inadequate discharge planning for post-acute and LTC continues to contribute to high rates of all-cause 30-day rehospitalization. The discharge process sometimes is deficient in: discussion of goals; assessment of discharge needs; appropriate choice of discharge locations; and the provision of additional or different home services.3 Discharge decisions are complicated by the stressful circumstances of hospitalization and discharge deadlines.
Hospital discharge planning decisions fall heavily on patients, families, and caregivers, often with inadequate information about choices and options. More than 30 states have passed the Caregiver Advise, Record, and Enable (CARE) Act into law to require hospitals to provide resources for family caregiver education and instruction,7 but hospitals do not have to provide information on all LTC options and provider quality ratings.
Quality report cards about LTC providers – a major innovation for consumer education and choice – are often not used in the discharge process for a number of reasons. A significant concern is that using report cards will extend the length of stay. Rather than extending the decision-making time and the length of stay, the use of report cards can reduce length of stay.9 A focus on identifying the first available nursing home bed or LTC provider often ignores the need to identify the most appropriate high-quality providers.
Hospitals and health plans often have established networks of post-acute and LTC providers and these networks must be taken into account in the discharge process. Most hospital and health plan networks have providers with a wide range of ratings, allowing for choices within networks.
The Centers for Medicare and Medicaid Services (CMS) established a web-based nursing home report card called Nursing Home Compare in 1998 that includes information on facility characteristics, deficiencies, staffing information (since 2000), and resident quality indicators (since 2002). In 2008, the website added a “five-star” rating system for all U.S. nursing homes and all-cause 30-day readmission rates and successful discharge rates from nursing homes were incorporated into the ratings in 2016.
CMS also established a web-based home health website, which provides quality ratings. This website has general information, quality measures, and patient surveys with information on readmission rates from home health agency services.
After establishment of the CMS Nursing Home Compare rating system in 2008, nursing homes improved their scores on certain quality measures and consumer demand significantly increased for the best (5-star) facilities and decreased for 1-star facilities.10 More recently, a clinical trial of the use of a personalized version of Nursing Home Compare in the hospital discharge planning process found greater patient satisfaction, patients being more likely to go to higher ranked nursing homes, patients traveling further to nursing homes, and patients having shorter hospital stays, compared with the control group.9
Quality report cards show wide variations within and across states ranging from one star (poorest quality) to five stars (highest quality). More than one-third of nursing homes had relatively low overall star ratings (1 or 2 stars) serving 39 percent of residents in 2015.11 Federal nursing home regulatory violations range from zero to more than 40 deficiencies (average of 7) with a scope and severity ranging from minor to widespread harm or jeopardy (including deaths).12 Total nurse staffing hours (average, 4.1 hours per resident day) range from less than 3 hours to more than 5.5 hours per resident day and RN hours are 3.5 times higher in some nursing homes than in the lowest staffed homes.13 Hospital readmission rates for short-stay residents from nursing homes also vary widely (4%-52%; average, 21%).12,14
Hospitalists and discharge planners should inform patients, families, and caregivers about the federal and state LTC quality report cards, provide education and choices, and engage and assist them in the decision making process. Hospitals, health plans, and accountable care organizations also need to be more informed about the availability of and benefits of using quality report cards for developing post-acute and LTC provider networks. The use of high quality LTC network providers should be able to reduce hospital length of stay and hospital readmission rates, and improve patient and caregiver satisfaction.
Charlene Harrington, PhD, RN, is professor of sociology and nursing; Leslie Ross, PhD, is a research specialist and principal investigator of the Calqualitycare.org website project; and Jeffrey Newman, MD, MPH, is a professor at the Institute for Health and Aging, all at the University of California, San Francisco.
References
1. Mor V et al. The revolving door of rehospitalization from skilled nursing facilities. Health Aff (Millwood). 2010;29(1):57-64.
2. Thompson, MP, Waters, TM, Kaplan et al. Most hospitals received annual penalties for excess readmissions, but some fared better than others. Health Aff (Millwood). 36(5):893-901.
3. Auerbach AD et al. Preventability and causes of readmissions in a national cohort of general medicine patients. JAMA Intern Med. 2016;176(4):484-93.
4. Jack B et al. A reengineered hospital discharge program to decrease rehospitalization: a randomized trial. Ann Intern Med. 2009;150(3):178-87.
5. Hansen LO et al. Project BOOST: effectiveness of a multihospital effort to reduce rehospitalization. J Hosp Med. 2013;8(8)421-7.
6. Naylor MD et al. The care span: The importance of transitional care in achieving health reform. Health Aff (Millwood). 2011;30(4):746-54.
7. Coleman EA. Family caregivers as partners in care transitions: The caregiver advise record and enable act. J Hosp Med. 2016 Dec;11(12):883-5.
8. Leppin AL et al. Preventing 30-day hospital readmissions: a systematic review and meta-analysis of randomized trials. JAMA Internal Med. 2014;174(7):1095-107.
9. Mukamel DB et al. Personalizing nursing home compare and the discharge from hospitals to nursing homes. Health Serv Res. 2016;1(6):2076-2094.
10. Werner RM et al. Changes in consumer demand following public reporting of summary quality ratings: An evaluation in nursing homes. Health Serv Res. 2016;51 Suppl 2:1291-309.
11. Boccuti C et al. Reading the stars: nursing home quality star ratings, nationally and by state. Kaiser Family Foundation Issue Brief. May 2015.
12. Centers for Medicare and Medicaid Services. Nursing home compare data archives. May 2017 monthly files. Quality MSR Claims data. https://data.medicare.gov/data/archives/nursing-home-compare. Accessed July 15, 2017.
13. Harrington C et al. The need for higher minimum staffing standards in U.S. nursing homes. Health Serv Insights. 2016;9:13-9.
14. Mor V et al. The revolving door of rehospitalization from skilled nursing facilities. Health Aff (Millwood). 2010;29(1):57-64.
Ensuring a smooth data collection process
Editor’s note: The Society of Hospital Medicine’s (SHM’s) Physician in Training Committee launched a scholarship program in 2015 for medical students to help transform health care and revolutionize patient care. The program has been expanded for the 2017-18 year, offering two options for students to receive funding and engage in scholarly work during their first, second and third years of medical school. As a part of the longitudinal (18-month) program, recipients are required to write about their experience on a monthly basis.
Piloting of data collection is finally underway! My mentor, Dr. Ian Jenkins, an attending in the Division of Hospital Medicine at the University of California, San Diego, and I are currently collaborating with the Surgical Intensive Care Unit at UC San Diego to conduct a daily review of urinary catheter (UC) necessity for patients on the unit, and subsequently coordinating with nursing staff on the unit to look for opportunities to implement UC alternatives.
As far as timeline, we are past the halfway point. One thing that has surprised me is how long it has taken to get piloting phase underway. To that end, I think that our initial project timeline was ambitious, especially because we were unclear on how well initial project enthusiasm would translate into subsequent project participation. Up until this point, our research approach has largely been to fine tune each process prospectively. For instance, we decided a pilot run of data collection prior to final project data collection would allow us to ensure a smoother data collection process. While this has slowed things initially, we are optimistic that this will allow us to progress more quickly and smoothly in the latter stages of the project. We are not currently planning to change this research approach for the time being, but we are open to the idea depending on how well the data piloting phase progresses.
Outside of data collection, the project has provided an excellent opportunity to learn and improve clinical skills. Specifically, the project has improved my understanding of the indications for urinary catheter use, as well as helped me to develop a more critical mindset regarding medical indications in general. The project has made me more aware of the importance of really asking and thinking about why a patient is on a specific medication or using a specific medical device, which is something that is very helpful for anticipating and avoiding errors in the clinical setting.
Overall, I have enjoyed my participation in the project to date and it has increased my enthusiasm for participating in a quality improvement project.
Victor Ekuta is a third-year medical student at UC San Diego.
Editor’s note: The Society of Hospital Medicine’s (SHM’s) Physician in Training Committee launched a scholarship program in 2015 for medical students to help transform health care and revolutionize patient care. The program has been expanded for the 2017-18 year, offering two options for students to receive funding and engage in scholarly work during their first, second and third years of medical school. As a part of the longitudinal (18-month) program, recipients are required to write about their experience on a monthly basis.
Piloting of data collection is finally underway! My mentor, Dr. Ian Jenkins, an attending in the Division of Hospital Medicine at the University of California, San Diego, and I are currently collaborating with the Surgical Intensive Care Unit at UC San Diego to conduct a daily review of urinary catheter (UC) necessity for patients on the unit, and subsequently coordinating with nursing staff on the unit to look for opportunities to implement UC alternatives.
As far as timeline, we are past the halfway point. One thing that has surprised me is how long it has taken to get piloting phase underway. To that end, I think that our initial project timeline was ambitious, especially because we were unclear on how well initial project enthusiasm would translate into subsequent project participation. Up until this point, our research approach has largely been to fine tune each process prospectively. For instance, we decided a pilot run of data collection prior to final project data collection would allow us to ensure a smoother data collection process. While this has slowed things initially, we are optimistic that this will allow us to progress more quickly and smoothly in the latter stages of the project. We are not currently planning to change this research approach for the time being, but we are open to the idea depending on how well the data piloting phase progresses.
Outside of data collection, the project has provided an excellent opportunity to learn and improve clinical skills. Specifically, the project has improved my understanding of the indications for urinary catheter use, as well as helped me to develop a more critical mindset regarding medical indications in general. The project has made me more aware of the importance of really asking and thinking about why a patient is on a specific medication or using a specific medical device, which is something that is very helpful for anticipating and avoiding errors in the clinical setting.
Overall, I have enjoyed my participation in the project to date and it has increased my enthusiasm for participating in a quality improvement project.
Victor Ekuta is a third-year medical student at UC San Diego.
Editor’s note: The Society of Hospital Medicine’s (SHM’s) Physician in Training Committee launched a scholarship program in 2015 for medical students to help transform health care and revolutionize patient care. The program has been expanded for the 2017-18 year, offering two options for students to receive funding and engage in scholarly work during their first, second and third years of medical school. As a part of the longitudinal (18-month) program, recipients are required to write about their experience on a monthly basis.
Piloting of data collection is finally underway! My mentor, Dr. Ian Jenkins, an attending in the Division of Hospital Medicine at the University of California, San Diego, and I are currently collaborating with the Surgical Intensive Care Unit at UC San Diego to conduct a daily review of urinary catheter (UC) necessity for patients on the unit, and subsequently coordinating with nursing staff on the unit to look for opportunities to implement UC alternatives.
As far as timeline, we are past the halfway point. One thing that has surprised me is how long it has taken to get piloting phase underway. To that end, I think that our initial project timeline was ambitious, especially because we were unclear on how well initial project enthusiasm would translate into subsequent project participation. Up until this point, our research approach has largely been to fine tune each process prospectively. For instance, we decided a pilot run of data collection prior to final project data collection would allow us to ensure a smoother data collection process. While this has slowed things initially, we are optimistic that this will allow us to progress more quickly and smoothly in the latter stages of the project. We are not currently planning to change this research approach for the time being, but we are open to the idea depending on how well the data piloting phase progresses.
Outside of data collection, the project has provided an excellent opportunity to learn and improve clinical skills. Specifically, the project has improved my understanding of the indications for urinary catheter use, as well as helped me to develop a more critical mindset regarding medical indications in general. The project has made me more aware of the importance of really asking and thinking about why a patient is on a specific medication or using a specific medical device, which is something that is very helpful for anticipating and avoiding errors in the clinical setting.
Overall, I have enjoyed my participation in the project to date and it has increased my enthusiasm for participating in a quality improvement project.
Victor Ekuta is a third-year medical student at UC San Diego.
Putting Choosing Wisely into practice
At Mount Sinai Hospital, Choosing Wisely’s guidelines for hospital medicine inspired Harry Cho, MD, FACP, and his colleagues to work on the rates of catheter-associated urinary tract infection in their hospital.
They launched their “Lose the Tube” project, creating an electronic catheter identification tool and instituting a daily multidisciplinary query. “On our patient list, we had a column with a green or red dot, indicating if the patient had a catheter or not,” Dr. Cho said. “From there, we wanted to give the onus to the provider. During multidisciplinary rounds, we queried the doctor – we were not ordering them – ‘Does this patient need the Foley?’ After a while, people started coming into multidisciplinary rounds knowing if their patients had a Foley. It was a culture shift.”
“That’s the model that you want to build,” Dr. Cho said. “That’s the culture that you need so that whenever projects like this happen, they just move forward.”
Reference
Cho HJ et al. “Lose the Tube”: A Choosing Wisely initiative to reduce catheter-associated urinary tract infections in hospitalist-led inpatient units. Am J Infect Control. 2017 Mar 1;45(3):333-5.
At Mount Sinai Hospital, Choosing Wisely’s guidelines for hospital medicine inspired Harry Cho, MD, FACP, and his colleagues to work on the rates of catheter-associated urinary tract infection in their hospital.
They launched their “Lose the Tube” project, creating an electronic catheter identification tool and instituting a daily multidisciplinary query. “On our patient list, we had a column with a green or red dot, indicating if the patient had a catheter or not,” Dr. Cho said. “From there, we wanted to give the onus to the provider. During multidisciplinary rounds, we queried the doctor – we were not ordering them – ‘Does this patient need the Foley?’ After a while, people started coming into multidisciplinary rounds knowing if their patients had a Foley. It was a culture shift.”
“That’s the model that you want to build,” Dr. Cho said. “That’s the culture that you need so that whenever projects like this happen, they just move forward.”
Reference
Cho HJ et al. “Lose the Tube”: A Choosing Wisely initiative to reduce catheter-associated urinary tract infections in hospitalist-led inpatient units. Am J Infect Control. 2017 Mar 1;45(3):333-5.
At Mount Sinai Hospital, Choosing Wisely’s guidelines for hospital medicine inspired Harry Cho, MD, FACP, and his colleagues to work on the rates of catheter-associated urinary tract infection in their hospital.
They launched their “Lose the Tube” project, creating an electronic catheter identification tool and instituting a daily multidisciplinary query. “On our patient list, we had a column with a green or red dot, indicating if the patient had a catheter or not,” Dr. Cho said. “From there, we wanted to give the onus to the provider. During multidisciplinary rounds, we queried the doctor – we were not ordering them – ‘Does this patient need the Foley?’ After a while, people started coming into multidisciplinary rounds knowing if their patients had a Foley. It was a culture shift.”
“That’s the model that you want to build,” Dr. Cho said. “That’s the culture that you need so that whenever projects like this happen, they just move forward.”
Reference
Cho HJ et al. “Lose the Tube”: A Choosing Wisely initiative to reduce catheter-associated urinary tract infections in hospitalist-led inpatient units. Am J Infect Control. 2017 Mar 1;45(3):333-5.
Reducing harm: When doing less is enough
Launched in April 2012 – the same year an article in the Journal of the American Medical Association estimated the U.S. health care system was wasting between $600 billion and $1 trillion annually because of issues such as overtreatment – Choosing Wisely continues to change both conversations and practices across the medical field.1
In creating Choosing Wisely, the ABIM Foundation sought to establish a framework for physicians to think about managing resources and to talk to patients about which medical tests and procedures might be unnecessary – or even harmful.
Today, more than 75 medical specialties have their own “five things” lists: procedures that practitioners should question before ordering. Hospitalists have a total of 10 – 5 for adults and 5 for pediatrics – and hospitalists play a pivotal role in Choosing Wisely’s implementation, with crucial control over service lines. “Hospitalists are on the front line of patient care,” said Moises Auron, MD, FAAP, FACP, SFHM, a hospitalist at the Cleveland Clinic. “We are actually the frontline workers in the hospital.”
Choosing Wisely’s successes
In terms of its initial goal – starting a conversation and encouraging physicians to interrogate their habits – Choosing Wisely has been a success.
“It’s brought a lot of awareness about the problem of matching best evidence with the patient you have in front of you,” said John Bulger , DO, MACP, MBA, SFHM, chief medical officer of Geisinger Health Plan. “Some people call that evidence-based medicine, but the problem with calling it that is that you can have a study, but it may not match up with the patient you’re seeing right now. There are many things we do because we did them in the past or because we didn’t have all the information, and I think Choosing Wisely has made people think twice about some of the things they do.” 
The message of Choosing Wisely continues to spread, even internationally. It’s now present in 18 countries, Mr. Wolfson said. “We’re also seeing on the horizon many state efforts, such as in Connecticut and Rhode Island; and Delaware is organizing a statewide effort. I see that as the next big thing: statewide efforts that pair delivery systems with multistakeholder groups, regional health collaboratives, and physician organizations, all working to reduce use.”As it spreads, Choosing Wisely is sparking a new generation of related initiatives, such as Costs of Care and Johns Hopkins’ High Value Practice Academic Alliance. There’s a new section in the Journal of Hospital Medicine called “Things We Do for No Reason” highlighting different practices each month, and a nationwide Student High Value Care Initiative introduces value concepts to medical students. “It’s not Choosing Wisely by itself; it’s provided the backbone for all these new efforts,” Dr. Auron said.
Challenges remain
While it has spread, Choosing Wisely also has met some obstacles. Among them is that even with the help of Consumer Reports’ tools, the physician-patient conversations can be difficult. A behavioral economics concept called loss aversion is part of the reason: It’s basic human nature to feel the pain of loss more acutely than the pleasure of gain.
“It’s tough because that conversation requires specific training,” he said. “It’s one thing to tell the clinician, or to have it pop up on an EHR, that provision of an antibiotic for this clinical presentation is not appropriate. However, it’s an entirely different thing to look a patient in the face who comes in expecting a course of antibiotics and tell them that they’re not going to get it.”
Another hurdle is the existing fee-for-service system, which obviously does not promote cost consciousness. Since there’s really no disincentive to a physician ordering an additional test, acceptance of Choosing Wisely can vary widely between institutions. “Choosing Wisely permeated very nicely here at the Cleveland Clinic,” Dr. Auron said. “But other hospitals – especially private hospitals that are not owned by doctors – what they want is just the service line.”
Physicians’ discomfort with uncertainty is another challenge, according to Mr. Mainor. “A lot of it can be by virtue of medical training and how particular residents were taught to always run this panel when you have this presentation,” he said. “Sometimes it’s hard to separate Choosing Wisely from the concept of defensive medicine, but this is more wanting to be able to tell the patient that you did everything that you could before proceeding to a particular next step or treatment.”
Getting patient input from the outset and making sure goals are aligned can help with some of these issues – but can itself be a hurdle.
The road ahead
The time it takes to have these conversations is more than a sticking point for Choosing Wisely, it’s an underlying challenge in our health care system.
“For example, it takes more time to have a discussion about what the alternatives are to alleviate pain – other than taking an opiate,” Dr. Bulger said. “The easiest thing to do is to write the script for the opiate – which is part of the reason why we got where we are with opioids – or to write the script for an antibiotic – which is part of the reason why we got here with drug resistance. We haven’t done a great deal to address those underlying drivers. Without doing that, you can only go so far with a campaign like Choosing Wisely.”
Issues around costs fall into a similar category: an underlying issue that demands a broader conversation. ”It’s just so elusive,” Dr. Cho said. “There are so many different versions of cost, and from a hospital medicine standpoint, that process is so prolonged. We may not touch base with that patient when they get their bill, so for us to have a conversation about exactly how much this would cost can be difficult. It’s so complex; I would love for that to be tackled so that it’s a little more straightforward.”
“There are people involved in career paths in education, quality and safety, research, and administration, but there are very few people actually focused on value – and then finding the resources and the mobilization to do that,” Dr. Cho said. “I think it would really be helpful moving forward to find more people doing this and getting more support from their organizations.”
In one step toward that goal, a value track has been added to the Society of Hospital Medicine annual meeting.
“I think you’re going to see more emphasis on this, especially with younger hospitalists that are really pushing the value theme,” Dr. Bulger said. “I think those are really the lessons learned in what we started with Choosing Wisely.”
References
1. Berwick DM et al. Eliminating waste in US health care. JAMA. 2012;307(14):1513-6.
2. Colla CH et al. Physician perceptions of Choosing Wisely and drivers of overuse. Am J Manag Care. 2016 May;22(5):337-43.
Launched in April 2012 – the same year an article in the Journal of the American Medical Association estimated the U.S. health care system was wasting between $600 billion and $1 trillion annually because of issues such as overtreatment – Choosing Wisely continues to change both conversations and practices across the medical field.1
In creating Choosing Wisely, the ABIM Foundation sought to establish a framework for physicians to think about managing resources and to talk to patients about which medical tests and procedures might be unnecessary – or even harmful.
Today, more than 75 medical specialties have their own “five things” lists: procedures that practitioners should question before ordering. Hospitalists have a total of 10 – 5 for adults and 5 for pediatrics – and hospitalists play a pivotal role in Choosing Wisely’s implementation, with crucial control over service lines. “Hospitalists are on the front line of patient care,” said Moises Auron, MD, FAAP, FACP, SFHM, a hospitalist at the Cleveland Clinic. “We are actually the frontline workers in the hospital.”
Choosing Wisely’s successes
In terms of its initial goal – starting a conversation and encouraging physicians to interrogate their habits – Choosing Wisely has been a success.
“It’s brought a lot of awareness about the problem of matching best evidence with the patient you have in front of you,” said John Bulger , DO, MACP, MBA, SFHM, chief medical officer of Geisinger Health Plan. “Some people call that evidence-based medicine, but the problem with calling it that is that you can have a study, but it may not match up with the patient you’re seeing right now. There are many things we do because we did them in the past or because we didn’t have all the information, and I think Choosing Wisely has made people think twice about some of the things they do.”
The message of Choosing Wisely continues to spread, even internationally. It’s now present in 18 countries, Mr. Wolfson said. “We’re also seeing on the horizon many state efforts, such as in Connecticut and Rhode Island; and Delaware is organizing a statewide effort. I see that as the next big thing: statewide efforts that pair delivery systems with multistakeholder groups, regional health collaboratives, and physician organizations, all working to reduce use.”As it spreads, Choosing Wisely is sparking a new generation of related initiatives, such as Costs of Care and Johns Hopkins’ High Value Practice Academic Alliance. There’s a new section in the Journal of Hospital Medicine called “Things We Do for No Reason” highlighting different practices each month, and a nationwide Student High Value Care Initiative introduces value concepts to medical students. “It’s not Choosing Wisely by itself; it’s provided the backbone for all these new efforts,” Dr. Auron said.
Challenges remain
While it has spread, Choosing Wisely also has met some obstacles. Among them is that even with the help of Consumer Reports’ tools, the physician-patient conversations can be difficult. A behavioral economics concept called loss aversion is part of the reason: It’s basic human nature to feel the pain of loss more acutely than the pleasure of gain.
“It’s tough because that conversation requires specific training,” he said. “It’s one thing to tell the clinician, or to have it pop up on an EHR, that provision of an antibiotic for this clinical presentation is not appropriate. However, it’s an entirely different thing to look a patient in the face who comes in expecting a course of antibiotics and tell them that they’re not going to get it.”
Another hurdle is the existing fee-for-service system, which obviously does not promote cost consciousness. Since there’s really no disincentive to a physician ordering an additional test, acceptance of Choosing Wisely can vary widely between institutions. “Choosing Wisely permeated very nicely here at the Cleveland Clinic,” Dr. Auron said. “But other hospitals – especially private hospitals that are not owned by doctors – what they want is just the service line.”
Physicians’ discomfort with uncertainty is another challenge, according to Mr. Mainor. “A lot of it can be by virtue of medical training and how particular residents were taught to always run this panel when you have this presentation,” he said. “Sometimes it’s hard to separate Choosing Wisely from the concept of defensive medicine, but this is more wanting to be able to tell the patient that you did everything that you could before proceeding to a particular next step or treatment.”
Getting patient input from the outset and making sure goals are aligned can help with some of these issues – but can itself be a hurdle.
The road ahead
The time it takes to have these conversations is more than a sticking point for Choosing Wisely, it’s an underlying challenge in our health care system.
“For example, it takes more time to have a discussion about what the alternatives are to alleviate pain – other than taking an opiate,” Dr. Bulger said. “The easiest thing to do is to write the script for the opiate – which is part of the reason why we got where we are with opioids – or to write the script for an antibiotic – which is part of the reason why we got here with drug resistance. We haven’t done a great deal to address those underlying drivers. Without doing that, you can only go so far with a campaign like Choosing Wisely.”
Issues around costs fall into a similar category: an underlying issue that demands a broader conversation. ”It’s just so elusive,” Dr. Cho said. “There are so many different versions of cost, and from a hospital medicine standpoint, that process is so prolonged. We may not touch base with that patient when they get their bill, so for us to have a conversation about exactly how much this would cost can be difficult. It’s so complex; I would love for that to be tackled so that it’s a little more straightforward.”
“There are people involved in career paths in education, quality and safety, research, and administration, but there are very few people actually focused on value – and then finding the resources and the mobilization to do that,” Dr. Cho said. “I think it would really be helpful moving forward to find more people doing this and getting more support from their organizations.”
In one step toward that goal, a value track has been added to the Society of Hospital Medicine annual meeting.
“I think you’re going to see more emphasis on this, especially with younger hospitalists that are really pushing the value theme,” Dr. Bulger said. “I think those are really the lessons learned in what we started with Choosing Wisely.”
References
1. Berwick DM et al. Eliminating waste in US health care. JAMA. 2012;307(14):1513-6.
2. Colla CH et al. Physician perceptions of Choosing Wisely and drivers of overuse. Am J Manag Care. 2016 May;22(5):337-43.
Launched in April 2012 – the same year an article in the Journal of the American Medical Association estimated the U.S. health care system was wasting between $600 billion and $1 trillion annually because of issues such as overtreatment – Choosing Wisely continues to change both conversations and practices across the medical field.1
In creating Choosing Wisely, the ABIM Foundation sought to establish a framework for physicians to think about managing resources and to talk to patients about which medical tests and procedures might be unnecessary – or even harmful.
Today, more than 75 medical specialties have their own “five things” lists: procedures that practitioners should question before ordering. Hospitalists have a total of 10 – 5 for adults and 5 for pediatrics – and hospitalists play a pivotal role in Choosing Wisely’s implementation, with crucial control over service lines. “Hospitalists are on the front line of patient care,” said Moises Auron, MD, FAAP, FACP, SFHM, a hospitalist at the Cleveland Clinic. “We are actually the frontline workers in the hospital.”
Choosing Wisely’s successes
In terms of its initial goal – starting a conversation and encouraging physicians to interrogate their habits – Choosing Wisely has been a success.
“It’s brought a lot of awareness about the problem of matching best evidence with the patient you have in front of you,” said John Bulger , DO, MACP, MBA, SFHM, chief medical officer of Geisinger Health Plan. “Some people call that evidence-based medicine, but the problem with calling it that is that you can have a study, but it may not match up with the patient you’re seeing right now. There are many things we do because we did them in the past or because we didn’t have all the information, and I think Choosing Wisely has made people think twice about some of the things they do.”
The message of Choosing Wisely continues to spread, even internationally. It’s now present in 18 countries, Mr. Wolfson said. “We’re also seeing on the horizon many state efforts, such as in Connecticut and Rhode Island; and Delaware is organizing a statewide effort. I see that as the next big thing: statewide efforts that pair delivery systems with multistakeholder groups, regional health collaboratives, and physician organizations, all working to reduce use.”As it spreads, Choosing Wisely is sparking a new generation of related initiatives, such as Costs of Care and Johns Hopkins’ High Value Practice Academic Alliance. There’s a new section in the Journal of Hospital Medicine called “Things We Do for No Reason” highlighting different practices each month, and a nationwide Student High Value Care Initiative introduces value concepts to medical students. “It’s not Choosing Wisely by itself; it’s provided the backbone for all these new efforts,” Dr. Auron said.
Challenges remain
While it has spread, Choosing Wisely also has met some obstacles. Among them is that even with the help of Consumer Reports’ tools, the physician-patient conversations can be difficult. A behavioral economics concept called loss aversion is part of the reason: It’s basic human nature to feel the pain of loss more acutely than the pleasure of gain.
“It’s tough because that conversation requires specific training,” he said. “It’s one thing to tell the clinician, or to have it pop up on an EHR, that provision of an antibiotic for this clinical presentation is not appropriate. However, it’s an entirely different thing to look a patient in the face who comes in expecting a course of antibiotics and tell them that they’re not going to get it.”
Another hurdle is the existing fee-for-service system, which obviously does not promote cost consciousness. Since there’s really no disincentive to a physician ordering an additional test, acceptance of Choosing Wisely can vary widely between institutions. “Choosing Wisely permeated very nicely here at the Cleveland Clinic,” Dr. Auron said. “But other hospitals – especially private hospitals that are not owned by doctors – what they want is just the service line.”
Physicians’ discomfort with uncertainty is another challenge, according to Mr. Mainor. “A lot of it can be by virtue of medical training and how particular residents were taught to always run this panel when you have this presentation,” he said. “Sometimes it’s hard to separate Choosing Wisely from the concept of defensive medicine, but this is more wanting to be able to tell the patient that you did everything that you could before proceeding to a particular next step or treatment.”
Getting patient input from the outset and making sure goals are aligned can help with some of these issues – but can itself be a hurdle.
The road ahead
The time it takes to have these conversations is more than a sticking point for Choosing Wisely, it’s an underlying challenge in our health care system.
“For example, it takes more time to have a discussion about what the alternatives are to alleviate pain – other than taking an opiate,” Dr. Bulger said. “The easiest thing to do is to write the script for the opiate – which is part of the reason why we got where we are with opioids – or to write the script for an antibiotic – which is part of the reason why we got here with drug resistance. We haven’t done a great deal to address those underlying drivers. Without doing that, you can only go so far with a campaign like Choosing Wisely.”
Issues around costs fall into a similar category: an underlying issue that demands a broader conversation. ”It’s just so elusive,” Dr. Cho said. “There are so many different versions of cost, and from a hospital medicine standpoint, that process is so prolonged. We may not touch base with that patient when they get their bill, so for us to have a conversation about exactly how much this would cost can be difficult. It’s so complex; I would love for that to be tackled so that it’s a little more straightforward.”
“There are people involved in career paths in education, quality and safety, research, and administration, but there are very few people actually focused on value – and then finding the resources and the mobilization to do that,” Dr. Cho said. “I think it would really be helpful moving forward to find more people doing this and getting more support from their organizations.”
In one step toward that goal, a value track has been added to the Society of Hospital Medicine annual meeting.
“I think you’re going to see more emphasis on this, especially with younger hospitalists that are really pushing the value theme,” Dr. Bulger said. “I think those are really the lessons learned in what we started with Choosing Wisely.”
References
1. Berwick DM et al. Eliminating waste in US health care. JAMA. 2012;307(14):1513-6.
2. Colla CH et al. Physician perceptions of Choosing Wisely and drivers of overuse. Am J Manag Care. 2016 May;22(5):337-43.
Safety-net hospitals would be hurt by hospital-wide 30-day readmission penalties
Considering all readmissions within 30 days of discharge in the Hospital Readmissions Reduction Program would modestly increase the number of hospitals eligible for penalties and would have a bigger impact on safety-net hospitals, based on a study of two years of Medicare claims data from 3,443 hospitals.
“Transition to a hospital-wide measure would require an adjustment in the penalty formula to keep penalties in the same range for most hospitals and without a change in procedures would have a deleterious effect on safety-net hospitals,” according to Rachael B. Zuckerman, PhD, from the Department of Health and Human Services, Washington, and her co-authors.
Analyzing 6,807,899 admissions for hospital-wide readmission measures and 4,392,658 admissions for condition-specific measures, the researchers found that a condition-specific approach would result in 3,238 hospitals being eligible for penalties for at least one condition. A hospital-wide measure of readmissions would result in 76 additional hospitals being eligible for penalties based on one year of admissions data, and 128 additional hospitals based on 3 years of admissions data (NEJM 2017, 377:1551-58. DOI: 10.1056/NEJMsa1701791).
Moving to a hospital-wide measure of readmissions also would significantly increase mean annual penalty rates across all hospitals by 0.89% of base diagnosis-related group (DRG) payments or $393,000; 43% of hospitals would be penalized under this standard.
“Moving to the hospital-wide readmission measure would also substantially increase the disparity between safety-net and other hospitals: the mean penalty as a percentage of base DRG payments would be 0.41 percentage points ($198,000) higher among safety net hospitals,” the authors wrote.
“Since safety-net hospitals tend to perform slightly worse on the hospital-wide measure, they are more likely to receive a penalty, which would increase the disparity in penalties between the two groups.”
The study was supported by the Department of Health and Human Services. One author declared grants from funding bodies and universities outside the submitted work. One author is an associate editor of the New England Journal of Medicine. One author was an employee of the Department of Health and Human Services at the time of the study. No other conflicts of interest were declared.
Considering all readmissions within 30 days of discharge in the Hospital Readmissions Reduction Program would modestly increase the number of hospitals eligible for penalties and would have a bigger impact on safety-net hospitals, based on a study of two years of Medicare claims data from 3,443 hospitals.
“Transition to a hospital-wide measure would require an adjustment in the penalty formula to keep penalties in the same range for most hospitals and without a change in procedures would have a deleterious effect on safety-net hospitals,” according to Rachael B. Zuckerman, PhD, from the Department of Health and Human Services, Washington, and her co-authors.
Analyzing 6,807,899 admissions for hospital-wide readmission measures and 4,392,658 admissions for condition-specific measures, the researchers found that a condition-specific approach would result in 3,238 hospitals being eligible for penalties for at least one condition. A hospital-wide measure of readmissions would result in 76 additional hospitals being eligible for penalties based on one year of admissions data, and 128 additional hospitals based on 3 years of admissions data (NEJM 2017, 377:1551-58. DOI: 10.1056/NEJMsa1701791).
Moving to a hospital-wide measure of readmissions also would significantly increase mean annual penalty rates across all hospitals by 0.89% of base diagnosis-related group (DRG) payments or $393,000; 43% of hospitals would be penalized under this standard.
“Moving to the hospital-wide readmission measure would also substantially increase the disparity between safety-net and other hospitals: the mean penalty as a percentage of base DRG payments would be 0.41 percentage points ($198,000) higher among safety net hospitals,” the authors wrote.
“Since safety-net hospitals tend to perform slightly worse on the hospital-wide measure, they are more likely to receive a penalty, which would increase the disparity in penalties between the two groups.”
The study was supported by the Department of Health and Human Services. One author declared grants from funding bodies and universities outside the submitted work. One author is an associate editor of the New England Journal of Medicine. One author was an employee of the Department of Health and Human Services at the time of the study. No other conflicts of interest were declared.
Considering all readmissions within 30 days of discharge in the Hospital Readmissions Reduction Program would modestly increase the number of hospitals eligible for penalties and would have a bigger impact on safety-net hospitals, based on a study of two years of Medicare claims data from 3,443 hospitals.
“Transition to a hospital-wide measure would require an adjustment in the penalty formula to keep penalties in the same range for most hospitals and without a change in procedures would have a deleterious effect on safety-net hospitals,” according to Rachael B. Zuckerman, PhD, from the Department of Health and Human Services, Washington, and her co-authors.
Analyzing 6,807,899 admissions for hospital-wide readmission measures and 4,392,658 admissions for condition-specific measures, the researchers found that a condition-specific approach would result in 3,238 hospitals being eligible for penalties for at least one condition. A hospital-wide measure of readmissions would result in 76 additional hospitals being eligible for penalties based on one year of admissions data, and 128 additional hospitals based on 3 years of admissions data (NEJM 2017, 377:1551-58. DOI: 10.1056/NEJMsa1701791).
Moving to a hospital-wide measure of readmissions also would significantly increase mean annual penalty rates across all hospitals by 0.89% of base diagnosis-related group (DRG) payments or $393,000; 43% of hospitals would be penalized under this standard.
“Moving to the hospital-wide readmission measure would also substantially increase the disparity between safety-net and other hospitals: the mean penalty as a percentage of base DRG payments would be 0.41 percentage points ($198,000) higher among safety net hospitals,” the authors wrote.
“Since safety-net hospitals tend to perform slightly worse on the hospital-wide measure, they are more likely to receive a penalty, which would increase the disparity in penalties between the two groups.”
The study was supported by the Department of Health and Human Services. One author declared grants from funding bodies and universities outside the submitted work. One author is an associate editor of the New England Journal of Medicine. One author was an employee of the Department of Health and Human Services at the time of the study. No other conflicts of interest were declared.
FROM NEJM
Key clinical point: Adopting a hospital-wide measure of 30-day readmissions for the Hospital Readmissions Reduction Program would modestly increase the number of hospitals eligible for penalties and would have a bigger impact on safety-net hospitals.
Major finding: With a hospital-wide measure of readmissions in the Hospital Readmissions Reduction Program, the mean penalty as a percentage of base DRG payments would be 0.41 percentage points ($198,000) higher among safety net hospitals.
Data source: Analysis of two years of Medicare claims data from 3,443 hospitals.
Disclosures: The study was supported by the Department of Health and Human Services. One author declared grants from funding bodies and universities outside the submitted work. One author is an associated editor of the New England Journal of Medicine. One author was an employee of the Department of Health and Human Services at the time of the study. No other conflicts of interest were declared.
Identifying high-value care practices
A new tool can help where hospitalists need it most: at the bedside.
The focus on providing high-value care (HVC) continues to grow and expand in health care today. Still, most education around HVC currently happens in a formalized setting – lectures, modules, and so on, says Carolyn D. Sy, MD, interim director of the Hospital Medicine Service at the University of Washington, Seattle, and coauthor of a recent abstract about a new tool to address this shortcoming. “There are no instruments for measuring HVC discussions or practices at the bedside, confounding efforts to assess behavior changes associated with curricular interventions,” she said.
So she and other doctors undertook a study to identify 10 HVC topics in three domains (quality, cost, patient values), then measured their reliability with the goal of designing an HVC Rounding Tool and showing that it is an effective tool to measure observable markers of HVC at the bedside. “This is critical as it addresses an important educational gap in translating HVC from theoretical knowledge to bedside practice,” Dr. Sy said.
The tool is designed to capture multidisciplinary participation, she says, including involvement from not only faculty, fellows, or trainees, but also nursing, pharmacists, families, and other members of the health care team. The tool can be used as a peer feedback instrument to help physicians integrate HVC topics during bedside rounds or as a metric to assess the educational efficacy of future curriculum.
“The HVC Rounding Tool provides an opportunity for faculty development through peer observation and feedback on the integration and role modeling of HVC at the bedside,” Dr. Sy said. “It also is an instrument to help assess the educational efficacy of formal HVC curriculum and translation into bedside practice. Lastly, it is a tool that could be used to measure the relationship between HVC behaviors and actual patient outcomes such as length of stay, readmissions, cost of hospitalization – a feature with increasing importance given our move toward value-based health care.”
Reference
Sy CD, McDaniel C, Bradford M, et al. The Development and Validation of a High Value Care Rounding Tool Using the Delphi Method [abstract]. J Hosp Med. 2017; 12 (suppl 2). http://www.shmabstracts.com/abstract/the-development-and-validation-of-a-high-value-care-rounding-tool-using-the-delphi-method/. Accessed June 6, 2017.
A new tool can help where hospitalists need it most: at the bedside.
The focus on providing high-value care (HVC) continues to grow and expand in health care today. Still, most education around HVC currently happens in a formalized setting – lectures, modules, and so on, says Carolyn D. Sy, MD, interim director of the Hospital Medicine Service at the University of Washington, Seattle, and coauthor of a recent abstract about a new tool to address this shortcoming. “There are no instruments for measuring HVC discussions or practices at the bedside, confounding efforts to assess behavior changes associated with curricular interventions,” she said.
So she and other doctors undertook a study to identify 10 HVC topics in three domains (quality, cost, patient values), then measured their reliability with the goal of designing an HVC Rounding Tool and showing that it is an effective tool to measure observable markers of HVC at the bedside. “This is critical as it addresses an important educational gap in translating HVC from theoretical knowledge to bedside practice,” Dr. Sy said.
The tool is designed to capture multidisciplinary participation, she says, including involvement from not only faculty, fellows, or trainees, but also nursing, pharmacists, families, and other members of the health care team. The tool can be used as a peer feedback instrument to help physicians integrate HVC topics during bedside rounds or as a metric to assess the educational efficacy of future curriculum.
“The HVC Rounding Tool provides an opportunity for faculty development through peer observation and feedback on the integration and role modeling of HVC at the bedside,” Dr. Sy said. “It also is an instrument to help assess the educational efficacy of formal HVC curriculum and translation into bedside practice. Lastly, it is a tool that could be used to measure the relationship between HVC behaviors and actual patient outcomes such as length of stay, readmissions, cost of hospitalization – a feature with increasing importance given our move toward value-based health care.”
Reference
Sy CD, McDaniel C, Bradford M, et al. The Development and Validation of a High Value Care Rounding Tool Using the Delphi Method [abstract]. J Hosp Med. 2017; 12 (suppl 2). http://www.shmabstracts.com/abstract/the-development-and-validation-of-a-high-value-care-rounding-tool-using-the-delphi-method/. Accessed June 6, 2017.
A new tool can help where hospitalists need it most: at the bedside.
The focus on providing high-value care (HVC) continues to grow and expand in health care today. Still, most education around HVC currently happens in a formalized setting – lectures, modules, and so on, says Carolyn D. Sy, MD, interim director of the Hospital Medicine Service at the University of Washington, Seattle, and coauthor of a recent abstract about a new tool to address this shortcoming. “There are no instruments for measuring HVC discussions or practices at the bedside, confounding efforts to assess behavior changes associated with curricular interventions,” she said.
So she and other doctors undertook a study to identify 10 HVC topics in three domains (quality, cost, patient values), then measured their reliability with the goal of designing an HVC Rounding Tool and showing that it is an effective tool to measure observable markers of HVC at the bedside. “This is critical as it addresses an important educational gap in translating HVC from theoretical knowledge to bedside practice,” Dr. Sy said.
The tool is designed to capture multidisciplinary participation, she says, including involvement from not only faculty, fellows, or trainees, but also nursing, pharmacists, families, and other members of the health care team. The tool can be used as a peer feedback instrument to help physicians integrate HVC topics during bedside rounds or as a metric to assess the educational efficacy of future curriculum.
“The HVC Rounding Tool provides an opportunity for faculty development through peer observation and feedback on the integration and role modeling of HVC at the bedside,” Dr. Sy said. “It also is an instrument to help assess the educational efficacy of formal HVC curriculum and translation into bedside practice. Lastly, it is a tool that could be used to measure the relationship between HVC behaviors and actual patient outcomes such as length of stay, readmissions, cost of hospitalization – a feature with increasing importance given our move toward value-based health care.”
Reference
Sy CD, McDaniel C, Bradford M, et al. The Development and Validation of a High Value Care Rounding Tool Using the Delphi Method [abstract]. J Hosp Med. 2017; 12 (suppl 2). http://www.shmabstracts.com/abstract/the-development-and-validation-of-a-high-value-care-rounding-tool-using-the-delphi-method/. Accessed June 6, 2017.
Applying Choosing Wisely principles to telemetry and catheter use
The Choosing Wisely recommendations for hospitalists have launched numerous research projects. One dealing with telemetry and catheter use was published in September’s American Journal of Medicine.
After reviewing the literature on how people were implementing these recommendations, the researchers noticed most projects “1) narrowly focused on only one of the recommendations; 2) often used intrusive interventions that appeared to be burdensome and not adaptable to physician workflow; and 3) were expensive to implement,” said lead author Charlie M. Wray, DO, MS, of the Division of Hospital Medicine, San Francisco Veterans Affairs Medical Center, and the University of California, San Francisco. “We set out to design a project that could minimize these aspects while hopefully decreasing the use of telemetry and Foley catheters.”
The researchers created a “silent” reminder that was posted on a widely used screen within their EHR and was only activated when the user clicked on it. “Additionally, we wanted to make sure that this intervention made its way to teaching rounds and the patients’ bedsides,” Dr. Wray said. “So, when the attendings and residents would print out their daily census, it would contain the reminders, which allowed the team to quickly review which patients were actively using telemetry or had a Foley and discuss, at a team-level, whose telemetry or Foley could be stopped.”
The project demonstrated a trend toward less telemetry use, less time spent on telemetry, fewer catheters ordered, and more selective utilization of catheters in sicker patients.
“We believe that our project shows that the bundling of interventions has the potential to impart an effect on a greater proportion of the population than those that focus on a single issue,” Dr. Wray said. “Second, future interventions that look to utilize EHR-based clinical reminders should consider utilizing a ‘silent’ design that is prominent but doesn’t intrude upon practitioners workflow.”
You don’t need to be at a large academic institution to implement this idea, he added. “A few hours with your IT expert and a champion who is willing to take the lead could easily implement this project and hopefully see similar outcomes.”
Reference
Wray, Charlie M. et al. Improving value by reducing unnecessary telemetry and urinary catheter utilization in hospitalized patients. Am J Med. 2017 Sep;130(9):1037-41.
The Choosing Wisely recommendations for hospitalists have launched numerous research projects. One dealing with telemetry and catheter use was published in September’s American Journal of Medicine.
After reviewing the literature on how people were implementing these recommendations, the researchers noticed most projects “1) narrowly focused on only one of the recommendations; 2) often used intrusive interventions that appeared to be burdensome and not adaptable to physician workflow; and 3) were expensive to implement,” said lead author Charlie M. Wray, DO, MS, of the Division of Hospital Medicine, San Francisco Veterans Affairs Medical Center, and the University of California, San Francisco. “We set out to design a project that could minimize these aspects while hopefully decreasing the use of telemetry and Foley catheters.”
The researchers created a “silent” reminder that was posted on a widely used screen within their EHR and was only activated when the user clicked on it. “Additionally, we wanted to make sure that this intervention made its way to teaching rounds and the patients’ bedsides,” Dr. Wray said. “So, when the attendings and residents would print out their daily census, it would contain the reminders, which allowed the team to quickly review which patients were actively using telemetry or had a Foley and discuss, at a team-level, whose telemetry or Foley could be stopped.”
The project demonstrated a trend toward less telemetry use, less time spent on telemetry, fewer catheters ordered, and more selective utilization of catheters in sicker patients.
“We believe that our project shows that the bundling of interventions has the potential to impart an effect on a greater proportion of the population than those that focus on a single issue,” Dr. Wray said. “Second, future interventions that look to utilize EHR-based clinical reminders should consider utilizing a ‘silent’ design that is prominent but doesn’t intrude upon practitioners workflow.”
You don’t need to be at a large academic institution to implement this idea, he added. “A few hours with your IT expert and a champion who is willing to take the lead could easily implement this project and hopefully see similar outcomes.”
Reference
Wray, Charlie M. et al. Improving value by reducing unnecessary telemetry and urinary catheter utilization in hospitalized patients. Am J Med. 2017 Sep;130(9):1037-41.
The Choosing Wisely recommendations for hospitalists have launched numerous research projects. One dealing with telemetry and catheter use was published in September’s American Journal of Medicine.
After reviewing the literature on how people were implementing these recommendations, the researchers noticed most projects “1) narrowly focused on only one of the recommendations; 2) often used intrusive interventions that appeared to be burdensome and not adaptable to physician workflow; and 3) were expensive to implement,” said lead author Charlie M. Wray, DO, MS, of the Division of Hospital Medicine, San Francisco Veterans Affairs Medical Center, and the University of California, San Francisco. “We set out to design a project that could minimize these aspects while hopefully decreasing the use of telemetry and Foley catheters.”
The researchers created a “silent” reminder that was posted on a widely used screen within their EHR and was only activated when the user clicked on it. “Additionally, we wanted to make sure that this intervention made its way to teaching rounds and the patients’ bedsides,” Dr. Wray said. “So, when the attendings and residents would print out their daily census, it would contain the reminders, which allowed the team to quickly review which patients were actively using telemetry or had a Foley and discuss, at a team-level, whose telemetry or Foley could be stopped.”
The project demonstrated a trend toward less telemetry use, less time spent on telemetry, fewer catheters ordered, and more selective utilization of catheters in sicker patients.
“We believe that our project shows that the bundling of interventions has the potential to impart an effect on a greater proportion of the population than those that focus on a single issue,” Dr. Wray said. “Second, future interventions that look to utilize EHR-based clinical reminders should consider utilizing a ‘silent’ design that is prominent but doesn’t intrude upon practitioners workflow.”
You don’t need to be at a large academic institution to implement this idea, he added. “A few hours with your IT expert and a champion who is willing to take the lead could easily implement this project and hopefully see similar outcomes.”
Reference
Wray, Charlie M. et al. Improving value by reducing unnecessary telemetry and urinary catheter utilization in hospitalized patients. Am J Med. 2017 Sep;130(9):1037-41.
Coordinating data collection in a QI project
Editor’s note: The Society of Hospital Medicine’s (SHM’s) Physician in Training Committee launched a scholarship program in 2015 for medical students to help transform health care and revolutionize patient care. The program has been expanded for the 2017-18 year, offering two options for students to receive funding and engage in scholarly work during their first, second and third years of medical school. As a part of the longitudinal (18-month) program, recipients are required to write about their experience on a monthly basis.
I am currently working with my mentor, Dr. Ian Jenkins, an attending in the Division of Hospital Medicine at the University of California, San Diego, to start piloting data collection on our project to cut catheter-associated urinary tract infections (CAUTI). We have contacted a number of potential units to recruit for CAUTI prevention efforts, but we are hoping to do a preliminary trial of data collection to better estimate the amount of time it takes to gather data for an individual unit.
I am quickly learning that conducting a successful quality improvement project requires one to be forward-looking in an attempt to identify challenges before they arise. With respect to coordinating data collection, it may have been helpful for us to initially meet with hospital staff to identify the best staff for coordinating data collection efforts (i.e. physician, nurse, trainee) within each individual unit. This could potentially have helped us to also better communicate and recruit individuals to partner with us for our project.
I am continuing to enjoy the challenges of performing a quality improvement project. One skill that I have developed is learning how to be forward-thinking in my approach to research in an attempt to handle challenges prospectively, as opposed to retrospectively. This has helped me improve everything from how I think about data collection to how I think about displaying results. I am truly grateful to my mentor Dr. Jenkins for his help in this regard.
Victor Ekuta is a third-year medical student at UC San Diego.
Editor’s note: The Society of Hospital Medicine’s (SHM’s) Physician in Training Committee launched a scholarship program in 2015 for medical students to help transform health care and revolutionize patient care. The program has been expanded for the 2017-18 year, offering two options for students to receive funding and engage in scholarly work during their first, second and third years of medical school. As a part of the longitudinal (18-month) program, recipients are required to write about their experience on a monthly basis.
I am currently working with my mentor, Dr. Ian Jenkins, an attending in the Division of Hospital Medicine at the University of California, San Diego, to start piloting data collection on our project to cut catheter-associated urinary tract infections (CAUTI). We have contacted a number of potential units to recruit for CAUTI prevention efforts, but we are hoping to do a preliminary trial of data collection to better estimate the amount of time it takes to gather data for an individual unit.
I am quickly learning that conducting a successful quality improvement project requires one to be forward-looking in an attempt to identify challenges before they arise. With respect to coordinating data collection, it may have been helpful for us to initially meet with hospital staff to identify the best staff for coordinating data collection efforts (i.e. physician, nurse, trainee) within each individual unit. This could potentially have helped us to also better communicate and recruit individuals to partner with us for our project.
I am continuing to enjoy the challenges of performing a quality improvement project. One skill that I have developed is learning how to be forward-thinking in my approach to research in an attempt to handle challenges prospectively, as opposed to retrospectively. This has helped me improve everything from how I think about data collection to how I think about displaying results. I am truly grateful to my mentor Dr. Jenkins for his help in this regard.
Victor Ekuta is a third-year medical student at UC San Diego.
Editor’s note: The Society of Hospital Medicine’s (SHM’s) Physician in Training Committee launched a scholarship program in 2015 for medical students to help transform health care and revolutionize patient care. The program has been expanded for the 2017-18 year, offering two options for students to receive funding and engage in scholarly work during their first, second and third years of medical school. As a part of the longitudinal (18-month) program, recipients are required to write about their experience on a monthly basis.
I am currently working with my mentor, Dr. Ian Jenkins, an attending in the Division of Hospital Medicine at the University of California, San Diego, to start piloting data collection on our project to cut catheter-associated urinary tract infections (CAUTI). We have contacted a number of potential units to recruit for CAUTI prevention efforts, but we are hoping to do a preliminary trial of data collection to better estimate the amount of time it takes to gather data for an individual unit.
I am quickly learning that conducting a successful quality improvement project requires one to be forward-looking in an attempt to identify challenges before they arise. With respect to coordinating data collection, it may have been helpful for us to initially meet with hospital staff to identify the best staff for coordinating data collection efforts (i.e. physician, nurse, trainee) within each individual unit. This could potentially have helped us to also better communicate and recruit individuals to partner with us for our project.
I am continuing to enjoy the challenges of performing a quality improvement project. One skill that I have developed is learning how to be forward-thinking in my approach to research in an attempt to handle challenges prospectively, as opposed to retrospectively. This has helped me improve everything from how I think about data collection to how I think about displaying results. I am truly grateful to my mentor Dr. Jenkins for his help in this regard.
Victor Ekuta is a third-year medical student at UC San Diego.