Quality

Although there are many benefits to the hospital medicine model of inpatient care, there is perhaps no greater Achilles heel than the discontinuity inherent to the care model. The trust and familiarity garnered from longitudinal patient-provider relationships is sacrificed for the benefits of focused practice, efficiency, and enhanced availability.

Any system involves competing priorities, and some degree of discontinuity is inevitable. Would it make sense for a hospitalist to stay on service until every panel patient is discharged? For obvious economic, lifestyle, and other reasons, of course not. Our charge then is not to make the perfect the enemy of the good, but to ensure thoughtful and consistent continuity for the good of the patient, the provider, and the hospital. The following tips should help your team achieve the best possible balance.
 

Avoid orphan rounding shifts

An “orphan” rounding shift refers to a single shift untethered to a stretch. For admitting or administrative duties, this generally poses no problem, but for a rounding shift it is undesirable. No matter how talented or industrious the provider, it is very difficult for them to effectively provide seamless care for a single day; such care is often disconcerting for patients, families, case managers, and consultants. In situations such as significant census spikes, this may be a necessary evil, but avoid this if you can.

Orphan shift duties

If you can’t avoid an orphan rounding shift, be creative regarding which patients get assigned. Can that provider cover observation or simple short stay patients who may be discharged, or consult follow ups that may be signed off? Can they see stable long-stay patients where the plan isn’t changing and the patient isn’t going anywhere? (Think guardianships, chronic ventilated patients awaiting a facility, stable patients with a history of intravenous drug abuse who may not be safely discharged with a line, etc.) Can they do lab, culture, or path report follow-up calls? Getting creative in responsibilities for an orphan shift can benefit all involved.

Rounding shifts following admitting shifts

Dedicated admitting and rounding shifts are the norm these days. But rather than a pure stretch of one or the other, consider a few days admitting followed by the rest of the stretch rounding. Particularly in a small- to mid-sized hospital, multiple admits done over a few days (and especially if also cross-covering floor calls) will mean many familiar cases when rounding thereafter.

Standard sign-out that travels with patients

The hospital is a dynamic environment. Patients, providers and staff move around a lot. Given this reality, the importance of a complete standardized and accessible sign-out is paramount.

Imagine a rounder starting their last day with 15 patients. By the end of the shift, some have been discharged, transferred to telemetry or the ICU, or left against medical advice, leaving seven patients to sign out. By the next day, there are eight new faces, including fresh admits or consults from the prior day, swing, and night providers as well as existing patients transferred from telemetry/ICU to the general medical ward. A practical solution incorporates an asynchronous sign-out that travels with the patient regardless of geographic location or which provider(s) are following them. Billing software or census reports can typically achieve this. Of course, allow for additional verbal communication as necessary and appropriate.
 

Geographic rounds, with exceptions

Geographic rounds make a lot of sense most of the time. Less transit time and phone tag and more frequent interactions with the care team make for a more efficient day. But sometimes it’s best to bend this rule.

A patient that you’ve seen for 5 days and was transferred off your telemetry floor to go home tomorrow might best be served by you trekking up a flight of stairs to do the discharge. Similarly, complicated medical, psychosocial, or other circumstances may argue for keeping the patient on your list despite a change in location.

The above rules are foundational elements for good continuity. Two bonus considerations include:
 

Wind up, wind down

It’s difficult to walk into a full panel of patients especially when many have been in house for a while. Consider overlapping providers coming onto and going off a shared service.

In a buddy arrangement the oncoming provider starting would take new patients from the outgoing provider finishing. The provider finishing discharges patients with long length of stays and continues to round on more-complicated patients with whom they are familiar. Opportunities for face-to-face verbal handover, and even bedside introduction to the provider starting, can improve care coordination and safety and enhance the patient experience.
 

Reconsider split rounding and admitting

Most physicians would attest that the second time seeing a patient is much easier than the first, the third easier than the second, and so on. This holds true even more so when the first encounter is the history and physical, and the provider subsequently rounds on the patient for the duration of the hospitalization.

You know what the plan is because you made it; you are confident that the patient’s leg with cellulitis looks better or the patient with congested lungs sounds clearer because the baseline against which you’re comparing is your own. It can be a challenge to interrupt a busy day of clinical rounds, discharges, and interdisciplinary meetings to admit a patient. But the upstream investment pays rich downstream dividends and is well worth consideration.

Hospital medicine outcomes as measured by cost, quality, and patient and provider experience are often hampered by suboptimal continuity of care. With recognition of the problem and some simple operational adjustments as outlined above, your team can minimize negative impacts.

Dr. Krisa is a former regional medical director for a national hospitalist group and currently serves as a physician advisor for St. Peter’s Health Partners, a large integrated health system in Albany, N.Y. You can contact him at johnkrisa@hotmail.com.

Although there are many benefits to the hospital medicine model of inpatient care, there is perhaps no greater Achilles heel than the discontinuity inherent to the care model. The trust and familiarity garnered from longitudinal patient-provider relationships is sacrificed for the benefits of focused practice, efficiency, and enhanced availability.

Any system involves competing priorities, and some degree of discontinuity is inevitable. Would it make sense for a hospitalist to stay on service until every panel patient is discharged? For obvious economic, lifestyle, and other reasons, of course not. Our charge then is not to make the perfect the enemy of the good, but to ensure thoughtful and consistent continuity for the good of the patient, the provider, and the hospital. The following tips should help your team achieve the best possible balance.
 

Avoid orphan rounding shifts

An “orphan” rounding shift refers to a single shift untethered to a stretch. For admitting or administrative duties, this generally poses no problem, but for a rounding shift it is undesirable. No matter how talented or industrious the provider, it is very difficult for them to effectively provide seamless care for a single day; such care is often disconcerting for patients, families, case managers, and consultants. In situations such as significant census spikes, this may be a necessary evil, but avoid this if you can.

Orphan shift duties

If you can’t avoid an orphan rounding shift, be creative regarding which patients get assigned. Can that provider cover observation or simple short stay patients who may be discharged, or consult follow ups that may be signed off? Can they see stable long-stay patients where the plan isn’t changing and the patient isn’t going anywhere? (Think guardianships, chronic ventilated patients awaiting a facility, stable patients with a history of intravenous drug abuse who may not be safely discharged with a line, etc.) Can they do lab, culture, or path report follow-up calls? Getting creative in responsibilities for an orphan shift can benefit all involved.

Rounding shifts following admitting shifts

Dedicated admitting and rounding shifts are the norm these days. But rather than a pure stretch of one or the other, consider a few days admitting followed by the rest of the stretch rounding. Particularly in a small- to mid-sized hospital, multiple admits done over a few days (and especially if also cross-covering floor calls) will mean many familiar cases when rounding thereafter.

Standard sign-out that travels with patients

The hospital is a dynamic environment. Patients, providers and staff move around a lot. Given this reality, the importance of a complete standardized and accessible sign-out is paramount.

Imagine a rounder starting their last day with 15 patients. By the end of the shift, some have been discharged, transferred to telemetry or the ICU, or left against medical advice, leaving seven patients to sign out. By the next day, there are eight new faces, including fresh admits or consults from the prior day, swing, and night providers as well as existing patients transferred from telemetry/ICU to the general medical ward. A practical solution incorporates an asynchronous sign-out that travels with the patient regardless of geographic location or which provider(s) are following them. Billing software or census reports can typically achieve this. Of course, allow for additional verbal communication as necessary and appropriate.
 

Geographic rounds, with exceptions

Geographic rounds make a lot of sense most of the time. Less transit time and phone tag and more frequent interactions with the care team make for a more efficient day. But sometimes it’s best to bend this rule.

A patient that you’ve seen for 5 days and was transferred off your telemetry floor to go home tomorrow might best be served by you trekking up a flight of stairs to do the discharge. Similarly, complicated medical, psychosocial, or other circumstances may argue for keeping the patient on your list despite a change in location.

The above rules are foundational elements for good continuity. Two bonus considerations include:
 

Wind up, wind down

It’s difficult to walk into a full panel of patients especially when many have been in house for a while. Consider overlapping providers coming onto and going off a shared service.

In a buddy arrangement the oncoming provider starting would take new patients from the outgoing provider finishing. The provider finishing discharges patients with long length of stays and continues to round on more-complicated patients with whom they are familiar. Opportunities for face-to-face verbal handover, and even bedside introduction to the provider starting, can improve care coordination and safety and enhance the patient experience.
 

Reconsider split rounding and admitting

Most physicians would attest that the second time seeing a patient is much easier than the first, the third easier than the second, and so on. This holds true even more so when the first encounter is the history and physical, and the provider subsequently rounds on the patient for the duration of the hospitalization.

You know what the plan is because you made it; you are confident that the patient’s leg with cellulitis looks better or the patient with congested lungs sounds clearer because the baseline against which you’re comparing is your own. It can be a challenge to interrupt a busy day of clinical rounds, discharges, and interdisciplinary meetings to admit a patient. But the upstream investment pays rich downstream dividends and is well worth consideration.

Hospital medicine outcomes as measured by cost, quality, and patient and provider experience are often hampered by suboptimal continuity of care. With recognition of the problem and some simple operational adjustments as outlined above, your team can minimize negative impacts.

Dr. Krisa is a former regional medical director for a national hospitalist group and currently serves as a physician advisor for St. Peter’s Health Partners, a large integrated health system in Albany, N.Y. You can contact him at johnkrisa@hotmail.com.

Although there are many benefits to the hospital medicine model of inpatient care, there is perhaps no greater Achilles heel than the discontinuity inherent to the care model. The trust and familiarity garnered from longitudinal patient-provider relationships is sacrificed for the benefits of focused practice, efficiency, and enhanced availability.

Any system involves competing priorities, and some degree of discontinuity is inevitable. Would it make sense for a hospitalist to stay on service until every panel patient is discharged? For obvious economic, lifestyle, and other reasons, of course not. Our charge then is not to make the perfect the enemy of the good, but to ensure thoughtful and consistent continuity for the good of the patient, the provider, and the hospital. The following tips should help your team achieve the best possible balance.
 

Avoid orphan rounding shifts

An “orphan” rounding shift refers to a single shift untethered to a stretch. For admitting or administrative duties, this generally poses no problem, but for a rounding shift it is undesirable. No matter how talented or industrious the provider, it is very difficult for them to effectively provide seamless care for a single day; such care is often disconcerting for patients, families, case managers, and consultants. In situations such as significant census spikes, this may be a necessary evil, but avoid this if you can.

Orphan shift duties

If you can’t avoid an orphan rounding shift, be creative regarding which patients get assigned. Can that provider cover observation or simple short stay patients who may be discharged, or consult follow ups that may be signed off? Can they see stable long-stay patients where the plan isn’t changing and the patient isn’t going anywhere? (Think guardianships, chronic ventilated patients awaiting a facility, stable patients with a history of intravenous drug abuse who may not be safely discharged with a line, etc.) Can they do lab, culture, or path report follow-up calls? Getting creative in responsibilities for an orphan shift can benefit all involved.

Rounding shifts following admitting shifts

Dedicated admitting and rounding shifts are the norm these days. But rather than a pure stretch of one or the other, consider a few days admitting followed by the rest of the stretch rounding. Particularly in a small- to mid-sized hospital, multiple admits done over a few days (and especially if also cross-covering floor calls) will mean many familiar cases when rounding thereafter.

Standard sign-out that travels with patients

The hospital is a dynamic environment. Patients, providers and staff move around a lot. Given this reality, the importance of a complete standardized and accessible sign-out is paramount.

Imagine a rounder starting their last day with 15 patients. By the end of the shift, some have been discharged, transferred to telemetry or the ICU, or left against medical advice, leaving seven patients to sign out. By the next day, there are eight new faces, including fresh admits or consults from the prior day, swing, and night providers as well as existing patients transferred from telemetry/ICU to the general medical ward. A practical solution incorporates an asynchronous sign-out that travels with the patient regardless of geographic location or which provider(s) are following them. Billing software or census reports can typically achieve this. Of course, allow for additional verbal communication as necessary and appropriate.
 

Geographic rounds, with exceptions

Geographic rounds make a lot of sense most of the time. Less transit time and phone tag and more frequent interactions with the care team make for a more efficient day. But sometimes it’s best to bend this rule.

A patient that you’ve seen for 5 days and was transferred off your telemetry floor to go home tomorrow might best be served by you trekking up a flight of stairs to do the discharge. Similarly, complicated medical, psychosocial, or other circumstances may argue for keeping the patient on your list despite a change in location.

The above rules are foundational elements for good continuity. Two bonus considerations include:
 

Wind up, wind down

It’s difficult to walk into a full panel of patients especially when many have been in house for a while. Consider overlapping providers coming onto and going off a shared service.

In a buddy arrangement the oncoming provider starting would take new patients from the outgoing provider finishing. The provider finishing discharges patients with long length of stays and continues to round on more-complicated patients with whom they are familiar. Opportunities for face-to-face verbal handover, and even bedside introduction to the provider starting, can improve care coordination and safety and enhance the patient experience.
 

Reconsider split rounding and admitting

Most physicians would attest that the second time seeing a patient is much easier than the first, the third easier than the second, and so on. This holds true even more so when the first encounter is the history and physical, and the provider subsequently rounds on the patient for the duration of the hospitalization.

You know what the plan is because you made it; you are confident that the patient’s leg with cellulitis looks better or the patient with congested lungs sounds clearer because the baseline against which you’re comparing is your own. It can be a challenge to interrupt a busy day of clinical rounds, discharges, and interdisciplinary meetings to admit a patient. But the upstream investment pays rich downstream dividends and is well worth consideration.

Hospital medicine outcomes as measured by cost, quality, and patient and provider experience are often hampered by suboptimal continuity of care. With recognition of the problem and some simple operational adjustments as outlined above, your team can minimize negative impacts.

Dr. Krisa is a former regional medical director for a national hospitalist group and currently serves as a physician advisor for St. Peter’s Health Partners, a large integrated health system in Albany, N.Y. You can contact him at johnkrisa@hotmail.com.

As I gear up to welcome and onboard new hires to our hospitalist group, I could not help but reflect on my first day as a hospitalist. Fresh out of residency, my orientation was a day and a half long.

The medical director gave me a brief overview of the program. The program administrator handed me a thick folder of policies followed by a quick tour of the hospital and an afternoon training for the computerized order entry system (that was a time before EHRs). The next morning, I was given my full panel of patients, my new lab coat, and sent off into the battlefield.

I can vividly remember feeling anxious, a bit confused, and quite overwhelmed as I went through my day. The days turned into a week and the next. I kept wondering if I was doing everything right. It took me a month to feel a little more comfortable. It all turned out fine. Since nobody told me otherwise, I assumed it did.

Quite a bit has changed since then in hospital medicine. Hospital medicine groups, nowadays, have to tackle the changing landscape of payment reform, take on responsibility for an increasing range of hospital quality metrics and juggle a swath of subspecialty comanagement agreements. Hospital medicine providers function from the inpatient to the post-acute care arena, all while continuing to demonstrate their value to the hospital administration. Simultaneously, they have to ensure their providers are engaged and functioning at their optimal level while battling the ever-increasing threat of burnout.

Thus, for new hires, all the above aspects of my orientation have become critical but alas terribly insufficient. Well into its third decade, the hospital medicine job market continues to boom but remains a revolving door. Hospital medicine groups continue to grow in size and integrate across hospitals in a given health system. The vast majority of the new hires tend to be fresh out of residency. The first year remains the most vulnerable period for a new hospitalist. Hospital medicine groups must design and implement a robust onboarding program for their new hires. It goes beyond welcoming and orientation of new hires to full integration and assimilation in order to transform them into highly efficient and productive team members. Effective onboarding is table stakes for a successful and thriving hospital medicine group.
 

The content

An effective onboarding program should focus on three key dimensions: the organizational, the technical, and the social.¹

1. The organizational or administrative aspect: The most common aspect of onboarding is providing new hires with information on the group’s policies and procedures: what to do and how to do it. Equally essential is giving them the tools and contacts that will help them understand and navigate their first few months. Information on how to contact consultants, signing on and off shifts, and so on can be easily conveyed through documents. However, having peers and the critical administrative staff communicate other aspects such as a detailed tour of the hospital, scheduling, and vacation policies is far more effective. It provides an excellent opportunity to introduce new hires to the key personnel in the group and vice versa as new hires get familiar with the unofficial workplace language. Breaking down all this information into meaningful, absorbable boluses, spread over time, is key to avoiding information overload. Allowing new hires to assimilate and adapt to the group norms requires follow-up and reinforcement. Group leaders should plan to meet with them at predetermined intervals, such as at 30, 60, 90 days, to engage them in conversations about the group’s values, performance measurements, rewards, and the opportunities for growth that exist within the group and institution.

2. The technical or the clinical aspect: The majority of physicians and advanced providers hired to a hospital medicine group have come immediately from training. Transition into the autonomous role of an attending, or a semi-autonomous role for advanced providers, with a larger patient panel can be quite unnerving and stressful. It can be disorientating even for experienced providers transitioning into a new health system. A well-structured onboarding can allow providers to deploy their training and experience at your organization effectively. Many onboarding programs have a clinical ramp-up period. The providers begin with a limited patient panel and gradually acclimatize into a full patient load. Many programs pair a senior hospitalist with the new hire during this period – a ‘buddy.’ Buddies are available to help new hires navigate the health system and familiarize them with the stakeholders. They help new hires by providing context to understand their new role and how they can contribute to the group’s success. In many instances, buddies help outline the unspoken rules of the group.

3. The social aspect – enculturation and networking: This is probably the most important of the three elements. It is quite common for new hires to feel like a stranger in a new land. A well-designed onboarding program provides new hires the space to forge relationships with each other and existing members of the hospital medicine team. Groups can do this in myriad ways – an informal welcome social, a meet and greet breakfast or lunch, in-person orientation when designing the administrative onboarding, and assignment of buddies or mentors during their clinical ramp-up period. It is all about providing a space to establish and nurture lasting relationships between the new hires and the group. When done well, this helps transform a group into a community. It also lays the groundwork to avoid stress and loneliness, some of the culprits that lead to physician burnout. It is through these interpersonal connections that new hires adapt to a hospital medicine group’s prevailing culture.

The personnel

Effective onboarding should be more than mere orientation. Group leaders should make an active attempt at understanding the core values and needs of the group. A good onboarding process assists new hires to internalize and accept the norms of the group. This process is not just a result of what comes from top management but also what they see and hear from the rank and file providers in the group. Hence it is critical to have the right people who understand and embody these values at the planning table. It is equally essential that necessary time and resources are devoted to building a program that meets the needs of the group. The practice management committee at SHM interviewed five different programs across a spectrum of settings. All of them had a designated onboarding program leader with a planning committee that included the administrative staff and senior frontline hospitalists.

The costs

According to one estimate, the cost of physician turnover is $400,000-$600,000 per provider.² Given such staggering costs, it is not difficult to justify the financial resources required to structure an effective onboarding program. Activities such as a detailed facility tour, a welcome breakfast, and a peer buddy system cost virtually nothing. They go a long way in building comradery, make new hires feel like they are part of a team, and reduce burnout and turnover. Costs of an onboarding program are typically related to wages during shadowing and clinical ramp-up. However, all the programs we interviewed acknowledged that the costs associated with onboarding, in the broader context, were small and necessary.

The bottom line

An effective onboarding program that is well planned, well structured, and well executed is inherently valuable. It sends a positive signal to new hires, reassuring them that they made a great decision by joining the group. It also reminds the existing providers why they want to be a part of the group and its culture.

It is not about what is said or done during the onboarding process or how long it lasts. It need not be overly complicated. It is how the process makes everyone feel about the group. At the end of the day, like in all aspects of life, that is what ultimately matters.

The SHM Practice Management Committee has created a document that outlines the guiding principles for effective onboarding with attached case studies. Visit the SHM website for more information: https://www.hospitalmedicine.org.
 

Dr. Irani is a hospitalist affiliated with Baystate Health in Springfield, Mass. He would like to thank Joshua Lapps, Luke Heisenger, and all the members of the SHM Practice Management Committee for their assistance and input in drafting the guiding principles of onboarding and the case studies that have heavily inspired the above article.

References

1. Carucci R. To Retain New Hires, Spend More Time Onboarding Them. Harvard Busines Review. Dec 3, 2018. https://hbr.org/2018/12/to-retain-new-hires-spend-more-time-onboarding-them

2. Franz D. The staggering costs of physician turnover. Today’s Hospitalist. August 2016. https://www.todayshospitalist.com/staggering-costs-physician-turnover/

As I gear up to welcome and onboard new hires to our hospitalist group, I could not help but reflect on my first day as a hospitalist. Fresh out of residency, my orientation was a day and a half long.

The medical director gave me a brief overview of the program. The program administrator handed me a thick folder of policies followed by a quick tour of the hospital and an afternoon training for the computerized order entry system (that was a time before EHRs). The next morning, I was given my full panel of patients, my new lab coat, and sent off into the battlefield.

I can vividly remember feeling anxious, a bit confused, and quite overwhelmed as I went through my day. The days turned into a week and the next. I kept wondering if I was doing everything right. It took me a month to feel a little more comfortable. It all turned out fine. Since nobody told me otherwise, I assumed it did.

Quite a bit has changed since then in hospital medicine. Hospital medicine groups, nowadays, have to tackle the changing landscape of payment reform, take on responsibility for an increasing range of hospital quality metrics and juggle a swath of subspecialty comanagement agreements. Hospital medicine providers function from the inpatient to the post-acute care arena, all while continuing to demonstrate their value to the hospital administration. Simultaneously, they have to ensure their providers are engaged and functioning at their optimal level while battling the ever-increasing threat of burnout.

Thus, for new hires, all the above aspects of my orientation have become critical but alas terribly insufficient. Well into its third decade, the hospital medicine job market continues to boom but remains a revolving door. Hospital medicine groups continue to grow in size and integrate across hospitals in a given health system. The vast majority of the new hires tend to be fresh out of residency. The first year remains the most vulnerable period for a new hospitalist. Hospital medicine groups must design and implement a robust onboarding program for their new hires. It goes beyond welcoming and orientation of new hires to full integration and assimilation in order to transform them into highly efficient and productive team members. Effective onboarding is table stakes for a successful and thriving hospital medicine group.
 

The content

An effective onboarding program should focus on three key dimensions: the organizational, the technical, and the social.¹

1. The organizational or administrative aspect: The most common aspect of onboarding is providing new hires with information on the group’s policies and procedures: what to do and how to do it. Equally essential is giving them the tools and contacts that will help them understand and navigate their first few months. Information on how to contact consultants, signing on and off shifts, and so on can be easily conveyed through documents. However, having peers and the critical administrative staff communicate other aspects such as a detailed tour of the hospital, scheduling, and vacation policies is far more effective. It provides an excellent opportunity to introduce new hires to the key personnel in the group and vice versa as new hires get familiar with the unofficial workplace language. Breaking down all this information into meaningful, absorbable boluses, spread over time, is key to avoiding information overload. Allowing new hires to assimilate and adapt to the group norms requires follow-up and reinforcement. Group leaders should plan to meet with them at predetermined intervals, such as at 30, 60, 90 days, to engage them in conversations about the group’s values, performance measurements, rewards, and the opportunities for growth that exist within the group and institution.

2. The technical or the clinical aspect: The majority of physicians and advanced providers hired to a hospital medicine group have come immediately from training. Transition into the autonomous role of an attending, or a semi-autonomous role for advanced providers, with a larger patient panel can be quite unnerving and stressful. It can be disorientating even for experienced providers transitioning into a new health system. A well-structured onboarding can allow providers to deploy their training and experience at your organization effectively. Many onboarding programs have a clinical ramp-up period. The providers begin with a limited patient panel and gradually acclimatize into a full patient load. Many programs pair a senior hospitalist with the new hire during this period – a ‘buddy.’ Buddies are available to help new hires navigate the health system and familiarize them with the stakeholders. They help new hires by providing context to understand their new role and how they can contribute to the group’s success. In many instances, buddies help outline the unspoken rules of the group.

3. The social aspect – enculturation and networking: This is probably the most important of the three elements. It is quite common for new hires to feel like a stranger in a new land. A well-designed onboarding program provides new hires the space to forge relationships with each other and existing members of the hospital medicine team. Groups can do this in myriad ways – an informal welcome social, a meet and greet breakfast or lunch, in-person orientation when designing the administrative onboarding, and assignment of buddies or mentors during their clinical ramp-up period. It is all about providing a space to establish and nurture lasting relationships between the new hires and the group. When done well, this helps transform a group into a community. It also lays the groundwork to avoid stress and loneliness, some of the culprits that lead to physician burnout. It is through these interpersonal connections that new hires adapt to a hospital medicine group’s prevailing culture.

The personnel

Effective onboarding should be more than mere orientation. Group leaders should make an active attempt at understanding the core values and needs of the group. A good onboarding process assists new hires to internalize and accept the norms of the group. This process is not just a result of what comes from top management but also what they see and hear from the rank and file providers in the group. Hence it is critical to have the right people who understand and embody these values at the planning table. It is equally essential that necessary time and resources are devoted to building a program that meets the needs of the group. The practice management committee at SHM interviewed five different programs across a spectrum of settings. All of them had a designated onboarding program leader with a planning committee that included the administrative staff and senior frontline hospitalists.

The costs

According to one estimate, the cost of physician turnover is $400,000-$600,000 per provider.² Given such staggering costs, it is not difficult to justify the financial resources required to structure an effective onboarding program. Activities such as a detailed facility tour, a welcome breakfast, and a peer buddy system cost virtually nothing. They go a long way in building comradery, make new hires feel like they are part of a team, and reduce burnout and turnover. Costs of an onboarding program are typically related to wages during shadowing and clinical ramp-up. However, all the programs we interviewed acknowledged that the costs associated with onboarding, in the broader context, were small and necessary.

The bottom line

An effective onboarding program that is well planned, well structured, and well executed is inherently valuable. It sends a positive signal to new hires, reassuring them that they made a great decision by joining the group. It also reminds the existing providers why they want to be a part of the group and its culture.

It is not about what is said or done during the onboarding process or how long it lasts. It need not be overly complicated. It is how the process makes everyone feel about the group. At the end of the day, like in all aspects of life, that is what ultimately matters.

The SHM Practice Management Committee has created a document that outlines the guiding principles for effective onboarding with attached case studies. Visit the SHM website for more information: https://www.hospitalmedicine.org.
 

Dr. Irani is a hospitalist affiliated with Baystate Health in Springfield, Mass. He would like to thank Joshua Lapps, Luke Heisenger, and all the members of the SHM Practice Management Committee for their assistance and input in drafting the guiding principles of onboarding and the case studies that have heavily inspired the above article.

References

1. Carucci R. To Retain New Hires, Spend More Time Onboarding Them. Harvard Busines Review. Dec 3, 2018. https://hbr.org/2018/12/to-retain-new-hires-spend-more-time-onboarding-them

2. Franz D. The staggering costs of physician turnover. Today’s Hospitalist. August 2016. https://www.todayshospitalist.com/staggering-costs-physician-turnover/

As I gear up to welcome and onboard new hires to our hospitalist group, I could not help but reflect on my first day as a hospitalist. Fresh out of residency, my orientation was a day and a half long.

The medical director gave me a brief overview of the program. The program administrator handed me a thick folder of policies followed by a quick tour of the hospital and an afternoon training for the computerized order entry system (that was a time before EHRs). The next morning, I was given my full panel of patients, my new lab coat, and sent off into the battlefield.

I can vividly remember feeling anxious, a bit confused, and quite overwhelmed as I went through my day. The days turned into a week and the next. I kept wondering if I was doing everything right. It took me a month to feel a little more comfortable. It all turned out fine. Since nobody told me otherwise, I assumed it did.

Quite a bit has changed since then in hospital medicine. Hospital medicine groups, nowadays, have to tackle the changing landscape of payment reform, take on responsibility for an increasing range of hospital quality metrics and juggle a swath of subspecialty comanagement agreements. Hospital medicine providers function from the inpatient to the post-acute care arena, all while continuing to demonstrate their value to the hospital administration. Simultaneously, they have to ensure their providers are engaged and functioning at their optimal level while battling the ever-increasing threat of burnout.

Thus, for new hires, all the above aspects of my orientation have become critical but alas terribly insufficient. Well into its third decade, the hospital medicine job market continues to boom but remains a revolving door. Hospital medicine groups continue to grow in size and integrate across hospitals in a given health system. The vast majority of the new hires tend to be fresh out of residency. The first year remains the most vulnerable period for a new hospitalist. Hospital medicine groups must design and implement a robust onboarding program for their new hires. It goes beyond welcoming and orientation of new hires to full integration and assimilation in order to transform them into highly efficient and productive team members. Effective onboarding is table stakes for a successful and thriving hospital medicine group.
 

The content

An effective onboarding program should focus on three key dimensions: the organizational, the technical, and the social.¹

1. The organizational or administrative aspect: The most common aspect of onboarding is providing new hires with information on the group’s policies and procedures: what to do and how to do it. Equally essential is giving them the tools and contacts that will help them understand and navigate their first few months. Information on how to contact consultants, signing on and off shifts, and so on can be easily conveyed through documents. However, having peers and the critical administrative staff communicate other aspects such as a detailed tour of the hospital, scheduling, and vacation policies is far more effective. It provides an excellent opportunity to introduce new hires to the key personnel in the group and vice versa as new hires get familiar with the unofficial workplace language. Breaking down all this information into meaningful, absorbable boluses, spread over time, is key to avoiding information overload. Allowing new hires to assimilate and adapt to the group norms requires follow-up and reinforcement. Group leaders should plan to meet with them at predetermined intervals, such as at 30, 60, 90 days, to engage them in conversations about the group’s values, performance measurements, rewards, and the opportunities for growth that exist within the group and institution.

2. The technical or the clinical aspect: The majority of physicians and advanced providers hired to a hospital medicine group have come immediately from training. Transition into the autonomous role of an attending, or a semi-autonomous role for advanced providers, with a larger patient panel can be quite unnerving and stressful. It can be disorientating even for experienced providers transitioning into a new health system. A well-structured onboarding can allow providers to deploy their training and experience at your organization effectively. Many onboarding programs have a clinical ramp-up period. The providers begin with a limited patient panel and gradually acclimatize into a full patient load. Many programs pair a senior hospitalist with the new hire during this period – a ‘buddy.’ Buddies are available to help new hires navigate the health system and familiarize them with the stakeholders. They help new hires by providing context to understand their new role and how they can contribute to the group’s success. In many instances, buddies help outline the unspoken rules of the group.

3. The social aspect – enculturation and networking: This is probably the most important of the three elements. It is quite common for new hires to feel like a stranger in a new land. A well-designed onboarding program provides new hires the space to forge relationships with each other and existing members of the hospital medicine team. Groups can do this in myriad ways – an informal welcome social, a meet and greet breakfast or lunch, in-person orientation when designing the administrative onboarding, and assignment of buddies or mentors during their clinical ramp-up period. It is all about providing a space to establish and nurture lasting relationships between the new hires and the group. When done well, this helps transform a group into a community. It also lays the groundwork to avoid stress and loneliness, some of the culprits that lead to physician burnout. It is through these interpersonal connections that new hires adapt to a hospital medicine group’s prevailing culture.

The personnel

Effective onboarding should be more than mere orientation. Group leaders should make an active attempt at understanding the core values and needs of the group. A good onboarding process assists new hires to internalize and accept the norms of the group. This process is not just a result of what comes from top management but also what they see and hear from the rank and file providers in the group. Hence it is critical to have the right people who understand and embody these values at the planning table. It is equally essential that necessary time and resources are devoted to building a program that meets the needs of the group. The practice management committee at SHM interviewed five different programs across a spectrum of settings. All of them had a designated onboarding program leader with a planning committee that included the administrative staff and senior frontline hospitalists.

The costs

According to one estimate, the cost of physician turnover is $400,000-$600,000 per provider.² Given such staggering costs, it is not difficult to justify the financial resources required to structure an effective onboarding program. Activities such as a detailed facility tour, a welcome breakfast, and a peer buddy system cost virtually nothing. They go a long way in building comradery, make new hires feel like they are part of a team, and reduce burnout and turnover. Costs of an onboarding program are typically related to wages during shadowing and clinical ramp-up. However, all the programs we interviewed acknowledged that the costs associated with onboarding, in the broader context, were small and necessary.

The bottom line

An effective onboarding program that is well planned, well structured, and well executed is inherently valuable. It sends a positive signal to new hires, reassuring them that they made a great decision by joining the group. It also reminds the existing providers why they want to be a part of the group and its culture.

It is not about what is said or done during the onboarding process or how long it lasts. It need not be overly complicated. It is how the process makes everyone feel about the group. At the end of the day, like in all aspects of life, that is what ultimately matters.

The SHM Practice Management Committee has created a document that outlines the guiding principles for effective onboarding with attached case studies. Visit the SHM website for more information: https://www.hospitalmedicine.org.
 

Dr. Irani is a hospitalist affiliated with Baystate Health in Springfield, Mass. He would like to thank Joshua Lapps, Luke Heisenger, and all the members of the SHM Practice Management Committee for their assistance and input in drafting the guiding principles of onboarding and the case studies that have heavily inspired the above article.

References

1. Carucci R. To Retain New Hires, Spend More Time Onboarding Them. Harvard Busines Review. Dec 3, 2018. https://hbr.org/2018/12/to-retain-new-hires-spend-more-time-onboarding-them

2. Franz D. The staggering costs of physician turnover. Today’s Hospitalist. August 2016. https://www.todayshospitalist.com/staggering-costs-physician-turnover/

Among Medicare beneficiaries admitted to the hospital between 2008 and 2016, there was an increase in postdischarge 30-day mortality for patients with heart failure, but not for those with acute myocardial infarction or pneumonia.

The finding comes from an effort to evaluate the use of services soon after discharge for conditions targeted in the U.S. Hospital Readmissions Reduction Program (HRRP), and patients’ outcomes.

“The announcement and implementation of the HRRP were associated with a reduction in readmissions within 30 days of discharge for heart failure, acute myocardial infarction, and pneumonia, as shown by a decrease in the overall national rate of readmissions,” first author Rohan Khera, MD, and colleagues wrote in a study published online Jan. 15, 2020, in the British Medical Journal (doi:10.1136/bmj.l6831).

“Concerns existed that pressures to reduce readmissions had led to the evolution of care patterns that may have adverse consequences through reducing access to care in appropriate settings. Therefore, determining whether patients who are seen in acute care settings, but not admitted to hospital, experience an increased risk of mortality is essential.”

Dr. Khera, a cardiologist at the University of Texas Southwestern Medical Center, Dallas, and colleagues limited the analysis to Medicare claims data from patients who were admitted to the hospital with heart failure, acute myocardial infarction (MI), or pneumonia between 2008 and 2016. Key outcomes of interest were: (1) postdischarge 30-day mortality; and (2) acute care utilization in inpatient units, observation units, and the ED during the postdischarge period.

During the study period there were 3,772,924 hospital admissions for heart failure, 1,570,113 for acute MI, and 3,131,162 for pneumonia. The greatest number of readmissions within 30 days of discharge was for heart failure patients (22.5%), followed by acute MI (17.5%), and pneumonia (17.2%).

The overall rates of observation stays were 1.7% for heart failure, 2.6% for acute MI, and 1.4% for pneumonia, while the overall rates of emergency department visits were 6.4% for heart failure, 6.8% for acute MI, and 6.3% for pneumonia. Cumulatively, about one-third of all admissions – 30.7% for heart failure, 26.9% for acute MI, and 24.8% for pneumonia – received postdischarge care in any acute care setting.

Dr. Khera and colleagues found that overall postdischarge 30-day mortality was 8.7% for heart failure, 7.3% for acute MI, and 8.4% for pneumonia. At the same time, postdischarge 30-day mortality was higher in patients with readmissions (13.2% for heart failure, 12.7% for acute MI, and 15.3% for pneumonia), compared with those who had observation stays (4.5% for heart failure, 2.7% for acute MI, and 4.6% for pneumonia), emergency department visits (9.7% for heart failure, 8.8% for acute MI, and 7.8% for pneumonia), or no postdischarge acute care (7.2% for heart failure, 6.0% for acute MI, and 6.9% for pneumonia). Risk adjusted mortality increased annually by 0.05% only for heart failure, while it decreased by 0.06% for acute MI, and did not significantly change for pneumonia.

“The study strongly suggests that the HRRP did not lead to harm through inappropriate triage of patients at high risk to observation units and the emergency department, and therefore provides evidence against calls to curtail the program owing to this theoretical concern (see JAMA 2018;320:2539-41),” the researchers concluded.

They acknowledged certain limitations of the study, including the fact that they were “unable to identify patterns of acute care during the index hospital admission that would be associated with a higher rate of postdischarge acute care in observation units and emergency departments and whether these visits represented avenues for planned postdischarge follow-up care. Moreover, the proportion of these care encounters that were preventable remains poorly understood.”

Dr. Khera disclosed that he is supported by the National Center for Advancing Translational Sciences of the National Institutes of Health. His coauthors reported having numerous disclosures.

dbrunk@mdedge.com

SOURCE: Khera et al. BMJ 2020;368:l6831.

Among Medicare beneficiaries admitted to the hospital between 2008 and 2016, there was an increase in postdischarge 30-day mortality for patients with heart failure, but not for those with acute myocardial infarction or pneumonia.

The finding comes from an effort to evaluate the use of services soon after discharge for conditions targeted in the U.S. Hospital Readmissions Reduction Program (HRRP), and patients’ outcomes.

“The announcement and implementation of the HRRP were associated with a reduction in readmissions within 30 days of discharge for heart failure, acute myocardial infarction, and pneumonia, as shown by a decrease in the overall national rate of readmissions,” first author Rohan Khera, MD, and colleagues wrote in a study published online Jan. 15, 2020, in the British Medical Journal (doi:10.1136/bmj.l6831).

“Concerns existed that pressures to reduce readmissions had led to the evolution of care patterns that may have adverse consequences through reducing access to care in appropriate settings. Therefore, determining whether patients who are seen in acute care settings, but not admitted to hospital, experience an increased risk of mortality is essential.”

Dr. Khera, a cardiologist at the University of Texas Southwestern Medical Center, Dallas, and colleagues limited the analysis to Medicare claims data from patients who were admitted to the hospital with heart failure, acute myocardial infarction (MI), or pneumonia between 2008 and 2016. Key outcomes of interest were: (1) postdischarge 30-day mortality; and (2) acute care utilization in inpatient units, observation units, and the ED during the postdischarge period.

During the study period there were 3,772,924 hospital admissions for heart failure, 1,570,113 for acute MI, and 3,131,162 for pneumonia. The greatest number of readmissions within 30 days of discharge was for heart failure patients (22.5%), followed by acute MI (17.5%), and pneumonia (17.2%).

The overall rates of observation stays were 1.7% for heart failure, 2.6% for acute MI, and 1.4% for pneumonia, while the overall rates of emergency department visits were 6.4% for heart failure, 6.8% for acute MI, and 6.3% for pneumonia. Cumulatively, about one-third of all admissions – 30.7% for heart failure, 26.9% for acute MI, and 24.8% for pneumonia – received postdischarge care in any acute care setting.

Dr. Khera and colleagues found that overall postdischarge 30-day mortality was 8.7% for heart failure, 7.3% for acute MI, and 8.4% for pneumonia. At the same time, postdischarge 30-day mortality was higher in patients with readmissions (13.2% for heart failure, 12.7% for acute MI, and 15.3% for pneumonia), compared with those who had observation stays (4.5% for heart failure, 2.7% for acute MI, and 4.6% for pneumonia), emergency department visits (9.7% for heart failure, 8.8% for acute MI, and 7.8% for pneumonia), or no postdischarge acute care (7.2% for heart failure, 6.0% for acute MI, and 6.9% for pneumonia). Risk adjusted mortality increased annually by 0.05% only for heart failure, while it decreased by 0.06% for acute MI, and did not significantly change for pneumonia.

“The study strongly suggests that the HRRP did not lead to harm through inappropriate triage of patients at high risk to observation units and the emergency department, and therefore provides evidence against calls to curtail the program owing to this theoretical concern (see JAMA 2018;320:2539-41),” the researchers concluded.

They acknowledged certain limitations of the study, including the fact that they were “unable to identify patterns of acute care during the index hospital admission that would be associated with a higher rate of postdischarge acute care in observation units and emergency departments and whether these visits represented avenues for planned postdischarge follow-up care. Moreover, the proportion of these care encounters that were preventable remains poorly understood.”

Dr. Khera disclosed that he is supported by the National Center for Advancing Translational Sciences of the National Institutes of Health. His coauthors reported having numerous disclosures.

dbrunk@mdedge.com

SOURCE: Khera et al. BMJ 2020;368:l6831.

Among Medicare beneficiaries admitted to the hospital between 2008 and 2016, there was an increase in postdischarge 30-day mortality for patients with heart failure, but not for those with acute myocardial infarction or pneumonia.

The finding comes from an effort to evaluate the use of services soon after discharge for conditions targeted in the U.S. Hospital Readmissions Reduction Program (HRRP), and patients’ outcomes.

“The announcement and implementation of the HRRP were associated with a reduction in readmissions within 30 days of discharge for heart failure, acute myocardial infarction, and pneumonia, as shown by a decrease in the overall national rate of readmissions,” first author Rohan Khera, MD, and colleagues wrote in a study published online Jan. 15, 2020, in the British Medical Journal (doi:10.1136/bmj.l6831).

“Concerns existed that pressures to reduce readmissions had led to the evolution of care patterns that may have adverse consequences through reducing access to care in appropriate settings. Therefore, determining whether patients who are seen in acute care settings, but not admitted to hospital, experience an increased risk of mortality is essential.”

Dr. Khera, a cardiologist at the University of Texas Southwestern Medical Center, Dallas, and colleagues limited the analysis to Medicare claims data from patients who were admitted to the hospital with heart failure, acute myocardial infarction (MI), or pneumonia between 2008 and 2016. Key outcomes of interest were: (1) postdischarge 30-day mortality; and (2) acute care utilization in inpatient units, observation units, and the ED during the postdischarge period.

During the study period there were 3,772,924 hospital admissions for heart failure, 1,570,113 for acute MI, and 3,131,162 for pneumonia. The greatest number of readmissions within 30 days of discharge was for heart failure patients (22.5%), followed by acute MI (17.5%), and pneumonia (17.2%).

The overall rates of observation stays were 1.7% for heart failure, 2.6% for acute MI, and 1.4% for pneumonia, while the overall rates of emergency department visits were 6.4% for heart failure, 6.8% for acute MI, and 6.3% for pneumonia. Cumulatively, about one-third of all admissions – 30.7% for heart failure, 26.9% for acute MI, and 24.8% for pneumonia – received postdischarge care in any acute care setting.

Dr. Khera and colleagues found that overall postdischarge 30-day mortality was 8.7% for heart failure, 7.3% for acute MI, and 8.4% for pneumonia. At the same time, postdischarge 30-day mortality was higher in patients with readmissions (13.2% for heart failure, 12.7% for acute MI, and 15.3% for pneumonia), compared with those who had observation stays (4.5% for heart failure, 2.7% for acute MI, and 4.6% for pneumonia), emergency department visits (9.7% for heart failure, 8.8% for acute MI, and 7.8% for pneumonia), or no postdischarge acute care (7.2% for heart failure, 6.0% for acute MI, and 6.9% for pneumonia). Risk adjusted mortality increased annually by 0.05% only for heart failure, while it decreased by 0.06% for acute MI, and did not significantly change for pneumonia.

“The study strongly suggests that the HRRP did not lead to harm through inappropriate triage of patients at high risk to observation units and the emergency department, and therefore provides evidence against calls to curtail the program owing to this theoretical concern (see JAMA 2018;320:2539-41),” the researchers concluded.

They acknowledged certain limitations of the study, including the fact that they were “unable to identify patterns of acute care during the index hospital admission that would be associated with a higher rate of postdischarge acute care in observation units and emergency departments and whether these visits represented avenues for planned postdischarge follow-up care. Moreover, the proportion of these care encounters that were preventable remains poorly understood.”

Dr. Khera disclosed that he is supported by the National Center for Advancing Translational Sciences of the National Institutes of Health. His coauthors reported having numerous disclosures.

dbrunk@mdedge.com

SOURCE: Khera et al. BMJ 2020;368:l6831.

While physicians acknowledge that the social determinants of health can impact outcomes from medical care, some may feel that trying to address factors such as homelessness, food insecurity, or lack of ready access to transportation or pharmacy services is just not part of the doctor’s job. A majority of 621 physicians surveyed in the summer of 2017 by Salt Lake City–based health care intelligence firm Leavitt Partners say they are neither capable of nor responsible for addressing such issues.¹

But that view may become unsustainable as the U.S. health care system continues to advance toward value- and population-based models of health care and as evidence mounts that social factors are important contributors to costly outcomes, such as avoidable hospital readmissions or emergency room visits. A recent report from the Robert Wood Johnson Foundation estimates that at least 40% of health outcomes are the result of social and economic factors, while only 20% can be attributed to medical care.²

“This is a hot topic – getting a lot of attention these days,” said hospitalist and care transitions expert Ramon Jacobs-Shaw, MD, MPA, regional medical officer for CareMore Health, a California-based physician-led health delivery organization and subsidiary of Anthem. “If you go around the country, some doctors still see social factors as the realm of the social worker. But large health care organizations are coming to recognize that social determinants are huge contributors to the health of their members and to the outcomes of their care.”

Hospitalists could be the natural providers to delve into the specific psychosocial aspects of their patients’ lives, or try to figure out how those factors contribute to health care needs, Dr. Jacobs-Shaw said. They typically confront such issues while the patient is in the hospital bed, but what are the steps that led to the hospitalization in the first place? What will happen after the patient is discharged?

“For example, if patients lack transportation, how can they get to their follow-up medical appointment in the primary care office in order to manage their diabetes? If you can’t follow up with them, their diabetes could get out of control, with complications as a result, such as an infected wound,” he said. Another big issue is access to affordable medications. “CareMore has pharmacists embedded on our care teams. They try to figure out the best medicine for the patient but at the lowest cost. They meet individually with patients and do medication counseling, particularly for those with polypharmacy issues.”

Making health care more equitable

Dr. Jacobs-Shaw has long held a personal interest in issues of inclusiveness, diversity, and how to make health care more equitable for historically underserved groups. Asking how to have a bigger impact on these issues is what brought him, after 13 years as a hospitalist on the East Coast, to CareMore, a company that has made addressing social needs central to its care model. “In California, where I am based, we are a wrap-around for patients who are covered by Medicare Advantage plans. We are whatever the patient needs us to be.”

He oversees a group of hospitalists, dubbed extensivists, who provide advanced patient care and chronic disease management. In the extensivist model, physicians and advanced practice nurses provide comprehensive and coordinated care to patients with complex medical issues, taking their scope of practice beyond the hospital into homes, post-acute care facilities, and other settings, with a focus on keeping patients healthier and reducing readmission.³

“Our patients get access to extra services and resources, some of which are available at our care centers – which are one-stop outpatient facilities. We also focus on a lot of things physicians didn’t historically think were within their wheelhouse. Hospitalists deal with these kinds of issues every day, but may not label them as social determinants of health,” Dr. Jacobs-Shaw said. He emphasized that hospitalists should realize that they are not powerless to address these issues, working in partnership with other groups in and out of the hospital. They should also know that health care payers increasingly are dedicating resources to these issues.

“We just started trying to address homelessness through a pilot in Orange County, working with nonprofit organizations and philanthropy to offer a transitional site of care for our patients who are being discharged from the hospital and have housing insecurity issues, to get them transitioned into more secure housing,” Dr. Jacobs-Shaw said. CareMore also has a transportation collaborative that offers no-cost, nonemergency transportation to medical appointments. “That’s meeting them where they are at, based on an assessment of their needs and resources.”
 

What are social determinants?

The social determinants of health – social, environmental, and other nonmedical factors that contribute to overall health status and medical need – have been defined by the World Health Organization as: “conditions in which people are born, grow, live, work, and age.” That is a broad complex of overlapping social and systems issues, but it provides a context for a broader understanding of the patient’s health and response to medical interventions.

Socioeconomic status is a huge determinant. Level of education may be more important than income if the person lacks the health literacy to navigate the system and access needed care. Housing instability may include poor sanitation, substandard dwellings, or unsafe neighborhoods – all of which can affect a person’s well-being. Environmental health may include compromised air quality – which can impact pulmonary health. Other issues include access to employment and child care, utility needs, and interpersonal violence.

A 2014 paper in Annals of Internal Medicine found that residence within a disadvantaged neighborhood was a factor in hospital readmission rates as often as was chronic pulmonary disease.⁴ A recent report on social determinants of health by the National Institute for Health Care Management notes that patients with food insecurity are 2.4 times more likely to go to the emergency room, while those with transportation needs are 2.6 times more likely.⁵

What can health care leaders do to better equip their clinicians and teams to help patients deal with this array of complex needs? Intermountain Healthcare, based in Salt Lake City, spearheaded in 2018 the development of the Alliance for the Determinants of Health, starting in the communities of Ogden and St. George, Utah. The Alliance seeks to promote health, improve access to care, and decrease health care costs through a charitable contribution of $12 million over 3 years to seed collaborative demonstration projects.

Lisa Nichols, assistant vice president for community health at Intermountain, said that, while hospitalists were not directly involved in planning the Alliance, hospitalists and ED physicians have become essential to the patient-screening process for health and social needs.

“We met with hospitalists, emergency departments, and hospital administrators, because we wanted their feedback on how to raise awareness of the social needs of patients,” she said. “They have good ideas. They see the patients who come in from the homeless shelters.”

Other hospitals are subsidizing apartments for homeless patients being discharged from the hospital. CommonSpirit Health, the new national Catholic health care organization formed by the 2019 merger of Dignity Health and Catholic Health Initiatives, has explored how to help create and sustain affordable housing in the communities it serves. Investments like this have inspired others, such as Kaiser Permanente, to get involved in supporting housing initiatives.⁶

Comprehensive community care

David Meltzer, MD, PhD, a hospitalist and professor of medicine at the University of Chicago, said most hospitalists these days believe social determinants of health are part of their job responsibilities.

“That’s not to say we all do it well. We may fail at addressing some of the barriers our patients face. But I don’t know anyone who still says it’s not their job,” he said.

Since 2012, Dr. Meltzer has led a pilot called Comprehensive Care Physicians (CCP), in which the same physician cares for patients with chronic health problems in the clinic and in the hospital, working with a team of nurse practitioners, social workers, care coordinators, and other specialists. A total of 2,000 patients with chronic health problems were enrolled in the study from 2012 to 2016, half assigned to standard care and half assigned to five CCP doctors. The result: The CCP model has shown large improvements in outcomes – particularly among the more vulnerable, less activated patients, is preferred by patients, and has significantly reduced health care utilization.

The next step for the research team is another randomized controlled trial called Comprehensive Care, Community, and Culture, designed to address unmet social needs. Study group patients will also be screened for unmet social needs and have access to a community health worker and to the initiative’s Artful Living Program, which includes community and cultural activities like yoga and dance classes, cooking classes, art classes, and music concerts. To address the complex dimensions and determinants of health, Dr. Meltzer explained, efforts to improve health must extend to sectors far beyond traditional health care.

“I think trying to understand your patients’ social and nonmedical needs starts with getting to know them, and asking about their needs,” he said. “The better you know them, the better you are able to make medical decisions that will promote positive outcomes.”

Sound Physicians, a national hospitalist company based in Tacoma, Wash., and working in 350 hospitals in 41 states, recently published a blog post on its website about the importance of social determinants of health.⁷ Sound Physicians participates in value-based care through bundled Medicare/Medicaid contracts based on episodes of care for hospitalized patients with certain diagnoses or DRGs, explained John Dickey, MD, the company’s chief medical officer for population health.

“We’ve been heavily involved in trying to improve cost and outcomes of care since 2015. Social determinants absolutely play into trying to lower costs of care and reduce rates of readmissions, which are often multifactorial in cause,” he said. Hospitalists are uniquely equipped to impact post-acute outcomes, Dr. Dickey said, working in partnership with a position Sound Physicians calls the clinical performance nurse.

“We can also partner with primary care providers, provide education for our hospitalist staff, and work with in-home care supports for patients such as these, who otherwise might end up in a skilled nursing facility – even though they’d rather be at home,” he said.

Innovations at Northwell Health

Northwell Health, a multihospital comprehensive health system serving the New York City metro area and Long Island, has shown innovative leadership in addressing social factors. The 23-hospital system initiated in early 2019 a 15-item Self-Reported Social Determinants Screening Tool, which is now used with hospitalized patients to connect them with the support they need to fully recover and avoid readmissions.

Northwell is also providing professional education on social determinants for different constituencies across its system, said Johanna Martinez, MD, MS, a hospitalist and GME Director of Diversity and Health Equity at the Zucker School of Medicine at Hofstra/Northwell. A day-long training retreat was offered to GME faculty, and learning platforms have been developed for physicians, social workers, nurses, and others.

“One of the questions that comes up is that if you find social needs, what do you do about them?” Dr. Martinez explained. That’s more a difficult challenge, she said, so at Northwell, orthopedic surgeons are now asking patients questions like: “What’s going to happen when you go home? What are your social supports? Can you get to the physical therapist’s office?”

Another example of Northwell’s innovations is its Food as Health Program, initially piloted at Long Island Jewish Hospital in Valley Stream, N.Y. Hospitalized patients are asked two questions using a validated screening tool called the Hunger Vital Sign to identify their food insecurities.⁸ Those who answer yes are referred to a dietitian, and if they have a nutrition-related diagnosis, they enter the multidisciplinary wraparound program.

A key element is the food and health center, located on the hospital campus, where they can get food to take home and referrals to other services, with culturally tailored, disease-specific food education incorporated into the discharge plan. One of the partnering organizations is Island Harvest Food Bank, which helps about 1 in every 10 residents of Long Island with their food insecurity issues.

“When I talk to clinicians, most of us went into medicine to save lives and cure people. Yet the research shows that no matter who we are, we can’t do the best work that our patients need unless we consider their social determinants,” Dr. Martinez said. Ultimately, she noted, there is a need to change the culture of health care. “We have to create system change, reimbursement change, policy change.”

Omolara Uwemedimo, MD, MPH, associate professor of pediatrics and occupational medicine at Northwell and a former nocturnist, said the treatment of illness and health improvement don’t begin in the hospital, they begin in the community. Identifying where people are struggling and what communities they come from requires a broader view of the provider’s role. “Are patients who are readmitted to the hospital generally coming from certain demographics or from certain zip codes?” she asked. “Start there. How can we better connect with those communities?”

Education is key

In 2020 and beyond, hospitalists will hear more about the social determinants of health, Dr. Jacobs-Shaw concluded. “Without addressing those social determinants, we aren’t going to be able to meaningfully impact outcomes or be effective stewards of health care costs – addressing the psychosocial factors and root causes of patients coming in and out of the hospital.”

He added that self-education is key for hospitalists and the teams they work with – to be more aware of the link between health outcomes and social determinants. Guidelines and other resources on social determinants of health are available from the American College of Physicians and the American Association of Family Physicians. ACP issued a position paper on addressing social determinants of health to improve patient care,while AAFP has a research page on its website dedicated to social determinants of health, highlighting a number of initiatives and resources for physicians and others.⁹

The American Hospital Association has produced fact sheets on ICD-10CM code categories for social determinants of health, including 11 ICD-10 “Z” codes, numbered Z55-Z65, which can be used for coding interventions to address social determinants of health. Other experts are looking at how to adapt the electronic health record to capture sociodemographic and behavioral factors, and then trigger referrals to resources in the hospital and the broader community, and how to mobilize artificial intelligence and machine learning to better identify social needs.

“Our doctors really want to be able to take care of the whole patient, while being stewards of health care resources. But sometimes we feel powerless and wonder how we can have a bigger impact on people, on populations” Dr. Jacobs-Shaw said. “Remember it only takes one voice within an organization to start to elevate this topic.”
 

References

1. Rappleye E. Physicians say social determinants of health are not their responsibility. Becker’s Hospital Review. 2018 May 15.

2. Robert Wood Johnson Foundation, University of Wisconsin Population Health Institute. County Health Rankings, 2014.

3. Freeman, GA. The extensivist model. Health Leaders Magazine, 2016 Sep 15.

4. Kind AJ et al. Neighborhood socioeconomic disadvantage and 30-day rehospitalization: A retrospective cohort study. Ann Intern Med. 2014 Dec 2;161(11):765-74.

5. National Institute for Health Care Management. Addressing social determinants of health can improve community health & reduce costs.

6. Vial PB. Boundless collaboration: A philosophy for sustainable and stabilizing housing investment strategies. Health Progress: Journal of the Catholic Health Association of the United States. September-October 2019.

7. Social determinants of health: New solutions for growing complexities. Op-Med, a blog by Sound Physicians. 2019 Aug 1.

8. The hunger vital sign: A new standard of care for preventive health.

9. Daniel H et al. Addressing social determinants to improve patient care and promote health equity: An American College of Physicians position paper. Ann Intern Med. 2018;168:557-578.

While physicians acknowledge that the social determinants of health can impact outcomes from medical care, some may feel that trying to address factors such as homelessness, food insecurity, or lack of ready access to transportation or pharmacy services is just not part of the doctor’s job. A majority of 621 physicians surveyed in the summer of 2017 by Salt Lake City–based health care intelligence firm Leavitt Partners say they are neither capable of nor responsible for addressing such issues.¹

But that view may become unsustainable as the U.S. health care system continues to advance toward value- and population-based models of health care and as evidence mounts that social factors are important contributors to costly outcomes, such as avoidable hospital readmissions or emergency room visits. A recent report from the Robert Wood Johnson Foundation estimates that at least 40% of health outcomes are the result of social and economic factors, while only 20% can be attributed to medical care.²

“This is a hot topic – getting a lot of attention these days,” said hospitalist and care transitions expert Ramon Jacobs-Shaw, MD, MPA, regional medical officer for CareMore Health, a California-based physician-led health delivery organization and subsidiary of Anthem. “If you go around the country, some doctors still see social factors as the realm of the social worker. But large health care organizations are coming to recognize that social determinants are huge contributors to the health of their members and to the outcomes of their care.”

Hospitalists could be the natural providers to delve into the specific psychosocial aspects of their patients’ lives, or try to figure out how those factors contribute to health care needs, Dr. Jacobs-Shaw said. They typically confront such issues while the patient is in the hospital bed, but what are the steps that led to the hospitalization in the first place? What will happen after the patient is discharged?

“For example, if patients lack transportation, how can they get to their follow-up medical appointment in the primary care office in order to manage their diabetes? If you can’t follow up with them, their diabetes could get out of control, with complications as a result, such as an infected wound,” he said. Another big issue is access to affordable medications. “CareMore has pharmacists embedded on our care teams. They try to figure out the best medicine for the patient but at the lowest cost. They meet individually with patients and do medication counseling, particularly for those with polypharmacy issues.”

Making health care more equitable

Dr. Jacobs-Shaw has long held a personal interest in issues of inclusiveness, diversity, and how to make health care more equitable for historically underserved groups. Asking how to have a bigger impact on these issues is what brought him, after 13 years as a hospitalist on the East Coast, to CareMore, a company that has made addressing social needs central to its care model. “In California, where I am based, we are a wrap-around for patients who are covered by Medicare Advantage plans. We are whatever the patient needs us to be.”

He oversees a group of hospitalists, dubbed extensivists, who provide advanced patient care and chronic disease management. In the extensivist model, physicians and advanced practice nurses provide comprehensive and coordinated care to patients with complex medical issues, taking their scope of practice beyond the hospital into homes, post-acute care facilities, and other settings, with a focus on keeping patients healthier and reducing readmission.³

“Our patients get access to extra services and resources, some of which are available at our care centers – which are one-stop outpatient facilities. We also focus on a lot of things physicians didn’t historically think were within their wheelhouse. Hospitalists deal with these kinds of issues every day, but may not label them as social determinants of health,” Dr. Jacobs-Shaw said. He emphasized that hospitalists should realize that they are not powerless to address these issues, working in partnership with other groups in and out of the hospital. They should also know that health care payers increasingly are dedicating resources to these issues.

“We just started trying to address homelessness through a pilot in Orange County, working with nonprofit organizations and philanthropy to offer a transitional site of care for our patients who are being discharged from the hospital and have housing insecurity issues, to get them transitioned into more secure housing,” Dr. Jacobs-Shaw said. CareMore also has a transportation collaborative that offers no-cost, nonemergency transportation to medical appointments. “That’s meeting them where they are at, based on an assessment of their needs and resources.”
 

What are social determinants?

The social determinants of health – social, environmental, and other nonmedical factors that contribute to overall health status and medical need – have been defined by the World Health Organization as: “conditions in which people are born, grow, live, work, and age.” That is a broad complex of overlapping social and systems issues, but it provides a context for a broader understanding of the patient’s health and response to medical interventions.

Socioeconomic status is a huge determinant. Level of education may be more important than income if the person lacks the health literacy to navigate the system and access needed care. Housing instability may include poor sanitation, substandard dwellings, or unsafe neighborhoods – all of which can affect a person’s well-being. Environmental health may include compromised air quality – which can impact pulmonary health. Other issues include access to employment and child care, utility needs, and interpersonal violence.

A 2014 paper in Annals of Internal Medicine found that residence within a disadvantaged neighborhood was a factor in hospital readmission rates as often as was chronic pulmonary disease.⁴ A recent report on social determinants of health by the National Institute for Health Care Management notes that patients with food insecurity are 2.4 times more likely to go to the emergency room, while those with transportation needs are 2.6 times more likely.⁵

What can health care leaders do to better equip their clinicians and teams to help patients deal with this array of complex needs? Intermountain Healthcare, based in Salt Lake City, spearheaded in 2018 the development of the Alliance for the Determinants of Health, starting in the communities of Ogden and St. George, Utah. The Alliance seeks to promote health, improve access to care, and decrease health care costs through a charitable contribution of $12 million over 3 years to seed collaborative demonstration projects.

Lisa Nichols, assistant vice president for community health at Intermountain, said that, while hospitalists were not directly involved in planning the Alliance, hospitalists and ED physicians have become essential to the patient-screening process for health and social needs.

“We met with hospitalists, emergency departments, and hospital administrators, because we wanted their feedback on how to raise awareness of the social needs of patients,” she said. “They have good ideas. They see the patients who come in from the homeless shelters.”

Other hospitals are subsidizing apartments for homeless patients being discharged from the hospital. CommonSpirit Health, the new national Catholic health care organization formed by the 2019 merger of Dignity Health and Catholic Health Initiatives, has explored how to help create and sustain affordable housing in the communities it serves. Investments like this have inspired others, such as Kaiser Permanente, to get involved in supporting housing initiatives.⁶

Comprehensive community care

David Meltzer, MD, PhD, a hospitalist and professor of medicine at the University of Chicago, said most hospitalists these days believe social determinants of health are part of their job responsibilities.

“That’s not to say we all do it well. We may fail at addressing some of the barriers our patients face. But I don’t know anyone who still says it’s not their job,” he said.

Since 2012, Dr. Meltzer has led a pilot called Comprehensive Care Physicians (CCP), in which the same physician cares for patients with chronic health problems in the clinic and in the hospital, working with a team of nurse practitioners, social workers, care coordinators, and other specialists. A total of 2,000 patients with chronic health problems were enrolled in the study from 2012 to 2016, half assigned to standard care and half assigned to five CCP doctors. The result: The CCP model has shown large improvements in outcomes – particularly among the more vulnerable, less activated patients, is preferred by patients, and has significantly reduced health care utilization.

The next step for the research team is another randomized controlled trial called Comprehensive Care, Community, and Culture, designed to address unmet social needs. Study group patients will also be screened for unmet social needs and have access to a community health worker and to the initiative’s Artful Living Program, which includes community and cultural activities like yoga and dance classes, cooking classes, art classes, and music concerts. To address the complex dimensions and determinants of health, Dr. Meltzer explained, efforts to improve health must extend to sectors far beyond traditional health care.

“I think trying to understand your patients’ social and nonmedical needs starts with getting to know them, and asking about their needs,” he said. “The better you know them, the better you are able to make medical decisions that will promote positive outcomes.”

Sound Physicians, a national hospitalist company based in Tacoma, Wash., and working in 350 hospitals in 41 states, recently published a blog post on its website about the importance of social determinants of health.⁷ Sound Physicians participates in value-based care through bundled Medicare/Medicaid contracts based on episodes of care for hospitalized patients with certain diagnoses or DRGs, explained John Dickey, MD, the company’s chief medical officer for population health.

“We’ve been heavily involved in trying to improve cost and outcomes of care since 2015. Social determinants absolutely play into trying to lower costs of care and reduce rates of readmissions, which are often multifactorial in cause,” he said. Hospitalists are uniquely equipped to impact post-acute outcomes, Dr. Dickey said, working in partnership with a position Sound Physicians calls the clinical performance nurse.

“We can also partner with primary care providers, provide education for our hospitalist staff, and work with in-home care supports for patients such as these, who otherwise might end up in a skilled nursing facility – even though they’d rather be at home,” he said.

Innovations at Northwell Health

Northwell Health, a multihospital comprehensive health system serving the New York City metro area and Long Island, has shown innovative leadership in addressing social factors. The 23-hospital system initiated in early 2019 a 15-item Self-Reported Social Determinants Screening Tool, which is now used with hospitalized patients to connect them with the support they need to fully recover and avoid readmissions.

Northwell is also providing professional education on social determinants for different constituencies across its system, said Johanna Martinez, MD, MS, a hospitalist and GME Director of Diversity and Health Equity at the Zucker School of Medicine at Hofstra/Northwell. A day-long training retreat was offered to GME faculty, and learning platforms have been developed for physicians, social workers, nurses, and others.

“One of the questions that comes up is that if you find social needs, what do you do about them?” Dr. Martinez explained. That’s more a difficult challenge, she said, so at Northwell, orthopedic surgeons are now asking patients questions like: “What’s going to happen when you go home? What are your social supports? Can you get to the physical therapist’s office?”

Another example of Northwell’s innovations is its Food as Health Program, initially piloted at Long Island Jewish Hospital in Valley Stream, N.Y. Hospitalized patients are asked two questions using a validated screening tool called the Hunger Vital Sign to identify their food insecurities.⁸ Those who answer yes are referred to a dietitian, and if they have a nutrition-related diagnosis, they enter the multidisciplinary wraparound program.

A key element is the food and health center, located on the hospital campus, where they can get food to take home and referrals to other services, with culturally tailored, disease-specific food education incorporated into the discharge plan. One of the partnering organizations is Island Harvest Food Bank, which helps about 1 in every 10 residents of Long Island with their food insecurity issues.

“When I talk to clinicians, most of us went into medicine to save lives and cure people. Yet the research shows that no matter who we are, we can’t do the best work that our patients need unless we consider their social determinants,” Dr. Martinez said. Ultimately, she noted, there is a need to change the culture of health care. “We have to create system change, reimbursement change, policy change.”

Omolara Uwemedimo, MD, MPH, associate professor of pediatrics and occupational medicine at Northwell and a former nocturnist, said the treatment of illness and health improvement don’t begin in the hospital, they begin in the community. Identifying where people are struggling and what communities they come from requires a broader view of the provider’s role. “Are patients who are readmitted to the hospital generally coming from certain demographics or from certain zip codes?” she asked. “Start there. How can we better connect with those communities?”

Education is key

In 2020 and beyond, hospitalists will hear more about the social determinants of health, Dr. Jacobs-Shaw concluded. “Without addressing those social determinants, we aren’t going to be able to meaningfully impact outcomes or be effective stewards of health care costs – addressing the psychosocial factors and root causes of patients coming in and out of the hospital.”

He added that self-education is key for hospitalists and the teams they work with – to be more aware of the link between health outcomes and social determinants. Guidelines and other resources on social determinants of health are available from the American College of Physicians and the American Association of Family Physicians. ACP issued a position paper on addressing social determinants of health to improve patient care,while AAFP has a research page on its website dedicated to social determinants of health, highlighting a number of initiatives and resources for physicians and others.⁹

The American Hospital Association has produced fact sheets on ICD-10CM code categories for social determinants of health, including 11 ICD-10 “Z” codes, numbered Z55-Z65, which can be used for coding interventions to address social determinants of health. Other experts are looking at how to adapt the electronic health record to capture sociodemographic and behavioral factors, and then trigger referrals to resources in the hospital and the broader community, and how to mobilize artificial intelligence and machine learning to better identify social needs.

“Our doctors really want to be able to take care of the whole patient, while being stewards of health care resources. But sometimes we feel powerless and wonder how we can have a bigger impact on people, on populations” Dr. Jacobs-Shaw said. “Remember it only takes one voice within an organization to start to elevate this topic.”
 

References

1. Rappleye E. Physicians say social determinants of health are not their responsibility. Becker’s Hospital Review. 2018 May 15.

2. Robert Wood Johnson Foundation, University of Wisconsin Population Health Institute. County Health Rankings, 2014.

3. Freeman, GA. The extensivist model. Health Leaders Magazine, 2016 Sep 15.

4. Kind AJ et al. Neighborhood socioeconomic disadvantage and 30-day rehospitalization: A retrospective cohort study. Ann Intern Med. 2014 Dec 2;161(11):765-74.

5. National Institute for Health Care Management. Addressing social determinants of health can improve community health & reduce costs.

6. Vial PB. Boundless collaboration: A philosophy for sustainable and stabilizing housing investment strategies. Health Progress: Journal of the Catholic Health Association of the United States. September-October 2019.

7. Social determinants of health: New solutions for growing complexities. Op-Med, a blog by Sound Physicians. 2019 Aug 1.

8. The hunger vital sign: A new standard of care for preventive health.

9. Daniel H et al. Addressing social determinants to improve patient care and promote health equity: An American College of Physicians position paper. Ann Intern Med. 2018;168:557-578.

While physicians acknowledge that the social determinants of health can impact outcomes from medical care, some may feel that trying to address factors such as homelessness, food insecurity, or lack of ready access to transportation or pharmacy services is just not part of the doctor’s job. A majority of 621 physicians surveyed in the summer of 2017 by Salt Lake City–based health care intelligence firm Leavitt Partners say they are neither capable of nor responsible for addressing such issues.¹

But that view may become unsustainable as the U.S. health care system continues to advance toward value- and population-based models of health care and as evidence mounts that social factors are important contributors to costly outcomes, such as avoidable hospital readmissions or emergency room visits. A recent report from the Robert Wood Johnson Foundation estimates that at least 40% of health outcomes are the result of social and economic factors, while only 20% can be attributed to medical care.²

“This is a hot topic – getting a lot of attention these days,” said hospitalist and care transitions expert Ramon Jacobs-Shaw, MD, MPA, regional medical officer for CareMore Health, a California-based physician-led health delivery organization and subsidiary of Anthem. “If you go around the country, some doctors still see social factors as the realm of the social worker. But large health care organizations are coming to recognize that social determinants are huge contributors to the health of their members and to the outcomes of their care.”

Hospitalists could be the natural providers to delve into the specific psychosocial aspects of their patients’ lives, or try to figure out how those factors contribute to health care needs, Dr. Jacobs-Shaw said. They typically confront such issues while the patient is in the hospital bed, but what are the steps that led to the hospitalization in the first place? What will happen after the patient is discharged?

“For example, if patients lack transportation, how can they get to their follow-up medical appointment in the primary care office in order to manage their diabetes? If you can’t follow up with them, their diabetes could get out of control, with complications as a result, such as an infected wound,” he said. Another big issue is access to affordable medications. “CareMore has pharmacists embedded on our care teams. They try to figure out the best medicine for the patient but at the lowest cost. They meet individually with patients and do medication counseling, particularly for those with polypharmacy issues.”

Making health care more equitable

Dr. Jacobs-Shaw has long held a personal interest in issues of inclusiveness, diversity, and how to make health care more equitable for historically underserved groups. Asking how to have a bigger impact on these issues is what brought him, after 13 years as a hospitalist on the East Coast, to CareMore, a company that has made addressing social needs central to its care model. “In California, where I am based, we are a wrap-around for patients who are covered by Medicare Advantage plans. We are whatever the patient needs us to be.”

He oversees a group of hospitalists, dubbed extensivists, who provide advanced patient care and chronic disease management. In the extensivist model, physicians and advanced practice nurses provide comprehensive and coordinated care to patients with complex medical issues, taking their scope of practice beyond the hospital into homes, post-acute care facilities, and other settings, with a focus on keeping patients healthier and reducing readmission.³

“Our patients get access to extra services and resources, some of which are available at our care centers – which are one-stop outpatient facilities. We also focus on a lot of things physicians didn’t historically think were within their wheelhouse. Hospitalists deal with these kinds of issues every day, but may not label them as social determinants of health,” Dr. Jacobs-Shaw said. He emphasized that hospitalists should realize that they are not powerless to address these issues, working in partnership with other groups in and out of the hospital. They should also know that health care payers increasingly are dedicating resources to these issues.

“We just started trying to address homelessness through a pilot in Orange County, working with nonprofit organizations and philanthropy to offer a transitional site of care for our patients who are being discharged from the hospital and have housing insecurity issues, to get them transitioned into more secure housing,” Dr. Jacobs-Shaw said. CareMore also has a transportation collaborative that offers no-cost, nonemergency transportation to medical appointments. “That’s meeting them where they are at, based on an assessment of their needs and resources.”
 

What are social determinants?

The social determinants of health – social, environmental, and other nonmedical factors that contribute to overall health status and medical need – have been defined by the World Health Organization as: “conditions in which people are born, grow, live, work, and age.” That is a broad complex of overlapping social and systems issues, but it provides a context for a broader understanding of the patient’s health and response to medical interventions.

Socioeconomic status is a huge determinant. Level of education may be more important than income if the person lacks the health literacy to navigate the system and access needed care. Housing instability may include poor sanitation, substandard dwellings, or unsafe neighborhoods – all of which can affect a person’s well-being. Environmental health may include compromised air quality – which can impact pulmonary health. Other issues include access to employment and child care, utility needs, and interpersonal violence.

A 2014 paper in Annals of Internal Medicine found that residence within a disadvantaged neighborhood was a factor in hospital readmission rates as often as was chronic pulmonary disease.⁴ A recent report on social determinants of health by the National Institute for Health Care Management notes that patients with food insecurity are 2.4 times more likely to go to the emergency room, while those with transportation needs are 2.6 times more likely.⁵

What can health care leaders do to better equip their clinicians and teams to help patients deal with this array of complex needs? Intermountain Healthcare, based in Salt Lake City, spearheaded in 2018 the development of the Alliance for the Determinants of Health, starting in the communities of Ogden and St. George, Utah. The Alliance seeks to promote health, improve access to care, and decrease health care costs through a charitable contribution of $12 million over 3 years to seed collaborative demonstration projects.

Lisa Nichols, assistant vice president for community health at Intermountain, said that, while hospitalists were not directly involved in planning the Alliance, hospitalists and ED physicians have become essential to the patient-screening process for health and social needs.

“We met with hospitalists, emergency departments, and hospital administrators, because we wanted their feedback on how to raise awareness of the social needs of patients,” she said. “They have good ideas. They see the patients who come in from the homeless shelters.”

Other hospitals are subsidizing apartments for homeless patients being discharged from the hospital. CommonSpirit Health, the new national Catholic health care organization formed by the 2019 merger of Dignity Health and Catholic Health Initiatives, has explored how to help create and sustain affordable housing in the communities it serves. Investments like this have inspired others, such as Kaiser Permanente, to get involved in supporting housing initiatives.⁶

Comprehensive community care

David Meltzer, MD, PhD, a hospitalist and professor of medicine at the University of Chicago, said most hospitalists these days believe social determinants of health are part of their job responsibilities.

“That’s not to say we all do it well. We may fail at addressing some of the barriers our patients face. But I don’t know anyone who still says it’s not their job,” he said.

Since 2012, Dr. Meltzer has led a pilot called Comprehensive Care Physicians (CCP), in which the same physician cares for patients with chronic health problems in the clinic and in the hospital, working with a team of nurse practitioners, social workers, care coordinators, and other specialists. A total of 2,000 patients with chronic health problems were enrolled in the study from 2012 to 2016, half assigned to standard care and half assigned to five CCP doctors. The result: The CCP model has shown large improvements in outcomes – particularly among the more vulnerable, less activated patients, is preferred by patients, and has significantly reduced health care utilization.

The next step for the research team is another randomized controlled trial called Comprehensive Care, Community, and Culture, designed to address unmet social needs. Study group patients will also be screened for unmet social needs and have access to a community health worker and to the initiative’s Artful Living Program, which includes community and cultural activities like yoga and dance classes, cooking classes, art classes, and music concerts. To address the complex dimensions and determinants of health, Dr. Meltzer explained, efforts to improve health must extend to sectors far beyond traditional health care.

“I think trying to understand your patients’ social and nonmedical needs starts with getting to know them, and asking about their needs,” he said. “The better you know them, the better you are able to make medical decisions that will promote positive outcomes.”

Sound Physicians, a national hospitalist company based in Tacoma, Wash., and working in 350 hospitals in 41 states, recently published a blog post on its website about the importance of social determinants of health.⁷ Sound Physicians participates in value-based care through bundled Medicare/Medicaid contracts based on episodes of care for hospitalized patients with certain diagnoses or DRGs, explained John Dickey, MD, the company’s chief medical officer for population health.

“We’ve been heavily involved in trying to improve cost and outcomes of care since 2015. Social determinants absolutely play into trying to lower costs of care and reduce rates of readmissions, which are often multifactorial in cause,” he said. Hospitalists are uniquely equipped to impact post-acute outcomes, Dr. Dickey said, working in partnership with a position Sound Physicians calls the clinical performance nurse.

“We can also partner with primary care providers, provide education for our hospitalist staff, and work with in-home care supports for patients such as these, who otherwise might end up in a skilled nursing facility – even though they’d rather be at home,” he said.

Innovations at Northwell Health

Northwell Health, a multihospital comprehensive health system serving the New York City metro area and Long Island, has shown innovative leadership in addressing social factors. The 23-hospital system initiated in early 2019 a 15-item Self-Reported Social Determinants Screening Tool, which is now used with hospitalized patients to connect them with the support they need to fully recover and avoid readmissions.

Northwell is also providing professional education on social determinants for different constituencies across its system, said Johanna Martinez, MD, MS, a hospitalist and GME Director of Diversity and Health Equity at the Zucker School of Medicine at Hofstra/Northwell. A day-long training retreat was offered to GME faculty, and learning platforms have been developed for physicians, social workers, nurses, and others.

“One of the questions that comes up is that if you find social needs, what do you do about them?” Dr. Martinez explained. That’s more a difficult challenge, she said, so at Northwell, orthopedic surgeons are now asking patients questions like: “What’s going to happen when you go home? What are your social supports? Can you get to the physical therapist’s office?”

Another example of Northwell’s innovations is its Food as Health Program, initially piloted at Long Island Jewish Hospital in Valley Stream, N.Y. Hospitalized patients are asked two questions using a validated screening tool called the Hunger Vital Sign to identify their food insecurities.⁸ Those who answer yes are referred to a dietitian, and if they have a nutrition-related diagnosis, they enter the multidisciplinary wraparound program.

A key element is the food and health center, located on the hospital campus, where they can get food to take home and referrals to other services, with culturally tailored, disease-specific food education incorporated into the discharge plan. One of the partnering organizations is Island Harvest Food Bank, which helps about 1 in every 10 residents of Long Island with their food insecurity issues.

“When I talk to clinicians, most of us went into medicine to save lives and cure people. Yet the research shows that no matter who we are, we can’t do the best work that our patients need unless we consider their social determinants,” Dr. Martinez said. Ultimately, she noted, there is a need to change the culture of health care. “We have to create system change, reimbursement change, policy change.”

Omolara Uwemedimo, MD, MPH, associate professor of pediatrics and occupational medicine at Northwell and a former nocturnist, said the treatment of illness and health improvement don’t begin in the hospital, they begin in the community. Identifying where people are struggling and what communities they come from requires a broader view of the provider’s role. “Are patients who are readmitted to the hospital generally coming from certain demographics or from certain zip codes?” she asked. “Start there. How can we better connect with those communities?”

Education is key

In 2020 and beyond, hospitalists will hear more about the social determinants of health, Dr. Jacobs-Shaw concluded. “Without addressing those social determinants, we aren’t going to be able to meaningfully impact outcomes or be effective stewards of health care costs – addressing the psychosocial factors and root causes of patients coming in and out of the hospital.”

He added that self-education is key for hospitalists and the teams they work with – to be more aware of the link between health outcomes and social determinants. Guidelines and other resources on social determinants of health are available from the American College of Physicians and the American Association of Family Physicians. ACP issued a position paper on addressing social determinants of health to improve patient care,while AAFP has a research page on its website dedicated to social determinants of health, highlighting a number of initiatives and resources for physicians and others.⁹

The American Hospital Association has produced fact sheets on ICD-10CM code categories for social determinants of health, including 11 ICD-10 “Z” codes, numbered Z55-Z65, which can be used for coding interventions to address social determinants of health. Other experts are looking at how to adapt the electronic health record to capture sociodemographic and behavioral factors, and then trigger referrals to resources in the hospital and the broader community, and how to mobilize artificial intelligence and machine learning to better identify social needs.

“Our doctors really want to be able to take care of the whole patient, while being stewards of health care resources. But sometimes we feel powerless and wonder how we can have a bigger impact on people, on populations” Dr. Jacobs-Shaw said. “Remember it only takes one voice within an organization to start to elevate this topic.”
 

References

1. Rappleye E. Physicians say social determinants of health are not their responsibility. Becker’s Hospital Review. 2018 May 15.

2. Robert Wood Johnson Foundation, University of Wisconsin Population Health Institute. County Health Rankings, 2014.

3. Freeman, GA. The extensivist model. Health Leaders Magazine, 2016 Sep 15.

4. Kind AJ et al. Neighborhood socioeconomic disadvantage and 30-day rehospitalization: A retrospective cohort study. Ann Intern Med. 2014 Dec 2;161(11):765-74.

5. National Institute for Health Care Management. Addressing social determinants of health can improve community health & reduce costs.

6. Vial PB. Boundless collaboration: A philosophy for sustainable and stabilizing housing investment strategies. Health Progress: Journal of the Catholic Health Association of the United States. September-October 2019.

7. Social determinants of health: New solutions for growing complexities. Op-Med, a blog by Sound Physicians. 2019 Aug 1.

8. The hunger vital sign: A new standard of care for preventive health.

9. Daniel H et al. Addressing social determinants to improve patient care and promote health equity: An American College of Physicians position paper. Ann Intern Med. 2018;168:557-578.

Simulation is commonly used in the education and training of health care professionals, but more recently it’s entering the quality improvement world.

“Instead of just thinking about training individuals and teams, people are starting to use simulation to look at the physical layout of resuscitation bays, to map work flows of a patient journey through hospitals, to identify latent safety threats,” said Victoria Brazil, MD, MBA, lead author of a study on the subject in BMJ Quality & Safety. “These are great things to do, but many of the people doing it didn’t have quality improvement skills or knowledge – that’s why we wrote this article.”

Dr. Brazil, a specialist in health care simulation at Gold Coast (Australia) Hospital and Health Service, explained that, “in terms of the top takeaways, for quality improvement teams – and I’m including everyday clinicians in this: Think about simulation as one of the tools that can be utilized when looking at the questions of how we make our performance better, whether that’s a team performance, environmental, investigational impacts, or one of my key interests, whether that’s about exploring and shaping culture in hospitals, which we’ve done a lot of work on using simulation.”

Quality improvement has become a very specialized field, she added, so hospitalists may think it’s outside their purview. “As clinicians, we don’t think about ourselves as being engaged in quality improvement. I think that’s a shame, because many of the things that we can do bit by bit to make our patient outcomes better, we need to be thinking about finding better ways to do those things. I suggest simulation is one way, and that doesn’t need to be a massive simulation center. It can be simulating the kind of things that are important to you, your teams, and your patients and using those to both explore improved performance.”

Dr. Brazil said that Gold Coast Hospital has used simulation as a way of getting people from different departments and different professions together to shape culture through understanding shared knowledge and goals around patient journeys.

“That’s been pretty successful for us, and I think it’s really important that quality improvement has that understanding of context and culture as well as the idea of having specific interventions – maybe like a simulation – to try and improve an outcome,” she said.

Reference

1. Brazil V et al.. Connecting simulation and quality improvement: How can healthcare simulation really improve patient care? BMJ Qual Saf. 2019 Jul 18. doi: 10.1136/bmjqs-2019-009767.

Simulation is commonly used in the education and training of health care professionals, but more recently it’s entering the quality improvement world.

“Instead of just thinking about training individuals and teams, people are starting to use simulation to look at the physical layout of resuscitation bays, to map work flows of a patient journey through hospitals, to identify latent safety threats,” said Victoria Brazil, MD, MBA, lead author of a study on the subject in BMJ Quality & Safety. “These are great things to do, but many of the people doing it didn’t have quality improvement skills or knowledge – that’s why we wrote this article.”

Dr. Brazil, a specialist in health care simulation at Gold Coast (Australia) Hospital and Health Service, explained that, “in terms of the top takeaways, for quality improvement teams – and I’m including everyday clinicians in this: Think about simulation as one of the tools that can be utilized when looking at the questions of how we make our performance better, whether that’s a team performance, environmental, investigational impacts, or one of my key interests, whether that’s about exploring and shaping culture in hospitals, which we’ve done a lot of work on using simulation.”

Quality improvement has become a very specialized field, she added, so hospitalists may think it’s outside their purview. “As clinicians, we don’t think about ourselves as being engaged in quality improvement. I think that’s a shame, because many of the things that we can do bit by bit to make our patient outcomes better, we need to be thinking about finding better ways to do those things. I suggest simulation is one way, and that doesn’t need to be a massive simulation center. It can be simulating the kind of things that are important to you, your teams, and your patients and using those to both explore improved performance.”

Dr. Brazil said that Gold Coast Hospital has used simulation as a way of getting people from different departments and different professions together to shape culture through understanding shared knowledge and goals around patient journeys.

“That’s been pretty successful for us, and I think it’s really important that quality improvement has that understanding of context and culture as well as the idea of having specific interventions – maybe like a simulation – to try and improve an outcome,” she said.

Reference

1. Brazil V et al.. Connecting simulation and quality improvement: How can healthcare simulation really improve patient care? BMJ Qual Saf. 2019 Jul 18. doi: 10.1136/bmjqs-2019-009767.

Simulation is commonly used in the education and training of health care professionals, but more recently it’s entering the quality improvement world.

“Instead of just thinking about training individuals and teams, people are starting to use simulation to look at the physical layout of resuscitation bays, to map work flows of a patient journey through hospitals, to identify latent safety threats,” said Victoria Brazil, MD, MBA, lead author of a study on the subject in BMJ Quality & Safety. “These are great things to do, but many of the people doing it didn’t have quality improvement skills or knowledge – that’s why we wrote this article.”

Dr. Brazil, a specialist in health care simulation at Gold Coast (Australia) Hospital and Health Service, explained that, “in terms of the top takeaways, for quality improvement teams – and I’m including everyday clinicians in this: Think about simulation as one of the tools that can be utilized when looking at the questions of how we make our performance better, whether that’s a team performance, environmental, investigational impacts, or one of my key interests, whether that’s about exploring and shaping culture in hospitals, which we’ve done a lot of work on using simulation.”

Quality improvement has become a very specialized field, she added, so hospitalists may think it’s outside their purview. “As clinicians, we don’t think about ourselves as being engaged in quality improvement. I think that’s a shame, because many of the things that we can do bit by bit to make our patient outcomes better, we need to be thinking about finding better ways to do those things. I suggest simulation is one way, and that doesn’t need to be a massive simulation center. It can be simulating the kind of things that are important to you, your teams, and your patients and using those to both explore improved performance.”

Dr. Brazil said that Gold Coast Hospital has used simulation as a way of getting people from different departments and different professions together to shape culture through understanding shared knowledge and goals around patient journeys.

“That’s been pretty successful for us, and I think it’s really important that quality improvement has that understanding of context and culture as well as the idea of having specific interventions – maybe like a simulation – to try and improve an outcome,” she said.

Reference

1. Brazil V et al.. Connecting simulation and quality improvement: How can healthcare simulation really improve patient care? BMJ Qual Saf. 2019 Jul 18. doi: 10.1136/bmjqs-2019-009767.

It is a well-known fact that health care expenditure in the United States occupies a large proportion of its gross domestic product. In fact, it was 17.8% in 2016, almost twice what is expended in other advanced countries. However, this expenditure does not necessarily translate into optimal patient outcomes.

In 2012, the Institute of Medicine reported that the U.S. health care system wastes $750 billion per year in spending that does not provide any meaningful outcome to patients or the system; and patients can also suffer a financial impact from the delivery of low-value care.

In 2013, the Pediatrics Committee of the Society of Hospital Medicine published five recommendations through the Choosing Wisely® campaign aimed to decrease the use of low-value interventions. These recommendations were:

1. Do not order chest radiographs (CXR) in children with asthma or bronchiolitis.

2. Do not use systemic corticosteroids in children aged under 2 years with a lower respiratory tract infection.

3. Do not use bronchodilators in children with bronchiolitis.

4. Do not treat gastroesophageal reflux in infants routinely with acid suppression therapy.

5. Do not use continuous pulse oximetry routinely in children with acute respiratory illness unless they are on supplemental oxygen.

This publication led to the implementation of quality improvement initiatives across different hospitals and institutions nationally. Eventually, a team of hospitalists developed a report card that could help measure the utilization of these interventions in hospitals that were part of the Children’s Hospital Association (CHA). The data stemming from the report card analysis would allow for benchmarking and comparing performance, as well as determining the secular trend in utilization of these procedures across the different institutions of the CHA.

Reyes et al. recently published the impact of utilization of these scorecards among all hospital members of the CHA in the Journal of Hospital Medicine, noting a positive impact of the SHM Choosing Wisely® recommendation in decreasing the utilization of low-value interventions. The authors compared the performance before and after the publication of the recommendations for a 9-year period (2008-2017). The most relevant impact occurred in children with bronchiolitis, with a decrease of 36% of bronchodilator use and of 31% in CXR utilization. In children with asthma, CXR utilization decreased by 20.8%. The authors found that, although there was a steady decrease in the utilization of low-value services, this was still limited.

What factors could impact the effectiveness of high-value quality initiatives? First of all, quality improvement requires a substantial investment of collective effort and time. It requires a change in culture that often involves changing longstanding paradigms. The Choosing Wisely® recommendations target a very specific, low-clinical-severity population – the focus is on “uncomplicated” disease. This is important as you don’t want to pursue aggressive unnecessary intervention in children and potentially cause harm – for example, unnecessary use of steroids in a child with uncomplicated bronchiolitis who may improve with nasal suctioning alone. There is a need to appraise patients with more complex presentation of these diseases (for example, patients that require escalation of care to ICU), and this is beyond the scope of Choosing Wisely®. Further research is needed to see if higher-value care interventions can be implemented among these higher acuity and severity patients.

In our institution, we have created specific care paths that facilitate following these recommendations. Essentially, we have leveraged the EHR order sets to avoid the inclusion of low-value interventions; all stakeholders (respiratory therapy, nursing, etc.) are aware of the care path and ensure compliance. Even further, as a consequence of the change in culture toward high-value care, we have identified low-value interventions in settings where high-value quality improvement can be implemented – for example, we found that at least 20% of noncritically ill children undergoing an appendectomy receive unnecessary antacid prophylaxis treatment.

Changes always start small; quality improvement requires a lot of effort, and we must focus our energy on “low-hanging fruit,” and also begin tackling higher complexity tasks. In the Choosing Wisely® manuscript cited above, the authors found that there was a change in performance with a tendency toward higher-value care, yet the change was not as substantial as originally thought.

How can we tackle higher complexity tasks if we find it difficult to implement solutions for those of lower complexity? My answer is simple. Maintain a consistent and continuous focus on high value, and ensure the message is iterative and redundant with feedback on performance, decrease in costs, and enhanced patient outcomes.

Dr. Auron is the quality improvement and patient safety officer in the department of hospital medicine at the Cleveland Clinic. He also serves as associate professor of medicine and pediatrics in the staff department of hospital medicine and department of pediatric hospital medicine. This article first appeared on the Hospital Leader, SHM’s official blog, at hospitalleader.org.

It is a well-known fact that health care expenditure in the United States occupies a large proportion of its gross domestic product. In fact, it was 17.8% in 2016, almost twice what is expended in other advanced countries. However, this expenditure does not necessarily translate into optimal patient outcomes.

In 2012, the Institute of Medicine reported that the U.S. health care system wastes $750 billion per year in spending that does not provide any meaningful outcome to patients or the system; and patients can also suffer a financial impact from the delivery of low-value care.

In 2013, the Pediatrics Committee of the Society of Hospital Medicine published five recommendations through the Choosing Wisely® campaign aimed to decrease the use of low-value interventions. These recommendations were:

1. Do not order chest radiographs (CXR) in children with asthma or bronchiolitis.

2. Do not use systemic corticosteroids in children aged under 2 years with a lower respiratory tract infection.

3. Do not use bronchodilators in children with bronchiolitis.

4. Do not treat gastroesophageal reflux in infants routinely with acid suppression therapy.

5. Do not use continuous pulse oximetry routinely in children with acute respiratory illness unless they are on supplemental oxygen.

This publication led to the implementation of quality improvement initiatives across different hospitals and institutions nationally. Eventually, a team of hospitalists developed a report card that could help measure the utilization of these interventions in hospitals that were part of the Children’s Hospital Association (CHA). The data stemming from the report card analysis would allow for benchmarking and comparing performance, as well as determining the secular trend in utilization of these procedures across the different institutions of the CHA.

Reyes et al. recently published the impact of utilization of these scorecards among all hospital members of the CHA in the Journal of Hospital Medicine, noting a positive impact of the SHM Choosing Wisely® recommendation in decreasing the utilization of low-value interventions. The authors compared the performance before and after the publication of the recommendations for a 9-year period (2008-2017). The most relevant impact occurred in children with bronchiolitis, with a decrease of 36% of bronchodilator use and of 31% in CXR utilization. In children with asthma, CXR utilization decreased by 20.8%. The authors found that, although there was a steady decrease in the utilization of low-value services, this was still limited.

What factors could impact the effectiveness of high-value quality initiatives? First of all, quality improvement requires a substantial investment of collective effort and time. It requires a change in culture that often involves changing longstanding paradigms. The Choosing Wisely® recommendations target a very specific, low-clinical-severity population – the focus is on “uncomplicated” disease. This is important as you don’t want to pursue aggressive unnecessary intervention in children and potentially cause harm – for example, unnecessary use of steroids in a child with uncomplicated bronchiolitis who may improve with nasal suctioning alone. There is a need to appraise patients with more complex presentation of these diseases (for example, patients that require escalation of care to ICU), and this is beyond the scope of Choosing Wisely®. Further research is needed to see if higher-value care interventions can be implemented among these higher acuity and severity patients.

In our institution, we have created specific care paths that facilitate following these recommendations. Essentially, we have leveraged the EHR order sets to avoid the inclusion of low-value interventions; all stakeholders (respiratory therapy, nursing, etc.) are aware of the care path and ensure compliance. Even further, as a consequence of the change in culture toward high-value care, we have identified low-value interventions in settings where high-value quality improvement can be implemented – for example, we found that at least 20% of noncritically ill children undergoing an appendectomy receive unnecessary antacid prophylaxis treatment.

Changes always start small; quality improvement requires a lot of effort, and we must focus our energy on “low-hanging fruit,” and also begin tackling higher complexity tasks. In the Choosing Wisely® manuscript cited above, the authors found that there was a change in performance with a tendency toward higher-value care, yet the change was not as substantial as originally thought.

How can we tackle higher complexity tasks if we find it difficult to implement solutions for those of lower complexity? My answer is simple. Maintain a consistent and continuous focus on high value, and ensure the message is iterative and redundant with feedback on performance, decrease in costs, and enhanced patient outcomes.

Dr. Auron is the quality improvement and patient safety officer in the department of hospital medicine at the Cleveland Clinic. He also serves as associate professor of medicine and pediatrics in the staff department of hospital medicine and department of pediatric hospital medicine. This article first appeared on the Hospital Leader, SHM’s official blog, at hospitalleader.org.

It is a well-known fact that health care expenditure in the United States occupies a large proportion of its gross domestic product. In fact, it was 17.8% in 2016, almost twice what is expended in other advanced countries. However, this expenditure does not necessarily translate into optimal patient outcomes.

In 2012, the Institute of Medicine reported that the U.S. health care system wastes $750 billion per year in spending that does not provide any meaningful outcome to patients or the system; and patients can also suffer a financial impact from the delivery of low-value care.

In 2013, the Pediatrics Committee of the Society of Hospital Medicine published five recommendations through the Choosing Wisely® campaign aimed to decrease the use of low-value interventions. These recommendations were:

1. Do not order chest radiographs (CXR) in children with asthma or bronchiolitis.

2. Do not use systemic corticosteroids in children aged under 2 years with a lower respiratory tract infection.

3. Do not use bronchodilators in children with bronchiolitis.

4. Do not treat gastroesophageal reflux in infants routinely with acid suppression therapy.

5. Do not use continuous pulse oximetry routinely in children with acute respiratory illness unless they are on supplemental oxygen.

This publication led to the implementation of quality improvement initiatives across different hospitals and institutions nationally. Eventually, a team of hospitalists developed a report card that could help measure the utilization of these interventions in hospitals that were part of the Children’s Hospital Association (CHA). The data stemming from the report card analysis would allow for benchmarking and comparing performance, as well as determining the secular trend in utilization of these procedures across the different institutions of the CHA.

Reyes et al. recently published the impact of utilization of these scorecards among all hospital members of the CHA in the Journal of Hospital Medicine, noting a positive impact of the SHM Choosing Wisely® recommendation in decreasing the utilization of low-value interventions. The authors compared the performance before and after the publication of the recommendations for a 9-year period (2008-2017). The most relevant impact occurred in children with bronchiolitis, with a decrease of 36% of bronchodilator use and of 31% in CXR utilization. In children with asthma, CXR utilization decreased by 20.8%. The authors found that, although there was a steady decrease in the utilization of low-value services, this was still limited.

What factors could impact the effectiveness of high-value quality initiatives? First of all, quality improvement requires a substantial investment of collective effort and time. It requires a change in culture that often involves changing longstanding paradigms. The Choosing Wisely® recommendations target a very specific, low-clinical-severity population – the focus is on “uncomplicated” disease. This is important as you don’t want to pursue aggressive unnecessary intervention in children and potentially cause harm – for example, unnecessary use of steroids in a child with uncomplicated bronchiolitis who may improve with nasal suctioning alone. There is a need to appraise patients with more complex presentation of these diseases (for example, patients that require escalation of care to ICU), and this is beyond the scope of Choosing Wisely®. Further research is needed to see if higher-value care interventions can be implemented among these higher acuity and severity patients.

In our institution, we have created specific care paths that facilitate following these recommendations. Essentially, we have leveraged the EHR order sets to avoid the inclusion of low-value interventions; all stakeholders (respiratory therapy, nursing, etc.) are aware of the care path and ensure compliance. Even further, as a consequence of the change in culture toward high-value care, we have identified low-value interventions in settings where high-value quality improvement can be implemented – for example, we found that at least 20% of noncritically ill children undergoing an appendectomy receive unnecessary antacid prophylaxis treatment.

Changes always start small; quality improvement requires a lot of effort, and we must focus our energy on “low-hanging fruit,” and also begin tackling higher complexity tasks. In the Choosing Wisely® manuscript cited above, the authors found that there was a change in performance with a tendency toward higher-value care, yet the change was not as substantial as originally thought.

How can we tackle higher complexity tasks if we find it difficult to implement solutions for those of lower complexity? My answer is simple. Maintain a consistent and continuous focus on high value, and ensure the message is iterative and redundant with feedback on performance, decrease in costs, and enhanced patient outcomes.

Dr. Auron is the quality improvement and patient safety officer in the department of hospital medicine at the Cleveland Clinic. He also serves as associate professor of medicine and pediatrics in the staff department of hospital medicine and department of pediatric hospital medicine. This article first appeared on the Hospital Leader, SHM’s official blog, at hospitalleader.org.

As fall arrives, new interns are rapidly gaining clinical confidence, and residency recruitment season is ramping up. It’s also time to announce the opening of the SHM Student Hospitalist Scholar Grant Program applications; we are now recruiting our sixth group of scholars for the summer and longitudinal programs.

Since its creation in 2015, the grant has supported 23 students in this incredible opportunity to allow trainees to engage in scholarly work with guidance from a mentor to better understand the practice of hospital medicine and to further grow our robust pipeline.

The 2018-2019 cohort of scholars, Matthew Fallon, Philip Huang, and Erin Rainosek, just concluded their projects and are currently preparing their abstracts for submission for Hospital Medicine 2020, where there is a track for Early-Career Hospitalists. The projects targeted a diverse set of domains, including improving upon the patient experience, readmission quality metrics, geographic cohorting, and clinical documentation integrity – all highly relevant topics for a practicing hospitalist.

Matthew Fallon collaborated with his mentor, Dr. Venkata Andukuri, at Creighton University, to reduce the rate of hospital readmission for patients with heart failure, by analyzing retrospective data in a root cause analysis to identify factors that influence readmission rate, then targeting those directly. They also integrated the patient experience by seeking out patient input as to the challenges they face in the management of their heart failure.

Philip Huang worked with his mentor, Dr. Ethan Kuperman, at the Carver College of Medicine, University of Iowa, to improve geographic localization for hospitalized patients to improve care efficiency. They worked closely with an industrial engineering team to create a workflow model integrated into the hospital EHR to designate patient location and were able to better understand the role that other professions play in improving the health care delivery.

Finally, Erin Rainosek teamed up with her mentor, Dr. Luci Leykum, at the University of Texas Health Science Center at San Antonio, to apply a design thinking strategy to redesign the health care experience for hospitalized patients. She engaged in over 120 hours of patient interviews and ultimately identified key themes that impact the experience of care, which will serve as target areas moving forward.

The student scholars in this cohort gained significant insight into the patient experience and quality issues relevant to the field of hospital medicine. We are proud of their accomplishments and look forward to their future successes and careers in hospital medicine. If you would like to learn more about the experience of our scholars this past summer, they have posted full write-ups on the Future Hospitalist RoundUp blog in HMX, SHM’s online community.

For students interested in becoming scholars, SHM offers two options to eligible medical students – the Summer Program and the Longitudinal Program. Both programs allow students to participate in projects related to quality improvement, patient safety, clinical research or hospital operations, in order to learn more about career paths in hospital medicine. Students will have the opportunity to conduct scholarly work with a mentor in these domains, with the option of participating over the summer during a 6-10-week period or longitudinally throughout the course of a year.

Discover additional benefits and how to apply on the SHM website. Applications will close in late January 2020.

Dr. Gottenborg is director of the Hospitalist Training Program within the Internal Medicine Residency Program at the University of Colorado. Dr. Duckett is assistant professor of medicine at the Medical University of South Carolina.

As fall arrives, new interns are rapidly gaining clinical confidence, and residency recruitment season is ramping up. It’s also time to announce the opening of the SHM Student Hospitalist Scholar Grant Program applications; we are now recruiting our sixth group of scholars for the summer and longitudinal programs.

Since its creation in 2015, the grant has supported 23 students in this incredible opportunity to allow trainees to engage in scholarly work with guidance from a mentor to better understand the practice of hospital medicine and to further grow our robust pipeline.

The 2018-2019 cohort of scholars, Matthew Fallon, Philip Huang, and Erin Rainosek, just concluded their projects and are currently preparing their abstracts for submission for Hospital Medicine 2020, where there is a track for Early-Career Hospitalists. The projects targeted a diverse set of domains, including improving upon the patient experience, readmission quality metrics, geographic cohorting, and clinical documentation integrity – all highly relevant topics for a practicing hospitalist.

Matthew Fallon collaborated with his mentor, Dr. Venkata Andukuri, at Creighton University, to reduce the rate of hospital readmission for patients with heart failure, by analyzing retrospective data in a root cause analysis to identify factors that influence readmission rate, then targeting those directly. They also integrated the patient experience by seeking out patient input as to the challenges they face in the management of their heart failure.

Philip Huang worked with his mentor, Dr. Ethan Kuperman, at the Carver College of Medicine, University of Iowa, to improve geographic localization for hospitalized patients to improve care efficiency. They worked closely with an industrial engineering team to create a workflow model integrated into the hospital EHR to designate patient location and were able to better understand the role that other professions play in improving the health care delivery.

Finally, Erin Rainosek teamed up with her mentor, Dr. Luci Leykum, at the University of Texas Health Science Center at San Antonio, to apply a design thinking strategy to redesign the health care experience for hospitalized patients. She engaged in over 120 hours of patient interviews and ultimately identified key themes that impact the experience of care, which will serve as target areas moving forward.

The student scholars in this cohort gained significant insight into the patient experience and quality issues relevant to the field of hospital medicine. We are proud of their accomplishments and look forward to their future successes and careers in hospital medicine. If you would like to learn more about the experience of our scholars this past summer, they have posted full write-ups on the Future Hospitalist RoundUp blog in HMX, SHM’s online community.

For students interested in becoming scholars, SHM offers two options to eligible medical students – the Summer Program and the Longitudinal Program. Both programs allow students to participate in projects related to quality improvement, patient safety, clinical research or hospital operations, in order to learn more about career paths in hospital medicine. Students will have the opportunity to conduct scholarly work with a mentor in these domains, with the option of participating over the summer during a 6-10-week period or longitudinally throughout the course of a year.

Discover additional benefits and how to apply on the SHM website. Applications will close in late January 2020.

Dr. Gottenborg is director of the Hospitalist Training Program within the Internal Medicine Residency Program at the University of Colorado. Dr. Duckett is assistant professor of medicine at the Medical University of South Carolina.

As fall arrives, new interns are rapidly gaining clinical confidence, and residency recruitment season is ramping up. It’s also time to announce the opening of the SHM Student Hospitalist Scholar Grant Program applications; we are now recruiting our sixth group of scholars for the summer and longitudinal programs.

Since its creation in 2015, the grant has supported 23 students in this incredible opportunity to allow trainees to engage in scholarly work with guidance from a mentor to better understand the practice of hospital medicine and to further grow our robust pipeline.

The 2018-2019 cohort of scholars, Matthew Fallon, Philip Huang, and Erin Rainosek, just concluded their projects and are currently preparing their abstracts for submission for Hospital Medicine 2020, where there is a track for Early-Career Hospitalists. The projects targeted a diverse set of domains, including improving upon the patient experience, readmission quality metrics, geographic cohorting, and clinical documentation integrity – all highly relevant topics for a practicing hospitalist.

Matthew Fallon collaborated with his mentor, Dr. Venkata Andukuri, at Creighton University, to reduce the rate of hospital readmission for patients with heart failure, by analyzing retrospective data in a root cause analysis to identify factors that influence readmission rate, then targeting those directly. They also integrated the patient experience by seeking out patient input as to the challenges they face in the management of their heart failure.

Philip Huang worked with his mentor, Dr. Ethan Kuperman, at the Carver College of Medicine, University of Iowa, to improve geographic localization for hospitalized patients to improve care efficiency. They worked closely with an industrial engineering team to create a workflow model integrated into the hospital EHR to designate patient location and were able to better understand the role that other professions play in improving the health care delivery.

Finally, Erin Rainosek teamed up with her mentor, Dr. Luci Leykum, at the University of Texas Health Science Center at San Antonio, to apply a design thinking strategy to redesign the health care experience for hospitalized patients. She engaged in over 120 hours of patient interviews and ultimately identified key themes that impact the experience of care, which will serve as target areas moving forward.

The student scholars in this cohort gained significant insight into the patient experience and quality issues relevant to the field of hospital medicine. We are proud of their accomplishments and look forward to their future successes and careers in hospital medicine. If you would like to learn more about the experience of our scholars this past summer, they have posted full write-ups on the Future Hospitalist RoundUp blog in HMX, SHM’s online community.

For students interested in becoming scholars, SHM offers two options to eligible medical students – the Summer Program and the Longitudinal Program. Both programs allow students to participate in projects related to quality improvement, patient safety, clinical research or hospital operations, in order to learn more about career paths in hospital medicine. Students will have the opportunity to conduct scholarly work with a mentor in these domains, with the option of participating over the summer during a 6-10-week period or longitudinally throughout the course of a year.

Discover additional benefits and how to apply on the SHM website. Applications will close in late January 2020.

Dr. Gottenborg is director of the Hospitalist Training Program within the Internal Medicine Residency Program at the University of Colorado. Dr. Duckett is assistant professor of medicine at the Medical University of South Carolina.

There is at least one aspect of “Obamacare” that my mother-in-law and I can firmly agree on: Hospitals should not get paid for frequent readmissions.

The Hospital Readmission Reduction Program (HRRP), enacted by the Centers for Medicare & Medicaid Services in 2012 with the goal of penalizing hospitals for excessive readmissions, has great face validity – and noble intentions. Does it also have a potentially disastrous downside?

On one side of the coin, the HRRP has been a remarkable success. It moved the national needle significantly on readmission rates. Yes, there are some caveats about increases in observation status patients and other shifts that could account for some of the difference, but it is fairly uncontroversial that overall, there are fewer 30-day readmissions across the country following initiation of HRRP. That is perhaps encouraging evidence of the potential positive impact that policy can make to drive changes for specific targets.

However, there is also a murkier – and more controversial – side. There have been a number of studies that have suggested reductions in readmission rates may have been associated with an increase in mortality in some patient groups. You discharge a patient and hope they won’t return to the hospital, but perhaps you should be more careful what you actually wish for.

Overall, the evidence of an association between readmissions and mortality has been complicated and conflicting. Headlines have alternately raised alarm about increased deaths and then reassured that there has been no change or perhaps even some concordant improvements in mortality. Not necessarily surprising, considering that these studies are all unavoidably of observational design and use different criteria, datasets and analytic models, which then drive their seemingly conflicting results.

An article published recently in the Journal of Hospital Medicine enters into this fray. The researchers examined the potential association between changes in rates of chronic obstructive pulmonary disease (COPD) readmissions and 30-day mortality following HRRP introduction. While the initial HRRP program and subsequent analyses included patients with heart failure, acute MI, and pneumonia, the program was extended in 2014 to include patients with COPD. So, what happened in this patient group?

Through a number of statistical gymnastics, which as a nonstatistician I am having difficulty truly wrapping my head around, the researchers seem to have found a number of important insights:

• The all-cause 30-day risk-standardized readmission rate declined from 2010 to 2017.
• The all-cause 30-day risk-standardized mortality rate increased from 2010 to 2017, and the rate of increase in mortality appears to be accelerating.
• Hospitals with higher readmission rates prior to COPD readmission penalties had a lower rate of increase in mortalities.
• Hospitals that had a larger decrease in readmission rates had a larger rate of increase in mortality.

These researchers could not evaluate data at the patient level and could not adjust for changes in disease severity. However, taken together, these findings suggest that something bad may be truly happening here.

The authors of this study also point out that the associations with increased mortality have largely been seen in patients with heart failure – and now in patients with COPD – which are both chronic diseases characterized by exacerbations, as opposed to acute MI and pneumonia, which are episodic and treatable. Perhaps in those types of disease, efforts to avoid readmissions may be more universally helpful. Maybe.

Even if it is challenging for me to adjudicate the complicated methods and results of this study, I find it concerning that there is “biological plausibility” for this association. Hospitalists know exactly how this might have happened. Have you heard of the pop-up alerts that fire in the emergency department to let the physicians know that this patient was discharged within the past 30 days? You know that alert is not meant to tell you what to do, but you just might want to consider trying to discharge them or at least place them in observation – use your clinical judgment, if you know what I mean.

Within the past decade, observation units quickly cropped up all over the country, often not staffed by hospitalists nor cardiologists, where patients with decompensated heart failure, chest pain, and/or COPD, can be given Lasix and/or nebulizer treatments – at least just enough to let them walk on back out that door without a hospital admission.

At the end of the day, whether mortality rates have truly increased in the real world, this well-intentioned program seems to have serious issues. As Ashish Jha, MD, wrote in 2018, “Right now, a high-readmission, low-mortality hospital will be penalized at 6-10 times the rate of a low-readmission, high-mortality hospital. The signal from policy makers is clear – readmissions matter a lot more than mortality – and this signal needs to stop.”

Dr. Moriates is a hospitalist, the assistant dean for health care value, and an associate professor of internal medicine at Dell Medical School at University of Texas, Austin. He is also director of implementation initiatives at Costs of Care. This article first appeared on the Hospital Leader, SHM’s official blog, at hospitalleader.org.

There is at least one aspect of “Obamacare” that my mother-in-law and I can firmly agree on: Hospitals should not get paid for frequent readmissions.

The Hospital Readmission Reduction Program (HRRP), enacted by the Centers for Medicare & Medicaid Services in 2012 with the goal of penalizing hospitals for excessive readmissions, has great face validity – and noble intentions. Does it also have a potentially disastrous downside?

On one side of the coin, the HRRP has been a remarkable success. It moved the national needle significantly on readmission rates. Yes, there are some caveats about increases in observation status patients and other shifts that could account for some of the difference, but it is fairly uncontroversial that overall, there are fewer 30-day readmissions across the country following initiation of HRRP. That is perhaps encouraging evidence of the potential positive impact that policy can make to drive changes for specific targets.

However, there is also a murkier – and more controversial – side. There have been a number of studies that have suggested reductions in readmission rates may have been associated with an increase in mortality in some patient groups. You discharge a patient and hope they won’t return to the hospital, but perhaps you should be more careful what you actually wish for.

Overall, the evidence of an association between readmissions and mortality has been complicated and conflicting. Headlines have alternately raised alarm about increased deaths and then reassured that there has been no change or perhaps even some concordant improvements in mortality. Not necessarily surprising, considering that these studies are all unavoidably of observational design and use different criteria, datasets and analytic models, which then drive their seemingly conflicting results.

An article published recently in the Journal of Hospital Medicine enters into this fray. The researchers examined the potential association between changes in rates of chronic obstructive pulmonary disease (COPD) readmissions and 30-day mortality following HRRP introduction. While the initial HRRP program and subsequent analyses included patients with heart failure, acute MI, and pneumonia, the program was extended in 2014 to include patients with COPD. So, what happened in this patient group?

Through a number of statistical gymnastics, which as a nonstatistician I am having difficulty truly wrapping my head around, the researchers seem to have found a number of important insights:

• The all-cause 30-day risk-standardized readmission rate declined from 2010 to 2017.
• The all-cause 30-day risk-standardized mortality rate increased from 2010 to 2017, and the rate of increase in mortality appears to be accelerating.
• Hospitals with higher readmission rates prior to COPD readmission penalties had a lower rate of increase in mortalities.
• Hospitals that had a larger decrease in readmission rates had a larger rate of increase in mortality.

These researchers could not evaluate data at the patient level and could not adjust for changes in disease severity. However, taken together, these findings suggest that something bad may be truly happening here.

The authors of this study also point out that the associations with increased mortality have largely been seen in patients with heart failure – and now in patients with COPD – which are both chronic diseases characterized by exacerbations, as opposed to acute MI and pneumonia, which are episodic and treatable. Perhaps in those types of disease, efforts to avoid readmissions may be more universally helpful. Maybe.

Even if it is challenging for me to adjudicate the complicated methods and results of this study, I find it concerning that there is “biological plausibility” for this association. Hospitalists know exactly how this might have happened. Have you heard of the pop-up alerts that fire in the emergency department to let the physicians know that this patient was discharged within the past 30 days? You know that alert is not meant to tell you what to do, but you just might want to consider trying to discharge them or at least place them in observation – use your clinical judgment, if you know what I mean.

Within the past decade, observation units quickly cropped up all over the country, often not staffed by hospitalists nor cardiologists, where patients with decompensated heart failure, chest pain, and/or COPD, can be given Lasix and/or nebulizer treatments – at least just enough to let them walk on back out that door without a hospital admission.

At the end of the day, whether mortality rates have truly increased in the real world, this well-intentioned program seems to have serious issues. As Ashish Jha, MD, wrote in 2018, “Right now, a high-readmission, low-mortality hospital will be penalized at 6-10 times the rate of a low-readmission, high-mortality hospital. The signal from policy makers is clear – readmissions matter a lot more than mortality – and this signal needs to stop.”

Dr. Moriates is a hospitalist, the assistant dean for health care value, and an associate professor of internal medicine at Dell Medical School at University of Texas, Austin. He is also director of implementation initiatives at Costs of Care. This article first appeared on the Hospital Leader, SHM’s official blog, at hospitalleader.org.

There is at least one aspect of “Obamacare” that my mother-in-law and I can firmly agree on: Hospitals should not get paid for frequent readmissions.

The Hospital Readmission Reduction Program (HRRP), enacted by the Centers for Medicare & Medicaid Services in 2012 with the goal of penalizing hospitals for excessive readmissions, has great face validity – and noble intentions. Does it also have a potentially disastrous downside?

On one side of the coin, the HRRP has been a remarkable success. It moved the national needle significantly on readmission rates. Yes, there are some caveats about increases in observation status patients and other shifts that could account for some of the difference, but it is fairly uncontroversial that overall, there are fewer 30-day readmissions across the country following initiation of HRRP. That is perhaps encouraging evidence of the potential positive impact that policy can make to drive changes for specific targets.

However, there is also a murkier – and more controversial – side. There have been a number of studies that have suggested reductions in readmission rates may have been associated with an increase in mortality in some patient groups. You discharge a patient and hope they won’t return to the hospital, but perhaps you should be more careful what you actually wish for.

Overall, the evidence of an association between readmissions and mortality has been complicated and conflicting. Headlines have alternately raised alarm about increased deaths and then reassured that there has been no change or perhaps even some concordant improvements in mortality. Not necessarily surprising, considering that these studies are all unavoidably of observational design and use different criteria, datasets and analytic models, which then drive their seemingly conflicting results.

An article published recently in the Journal of Hospital Medicine enters into this fray. The researchers examined the potential association between changes in rates of chronic obstructive pulmonary disease (COPD) readmissions and 30-day mortality following HRRP introduction. While the initial HRRP program and subsequent analyses included patients with heart failure, acute MI, and pneumonia, the program was extended in 2014 to include patients with COPD. So, what happened in this patient group?

Through a number of statistical gymnastics, which as a nonstatistician I am having difficulty truly wrapping my head around, the researchers seem to have found a number of important insights:

• The all-cause 30-day risk-standardized readmission rate declined from 2010 to 2017.
• The all-cause 30-day risk-standardized mortality rate increased from 2010 to 2017, and the rate of increase in mortality appears to be accelerating.
• Hospitals with higher readmission rates prior to COPD readmission penalties had a lower rate of increase in mortalities.
• Hospitals that had a larger decrease in readmission rates had a larger rate of increase in mortality.

These researchers could not evaluate data at the patient level and could not adjust for changes in disease severity. However, taken together, these findings suggest that something bad may be truly happening here.

The authors of this study also point out that the associations with increased mortality have largely been seen in patients with heart failure – and now in patients with COPD – which are both chronic diseases characterized by exacerbations, as opposed to acute MI and pneumonia, which are episodic and treatable. Perhaps in those types of disease, efforts to avoid readmissions may be more universally helpful. Maybe.

Even if it is challenging for me to adjudicate the complicated methods and results of this study, I find it concerning that there is “biological plausibility” for this association. Hospitalists know exactly how this might have happened. Have you heard of the pop-up alerts that fire in the emergency department to let the physicians know that this patient was discharged within the past 30 days? You know that alert is not meant to tell you what to do, but you just might want to consider trying to discharge them or at least place them in observation – use your clinical judgment, if you know what I mean.

Within the past decade, observation units quickly cropped up all over the country, often not staffed by hospitalists nor cardiologists, where patients with decompensated heart failure, chest pain, and/or COPD, can be given Lasix and/or nebulizer treatments – at least just enough to let them walk on back out that door without a hospital admission.

At the end of the day, whether mortality rates have truly increased in the real world, this well-intentioned program seems to have serious issues. As Ashish Jha, MD, wrote in 2018, “Right now, a high-readmission, low-mortality hospital will be penalized at 6-10 times the rate of a low-readmission, high-mortality hospital. The signal from policy makers is clear – readmissions matter a lot more than mortality – and this signal needs to stop.”

Dr. Moriates is a hospitalist, the assistant dean for health care value, and an associate professor of internal medicine at Dell Medical School at University of Texas, Austin. He is also director of implementation initiatives at Costs of Care. This article first appeared on the Hospital Leader, SHM’s official blog, at hospitalleader.org.

As many hospitalists know, a frequently deployed approach to quality improvement (QI) is the Plan-Do-Study-Act (PDSA) cycle method. But it comes with challenges, according to a recent paper in BMJ Quality & Safety.

“There is little evidence on the fidelity of PDSA cycles used by frontline teams, nor how to support and improve the method’s use,” according to the authors. They used document analysis and interviews to review 421 PDSA cycles, tracking fidelity over three annual rounds of projects.

The researchers found that modest, statistically significant improvements in PDSA fidelity occurred, but overall fidelity was low.

“Challenges to achieving greater fidelity reflected problems with understanding the PDSA methodology, intention to use and application in practice,” the authors reported. “These problems were exacerbated by assumptions made in the original QI training and support strategies: that PDSA was easy to understand, that teams would be motivated and willing to use PDSA, and that PDSA is easy to apply.”

The study describes several strategies to help improve PDSA cycle fidelity: different project selection process, redesign of training, increased hands-on support, and investment in training quality improvement support staff. “The findings suggest achieving high PDSA fidelity requires a gradual and negotiated process to explore different perspectives and encourage new ways of working,” the authors concluded.

Reference

1. McNicholas C et al. Evolving quality improvement support strategies to improve Plan-Do-Study–Act cycle fidelity: A retrospective mixed-methods study. BMJ Qual Saf. 2019 Mar 18. doi: 10.1136/bmjqs-2017-007605.

As many hospitalists know, a frequently deployed approach to quality improvement (QI) is the Plan-Do-Study-Act (PDSA) cycle method. But it comes with challenges, according to a recent paper in BMJ Quality & Safety.

“There is little evidence on the fidelity of PDSA cycles used by frontline teams, nor how to support and improve the method’s use,” according to the authors. They used document analysis and interviews to review 421 PDSA cycles, tracking fidelity over three annual rounds of projects.

The researchers found that modest, statistically significant improvements in PDSA fidelity occurred, but overall fidelity was low.

“Challenges to achieving greater fidelity reflected problems with understanding the PDSA methodology, intention to use and application in practice,” the authors reported. “These problems were exacerbated by assumptions made in the original QI training and support strategies: that PDSA was easy to understand, that teams would be motivated and willing to use PDSA, and that PDSA is easy to apply.”

The study describes several strategies to help improve PDSA cycle fidelity: different project selection process, redesign of training, increased hands-on support, and investment in training quality improvement support staff. “The findings suggest achieving high PDSA fidelity requires a gradual and negotiated process to explore different perspectives and encourage new ways of working,” the authors concluded.

Reference

1. McNicholas C et al. Evolving quality improvement support strategies to improve Plan-Do-Study–Act cycle fidelity: A retrospective mixed-methods study. BMJ Qual Saf. 2019 Mar 18. doi: 10.1136/bmjqs-2017-007605.

As many hospitalists know, a frequently deployed approach to quality improvement (QI) is the Plan-Do-Study-Act (PDSA) cycle method. But it comes with challenges, according to a recent paper in BMJ Quality & Safety.

“There is little evidence on the fidelity of PDSA cycles used by frontline teams, nor how to support and improve the method’s use,” according to the authors. They used document analysis and interviews to review 421 PDSA cycles, tracking fidelity over three annual rounds of projects.

The researchers found that modest, statistically significant improvements in PDSA fidelity occurred, but overall fidelity was low.

“Challenges to achieving greater fidelity reflected problems with understanding the PDSA methodology, intention to use and application in practice,” the authors reported. “These problems were exacerbated by assumptions made in the original QI training and support strategies: that PDSA was easy to understand, that teams would be motivated and willing to use PDSA, and that PDSA is easy to apply.”

The study describes several strategies to help improve PDSA cycle fidelity: different project selection process, redesign of training, increased hands-on support, and investment in training quality improvement support staff. “The findings suggest achieving high PDSA fidelity requires a gradual and negotiated process to explore different perspectives and encourage new ways of working,” the authors concluded.

Reference

1. McNicholas C et al. Evolving quality improvement support strategies to improve Plan-Do-Study–Act cycle fidelity: A retrospective mixed-methods study. BMJ Qual Saf. 2019 Mar 18. doi: 10.1136/bmjqs-2017-007605.

Emergency department overcrowding is common, and it can result in both increased costs and poor clinical outcomes.

EyeMark/thinkstockphotos.com

“We sought to evaluate the impact and safety of hospitalist-directed transfers on patients boarding in the ER as a means to alleviate overcrowding,” said Yihan Chen, MD, MPH, of the University of California, Los Angeles. “High inpatient census has been shown to impair ER throughput by increasing the number of ER ‘boarders,’ which creates a suboptimal care environment for practicing hospitalists. For example, some studies have shown associations with delays in medical decision making when admitted patients remain and receive care in the emergency department.”

Dr. Chen was the lead author of an abstract describing a chart review on 1,016 admissions to the hospitalist service. About half remained at the reference hospital and half were transferred to a nearby affiliate hospital.

In analyzing the data, the researchers’ top takeaway was the many benefits for the transferred patients. “Hospitalist-directed transfer and direct admission of stable ER patients to an affiliate facility with greater bed availability is associated with shorter ER lengths of stay, fewer adverse events, and lower rates of readmission within 30 days of hospitalization,” Dr. Chen said. “Having a system in place to transfer patients to an affiliate hospital with lower census is a way to improve flow.”

Hospitalists have a unique opportunity to take on a triage role in the ED to safely and effectively decrease ED overcrowding and throughput, improve resource utilization at the hospital level, and allow for other hospitalists at their institution to optimize patient care on the inpatient ward rather than in the ED, Dr. Chen said.

“Health systems privileged to have more than one facility should consider an intra–health system transfer process lead by triage hospitalists to identify stable patients who can be directly admitted to the off-site, affiliate hospital,” she said. “By improving patient throughput, hospitalists would play a critical role in relieving institutional stressors, impacting cost and quality of care, and enhancing clinical outcomes.”

Reference

1. Chen Y et al. Hospitalist-Directed Transfers Improve Emergency Room Length of Stay. Hospital Medicine 2018, Abstract 12. Accessed April 3, 2019.

Emergency department overcrowding is common, and it can result in both increased costs and poor clinical outcomes.

EyeMark/thinkstockphotos.com

“We sought to evaluate the impact and safety of hospitalist-directed transfers on patients boarding in the ER as a means to alleviate overcrowding,” said Yihan Chen, MD, MPH, of the University of California, Los Angeles. “High inpatient census has been shown to impair ER throughput by increasing the number of ER ‘boarders,’ which creates a suboptimal care environment for practicing hospitalists. For example, some studies have shown associations with delays in medical decision making when admitted patients remain and receive care in the emergency department.”

Dr. Chen was the lead author of an abstract describing a chart review on 1,016 admissions to the hospitalist service. About half remained at the reference hospital and half were transferred to a nearby affiliate hospital.

In analyzing the data, the researchers’ top takeaway was the many benefits for the transferred patients. “Hospitalist-directed transfer and direct admission of stable ER patients to an affiliate facility with greater bed availability is associated with shorter ER lengths of stay, fewer adverse events, and lower rates of readmission within 30 days of hospitalization,” Dr. Chen said. “Having a system in place to transfer patients to an affiliate hospital with lower census is a way to improve flow.”

Hospitalists have a unique opportunity to take on a triage role in the ED to safely and effectively decrease ED overcrowding and throughput, improve resource utilization at the hospital level, and allow for other hospitalists at their institution to optimize patient care on the inpatient ward rather than in the ED, Dr. Chen said.

“Health systems privileged to have more than one facility should consider an intra–health system transfer process lead by triage hospitalists to identify stable patients who can be directly admitted to the off-site, affiliate hospital,” she said. “By improving patient throughput, hospitalists would play a critical role in relieving institutional stressors, impacting cost and quality of care, and enhancing clinical outcomes.”

Reference

1. Chen Y et al. Hospitalist-Directed Transfers Improve Emergency Room Length of Stay. Hospital Medicine 2018, Abstract 12. Accessed April 3, 2019.

Emergency department overcrowding is common, and it can result in both increased costs and poor clinical outcomes.

EyeMark/thinkstockphotos.com

“We sought to evaluate the impact and safety of hospitalist-directed transfers on patients boarding in the ER as a means to alleviate overcrowding,” said Yihan Chen, MD, MPH, of the University of California, Los Angeles. “High inpatient census has been shown to impair ER throughput by increasing the number of ER ‘boarders,’ which creates a suboptimal care environment for practicing hospitalists. For example, some studies have shown associations with delays in medical decision making when admitted patients remain and receive care in the emergency department.”

Dr. Chen was the lead author of an abstract describing a chart review on 1,016 admissions to the hospitalist service. About half remained at the reference hospital and half were transferred to a nearby affiliate hospital.

In analyzing the data, the researchers’ top takeaway was the many benefits for the transferred patients. “Hospitalist-directed transfer and direct admission of stable ER patients to an affiliate facility with greater bed availability is associated with shorter ER lengths of stay, fewer adverse events, and lower rates of readmission within 30 days of hospitalization,” Dr. Chen said. “Having a system in place to transfer patients to an affiliate hospital with lower census is a way to improve flow.”

Hospitalists have a unique opportunity to take on a triage role in the ED to safely and effectively decrease ED overcrowding and throughput, improve resource utilization at the hospital level, and allow for other hospitalists at their institution to optimize patient care on the inpatient ward rather than in the ED, Dr. Chen said.

“Health systems privileged to have more than one facility should consider an intra–health system transfer process lead by triage hospitalists to identify stable patients who can be directly admitted to the off-site, affiliate hospital,” she said. “By improving patient throughput, hospitalists would play a critical role in relieving institutional stressors, impacting cost and quality of care, and enhancing clinical outcomes.”

Reference

1. Chen Y et al. Hospitalist-Directed Transfers Improve Emergency Room Length of Stay. Hospital Medicine 2018, Abstract 12. Accessed April 3, 2019.