Quality

Session presenters

Surekha Bhamidipati, MD, FACP; Preetham Talari, MD, FACP, SFHM; Mark V. Williams, MD, FACP, MHM
 

Session title

Interprofessional rounds: What’s the right way?
 

Session summary

Interprofessional or multidisciplinary rounds involve all members of the care delivery team, including physicians, nurses, case managers, social workers, pharmacists, nurse facilitators, and of course, patients. The primary goal for these rounds is patient-centered care, and to improve communication among the health care team members, as well as with patients and their families.

At HM19, Dr. Preetham Talari and Dr. Mark Williams of the University of Kentucky, and Dr. Surekha Bhamidipati of Christiana Care Health System in Newark, Del., discussed their system-based efforts to try to implement interprofessional rounds, and the role of these rounds in improving patient outcome measures.

The presenters noted that the purpose of these rounds is effective communication and efficient patient care. As shown by multiple studies, there is significant impact in team member satisfaction, decrease in length of stay,¹ reduction in adverse events² and improvement in patient experience.³ They emphasized the importance of implementing these rounds at the bedside, so that patients and families can be engaged in the patient’s care, thereby improving closed communication among the team and the patient. These rounds always offer an opportunity for the patient to ask questions of multiple health care team members as they are gathered together at the same time.

The University of Kentucky named these rounds the “Interprofessional Teamwork Innovation Model (ITIM),” to promote communication and patient-centered coordinated care. Their model showed a significant reduction in readmission rates, and no increase in costs despite adding pharmacy and case managers to the rounds.

Dr. Bhamidipati described how Christiana Care Health System designed multidisciplinary rounds based on the application of Team STEPPS 2.0, a teamwork system developed by the Department of Defense and the Agency for Healthcare Research and Quality to improve the institutional collaboration and communication relating to patient safety.

The Christiana Care model is based on a few principles of team structure, communication, leadership, situation monitoring, and mutual support. The interprofessional team was trained and observed, and a short video recording was made. This video was used as an educational tool in coaching the rest of the team. Dr. Bhamidipati described the importance of interprofessional leaders as coaches to train other team members, and highlighted the engagement of unit leaders in successfully implementing these rounds. The Christiana Care team used its informational technology system to collect real-time data, which was then used for team review.

In summary, the presenters from both the University of Kentucky and Christiana Care highlighted the importance of interprofessional rounds, as well as the need for continued measurement of process and outcome metrics.
 

Dr. Jonnalagadda is a physician advisor, and Dr. Medarametla is medical director, Hospital Medicine, at Baystate Medical Center, Springfield, Mass.

References

1. Yoo JW et al. Effects of an internal medicine floor interdisciplinary team on hospital and clinical outcomes of seniors with acute medical illness. Geriatr Gerontol Int. 2013 Oct;13(4):942-8. doi: 10.1111/ggi.12035. Epub 2013 Feb 26.

2. O’Leary KJ et al. Structured interdisciplinary rounds in a medical teaching unit: improving patient safety. Arch Intern Med. 2011 Apr 11;171(7):678-84. doi: 10.1001/archinternmed.2011.128.

3. Ratelle JT et al. Implementing bedside rounds to improve patient-centred outcomes: a systematic review. BMJ Qual Saf. 2019;28:317-326.

Session presenters

Surekha Bhamidipati, MD, FACP; Preetham Talari, MD, FACP, SFHM; Mark V. Williams, MD, FACP, MHM
 

Session title

Interprofessional rounds: What’s the right way?
 

Session summary

Interprofessional or multidisciplinary rounds involve all members of the care delivery team, including physicians, nurses, case managers, social workers, pharmacists, nurse facilitators, and of course, patients. The primary goal for these rounds is patient-centered care, and to improve communication among the health care team members, as well as with patients and their families.

At HM19, Dr. Preetham Talari and Dr. Mark Williams of the University of Kentucky, and Dr. Surekha Bhamidipati of Christiana Care Health System in Newark, Del., discussed their system-based efforts to try to implement interprofessional rounds, and the role of these rounds in improving patient outcome measures.

The presenters noted that the purpose of these rounds is effective communication and efficient patient care. As shown by multiple studies, there is significant impact in team member satisfaction, decrease in length of stay,¹ reduction in adverse events² and improvement in patient experience.³ They emphasized the importance of implementing these rounds at the bedside, so that patients and families can be engaged in the patient’s care, thereby improving closed communication among the team and the patient. These rounds always offer an opportunity for the patient to ask questions of multiple health care team members as they are gathered together at the same time.

The University of Kentucky named these rounds the “Interprofessional Teamwork Innovation Model (ITIM),” to promote communication and patient-centered coordinated care. Their model showed a significant reduction in readmission rates, and no increase in costs despite adding pharmacy and case managers to the rounds.

Dr. Bhamidipati described how Christiana Care Health System designed multidisciplinary rounds based on the application of Team STEPPS 2.0, a teamwork system developed by the Department of Defense and the Agency for Healthcare Research and Quality to improve the institutional collaboration and communication relating to patient safety.

The Christiana Care model is based on a few principles of team structure, communication, leadership, situation monitoring, and mutual support. The interprofessional team was trained and observed, and a short video recording was made. This video was used as an educational tool in coaching the rest of the team. Dr. Bhamidipati described the importance of interprofessional leaders as coaches to train other team members, and highlighted the engagement of unit leaders in successfully implementing these rounds. The Christiana Care team used its informational technology system to collect real-time data, which was then used for team review.

In summary, the presenters from both the University of Kentucky and Christiana Care highlighted the importance of interprofessional rounds, as well as the need for continued measurement of process and outcome metrics.
 

Dr. Jonnalagadda is a physician advisor, and Dr. Medarametla is medical director, Hospital Medicine, at Baystate Medical Center, Springfield, Mass.

References

1. Yoo JW et al. Effects of an internal medicine floor interdisciplinary team on hospital and clinical outcomes of seniors with acute medical illness. Geriatr Gerontol Int. 2013 Oct;13(4):942-8. doi: 10.1111/ggi.12035. Epub 2013 Feb 26.

2. O’Leary KJ et al. Structured interdisciplinary rounds in a medical teaching unit: improving patient safety. Arch Intern Med. 2011 Apr 11;171(7):678-84. doi: 10.1001/archinternmed.2011.128.

3. Ratelle JT et al. Implementing bedside rounds to improve patient-centred outcomes: a systematic review. BMJ Qual Saf. 2019;28:317-326.

Session presenters

Surekha Bhamidipati, MD, FACP; Preetham Talari, MD, FACP, SFHM; Mark V. Williams, MD, FACP, MHM
 

Session title

Interprofessional rounds: What’s the right way?
 

Session summary

Interprofessional or multidisciplinary rounds involve all members of the care delivery team, including physicians, nurses, case managers, social workers, pharmacists, nurse facilitators, and of course, patients. The primary goal for these rounds is patient-centered care, and to improve communication among the health care team members, as well as with patients and their families.

At HM19, Dr. Preetham Talari and Dr. Mark Williams of the University of Kentucky, and Dr. Surekha Bhamidipati of Christiana Care Health System in Newark, Del., discussed their system-based efforts to try to implement interprofessional rounds, and the role of these rounds in improving patient outcome measures.

The presenters noted that the purpose of these rounds is effective communication and efficient patient care. As shown by multiple studies, there is significant impact in team member satisfaction, decrease in length of stay,¹ reduction in adverse events² and improvement in patient experience.³ They emphasized the importance of implementing these rounds at the bedside, so that patients and families can be engaged in the patient’s care, thereby improving closed communication among the team and the patient. These rounds always offer an opportunity for the patient to ask questions of multiple health care team members as they are gathered together at the same time.

The University of Kentucky named these rounds the “Interprofessional Teamwork Innovation Model (ITIM),” to promote communication and patient-centered coordinated care. Their model showed a significant reduction in readmission rates, and no increase in costs despite adding pharmacy and case managers to the rounds.

Dr. Bhamidipati described how Christiana Care Health System designed multidisciplinary rounds based on the application of Team STEPPS 2.0, a teamwork system developed by the Department of Defense and the Agency for Healthcare Research and Quality to improve the institutional collaboration and communication relating to patient safety.

The Christiana Care model is based on a few principles of team structure, communication, leadership, situation monitoring, and mutual support. The interprofessional team was trained and observed, and a short video recording was made. This video was used as an educational tool in coaching the rest of the team. Dr. Bhamidipati described the importance of interprofessional leaders as coaches to train other team members, and highlighted the engagement of unit leaders in successfully implementing these rounds. The Christiana Care team used its informational technology system to collect real-time data, which was then used for team review.

In summary, the presenters from both the University of Kentucky and Christiana Care highlighted the importance of interprofessional rounds, as well as the need for continued measurement of process and outcome metrics.
 

Dr. Jonnalagadda is a physician advisor, and Dr. Medarametla is medical director, Hospital Medicine, at Baystate Medical Center, Springfield, Mass.

References

1. Yoo JW et al. Effects of an internal medicine floor interdisciplinary team on hospital and clinical outcomes of seniors with acute medical illness. Geriatr Gerontol Int. 2013 Oct;13(4):942-8. doi: 10.1111/ggi.12035. Epub 2013 Feb 26.

2. O’Leary KJ et al. Structured interdisciplinary rounds in a medical teaching unit: improving patient safety. Arch Intern Med. 2011 Apr 11;171(7):678-84. doi: 10.1001/archinternmed.2011.128.

3. Ratelle JT et al. Implementing bedside rounds to improve patient-centred outcomes: a systematic review. BMJ Qual Saf. 2019;28:317-326.

“To me, teamwork is the beauty of our sport, where you have five acting as one. You become selfless.” – Mike Krzyzewski

High-performing teams plan, communicate, reflect, and take action together. Teamwork can transform seemingly impossible tasks into opportunities for people to come together and create value.

The increasing complexity of health care makes team-based care necessary to achieve successful health outcomes for patients. At the Brooklyn (N.Y.) Hospital Center, a 464-bed care center, we transformed the model of care on the medical wards into a geographic, unit-based team model. Here we describe our journey – the successes, the challenges, and the opportunities for growth.

Previous model

In the previous care model on our medical wards, no set structures were in place. Teams would travel to multiple wards throughout the hospital to see the patients they were rounding on. Each floor had its own set of social workers and case managers, therefore a hospital medicine team routinely dealt with more than eight social workers and case managers to address their patients’ needs in a single day.

Multidisciplinary rounds for all medical patients were held at 11 a.m. in a room located a significant distance away from the medical wards. All case managers and social workers would sit in this room from 11 a.m. until noon, and teams would travel to that room to discuss their patients.

Many challenges were identified in this model, including a lack of communication, a de-emphasis on teamwork, and a design that did not take physician workflows into account resulting in low efficiency. Thus, these challenges sparked a desire to create a more effective and team-based methodology of accomplishing excellence in delivery of clinical care. Dr. Pendharkar, having worked primarily in centers with unit-based care, determined that a geographic, unit-based model of care could transform care delivery at the Brooklyn Hospital Center.
 

Looking ahead

The efforts for transforming the vision of geographic, unit-based teams into a reality started by gathering all stakeholders together to unite for a common mission. Initial meetings were held with all parties including social workers, case managers, residents, nursing staff, bed board and attending physicians in internal medicine, and the emergency department.

The vision of a geographic, unit-based team was shared and explained to all team members. Exercises in LEAN methodology were conducted, including one-piece flow exercises, to highlight the possibilities of what could be accomplished through teamwork. Once support for the vision was in place from all parties, the logistics were addressed.

The biggest challenge to overcome was how to place all of one team’s patients on a singular medical ward. In our hospital, a medical ward holds anywhere from 30 to 33 patients. Each hospital medicine team, of which there are many, typically carries 20-23 patients. We created a blueprint to map out the floor to which each team and attending would be assigned. Next, we partnered with both IT and bed board to design an admission order set that specified the particular geographic location that a team and attending were associated with so that patients could be placed accordingly from the ED.

It was important for the ED doctors, bed board, and the internal medicine residents to understand these changes because all of these parties were involved in the initial admitting process. Dr. Pendharkar and Dr. Malieckal provided all groups with in-person training on how the logistics of the system would unfold. Noon conference lectures were also held to explain the vision to residents.

Over 3 weeks, the first ward we chose to implement our model on slowly accumulated the patients of one team – this was the gradual trickle phase. We then selected a “re-set” date. On the re-set date, it was determined that all patients would go to the team that was assigned to that floor, with the exception of any private attendings’ patients.

On the day before the re-set date, time was spent ensuring that all hand-offs were safe. Dr. Pendharkar and Dr. Malieckal spoke with every intern and team that would be handing off and/or receiving patients as a result of the re-set policy. The goal was to ensure that on that date a ward had close to 100% of its patients belonging to the team/attending that was assigned to that area.
 

The good

Once we began our geographic, unit-based model, our rounding process was transformed.

Now, our morning rounds were joined by the bedside nurse, case manager, social worker, clinical pharmacy, and nutrition in addition to the core team. The entire team went from room to room on one ward rounding on all 20 to 25 patients back to back, which created an unparalleled level of efficiency and a forum for effective communication lasting throughout the day.

The bad

The biggest challenges that we are working through with this model are hand-offs and transfer of patients from one team to another. Sometimes, it happens that one team’s patient will wind up on a floor that is the designated floor of another team because of bed availability. We continue to work with bed board to address this issue. We want to minimize transfers and hand-offs to promote continuity and have to balance that with the need for geographic location. With clear communication, hospital collaboration from bed board and safe hand-off methods, this problem can be safely addressed.

Conclusions

The experience of implementing the unit-based team model has been an eye-opening journey. One thing that stands out is that, in an increasingly complex health care system, design thinking is critical.

Design thinking takes into consideration the needs of those who are using a system. In this case, patients and health care workers including doctors, nurses, case managers, and social workers are the end users of the health care system. All parties are utilizing the health care system to optimize patient health. Therefore, we must create systems that are easy to navigate and use by patients and health care workers so that they can ensure the success of patients.

Unit-based teams offer a basic framework to optimize the inpatient system to facilitate better workflow. In our system, it allowed us to optimize communications between health care workers and also between health care workers and patients. It allowed team members to work in close proximity to better share ideas with each other.

We spent a significant amount of time upfront earning the support of all of the disciplines for this effort. We had support from all leaders within the organization and continue to make our case for this model by sharing metrics and holding forums to discuss the process.

Initial data show a marked improvement in many domains of HCAHPS scores. Our frontline staff, including attendings, residents, nursing, case managers, and social workers, also continue to support this effort since it has a positive impact on their workflow and improves their workday quality. One nurse mentioned specifically, “in my 30 years at this hospital I have never seen people work together so well.”

To sustain this effort, we continue to have regular meetings, and there are new features that we would like to add to the program. For example, we are working with our IT group to ensure that each unit-based team will have dashboards available to incorporate real time, actionable data into daily workflows.

We are excited by the potential of our high-performing teams to highlight the patient experience, placing the patient at the center for care, decision making, and rounding. Health care is a team sport, and anytime you build something where all teams are playing together and approaching the finish line as a unit, you will never go wrong!
 

Dr. Pendharkar is division chief of hospital medicine at the Brooklyn (N.Y.) Hospital Center, medical director of inpatient services and director of quality for the department of medicine at the Brooklyn Hospital Center and assistant professor of medicine, Icahn School of Medicine at Mount Sinai, New York. Dr. Malieckal is chief resident, internal medicine, at the Brooklyn Hospital Center. Dr. Gasperino is chair, department of medicine; vice president for critical care, perioperative, and hospital medicine; and associate chief medical officer at the Brooklyn Hospital Center.

“To me, teamwork is the beauty of our sport, where you have five acting as one. You become selfless.” – Mike Krzyzewski

High-performing teams plan, communicate, reflect, and take action together. Teamwork can transform seemingly impossible tasks into opportunities for people to come together and create value.

The increasing complexity of health care makes team-based care necessary to achieve successful health outcomes for patients. At the Brooklyn (N.Y.) Hospital Center, a 464-bed care center, we transformed the model of care on the medical wards into a geographic, unit-based team model. Here we describe our journey – the successes, the challenges, and the opportunities for growth.

Previous model

In the previous care model on our medical wards, no set structures were in place. Teams would travel to multiple wards throughout the hospital to see the patients they were rounding on. Each floor had its own set of social workers and case managers, therefore a hospital medicine team routinely dealt with more than eight social workers and case managers to address their patients’ needs in a single day.

Multidisciplinary rounds for all medical patients were held at 11 a.m. in a room located a significant distance away from the medical wards. All case managers and social workers would sit in this room from 11 a.m. until noon, and teams would travel to that room to discuss their patients.

Many challenges were identified in this model, including a lack of communication, a de-emphasis on teamwork, and a design that did not take physician workflows into account resulting in low efficiency. Thus, these challenges sparked a desire to create a more effective and team-based methodology of accomplishing excellence in delivery of clinical care. Dr. Pendharkar, having worked primarily in centers with unit-based care, determined that a geographic, unit-based model of care could transform care delivery at the Brooklyn Hospital Center.
 

Looking ahead

The efforts for transforming the vision of geographic, unit-based teams into a reality started by gathering all stakeholders together to unite for a common mission. Initial meetings were held with all parties including social workers, case managers, residents, nursing staff, bed board and attending physicians in internal medicine, and the emergency department.

The vision of a geographic, unit-based team was shared and explained to all team members. Exercises in LEAN methodology were conducted, including one-piece flow exercises, to highlight the possibilities of what could be accomplished through teamwork. Once support for the vision was in place from all parties, the logistics were addressed.

The biggest challenge to overcome was how to place all of one team’s patients on a singular medical ward. In our hospital, a medical ward holds anywhere from 30 to 33 patients. Each hospital medicine team, of which there are many, typically carries 20-23 patients. We created a blueprint to map out the floor to which each team and attending would be assigned. Next, we partnered with both IT and bed board to design an admission order set that specified the particular geographic location that a team and attending were associated with so that patients could be placed accordingly from the ED.

It was important for the ED doctors, bed board, and the internal medicine residents to understand these changes because all of these parties were involved in the initial admitting process. Dr. Pendharkar and Dr. Malieckal provided all groups with in-person training on how the logistics of the system would unfold. Noon conference lectures were also held to explain the vision to residents.

Over 3 weeks, the first ward we chose to implement our model on slowly accumulated the patients of one team – this was the gradual trickle phase. We then selected a “re-set” date. On the re-set date, it was determined that all patients would go to the team that was assigned to that floor, with the exception of any private attendings’ patients.

On the day before the re-set date, time was spent ensuring that all hand-offs were safe. Dr. Pendharkar and Dr. Malieckal spoke with every intern and team that would be handing off and/or receiving patients as a result of the re-set policy. The goal was to ensure that on that date a ward had close to 100% of its patients belonging to the team/attending that was assigned to that area.
 

The good

Once we began our geographic, unit-based model, our rounding process was transformed.

Now, our morning rounds were joined by the bedside nurse, case manager, social worker, clinical pharmacy, and nutrition in addition to the core team. The entire team went from room to room on one ward rounding on all 20 to 25 patients back to back, which created an unparalleled level of efficiency and a forum for effective communication lasting throughout the day.

The bad

The biggest challenges that we are working through with this model are hand-offs and transfer of patients from one team to another. Sometimes, it happens that one team’s patient will wind up on a floor that is the designated floor of another team because of bed availability. We continue to work with bed board to address this issue. We want to minimize transfers and hand-offs to promote continuity and have to balance that with the need for geographic location. With clear communication, hospital collaboration from bed board and safe hand-off methods, this problem can be safely addressed.

Conclusions

The experience of implementing the unit-based team model has been an eye-opening journey. One thing that stands out is that, in an increasingly complex health care system, design thinking is critical.

Design thinking takes into consideration the needs of those who are using a system. In this case, patients and health care workers including doctors, nurses, case managers, and social workers are the end users of the health care system. All parties are utilizing the health care system to optimize patient health. Therefore, we must create systems that are easy to navigate and use by patients and health care workers so that they can ensure the success of patients.

Unit-based teams offer a basic framework to optimize the inpatient system to facilitate better workflow. In our system, it allowed us to optimize communications between health care workers and also between health care workers and patients. It allowed team members to work in close proximity to better share ideas with each other.

We spent a significant amount of time upfront earning the support of all of the disciplines for this effort. We had support from all leaders within the organization and continue to make our case for this model by sharing metrics and holding forums to discuss the process.

Initial data show a marked improvement in many domains of HCAHPS scores. Our frontline staff, including attendings, residents, nursing, case managers, and social workers, also continue to support this effort since it has a positive impact on their workflow and improves their workday quality. One nurse mentioned specifically, “in my 30 years at this hospital I have never seen people work together so well.”

To sustain this effort, we continue to have regular meetings, and there are new features that we would like to add to the program. For example, we are working with our IT group to ensure that each unit-based team will have dashboards available to incorporate real time, actionable data into daily workflows.

We are excited by the potential of our high-performing teams to highlight the patient experience, placing the patient at the center for care, decision making, and rounding. Health care is a team sport, and anytime you build something where all teams are playing together and approaching the finish line as a unit, you will never go wrong!
 

Dr. Pendharkar is division chief of hospital medicine at the Brooklyn (N.Y.) Hospital Center, medical director of inpatient services and director of quality for the department of medicine at the Brooklyn Hospital Center and assistant professor of medicine, Icahn School of Medicine at Mount Sinai, New York. Dr. Malieckal is chief resident, internal medicine, at the Brooklyn Hospital Center. Dr. Gasperino is chair, department of medicine; vice president for critical care, perioperative, and hospital medicine; and associate chief medical officer at the Brooklyn Hospital Center.

“To me, teamwork is the beauty of our sport, where you have five acting as one. You become selfless.” – Mike Krzyzewski

High-performing teams plan, communicate, reflect, and take action together. Teamwork can transform seemingly impossible tasks into opportunities for people to come together and create value.

The increasing complexity of health care makes team-based care necessary to achieve successful health outcomes for patients. At the Brooklyn (N.Y.) Hospital Center, a 464-bed care center, we transformed the model of care on the medical wards into a geographic, unit-based team model. Here we describe our journey – the successes, the challenges, and the opportunities for growth.

Previous model

In the previous care model on our medical wards, no set structures were in place. Teams would travel to multiple wards throughout the hospital to see the patients they were rounding on. Each floor had its own set of social workers and case managers, therefore a hospital medicine team routinely dealt with more than eight social workers and case managers to address their patients’ needs in a single day.

Multidisciplinary rounds for all medical patients were held at 11 a.m. in a room located a significant distance away from the medical wards. All case managers and social workers would sit in this room from 11 a.m. until noon, and teams would travel to that room to discuss their patients.

Many challenges were identified in this model, including a lack of communication, a de-emphasis on teamwork, and a design that did not take physician workflows into account resulting in low efficiency. Thus, these challenges sparked a desire to create a more effective and team-based methodology of accomplishing excellence in delivery of clinical care. Dr. Pendharkar, having worked primarily in centers with unit-based care, determined that a geographic, unit-based model of care could transform care delivery at the Brooklyn Hospital Center.
 

Looking ahead

The efforts for transforming the vision of geographic, unit-based teams into a reality started by gathering all stakeholders together to unite for a common mission. Initial meetings were held with all parties including social workers, case managers, residents, nursing staff, bed board and attending physicians in internal medicine, and the emergency department.

The vision of a geographic, unit-based team was shared and explained to all team members. Exercises in LEAN methodology were conducted, including one-piece flow exercises, to highlight the possibilities of what could be accomplished through teamwork. Once support for the vision was in place from all parties, the logistics were addressed.

The biggest challenge to overcome was how to place all of one team’s patients on a singular medical ward. In our hospital, a medical ward holds anywhere from 30 to 33 patients. Each hospital medicine team, of which there are many, typically carries 20-23 patients. We created a blueprint to map out the floor to which each team and attending would be assigned. Next, we partnered with both IT and bed board to design an admission order set that specified the particular geographic location that a team and attending were associated with so that patients could be placed accordingly from the ED.

It was important for the ED doctors, bed board, and the internal medicine residents to understand these changes because all of these parties were involved in the initial admitting process. Dr. Pendharkar and Dr. Malieckal provided all groups with in-person training on how the logistics of the system would unfold. Noon conference lectures were also held to explain the vision to residents.

Over 3 weeks, the first ward we chose to implement our model on slowly accumulated the patients of one team – this was the gradual trickle phase. We then selected a “re-set” date. On the re-set date, it was determined that all patients would go to the team that was assigned to that floor, with the exception of any private attendings’ patients.

On the day before the re-set date, time was spent ensuring that all hand-offs were safe. Dr. Pendharkar and Dr. Malieckal spoke with every intern and team that would be handing off and/or receiving patients as a result of the re-set policy. The goal was to ensure that on that date a ward had close to 100% of its patients belonging to the team/attending that was assigned to that area.
 

The good

Once we began our geographic, unit-based model, our rounding process was transformed.

Now, our morning rounds were joined by the bedside nurse, case manager, social worker, clinical pharmacy, and nutrition in addition to the core team. The entire team went from room to room on one ward rounding on all 20 to 25 patients back to back, which created an unparalleled level of efficiency and a forum for effective communication lasting throughout the day.

The bad

The biggest challenges that we are working through with this model are hand-offs and transfer of patients from one team to another. Sometimes, it happens that one team’s patient will wind up on a floor that is the designated floor of another team because of bed availability. We continue to work with bed board to address this issue. We want to minimize transfers and hand-offs to promote continuity and have to balance that with the need for geographic location. With clear communication, hospital collaboration from bed board and safe hand-off methods, this problem can be safely addressed.

Conclusions

The experience of implementing the unit-based team model has been an eye-opening journey. One thing that stands out is that, in an increasingly complex health care system, design thinking is critical.

Design thinking takes into consideration the needs of those who are using a system. In this case, patients and health care workers including doctors, nurses, case managers, and social workers are the end users of the health care system. All parties are utilizing the health care system to optimize patient health. Therefore, we must create systems that are easy to navigate and use by patients and health care workers so that they can ensure the success of patients.

Unit-based teams offer a basic framework to optimize the inpatient system to facilitate better workflow. In our system, it allowed us to optimize communications between health care workers and also between health care workers and patients. It allowed team members to work in close proximity to better share ideas with each other.

We spent a significant amount of time upfront earning the support of all of the disciplines for this effort. We had support from all leaders within the organization and continue to make our case for this model by sharing metrics and holding forums to discuss the process.

Initial data show a marked improvement in many domains of HCAHPS scores. Our frontline staff, including attendings, residents, nursing, case managers, and social workers, also continue to support this effort since it has a positive impact on their workflow and improves their workday quality. One nurse mentioned specifically, “in my 30 years at this hospital I have never seen people work together so well.”

To sustain this effort, we continue to have regular meetings, and there are new features that we would like to add to the program. For example, we are working with our IT group to ensure that each unit-based team will have dashboards available to incorporate real time, actionable data into daily workflows.

We are excited by the potential of our high-performing teams to highlight the patient experience, placing the patient at the center for care, decision making, and rounding. Health care is a team sport, and anytime you build something where all teams are playing together and approaching the finish line as a unit, you will never go wrong!
 

Dr. Pendharkar is division chief of hospital medicine at the Brooklyn (N.Y.) Hospital Center, medical director of inpatient services and director of quality for the department of medicine at the Brooklyn Hospital Center and assistant professor of medicine, Icahn School of Medicine at Mount Sinai, New York. Dr. Malieckal is chief resident, internal medicine, at the Brooklyn Hospital Center. Dr. Gasperino is chair, department of medicine; vice president for critical care, perioperative, and hospital medicine; and associate chief medical officer at the Brooklyn Hospital Center.

Quality improvement (QI) is essential to the advancement of medicine. QI differs from research as it focuses on already proven knowledge and aims to make quick, sustainable change in local health care systems. Community hospitals may not have organized quality improvement initiatives and often rely on individual hospitalists to be their champions.

Although there are resources for quality improvement projects, initiating a project can seem daunting to a hospitalist. Our aim is to equip the community hospitalist with basic skills to initiate their own successful project. We present our “Top 10” tips to review.



1. Start small: Many quality improvement ideas include grandiose changes that require a large buy-in or worse, more money. When starting a QI project, you need to consider low-cost, high-impact projects. Even the smallest projects can make considerable change. Focus on ideas that require only one or two improvement cycles to implement. Understand your hospital culture, flow, and processes, and then pick a project that is reasonable.

Projects can be as simple as decreasing the number of daily labs ordered by your hospitalist group. Projects that are small could still improve patient satisfaction and decrease costs. Listen to your colleagues, if they are discussing an issue, turn this into an idea! As you learn the culture of your hospital you will be able to tackle larger projects. Plus, it gets your name out there!

2. Establish buy-in: Surround yourself with champions of your cause. Properly identifying and engaging key players is paramount to a successful QI project. First, start with your hospital administration, and garner their support by aligning your project with the goals and objectives that the administration leaders have identified to be important for your institution. Next, select a motivated multidisciplinary team. When choosing your team, be sure to include a representative from the various stakeholders, that is, the individuals who have a variety of hospital roles likely to be affected by the outcome of the project. Stakeholders ensure the success of the project because they have a fundamental understanding of how the project will influence workflow, can predict issues before they arise, and often become empowered to make changes that directly influence their work.

Lastly, include at least one well-respected and highly influential member on your team. Change is always hard, and this person’s support and endorsement of the project, can often move mountains when challenges arise.

5. Remove waste: When determining QI projects, consider focusing on health care waste. Many of the current processes at our institutions have redundancies that add unhealthy time, effort, and inefficiency to our days that can not only impede patient care but also can lead to burnout. When outlining a project idea, consider mapping the process in your interested area to identify those redundancies and inefficiencies. Consider focusing on these instead of building an entirely new process. Improving inefficiencies also can help with provider buy-in with process changes, especially if this helps in improving their everyday frustrations.

6. Express your values: Create a sense of urgency around the problem you are trying to solve. Educate your colleagues to understand the depth of the QI initiative and its impact on their ability to care for patients and patient safety. Express genuine interest in improving your colleagues’ ability to care for patients and improve their days.

Sharing your passion about your project allows people to understand your vested interest in improving the system. This will inspire team members to lead the way to change and encourage colleagues to adopt the recommended changes.

7. Recognize and reward your team: Involve “champions” in every process change. Identify people who are part of your team and ensure they feel valued. Recognition and acknowledgment will allow people to feel more involved and to gain their buy-in. When it comes to results or progress, consider your group’s dynamics. If they are competitive, consider posting progress results on a publicly displayed run chart. If your group is less likely to be motivated by competition, hold individual meetings to help show progress. This is a crucial dynamic to understand, because creating a competitive environment may alienate some members of your group. Remember, the final result is not to blame those lagging behind but to encourage everyone to find the best pathway to success.

8. Be okay with failure: Celebrate your failures because failure is a chance to learn. Every failure is an educational opportunity to understand what not to do, or a chance to gain insight into a process that did not work.

Be a divergent thinker. Start considering problems as part of the path to solution, rather than a barrier in the way. Be open to change and learn from your mistakes. Don’t just be okay with your failures, own them. This will lead to trust with your team members and show your commitment.

9. Finish: This is key. You must finish your project. Even if you anticipate that the project will fail, you should see the project through to its completion. This proves both you and the process of QI are valid and worthwhile; you have to see results and share them with others.

Completing your project also shows your colleagues that you are resilient, committed, and dedicated. Completing a QI project, even with disappointing results, is a success in and of itself. In the end, it is most important to remember to show progress, not perfection.

10. Create sustainability: When your QI project is finished, you need to decide if the changes are sustainable. Some projects show small change and do not need permanent implementation, rather reminders over time. Other projects may be sustainable with EHR or organizational changes. Once you have successful results, your goal should be to find a way to ensure that the process stays in place over time. This is where all your hard work establishing buy-in comes in handy. Your team is more likely to create sustainable change with the hard work you forged through following these key tips.

These Top 10 tips are a hospitalist’s starting point to begin making changes at their own community hospital. Your motivation and effort in making quality change will not go unnoticed. Small ideas will open doors for larger, more sustainable QI projects. Remember, a failure just means a new idea for the next cycle! Enjoy the process of working collaboratively with your hospital on improving quality. Good luck!

Dr. Astik is a hospitalist and instructor of medicine at Northwestern Memorial Hospital, Chicago. Dr. Corbett is a hospitalist and assistant professor at the University of Oklahoma, Tulsa. Dr. Patel is a hospitalist and assistant professor at the University of Colorado, Denver. Dr. Ronan is a hospitalist and associate professor at Christus St. Vincent Regional Medical Center, Santa Fe, NM.

Quality improvement (QI) is essential to the advancement of medicine. QI differs from research as it focuses on already proven knowledge and aims to make quick, sustainable change in local health care systems. Community hospitals may not have organized quality improvement initiatives and often rely on individual hospitalists to be their champions.

Although there are resources for quality improvement projects, initiating a project can seem daunting to a hospitalist. Our aim is to equip the community hospitalist with basic skills to initiate their own successful project. We present our “Top 10” tips to review.



1. Start small: Many quality improvement ideas include grandiose changes that require a large buy-in or worse, more money. When starting a QI project, you need to consider low-cost, high-impact projects. Even the smallest projects can make considerable change. Focus on ideas that require only one or two improvement cycles to implement. Understand your hospital culture, flow, and processes, and then pick a project that is reasonable.

Projects can be as simple as decreasing the number of daily labs ordered by your hospitalist group. Projects that are small could still improve patient satisfaction and decrease costs. Listen to your colleagues, if they are discussing an issue, turn this into an idea! As you learn the culture of your hospital you will be able to tackle larger projects. Plus, it gets your name out there!

2. Establish buy-in: Surround yourself with champions of your cause. Properly identifying and engaging key players is paramount to a successful QI project. First, start with your hospital administration, and garner their support by aligning your project with the goals and objectives that the administration leaders have identified to be important for your institution. Next, select a motivated multidisciplinary team. When choosing your team, be sure to include a representative from the various stakeholders, that is, the individuals who have a variety of hospital roles likely to be affected by the outcome of the project. Stakeholders ensure the success of the project because they have a fundamental understanding of how the project will influence workflow, can predict issues before they arise, and often become empowered to make changes that directly influence their work.

Lastly, include at least one well-respected and highly influential member on your team. Change is always hard, and this person’s support and endorsement of the project, can often move mountains when challenges arise.

5. Remove waste: When determining QI projects, consider focusing on health care waste. Many of the current processes at our institutions have redundancies that add unhealthy time, effort, and inefficiency to our days that can not only impede patient care but also can lead to burnout. When outlining a project idea, consider mapping the process in your interested area to identify those redundancies and inefficiencies. Consider focusing on these instead of building an entirely new process. Improving inefficiencies also can help with provider buy-in with process changes, especially if this helps in improving their everyday frustrations.

6. Express your values: Create a sense of urgency around the problem you are trying to solve. Educate your colleagues to understand the depth of the QI initiative and its impact on their ability to care for patients and patient safety. Express genuine interest in improving your colleagues’ ability to care for patients and improve their days.

Sharing your passion about your project allows people to understand your vested interest in improving the system. This will inspire team members to lead the way to change and encourage colleagues to adopt the recommended changes.

7. Recognize and reward your team: Involve “champions” in every process change. Identify people who are part of your team and ensure they feel valued. Recognition and acknowledgment will allow people to feel more involved and to gain their buy-in. When it comes to results or progress, consider your group’s dynamics. If they are competitive, consider posting progress results on a publicly displayed run chart. If your group is less likely to be motivated by competition, hold individual meetings to help show progress. This is a crucial dynamic to understand, because creating a competitive environment may alienate some members of your group. Remember, the final result is not to blame those lagging behind but to encourage everyone to find the best pathway to success.

8. Be okay with failure: Celebrate your failures because failure is a chance to learn. Every failure is an educational opportunity to understand what not to do, or a chance to gain insight into a process that did not work.

Be a divergent thinker. Start considering problems as part of the path to solution, rather than a barrier in the way. Be open to change and learn from your mistakes. Don’t just be okay with your failures, own them. This will lead to trust with your team members and show your commitment.

9. Finish: This is key. You must finish your project. Even if you anticipate that the project will fail, you should see the project through to its completion. This proves both you and the process of QI are valid and worthwhile; you have to see results and share them with others.

Completing your project also shows your colleagues that you are resilient, committed, and dedicated. Completing a QI project, even with disappointing results, is a success in and of itself. In the end, it is most important to remember to show progress, not perfection.

10. Create sustainability: When your QI project is finished, you need to decide if the changes are sustainable. Some projects show small change and do not need permanent implementation, rather reminders over time. Other projects may be sustainable with EHR or organizational changes. Once you have successful results, your goal should be to find a way to ensure that the process stays in place over time. This is where all your hard work establishing buy-in comes in handy. Your team is more likely to create sustainable change with the hard work you forged through following these key tips.

These Top 10 tips are a hospitalist’s starting point to begin making changes at their own community hospital. Your motivation and effort in making quality change will not go unnoticed. Small ideas will open doors for larger, more sustainable QI projects. Remember, a failure just means a new idea for the next cycle! Enjoy the process of working collaboratively with your hospital on improving quality. Good luck!

Dr. Astik is a hospitalist and instructor of medicine at Northwestern Memorial Hospital, Chicago. Dr. Corbett is a hospitalist and assistant professor at the University of Oklahoma, Tulsa. Dr. Patel is a hospitalist and assistant professor at the University of Colorado, Denver. Dr. Ronan is a hospitalist and associate professor at Christus St. Vincent Regional Medical Center, Santa Fe, NM.

Quality improvement (QI) is essential to the advancement of medicine. QI differs from research as it focuses on already proven knowledge and aims to make quick, sustainable change in local health care systems. Community hospitals may not have organized quality improvement initiatives and often rely on individual hospitalists to be their champions.

Although there are resources for quality improvement projects, initiating a project can seem daunting to a hospitalist. Our aim is to equip the community hospitalist with basic skills to initiate their own successful project. We present our “Top 10” tips to review.



1. Start small: Many quality improvement ideas include grandiose changes that require a large buy-in or worse, more money. When starting a QI project, you need to consider low-cost, high-impact projects. Even the smallest projects can make considerable change. Focus on ideas that require only one or two improvement cycles to implement. Understand your hospital culture, flow, and processes, and then pick a project that is reasonable.

Projects can be as simple as decreasing the number of daily labs ordered by your hospitalist group. Projects that are small could still improve patient satisfaction and decrease costs. Listen to your colleagues, if they are discussing an issue, turn this into an idea! As you learn the culture of your hospital you will be able to tackle larger projects. Plus, it gets your name out there!

2. Establish buy-in: Surround yourself with champions of your cause. Properly identifying and engaging key players is paramount to a successful QI project. First, start with your hospital administration, and garner their support by aligning your project with the goals and objectives that the administration leaders have identified to be important for your institution. Next, select a motivated multidisciplinary team. When choosing your team, be sure to include a representative from the various stakeholders, that is, the individuals who have a variety of hospital roles likely to be affected by the outcome of the project. Stakeholders ensure the success of the project because they have a fundamental understanding of how the project will influence workflow, can predict issues before they arise, and often become empowered to make changes that directly influence their work.

Lastly, include at least one well-respected and highly influential member on your team. Change is always hard, and this person’s support and endorsement of the project, can often move mountains when challenges arise.

5. Remove waste: When determining QI projects, consider focusing on health care waste. Many of the current processes at our institutions have redundancies that add unhealthy time, effort, and inefficiency to our days that can not only impede patient care but also can lead to burnout. When outlining a project idea, consider mapping the process in your interested area to identify those redundancies and inefficiencies. Consider focusing on these instead of building an entirely new process. Improving inefficiencies also can help with provider buy-in with process changes, especially if this helps in improving their everyday frustrations.

6. Express your values: Create a sense of urgency around the problem you are trying to solve. Educate your colleagues to understand the depth of the QI initiative and its impact on their ability to care for patients and patient safety. Express genuine interest in improving your colleagues’ ability to care for patients and improve their days.

Sharing your passion about your project allows people to understand your vested interest in improving the system. This will inspire team members to lead the way to change and encourage colleagues to adopt the recommended changes.

7. Recognize and reward your team: Involve “champions” in every process change. Identify people who are part of your team and ensure they feel valued. Recognition and acknowledgment will allow people to feel more involved and to gain their buy-in. When it comes to results or progress, consider your group’s dynamics. If they are competitive, consider posting progress results on a publicly displayed run chart. If your group is less likely to be motivated by competition, hold individual meetings to help show progress. This is a crucial dynamic to understand, because creating a competitive environment may alienate some members of your group. Remember, the final result is not to blame those lagging behind but to encourage everyone to find the best pathway to success.

8. Be okay with failure: Celebrate your failures because failure is a chance to learn. Every failure is an educational opportunity to understand what not to do, or a chance to gain insight into a process that did not work.

Be a divergent thinker. Start considering problems as part of the path to solution, rather than a barrier in the way. Be open to change and learn from your mistakes. Don’t just be okay with your failures, own them. This will lead to trust with your team members and show your commitment.

9. Finish: This is key. You must finish your project. Even if you anticipate that the project will fail, you should see the project through to its completion. This proves both you and the process of QI are valid and worthwhile; you have to see results and share them with others.

Completing your project also shows your colleagues that you are resilient, committed, and dedicated. Completing a QI project, even with disappointing results, is a success in and of itself. In the end, it is most important to remember to show progress, not perfection.

10. Create sustainability: When your QI project is finished, you need to decide if the changes are sustainable. Some projects show small change and do not need permanent implementation, rather reminders over time. Other projects may be sustainable with EHR or organizational changes. Once you have successful results, your goal should be to find a way to ensure that the process stays in place over time. This is where all your hard work establishing buy-in comes in handy. Your team is more likely to create sustainable change with the hard work you forged through following these key tips.

These Top 10 tips are a hospitalist’s starting point to begin making changes at their own community hospital. Your motivation and effort in making quality change will not go unnoticed. Small ideas will open doors for larger, more sustainable QI projects. Remember, a failure just means a new idea for the next cycle! Enjoy the process of working collaboratively with your hospital on improving quality. Good luck!

Dr. Astik is a hospitalist and instructor of medicine at Northwestern Memorial Hospital, Chicago. Dr. Corbett is a hospitalist and assistant professor at the University of Oklahoma, Tulsa. Dr. Patel is a hospitalist and assistant professor at the University of Colorado, Denver. Dr. Ronan is a hospitalist and associate professor at Christus St. Vincent Regional Medical Center, Santa Fe, NM.

The practice of hospital medicine is rapidly changing. Higher-acuity patients are being admitted to hospitals already struggling with capacity, and hospitalists are being instructed to pay attention to length of stay, improve their documentation and billing, and participate in initiatives to improve hospital throughput, all while delivering high-quality patient care.

As hospitalists and SHM members who are also physician advisors, we have a unique understanding of these pressures. In this article, we answer common questions we receive from hospitalists regarding utilization management, care coordination, clinical documentation, and CMS regulations.
 

Why do physician advisors exist, and what do they do?

A physician advisor is hired by the hospital to act as a liaison between the hospital administration, clinical staff, and support personnel in order to ensure regulatory compliance, advise physicians on medical necessity, and assist hospital leadership in meeting overall organizational goals related to the efficient utilization of health care services.¹

Given their deep knowledge of hospital systems and processes, and ability to collaborate and teach, hospitalists are well-positioned to serve in this capacity. Our primary goal as physician advisors is to help physicians continue to focus on the parts of medicine they enjoy – clinical care, education, quality improvement, research etc. – by helping to demystify complex regulatory requirements and by creating streamlined processes to make following these requirements easier.
 

Why does this matter?

We understand that regulatory and hospital systems issues such as patient class determination, appropriate clinical documentation, and hospital throughput and capacity management can feel tedious, and sometimes overwhelming, to busy hospitalists. While it is easy to attribute these problems solely to hospitals’ desire for increased revenue, these issues directly impact the quality of care we provide to their patients.

In addition, our entire financial system is predicated on appropriate health care resource utilization, financial reimbursement, demonstration of medical acuity, and our impact on the care of a patient. Thus, our ability to advocate for our patients and for ourselves is directly connected with this endeavor. Developing a working knowledge of regulatory and systems issues allows hospitalists to be more engaged in leadership and negotiations and allows us to advocate for resources we deem most important.
 

Why are clinical documentation integrity teams so important?

Accurately and specifically describing how sick your patients are helps ensure that hospitals are reimbursed appropriately, coded data is accurate for research purposes, quality metrics are attributed correctly, and patients receive the correct diagnoses.

Clarification of documentation and/or addressing “clinical validity” of a given diagnosis (e.g., acute hypoxic respiratory failure requires both hypoxia and respiratory distress) may support an increase or result in a decrease in hospital reimbursement. For example, if the reason for a patient’s admission is renal failure, renal failure with true acute hypoxic respiratory failure will be reimbursed at a rate 40% higher than renal failure without the documentation of other conditions that reflect how ill the patient really is. The patient with acute hypoxic respiratory failure (or other major comorbid condition) is genuinely sicker, thus requiring more time (length of stay) and resources (deserved higher reimbursement).
 

What is the two-midnight rule, and why does it matter?

In October of 2013, the Centers for Medicare & Medicaid Services initiated the two-midnight rule, which states a Medicare patient can be an “inpatient” class if the admitting provider determines that 1) the patient requires medically necessary care which cannot be provided outside the hospital and 2) the patient is expected to stay at least 2 midnights in the hospital.

If, at the time of admission, an admitting provider thinks it is likely that the patient may be discharged prior to 2 midnights, then outpatient care with “observation” designation is appropriate. Incorrect patient class assignment may result in significant adverse consequences for hospitals, including improper patient billing, decreased hospital reimbursement, substantial risk for external auditing, violation of Medicare conditions of participation, and even loss of accreditation.
 

Who can I talk to if I have a question about a patient’s class? What should I do if I disagree with the class assigned to my patient?

The Utilization Management team typically consists of nurses and physician advisors specifically trained in UM. This team functions as a liaison between providers and payers (particularly Medicare and Medicaid) regarding medical necessity, appropriateness of care received, and efficiency of health care services.

When it comes to discussions about patient class, start by learning more about why the determination was made. The most common reason for patient class disagreements is simply that the documentation does not reflect the severity of illness or accurately reflect the care the patient is receiving. Your documentation should communicate that your patient needs services that only the hospital can provide, and/or they need monitoring that must be done in the hospital to meet the medical necessity criteria that CMS requires for a patient to be “inpatient” class.

If you disagree with a determination provided by the UM nurse and/or physician advisor, then the case will be presented to the hospital UM committee for further review. Two physicians from the UM committee must review the case and provide their own determinations of patient status, and whichever admission determination has two votes is the one that is appropriate.
 

How do I talk to patients about class determinations?

As media coverage continues about the two-midnight rule and the impact this has on patients, providers should expect more questions about class determination from their patients.

An AARP Bulletin article from 2012 advised patients to “ask [their] own doctor whether observation status is justified … and if not ask him or her to call the hospital to explain the medical reasons why they should be admitted as inpatient.”² Patients should be informed that providers understand the implications of patient class determinations and are making these decisions as outlined by CMS.

We recommend informing patients that the decision about whether a patient is “inpatient” or “outpatient with observation” class is complex and involves taking into consideration a patient’s medical history, the severity of their current medical condition, need for diagnostic testing, and degree of health resource utilization, as well as a provider’s medical opinion of the risk of an adverse event occurring.
 

Is it true that observation patients receive higher hospital bills?

It is a common misperception that a designation of “observation” class means that a patient’s medical bill will be higher than “inpatient” class. In 2016, CMS changed the way observation class patients are billed so that, in most scenarios, patients do not receive a higher hospital bill when placed in “observation” class.

How do I approach a denial from a payer?

Commercial payers review all hospitalizations for medical necessity and appropriateness of care received during a patient’s hospitalization. If you receive notice that all or part of your patient’s hospital stay was denied coverage, you have the option of discussing the case with the medical director of the insurance company – this is called a peer-to-peer discussion.

We recommend reviewing the patient’s case and your documentation of the care you provided prior to the peer to peer, especially since these denials may come weeks to months after you have cared for the patient. Begin your conversation by learning why the insurance company denied coverage of the stay and then provide an accurate portrayal of the acuity of illness of the patient, and the resources your hospital used in caring for them. Consider consulting with your hospital’s physician advisor for other high-yield tips.
 

How can care management help with ‘nonmedical’ hospitalizations?

Care managers are your allies for all patients, especially those with complex discharge needs. Often patients admitted for “nonmedical” reasons do not have the ability to discharge to a skilled nursing facility, long-term care facility, or home due to lack of insurance coverage or resources and/or assistance. Care managers can help you creatively problem solve and coordinate care. Physician advisors are your allies in helping create system-level interventions that might avert some of these “nonmedical” admissions. Consider involving both care managers and physician advisors early in the admission to help navigate social complexities.

How can hospitalists get involved?

According to CMS, the decision on “whether patients will require further treatment as hospital inpatients or if they are able to be discharged from the hospital … can typically be made in less than 48 hours, usually in less than 24 hours.”³ In reality, this is not black and white. The “2 midnights” has brought a host of new challenges for hospitals, hospitalists, and patients to navigate. The Society of Hospital Medicine released an Observation White Paper in 2017 challenging the status quo and proposing comprehensive observation reform.⁴

We encourage hospital medicine providers to more routinely engage with their institutional physician advisors and consider joining the SHM Public Policy Committee to become more involved in advocacy, and/or consider becoming a physician advisor.
 

Dr. Singh is physician advisor for Utilization & CM in the division of hospital medicine at the University of Colorado at Denver, Aurora. Dr. Patel is a hospitalist and assistant professor of medicine at the university. Dr. Anoff is director of clinical operations and director of nights for the Hospital Medicine Group at the University of Colorado at Denver. Dr. Stella is a hospitalist at Denver Health and Hospital Authority and an associate professor of medicine at the university.

References

1. What is a physician advisor? 2017 Oct 9.

2. Barry P. Medicare: Inpatient or outpatient. AARP Bulletin. 2012 Oct.

3. Goldberg TH. The long-term and post-acute care continuum. WV Med J. 2014 Nov-Dec;10(6):24-30.

4. Society of Hospital Medicine Public Policy Committee. The hospital observation care problem. Perspectives and solutions from the Society of Hospital Medicine. 2017 Sep.

The practice of hospital medicine is rapidly changing. Higher-acuity patients are being admitted to hospitals already struggling with capacity, and hospitalists are being instructed to pay attention to length of stay, improve their documentation and billing, and participate in initiatives to improve hospital throughput, all while delivering high-quality patient care.

As hospitalists and SHM members who are also physician advisors, we have a unique understanding of these pressures. In this article, we answer common questions we receive from hospitalists regarding utilization management, care coordination, clinical documentation, and CMS regulations.
 

Why do physician advisors exist, and what do they do?

A physician advisor is hired by the hospital to act as a liaison between the hospital administration, clinical staff, and support personnel in order to ensure regulatory compliance, advise physicians on medical necessity, and assist hospital leadership in meeting overall organizational goals related to the efficient utilization of health care services.¹

Given their deep knowledge of hospital systems and processes, and ability to collaborate and teach, hospitalists are well-positioned to serve in this capacity. Our primary goal as physician advisors is to help physicians continue to focus on the parts of medicine they enjoy – clinical care, education, quality improvement, research etc. – by helping to demystify complex regulatory requirements and by creating streamlined processes to make following these requirements easier.
 

Why does this matter?

We understand that regulatory and hospital systems issues such as patient class determination, appropriate clinical documentation, and hospital throughput and capacity management can feel tedious, and sometimes overwhelming, to busy hospitalists. While it is easy to attribute these problems solely to hospitals’ desire for increased revenue, these issues directly impact the quality of care we provide to their patients.

In addition, our entire financial system is predicated on appropriate health care resource utilization, financial reimbursement, demonstration of medical acuity, and our impact on the care of a patient. Thus, our ability to advocate for our patients and for ourselves is directly connected with this endeavor. Developing a working knowledge of regulatory and systems issues allows hospitalists to be more engaged in leadership and negotiations and allows us to advocate for resources we deem most important.
 

Why are clinical documentation integrity teams so important?

Accurately and specifically describing how sick your patients are helps ensure that hospitals are reimbursed appropriately, coded data is accurate for research purposes, quality metrics are attributed correctly, and patients receive the correct diagnoses.

Clarification of documentation and/or addressing “clinical validity” of a given diagnosis (e.g., acute hypoxic respiratory failure requires both hypoxia and respiratory distress) may support an increase or result in a decrease in hospital reimbursement. For example, if the reason for a patient’s admission is renal failure, renal failure with true acute hypoxic respiratory failure will be reimbursed at a rate 40% higher than renal failure without the documentation of other conditions that reflect how ill the patient really is. The patient with acute hypoxic respiratory failure (or other major comorbid condition) is genuinely sicker, thus requiring more time (length of stay) and resources (deserved higher reimbursement).
 

What is the two-midnight rule, and why does it matter?

In October of 2013, the Centers for Medicare & Medicaid Services initiated the two-midnight rule, which states a Medicare patient can be an “inpatient” class if the admitting provider determines that 1) the patient requires medically necessary care which cannot be provided outside the hospital and 2) the patient is expected to stay at least 2 midnights in the hospital.

If, at the time of admission, an admitting provider thinks it is likely that the patient may be discharged prior to 2 midnights, then outpatient care with “observation” designation is appropriate. Incorrect patient class assignment may result in significant adverse consequences for hospitals, including improper patient billing, decreased hospital reimbursement, substantial risk for external auditing, violation of Medicare conditions of participation, and even loss of accreditation.
 

Who can I talk to if I have a question about a patient’s class? What should I do if I disagree with the class assigned to my patient?

The Utilization Management team typically consists of nurses and physician advisors specifically trained in UM. This team functions as a liaison between providers and payers (particularly Medicare and Medicaid) regarding medical necessity, appropriateness of care received, and efficiency of health care services.

When it comes to discussions about patient class, start by learning more about why the determination was made. The most common reason for patient class disagreements is simply that the documentation does not reflect the severity of illness or accurately reflect the care the patient is receiving. Your documentation should communicate that your patient needs services that only the hospital can provide, and/or they need monitoring that must be done in the hospital to meet the medical necessity criteria that CMS requires for a patient to be “inpatient” class.

If you disagree with a determination provided by the UM nurse and/or physician advisor, then the case will be presented to the hospital UM committee for further review. Two physicians from the UM committee must review the case and provide their own determinations of patient status, and whichever admission determination has two votes is the one that is appropriate.
 

How do I talk to patients about class determinations?

As media coverage continues about the two-midnight rule and the impact this has on patients, providers should expect more questions about class determination from their patients.

An AARP Bulletin article from 2012 advised patients to “ask [their] own doctor whether observation status is justified … and if not ask him or her to call the hospital to explain the medical reasons why they should be admitted as inpatient.”² Patients should be informed that providers understand the implications of patient class determinations and are making these decisions as outlined by CMS.

We recommend informing patients that the decision about whether a patient is “inpatient” or “outpatient with observation” class is complex and involves taking into consideration a patient’s medical history, the severity of their current medical condition, need for diagnostic testing, and degree of health resource utilization, as well as a provider’s medical opinion of the risk of an adverse event occurring.
 

Is it true that observation patients receive higher hospital bills?

It is a common misperception that a designation of “observation” class means that a patient’s medical bill will be higher than “inpatient” class. In 2016, CMS changed the way observation class patients are billed so that, in most scenarios, patients do not receive a higher hospital bill when placed in “observation” class.

How do I approach a denial from a payer?

Commercial payers review all hospitalizations for medical necessity and appropriateness of care received during a patient’s hospitalization. If you receive notice that all or part of your patient’s hospital stay was denied coverage, you have the option of discussing the case with the medical director of the insurance company – this is called a peer-to-peer discussion.

We recommend reviewing the patient’s case and your documentation of the care you provided prior to the peer to peer, especially since these denials may come weeks to months after you have cared for the patient. Begin your conversation by learning why the insurance company denied coverage of the stay and then provide an accurate portrayal of the acuity of illness of the patient, and the resources your hospital used in caring for them. Consider consulting with your hospital’s physician advisor for other high-yield tips.
 

How can care management help with ‘nonmedical’ hospitalizations?

Care managers are your allies for all patients, especially those with complex discharge needs. Often patients admitted for “nonmedical” reasons do not have the ability to discharge to a skilled nursing facility, long-term care facility, or home due to lack of insurance coverage or resources and/or assistance. Care managers can help you creatively problem solve and coordinate care. Physician advisors are your allies in helping create system-level interventions that might avert some of these “nonmedical” admissions. Consider involving both care managers and physician advisors early in the admission to help navigate social complexities.

How can hospitalists get involved?

According to CMS, the decision on “whether patients will require further treatment as hospital inpatients or if they are able to be discharged from the hospital … can typically be made in less than 48 hours, usually in less than 24 hours.”³ In reality, this is not black and white. The “2 midnights” has brought a host of new challenges for hospitals, hospitalists, and patients to navigate. The Society of Hospital Medicine released an Observation White Paper in 2017 challenging the status quo and proposing comprehensive observation reform.⁴

We encourage hospital medicine providers to more routinely engage with their institutional physician advisors and consider joining the SHM Public Policy Committee to become more involved in advocacy, and/or consider becoming a physician advisor.
 

Dr. Singh is physician advisor for Utilization & CM in the division of hospital medicine at the University of Colorado at Denver, Aurora. Dr. Patel is a hospitalist and assistant professor of medicine at the university. Dr. Anoff is director of clinical operations and director of nights for the Hospital Medicine Group at the University of Colorado at Denver. Dr. Stella is a hospitalist at Denver Health and Hospital Authority and an associate professor of medicine at the university.

References

1. What is a physician advisor? 2017 Oct 9.

2. Barry P. Medicare: Inpatient or outpatient. AARP Bulletin. 2012 Oct.

3. Goldberg TH. The long-term and post-acute care continuum. WV Med J. 2014 Nov-Dec;10(6):24-30.

4. Society of Hospital Medicine Public Policy Committee. The hospital observation care problem. Perspectives and solutions from the Society of Hospital Medicine. 2017 Sep.

The practice of hospital medicine is rapidly changing. Higher-acuity patients are being admitted to hospitals already struggling with capacity, and hospitalists are being instructed to pay attention to length of stay, improve their documentation and billing, and participate in initiatives to improve hospital throughput, all while delivering high-quality patient care.

As hospitalists and SHM members who are also physician advisors, we have a unique understanding of these pressures. In this article, we answer common questions we receive from hospitalists regarding utilization management, care coordination, clinical documentation, and CMS regulations.
 

Why do physician advisors exist, and what do they do?

A physician advisor is hired by the hospital to act as a liaison between the hospital administration, clinical staff, and support personnel in order to ensure regulatory compliance, advise physicians on medical necessity, and assist hospital leadership in meeting overall organizational goals related to the efficient utilization of health care services.¹

Given their deep knowledge of hospital systems and processes, and ability to collaborate and teach, hospitalists are well-positioned to serve in this capacity. Our primary goal as physician advisors is to help physicians continue to focus on the parts of medicine they enjoy – clinical care, education, quality improvement, research etc. – by helping to demystify complex regulatory requirements and by creating streamlined processes to make following these requirements easier.
 

Why does this matter?

We understand that regulatory and hospital systems issues such as patient class determination, appropriate clinical documentation, and hospital throughput and capacity management can feel tedious, and sometimes overwhelming, to busy hospitalists. While it is easy to attribute these problems solely to hospitals’ desire for increased revenue, these issues directly impact the quality of care we provide to their patients.

In addition, our entire financial system is predicated on appropriate health care resource utilization, financial reimbursement, demonstration of medical acuity, and our impact on the care of a patient. Thus, our ability to advocate for our patients and for ourselves is directly connected with this endeavor. Developing a working knowledge of regulatory and systems issues allows hospitalists to be more engaged in leadership and negotiations and allows us to advocate for resources we deem most important.
 

Why are clinical documentation integrity teams so important?

Accurately and specifically describing how sick your patients are helps ensure that hospitals are reimbursed appropriately, coded data is accurate for research purposes, quality metrics are attributed correctly, and patients receive the correct diagnoses.

Clarification of documentation and/or addressing “clinical validity” of a given diagnosis (e.g., acute hypoxic respiratory failure requires both hypoxia and respiratory distress) may support an increase or result in a decrease in hospital reimbursement. For example, if the reason for a patient’s admission is renal failure, renal failure with true acute hypoxic respiratory failure will be reimbursed at a rate 40% higher than renal failure without the documentation of other conditions that reflect how ill the patient really is. The patient with acute hypoxic respiratory failure (or other major comorbid condition) is genuinely sicker, thus requiring more time (length of stay) and resources (deserved higher reimbursement).
 

What is the two-midnight rule, and why does it matter?

In October of 2013, the Centers for Medicare & Medicaid Services initiated the two-midnight rule, which states a Medicare patient can be an “inpatient” class if the admitting provider determines that 1) the patient requires medically necessary care which cannot be provided outside the hospital and 2) the patient is expected to stay at least 2 midnights in the hospital.

If, at the time of admission, an admitting provider thinks it is likely that the patient may be discharged prior to 2 midnights, then outpatient care with “observation” designation is appropriate. Incorrect patient class assignment may result in significant adverse consequences for hospitals, including improper patient billing, decreased hospital reimbursement, substantial risk for external auditing, violation of Medicare conditions of participation, and even loss of accreditation.
 

Who can I talk to if I have a question about a patient’s class? What should I do if I disagree with the class assigned to my patient?

The Utilization Management team typically consists of nurses and physician advisors specifically trained in UM. This team functions as a liaison between providers and payers (particularly Medicare and Medicaid) regarding medical necessity, appropriateness of care received, and efficiency of health care services.

When it comes to discussions about patient class, start by learning more about why the determination was made. The most common reason for patient class disagreements is simply that the documentation does not reflect the severity of illness or accurately reflect the care the patient is receiving. Your documentation should communicate that your patient needs services that only the hospital can provide, and/or they need monitoring that must be done in the hospital to meet the medical necessity criteria that CMS requires for a patient to be “inpatient” class.

If you disagree with a determination provided by the UM nurse and/or physician advisor, then the case will be presented to the hospital UM committee for further review. Two physicians from the UM committee must review the case and provide their own determinations of patient status, and whichever admission determination has two votes is the one that is appropriate.
 

How do I talk to patients about class determinations?

As media coverage continues about the two-midnight rule and the impact this has on patients, providers should expect more questions about class determination from their patients.

An AARP Bulletin article from 2012 advised patients to “ask [their] own doctor whether observation status is justified … and if not ask him or her to call the hospital to explain the medical reasons why they should be admitted as inpatient.”² Patients should be informed that providers understand the implications of patient class determinations and are making these decisions as outlined by CMS.

We recommend informing patients that the decision about whether a patient is “inpatient” or “outpatient with observation” class is complex and involves taking into consideration a patient’s medical history, the severity of their current medical condition, need for diagnostic testing, and degree of health resource utilization, as well as a provider’s medical opinion of the risk of an adverse event occurring.
 

Is it true that observation patients receive higher hospital bills?

It is a common misperception that a designation of “observation” class means that a patient’s medical bill will be higher than “inpatient” class. In 2016, CMS changed the way observation class patients are billed so that, in most scenarios, patients do not receive a higher hospital bill when placed in “observation” class.

How do I approach a denial from a payer?

Commercial payers review all hospitalizations for medical necessity and appropriateness of care received during a patient’s hospitalization. If you receive notice that all or part of your patient’s hospital stay was denied coverage, you have the option of discussing the case with the medical director of the insurance company – this is called a peer-to-peer discussion.

We recommend reviewing the patient’s case and your documentation of the care you provided prior to the peer to peer, especially since these denials may come weeks to months after you have cared for the patient. Begin your conversation by learning why the insurance company denied coverage of the stay and then provide an accurate portrayal of the acuity of illness of the patient, and the resources your hospital used in caring for them. Consider consulting with your hospital’s physician advisor for other high-yield tips.
 

How can care management help with ‘nonmedical’ hospitalizations?

Care managers are your allies for all patients, especially those with complex discharge needs. Often patients admitted for “nonmedical” reasons do not have the ability to discharge to a skilled nursing facility, long-term care facility, or home due to lack of insurance coverage or resources and/or assistance. Care managers can help you creatively problem solve and coordinate care. Physician advisors are your allies in helping create system-level interventions that might avert some of these “nonmedical” admissions. Consider involving both care managers and physician advisors early in the admission to help navigate social complexities.

How can hospitalists get involved?

According to CMS, the decision on “whether patients will require further treatment as hospital inpatients or if they are able to be discharged from the hospital … can typically be made in less than 48 hours, usually in less than 24 hours.”³ In reality, this is not black and white. The “2 midnights” has brought a host of new challenges for hospitals, hospitalists, and patients to navigate. The Society of Hospital Medicine released an Observation White Paper in 2017 challenging the status quo and proposing comprehensive observation reform.⁴

We encourage hospital medicine providers to more routinely engage with their institutional physician advisors and consider joining the SHM Public Policy Committee to become more involved in advocacy, and/or consider becoming a physician advisor.
 

Dr. Singh is physician advisor for Utilization & CM in the division of hospital medicine at the University of Colorado at Denver, Aurora. Dr. Patel is a hospitalist and assistant professor of medicine at the university. Dr. Anoff is director of clinical operations and director of nights for the Hospital Medicine Group at the University of Colorado at Denver. Dr. Stella is a hospitalist at Denver Health and Hospital Authority and an associate professor of medicine at the university.

References

1. What is a physician advisor? 2017 Oct 9.

2. Barry P. Medicare: Inpatient or outpatient. AARP Bulletin. 2012 Oct.

3. Goldberg TH. The long-term and post-acute care continuum. WV Med J. 2014 Nov-Dec;10(6):24-30.

4. Society of Hospital Medicine Public Policy Committee. The hospital observation care problem. Perspectives and solutions from the Society of Hospital Medicine. 2017 Sep.

U.S. spending on health care is growing rapidly and expected to reach 19.7% of gross domestic product by 2026.¹ In response, the Centers for Medicare and Medicaid Services and national organizations such as the American Board of Internal Medicine (ABIM) and the American College of Physicians (ACP) have launched initiatives to ensure that the value being delivered to patients is on par with the escalating cost of care.

Over the past 10 years, I have led and advised hundreds of small- and large-scale projects that focused on improving patient care quality and cost. Below, I share what I, along with other leaders in high-value care, have observed that it takes to implement successful and lasting improvements – for the benefit of patients and hospitals.
 

A brief history of high-value care

When compared to other wealthy countries, the United States spends disproportionately more money on health care. In 2016, U.S. health care spending was $3.3 trillion¹, or $10,348 per person.² Hospital care alone was responsible for a third of health spending and amounted to $1.1 trillion in 2016¹. By 2026, national health spending is projected to reach $5.7 trillion¹.

In response to escalating health care costs, CMS and other payers have shifted toward value-based reimbursements that tie payments to health care facilities and clinicians to their performance on selected quality, cost, and efficiency measures. For example, under the CMS Merit-based Incentive Payment System (MIPS), 5% of clinicians’ revenue in 2020 is tied to their 2018 performance in four categories: Quality, Cost, Improvement Activities, and Promoting Interoperability. The percentage of revenue at risk will increase to 9% in 2022, based on 2020 performance.

Rising health care costs put a burden not just on the federal and state budgets, but on individual and family budgets as well. Out-of-pocket spending grew 3.9% in 2016 to $352.5 billion¹ and is expected to increase in the future. High health care costs rightfully bring into question the value individual consumers of health care services are getting in return. If value is defined as the level of benefit achieved for a given cost, what is high-value care? The 2013 Institute of Medicine report³ defined high-value care as “the best care for the patient, with the optimal result for the circumstances, delivered at the right price.” It goes beyond a set of quality and cost measures used by payers to affect provider reimbursement and is driven by day-to-day individual providers’ decisions that affect individual patients’ outcomes and their cost of care.

High-value care has been embraced by national organizations. In 2012, the ABIM Foundation launched the Choosing Wisely initiative to support and promote conversations between clinicians and patients in choosing care that is truly necessary, supported by evidence, and free from harm. The result was an evidence-based list of recommendations from 540 specialty societies, including the Society of Hospital Medicine. The SHM – Adult Hospital Medicine list⁴ features the following “Five things physicians and patients should question”:

• Don’t place, or leave in place, urinary catheters for incontinence or convenience or monitoring of output for non–critically ill patients.
• Don’t prescribe medications for stress ulcer prophylaxis to medical inpatients unless at high risk for GI complications.
• Avoid transfusions of red blood cells for arbitrary hemoglobin or hematocrit thresholds and in the absence of symptoms of active coronary disease, heart failure, or stroke.
• Don’t order continuous telemetry monitoring outside of the ICU without using a protocol that governs continuation.
• Don’t perform repetitive CBC and chemistry testing in the face of clinical and lab stability.

The ACP launched a high-value care initiative that offers learning resources for clinicians and medical educators, clinical guidelines, and best practice advice. In 2012, a workgroup of internists convened by ACP developed a list of 37 clinical situations in which medical tests are commonly used but do not provide high value.⁵ Seven of those situations are applicable to adult hospital medicine.
 

High-value care today: What the experts say

More than 5 years later, what progress have hospitalists made in adopting high-value care practices? To answer this and other questions, I reached out to three national experts in high-value care in hospital medicine: Amit Pahwa, MD, assistant professor of medicine and pediatrics at Johns Hopkins University, Baltimore, and a course director of “Topics in interdisciplinary medicine: High-value health care”; Christopher Petrilli, MD, clinical assistant professor in the department of medicine at New York University Langone Health and clinical lead, Manhattan campus, value-based management; and Charlie Wray, DO, MS, assistant professor of medicine at the University of California in San Francisco and a coauthor of an article on high-value care in hospital medicine published recently in the Journal of General Internal Medicine^6.

The experts agree that awareness of high-value care among practicing physicians and medical trainees has increased in the last few years. Major professional publications have highlighted the topic, including The Journal of Hospital Medicine’s “Things We Do For No Reason” series, JAMA’s “Teachable Moments,” and the American Journal of Medicine’s recurring column dedicated to high-value care practice. Leading teaching institutions have built high-value care curricula as a part of their medical student and resident training. However, widespread adoption has been slow and sometimes difficult.

The barriers to adoption of high-value practices among hospitalists are numerous and deep rooted in historical practices and culture. As Dr. Petrilli said, the “culture of overordering [diagnostic tests] is hard to break.” Hospitalists may not have well-developed relationships with patients, or time to explain why some tests or treatments are unnecessary. There is a lack of cost transparency, including the cost of the tests themselves and the downstream costs of additional tests and follow-ups. The best intended interventions fail to produce durable change unless they are seamlessly integrated into a hospitalist’s daily workflow.
 

Six steps to implementing a successful high-value care initiative

What can hospitalists do to improve the value of care they provide to their patients and hospital partners?

1. Identify high-value care opportunities at your hospital.

Dr. Wray pointed out that “all high-value care is local.” Start by looking at the national guidelines and talking to your senior clinical leaders and colleagues. Review your hospital data to identify opportunities and understand the root causes, including variability among providers.

If you choose to analyze and present provider-specific data, first be transparent on why you are doing that. Your goal is not to tell physicians how to practice or to score them, but instead, to promote adoption of evidence-based high-value care by identifying and discussing provider practice variations, and to generate possible solutions. Second, make sure that the data you present is credible and trustworthy by clearly outlining the data source, time frame, sample size per provider, any inclusion and exclusion criteria, attribution logic, and severity adjustment methodology. Third, expect initial pushback as transparency and change can be scary. But most doctors are inherently competitive and will want to be the best at caring for their patients.
 

2. Assemble the team.

Identify an executive sponsor – a senior clinical executive (for example, the chief medical officer or vice president of medical affairs) whose role is to help engage stakeholders, secure resources, and remove barriers. When assembling the rest of the team, include a representative from each major stakeholder group, but keep the team small enough to be effective. For example, if your project focuses on improving telemetry utilization, seek representation from hospitalists, cardiologists, nurses, utilization managers, and possibly IT. Look for people with the relevant knowledge and experience who are respected by their peers and can influence opinion.

3. Design a sustainable solution.

To be sustainable, a solution must be evidence based, well integrated in provider workflow, and have acceptable impact on daily workload (e.g., additional time per patient). If an estimated impact is significant, you need to discuss adding resources or negotiating trade-offs.

A great example of a sustainable solution, aimed to control overutilization of telemetry and urinary catheters, is the one implemented by Dr. Wray and his team.⁷ They designed an EHR-based “silent” indicator that clearly signaled an active telemetry or urinary catheter order for each patient. Clicking on the indicator directed a provider to a “manage order” screen where she could cancel the order, if necessary.
 

4. Engage providers.

You may design the best solution, but it will not succeed unless it is embraced by others. To engage providers, you must clearly communicate why the change is urgently needed for the benefit of their patients, hospital, or community, and appeal to their minds, hearts, and competitive nature.

For example, if you are focusing on overutilization of urinary catheters, you may share your hospital’s urinary catheter device utilization ratio (# of indwelling catheter days/# patient days) against national benchmarks, or the impact on hospital catheter–associated urinary tract infections (CAUTI) rates to appeal to the physicians’ minds. Often, data alone are not enough to move people to action. You must appeal to their hearts by sharing stories of real patients whose lives were affected by preventable CAUTI. Leverage physicians’ competitive nature by using provider-specific data to compare against their peers to spark a discussion.
 

5. Evaluate impact.

Even before you implement a solution, select metrics to measure impact and set SMART (specific, measurable, achievable, relevant, and time-bound) goals. As your implementation moves forward, do not let up or give up – continue to evaluate impact, remove barriers, refine your solution to get back on track if needed, and constantly communicate to share ongoing project results and lessons learned.

6. Sustain improvements.

Sustainable improvements require well-designed solutions integrated into provider workflow, but that is just the first step. Once you demonstrate the impact, consider including the metric (e.g., telemetry or urinary catheter utilization) in your team and/or individual provider performance dashboard, regularly reviewing and discussing performance during your team meetings to maintain engagement, and if needed, making improvements to get back on track.

Successful adoption of high-value care practices requires a disciplined approach to design and implement solutions that are patient-centric, evidence-based, data-driven and integrated in provider workflow.
 

Dr. Farah is a hospitalist, Physician Advisor, and Lean Six Sigma Black Belt. She is a performance improvement consultant based in Corvallis, Ore., and a member of The Hospitalist’s editorial advisory board.

References

1. From the Centers for Medicare & Medicaid Services: National Health Expenditure Projections 2018-2027.

2. Peterson-Kaiser Health System Tracker: How does health spending in the U.S. compare to other countries?

3. Creating a new culture of care, in “Best care at lower cost: The path to continuously learning health care in America.” (Washington: National Academies Press, 2013, pp. 255-80).

4. Choosing Wisely: SHM – Adult Hospital Medicine; Five things physicians and patients should question.

5. Qaseem A et al. Appropriate use of screening and diagnostic tests to foster high-value, cost-conscious care. Ann Intern Med. 2012 Jan 17;156(2):147-9.

6. Cho HJ et al. Right care in hospital medicine: Co-creation of ten opportunities in overuse and underuse for improving value in hospital medicine. J Gen Intern Med. 2018 Jun;33(6):804-6.

7. Wray CM et al. Improving value by reducing unnecessary telemetry and urinary catheter utilization in hospitalized patients. Am J Med. 2017 Sep;130(9):1037-41.

U.S. spending on health care is growing rapidly and expected to reach 19.7% of gross domestic product by 2026.¹ In response, the Centers for Medicare and Medicaid Services and national organizations such as the American Board of Internal Medicine (ABIM) and the American College of Physicians (ACP) have launched initiatives to ensure that the value being delivered to patients is on par with the escalating cost of care.

Over the past 10 years, I have led and advised hundreds of small- and large-scale projects that focused on improving patient care quality and cost. Below, I share what I, along with other leaders in high-value care, have observed that it takes to implement successful and lasting improvements – for the benefit of patients and hospitals.
 

A brief history of high-value care

When compared to other wealthy countries, the United States spends disproportionately more money on health care. In 2016, U.S. health care spending was $3.3 trillion¹, or $10,348 per person.² Hospital care alone was responsible for a third of health spending and amounted to $1.1 trillion in 2016¹. By 2026, national health spending is projected to reach $5.7 trillion¹.

In response to escalating health care costs, CMS and other payers have shifted toward value-based reimbursements that tie payments to health care facilities and clinicians to their performance on selected quality, cost, and efficiency measures. For example, under the CMS Merit-based Incentive Payment System (MIPS), 5% of clinicians’ revenue in 2020 is tied to their 2018 performance in four categories: Quality, Cost, Improvement Activities, and Promoting Interoperability. The percentage of revenue at risk will increase to 9% in 2022, based on 2020 performance.

Rising health care costs put a burden not just on the federal and state budgets, but on individual and family budgets as well. Out-of-pocket spending grew 3.9% in 2016 to $352.5 billion¹ and is expected to increase in the future. High health care costs rightfully bring into question the value individual consumers of health care services are getting in return. If value is defined as the level of benefit achieved for a given cost, what is high-value care? The 2013 Institute of Medicine report³ defined high-value care as “the best care for the patient, with the optimal result for the circumstances, delivered at the right price.” It goes beyond a set of quality and cost measures used by payers to affect provider reimbursement and is driven by day-to-day individual providers’ decisions that affect individual patients’ outcomes and their cost of care.

High-value care has been embraced by national organizations. In 2012, the ABIM Foundation launched the Choosing Wisely initiative to support and promote conversations between clinicians and patients in choosing care that is truly necessary, supported by evidence, and free from harm. The result was an evidence-based list of recommendations from 540 specialty societies, including the Society of Hospital Medicine. The SHM – Adult Hospital Medicine list⁴ features the following “Five things physicians and patients should question”:

• Don’t place, or leave in place, urinary catheters for incontinence or convenience or monitoring of output for non–critically ill patients.
• Don’t prescribe medications for stress ulcer prophylaxis to medical inpatients unless at high risk for GI complications.
• Avoid transfusions of red blood cells for arbitrary hemoglobin or hematocrit thresholds and in the absence of symptoms of active coronary disease, heart failure, or stroke.
• Don’t order continuous telemetry monitoring outside of the ICU without using a protocol that governs continuation.
• Don’t perform repetitive CBC and chemistry testing in the face of clinical and lab stability.

The ACP launched a high-value care initiative that offers learning resources for clinicians and medical educators, clinical guidelines, and best practice advice. In 2012, a workgroup of internists convened by ACP developed a list of 37 clinical situations in which medical tests are commonly used but do not provide high value.⁵ Seven of those situations are applicable to adult hospital medicine.
 

High-value care today: What the experts say

More than 5 years later, what progress have hospitalists made in adopting high-value care practices? To answer this and other questions, I reached out to three national experts in high-value care in hospital medicine: Amit Pahwa, MD, assistant professor of medicine and pediatrics at Johns Hopkins University, Baltimore, and a course director of “Topics in interdisciplinary medicine: High-value health care”; Christopher Petrilli, MD, clinical assistant professor in the department of medicine at New York University Langone Health and clinical lead, Manhattan campus, value-based management; and Charlie Wray, DO, MS, assistant professor of medicine at the University of California in San Francisco and a coauthor of an article on high-value care in hospital medicine published recently in the Journal of General Internal Medicine^6.

The experts agree that awareness of high-value care among practicing physicians and medical trainees has increased in the last few years. Major professional publications have highlighted the topic, including The Journal of Hospital Medicine’s “Things We Do For No Reason” series, JAMA’s “Teachable Moments,” and the American Journal of Medicine’s recurring column dedicated to high-value care practice. Leading teaching institutions have built high-value care curricula as a part of their medical student and resident training. However, widespread adoption has been slow and sometimes difficult.

The barriers to adoption of high-value practices among hospitalists are numerous and deep rooted in historical practices and culture. As Dr. Petrilli said, the “culture of overordering [diagnostic tests] is hard to break.” Hospitalists may not have well-developed relationships with patients, or time to explain why some tests or treatments are unnecessary. There is a lack of cost transparency, including the cost of the tests themselves and the downstream costs of additional tests and follow-ups. The best intended interventions fail to produce durable change unless they are seamlessly integrated into a hospitalist’s daily workflow.
 

Six steps to implementing a successful high-value care initiative

What can hospitalists do to improve the value of care they provide to their patients and hospital partners?

1. Identify high-value care opportunities at your hospital.

Dr. Wray pointed out that “all high-value care is local.” Start by looking at the national guidelines and talking to your senior clinical leaders and colleagues. Review your hospital data to identify opportunities and understand the root causes, including variability among providers.

If you choose to analyze and present provider-specific data, first be transparent on why you are doing that. Your goal is not to tell physicians how to practice or to score them, but instead, to promote adoption of evidence-based high-value care by identifying and discussing provider practice variations, and to generate possible solutions. Second, make sure that the data you present is credible and trustworthy by clearly outlining the data source, time frame, sample size per provider, any inclusion and exclusion criteria, attribution logic, and severity adjustment methodology. Third, expect initial pushback as transparency and change can be scary. But most doctors are inherently competitive and will want to be the best at caring for their patients.
 

2. Assemble the team.

Identify an executive sponsor – a senior clinical executive (for example, the chief medical officer or vice president of medical affairs) whose role is to help engage stakeholders, secure resources, and remove barriers. When assembling the rest of the team, include a representative from each major stakeholder group, but keep the team small enough to be effective. For example, if your project focuses on improving telemetry utilization, seek representation from hospitalists, cardiologists, nurses, utilization managers, and possibly IT. Look for people with the relevant knowledge and experience who are respected by their peers and can influence opinion.

3. Design a sustainable solution.

To be sustainable, a solution must be evidence based, well integrated in provider workflow, and have acceptable impact on daily workload (e.g., additional time per patient). If an estimated impact is significant, you need to discuss adding resources or negotiating trade-offs.

A great example of a sustainable solution, aimed to control overutilization of telemetry and urinary catheters, is the one implemented by Dr. Wray and his team.⁷ They designed an EHR-based “silent” indicator that clearly signaled an active telemetry or urinary catheter order for each patient. Clicking on the indicator directed a provider to a “manage order” screen where she could cancel the order, if necessary.
 

4. Engage providers.

You may design the best solution, but it will not succeed unless it is embraced by others. To engage providers, you must clearly communicate why the change is urgently needed for the benefit of their patients, hospital, or community, and appeal to their minds, hearts, and competitive nature.

For example, if you are focusing on overutilization of urinary catheters, you may share your hospital’s urinary catheter device utilization ratio (# of indwelling catheter days/# patient days) against national benchmarks, or the impact on hospital catheter–associated urinary tract infections (CAUTI) rates to appeal to the physicians’ minds. Often, data alone are not enough to move people to action. You must appeal to their hearts by sharing stories of real patients whose lives were affected by preventable CAUTI. Leverage physicians’ competitive nature by using provider-specific data to compare against their peers to spark a discussion.
 

5. Evaluate impact.

Even before you implement a solution, select metrics to measure impact and set SMART (specific, measurable, achievable, relevant, and time-bound) goals. As your implementation moves forward, do not let up or give up – continue to evaluate impact, remove barriers, refine your solution to get back on track if needed, and constantly communicate to share ongoing project results and lessons learned.

6. Sustain improvements.

Sustainable improvements require well-designed solutions integrated into provider workflow, but that is just the first step. Once you demonstrate the impact, consider including the metric (e.g., telemetry or urinary catheter utilization) in your team and/or individual provider performance dashboard, regularly reviewing and discussing performance during your team meetings to maintain engagement, and if needed, making improvements to get back on track.

Successful adoption of high-value care practices requires a disciplined approach to design and implement solutions that are patient-centric, evidence-based, data-driven and integrated in provider workflow.
 

Dr. Farah is a hospitalist, Physician Advisor, and Lean Six Sigma Black Belt. She is a performance improvement consultant based in Corvallis, Ore., and a member of The Hospitalist’s editorial advisory board.

References

1. From the Centers for Medicare & Medicaid Services: National Health Expenditure Projections 2018-2027.

2. Peterson-Kaiser Health System Tracker: How does health spending in the U.S. compare to other countries?

3. Creating a new culture of care, in “Best care at lower cost: The path to continuously learning health care in America.” (Washington: National Academies Press, 2013, pp. 255-80).

4. Choosing Wisely: SHM – Adult Hospital Medicine; Five things physicians and patients should question.

5. Qaseem A et al. Appropriate use of screening and diagnostic tests to foster high-value, cost-conscious care. Ann Intern Med. 2012 Jan 17;156(2):147-9.

6. Cho HJ et al. Right care in hospital medicine: Co-creation of ten opportunities in overuse and underuse for improving value in hospital medicine. J Gen Intern Med. 2018 Jun;33(6):804-6.

7. Wray CM et al. Improving value by reducing unnecessary telemetry and urinary catheter utilization in hospitalized patients. Am J Med. 2017 Sep;130(9):1037-41.

U.S. spending on health care is growing rapidly and expected to reach 19.7% of gross domestic product by 2026.¹ In response, the Centers for Medicare and Medicaid Services and national organizations such as the American Board of Internal Medicine (ABIM) and the American College of Physicians (ACP) have launched initiatives to ensure that the value being delivered to patients is on par with the escalating cost of care.

Over the past 10 years, I have led and advised hundreds of small- and large-scale projects that focused on improving patient care quality and cost. Below, I share what I, along with other leaders in high-value care, have observed that it takes to implement successful and lasting improvements – for the benefit of patients and hospitals.
 

A brief history of high-value care

When compared to other wealthy countries, the United States spends disproportionately more money on health care. In 2016, U.S. health care spending was $3.3 trillion¹, or $10,348 per person.² Hospital care alone was responsible for a third of health spending and amounted to $1.1 trillion in 2016¹. By 2026, national health spending is projected to reach $5.7 trillion¹.

In response to escalating health care costs, CMS and other payers have shifted toward value-based reimbursements that tie payments to health care facilities and clinicians to their performance on selected quality, cost, and efficiency measures. For example, under the CMS Merit-based Incentive Payment System (MIPS), 5% of clinicians’ revenue in 2020 is tied to their 2018 performance in four categories: Quality, Cost, Improvement Activities, and Promoting Interoperability. The percentage of revenue at risk will increase to 9% in 2022, based on 2020 performance.

Rising health care costs put a burden not just on the federal and state budgets, but on individual and family budgets as well. Out-of-pocket spending grew 3.9% in 2016 to $352.5 billion¹ and is expected to increase in the future. High health care costs rightfully bring into question the value individual consumers of health care services are getting in return. If value is defined as the level of benefit achieved for a given cost, what is high-value care? The 2013 Institute of Medicine report³ defined high-value care as “the best care for the patient, with the optimal result for the circumstances, delivered at the right price.” It goes beyond a set of quality and cost measures used by payers to affect provider reimbursement and is driven by day-to-day individual providers’ decisions that affect individual patients’ outcomes and their cost of care.

High-value care has been embraced by national organizations. In 2012, the ABIM Foundation launched the Choosing Wisely initiative to support and promote conversations between clinicians and patients in choosing care that is truly necessary, supported by evidence, and free from harm. The result was an evidence-based list of recommendations from 540 specialty societies, including the Society of Hospital Medicine. The SHM – Adult Hospital Medicine list⁴ features the following “Five things physicians and patients should question”:

• Don’t place, or leave in place, urinary catheters for incontinence or convenience or monitoring of output for non–critically ill patients.
• Don’t prescribe medications for stress ulcer prophylaxis to medical inpatients unless at high risk for GI complications.
• Avoid transfusions of red blood cells for arbitrary hemoglobin or hematocrit thresholds and in the absence of symptoms of active coronary disease, heart failure, or stroke.
• Don’t order continuous telemetry monitoring outside of the ICU without using a protocol that governs continuation.
• Don’t perform repetitive CBC and chemistry testing in the face of clinical and lab stability.

The ACP launched a high-value care initiative that offers learning resources for clinicians and medical educators, clinical guidelines, and best practice advice. In 2012, a workgroup of internists convened by ACP developed a list of 37 clinical situations in which medical tests are commonly used but do not provide high value.⁵ Seven of those situations are applicable to adult hospital medicine.
 

High-value care today: What the experts say

More than 5 years later, what progress have hospitalists made in adopting high-value care practices? To answer this and other questions, I reached out to three national experts in high-value care in hospital medicine: Amit Pahwa, MD, assistant professor of medicine and pediatrics at Johns Hopkins University, Baltimore, and a course director of “Topics in interdisciplinary medicine: High-value health care”; Christopher Petrilli, MD, clinical assistant professor in the department of medicine at New York University Langone Health and clinical lead, Manhattan campus, value-based management; and Charlie Wray, DO, MS, assistant professor of medicine at the University of California in San Francisco and a coauthor of an article on high-value care in hospital medicine published recently in the Journal of General Internal Medicine^6.

The experts agree that awareness of high-value care among practicing physicians and medical trainees has increased in the last few years. Major professional publications have highlighted the topic, including The Journal of Hospital Medicine’s “Things We Do For No Reason” series, JAMA’s “Teachable Moments,” and the American Journal of Medicine’s recurring column dedicated to high-value care practice. Leading teaching institutions have built high-value care curricula as a part of their medical student and resident training. However, widespread adoption has been slow and sometimes difficult.

The barriers to adoption of high-value practices among hospitalists are numerous and deep rooted in historical practices and culture. As Dr. Petrilli said, the “culture of overordering [diagnostic tests] is hard to break.” Hospitalists may not have well-developed relationships with patients, or time to explain why some tests or treatments are unnecessary. There is a lack of cost transparency, including the cost of the tests themselves and the downstream costs of additional tests and follow-ups. The best intended interventions fail to produce durable change unless they are seamlessly integrated into a hospitalist’s daily workflow.
 

Six steps to implementing a successful high-value care initiative

What can hospitalists do to improve the value of care they provide to their patients and hospital partners?

1. Identify high-value care opportunities at your hospital.

Dr. Wray pointed out that “all high-value care is local.” Start by looking at the national guidelines and talking to your senior clinical leaders and colleagues. Review your hospital data to identify opportunities and understand the root causes, including variability among providers.

If you choose to analyze and present provider-specific data, first be transparent on why you are doing that. Your goal is not to tell physicians how to practice or to score them, but instead, to promote adoption of evidence-based high-value care by identifying and discussing provider practice variations, and to generate possible solutions. Second, make sure that the data you present is credible and trustworthy by clearly outlining the data source, time frame, sample size per provider, any inclusion and exclusion criteria, attribution logic, and severity adjustment methodology. Third, expect initial pushback as transparency and change can be scary. But most doctors are inherently competitive and will want to be the best at caring for their patients.
 

2. Assemble the team.

Identify an executive sponsor – a senior clinical executive (for example, the chief medical officer or vice president of medical affairs) whose role is to help engage stakeholders, secure resources, and remove barriers. When assembling the rest of the team, include a representative from each major stakeholder group, but keep the team small enough to be effective. For example, if your project focuses on improving telemetry utilization, seek representation from hospitalists, cardiologists, nurses, utilization managers, and possibly IT. Look for people with the relevant knowledge and experience who are respected by their peers and can influence opinion.

3. Design a sustainable solution.

To be sustainable, a solution must be evidence based, well integrated in provider workflow, and have acceptable impact on daily workload (e.g., additional time per patient). If an estimated impact is significant, you need to discuss adding resources or negotiating trade-offs.

A great example of a sustainable solution, aimed to control overutilization of telemetry and urinary catheters, is the one implemented by Dr. Wray and his team.⁷ They designed an EHR-based “silent” indicator that clearly signaled an active telemetry or urinary catheter order for each patient. Clicking on the indicator directed a provider to a “manage order” screen where she could cancel the order, if necessary.
 

4. Engage providers.

You may design the best solution, but it will not succeed unless it is embraced by others. To engage providers, you must clearly communicate why the change is urgently needed for the benefit of their patients, hospital, or community, and appeal to their minds, hearts, and competitive nature.

For example, if you are focusing on overutilization of urinary catheters, you may share your hospital’s urinary catheter device utilization ratio (# of indwelling catheter days/# patient days) against national benchmarks, or the impact on hospital catheter–associated urinary tract infections (CAUTI) rates to appeal to the physicians’ minds. Often, data alone are not enough to move people to action. You must appeal to their hearts by sharing stories of real patients whose lives were affected by preventable CAUTI. Leverage physicians’ competitive nature by using provider-specific data to compare against their peers to spark a discussion.
 

5. Evaluate impact.

Even before you implement a solution, select metrics to measure impact and set SMART (specific, measurable, achievable, relevant, and time-bound) goals. As your implementation moves forward, do not let up or give up – continue to evaluate impact, remove barriers, refine your solution to get back on track if needed, and constantly communicate to share ongoing project results and lessons learned.

6. Sustain improvements.

Sustainable improvements require well-designed solutions integrated into provider workflow, but that is just the first step. Once you demonstrate the impact, consider including the metric (e.g., telemetry or urinary catheter utilization) in your team and/or individual provider performance dashboard, regularly reviewing and discussing performance during your team meetings to maintain engagement, and if needed, making improvements to get back on track.

Successful adoption of high-value care practices requires a disciplined approach to design and implement solutions that are patient-centric, evidence-based, data-driven and integrated in provider workflow.
 

Dr. Farah is a hospitalist, Physician Advisor, and Lean Six Sigma Black Belt. She is a performance improvement consultant based in Corvallis, Ore., and a member of The Hospitalist’s editorial advisory board.

References

1. From the Centers for Medicare & Medicaid Services: National Health Expenditure Projections 2018-2027.

2. Peterson-Kaiser Health System Tracker: How does health spending in the U.S. compare to other countries?

3. Creating a new culture of care, in “Best care at lower cost: The path to continuously learning health care in America.” (Washington: National Academies Press, 2013, pp. 255-80).

4. Choosing Wisely: SHM – Adult Hospital Medicine; Five things physicians and patients should question.

5. Qaseem A et al. Appropriate use of screening and diagnostic tests to foster high-value, cost-conscious care. Ann Intern Med. 2012 Jan 17;156(2):147-9.

6. Cho HJ et al. Right care in hospital medicine: Co-creation of ten opportunities in overuse and underuse for improving value in hospital medicine. J Gen Intern Med. 2018 Jun;33(6):804-6.

7. Wray CM et al. Improving value by reducing unnecessary telemetry and urinary catheter utilization in hospitalized patients. Am J Med. 2017 Sep;130(9):1037-41.

Hospitalists pay attention to length of stay as a measure of hospital efficiency and resource utilization; outliers on that measure – “long stay patients” – who present complex discharges are a barrier to length of stay reduction. To address this challenge, one institution formed a multidisciplinary Long Stay Committee and described the results in an abstract.

The Long Stay Committee is composed of medical directors, the chief quality officer, directors in nursing, directors of case management/social work, hospitalists, risk management, finance, ethics, psychiatry, and directors of rehabilitation. The most complex patient discharges, identified by case management and social work, are brought to the Long Stay Committee.

“Lack of guardianship is one of the most encountered barriers,” according to the authors. “The Long Stay Committee played an integral part in our institution partnering with the local county to form a guardian service board which facilitates guardianship appointments. Other solutions have included working with the patient and support persons to find appropriate discharge levels of care throughout the United States and other countries as well as guiding them through the process to gain the necessary financial resources.”

The authors conclude that the foundation of the committee’s success in coming up with innovative discharge solutions is the broad range of disciplines that attend this committee and the atmosphere of teamwork it creates.

Reference

Heacock A et al. Long Stay Committee finds innovative discharge plans for difficult discharges. Hospital Medicine 2018, Abstract 312. .

Hospitalists pay attention to length of stay as a measure of hospital efficiency and resource utilization; outliers on that measure – “long stay patients” – who present complex discharges are a barrier to length of stay reduction. To address this challenge, one institution formed a multidisciplinary Long Stay Committee and described the results in an abstract.

The Long Stay Committee is composed of medical directors, the chief quality officer, directors in nursing, directors of case management/social work, hospitalists, risk management, finance, ethics, psychiatry, and directors of rehabilitation. The most complex patient discharges, identified by case management and social work, are brought to the Long Stay Committee.

“Lack of guardianship is one of the most encountered barriers,” according to the authors. “The Long Stay Committee played an integral part in our institution partnering with the local county to form a guardian service board which facilitates guardianship appointments. Other solutions have included working with the patient and support persons to find appropriate discharge levels of care throughout the United States and other countries as well as guiding them through the process to gain the necessary financial resources.”

The authors conclude that the foundation of the committee’s success in coming up with innovative discharge solutions is the broad range of disciplines that attend this committee and the atmosphere of teamwork it creates.

Reference

Heacock A et al. Long Stay Committee finds innovative discharge plans for difficult discharges. Hospital Medicine 2018, Abstract 312. .

Hospitalists pay attention to length of stay as a measure of hospital efficiency and resource utilization; outliers on that measure – “long stay patients” – who present complex discharges are a barrier to length of stay reduction. To address this challenge, one institution formed a multidisciplinary Long Stay Committee and described the results in an abstract.

The Long Stay Committee is composed of medical directors, the chief quality officer, directors in nursing, directors of case management/social work, hospitalists, risk management, finance, ethics, psychiatry, and directors of rehabilitation. The most complex patient discharges, identified by case management and social work, are brought to the Long Stay Committee.

“Lack of guardianship is one of the most encountered barriers,” according to the authors. “The Long Stay Committee played an integral part in our institution partnering with the local county to form a guardian service board which facilitates guardianship appointments. Other solutions have included working with the patient and support persons to find appropriate discharge levels of care throughout the United States and other countries as well as guiding them through the process to gain the necessary financial resources.”

The authors conclude that the foundation of the committee’s success in coming up with innovative discharge solutions is the broad range of disciplines that attend this committee and the atmosphere of teamwork it creates.

Reference

Heacock A et al. Long Stay Committee finds innovative discharge plans for difficult discharges. Hospital Medicine 2018, Abstract 312. .

Hospitalists can have a role in helping patients choose and receive high-value care from the vast array of health care choices they face. Helping them use quality and cost reports is one way to do that, according to a recent editorial by Jeffrey T. Kullgren, MD, MS, MPH.

We know that if consumers used public reporting of quality and costs to choose facilities that generate the best health outcomes for the resources utilized, it might improve the overall value of health care spending. But most people choose health care services based on personal recommendations or the requirements of their insurance network. Even if they wanted to use reports of quality or cost, the information in these reports is meant for providers and would likely be unhelpful for consumers.

Research suggests that different presentation of the information could make a difference. “Simpler presentations of information in public reports may be more likely to help consumers choose higher-value providers and facilities,” Dr. Kullgren said.

He concluded that consumers may also need additional incentives, “such as financial incentives to encourage high-value choices or programs that educate consumers about how to use cost and quality information when seeking care,” he said.

There’s an opportunity for hospitalists to help consumers learn to use that information. “This strategy would approach consumerism as a teachable health behavior and could be particularly helpful for consumers with ongoing medical needs who face high cost sharing,” he wrote.

“Some hospitalists may be involved in the implementation of programs to publicly report quality and costs for their institutions,” he said. “Others may treat patients who have chosen hospitals based on publicly reported information, or patients who might be interested in using such information to choose sites of postdischarge outpatient care. In each of these cases, it is important for hospitalists to understand the opportunities and limits of such public reports so as to best help patients receive high-value care.” 

Reference

Kullgren JT. Helping consumers make high value health care choices: The devil is in the details. Health Serv Res. 2018;53(4). http://www.hsr.org/hsr/abstract.jsp?aid=53301961729.

Hospitalists can have a role in helping patients choose and receive high-value care from the vast array of health care choices they face. Helping them use quality and cost reports is one way to do that, according to a recent editorial by Jeffrey T. Kullgren, MD, MS, MPH.

We know that if consumers used public reporting of quality and costs to choose facilities that generate the best health outcomes for the resources utilized, it might improve the overall value of health care spending. But most people choose health care services based on personal recommendations or the requirements of their insurance network. Even if they wanted to use reports of quality or cost, the information in these reports is meant for providers and would likely be unhelpful for consumers.

Research suggests that different presentation of the information could make a difference. “Simpler presentations of information in public reports may be more likely to help consumers choose higher-value providers and facilities,” Dr. Kullgren said.

He concluded that consumers may also need additional incentives, “such as financial incentives to encourage high-value choices or programs that educate consumers about how to use cost and quality information when seeking care,” he said.

There’s an opportunity for hospitalists to help consumers learn to use that information. “This strategy would approach consumerism as a teachable health behavior and could be particularly helpful for consumers with ongoing medical needs who face high cost sharing,” he wrote.

“Some hospitalists may be involved in the implementation of programs to publicly report quality and costs for their institutions,” he said. “Others may treat patients who have chosen hospitals based on publicly reported information, or patients who might be interested in using such information to choose sites of postdischarge outpatient care. In each of these cases, it is important for hospitalists to understand the opportunities and limits of such public reports so as to best help patients receive high-value care.” 

Reference

Kullgren JT. Helping consumers make high value health care choices: The devil is in the details. Health Serv Res. 2018;53(4). http://www.hsr.org/hsr/abstract.jsp?aid=53301961729.

Hospitalists can have a role in helping patients choose and receive high-value care from the vast array of health care choices they face. Helping them use quality and cost reports is one way to do that, according to a recent editorial by Jeffrey T. Kullgren, MD, MS, MPH.

We know that if consumers used public reporting of quality and costs to choose facilities that generate the best health outcomes for the resources utilized, it might improve the overall value of health care spending. But most people choose health care services based on personal recommendations or the requirements of their insurance network. Even if they wanted to use reports of quality or cost, the information in these reports is meant for providers and would likely be unhelpful for consumers.

Research suggests that different presentation of the information could make a difference. “Simpler presentations of information in public reports may be more likely to help consumers choose higher-value providers and facilities,” Dr. Kullgren said.

He concluded that consumers may also need additional incentives, “such as financial incentives to encourage high-value choices or programs that educate consumers about how to use cost and quality information when seeking care,” he said.

There’s an opportunity for hospitalists to help consumers learn to use that information. “This strategy would approach consumerism as a teachable health behavior and could be particularly helpful for consumers with ongoing medical needs who face high cost sharing,” he wrote.

“Some hospitalists may be involved in the implementation of programs to publicly report quality and costs for their institutions,” he said. “Others may treat patients who have chosen hospitals based on publicly reported information, or patients who might be interested in using such information to choose sites of postdischarge outpatient care. In each of these cases, it is important for hospitalists to understand the opportunities and limits of such public reports so as to best help patients receive high-value care.” 

Reference

Kullgren JT. Helping consumers make high value health care choices: The devil is in the details. Health Serv Res. 2018;53(4). http://www.hsr.org/hsr/abstract.jsp?aid=53301961729.

As artificial intelligence (AI) takes on more and more tasks in medical care that mimic human cognition, hospitalists and other physicians will need to adapt to a changing role.

Today AI can identify tuberculosis infections in chest radiographs with almost complete accuracy, diagnose melanoma from images of skin lesions more accurately than dermatologists can, and identify metastatic cells in images of lymph node tissue more accurately than pathologists can. The next 20 years are likely to see further acceleration in the capabilities, according to a recent article by S. Claiborne Johnston, MD, PhD.

“AI will change the practice of medicine. The art of medicine, including all the humanistic components, will only become more important over time. As dean of a medical school, I’m training students who will be practicing in 2065,” Dr. Johnston said. “If I’m not thinking about the future, I’m failing my students and the society they will serve.”

The contributions of AI will shift the emphasis for human caregivers to the caring. Studies have shown that the skills of caring are associated with improved patient outcomes, but most medical schools allocate substantial time in the curriculum to memorization and analysis – tasks that will become less demanding as artificial intelligence improves. The art of caring – communication, empathy, shared decision making, leadership, and team building – is usually a minor part of the medical school curriculum.

Effective leadership and creativity are distant aspirations for artificial intelligence but are growing needs in a system of care that is ever more complex.

At Dr. Johnston’s school, the Dell Medical School at the University of Texas at Austin, they have reduced the duration of basic science instruction to 12 months and emphasized group problem solving, while deemphasizing memorization. This has freed up additional time for instruction in the art of caring, leadership, and creativity.

“Hospitalists should acknowledge the value of caring,” Dr. Johnston said. “They do it every day with every patient. It is important today, and will be more important tomorrow.”
 

Reference

Johnston SC. Anticipating and training the physician of the future: The importance of caring in an age of artificial intelligence. Acad Med. 2018;93(8):1105-6. doi: 10.1097/ACM.0000000000002175.

As artificial intelligence (AI) takes on more and more tasks in medical care that mimic human cognition, hospitalists and other physicians will need to adapt to a changing role.

Today AI can identify tuberculosis infections in chest radiographs with almost complete accuracy, diagnose melanoma from images of skin lesions more accurately than dermatologists can, and identify metastatic cells in images of lymph node tissue more accurately than pathologists can. The next 20 years are likely to see further acceleration in the capabilities, according to a recent article by S. Claiborne Johnston, MD, PhD.

“AI will change the practice of medicine. The art of medicine, including all the humanistic components, will only become more important over time. As dean of a medical school, I’m training students who will be practicing in 2065,” Dr. Johnston said. “If I’m not thinking about the future, I’m failing my students and the society they will serve.”

The contributions of AI will shift the emphasis for human caregivers to the caring. Studies have shown that the skills of caring are associated with improved patient outcomes, but most medical schools allocate substantial time in the curriculum to memorization and analysis – tasks that will become less demanding as artificial intelligence improves. The art of caring – communication, empathy, shared decision making, leadership, and team building – is usually a minor part of the medical school curriculum.

Effective leadership and creativity are distant aspirations for artificial intelligence but are growing needs in a system of care that is ever more complex.

At Dr. Johnston’s school, the Dell Medical School at the University of Texas at Austin, they have reduced the duration of basic science instruction to 12 months and emphasized group problem solving, while deemphasizing memorization. This has freed up additional time for instruction in the art of caring, leadership, and creativity.

“Hospitalists should acknowledge the value of caring,” Dr. Johnston said. “They do it every day with every patient. It is important today, and will be more important tomorrow.”
 

Reference

Johnston SC. Anticipating and training the physician of the future: The importance of caring in an age of artificial intelligence. Acad Med. 2018;93(8):1105-6. doi: 10.1097/ACM.0000000000002175.

As artificial intelligence (AI) takes on more and more tasks in medical care that mimic human cognition, hospitalists and other physicians will need to adapt to a changing role.

Today AI can identify tuberculosis infections in chest radiographs with almost complete accuracy, diagnose melanoma from images of skin lesions more accurately than dermatologists can, and identify metastatic cells in images of lymph node tissue more accurately than pathologists can. The next 20 years are likely to see further acceleration in the capabilities, according to a recent article by S. Claiborne Johnston, MD, PhD.

“AI will change the practice of medicine. The art of medicine, including all the humanistic components, will only become more important over time. As dean of a medical school, I’m training students who will be practicing in 2065,” Dr. Johnston said. “If I’m not thinking about the future, I’m failing my students and the society they will serve.”

The contributions of AI will shift the emphasis for human caregivers to the caring. Studies have shown that the skills of caring are associated with improved patient outcomes, but most medical schools allocate substantial time in the curriculum to memorization and analysis – tasks that will become less demanding as artificial intelligence improves. The art of caring – communication, empathy, shared decision making, leadership, and team building – is usually a minor part of the medical school curriculum.

Effective leadership and creativity are distant aspirations for artificial intelligence but are growing needs in a system of care that is ever more complex.

At Dr. Johnston’s school, the Dell Medical School at the University of Texas at Austin, they have reduced the duration of basic science instruction to 12 months and emphasized group problem solving, while deemphasizing memorization. This has freed up additional time for instruction in the art of caring, leadership, and creativity.

“Hospitalists should acknowledge the value of caring,” Dr. Johnston said. “They do it every day with every patient. It is important today, and will be more important tomorrow.”
 

Reference

Johnston SC. Anticipating and training the physician of the future: The importance of caring in an age of artificial intelligence. Acad Med. 2018;93(8):1105-6. doi: 10.1097/ACM.0000000000002175.

Sanctimonious, self-righteous, discharge saboteurs. These are just a few descriptors I’ve heard hospitalists use to describe my physical therapy (PT) colleagues.

These charged comments come mostly after a hospitalist reads therapy notes and encounters a contradiction to their chosen discharge location for a patient.

I recently met with hospitalists from four different hospitals. They echoed the frustrations of their physician colleagues across the country. The PTs they work with write “the patient requires 24-hour supervision and 3 hours of therapy a day,” or “the patient is unsafe to go home and needs continued therapy at an inpatient rehabilitation center.” The hospitalists in turn want to know “If I discharge the patient home am I liable if the patient falls or has some other negative outcome?” The frustration hospitalists experience is palpable and understandable as their attempts to support a home recovery are often contradicted.
 

Outside the four walls

The transition from fee-for-service to value-based care now calls upon hospitalists to be innovators in managing patients in alternative payment models, such as accountable care organizations, bundled payment programs, and Medicare Advantage plans. Each model looks to support a home recovery whenever possible and prevent readmissions.

Case managers for Medicare Advantage programs routinely review PT notes to inform hospital discharge disposition and post-acute authorization for skilled nursing facility (SNF) admissions and days in SNF. Hospitalists, working with care managers, can follow suit to succeed in alternative payment models. They have the advantage of in-person access to PT colleagues for elaboration and push-back as necessary. For hospitalists, working collaboratively with PTs is crucial to improving the value of care provided as patients transition beyond the four walls of the hospital.
 

The evolution of PT in acute care

Prior to diagnosis-related groups (DRGs), PTs were profit centers for hospitals – rehabilitation departments were well staffed and easily accommodated consults and requests for mobility.

With the advent of DRGs, physical therapy became a cost center, and rehabilitation staffs were reduced. PTs became overextended, were less available for consultations for mobilization, and patients suffered the deleterious effects of immobility. With reduced staffing and a rush to get patients out of the hospital, acute PT practice morphed into evaluating functional status and determining discharge destination.

Now, as members of an aligned health care team, PTs need to facilitate a safe home discharge whenever possible and determine what skilled services a patient needs post-acute stay, not where they should receive them.
 

Discharge disposition and longitudinal recovery

PTs, as experts in function, have a series of “special tests” at their disposal beyond pain, range of motion, and strength assessments. These include: Activity Measure for Post-Acute Care (AM-PAC) or “6-Clicks” Mobility Score, Timed Up and Go, Six-Minute Walk Test, Tinetti, Berg Balance Scale, Modified Barthel Index, Five Times Chair Rise, and Thirty-Second Chair Rise. These are all objective measures of function that can be used to inform discharge disposition and guide longitudinal recovery.

To elaborate on one tool, the 6-Clicks Mobility Score is a validated test that allows PTs to assess basic mobility.^1,2 It rates six functional tasks (hence 6 clicks) that include: turning over in bed, moving from lying to sitting, moving to/from bed to chair, transitioning from sitting to standing from a chair, walking in a hospital room, and climbing three to five steps. These functional tasks are scored based on the amount of assistance needed. The scores, in turn, have been shown to support discharge destination planning.¹ In addition to informing discharge destination decisions, hospitalists and the rest of the health care team can use 6-Clicks to estimate prolonged hospital stays, readmissions, and emergency department (ED) visits.³

Of course, discharge disposition is influenced by many factors in addition to functional status. Hospitalists are the obvious choice to lead the health care team in interpreting relevant data and test results, and to communicate these results to patients and caregivers so together they can decide the most appropriate discharge destination.

I envision a conversation between a fully informed hospitalist and a patient as follows: “Based on your past history, your living situation, all of your test results including labs, x-rays and the functional tests performed by your PT, your potential for a full recovery is good. You have a moderate decline in function with a high likelihood of returning home in the next 7-10 days. I recommend you go to a SNF for high-intensity rehabilitation for 7 days and that the SNF order PT and OT twice a day and walks with nursing every evening.”

This fully informed conversation can only take place if hospitalists are provided clear, concise documentation, including results of objective functional testing, by their physical therapy colleagues.

In conclusion, PTs working in the acute setting need to use validated tests to objectively assess function and educate their hospitalist colleagues on the meaning of these tests. Hospitalists in turn can incorporate these assessments into a discussion of discharge disposition and longitudinal recovery with patients. In this way, hospitalists and physical therapists can work together to achieve patient-centered, high-value care during and following a hospitalization.
 

Ms. Tammany is SVP of clinical strategy & innovation for Remedy Partners, Norwalk, Conn.

References

1. Jette DU et al. AM-PAC “6-Clicks” functional assessment scores predict acute care hospital discharge destination. Phys Ther. 2014 Sep;94(9):1252-61.

2. Jette DU et al. Validity of the AM-PAC “6-Clicks” inpatient daily activity and basic mobility short forms. Phys Ther. 2014 Mar;94(3):379-91.

3. Menendez ME et al. Does “6-Clicks” Day 1 Postoperative Mobility Score Predict Discharge Disposition After Total Hip and Knee Arthroplasties?” J Arthroplasty. 2016 Sep;31(9):1916-20.

Sanctimonious, self-righteous, discharge saboteurs. These are just a few descriptors I’ve heard hospitalists use to describe my physical therapy (PT) colleagues.

These charged comments come mostly after a hospitalist reads therapy notes and encounters a contradiction to their chosen discharge location for a patient.

I recently met with hospitalists from four different hospitals. They echoed the frustrations of their physician colleagues across the country. The PTs they work with write “the patient requires 24-hour supervision and 3 hours of therapy a day,” or “the patient is unsafe to go home and needs continued therapy at an inpatient rehabilitation center.” The hospitalists in turn want to know “If I discharge the patient home am I liable if the patient falls or has some other negative outcome?” The frustration hospitalists experience is palpable and understandable as their attempts to support a home recovery are often contradicted.
 

Outside the four walls

The transition from fee-for-service to value-based care now calls upon hospitalists to be innovators in managing patients in alternative payment models, such as accountable care organizations, bundled payment programs, and Medicare Advantage plans. Each model looks to support a home recovery whenever possible and prevent readmissions.

Case managers for Medicare Advantage programs routinely review PT notes to inform hospital discharge disposition and post-acute authorization for skilled nursing facility (SNF) admissions and days in SNF. Hospitalists, working with care managers, can follow suit to succeed in alternative payment models. They have the advantage of in-person access to PT colleagues for elaboration and push-back as necessary. For hospitalists, working collaboratively with PTs is crucial to improving the value of care provided as patients transition beyond the four walls of the hospital.
 

The evolution of PT in acute care

Prior to diagnosis-related groups (DRGs), PTs were profit centers for hospitals – rehabilitation departments were well staffed and easily accommodated consults and requests for mobility.

With the advent of DRGs, physical therapy became a cost center, and rehabilitation staffs were reduced. PTs became overextended, were less available for consultations for mobilization, and patients suffered the deleterious effects of immobility. With reduced staffing and a rush to get patients out of the hospital, acute PT practice morphed into evaluating functional status and determining discharge destination.

Now, as members of an aligned health care team, PTs need to facilitate a safe home discharge whenever possible and determine what skilled services a patient needs post-acute stay, not where they should receive them.
 

Discharge disposition and longitudinal recovery

PTs, as experts in function, have a series of “special tests” at their disposal beyond pain, range of motion, and strength assessments. These include: Activity Measure for Post-Acute Care (AM-PAC) or “6-Clicks” Mobility Score, Timed Up and Go, Six-Minute Walk Test, Tinetti, Berg Balance Scale, Modified Barthel Index, Five Times Chair Rise, and Thirty-Second Chair Rise. These are all objective measures of function that can be used to inform discharge disposition and guide longitudinal recovery.

To elaborate on one tool, the 6-Clicks Mobility Score is a validated test that allows PTs to assess basic mobility.^1,2 It rates six functional tasks (hence 6 clicks) that include: turning over in bed, moving from lying to sitting, moving to/from bed to chair, transitioning from sitting to standing from a chair, walking in a hospital room, and climbing three to five steps. These functional tasks are scored based on the amount of assistance needed. The scores, in turn, have been shown to support discharge destination planning.¹ In addition to informing discharge destination decisions, hospitalists and the rest of the health care team can use 6-Clicks to estimate prolonged hospital stays, readmissions, and emergency department (ED) visits.³

Of course, discharge disposition is influenced by many factors in addition to functional status. Hospitalists are the obvious choice to lead the health care team in interpreting relevant data and test results, and to communicate these results to patients and caregivers so together they can decide the most appropriate discharge destination.

I envision a conversation between a fully informed hospitalist and a patient as follows: “Based on your past history, your living situation, all of your test results including labs, x-rays and the functional tests performed by your PT, your potential for a full recovery is good. You have a moderate decline in function with a high likelihood of returning home in the next 7-10 days. I recommend you go to a SNF for high-intensity rehabilitation for 7 days and that the SNF order PT and OT twice a day and walks with nursing every evening.”

This fully informed conversation can only take place if hospitalists are provided clear, concise documentation, including results of objective functional testing, by their physical therapy colleagues.

In conclusion, PTs working in the acute setting need to use validated tests to objectively assess function and educate their hospitalist colleagues on the meaning of these tests. Hospitalists in turn can incorporate these assessments into a discussion of discharge disposition and longitudinal recovery with patients. In this way, hospitalists and physical therapists can work together to achieve patient-centered, high-value care during and following a hospitalization.
 

Ms. Tammany is SVP of clinical strategy & innovation for Remedy Partners, Norwalk, Conn.

References

1. Jette DU et al. AM-PAC “6-Clicks” functional assessment scores predict acute care hospital discharge destination. Phys Ther. 2014 Sep;94(9):1252-61.

2. Jette DU et al. Validity of the AM-PAC “6-Clicks” inpatient daily activity and basic mobility short forms. Phys Ther. 2014 Mar;94(3):379-91.

3. Menendez ME et al. Does “6-Clicks” Day 1 Postoperative Mobility Score Predict Discharge Disposition After Total Hip and Knee Arthroplasties?” J Arthroplasty. 2016 Sep;31(9):1916-20.

Sanctimonious, self-righteous, discharge saboteurs. These are just a few descriptors I’ve heard hospitalists use to describe my physical therapy (PT) colleagues.

These charged comments come mostly after a hospitalist reads therapy notes and encounters a contradiction to their chosen discharge location for a patient.

I recently met with hospitalists from four different hospitals. They echoed the frustrations of their physician colleagues across the country. The PTs they work with write “the patient requires 24-hour supervision and 3 hours of therapy a day,” or “the patient is unsafe to go home and needs continued therapy at an inpatient rehabilitation center.” The hospitalists in turn want to know “If I discharge the patient home am I liable if the patient falls or has some other negative outcome?” The frustration hospitalists experience is palpable and understandable as their attempts to support a home recovery are often contradicted.
 

Outside the four walls

The transition from fee-for-service to value-based care now calls upon hospitalists to be innovators in managing patients in alternative payment models, such as accountable care organizations, bundled payment programs, and Medicare Advantage plans. Each model looks to support a home recovery whenever possible and prevent readmissions.

Case managers for Medicare Advantage programs routinely review PT notes to inform hospital discharge disposition and post-acute authorization for skilled nursing facility (SNF) admissions and days in SNF. Hospitalists, working with care managers, can follow suit to succeed in alternative payment models. They have the advantage of in-person access to PT colleagues for elaboration and push-back as necessary. For hospitalists, working collaboratively with PTs is crucial to improving the value of care provided as patients transition beyond the four walls of the hospital.
 

The evolution of PT in acute care

Prior to diagnosis-related groups (DRGs), PTs were profit centers for hospitals – rehabilitation departments were well staffed and easily accommodated consults and requests for mobility.

With the advent of DRGs, physical therapy became a cost center, and rehabilitation staffs were reduced. PTs became overextended, were less available for consultations for mobilization, and patients suffered the deleterious effects of immobility. With reduced staffing and a rush to get patients out of the hospital, acute PT practice morphed into evaluating functional status and determining discharge destination.

Now, as members of an aligned health care team, PTs need to facilitate a safe home discharge whenever possible and determine what skilled services a patient needs post-acute stay, not where they should receive them.
 

Discharge disposition and longitudinal recovery

PTs, as experts in function, have a series of “special tests” at their disposal beyond pain, range of motion, and strength assessments. These include: Activity Measure for Post-Acute Care (AM-PAC) or “6-Clicks” Mobility Score, Timed Up and Go, Six-Minute Walk Test, Tinetti, Berg Balance Scale, Modified Barthel Index, Five Times Chair Rise, and Thirty-Second Chair Rise. These are all objective measures of function that can be used to inform discharge disposition and guide longitudinal recovery.

To elaborate on one tool, the 6-Clicks Mobility Score is a validated test that allows PTs to assess basic mobility.^1,2 It rates six functional tasks (hence 6 clicks) that include: turning over in bed, moving from lying to sitting, moving to/from bed to chair, transitioning from sitting to standing from a chair, walking in a hospital room, and climbing three to five steps. These functional tasks are scored based on the amount of assistance needed. The scores, in turn, have been shown to support discharge destination planning.¹ In addition to informing discharge destination decisions, hospitalists and the rest of the health care team can use 6-Clicks to estimate prolonged hospital stays, readmissions, and emergency department (ED) visits.³

Of course, discharge disposition is influenced by many factors in addition to functional status. Hospitalists are the obvious choice to lead the health care team in interpreting relevant data and test results, and to communicate these results to patients and caregivers so together they can decide the most appropriate discharge destination.

I envision a conversation between a fully informed hospitalist and a patient as follows: “Based on your past history, your living situation, all of your test results including labs, x-rays and the functional tests performed by your PT, your potential for a full recovery is good. You have a moderate decline in function with a high likelihood of returning home in the next 7-10 days. I recommend you go to a SNF for high-intensity rehabilitation for 7 days and that the SNF order PT and OT twice a day and walks with nursing every evening.”

This fully informed conversation can only take place if hospitalists are provided clear, concise documentation, including results of objective functional testing, by their physical therapy colleagues.

In conclusion, PTs working in the acute setting need to use validated tests to objectively assess function and educate their hospitalist colleagues on the meaning of these tests. Hospitalists in turn can incorporate these assessments into a discussion of discharge disposition and longitudinal recovery with patients. In this way, hospitalists and physical therapists can work together to achieve patient-centered, high-value care during and following a hospitalization.
 

Ms. Tammany is SVP of clinical strategy & innovation for Remedy Partners, Norwalk, Conn.

References

1. Jette DU et al. AM-PAC “6-Clicks” functional assessment scores predict acute care hospital discharge destination. Phys Ther. 2014 Sep;94(9):1252-61.

2. Jette DU et al. Validity of the AM-PAC “6-Clicks” inpatient daily activity and basic mobility short forms. Phys Ther. 2014 Mar;94(3):379-91.

3. Menendez ME et al. Does “6-Clicks” Day 1 Postoperative Mobility Score Predict Discharge Disposition After Total Hip and Knee Arthroplasties?” J Arthroplasty. 2016 Sep;31(9):1916-20.