Quality

Decreasing antimicrobial resistance and improving the correct use of antimicrobials is a national priority. According to CDC estimates, at least 2 million illnesses and 23,000 deaths annually are caused by antibiotic-resistant bacteria in the United States alone.

“Antimicrobial resistance is a serious global healthcare issue,” says Kelly Podgorny, DNP, MS, CPHQ, RN, project director at The Joint Commission. “If you review the scientific literature, it will indicate that we’re in crisis mode right now because of this.”

That’s why The Joint Commission recently announced a new Medication Management (MM) standard for hospitals, critical-access hospitals, and nursing care centers. This standard addresses antimicrobial stewardship and becomes effective January 1, 2017.

The Joint Commission is one of many organizations implementing plans to support the national action plan on this issue developed by the White House and signed by President Barack Obama. The purpose of The Joint Commission’s antimicrobial stewardship standard is to improve quality and patient safety and also to support, through its accreditation process, imperatives and actions at a national level.

The Joint Commission’s standard includes medications beyond just antibiotics by addressing antimicrobial stewardship. Clifford Chen, MD and Steven Eagle, MD

“Most of the organizations are focusing on antibiotics,” Podgorny says. “We broadened our perspective. The World Health Organization states that antimicrobial resistance threatens the effective prevention and treatment of an ever-increasing range of infections caused by bacteria, which would be antibiotics, but also includes parasites, viruses, and fungi.”

She emphasizes that hospitals need to have an effective antimicrobial stewardship program supported by hospital leadership. In fact, in The Joint Commission’s standard, the first element of performance requires leadership to establish antimicrobial stewardship as an organizational priority.

For hospitalists, antimicrobial stewardship should be a major issue in their daily work lives.

“The CDC states that studies indicate that 30–50% percent of antibiotics, and we’re just talking about antibiotics here, prescribed in hospitals are unnecessary or inappropriate,” Podgorny says.

References

1. Centers for Disease Control and Prevention. Antibiotic Resistance Threats in the United States, 2012.

   2. The Joint Commission. New Antimicrobial Stewardship Standard. Accessed September 25, 2016.

Quick Byte

Improving the Bundled Payment Model

Researchers took national Medicare fee-for-service claims for the period 2011–2012 and evaluated how 30- and 90-day episode-based spending related to patient satisfaction and surgical mortality. Results showed patients who had major surgery at high-quality hospitals cost Medicare less than patients at low-quality hospitals. Post-acute care accounted for 59.5% of the difference in 30-day episode spending. Researchers concluded that efforts to increase value with bundled payment should pay attention to improving the care at low-quality hospitals and reducing unnecessary post-acute care.

Reference

1. Tsai TC, Greaves F, Zheng J, Orav EJ, Zinner MJ, Jha AK. Better patient care at high-quality hospitals may save Medicare money and bolster episode-based payment models. Health Aff (Millwood). 2016;35(9):1681-1689.

Decreasing antimicrobial resistance and improving the correct use of antimicrobials is a national priority. According to CDC estimates, at least 2 million illnesses and 23,000 deaths annually are caused by antibiotic-resistant bacteria in the United States alone.

“Antimicrobial resistance is a serious global healthcare issue,” says Kelly Podgorny, DNP, MS, CPHQ, RN, project director at The Joint Commission. “If you review the scientific literature, it will indicate that we’re in crisis mode right now because of this.”

That’s why The Joint Commission recently announced a new Medication Management (MM) standard for hospitals, critical-access hospitals, and nursing care centers. This standard addresses antimicrobial stewardship and becomes effective January 1, 2017.

The Joint Commission is one of many organizations implementing plans to support the national action plan on this issue developed by the White House and signed by President Barack Obama. The purpose of The Joint Commission’s antimicrobial stewardship standard is to improve quality and patient safety and also to support, through its accreditation process, imperatives and actions at a national level.

The Joint Commission’s standard includes medications beyond just antibiotics by addressing antimicrobial stewardship. Clifford Chen, MD and Steven Eagle, MD

“Most of the organizations are focusing on antibiotics,” Podgorny says. “We broadened our perspective. The World Health Organization states that antimicrobial resistance threatens the effective prevention and treatment of an ever-increasing range of infections caused by bacteria, which would be antibiotics, but also includes parasites, viruses, and fungi.”

She emphasizes that hospitals need to have an effective antimicrobial stewardship program supported by hospital leadership. In fact, in The Joint Commission’s standard, the first element of performance requires leadership to establish antimicrobial stewardship as an organizational priority.

For hospitalists, antimicrobial stewardship should be a major issue in their daily work lives.

“The CDC states that studies indicate that 30–50% percent of antibiotics, and we’re just talking about antibiotics here, prescribed in hospitals are unnecessary or inappropriate,” Podgorny says.

References

1. Centers for Disease Control and Prevention. Antibiotic Resistance Threats in the United States, 2012.

   2. The Joint Commission. New Antimicrobial Stewardship Standard. Accessed September 25, 2016.

Quick Byte

Improving the Bundled Payment Model

Researchers took national Medicare fee-for-service claims for the period 2011–2012 and evaluated how 30- and 90-day episode-based spending related to patient satisfaction and surgical mortality. Results showed patients who had major surgery at high-quality hospitals cost Medicare less than patients at low-quality hospitals. Post-acute care accounted for 59.5% of the difference in 30-day episode spending. Researchers concluded that efforts to increase value with bundled payment should pay attention to improving the care at low-quality hospitals and reducing unnecessary post-acute care.

Reference

1. Tsai TC, Greaves F, Zheng J, Orav EJ, Zinner MJ, Jha AK. Better patient care at high-quality hospitals may save Medicare money and bolster episode-based payment models. Health Aff (Millwood). 2016;35(9):1681-1689.

Decreasing antimicrobial resistance and improving the correct use of antimicrobials is a national priority. According to CDC estimates, at least 2 million illnesses and 23,000 deaths annually are caused by antibiotic-resistant bacteria in the United States alone.

“Antimicrobial resistance is a serious global healthcare issue,” says Kelly Podgorny, DNP, MS, CPHQ, RN, project director at The Joint Commission. “If you review the scientific literature, it will indicate that we’re in crisis mode right now because of this.”

That’s why The Joint Commission recently announced a new Medication Management (MM) standard for hospitals, critical-access hospitals, and nursing care centers. This standard addresses antimicrobial stewardship and becomes effective January 1, 2017.

The Joint Commission is one of many organizations implementing plans to support the national action plan on this issue developed by the White House and signed by President Barack Obama. The purpose of The Joint Commission’s antimicrobial stewardship standard is to improve quality and patient safety and also to support, through its accreditation process, imperatives and actions at a national level.

The Joint Commission’s standard includes medications beyond just antibiotics by addressing antimicrobial stewardship. Clifford Chen, MD and Steven Eagle, MD

“Most of the organizations are focusing on antibiotics,” Podgorny says. “We broadened our perspective. The World Health Organization states that antimicrobial resistance threatens the effective prevention and treatment of an ever-increasing range of infections caused by bacteria, which would be antibiotics, but also includes parasites, viruses, and fungi.”

She emphasizes that hospitals need to have an effective antimicrobial stewardship program supported by hospital leadership. In fact, in The Joint Commission’s standard, the first element of performance requires leadership to establish antimicrobial stewardship as an organizational priority.

For hospitalists, antimicrobial stewardship should be a major issue in their daily work lives.

“The CDC states that studies indicate that 30–50% percent of antibiotics, and we’re just talking about antibiotics here, prescribed in hospitals are unnecessary or inappropriate,” Podgorny says.

References

1. Centers for Disease Control and Prevention. Antibiotic Resistance Threats in the United States, 2012.

   2. The Joint Commission. New Antimicrobial Stewardship Standard. Accessed September 25, 2016.

Quick Byte

Improving the Bundled Payment Model

Researchers took national Medicare fee-for-service claims for the period 2011–2012 and evaluated how 30- and 90-day episode-based spending related to patient satisfaction and surgical mortality. Results showed patients who had major surgery at high-quality hospitals cost Medicare less than patients at low-quality hospitals. Post-acute care accounted for 59.5% of the difference in 30-day episode spending. Researchers concluded that efforts to increase value with bundled payment should pay attention to improving the care at low-quality hospitals and reducing unnecessary post-acute care.

Reference

1. Tsai TC, Greaves F, Zheng J, Orav EJ, Zinner MJ, Jha AK. Better patient care at high-quality hospitals may save Medicare money and bolster episode-based payment models. Health Aff (Millwood). 2016;35(9):1681-1689.

The aviation safety model is often discussed in a healthcare context but in a way that may miss the most important points, a new article in BMJ Quality & Safety suggests.

The article, “Learning from Near Misses in Aviation: So Much More to It Than You Thought” by Robert Wears, MD, PhD, MS, of University of Florida’s Department of Emergency Medicine, suggests healthcare still has important lessons to learn from aviation. The article focuses on a book called Close Calls: Managing Risk and Resilience in Airline Flight Safety by Carl Macrae.

“Although the book itself is about airlines, it has important lessons for improving safety in healthcare, especially with respect to management of incidents or ‘near misses,’” Dr. Wears writes. “Its rich descriptions and detailed explanation of the practical, everyday work of flight safety investigators should be required reading for anyone interested in patient safety. It will destroy many of the myths and misconceptions about reporting systems and learning from incidents that have caused us to expend so much effort for such meager results; it will also overturn the normative model of safety prevalent in healthcare.”

Dr. Wears says he wanted to write the article for two reasons.

“First, the patient safety orthodoxy has been obsessed with systems for reporting incidents, accidents, hazards, general ‘hiccups’ in clinical work for years, but almost nothing of value has come from this effort despite frequent badgering of physicians to report more,” he says. “Second, mainstream patient safety has also been enamored of the aviation safety model, but its ideas about how aviation safety is actually accomplished are naive and simplistic.”

He emphasizes that patient safety efforts to date have focused on the wrong things: too much on acquiring and storing reports and too little on analyzing them to develop an understanding of the systems in which hazards to patients arise.

“Making sense of incidents is far more important than classifying, counting, or trending them,” Dr. Wears says.

Hospitalists are on the front line of these issues, of course.

“Hospitalists regularly encounter hazards to patients in their daily work and, for the most part, successfully manage to mitigate or work around them, but the hazards remain in the system, only to pop up again sometime later. … A rich description of how a successful and effective safety reporting and analysis effort really works—not how we imagine it to work—could help us exchange our current wasteful and ineffective approach for something better,” he says.

Reference

1. Wears R. Learning from near misses in aviation: so much more to it than you thought [published online ahead of print September 1, 2016]. BMJ Qual Saf. doi:10.1136/bmjqs-2016-005990.

The aviation safety model is often discussed in a healthcare context but in a way that may miss the most important points, a new article in BMJ Quality & Safety suggests.

The article, “Learning from Near Misses in Aviation: So Much More to It Than You Thought” by Robert Wears, MD, PhD, MS, of University of Florida’s Department of Emergency Medicine, suggests healthcare still has important lessons to learn from aviation. The article focuses on a book called Close Calls: Managing Risk and Resilience in Airline Flight Safety by Carl Macrae.

“Although the book itself is about airlines, it has important lessons for improving safety in healthcare, especially with respect to management of incidents or ‘near misses,’” Dr. Wears writes. “Its rich descriptions and detailed explanation of the practical, everyday work of flight safety investigators should be required reading for anyone interested in patient safety. It will destroy many of the myths and misconceptions about reporting systems and learning from incidents that have caused us to expend so much effort for such meager results; it will also overturn the normative model of safety prevalent in healthcare.”

Dr. Wears says he wanted to write the article for two reasons.

“First, the patient safety orthodoxy has been obsessed with systems for reporting incidents, accidents, hazards, general ‘hiccups’ in clinical work for years, but almost nothing of value has come from this effort despite frequent badgering of physicians to report more,” he says. “Second, mainstream patient safety has also been enamored of the aviation safety model, but its ideas about how aviation safety is actually accomplished are naive and simplistic.”

He emphasizes that patient safety efforts to date have focused on the wrong things: too much on acquiring and storing reports and too little on analyzing them to develop an understanding of the systems in which hazards to patients arise.

“Making sense of incidents is far more important than classifying, counting, or trending them,” Dr. Wears says.

Hospitalists are on the front line of these issues, of course.

“Hospitalists regularly encounter hazards to patients in their daily work and, for the most part, successfully manage to mitigate or work around them, but the hazards remain in the system, only to pop up again sometime later. … A rich description of how a successful and effective safety reporting and analysis effort really works—not how we imagine it to work—could help us exchange our current wasteful and ineffective approach for something better,” he says.

Reference

1. Wears R. Learning from near misses in aviation: so much more to it than you thought [published online ahead of print September 1, 2016]. BMJ Qual Saf. doi:10.1136/bmjqs-2016-005990.

The aviation safety model is often discussed in a healthcare context but in a way that may miss the most important points, a new article in BMJ Quality & Safety suggests.

The article, “Learning from Near Misses in Aviation: So Much More to It Than You Thought” by Robert Wears, MD, PhD, MS, of University of Florida’s Department of Emergency Medicine, suggests healthcare still has important lessons to learn from aviation. The article focuses on a book called Close Calls: Managing Risk and Resilience in Airline Flight Safety by Carl Macrae.

“Although the book itself is about airlines, it has important lessons for improving safety in healthcare, especially with respect to management of incidents or ‘near misses,’” Dr. Wears writes. “Its rich descriptions and detailed explanation of the practical, everyday work of flight safety investigators should be required reading for anyone interested in patient safety. It will destroy many of the myths and misconceptions about reporting systems and learning from incidents that have caused us to expend so much effort for such meager results; it will also overturn the normative model of safety prevalent in healthcare.”

Dr. Wears says he wanted to write the article for two reasons.

“First, the patient safety orthodoxy has been obsessed with systems for reporting incidents, accidents, hazards, general ‘hiccups’ in clinical work for years, but almost nothing of value has come from this effort despite frequent badgering of physicians to report more,” he says. “Second, mainstream patient safety has also been enamored of the aviation safety model, but its ideas about how aviation safety is actually accomplished are naive and simplistic.”

He emphasizes that patient safety efforts to date have focused on the wrong things: too much on acquiring and storing reports and too little on analyzing them to develop an understanding of the systems in which hazards to patients arise.

“Making sense of incidents is far more important than classifying, counting, or trending them,” Dr. Wears says.

Hospitalists are on the front line of these issues, of course.

“Hospitalists regularly encounter hazards to patients in their daily work and, for the most part, successfully manage to mitigate or work around them, but the hazards remain in the system, only to pop up again sometime later. … A rich description of how a successful and effective safety reporting and analysis effort really works—not how we imagine it to work—could help us exchange our current wasteful and ineffective approach for something better,” he says.

Reference

1. Wears R. Learning from near misses in aviation: so much more to it than you thought [published online ahead of print September 1, 2016]. BMJ Qual Saf. doi:10.1136/bmjqs-2016-005990.

One of the biggest complaints of hospital patients today is poor sleep, which is not conducive to healing or good health in general.

“The reason I’m interested, as a cardiologist, is that sleep disorders are associated with an increased risk of cardiovascular mortality,” says Peter M. Farrehi, MD, assistant professor of internal medicine at the University of Michigan and lead author of a recent sleep study published in The American Journal of Medicine.

Most information about sleeping in the hospital comes from ICU studies, he says.

Dr. Farrehi wanted to actually test an intervention rather than simply survey patients. All patients received an eye mask, ear plugs, and a white-noise machine, then were randomized to receive an education-based script on the importance of using these sleep-enhancing tools or a discussion about the general benefits of sleep.

“To avoid bias in the study both from the research staff and also hospital staff, I didn't want only the intervention to have the tools,” he says. “This was a double-blind, randomized control trial in the hospital, which is really unusual.”

Patients in the group that was taught about the sleep-enhancing tools had a statistically significant difference in their perceptions of fatigue and a trend toward improving their sleep and wake disturbances.

Dr. Farrehi suggests hospitalists talk to their patients complaining of poor sleep about these sleep tools. If they are not available in their hospital, hospitalists might refer their medical director to this paper to see if there is any interest in purchasing these sleep tools.

Reference

1. 1. Farrehi PM, Clore KR, Scott JR, Vanini G, Clauw DJ. Efficacy of sleep tool education during hospitalization: a randomized controlled trial [published online ahead of print August 23, 2016]. Am J Med. doi:10.1016/j.amjmed.2016.08.001.

One of the biggest complaints of hospital patients today is poor sleep, which is not conducive to healing or good health in general.

“The reason I’m interested, as a cardiologist, is that sleep disorders are associated with an increased risk of cardiovascular mortality,” says Peter M. Farrehi, MD, assistant professor of internal medicine at the University of Michigan and lead author of a recent sleep study published in The American Journal of Medicine.

Most information about sleeping in the hospital comes from ICU studies, he says.

Dr. Farrehi wanted to actually test an intervention rather than simply survey patients. All patients received an eye mask, ear plugs, and a white-noise machine, then were randomized to receive an education-based script on the importance of using these sleep-enhancing tools or a discussion about the general benefits of sleep.

“To avoid bias in the study both from the research staff and also hospital staff, I didn't want only the intervention to have the tools,” he says. “This was a double-blind, randomized control trial in the hospital, which is really unusual.”

Patients in the group that was taught about the sleep-enhancing tools had a statistically significant difference in their perceptions of fatigue and a trend toward improving their sleep and wake disturbances.

Dr. Farrehi suggests hospitalists talk to their patients complaining of poor sleep about these sleep tools. If they are not available in their hospital, hospitalists might refer their medical director to this paper to see if there is any interest in purchasing these sleep tools.

Reference

1. 1. Farrehi PM, Clore KR, Scott JR, Vanini G, Clauw DJ. Efficacy of sleep tool education during hospitalization: a randomized controlled trial [published online ahead of print August 23, 2016]. Am J Med. doi:10.1016/j.amjmed.2016.08.001.

One of the biggest complaints of hospital patients today is poor sleep, which is not conducive to healing or good health in general.

“The reason I’m interested, as a cardiologist, is that sleep disorders are associated with an increased risk of cardiovascular mortality,” says Peter M. Farrehi, MD, assistant professor of internal medicine at the University of Michigan and lead author of a recent sleep study published in The American Journal of Medicine.

Most information about sleeping in the hospital comes from ICU studies, he says.

Dr. Farrehi wanted to actually test an intervention rather than simply survey patients. All patients received an eye mask, ear plugs, and a white-noise machine, then were randomized to receive an education-based script on the importance of using these sleep-enhancing tools or a discussion about the general benefits of sleep.

“To avoid bias in the study both from the research staff and also hospital staff, I didn't want only the intervention to have the tools,” he says. “This was a double-blind, randomized control trial in the hospital, which is really unusual.”

Patients in the group that was taught about the sleep-enhancing tools had a statistically significant difference in their perceptions of fatigue and a trend toward improving their sleep and wake disturbances.

Dr. Farrehi suggests hospitalists talk to their patients complaining of poor sleep about these sleep tools. If they are not available in their hospital, hospitalists might refer their medical director to this paper to see if there is any interest in purchasing these sleep tools.

Reference

1. 1. Farrehi PM, Clore KR, Scott JR, Vanini G, Clauw DJ. Efficacy of sleep tool education during hospitalization: a randomized controlled trial [published online ahead of print August 23, 2016]. Am J Med. doi:10.1016/j.amjmed.2016.08.001.

As compared with the general population, hospitalists are especially prone to stress and burnout, according to an abstract published in the Journal of Hospital Medicine.

The study’s scoring showed that hospitalists started with higher levels of perceived stress than the general population of adults of similar ages. Among hospitalists who attended an average of two mindfulness sessions over five weeks, there was a statistically significant increase in mindfulness and a decrease in perceived stress.

The low number of participants, seven hospitalists, makes extrapolation difficult, but the results are suggestive.

“Even with those seven people, we did see there was a significant difference in their stress and an increase in their mindfulness, which I thought was kind of impressive just for going to only two or three sessions,” says study co-author Dennis Chang, MD, of the Icahn School of Medicine at Mount Sinai. “I think the biggest thing that I would like to see is if it actually improves how we take care of our patients, not just ourselves.”

Dr. Chang says one factor that inspired the study was a hospital survey.

“We do an annual survey of our hospitalists, and it seemed that we had, as a lot of hospital groups do, a burnout problem: People were feeling a little bit burnt out,” Dr. Chang says. “We read some articles on mindfulness, and we thought it might be interesting to see if it would help our hospital.”

Starting this Fall, Mount Sinai will offer a tailored mindfulness session for providers.

“We’re hoping we’ll see if these results really stand up,” Dr. Chang says.

He encourages hospitalists to learn more about mindfulness and to realize that small changes can have an impact.

“Even doing some breathing exercises for a couple of minutes a day can actually make a big difference,” he says. “It doesn’t take a lot of time. Maybe even going to one mindfulness session can give you some tools that you can use. It can make a huge difference in your stress levels and how you take care of patients.”

Reference

1. Chablani S, Nguyen VT, Chang D. Mindfulness for hospitalists: a pilot study investigating the effect of a mindfulness initiative on mindfulness and perceived stress among hospitalists [abstract]. J Hosp Med. 2016;11(suppl 1). Accessed September 9, 2016.

As compared with the general population, hospitalists are especially prone to stress and burnout, according to an abstract published in the Journal of Hospital Medicine.

The study’s scoring showed that hospitalists started with higher levels of perceived stress than the general population of adults of similar ages. Among hospitalists who attended an average of two mindfulness sessions over five weeks, there was a statistically significant increase in mindfulness and a decrease in perceived stress.

The low number of participants, seven hospitalists, makes extrapolation difficult, but the results are suggestive.

“Even with those seven people, we did see there was a significant difference in their stress and an increase in their mindfulness, which I thought was kind of impressive just for going to only two or three sessions,” says study co-author Dennis Chang, MD, of the Icahn School of Medicine at Mount Sinai. “I think the biggest thing that I would like to see is if it actually improves how we take care of our patients, not just ourselves.”

Dr. Chang says one factor that inspired the study was a hospital survey.

“We do an annual survey of our hospitalists, and it seemed that we had, as a lot of hospital groups do, a burnout problem: People were feeling a little bit burnt out,” Dr. Chang says. “We read some articles on mindfulness, and we thought it might be interesting to see if it would help our hospital.”

Starting this Fall, Mount Sinai will offer a tailored mindfulness session for providers.

“We’re hoping we’ll see if these results really stand up,” Dr. Chang says.

He encourages hospitalists to learn more about mindfulness and to realize that small changes can have an impact.

“Even doing some breathing exercises for a couple of minutes a day can actually make a big difference,” he says. “It doesn’t take a lot of time. Maybe even going to one mindfulness session can give you some tools that you can use. It can make a huge difference in your stress levels and how you take care of patients.”

Reference

1. Chablani S, Nguyen VT, Chang D. Mindfulness for hospitalists: a pilot study investigating the effect of a mindfulness initiative on mindfulness and perceived stress among hospitalists [abstract]. J Hosp Med. 2016;11(suppl 1). Accessed September 9, 2016.

As compared with the general population, hospitalists are especially prone to stress and burnout, according to an abstract published in the Journal of Hospital Medicine.

The study’s scoring showed that hospitalists started with higher levels of perceived stress than the general population of adults of similar ages. Among hospitalists who attended an average of two mindfulness sessions over five weeks, there was a statistically significant increase in mindfulness and a decrease in perceived stress.

The low number of participants, seven hospitalists, makes extrapolation difficult, but the results are suggestive.

“Even with those seven people, we did see there was a significant difference in their stress and an increase in their mindfulness, which I thought was kind of impressive just for going to only two or three sessions,” says study co-author Dennis Chang, MD, of the Icahn School of Medicine at Mount Sinai. “I think the biggest thing that I would like to see is if it actually improves how we take care of our patients, not just ourselves.”

Dr. Chang says one factor that inspired the study was a hospital survey.

“We do an annual survey of our hospitalists, and it seemed that we had, as a lot of hospital groups do, a burnout problem: People were feeling a little bit burnt out,” Dr. Chang says. “We read some articles on mindfulness, and we thought it might be interesting to see if it would help our hospital.”

Starting this Fall, Mount Sinai will offer a tailored mindfulness session for providers.

“We’re hoping we’ll see if these results really stand up,” Dr. Chang says.

He encourages hospitalists to learn more about mindfulness and to realize that small changes can have an impact.

“Even doing some breathing exercises for a couple of minutes a day can actually make a big difference,” he says. “It doesn’t take a lot of time. Maybe even going to one mindfulness session can give you some tools that you can use. It can make a huge difference in your stress levels and how you take care of patients.”

Reference

1. Chablani S, Nguyen VT, Chang D. Mindfulness for hospitalists: a pilot study investigating the effect of a mindfulness initiative on mindfulness and perceived stress among hospitalists [abstract]. J Hosp Med. 2016;11(suppl 1). Accessed September 9, 2016.

Recent wars have led to innovations in military trauma care that can be applied to civilians, say the authors of a JAMA Viewpoint published in June.¹

During the Afghanistan and Iraq wars, the percentage of wounded soldiers who died as a result of their injuries reached its lowest point in recorded history, writes lead author Donald M. Berwick, MD, MPP, of the Institute for Healthcare Improvement in Cambridge, Mass., along with colleagues from the National Academies of Sciences, Engineering, and Medicine in Washington, D.C.

“Effective bleeding-control measures, improved resuscitation techniques, and aggressive neurocritical care interventions are among many advances that saved lives on the battlefield that otherwise would have been lost,” they write.

The reduction in injury-related deaths is in part due to the Military Health System and its Joint Trauma System embracing a culture of continuous performance improvement and an agile approach, a model called “focused empiricism,” the authors say. A new report from the National Academies of Sciences, Engineering, and Medicine clarifies the components of such a learning health system, which can also be applied to civilian care:

• Leadership and a culture of learning: “A learning health system must be stewarded by leadership committed to nurturing a culture of continuous learning and improvement. ... Such a system should unite military and civilian trauma care leaders around a common, core aim established at the highest level in the nation; namely, to achieve zero preventable deaths after injury and minimize trauma-related disability.”
• Transparency and incentives for quality trauma care: “Trauma care practitioners at all levels, including trauma surgeons and other physicians, nurses, technicians, and prehospital care personnel, should have access to data on their performance relative to that of their peers.”
• Systems for ensuring an expert trauma care workforce: “A joint, integrated network of military and civilian trauma centers should be created as a training platform to prepare and sustain an expert workforce and to promote the translation of best practices between sectors.”

The progress made by the military’s trauma system could be lost, the writers conclude, without concerted efforts to disseminate and maintain the advances. The authors note that in the United States, there are nearly 150,000 deaths from trauma each year, and injury is the third-leading cause of death.

The “hundreds of thousands of civilians who have sustained trauma deserve the benefits of care improvements achieved in military medicine,” they conclude.

Reference

1. Berwick DM, Downey AS, Cornett EA. A national trauma care system to achieve zero preventable deaths after injury: recommendations from a National Academies of Sciences, Engineering, and Medicine report [published online ahead of print June 17, 2006]. JAMA. doi:10.1001/jama.2016.8524.

Quick Byte

Rating RTLS Options

The healthcare industry typically uses real-time location systems (RTLS) to help improve care quality, workflow efficiency, and bottom lines, according to a recent article in HealthcareITNews. The research firm KLAS rated 11 RTLS vendors and gave Centrak the highest overall performance score, beating competitors including AwarePoint, Cerner, GE Healthcare, and Intelligent Insights.

Reference

1. Siwicki B. KLAS ranks real-time location systems from AwarePoint, Cerner, CenTrak, Versus and others. HealthcareITNews website. Accessed July 13, 2016.

Recent wars have led to innovations in military trauma care that can be applied to civilians, say the authors of a JAMA Viewpoint published in June.¹

During the Afghanistan and Iraq wars, the percentage of wounded soldiers who died as a result of their injuries reached its lowest point in recorded history, writes lead author Donald M. Berwick, MD, MPP, of the Institute for Healthcare Improvement in Cambridge, Mass., along with colleagues from the National Academies of Sciences, Engineering, and Medicine in Washington, D.C.

“Effective bleeding-control measures, improved resuscitation techniques, and aggressive neurocritical care interventions are among many advances that saved lives on the battlefield that otherwise would have been lost,” they write.

The reduction in injury-related deaths is in part due to the Military Health System and its Joint Trauma System embracing a culture of continuous performance improvement and an agile approach, a model called “focused empiricism,” the authors say. A new report from the National Academies of Sciences, Engineering, and Medicine clarifies the components of such a learning health system, which can also be applied to civilian care:

• Leadership and a culture of learning: “A learning health system must be stewarded by leadership committed to nurturing a culture of continuous learning and improvement. ... Such a system should unite military and civilian trauma care leaders around a common, core aim established at the highest level in the nation; namely, to achieve zero preventable deaths after injury and minimize trauma-related disability.”
• Transparency and incentives for quality trauma care: “Trauma care practitioners at all levels, including trauma surgeons and other physicians, nurses, technicians, and prehospital care personnel, should have access to data on their performance relative to that of their peers.”
• Systems for ensuring an expert trauma care workforce: “A joint, integrated network of military and civilian trauma centers should be created as a training platform to prepare and sustain an expert workforce and to promote the translation of best practices between sectors.”

The progress made by the military’s trauma system could be lost, the writers conclude, without concerted efforts to disseminate and maintain the advances. The authors note that in the United States, there are nearly 150,000 deaths from trauma each year, and injury is the third-leading cause of death.

The “hundreds of thousands of civilians who have sustained trauma deserve the benefits of care improvements achieved in military medicine,” they conclude.

Reference

1. Berwick DM, Downey AS, Cornett EA. A national trauma care system to achieve zero preventable deaths after injury: recommendations from a National Academies of Sciences, Engineering, and Medicine report [published online ahead of print June 17, 2006]. JAMA. doi:10.1001/jama.2016.8524.

Quick Byte

Rating RTLS Options

The healthcare industry typically uses real-time location systems (RTLS) to help improve care quality, workflow efficiency, and bottom lines, according to a recent article in HealthcareITNews. The research firm KLAS rated 11 RTLS vendors and gave Centrak the highest overall performance score, beating competitors including AwarePoint, Cerner, GE Healthcare, and Intelligent Insights.

Reference

1. Siwicki B. KLAS ranks real-time location systems from AwarePoint, Cerner, CenTrak, Versus and others. HealthcareITNews website. Accessed July 13, 2016.

Recent wars have led to innovations in military trauma care that can be applied to civilians, say the authors of a JAMA Viewpoint published in June.¹

During the Afghanistan and Iraq wars, the percentage of wounded soldiers who died as a result of their injuries reached its lowest point in recorded history, writes lead author Donald M. Berwick, MD, MPP, of the Institute for Healthcare Improvement in Cambridge, Mass., along with colleagues from the National Academies of Sciences, Engineering, and Medicine in Washington, D.C.

“Effective bleeding-control measures, improved resuscitation techniques, and aggressive neurocritical care interventions are among many advances that saved lives on the battlefield that otherwise would have been lost,” they write.

The reduction in injury-related deaths is in part due to the Military Health System and its Joint Trauma System embracing a culture of continuous performance improvement and an agile approach, a model called “focused empiricism,” the authors say. A new report from the National Academies of Sciences, Engineering, and Medicine clarifies the components of such a learning health system, which can also be applied to civilian care:

• Leadership and a culture of learning: “A learning health system must be stewarded by leadership committed to nurturing a culture of continuous learning and improvement. ... Such a system should unite military and civilian trauma care leaders around a common, core aim established at the highest level in the nation; namely, to achieve zero preventable deaths after injury and minimize trauma-related disability.”
• Transparency and incentives for quality trauma care: “Trauma care practitioners at all levels, including trauma surgeons and other physicians, nurses, technicians, and prehospital care personnel, should have access to data on their performance relative to that of their peers.”
• Systems for ensuring an expert trauma care workforce: “A joint, integrated network of military and civilian trauma centers should be created as a training platform to prepare and sustain an expert workforce and to promote the translation of best practices between sectors.”

The progress made by the military’s trauma system could be lost, the writers conclude, without concerted efforts to disseminate and maintain the advances. The authors note that in the United States, there are nearly 150,000 deaths from trauma each year, and injury is the third-leading cause of death.

The “hundreds of thousands of civilians who have sustained trauma deserve the benefits of care improvements achieved in military medicine,” they conclude.

Reference

1. Berwick DM, Downey AS, Cornett EA. A national trauma care system to achieve zero preventable deaths after injury: recommendations from a National Academies of Sciences, Engineering, and Medicine report [published online ahead of print June 17, 2006]. JAMA. doi:10.1001/jama.2016.8524.

Quick Byte

Rating RTLS Options

The healthcare industry typically uses real-time location systems (RTLS) to help improve care quality, workflow efficiency, and bottom lines, according to a recent article in HealthcareITNews. The research firm KLAS rated 11 RTLS vendors and gave Centrak the highest overall performance score, beating competitors including AwarePoint, Cerner, GE Healthcare, and Intelligent Insights.

Reference

1. Siwicki B. KLAS ranks real-time location systems from AwarePoint, Cerner, CenTrak, Versus and others. HealthcareITNews website. Accessed July 13, 2016.

The Society of Hospital Medicine asserts that one of the key principles of an effective hospital medicine group is demonstrating a commitment to continuous quality improvement (QI) and actively participating in initiatives directed at quality and patient safety.¹ Large hospitalist groups expect their physicians to contribute to the QI initiatives of the hospitals they staff. But as any hospitalist practicing in a community setting can tell you, QI is much easier said than done.

Acknowledge, Overcome the Obstacles

One of the first hurdles hospitalists must overcome when initiating a QI program is finding the time in their schedule as well as obtaining the time commitment from group leadership and fellow clinicians.

“If a hospitalist has no dedicated time and is working clinically, it is difficult to find time to organize a study,” says Kenneth Epstein, MD, chief medical officer of Hospitalist Consultants, the hospitalist management division of ECI Healthcare Partners, in Traverse City, Mich.

However, many national hospitalist management groups, including ECI and IPC Healthcare of North Hollywood, Calif., expect their clinicians to be continuously engaged in QI projects relative to their facility.

Beyond time, an even tougher obstacle to surmount is a lack of training, according to Kerry Weiner, MD, IPC chief medical officer. He says that each of IPC’s clinical practice leaders must participate in a one-year training program that includes a QI project conducted within their facility and mentored by University of California, San Francisco faculty.

David Nash, MD, founding dean of Jefferson College of Population Health in Philadelphia, says The Joint Commission, as part of its accreditation process, requires hospitals to robustly review errors and “have a performance improvement system in place.” He believes the only way community hospitals can successfully undertake this effort is to make sure hospitalists have adequate training in quality and safety.

Training is available from SHM via its Quality and Safety Educators Academy  as well as the American Association for Physician Leadership and the Institute for Healthcare Improvement. However, Dr. Nash recommends graduate-level programs in quality and safety available at several schools including Jefferson, Northwestern University in Chicago, and George Washington University in Washington, D.C.

Yet another hurdle is access to data. Many community hospitals have limited financial and human resources to collect accurate data to use for choosing an area to focus on and measuring improvement.

“Despite all the money invested in electronic medical records, finding timely and accurate data is still challenging,” says Jasen Gundersen, MD, president of Knoxville, Tenn.–based TeamHealth Acute Care Services. “The data may exist, but a community hospital may be limited when it comes to finding people to mine, configure, and analyze the data. Community hospitals tend to be focused on publically reported, whole-hospital data.

“If your project is not related to these metrics, you may have trouble getting quality department support.”

Dr. Weiner echoes that sentiment, noting most community hospitals “react to bad metrics, such as low HCAHPS scores. To get the most support possible,” he says, “design a QI program that people see as a genuine problem that needs to be fixed using their resources.”

Get Involved

Experience is another barrier to community-based QI projects. Dr. Gundersen believes that hospitalists who want to get involved in quality should first join a QI committee.

“One of the best ways to effect change in a hospital is to get to know the players—who’s who, who does what, and who is willing to help,” he says.

 

Arnu Mohan, MD, chief medical officer of hospital medicine at ApolloMD in Atlanta, agrees with gaining experience before setting out on your own.

“Joining a QI committee is almost never a bad idea,” Dr. Mohan says. “You’ll meet people who can support your work, get insight into the needs of the institution, be exposed to other work being done, and better understand the resources available.”

Choose Your Project Carefully

Dr. Gundersen recommends that before settling on a QI project, hospitalists should first consider what their career goals are.

“Ask yourself why you want to do it,” he says. “Do you have the ambition to become a medical director or chief quality officer? In that case, you need a few QI projects under your belt, and you want to choose a system-wide project. Or is there just something in your everyday life that frustrates you so much you must fix it?”

If the project that compels the clinician is not aligned with the needs of the hospital, “it is worthy of a discussion to make sure you are working on the right project,” he adds. “Is the hospitalist off base, or does the administration need to pay more attention to what is happening on the floor?”

Obtain Buy-in

A QI project has a greater chance at being successful if the participants have a high level of interest in the initiative and there is visible support from the administration: high-level people making public statements, making appearances at QI team meetings, and diverting resources such as information technology and process mapping support to sustain the project. This will only happen if community-based hospitalists are successful at selling their project to the C-suite.

“When you approach senior management, you have only 15 minutes to get their attention about your project,” Dr. Weiner says. “You need to show them that you are bringing part of the solution and your idea will affect their bottom line.”

Jeff Brady, MD, director of the Center for Quality Improvement and Patient Safety, says organization commitment is key to any patient safety initiative.

“In addition to the active engagement of leaders who focus on safety and quality, an organization’s culture is another factor that can either enable or thwart progress toward improving the care they deliver,” he says. “AHRQ [the Agency for Healthcare Research and Quality] developed a collection of instruments—AHRQ Surveys on Patient Safety Culture—to help organizations assess and better understand facilitators and barriers their organizations may encounter as they work to improve safety and quality.”2

Politics also can be a factor. Dr. Gundersen points out that smaller hospitals typically are used to “doing things one way.”

“They may not be receptive to changes a QI program would initiate,” he says. “You have to figure out a way to enlist people to move the project forward. Your ability to drive and influence change may be your most important quality as a physician leader.”

Dr. Mohan believes that the best approach is to find a mentor who has worked on QI initiatives before and can champion your efforts.

“You will need the support of the hospital to access required data, change processes, and implement new tools,” he says. “Many hospitals will have a chief medical officer, chief quality officer, or director of QI who can serve as an important ally to mobilize resources on your behalf.”

Go Beyond Hospital Medicine

Even with administrative support, it is better to assemble a team than attempt to go it alone. Successful QI projects, Dr. Mohan says, tend to be team efforts.

 

“Finding a community of people who will support your work is critical,” he adds. “A multidisciplinary team, including areas such as nursing, therapy, and administration, that engages people who will complement one another increases the likelihood of success.

“That said, multidisciplinary teams have their challenges. They can be unwieldy to lead and without clear roles and responsibilities. I would recommend a group of two to five people who are passionate about the issue you are trying to solve. And be clear from the beginning what each person’s role is within the group.”

Support can also be found in areas outside of the medical staff.

“Key people in other hospital departments can assist with supplying data, financial solutions, and institutional support,” Dr. Mohan says. “These people may be in various departments, such as quality improvement and case management.

“In the current era of value-based purchasing, where Medicare reimbursement is tied to quality metrics, it’s advantageous to show potential financial impact of the QI initiative on hospital revenue, so assistance by the CFO or others in finance may be helpful.”

Dr. Gundersen suggests hospitalists seek out a “lateral mentor,” someone in a department outside the medical staff who is looking for change and can offer resources.

“For example, physicians are looking for quality improvement, and those in the finance department are looking for good economic return. Physicians can explain medical reasons things need to be done, and the finance people can explain the impact of these choices,” he says. “Working together, they can improve both quality and the bottom line.”

Lateral mentoring also is an effective way to meet the challenge of obtaining accurate data, as it opens up the potential to mine data from various departments.

“At different institutions, data may reside in different departments,” Dr. Epstein says. “For example, patient satisfaction may reside with the CMO, core measures or readmissions may reside with the quality management department, and length of stay may be the purview of the finance department.”

Connections in other departments could be the source of your best data, according to Dr. Epstein.

Consider Incentives, Penalties

In addition to buy-in from administration and professionals in other departments, hospitalists also need the commitment of fellow clinicians. Dr. Weiner believes the only way to do this is through financial incentives.

“In a community setting, start with a meaningful reward for improvement. It must be enough that the hospitalist makes the QI project a priority,” he says.

Dr. Weiner also recommends a small penalty for non-participation.

“Most providers realize QI is just good practice, but for some individuals, you need a consequence. It must be part of the system so it isn’t personal,” Dr. Weiner says. “One way is to mandate that if you do not participate, not only do you not get any of the incentive pay, you might lose some of a productivity bonus. You need to be creative when thinking about how to promote QI.”

In the community hospital setting, Dr. Weiner says, practicality ultimately rules.

“The community hospital has real problems to deal with, so don’t make your project pie-in-the-sky,” he says. “Tie it to the bottom line of the hospital if you can. That’s where you start.” TH

---

Maybelle Cowan-Lincoln is a freelance writer in New Jersey.

References

1. Cawley P, Deitelzweig S, Flores L. The key principles and characteristics of an effective hospital medicine group: as assessment guide for hospitals and hospitalists. J Hosp Med. 2014;9:123-128.
2. Surveys on patient safety culture. AHRQ website. Accessed October 12, 2015.
3. AHRQ Quality Indicators Toolkit for Hospitals: fact sheet. AHRQ website. Accessed October 10, 2015.
4. Practice facilitation handbook. AHRQ website. Accessed on September 25, 2015.
5. 5. SHM signature programs. SHM website. Accessed October 10, 2015.

 

The Society of Hospital Medicine asserts that one of the key principles of an effective hospital medicine group is demonstrating a commitment to continuous quality improvement (QI) and actively participating in initiatives directed at quality and patient safety.¹ Large hospitalist groups expect their physicians to contribute to the QI initiatives of the hospitals they staff. But as any hospitalist practicing in a community setting can tell you, QI is much easier said than done.

Acknowledge, Overcome the Obstacles

One of the first hurdles hospitalists must overcome when initiating a QI program is finding the time in their schedule as well as obtaining the time commitment from group leadership and fellow clinicians.

“If a hospitalist has no dedicated time and is working clinically, it is difficult to find time to organize a study,” says Kenneth Epstein, MD, chief medical officer of Hospitalist Consultants, the hospitalist management division of ECI Healthcare Partners, in Traverse City, Mich.

However, many national hospitalist management groups, including ECI and IPC Healthcare of North Hollywood, Calif., expect their clinicians to be continuously engaged in QI projects relative to their facility.

Beyond time, an even tougher obstacle to surmount is a lack of training, according to Kerry Weiner, MD, IPC chief medical officer. He says that each of IPC’s clinical practice leaders must participate in a one-year training program that includes a QI project conducted within their facility and mentored by University of California, San Francisco faculty.

David Nash, MD, founding dean of Jefferson College of Population Health in Philadelphia, says The Joint Commission, as part of its accreditation process, requires hospitals to robustly review errors and “have a performance improvement system in place.” He believes the only way community hospitals can successfully undertake this effort is to make sure hospitalists have adequate training in quality and safety.

Training is available from SHM via its Quality and Safety Educators Academy  as well as the American Association for Physician Leadership and the Institute for Healthcare Improvement. However, Dr. Nash recommends graduate-level programs in quality and safety available at several schools including Jefferson, Northwestern University in Chicago, and George Washington University in Washington, D.C.

Yet another hurdle is access to data. Many community hospitals have limited financial and human resources to collect accurate data to use for choosing an area to focus on and measuring improvement.

“Despite all the money invested in electronic medical records, finding timely and accurate data is still challenging,” says Jasen Gundersen, MD, president of Knoxville, Tenn.–based TeamHealth Acute Care Services. “The data may exist, but a community hospital may be limited when it comes to finding people to mine, configure, and analyze the data. Community hospitals tend to be focused on publically reported, whole-hospital data.

“If your project is not related to these metrics, you may have trouble getting quality department support.”

Dr. Weiner echoes that sentiment, noting most community hospitals “react to bad metrics, such as low HCAHPS scores. To get the most support possible,” he says, “design a QI program that people see as a genuine problem that needs to be fixed using their resources.”

Get Involved

Experience is another barrier to community-based QI projects. Dr. Gundersen believes that hospitalists who want to get involved in quality should first join a QI committee.

“One of the best ways to effect change in a hospital is to get to know the players—who’s who, who does what, and who is willing to help,” he says.

 

Arnu Mohan, MD, chief medical officer of hospital medicine at ApolloMD in Atlanta, agrees with gaining experience before setting out on your own.

“Joining a QI committee is almost never a bad idea,” Dr. Mohan says. “You’ll meet people who can support your work, get insight into the needs of the institution, be exposed to other work being done, and better understand the resources available.”

Choose Your Project Carefully

Dr. Gundersen recommends that before settling on a QI project, hospitalists should first consider what their career goals are.

“Ask yourself why you want to do it,” he says. “Do you have the ambition to become a medical director or chief quality officer? In that case, you need a few QI projects under your belt, and you want to choose a system-wide project. Or is there just something in your everyday life that frustrates you so much you must fix it?”

If the project that compels the clinician is not aligned with the needs of the hospital, “it is worthy of a discussion to make sure you are working on the right project,” he adds. “Is the hospitalist off base, or does the administration need to pay more attention to what is happening on the floor?”

Obtain Buy-in

A QI project has a greater chance at being successful if the participants have a high level of interest in the initiative and there is visible support from the administration: high-level people making public statements, making appearances at QI team meetings, and diverting resources such as information technology and process mapping support to sustain the project. This will only happen if community-based hospitalists are successful at selling their project to the C-suite.

“When you approach senior management, you have only 15 minutes to get their attention about your project,” Dr. Weiner says. “You need to show them that you are bringing part of the solution and your idea will affect their bottom line.”

Jeff Brady, MD, director of the Center for Quality Improvement and Patient Safety, says organization commitment is key to any patient safety initiative.

“In addition to the active engagement of leaders who focus on safety and quality, an organization’s culture is another factor that can either enable or thwart progress toward improving the care they deliver,” he says. “AHRQ [the Agency for Healthcare Research and Quality] developed a collection of instruments—AHRQ Surveys on Patient Safety Culture—to help organizations assess and better understand facilitators and barriers their organizations may encounter as they work to improve safety and quality.”2

Politics also can be a factor. Dr. Gundersen points out that smaller hospitals typically are used to “doing things one way.”

“They may not be receptive to changes a QI program would initiate,” he says. “You have to figure out a way to enlist people to move the project forward. Your ability to drive and influence change may be your most important quality as a physician leader.”

Dr. Mohan believes that the best approach is to find a mentor who has worked on QI initiatives before and can champion your efforts.

“You will need the support of the hospital to access required data, change processes, and implement new tools,” he says. “Many hospitals will have a chief medical officer, chief quality officer, or director of QI who can serve as an important ally to mobilize resources on your behalf.”

Go Beyond Hospital Medicine

Even with administrative support, it is better to assemble a team than attempt to go it alone. Successful QI projects, Dr. Mohan says, tend to be team efforts.

 

“Finding a community of people who will support your work is critical,” he adds. “A multidisciplinary team, including areas such as nursing, therapy, and administration, that engages people who will complement one another increases the likelihood of success.

“That said, multidisciplinary teams have their challenges. They can be unwieldy to lead and without clear roles and responsibilities. I would recommend a group of two to five people who are passionate about the issue you are trying to solve. And be clear from the beginning what each person’s role is within the group.”

Support can also be found in areas outside of the medical staff.

“Key people in other hospital departments can assist with supplying data, financial solutions, and institutional support,” Dr. Mohan says. “These people may be in various departments, such as quality improvement and case management.

“In the current era of value-based purchasing, where Medicare reimbursement is tied to quality metrics, it’s advantageous to show potential financial impact of the QI initiative on hospital revenue, so assistance by the CFO or others in finance may be helpful.”

Dr. Gundersen suggests hospitalists seek out a “lateral mentor,” someone in a department outside the medical staff who is looking for change and can offer resources.

“For example, physicians are looking for quality improvement, and those in the finance department are looking for good economic return. Physicians can explain medical reasons things need to be done, and the finance people can explain the impact of these choices,” he says. “Working together, they can improve both quality and the bottom line.”

Lateral mentoring also is an effective way to meet the challenge of obtaining accurate data, as it opens up the potential to mine data from various departments.

“At different institutions, data may reside in different departments,” Dr. Epstein says. “For example, patient satisfaction may reside with the CMO, core measures or readmissions may reside with the quality management department, and length of stay may be the purview of the finance department.”

Connections in other departments could be the source of your best data, according to Dr. Epstein.

Consider Incentives, Penalties

In addition to buy-in from administration and professionals in other departments, hospitalists also need the commitment of fellow clinicians. Dr. Weiner believes the only way to do this is through financial incentives.

“In a community setting, start with a meaningful reward for improvement. It must be enough that the hospitalist makes the QI project a priority,” he says.

Dr. Weiner also recommends a small penalty for non-participation.

“Most providers realize QI is just good practice, but for some individuals, you need a consequence. It must be part of the system so it isn’t personal,” Dr. Weiner says. “One way is to mandate that if you do not participate, not only do you not get any of the incentive pay, you might lose some of a productivity bonus. You need to be creative when thinking about how to promote QI.”

In the community hospital setting, Dr. Weiner says, practicality ultimately rules.

“The community hospital has real problems to deal with, so don’t make your project pie-in-the-sky,” he says. “Tie it to the bottom line of the hospital if you can. That’s where you start.” TH

---

Maybelle Cowan-Lincoln is a freelance writer in New Jersey.

References

1. Cawley P, Deitelzweig S, Flores L. The key principles and characteristics of an effective hospital medicine group: as assessment guide for hospitals and hospitalists. J Hosp Med. 2014;9:123-128.
2. Surveys on patient safety culture. AHRQ website. Accessed October 12, 2015.
3. AHRQ Quality Indicators Toolkit for Hospitals: fact sheet. AHRQ website. Accessed October 10, 2015.
4. Practice facilitation handbook. AHRQ website. Accessed on September 25, 2015.
5. 5. SHM signature programs. SHM website. Accessed October 10, 2015.

 

The Society of Hospital Medicine asserts that one of the key principles of an effective hospital medicine group is demonstrating a commitment to continuous quality improvement (QI) and actively participating in initiatives directed at quality and patient safety.¹ Large hospitalist groups expect their physicians to contribute to the QI initiatives of the hospitals they staff. But as any hospitalist practicing in a community setting can tell you, QI is much easier said than done.

Acknowledge, Overcome the Obstacles

One of the first hurdles hospitalists must overcome when initiating a QI program is finding the time in their schedule as well as obtaining the time commitment from group leadership and fellow clinicians.

“If a hospitalist has no dedicated time and is working clinically, it is difficult to find time to organize a study,” says Kenneth Epstein, MD, chief medical officer of Hospitalist Consultants, the hospitalist management division of ECI Healthcare Partners, in Traverse City, Mich.

However, many national hospitalist management groups, including ECI and IPC Healthcare of North Hollywood, Calif., expect their clinicians to be continuously engaged in QI projects relative to their facility.

Beyond time, an even tougher obstacle to surmount is a lack of training, according to Kerry Weiner, MD, IPC chief medical officer. He says that each of IPC’s clinical practice leaders must participate in a one-year training program that includes a QI project conducted within their facility and mentored by University of California, San Francisco faculty.

David Nash, MD, founding dean of Jefferson College of Population Health in Philadelphia, says The Joint Commission, as part of its accreditation process, requires hospitals to robustly review errors and “have a performance improvement system in place.” He believes the only way community hospitals can successfully undertake this effort is to make sure hospitalists have adequate training in quality and safety.

Training is available from SHM via its Quality and Safety Educators Academy  as well as the American Association for Physician Leadership and the Institute for Healthcare Improvement. However, Dr. Nash recommends graduate-level programs in quality and safety available at several schools including Jefferson, Northwestern University in Chicago, and George Washington University in Washington, D.C.

Yet another hurdle is access to data. Many community hospitals have limited financial and human resources to collect accurate data to use for choosing an area to focus on and measuring improvement.

“Despite all the money invested in electronic medical records, finding timely and accurate data is still challenging,” says Jasen Gundersen, MD, president of Knoxville, Tenn.–based TeamHealth Acute Care Services. “The data may exist, but a community hospital may be limited when it comes to finding people to mine, configure, and analyze the data. Community hospitals tend to be focused on publically reported, whole-hospital data.

“If your project is not related to these metrics, you may have trouble getting quality department support.”

Dr. Weiner echoes that sentiment, noting most community hospitals “react to bad metrics, such as low HCAHPS scores. To get the most support possible,” he says, “design a QI program that people see as a genuine problem that needs to be fixed using their resources.”

Get Involved

Experience is another barrier to community-based QI projects. Dr. Gundersen believes that hospitalists who want to get involved in quality should first join a QI committee.

“One of the best ways to effect change in a hospital is to get to know the players—who’s who, who does what, and who is willing to help,” he says.

 

Arnu Mohan, MD, chief medical officer of hospital medicine at ApolloMD in Atlanta, agrees with gaining experience before setting out on your own.

“Joining a QI committee is almost never a bad idea,” Dr. Mohan says. “You’ll meet people who can support your work, get insight into the needs of the institution, be exposed to other work being done, and better understand the resources available.”

Choose Your Project Carefully

Dr. Gundersen recommends that before settling on a QI project, hospitalists should first consider what their career goals are.

“Ask yourself why you want to do it,” he says. “Do you have the ambition to become a medical director or chief quality officer? In that case, you need a few QI projects under your belt, and you want to choose a system-wide project. Or is there just something in your everyday life that frustrates you so much you must fix it?”

If the project that compels the clinician is not aligned with the needs of the hospital, “it is worthy of a discussion to make sure you are working on the right project,” he adds. “Is the hospitalist off base, or does the administration need to pay more attention to what is happening on the floor?”

Obtain Buy-in

A QI project has a greater chance at being successful if the participants have a high level of interest in the initiative and there is visible support from the administration: high-level people making public statements, making appearances at QI team meetings, and diverting resources such as information technology and process mapping support to sustain the project. This will only happen if community-based hospitalists are successful at selling their project to the C-suite.

“When you approach senior management, you have only 15 minutes to get their attention about your project,” Dr. Weiner says. “You need to show them that you are bringing part of the solution and your idea will affect their bottom line.”

Jeff Brady, MD, director of the Center for Quality Improvement and Patient Safety, says organization commitment is key to any patient safety initiative.

“In addition to the active engagement of leaders who focus on safety and quality, an organization’s culture is another factor that can either enable or thwart progress toward improving the care they deliver,” he says. “AHRQ [the Agency for Healthcare Research and Quality] developed a collection of instruments—AHRQ Surveys on Patient Safety Culture—to help organizations assess and better understand facilitators and barriers their organizations may encounter as they work to improve safety and quality.”2

Politics also can be a factor. Dr. Gundersen points out that smaller hospitals typically are used to “doing things one way.”

“They may not be receptive to changes a QI program would initiate,” he says. “You have to figure out a way to enlist people to move the project forward. Your ability to drive and influence change may be your most important quality as a physician leader.”

Dr. Mohan believes that the best approach is to find a mentor who has worked on QI initiatives before and can champion your efforts.

“You will need the support of the hospital to access required data, change processes, and implement new tools,” he says. “Many hospitals will have a chief medical officer, chief quality officer, or director of QI who can serve as an important ally to mobilize resources on your behalf.”

Go Beyond Hospital Medicine

Even with administrative support, it is better to assemble a team than attempt to go it alone. Successful QI projects, Dr. Mohan says, tend to be team efforts.

 

“Finding a community of people who will support your work is critical,” he adds. “A multidisciplinary team, including areas such as nursing, therapy, and administration, that engages people who will complement one another increases the likelihood of success.

“That said, multidisciplinary teams have their challenges. They can be unwieldy to lead and without clear roles and responsibilities. I would recommend a group of two to five people who are passionate about the issue you are trying to solve. And be clear from the beginning what each person’s role is within the group.”

Support can also be found in areas outside of the medical staff.

“Key people in other hospital departments can assist with supplying data, financial solutions, and institutional support,” Dr. Mohan says. “These people may be in various departments, such as quality improvement and case management.

“In the current era of value-based purchasing, where Medicare reimbursement is tied to quality metrics, it’s advantageous to show potential financial impact of the QI initiative on hospital revenue, so assistance by the CFO or others in finance may be helpful.”

Dr. Gundersen suggests hospitalists seek out a “lateral mentor,” someone in a department outside the medical staff who is looking for change and can offer resources.

“For example, physicians are looking for quality improvement, and those in the finance department are looking for good economic return. Physicians can explain medical reasons things need to be done, and the finance people can explain the impact of these choices,” he says. “Working together, they can improve both quality and the bottom line.”

Lateral mentoring also is an effective way to meet the challenge of obtaining accurate data, as it opens up the potential to mine data from various departments.

“At different institutions, data may reside in different departments,” Dr. Epstein says. “For example, patient satisfaction may reside with the CMO, core measures or readmissions may reside with the quality management department, and length of stay may be the purview of the finance department.”

Connections in other departments could be the source of your best data, according to Dr. Epstein.

Consider Incentives, Penalties

In addition to buy-in from administration and professionals in other departments, hospitalists also need the commitment of fellow clinicians. Dr. Weiner believes the only way to do this is through financial incentives.

“In a community setting, start with a meaningful reward for improvement. It must be enough that the hospitalist makes the QI project a priority,” he says.

Dr. Weiner also recommends a small penalty for non-participation.

“Most providers realize QI is just good practice, but for some individuals, you need a consequence. It must be part of the system so it isn’t personal,” Dr. Weiner says. “One way is to mandate that if you do not participate, not only do you not get any of the incentive pay, you might lose some of a productivity bonus. You need to be creative when thinking about how to promote QI.”

In the community hospital setting, Dr. Weiner says, practicality ultimately rules.

“The community hospital has real problems to deal with, so don’t make your project pie-in-the-sky,” he says. “Tie it to the bottom line of the hospital if you can. That’s where you start.” TH

---

Maybelle Cowan-Lincoln is a freelance writer in New Jersey.

References

1. Cawley P, Deitelzweig S, Flores L. The key principles and characteristics of an effective hospital medicine group: as assessment guide for hospitals and hospitalists. J Hosp Med. 2014;9:123-128.
2. Surveys on patient safety culture. AHRQ website. Accessed October 12, 2015.
3. AHRQ Quality Indicators Toolkit for Hospitals: fact sheet. AHRQ website. Accessed October 10, 2015.
4. Practice facilitation handbook. AHRQ website. Accessed on September 25, 2015.
5. 5. SHM signature programs. SHM website. Accessed October 10, 2015.

 

Delirium may be preventable among the elderly population, according to an abstract presented at the 2016 SHM annual meeting.1

The development of delirium involves an interrelationship between predisposing factors and precipitating factors in vulnerable patients. In 2015, a pilot project was conducted at Guthrie Robert Packer Hospital in Sayre, Penn., that included post-orthopedic surgery patients 60 years of age and older and patients with dementia at baseline cognitive function on admission.

The focus was on managing five risk factors: cognitive impairment, sleep deprivation, immobility, visual/hearing impairment, and medications. The nurses and residents caring for the patients were educated about methods that were proven to decrease the incidence of delirium. These include:

• Using clocks and blinds to help restore circadian balance
• Encouraging cognitive stimulation and regular visits from family and friends
• Facilitating physiologic sleep with avoidance of interruption during sleeping hours
• Initiating early mobilization and minimizing use of physical restraints

The result? In the pre-intervention group, 48% of the patients were found to have delirium with different precipitating factors. In the post-intervention group, the incidence decreased to 26.9%.

“This project was undertaken to increase the awareness of a non-costly, easy, and available intervention to prevent delirium,” says lead author Marcelle Meseeha, MD, a hospitalist at Guthrie Robert Packer Hospital. “Post-intervention study showed that the incidence of delirium has significantly decreased applying simple interventions. These familiar practices should be a mandatory process or a reminder in electronic health records. Also, education of providers and nursing staff must be an ongoing process. This will help reduce the incidence of delirium with its deleterious sequelae.” TH

Reference

1. Meseeha M, Attia M. Ways to reduce incidence of hospital ward-acquired delirium; a quality improvement project [abstract]. J Hosp Med. 2016;11(suppl 1). Accessed July 18, 2016.

Delirium may be preventable among the elderly population, according to an abstract presented at the 2016 SHM annual meeting.1

The development of delirium involves an interrelationship between predisposing factors and precipitating factors in vulnerable patients. In 2015, a pilot project was conducted at Guthrie Robert Packer Hospital in Sayre, Penn., that included post-orthopedic surgery patients 60 years of age and older and patients with dementia at baseline cognitive function on admission.

The focus was on managing five risk factors: cognitive impairment, sleep deprivation, immobility, visual/hearing impairment, and medications. The nurses and residents caring for the patients were educated about methods that were proven to decrease the incidence of delirium. These include:

• Using clocks and blinds to help restore circadian balance
• Encouraging cognitive stimulation and regular visits from family and friends
• Facilitating physiologic sleep with avoidance of interruption during sleeping hours
• Initiating early mobilization and minimizing use of physical restraints

The result? In the pre-intervention group, 48% of the patients were found to have delirium with different precipitating factors. In the post-intervention group, the incidence decreased to 26.9%.

“This project was undertaken to increase the awareness of a non-costly, easy, and available intervention to prevent delirium,” says lead author Marcelle Meseeha, MD, a hospitalist at Guthrie Robert Packer Hospital. “Post-intervention study showed that the incidence of delirium has significantly decreased applying simple interventions. These familiar practices should be a mandatory process or a reminder in electronic health records. Also, education of providers and nursing staff must be an ongoing process. This will help reduce the incidence of delirium with its deleterious sequelae.” TH

Reference

1. Meseeha M, Attia M. Ways to reduce incidence of hospital ward-acquired delirium; a quality improvement project [abstract]. J Hosp Med. 2016;11(suppl 1). Accessed July 18, 2016.

Delirium may be preventable among the elderly population, according to an abstract presented at the 2016 SHM annual meeting.1

The development of delirium involves an interrelationship between predisposing factors and precipitating factors in vulnerable patients. In 2015, a pilot project was conducted at Guthrie Robert Packer Hospital in Sayre, Penn., that included post-orthopedic surgery patients 60 years of age and older and patients with dementia at baseline cognitive function on admission.

The focus was on managing five risk factors: cognitive impairment, sleep deprivation, immobility, visual/hearing impairment, and medications. The nurses and residents caring for the patients were educated about methods that were proven to decrease the incidence of delirium. These include:

• Using clocks and blinds to help restore circadian balance
• Encouraging cognitive stimulation and regular visits from family and friends
• Facilitating physiologic sleep with avoidance of interruption during sleeping hours
• Initiating early mobilization and minimizing use of physical restraints

The result? In the pre-intervention group, 48% of the patients were found to have delirium with different precipitating factors. In the post-intervention group, the incidence decreased to 26.9%.

“This project was undertaken to increase the awareness of a non-costly, easy, and available intervention to prevent delirium,” says lead author Marcelle Meseeha, MD, a hospitalist at Guthrie Robert Packer Hospital. “Post-intervention study showed that the incidence of delirium has significantly decreased applying simple interventions. These familiar practices should be a mandatory process or a reminder in electronic health records. Also, education of providers and nursing staff must be an ongoing process. This will help reduce the incidence of delirium with its deleterious sequelae.” TH

Reference

1. Meseeha M, Attia M. Ways to reduce incidence of hospital ward-acquired delirium; a quality improvement project [abstract]. J Hosp Med. 2016;11(suppl 1). Accessed July 18, 2016.

Compared to other healthcare-associated infections, catheter-associated urinary tract infections (CAUTIs) cause relatively low rates of mortality and morbidity, but their prevalence nevertheless leads to a considerable cumulative burden.

Hospitalists can impact CAUTI rates by using a simple bundle of interventions. This idea was recently demonstrated by a quality improvement project addressing high CAUTI rates in the hospital setting. The project was summarized in a paper published in The Joint Commission Journal on Quality and Patient Safety.

The project identified a bundle of primary interventions to reduce CAUTI, which consisted of six elements: the “6 Cs” of CAUTI reduction. These include “consider alternatives,” “culture urine only when indication is clear,” and “connect with a securement device.” The interventions were implemented on one ICU with excellent results and subsequently diffused throughout the healthcare facility using multimedia tools. CAUTI rates decreased by 70%.

“The first steps in CAUTI prevention are to ensure that catheters are placed only when necessary, aseptic technique used for placement, and that they are removed when no longer essential,” says lead author Priya Sampathkumar, MD, Mayo Clinic associate professor of medicine. “Once this has been achieved, if CAUTI rates are still high, a secondary bundle of CAUTI prevention can help to reduce CAUTI further.”

About one in four hospitalized patients have a urinary catheter in place.2 “Hospitalists, therefore, can have a significant impact on CAUTI by being mindful about catheter use and catheter management.” Dr. Sampathkumar says.

References

1. Sampathkumar P, Barth JW, Johnson M, et al. Mayo Clinic reduces catheter-associated urinary tract infections. Jt Comm J Qual Patient Saf. 2016;42(6):254-265.
2. Catheter-associated urinary tract infections (CAUTI). Centers for Disease Control and Prevention website. Accessed August 8, 2016.

Compared to other healthcare-associated infections, catheter-associated urinary tract infections (CAUTIs) cause relatively low rates of mortality and morbidity, but their prevalence nevertheless leads to a considerable cumulative burden.

Hospitalists can impact CAUTI rates by using a simple bundle of interventions. This idea was recently demonstrated by a quality improvement project addressing high CAUTI rates in the hospital setting. The project was summarized in a paper published in The Joint Commission Journal on Quality and Patient Safety.

The project identified a bundle of primary interventions to reduce CAUTI, which consisted of six elements: the “6 Cs” of CAUTI reduction. These include “consider alternatives,” “culture urine only when indication is clear,” and “connect with a securement device.” The interventions were implemented on one ICU with excellent results and subsequently diffused throughout the healthcare facility using multimedia tools. CAUTI rates decreased by 70%.

“The first steps in CAUTI prevention are to ensure that catheters are placed only when necessary, aseptic technique used for placement, and that they are removed when no longer essential,” says lead author Priya Sampathkumar, MD, Mayo Clinic associate professor of medicine. “Once this has been achieved, if CAUTI rates are still high, a secondary bundle of CAUTI prevention can help to reduce CAUTI further.”

About one in four hospitalized patients have a urinary catheter in place.2 “Hospitalists, therefore, can have a significant impact on CAUTI by being mindful about catheter use and catheter management.” Dr. Sampathkumar says.

References

1. Sampathkumar P, Barth JW, Johnson M, et al. Mayo Clinic reduces catheter-associated urinary tract infections. Jt Comm J Qual Patient Saf. 2016;42(6):254-265.
2. Catheter-associated urinary tract infections (CAUTI). Centers for Disease Control and Prevention website. Accessed August 8, 2016.

Compared to other healthcare-associated infections, catheter-associated urinary tract infections (CAUTIs) cause relatively low rates of mortality and morbidity, but their prevalence nevertheless leads to a considerable cumulative burden.

Hospitalists can impact CAUTI rates by using a simple bundle of interventions. This idea was recently demonstrated by a quality improvement project addressing high CAUTI rates in the hospital setting. The project was summarized in a paper published in The Joint Commission Journal on Quality and Patient Safety.

The project identified a bundle of primary interventions to reduce CAUTI, which consisted of six elements: the “6 Cs” of CAUTI reduction. These include “consider alternatives,” “culture urine only when indication is clear,” and “connect with a securement device.” The interventions were implemented on one ICU with excellent results and subsequently diffused throughout the healthcare facility using multimedia tools. CAUTI rates decreased by 70%.

“The first steps in CAUTI prevention are to ensure that catheters are placed only when necessary, aseptic technique used for placement, and that they are removed when no longer essential,” says lead author Priya Sampathkumar, MD, Mayo Clinic associate professor of medicine. “Once this has been achieved, if CAUTI rates are still high, a secondary bundle of CAUTI prevention can help to reduce CAUTI further.”

About one in four hospitalized patients have a urinary catheter in place.2 “Hospitalists, therefore, can have a significant impact on CAUTI by being mindful about catheter use and catheter management.” Dr. Sampathkumar says.

References

1. Sampathkumar P, Barth JW, Johnson M, et al. Mayo Clinic reduces catheter-associated urinary tract infections. Jt Comm J Qual Patient Saf. 2016;42(6):254-265.
2. Catheter-associated urinary tract infections (CAUTI). Centers for Disease Control and Prevention website. Accessed August 8, 2016.

Although effective palliative care has always been a must-have for patients and caregivers facing serious illness, it hasn’t always been readily available. With the emergence of value-based healthcare models—and their potent incentives to reduce avoidable readmissions—there is renewed hope that such care will be accessible to those who need it.

Palliative and end-of-life care have long been promoted as core skills for hospitalists. The topic has regularly been included at SHM annual meetings and other prominent hospital medicine conferences, in the American Board of Internal Medicine blueprint for recognition of focused practice in hospital medicine, and in a number of influential references for hospitalists. Still, as I look at hospitalist programs around the country, there is a clear need to improve hospitalists’ delivery of palliative and end-of-life care.

Care of patients with chronic illness in their last two years of life accounts for a third of all Medicare spending.1 As hospitalists, we encounter many of these patients as they are hospitalized—and often re-hospitalized. Palliative care, which can improve quality of life and decrease costs for patients while leading to increased satisfaction and better outcomes for caregivers, can help alleviate unneeded and unwanted aggressive interventions like hospitalization.2,3

In its 2014 report, Dying in America, the Institute of Medicine (IOM) identified several areas for improvement, including better advance care planning and payment systems supporting high quality end-of-life care.4 As I write this column in mid 2016, there are two notable achievements since the IOM report: two E&M codes for advance care planning and a substantial and growing number of hospitalist patients in alternative payment models like bundled payments or ACOs.5 I believe we are entering a time when the availability of good palliative care will be accelerated due to broader forces in healthcare that for the first time align incentives between patients’ wishes and how care is paid for.

Palliative Care Skills for Hospitalists

The following are key actions for physicians in addressing palliative care for the hospitalized patient. At the risk of oversimplifying the discipline, I offer a few key actions for hospitalists to keep in mind.

Identify patients who would benefit from palliative care. The surprise question—“Would I be surprised if this patient died in the next year?”—has the ability to predict which patients would benefit from palliative care. In one observation from a group of patients with cancer, a “no” answer identified 60% of patients who died within a year.6 The surprise question has previously been shown to be predictive in other cancer and non-cancer populations.7,8

Weisman and Meier suggest using the following in a checklist at the time of hospital admission as “primary criteria to screen for unmet palliative care needs”:9

• The surprise question
• Frequent admissions
• Admission prompted by difficult-to-control physical or psychological symptoms
• Complex care requirements
• Decline in function, feeding intolerance, or unintended decline in weight

Hold a “goals of care” meeting. A notable step forward for supporting conversations between physicians and patients occurred on Jan. 1, when the Centers for Medicare & Medicaid Services (CMS) announced the Advance Care Planning E&M codes. These are CPT codes 99497 and 99498. They can be used on the same day as other E&M codes and cover discussions regarding advance care planning issues including discussing advance directives, appointing a healthcare proxy or durable power of attorney, discussing a living will, or addressing orders for life-sustaining treatment like the role of hydration or future hospitalizations. (For more information on how to use them, visit the CMS website and search for the FAQ.)

What should hospitalists concentrate on when having “goals of care” conversations with patients and caregivers? Ariadne Labs, a Harvard-affiliated health innovation group, offers the following as elements of a serious illness conversation:10

 

• Patients’ understanding of their illness
• Patients’ preferences for information and for family involvement
• Personal life goals, fears, and anxieties
• Trade-offs they are willing to accept

For hospitalists, an important area to pay particular attention to is the role of future hospitalizations in patients’ wishes for care, as some patients, if offered appropriate symptom control, would prefer to remain at home.

Two other crucial elements of inpatient palliative care—offer psychosocial support and symptom relief and hand off patient to effective post-hospital palliative care—are outside the scope of this article. However, they should be kept in mind and, of course, applied.

Understand the role of the palliative care consultation. Busy hospitalists might reasonably think, “I simply don’t have time to address palliative care in patients who aren’t likely to die during this hospitalization or soon after.” The palliative care consult service, if available, should be accessed when patients are identified as palliative care candidates but the primary hospitalist does not have the time or resources—including specialized knowledge in some cases—to deliver adequate palliative care. Palliative care specialists can also help bridge the gap between inpatient and outpatient palliative care resources.

In sum, the move to value-based payment models and the new advance care planning E&M codes provide a renewed focus—with more aligned incentives—and the opportunity to provide good palliative care to all who need it.

For hospitalists, identifying those who would benefit from palliative care and working with the healthcare team to ensure the care is delivered are at the heart of our professional mission. TH

References

1. End-of-life care. The Darmouth Atlas of Health Care website. Accessed June 23, 2016.
2. Gade G, Venohr I, Conner D, et al. Impact of an inpatient palliative care team: a randomized control trial. J Palliat Med. 2008;11(2):180-190.
3. Morrison RS, Penrod JD, Cassel JB, et al. Cost savings associated with US hospital palliative care consultation programs. Arch Int Med. 2008;168(16):1783-1790.
4. Institute of Medicine. Dying in America: Improving Quality and Honoring Individual Preferences near the End of Life. 2014.
5. BPCI Model 2: Retrospective acute & post acute care episode. Centers for Medicare & Medicaid Services website. Accessed June 24, 2016.
6. Vick JB, Pertsch N, Hutchings M, et al. The utility of the surprise question in identifying patients most at risk of death. J Clin Oncol. 2015;33(suppl):8.
7. Moss AH, Ganjoo J, Sharma S, et al. Utility of the “surprise” question to identify dialysis patients with high mortality. Clin J Am Soc Nephrol. 2008;3:1379-1384.
8. Moss AH, Lunney JR, Culp S, et al. Prognostic significance of the “surprise” question in cancer patients. J Palliat Med. 2010;13(7):837-840.
9. Weissman D, Meier C. Identifying patients in need of a palliative care assessment in the hospital setting: a consensus report from the Center to Advance Palliative Care. J Palliat Med. 2011;14(1):17-23.
10. Serious illness care resources. Ariadne Labs website. Accessed June 24, 2016.

Although effective palliative care has always been a must-have for patients and caregivers facing serious illness, it hasn’t always been readily available. With the emergence of value-based healthcare models—and their potent incentives to reduce avoidable readmissions—there is renewed hope that such care will be accessible to those who need it.

Palliative and end-of-life care have long been promoted as core skills for hospitalists. The topic has regularly been included at SHM annual meetings and other prominent hospital medicine conferences, in the American Board of Internal Medicine blueprint for recognition of focused practice in hospital medicine, and in a number of influential references for hospitalists. Still, as I look at hospitalist programs around the country, there is a clear need to improve hospitalists’ delivery of palliative and end-of-life care.

Care of patients with chronic illness in their last two years of life accounts for a third of all Medicare spending.1 As hospitalists, we encounter many of these patients as they are hospitalized—and often re-hospitalized. Palliative care, which can improve quality of life and decrease costs for patients while leading to increased satisfaction and better outcomes for caregivers, can help alleviate unneeded and unwanted aggressive interventions like hospitalization.2,3

In its 2014 report, Dying in America, the Institute of Medicine (IOM) identified several areas for improvement, including better advance care planning and payment systems supporting high quality end-of-life care.4 As I write this column in mid 2016, there are two notable achievements since the IOM report: two E&M codes for advance care planning and a substantial and growing number of hospitalist patients in alternative payment models like bundled payments or ACOs.5 I believe we are entering a time when the availability of good palliative care will be accelerated due to broader forces in healthcare that for the first time align incentives between patients’ wishes and how care is paid for.

Palliative Care Skills for Hospitalists

The following are key actions for physicians in addressing palliative care for the hospitalized patient. At the risk of oversimplifying the discipline, I offer a few key actions for hospitalists to keep in mind.

Identify patients who would benefit from palliative care. The surprise question—“Would I be surprised if this patient died in the next year?”—has the ability to predict which patients would benefit from palliative care. In one observation from a group of patients with cancer, a “no” answer identified 60% of patients who died within a year.6 The surprise question has previously been shown to be predictive in other cancer and non-cancer populations.7,8

Weisman and Meier suggest using the following in a checklist at the time of hospital admission as “primary criteria to screen for unmet palliative care needs”:9

• The surprise question
• Frequent admissions
• Admission prompted by difficult-to-control physical or psychological symptoms
• Complex care requirements
• Decline in function, feeding intolerance, or unintended decline in weight

Hold a “goals of care” meeting. A notable step forward for supporting conversations between physicians and patients occurred on Jan. 1, when the Centers for Medicare & Medicaid Services (CMS) announced the Advance Care Planning E&M codes. These are CPT codes 99497 and 99498. They can be used on the same day as other E&M codes and cover discussions regarding advance care planning issues including discussing advance directives, appointing a healthcare proxy or durable power of attorney, discussing a living will, or addressing orders for life-sustaining treatment like the role of hydration or future hospitalizations. (For more information on how to use them, visit the CMS website and search for the FAQ.)

What should hospitalists concentrate on when having “goals of care” conversations with patients and caregivers? Ariadne Labs, a Harvard-affiliated health innovation group, offers the following as elements of a serious illness conversation:10

 

• Patients’ understanding of their illness
• Patients’ preferences for information and for family involvement
• Personal life goals, fears, and anxieties
• Trade-offs they are willing to accept

For hospitalists, an important area to pay particular attention to is the role of future hospitalizations in patients’ wishes for care, as some patients, if offered appropriate symptom control, would prefer to remain at home.

Two other crucial elements of inpatient palliative care—offer psychosocial support and symptom relief and hand off patient to effective post-hospital palliative care—are outside the scope of this article. However, they should be kept in mind and, of course, applied.

Understand the role of the palliative care consultation. Busy hospitalists might reasonably think, “I simply don’t have time to address palliative care in patients who aren’t likely to die during this hospitalization or soon after.” The palliative care consult service, if available, should be accessed when patients are identified as palliative care candidates but the primary hospitalist does not have the time or resources—including specialized knowledge in some cases—to deliver adequate palliative care. Palliative care specialists can also help bridge the gap between inpatient and outpatient palliative care resources.

In sum, the move to value-based payment models and the new advance care planning E&M codes provide a renewed focus—with more aligned incentives—and the opportunity to provide good palliative care to all who need it.

For hospitalists, identifying those who would benefit from palliative care and working with the healthcare team to ensure the care is delivered are at the heart of our professional mission. TH

References

1. End-of-life care. The Darmouth Atlas of Health Care website. Accessed June 23, 2016.
2. Gade G, Venohr I, Conner D, et al. Impact of an inpatient palliative care team: a randomized control trial. J Palliat Med. 2008;11(2):180-190.
3. Morrison RS, Penrod JD, Cassel JB, et al. Cost savings associated with US hospital palliative care consultation programs. Arch Int Med. 2008;168(16):1783-1790.
4. Institute of Medicine. Dying in America: Improving Quality and Honoring Individual Preferences near the End of Life. 2014.
5. BPCI Model 2: Retrospective acute & post acute care episode. Centers for Medicare & Medicaid Services website. Accessed June 24, 2016.
6. Vick JB, Pertsch N, Hutchings M, et al. The utility of the surprise question in identifying patients most at risk of death. J Clin Oncol. 2015;33(suppl):8.
7. Moss AH, Ganjoo J, Sharma S, et al. Utility of the “surprise” question to identify dialysis patients with high mortality. Clin J Am Soc Nephrol. 2008;3:1379-1384.
8. Moss AH, Lunney JR, Culp S, et al. Prognostic significance of the “surprise” question in cancer patients. J Palliat Med. 2010;13(7):837-840.
9. Weissman D, Meier C. Identifying patients in need of a palliative care assessment in the hospital setting: a consensus report from the Center to Advance Palliative Care. J Palliat Med. 2011;14(1):17-23.
10. Serious illness care resources. Ariadne Labs website. Accessed June 24, 2016.

Although effective palliative care has always been a must-have for patients and caregivers facing serious illness, it hasn’t always been readily available. With the emergence of value-based healthcare models—and their potent incentives to reduce avoidable readmissions—there is renewed hope that such care will be accessible to those who need it.

Palliative and end-of-life care have long been promoted as core skills for hospitalists. The topic has regularly been included at SHM annual meetings and other prominent hospital medicine conferences, in the American Board of Internal Medicine blueprint for recognition of focused practice in hospital medicine, and in a number of influential references for hospitalists. Still, as I look at hospitalist programs around the country, there is a clear need to improve hospitalists’ delivery of palliative and end-of-life care.

Care of patients with chronic illness in their last two years of life accounts for a third of all Medicare spending.1 As hospitalists, we encounter many of these patients as they are hospitalized—and often re-hospitalized. Palliative care, which can improve quality of life and decrease costs for patients while leading to increased satisfaction and better outcomes for caregivers, can help alleviate unneeded and unwanted aggressive interventions like hospitalization.2,3

In its 2014 report, Dying in America, the Institute of Medicine (IOM) identified several areas for improvement, including better advance care planning and payment systems supporting high quality end-of-life care.4 As I write this column in mid 2016, there are two notable achievements since the IOM report: two E&M codes for advance care planning and a substantial and growing number of hospitalist patients in alternative payment models like bundled payments or ACOs.5 I believe we are entering a time when the availability of good palliative care will be accelerated due to broader forces in healthcare that for the first time align incentives between patients’ wishes and how care is paid for.

Palliative Care Skills for Hospitalists

The following are key actions for physicians in addressing palliative care for the hospitalized patient. At the risk of oversimplifying the discipline, I offer a few key actions for hospitalists to keep in mind.

Identify patients who would benefit from palliative care. The surprise question—“Would I be surprised if this patient died in the next year?”—has the ability to predict which patients would benefit from palliative care. In one observation from a group of patients with cancer, a “no” answer identified 60% of patients who died within a year.6 The surprise question has previously been shown to be predictive in other cancer and non-cancer populations.7,8

Weisman and Meier suggest using the following in a checklist at the time of hospital admission as “primary criteria to screen for unmet palliative care needs”:9

• The surprise question
• Frequent admissions
• Admission prompted by difficult-to-control physical or psychological symptoms
• Complex care requirements
• Decline in function, feeding intolerance, or unintended decline in weight

Hold a “goals of care” meeting. A notable step forward for supporting conversations between physicians and patients occurred on Jan. 1, when the Centers for Medicare & Medicaid Services (CMS) announced the Advance Care Planning E&M codes. These are CPT codes 99497 and 99498. They can be used on the same day as other E&M codes and cover discussions regarding advance care planning issues including discussing advance directives, appointing a healthcare proxy or durable power of attorney, discussing a living will, or addressing orders for life-sustaining treatment like the role of hydration or future hospitalizations. (For more information on how to use them, visit the CMS website and search for the FAQ.)

What should hospitalists concentrate on when having “goals of care” conversations with patients and caregivers? Ariadne Labs, a Harvard-affiliated health innovation group, offers the following as elements of a serious illness conversation:10

 

• Patients’ understanding of their illness
• Patients’ preferences for information and for family involvement
• Personal life goals, fears, and anxieties
• Trade-offs they are willing to accept

For hospitalists, an important area to pay particular attention to is the role of future hospitalizations in patients’ wishes for care, as some patients, if offered appropriate symptom control, would prefer to remain at home.

Two other crucial elements of inpatient palliative care—offer psychosocial support and symptom relief and hand off patient to effective post-hospital palliative care—are outside the scope of this article. However, they should be kept in mind and, of course, applied.

Understand the role of the palliative care consultation. Busy hospitalists might reasonably think, “I simply don’t have time to address palliative care in patients who aren’t likely to die during this hospitalization or soon after.” The palliative care consult service, if available, should be accessed when patients are identified as palliative care candidates but the primary hospitalist does not have the time or resources—including specialized knowledge in some cases—to deliver adequate palliative care. Palliative care specialists can also help bridge the gap between inpatient and outpatient palliative care resources.

In sum, the move to value-based payment models and the new advance care planning E&M codes provide a renewed focus—with more aligned incentives—and the opportunity to provide good palliative care to all who need it.

For hospitalists, identifying those who would benefit from palliative care and working with the healthcare team to ensure the care is delivered are at the heart of our professional mission. TH

References

1. End-of-life care. The Darmouth Atlas of Health Care website. Accessed June 23, 2016.
2. Gade G, Venohr I, Conner D, et al. Impact of an inpatient palliative care team: a randomized control trial. J Palliat Med. 2008;11(2):180-190.
3. Morrison RS, Penrod JD, Cassel JB, et al. Cost savings associated with US hospital palliative care consultation programs. Arch Int Med. 2008;168(16):1783-1790.
4. Institute of Medicine. Dying in America: Improving Quality and Honoring Individual Preferences near the End of Life. 2014.
5. BPCI Model 2: Retrospective acute & post acute care episode. Centers for Medicare & Medicaid Services website. Accessed June 24, 2016.
6. Vick JB, Pertsch N, Hutchings M, et al. The utility of the surprise question in identifying patients most at risk of death. J Clin Oncol. 2015;33(suppl):8.
7. Moss AH, Ganjoo J, Sharma S, et al. Utility of the “surprise” question to identify dialysis patients with high mortality. Clin J Am Soc Nephrol. 2008;3:1379-1384.
8. Moss AH, Lunney JR, Culp S, et al. Prognostic significance of the “surprise” question in cancer patients. J Palliat Med. 2010;13(7):837-840.
9. Weissman D, Meier C. Identifying patients in need of a palliative care assessment in the hospital setting: a consensus report from the Center to Advance Palliative Care. J Palliat Med. 2011;14(1):17-23.
10. Serious illness care resources. Ariadne Labs website. Accessed June 24, 2016.

It seems as though the negative stories always make the headlines: The humanitarian physician group sent to aid Haiti earthquake victims that posted not only patient photos on Facebook but also pictures of doctors drinking alcohol and brandishing soldiers’ firearms.1 Or there’s the story of the Redding, Calif.–based hospital accused of sharing a patient’s files with journalists and communicating via email about her treatment to hundreds of hospital workers.2

The pitfalls that can complicate the intersection of social media and patient privacy often come as no surprise when they arise, but digital communications, and social media sites in particular, also have made many positive contributions to the medical profession.

“Social media allows physicians to communicate with each other, to publicize items of interest, to solicit input from colleagues—even people that we don’t know—on a variety of topics,” says Brian Clay, MD, SFHM, interim chief medical informatics officer and associate program director of the internal medicine residency-training program at the University of California at San Diego.

But there is a dark side of social media, too, and some physicians have made significant missteps in social media use. Ryan Greysen, MD, MHS, FHM, assistant professor in the division of hospital medicine at the University of California at San Francisco, has authored multiple studies on physician violations of online professionalism. In a report published in the March 2012 issue of JAMA, Dr. Greysen and co-authors note that 92% of the executive directors at state medical and osteopathic boards surveyed reported encountering at least one violation of online professionalism.3 Another report in the January 2013 issue of the Annals of Internal Medicine co-authored by Dr. Greysen notes that 71% of state medical boards have investigated physicians for violations of professionalism online.4 The consequences of these errors in judgment can be dire: Should your employer come across it or a colleague report it, you could lose your position and even lose your license.

Professional Guidelines

To avoid these significant and potentially career-ending blunders, the American College of Physicians (ACP)—in conjunction with the Federation of State Medical Boards (FSMB)—published recommendations offering ethical guidance in preserving the patient-physician relationship in context of social media.5 Similarly, the American Medical Association (AMA) published an opinion on professionalism in the use of social media.6 Their guidelines can be summarized in five succinct points.

• Maintain standards of professional ethics in online communications, including respect for patient privacy.

Katherine Chretien, MD, associate professor of medicine at George Washington University in Washington, D.C., a clinical associate professor in medicine at the Uniformed Services University of the Health Sciences in Bethesda, Md., and chief of the hospitalist section at the Veterans Affairs Medical Center also in Washington, D.C., warns physicians to use the utmost caution to maintain patient anonymity when publishing case stories online. When publishing clinical vignettes, physician blogs, and other forms of online media, all details that can identify a patient must be completely removed, including all forms of the date (references to “yesterday” or “last week,” for example, can identify the date). Check anything you intend to publish against the HIPPA list of 18 identifiers.7 (See “HIPPA Identifiers” below)

“The safest way to proceed when publishing patient narratives online is to get consent,” Dr. Chretien says. “If consent is not possible, as in cases of incidents that occurred several years ago, change the personal details, such as location, and clearly disclose that you have. Or make the example very general.” For example, instead of discussing how frustrated you became with a patient with asthma who you saw at a particular hospital in a certain year (a clear violation of patient privacy), paint the illustration in broad strokes. Dr. Chretien suggests you might phrase your observations in this way: “One of the frustrations I find when treating asthma patients is …”

 

It would also be wise to seek advice from colleagues before posting patient information, she notes.

• Do not blur the boundaries between your professional and social spheres.

In a 2011 study, Gabriel Bosslet, MD, assistant professor of clinical medicine and associate director of the fellowship in pulmonary and critical care medicine at Indiana University–Purdue University at Indianapolis, noted that 34% of participating physicians reported receiving a Facebook friend request from a patient or patient’s family member. As Dr. Chretien points out, this is less of a problem for hospitalists than private-practice physicians because the relationship with patients is transitory. The AMA, as well as the ACP and FSMB, note that physicians should not “friend” patients, accept friend requests, or contact patients through social media. Physicians are advised to keep their public and professional online personas separate, even to the point of creating distinct online identities for their personal and professional lives.

• Maintain professionalism in your online persona, and continually monitor your online image to ensure it reflects positively on yourself and the medical profession.

Some physicians fall into the trap of placing questionable postings on their personal pages, including posting content that can be inappropriate for public consumption or venting about patients and employers. Stories or incidents that medical professionals find intriguing or exciting may be disturbing to those outside their community, and medical humor can be offensive.

“[Physicians] assume [their social media page] is their personal space, so they can post whatever they want,” adds Dr. Chretien. “Part of their error is that they believe they are addressing a small group of close friends, but they forget that postings go out to the larger, peripheral audience of all Facebook friends and can often be accessed by the general public.” An ill-considered anecdote can damage not only your own reputation but also the overall perception of the profession. Physicians are always viewed in their professional role, even in social interactions.

• Use email and other forms of electronic communication only in cases of an established physician-patient relationship and only with informed patient consent. Documentation of these communications should be kept in the patient’s medical record.

Any request a physician receives for medical advice through a social media site or email must be handled with caution. The ACP and FSMB state that email and text communications with established patients can be beneficial but should occur only after both parties discuss privacy risks, the appropriate types of information that will be exchanged electronically, and how long patients should expect to wait for a physician response. Patient preference should guide the use of electronic communication with physicians, especially text messaging, says Dr. Greysen.

• Be aware that any postings on the Internet, because of its significant and unprecedented reach, can have future career ramifications. Consequently, physicians are advised to frequently monitor their online presence to control their image.

Dr. Greysen points out that presenting a positive image of physicians in the media is not a new challenge. “Physicians have been publishing books about their experiences for decades. But posting online without oversight, or in the moment without reflection, can be devastating to a physician’s career because the reach of the Internet is exponentially vaster than that of any printed material,” Dr. Greysen says.

Deliver Better Healthcare through Social Media

Perhaps one of the most dramatic ways in which social media is positively impacting healthcare is the FOAM movement, or free open access medical education. Jeanne Farnan, MD, associate professor of medicine at the University of Chicago Department of Medicine and lead author of the ACP and FSMB social media position paper, points to the dynamic collection of resources and tools for ongoing medical education as well as the community that participates in openly sharing knowledge as examples. FOAM resources are predominantly social media based and include blogs, podcasts, tweets, online videos, graphics, web-based applications, text documents, and photographs, many of which are available by following the Twitter feed @FOAMed (see “FOAM Links” below). This FOAM community is dedicated to the belief that high-quality medical education resources and interactions should be free and accessible to all who care for patients and especially to those who educate future physicians.8

 

Social media also affords physicians the opportunity to be a force in public health policies. “There is an active group of physician and medical student social media users in the blogosphere and on Twitter who use their social media presence for activism, and this presence is intimately tied to how they see themselves as a medical professional,” Dr. Farnan says. “They blog and tweet about medical education issues and other public topics such as access to care and care disparity.”

Michelle Vangel, director of insight services with Cision, a Chicago-based public relations company specializing in social media communications, praises the power of social media for raising awareness of public health issues.

“In terms of public health, social media is valuable to better understand how health-related news resonates with the public,” Vangel says. “Two salient examples of major health crises reactions tracked on social media were the Ebola outbreak in Africa and the measles outbreak at Disneyland in California. At times, there was near hysteria over Ebola and vaccine debates, with misinformation spreading quickly. However, many hospitals and physicians tried to get ahead of the hysteria by providing concise, accurate information on different social media platforms, with Facebook often a popular channel to post information.”

Social media sites can also help by making emotional support available at disease-specific sites. These communities address the patient experience of the disease that goes beyond purely medical disease information. Vangel points to several online communities that “host pivotal conversations for patients,” she says. “There are Facebook community pages dedicated to a host of conditions, including diabetes, hypertension, and cystic fibrosis, where patients discuss the challenges of medication compliance, side effects, and even dissatisfaction with healthcare professionals. BabyCenter.com provides message boards about a wide array of topics for people trying to conceive, pregnant women with health conditions, and parents of babies with health issues. CancerForums.net and the health and wellness boards at DelphiForums.com provide support to specific disease populations.”

Vangel encourages physicians to monitor online patient-support sites to better understand the difficulties patients experience while under treatment. These sites can also help physicians recognize and address the gaps in patient understanding about various diseases and explore programs geared toward the populations suffering from a wide range of conditions. TH

---

Maybelle Cowan-Lincoln is a freelance writer in New Jersey.

References

1. Photos of drinking, grinning aid mission doctors cause uproar. CNN website. Accessed December 2, 2015.
2. Terhune C. Hospital violated patient confidentiality, state says. Los Angeles Times website. Accessed December 3, 2015.
3. Greysen SR, Chretien KC, Kind T, Young A, Gross CP. Physician violations of online professionalism and disciplinary actions: a national survey of state medical boards. JAMA. 2012;(307):1141-1142.
4. Greysen SR, Johnson D, Kind T, et al. Online professional investigations by state medical boards: first, do no harm. Ann Intern Med. 2013;(158):124-130.
5. New recommendations offer physicians ethical guidance for preserving trust in patient-physician relationships and the profession when using social media. American College of Physicians website. Accessed July 3, 2015.
6. Opinion 9.124—professionalism in the use of social media. American Medical Association website. Accessed July 3, 2015.
7. HIPPA PHI: list of 18 identifiers and definition of PHI. The Committee for Protection of Human Subjects website. Accessed July 10, 2015.
8. FOAM. Life in the Fastlane website. Accessed September 6, 2015.

 

It seems as though the negative stories always make the headlines: The humanitarian physician group sent to aid Haiti earthquake victims that posted not only patient photos on Facebook but also pictures of doctors drinking alcohol and brandishing soldiers’ firearms.1 Or there’s the story of the Redding, Calif.–based hospital accused of sharing a patient’s files with journalists and communicating via email about her treatment to hundreds of hospital workers.2

The pitfalls that can complicate the intersection of social media and patient privacy often come as no surprise when they arise, but digital communications, and social media sites in particular, also have made many positive contributions to the medical profession.

“Social media allows physicians to communicate with each other, to publicize items of interest, to solicit input from colleagues—even people that we don’t know—on a variety of topics,” says Brian Clay, MD, SFHM, interim chief medical informatics officer and associate program director of the internal medicine residency-training program at the University of California at San Diego.

But there is a dark side of social media, too, and some physicians have made significant missteps in social media use. Ryan Greysen, MD, MHS, FHM, assistant professor in the division of hospital medicine at the University of California at San Francisco, has authored multiple studies on physician violations of online professionalism. In a report published in the March 2012 issue of JAMA, Dr. Greysen and co-authors note that 92% of the executive directors at state medical and osteopathic boards surveyed reported encountering at least one violation of online professionalism.3 Another report in the January 2013 issue of the Annals of Internal Medicine co-authored by Dr. Greysen notes that 71% of state medical boards have investigated physicians for violations of professionalism online.4 The consequences of these errors in judgment can be dire: Should your employer come across it or a colleague report it, you could lose your position and even lose your license.

Professional Guidelines

To avoid these significant and potentially career-ending blunders, the American College of Physicians (ACP)—in conjunction with the Federation of State Medical Boards (FSMB)—published recommendations offering ethical guidance in preserving the patient-physician relationship in context of social media.5 Similarly, the American Medical Association (AMA) published an opinion on professionalism in the use of social media.6 Their guidelines can be summarized in five succinct points.

• Maintain standards of professional ethics in online communications, including respect for patient privacy.

Katherine Chretien, MD, associate professor of medicine at George Washington University in Washington, D.C., a clinical associate professor in medicine at the Uniformed Services University of the Health Sciences in Bethesda, Md., and chief of the hospitalist section at the Veterans Affairs Medical Center also in Washington, D.C., warns physicians to use the utmost caution to maintain patient anonymity when publishing case stories online. When publishing clinical vignettes, physician blogs, and other forms of online media, all details that can identify a patient must be completely removed, including all forms of the date (references to “yesterday” or “last week,” for example, can identify the date). Check anything you intend to publish against the HIPPA list of 18 identifiers.7 (See “HIPPA Identifiers” below)

“The safest way to proceed when publishing patient narratives online is to get consent,” Dr. Chretien says. “If consent is not possible, as in cases of incidents that occurred several years ago, change the personal details, such as location, and clearly disclose that you have. Or make the example very general.” For example, instead of discussing how frustrated you became with a patient with asthma who you saw at a particular hospital in a certain year (a clear violation of patient privacy), paint the illustration in broad strokes. Dr. Chretien suggests you might phrase your observations in this way: “One of the frustrations I find when treating asthma patients is …”

 

It would also be wise to seek advice from colleagues before posting patient information, she notes.

• Do not blur the boundaries between your professional and social spheres.

In a 2011 study, Gabriel Bosslet, MD, assistant professor of clinical medicine and associate director of the fellowship in pulmonary and critical care medicine at Indiana University–Purdue University at Indianapolis, noted that 34% of participating physicians reported receiving a Facebook friend request from a patient or patient’s family member. As Dr. Chretien points out, this is less of a problem for hospitalists than private-practice physicians because the relationship with patients is transitory. The AMA, as well as the ACP and FSMB, note that physicians should not “friend” patients, accept friend requests, or contact patients through social media. Physicians are advised to keep their public and professional online personas separate, even to the point of creating distinct online identities for their personal and professional lives.

• Maintain professionalism in your online persona, and continually monitor your online image to ensure it reflects positively on yourself and the medical profession.

Some physicians fall into the trap of placing questionable postings on their personal pages, including posting content that can be inappropriate for public consumption or venting about patients and employers. Stories or incidents that medical professionals find intriguing or exciting may be disturbing to those outside their community, and medical humor can be offensive.

“[Physicians] assume [their social media page] is their personal space, so they can post whatever they want,” adds Dr. Chretien. “Part of their error is that they believe they are addressing a small group of close friends, but they forget that postings go out to the larger, peripheral audience of all Facebook friends and can often be accessed by the general public.” An ill-considered anecdote can damage not only your own reputation but also the overall perception of the profession. Physicians are always viewed in their professional role, even in social interactions.

• Use email and other forms of electronic communication only in cases of an established physician-patient relationship and only with informed patient consent. Documentation of these communications should be kept in the patient’s medical record.

Any request a physician receives for medical advice through a social media site or email must be handled with caution. The ACP and FSMB state that email and text communications with established patients can be beneficial but should occur only after both parties discuss privacy risks, the appropriate types of information that will be exchanged electronically, and how long patients should expect to wait for a physician response. Patient preference should guide the use of electronic communication with physicians, especially text messaging, says Dr. Greysen.

• Be aware that any postings on the Internet, because of its significant and unprecedented reach, can have future career ramifications. Consequently, physicians are advised to frequently monitor their online presence to control their image.

Dr. Greysen points out that presenting a positive image of physicians in the media is not a new challenge. “Physicians have been publishing books about their experiences for decades. But posting online without oversight, or in the moment without reflection, can be devastating to a physician’s career because the reach of the Internet is exponentially vaster than that of any printed material,” Dr. Greysen says.

Deliver Better Healthcare through Social Media

Perhaps one of the most dramatic ways in which social media is positively impacting healthcare is the FOAM movement, or free open access medical education. Jeanne Farnan, MD, associate professor of medicine at the University of Chicago Department of Medicine and lead author of the ACP and FSMB social media position paper, points to the dynamic collection of resources and tools for ongoing medical education as well as the community that participates in openly sharing knowledge as examples. FOAM resources are predominantly social media based and include blogs, podcasts, tweets, online videos, graphics, web-based applications, text documents, and photographs, many of which are available by following the Twitter feed @FOAMed (see “FOAM Links” below). This FOAM community is dedicated to the belief that high-quality medical education resources and interactions should be free and accessible to all who care for patients and especially to those who educate future physicians.8

 

Social media also affords physicians the opportunity to be a force in public health policies. “There is an active group of physician and medical student social media users in the blogosphere and on Twitter who use their social media presence for activism, and this presence is intimately tied to how they see themselves as a medical professional,” Dr. Farnan says. “They blog and tweet about medical education issues and other public topics such as access to care and care disparity.”

Michelle Vangel, director of insight services with Cision, a Chicago-based public relations company specializing in social media communications, praises the power of social media for raising awareness of public health issues.

“In terms of public health, social media is valuable to better understand how health-related news resonates with the public,” Vangel says. “Two salient examples of major health crises reactions tracked on social media were the Ebola outbreak in Africa and the measles outbreak at Disneyland in California. At times, there was near hysteria over Ebola and vaccine debates, with misinformation spreading quickly. However, many hospitals and physicians tried to get ahead of the hysteria by providing concise, accurate information on different social media platforms, with Facebook often a popular channel to post information.”

Social media sites can also help by making emotional support available at disease-specific sites. These communities address the patient experience of the disease that goes beyond purely medical disease information. Vangel points to several online communities that “host pivotal conversations for patients,” she says. “There are Facebook community pages dedicated to a host of conditions, including diabetes, hypertension, and cystic fibrosis, where patients discuss the challenges of medication compliance, side effects, and even dissatisfaction with healthcare professionals. BabyCenter.com provides message boards about a wide array of topics for people trying to conceive, pregnant women with health conditions, and parents of babies with health issues. CancerForums.net and the health and wellness boards at DelphiForums.com provide support to specific disease populations.”

Vangel encourages physicians to monitor online patient-support sites to better understand the difficulties patients experience while under treatment. These sites can also help physicians recognize and address the gaps in patient understanding about various diseases and explore programs geared toward the populations suffering from a wide range of conditions. TH

---

Maybelle Cowan-Lincoln is a freelance writer in New Jersey.

References

1. Photos of drinking, grinning aid mission doctors cause uproar. CNN website. Accessed December 2, 2015.
2. Terhune C. Hospital violated patient confidentiality, state says. Los Angeles Times website. Accessed December 3, 2015.
3. Greysen SR, Chretien KC, Kind T, Young A, Gross CP. Physician violations of online professionalism and disciplinary actions: a national survey of state medical boards. JAMA. 2012;(307):1141-1142.
4. Greysen SR, Johnson D, Kind T, et al. Online professional investigations by state medical boards: first, do no harm. Ann Intern Med. 2013;(158):124-130.
5. New recommendations offer physicians ethical guidance for preserving trust in patient-physician relationships and the profession when using social media. American College of Physicians website. Accessed July 3, 2015.
6. Opinion 9.124—professionalism in the use of social media. American Medical Association website. Accessed July 3, 2015.
7. HIPPA PHI: list of 18 identifiers and definition of PHI. The Committee for Protection of Human Subjects website. Accessed July 10, 2015.
8. FOAM. Life in the Fastlane website. Accessed September 6, 2015.

 

It seems as though the negative stories always make the headlines: The humanitarian physician group sent to aid Haiti earthquake victims that posted not only patient photos on Facebook but also pictures of doctors drinking alcohol and brandishing soldiers’ firearms.1 Or there’s the story of the Redding, Calif.–based hospital accused of sharing a patient’s files with journalists and communicating via email about her treatment to hundreds of hospital workers.2

The pitfalls that can complicate the intersection of social media and patient privacy often come as no surprise when they arise, but digital communications, and social media sites in particular, also have made many positive contributions to the medical profession.

“Social media allows physicians to communicate with each other, to publicize items of interest, to solicit input from colleagues—even people that we don’t know—on a variety of topics,” says Brian Clay, MD, SFHM, interim chief medical informatics officer and associate program director of the internal medicine residency-training program at the University of California at San Diego.

But there is a dark side of social media, too, and some physicians have made significant missteps in social media use. Ryan Greysen, MD, MHS, FHM, assistant professor in the division of hospital medicine at the University of California at San Francisco, has authored multiple studies on physician violations of online professionalism. In a report published in the March 2012 issue of JAMA, Dr. Greysen and co-authors note that 92% of the executive directors at state medical and osteopathic boards surveyed reported encountering at least one violation of online professionalism.3 Another report in the January 2013 issue of the Annals of Internal Medicine co-authored by Dr. Greysen notes that 71% of state medical boards have investigated physicians for violations of professionalism online.4 The consequences of these errors in judgment can be dire: Should your employer come across it or a colleague report it, you could lose your position and even lose your license.

Professional Guidelines

To avoid these significant and potentially career-ending blunders, the American College of Physicians (ACP)—in conjunction with the Federation of State Medical Boards (FSMB)—published recommendations offering ethical guidance in preserving the patient-physician relationship in context of social media.5 Similarly, the American Medical Association (AMA) published an opinion on professionalism in the use of social media.6 Their guidelines can be summarized in five succinct points.

• Maintain standards of professional ethics in online communications, including respect for patient privacy.

Katherine Chretien, MD, associate professor of medicine at George Washington University in Washington, D.C., a clinical associate professor in medicine at the Uniformed Services University of the Health Sciences in Bethesda, Md., and chief of the hospitalist section at the Veterans Affairs Medical Center also in Washington, D.C., warns physicians to use the utmost caution to maintain patient anonymity when publishing case stories online. When publishing clinical vignettes, physician blogs, and other forms of online media, all details that can identify a patient must be completely removed, including all forms of the date (references to “yesterday” or “last week,” for example, can identify the date). Check anything you intend to publish against the HIPPA list of 18 identifiers.7 (See “HIPPA Identifiers” below)

“The safest way to proceed when publishing patient narratives online is to get consent,” Dr. Chretien says. “If consent is not possible, as in cases of incidents that occurred several years ago, change the personal details, such as location, and clearly disclose that you have. Or make the example very general.” For example, instead of discussing how frustrated you became with a patient with asthma who you saw at a particular hospital in a certain year (a clear violation of patient privacy), paint the illustration in broad strokes. Dr. Chretien suggests you might phrase your observations in this way: “One of the frustrations I find when treating asthma patients is …”

 

It would also be wise to seek advice from colleagues before posting patient information, she notes.

• Do not blur the boundaries between your professional and social spheres.

In a 2011 study, Gabriel Bosslet, MD, assistant professor of clinical medicine and associate director of the fellowship in pulmonary and critical care medicine at Indiana University–Purdue University at Indianapolis, noted that 34% of participating physicians reported receiving a Facebook friend request from a patient or patient’s family member. As Dr. Chretien points out, this is less of a problem for hospitalists than private-practice physicians because the relationship with patients is transitory. The AMA, as well as the ACP and FSMB, note that physicians should not “friend” patients, accept friend requests, or contact patients through social media. Physicians are advised to keep their public and professional online personas separate, even to the point of creating distinct online identities for their personal and professional lives.

• Maintain professionalism in your online persona, and continually monitor your online image to ensure it reflects positively on yourself and the medical profession.

Some physicians fall into the trap of placing questionable postings on their personal pages, including posting content that can be inappropriate for public consumption or venting about patients and employers. Stories or incidents that medical professionals find intriguing or exciting may be disturbing to those outside their community, and medical humor can be offensive.

“[Physicians] assume [their social media page] is their personal space, so they can post whatever they want,” adds Dr. Chretien. “Part of their error is that they believe they are addressing a small group of close friends, but they forget that postings go out to the larger, peripheral audience of all Facebook friends and can often be accessed by the general public.” An ill-considered anecdote can damage not only your own reputation but also the overall perception of the profession. Physicians are always viewed in their professional role, even in social interactions.

• Use email and other forms of electronic communication only in cases of an established physician-patient relationship and only with informed patient consent. Documentation of these communications should be kept in the patient’s medical record.

Any request a physician receives for medical advice through a social media site or email must be handled with caution. The ACP and FSMB state that email and text communications with established patients can be beneficial but should occur only after both parties discuss privacy risks, the appropriate types of information that will be exchanged electronically, and how long patients should expect to wait for a physician response. Patient preference should guide the use of electronic communication with physicians, especially text messaging, says Dr. Greysen.

• Be aware that any postings on the Internet, because of its significant and unprecedented reach, can have future career ramifications. Consequently, physicians are advised to frequently monitor their online presence to control their image.

Dr. Greysen points out that presenting a positive image of physicians in the media is not a new challenge. “Physicians have been publishing books about their experiences for decades. But posting online without oversight, or in the moment without reflection, can be devastating to a physician’s career because the reach of the Internet is exponentially vaster than that of any printed material,” Dr. Greysen says.

Deliver Better Healthcare through Social Media

Perhaps one of the most dramatic ways in which social media is positively impacting healthcare is the FOAM movement, or free open access medical education. Jeanne Farnan, MD, associate professor of medicine at the University of Chicago Department of Medicine and lead author of the ACP and FSMB social media position paper, points to the dynamic collection of resources and tools for ongoing medical education as well as the community that participates in openly sharing knowledge as examples. FOAM resources are predominantly social media based and include blogs, podcasts, tweets, online videos, graphics, web-based applications, text documents, and photographs, many of which are available by following the Twitter feed @FOAMed (see “FOAM Links” below). This FOAM community is dedicated to the belief that high-quality medical education resources and interactions should be free and accessible to all who care for patients and especially to those who educate future physicians.8

 

Social media also affords physicians the opportunity to be a force in public health policies. “There is an active group of physician and medical student social media users in the blogosphere and on Twitter who use their social media presence for activism, and this presence is intimately tied to how they see themselves as a medical professional,” Dr. Farnan says. “They blog and tweet about medical education issues and other public topics such as access to care and care disparity.”

Michelle Vangel, director of insight services with Cision, a Chicago-based public relations company specializing in social media communications, praises the power of social media for raising awareness of public health issues.

“In terms of public health, social media is valuable to better understand how health-related news resonates with the public,” Vangel says. “Two salient examples of major health crises reactions tracked on social media were the Ebola outbreak in Africa and the measles outbreak at Disneyland in California. At times, there was near hysteria over Ebola and vaccine debates, with misinformation spreading quickly. However, many hospitals and physicians tried to get ahead of the hysteria by providing concise, accurate information on different social media platforms, with Facebook often a popular channel to post information.”

Social media sites can also help by making emotional support available at disease-specific sites. These communities address the patient experience of the disease that goes beyond purely medical disease information. Vangel points to several online communities that “host pivotal conversations for patients,” she says. “There are Facebook community pages dedicated to a host of conditions, including diabetes, hypertension, and cystic fibrosis, where patients discuss the challenges of medication compliance, side effects, and even dissatisfaction with healthcare professionals. BabyCenter.com provides message boards about a wide array of topics for people trying to conceive, pregnant women with health conditions, and parents of babies with health issues. CancerForums.net and the health and wellness boards at DelphiForums.com provide support to specific disease populations.”

Vangel encourages physicians to monitor online patient-support sites to better understand the difficulties patients experience while under treatment. These sites can also help physicians recognize and address the gaps in patient understanding about various diseases and explore programs geared toward the populations suffering from a wide range of conditions. TH

---

Maybelle Cowan-Lincoln is a freelance writer in New Jersey.

References

1. Photos of drinking, grinning aid mission doctors cause uproar. CNN website. Accessed December 2, 2015.
2. Terhune C. Hospital violated patient confidentiality, state says. Los Angeles Times website. Accessed December 3, 2015.
3. Greysen SR, Chretien KC, Kind T, Young A, Gross CP. Physician violations of online professionalism and disciplinary actions: a national survey of state medical boards. JAMA. 2012;(307):1141-1142.
4. Greysen SR, Johnson D, Kind T, et al. Online professional investigations by state medical boards: first, do no harm. Ann Intern Med. 2013;(158):124-130.
5. New recommendations offer physicians ethical guidance for preserving trust in patient-physician relationships and the profession when using social media. American College of Physicians website. Accessed July 3, 2015.
6. Opinion 9.124—professionalism in the use of social media. American Medical Association website. Accessed July 3, 2015.
7. HIPPA PHI: list of 18 identifiers and definition of PHI. The Committee for Protection of Human Subjects website. Accessed July 10, 2015.
8. FOAM. Life in the Fastlane website. Accessed September 6, 2015.