Transforming Healthcare

Healthcare quality is defined as the degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge.1 Delivering high quality care to patients in the hospital setting is especially challenging, given the rapid pace of clinical care, the severity and multitude of patient conditions, and the interdependence of complex processes within the hospital system. Research has shown that hospitalized patients do not consistently receive recommended care2 and are at risk for experiencing preventable harm.3 In an effort to stimulate improvement, stakeholders have called for increased accountability, including enhanced transparency and differential payment based on performance. A growing number of hospital process and outcome measures are readily available to the public via the Internet.46 The Joint Commission, which accredits US hospitals, requires the collection of core quality measure data7 and sets the expectation that National Patient Safety Goals be met to maintain accreditation.8 Moreover, the Center for Medicare and Medicaid Services (CMS) has developed a Value‐Based Purchasing (VBP) plan intended to adjust hospital payment based on quality measures and the occurrence of certain hospital‐acquired conditions.9, 10

Because of their clinical expertise, understanding of hospital clinical operations, leadership of multidisciplinary inpatient teams, and vested interest to improve the systems in which they work, hospitalists are perfectly positioned to collaborate with their institutions to improve the quality of care delivered to inpatients. However, many hospitalists are inadequately prepared to engage in efforts to improve quality, because medical schools and residency programs have not traditionally included or emphasized healthcare quality and patient safety in their curricula.1113 In a survey of 389 internal medicine‐trained hospitalists, significant educational deficiencies were identified in the area of systems‐based practice.14 Specifically, the topics of quality improvement, team management, practice guideline development, health information systems management, and coordination of care between healthcare settings were listed as essential skills for hospitalist practice but underemphasized in residency training. Recognizing the gap between the needs of practicing physicians and current medical education provided in healthcare quality, professional societies have recently published position papers calling for increased training in quality, safety, and systems, both in medical school11 and residency training.15, 16

The Society of Hospital Medicine (SHM) convened a Quality Summit in December 2008 to develop strategic plans related to healthcare quality. Summit attendees felt that most hospitalists lack the formal training necessary to evaluate, implement, and sustain system changes within the hospital. In response, the SHM Hospital Quality and Patient Safety (HQPS) Committee formed a Quality Improvement Education (QIE) subcommittee in 2009 to assess the needs of hospitalists with respect to hospital quality and patient safety, and to evaluate and expand upon existing educational programs in this area. Membership of the QIE subcommittee consisted of hospitalists with extensive experience in healthcare quality and medical education. The QIE subcommittee refined and expanded upon the healthcare quality and patient safety‐related competencies initially described in the Core Competencies in Hospital Medicine.17 The purpose of this report is to describe the development, provide definitions, and make recommendations on the use of the Hospital Quality and Patient Safety (HQPS) Competencies.

Development of The Hospital Quality and Patient Safety Competencies

The multistep process used by the SHM QIE subcommittee to develop the HQPS Competencies is summarized in Figure 1. We performed an in‐depth evaluation of current educational materials and offerings, including a review of the Core Competencies in Hospital Medicine, past annual SHM Quality Improvement Pre‐Course objectives, and the content of training courses offered by other organizations.1722 Throughout our analysis, we emphasized the identification of gaps in content relevant to hospitalists. We then used the Institute of Medicine's (IOM) 6 aims for healthcare quality as a foundation for developing the HQPS Competencies.1 Specifically, the IOM states that healthcare should be safe, effective, patient‐centered, timely, efficient, and equitable. Additionally, we reviewed and integrated elements of the Practice‐Based Learning and Improvement (PBLI) and Systems‐Based Practice (SBP) competencies as defined by the Accreditation Council for Graduate Medical Education (ACGME).23 We defined general areas of competence and specific standards for knowledge, skills, and attitudes within each area. Subcommittee members reflected on their own experience, as clinicians, educators, and leaders in healthcare quality and patient safety, to inform and refine the competency definitions and standards. Acknowledging that some hospitalists may serve as collaborators or clinical content experts, while others may serve as leaders of hospital quality initiatives, 3 levels of expertise were established: basic, intermediate, and advanced.

Figure 1

The QIE subcommittee presented a draft version of the HQPS Competencies to the HQPS Committee in the fall of 2009 and incorporated suggested revisions. The revised set of competencies was then reviewed by members of the Leadership and Education Committees during the winter of 2009‐2010, and additional recommendations were included in the final version now described.

Description of The Competencies

The 8 areas of competence include: Quality Measurement and Stakeholder Interests, Data Acquisition and Interpretation, Organizational Knowledge and Leadership Skills, Patient Safety Principles, Teamwork and Communication, Quality and Safety Improvement Methods, Health Information Systems, and Patient Centeredness. Three levels of competence and standards within each level and area are defined in Table 1. Standards use carefully selected action verbs to reflect educational goals for hospitalists at each level.24 The basic level represents a minimum level of competency for all practicing hospitalists. The intermediate level represents a hospitalist who is prepared to meaningfully engage and collaborate with his or her institution in quality improvement efforts. A hospitalist at this level may also lead uncomplicated improvement projects for his or her medical center and/or hospital medicine group. The advanced level represents a hospitalist prepared to lead quality improvement efforts for his or her institution and/or hospital medicine group. Many hospitalists at this level will have, or will be prepared to have, leadership positions in quality and patient safety at their institutions. Advanced level hospitalists will also have the expertise to teach and mentor other individuals in their quality improvement efforts.

Recommended Use of The Competencies

The HQPS Competencies provide a framework for curricula and other professional development experiences in healthcare quality and patient safety. We recommend a step‐wise approach to curriculum development which includes conducting a targeted needs assessment, defining goals and specific learning objectives, and evaluation of the curriculum.25 The HQPS Competencies can be used at each step and provide educational targets for learners across a range of interest and experience.

Conclusion

Hospitalists are poised to have a tremendous impact on improving the quality of care for hospitalized patients. The lack of training in quality improvement in traditional medical education programs, in which most current hospitalists were trained, can be overcome through appropriate use of the HQPS Competencies. Formal incorporation of the HQPS Competencies into professional development programs, and innovative educational initiatives and curricula, will help provide current hospitalists and the next generations of hospitalists with the needed skills to be successful.

Healthcare quality is defined as the degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge.1 Delivering high quality care to patients in the hospital setting is especially challenging, given the rapid pace of clinical care, the severity and multitude of patient conditions, and the interdependence of complex processes within the hospital system. Research has shown that hospitalized patients do not consistently receive recommended care2 and are at risk for experiencing preventable harm.3 In an effort to stimulate improvement, stakeholders have called for increased accountability, including enhanced transparency and differential payment based on performance. A growing number of hospital process and outcome measures are readily available to the public via the Internet.46 The Joint Commission, which accredits US hospitals, requires the collection of core quality measure data7 and sets the expectation that National Patient Safety Goals be met to maintain accreditation.8 Moreover, the Center for Medicare and Medicaid Services (CMS) has developed a Value‐Based Purchasing (VBP) plan intended to adjust hospital payment based on quality measures and the occurrence of certain hospital‐acquired conditions.9, 10

Because of their clinical expertise, understanding of hospital clinical operations, leadership of multidisciplinary inpatient teams, and vested interest to improve the systems in which they work, hospitalists are perfectly positioned to collaborate with their institutions to improve the quality of care delivered to inpatients. However, many hospitalists are inadequately prepared to engage in efforts to improve quality, because medical schools and residency programs have not traditionally included or emphasized healthcare quality and patient safety in their curricula.1113 In a survey of 389 internal medicine‐trained hospitalists, significant educational deficiencies were identified in the area of systems‐based practice.14 Specifically, the topics of quality improvement, team management, practice guideline development, health information systems management, and coordination of care between healthcare settings were listed as essential skills for hospitalist practice but underemphasized in residency training. Recognizing the gap between the needs of practicing physicians and current medical education provided in healthcare quality, professional societies have recently published position papers calling for increased training in quality, safety, and systems, both in medical school11 and residency training.15, 16

The Society of Hospital Medicine (SHM) convened a Quality Summit in December 2008 to develop strategic plans related to healthcare quality. Summit attendees felt that most hospitalists lack the formal training necessary to evaluate, implement, and sustain system changes within the hospital. In response, the SHM Hospital Quality and Patient Safety (HQPS) Committee formed a Quality Improvement Education (QIE) subcommittee in 2009 to assess the needs of hospitalists with respect to hospital quality and patient safety, and to evaluate and expand upon existing educational programs in this area. Membership of the QIE subcommittee consisted of hospitalists with extensive experience in healthcare quality and medical education. The QIE subcommittee refined and expanded upon the healthcare quality and patient safety‐related competencies initially described in the Core Competencies in Hospital Medicine.17 The purpose of this report is to describe the development, provide definitions, and make recommendations on the use of the Hospital Quality and Patient Safety (HQPS) Competencies.

Development of The Hospital Quality and Patient Safety Competencies

The multistep process used by the SHM QIE subcommittee to develop the HQPS Competencies is summarized in Figure 1. We performed an in‐depth evaluation of current educational materials and offerings, including a review of the Core Competencies in Hospital Medicine, past annual SHM Quality Improvement Pre‐Course objectives, and the content of training courses offered by other organizations.1722 Throughout our analysis, we emphasized the identification of gaps in content relevant to hospitalists. We then used the Institute of Medicine's (IOM) 6 aims for healthcare quality as a foundation for developing the HQPS Competencies.1 Specifically, the IOM states that healthcare should be safe, effective, patient‐centered, timely, efficient, and equitable. Additionally, we reviewed and integrated elements of the Practice‐Based Learning and Improvement (PBLI) and Systems‐Based Practice (SBP) competencies as defined by the Accreditation Council for Graduate Medical Education (ACGME).23 We defined general areas of competence and specific standards for knowledge, skills, and attitudes within each area. Subcommittee members reflected on their own experience, as clinicians, educators, and leaders in healthcare quality and patient safety, to inform and refine the competency definitions and standards. Acknowledging that some hospitalists may serve as collaborators or clinical content experts, while others may serve as leaders of hospital quality initiatives, 3 levels of expertise were established: basic, intermediate, and advanced.

Figure 1

The QIE subcommittee presented a draft version of the HQPS Competencies to the HQPS Committee in the fall of 2009 and incorporated suggested revisions. The revised set of competencies was then reviewed by members of the Leadership and Education Committees during the winter of 2009‐2010, and additional recommendations were included in the final version now described.

Description of The Competencies

The 8 areas of competence include: Quality Measurement and Stakeholder Interests, Data Acquisition and Interpretation, Organizational Knowledge and Leadership Skills, Patient Safety Principles, Teamwork and Communication, Quality and Safety Improvement Methods, Health Information Systems, and Patient Centeredness. Three levels of competence and standards within each level and area are defined in Table 1. Standards use carefully selected action verbs to reflect educational goals for hospitalists at each level.24 The basic level represents a minimum level of competency for all practicing hospitalists. The intermediate level represents a hospitalist who is prepared to meaningfully engage and collaborate with his or her institution in quality improvement efforts. A hospitalist at this level may also lead uncomplicated improvement projects for his or her medical center and/or hospital medicine group. The advanced level represents a hospitalist prepared to lead quality improvement efforts for his or her institution and/or hospital medicine group. Many hospitalists at this level will have, or will be prepared to have, leadership positions in quality and patient safety at their institutions. Advanced level hospitalists will also have the expertise to teach and mentor other individuals in their quality improvement efforts.

Recommended Use of The Competencies

The HQPS Competencies provide a framework for curricula and other professional development experiences in healthcare quality and patient safety. We recommend a step‐wise approach to curriculum development which includes conducting a targeted needs assessment, defining goals and specific learning objectives, and evaluation of the curriculum.25 The HQPS Competencies can be used at each step and provide educational targets for learners across a range of interest and experience.

Conclusion

Hospitalists are poised to have a tremendous impact on improving the quality of care for hospitalized patients. The lack of training in quality improvement in traditional medical education programs, in which most current hospitalists were trained, can be overcome through appropriate use of the HQPS Competencies. Formal incorporation of the HQPS Competencies into professional development programs, and innovative educational initiatives and curricula, will help provide current hospitalists and the next generations of hospitalists with the needed skills to be successful.

Healthcare quality is defined as the degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge.1 Delivering high quality care to patients in the hospital setting is especially challenging, given the rapid pace of clinical care, the severity and multitude of patient conditions, and the interdependence of complex processes within the hospital system. Research has shown that hospitalized patients do not consistently receive recommended care2 and are at risk for experiencing preventable harm.3 In an effort to stimulate improvement, stakeholders have called for increased accountability, including enhanced transparency and differential payment based on performance. A growing number of hospital process and outcome measures are readily available to the public via the Internet.46 The Joint Commission, which accredits US hospitals, requires the collection of core quality measure data7 and sets the expectation that National Patient Safety Goals be met to maintain accreditation.8 Moreover, the Center for Medicare and Medicaid Services (CMS) has developed a Value‐Based Purchasing (VBP) plan intended to adjust hospital payment based on quality measures and the occurrence of certain hospital‐acquired conditions.9, 10

Because of their clinical expertise, understanding of hospital clinical operations, leadership of multidisciplinary inpatient teams, and vested interest to improve the systems in which they work, hospitalists are perfectly positioned to collaborate with their institutions to improve the quality of care delivered to inpatients. However, many hospitalists are inadequately prepared to engage in efforts to improve quality, because medical schools and residency programs have not traditionally included or emphasized healthcare quality and patient safety in their curricula.1113 In a survey of 389 internal medicine‐trained hospitalists, significant educational deficiencies were identified in the area of systems‐based practice.14 Specifically, the topics of quality improvement, team management, practice guideline development, health information systems management, and coordination of care between healthcare settings were listed as essential skills for hospitalist practice but underemphasized in residency training. Recognizing the gap between the needs of practicing physicians and current medical education provided in healthcare quality, professional societies have recently published position papers calling for increased training in quality, safety, and systems, both in medical school11 and residency training.15, 16

The Society of Hospital Medicine (SHM) convened a Quality Summit in December 2008 to develop strategic plans related to healthcare quality. Summit attendees felt that most hospitalists lack the formal training necessary to evaluate, implement, and sustain system changes within the hospital. In response, the SHM Hospital Quality and Patient Safety (HQPS) Committee formed a Quality Improvement Education (QIE) subcommittee in 2009 to assess the needs of hospitalists with respect to hospital quality and patient safety, and to evaluate and expand upon existing educational programs in this area. Membership of the QIE subcommittee consisted of hospitalists with extensive experience in healthcare quality and medical education. The QIE subcommittee refined and expanded upon the healthcare quality and patient safety‐related competencies initially described in the Core Competencies in Hospital Medicine.17 The purpose of this report is to describe the development, provide definitions, and make recommendations on the use of the Hospital Quality and Patient Safety (HQPS) Competencies.

Development of The Hospital Quality and Patient Safety Competencies

The multistep process used by the SHM QIE subcommittee to develop the HQPS Competencies is summarized in Figure 1. We performed an in‐depth evaluation of current educational materials and offerings, including a review of the Core Competencies in Hospital Medicine, past annual SHM Quality Improvement Pre‐Course objectives, and the content of training courses offered by other organizations.1722 Throughout our analysis, we emphasized the identification of gaps in content relevant to hospitalists. We then used the Institute of Medicine's (IOM) 6 aims for healthcare quality as a foundation for developing the HQPS Competencies.1 Specifically, the IOM states that healthcare should be safe, effective, patient‐centered, timely, efficient, and equitable. Additionally, we reviewed and integrated elements of the Practice‐Based Learning and Improvement (PBLI) and Systems‐Based Practice (SBP) competencies as defined by the Accreditation Council for Graduate Medical Education (ACGME).23 We defined general areas of competence and specific standards for knowledge, skills, and attitudes within each area. Subcommittee members reflected on their own experience, as clinicians, educators, and leaders in healthcare quality and patient safety, to inform and refine the competency definitions and standards. Acknowledging that some hospitalists may serve as collaborators or clinical content experts, while others may serve as leaders of hospital quality initiatives, 3 levels of expertise were established: basic, intermediate, and advanced.

Figure 1

The QIE subcommittee presented a draft version of the HQPS Competencies to the HQPS Committee in the fall of 2009 and incorporated suggested revisions. The revised set of competencies was then reviewed by members of the Leadership and Education Committees during the winter of 2009‐2010, and additional recommendations were included in the final version now described.

Description of The Competencies

The 8 areas of competence include: Quality Measurement and Stakeholder Interests, Data Acquisition and Interpretation, Organizational Knowledge and Leadership Skills, Patient Safety Principles, Teamwork and Communication, Quality and Safety Improvement Methods, Health Information Systems, and Patient Centeredness. Three levels of competence and standards within each level and area are defined in Table 1. Standards use carefully selected action verbs to reflect educational goals for hospitalists at each level.24 The basic level represents a minimum level of competency for all practicing hospitalists. The intermediate level represents a hospitalist who is prepared to meaningfully engage and collaborate with his or her institution in quality improvement efforts. A hospitalist at this level may also lead uncomplicated improvement projects for his or her medical center and/or hospital medicine group. The advanced level represents a hospitalist prepared to lead quality improvement efforts for his or her institution and/or hospital medicine group. Many hospitalists at this level will have, or will be prepared to have, leadership positions in quality and patient safety at their institutions. Advanced level hospitalists will also have the expertise to teach and mentor other individuals in their quality improvement efforts.

Recommended Use of The Competencies

The HQPS Competencies provide a framework for curricula and other professional development experiences in healthcare quality and patient safety. We recommend a step‐wise approach to curriculum development which includes conducting a targeted needs assessment, defining goals and specific learning objectives, and evaluation of the curriculum.25 The HQPS Competencies can be used at each step and provide educational targets for learners across a range of interest and experience.

Conclusion

Hospitalists are poised to have a tremendous impact on improving the quality of care for hospitalized patients. The lack of training in quality improvement in traditional medical education programs, in which most current hospitalists were trained, can be overcome through appropriate use of the HQPS Competencies. Formal incorporation of the HQPS Competencies into professional development programs, and innovative educational initiatives and curricula, will help provide current hospitalists and the next generations of hospitalists with the needed skills to be successful.

There is growing demand for safe and effective procedural sedation in pediatric facilities around the country. Multiple articles published in the last 10 years have addressed the shortage of pediatric anesthesiologists to meet this rising need.14 In 2005, Lalwani and Michel published results of a survey of North American children's hospitals that showed 87% of institutions reporting barriers to development of a pediatric sedation service, and that the most common barrier was shortage of anesthesiologists.5 In our hospital, the wait time for an outpatient sedated pediatric magnetic resonance imaging (MRI) grew to as long as 6 weeks. Many institutions have had to look for unique ways to solve this problem. Pediatric sedation programs have been developed which utilize intensivists, emergency medicine physicians, nurse anesthetists, or trained sedation nurses to provide safe pediatric sedation.611 Each of these programs has grown from the particular strengths and needs at each institution. In many institutions, hospitalists are the best candidates to meet this need because of their knowledge of patient needs and safety. They are accessible and receptive to obtaining additional training and, therefore, are a natural fit to provide this service.

As more non‐anesthesiologists are called upon to meet this growing need, the principles and practice of safe sedation must be followed. The Pediatric Sedation Research Consortium, a collaborative group of 37 locations that provide data on pediatric sedations, has published their findings on the safety of pediatric sedation/anesthesia outside of the operating room (OR) performed by anesthesiologists and non‐anesthesiologists.1213 This data has been very valuable, given that studies from single institutions will often lack the power to investigate the rare, but potentially devastating, adverse events which can occur in pediatric sedation/anesthesia.

Despite the widespread use of propofol by non‐anesthesiologists, the lack of substantial data regarding safety by these providers makes its use controversial. A search of the literature finds only 1 prior article that describes the use of propofol by general pediatricians. This was sedation for endoscopy, and the sedation was performed by specially trained pediatric residents in Italy.14 A recently published study from the Consortium regarding the use of propofol showed that the majority of propofol sedations were being performed by intensivists (49%), emergency medicine physicians (36%), or anesthesiologists (10%). General pediatricians or hospitalists performed just 2% of the cases in this series.13

In 2003, a large group of experienced pediatric hospitalists were already providing sedation in the Emergency Unit (EU) and Center for After‐hours Referrals for Emergency Services (CARES) at St Louis Children's Hospital. The Division of Hospital Medicine was approached to meet the demand for increased sedation services at our institution. The Division of Pediatric Anesthesia agreed to provide our physicians with the appropriate training to provide safe, effective, and efficient sedations for painful and non‐painful procedures outside of the OR. One of our sedation units, the Ambulatory Procedure Center (APC), has been described in detail in a prior publication by Strauser Sterni et al.15 Here, we will describe the operations of our sedation services, and specifically describe the training required for our hospitalists to provide sedation services.

METHODS

St Louis Children's Hospital is a 250‐bed tertiary‐care teaching hospital affiliated with Washington University School of Medicine. The Division of Hospitalist Medicine is today comprised of 43 physicians who provide care in the EU, CARES, inpatient units, Transport, and Sedation Services at St Louis Children's Hospital. Our division also provides pediatric care in the EU, inpatient units, newborn nursery, and labor and delivery at 3 affiliated hospitals. In 2003, we developed a dedicated program in our division to meet our institutional need for sedation, with training and oversight by the Division of Pediatric Anesthesia. We developed a structured 3‐tiered program of sedation providers to manage all of our sedation needs. We then designed a training program for these 3 tiers of sedation providers. The 3‐tired program is based on the level of sedation training of each member.

Current American Academy of Pediatrics (AAP) guidelines state:

The practitioner responsible for the treatment of the patient and/or the administration of drugs for sedation must be competent to use such techniques, provide the level of monitoring provided in these guidelines, and manage complications of these techniques (ie, to be able to rescue the patient). Because the level of intended sedation may be exceeded, the practitioner must be sufficiently skilled to provide rescue should the child progress to a level of deep sedation. The practitioner must be trained in, and capable of providing, at the minimum, bag‐valve‐mask ventilation to be able to oxygenate a child who develops airway obstruction or apnea. Training in, and maintenance of, advanced pediatric airway skills is required; regular skills reinforcement is strongly encouraged.16

Our first‐tier sedation providers are junior faculty who provide sedation in the EU and CARES, and in the EU at our community hospitals. The first tier completes sedation training as part of overall hospitalist orientation in order to provide this service. The second tier goes through an advanced sedation provider program to provide sedation in the APC, Pediatric Acute Wound Service (PAWS), inpatient units, and After Hours sedation call, as well as the locations from the first tier. The third tier completes a more complex advanced sedation training program, specifically using propofol, and provides propofol sedation in the APC only, as well as providing sedation in all of the units from the first and second tiers. The responsibilities of the hospitalist providing sedation are described in detail by tier below, including the specific training requirements necessary for each tier (Table 1).

RESULTS

Utilizing this design and training method, we have developed a successful pediatric hospitalist sedation program. Based on fiscal year 2009 billing data, the Division of Hospital Medicine performed 2471 sedations. There were 2069 sedations performed in APC or PAWS; of those, 1017 were performed on inpatients and 1052 were performed on outpatients. Hospitalists performed 402 sedations on patients in the EU. The EU numbers are likely much larger given that, for over half the year, billing data was not collected from the EU. Unfortunately, we did not have billing data regarding night and weekend sedations, but our best estimate is 1 to 2 per week. The wait time for an outpatient sedated pediatric MRI has gone from 6 weeks to 2 days or less. As of July 2010, we have trained 90 providers at Tier One, 32 at Tier Two, and 11 at Tier Three. We currently have 43 hospitalists providing Tier‐One sedation, 18 providing Tier‐Two, and 6 providing Tier‐Three. Average cumulative hospitalist experience is 1 year for Tier One, 5 years for Tier Two, and 10 years for Tier Three.

DISCUSSION

We believe this is the first description of a pediatric hospitalist training program for a sedation service. However, it is clear that many other pediatric hospitalists are performing sedation and developing similar training programs. When starting a program such as this, there are many things to consider. First, patient volume/demand must allow for each hospitalist to perform sedations on a regular basis, both for training and Maintenance of Certification. Second, Anesthesia must be willing to provide training and oversight. Third, the hospital or university must be willing to support the cost associated with the training period. Finally, negotiating with third party payers for reimbursement is critical to financial sustainability.

The success of our program hinged upon the ability to develop a strong and collaborative relationship with Anesthesiology. Many factors played into making this relationship work. Initially, Anesthesia approached us to help them meet an unmet clinical need. Because of this, we were viewed as helpful and as problem solvers, rather than as a threat. Additionally, each division had a sedation service champion that pushed for the development of a hospitalist sedation service. Lastly, regular meetings with Anesthesia, and the intense training program itself, helped to develop a sense of collegiality between the divisions.

We have faced many challenges and learned many lessons while developing this program. There is a significant cost to training sedation providers; 47 hospitalists trained to provide Tier‐One sedation have left the program. Of those, 16 hospitalists completed training for Tier‐Two sedation, and 5 completed Tier Three. The Tier‐Two training described earlier requires approximately 50 hours of dedicated time away from other hospitalist duties, while Tier Three requires an additional 125 hours. The majority of our turnover occurred in the first few years of the program. From a financial perspective, we have had to reserve sedation training beyond Tier One to hospitalists who are able to demonstrate evidence of a long‐term commitment to our division. Every person providing Tier‐Three sedation has been with the division over 6 years. From a broader perspective, we are providing hospitalists with an important and useful skill that may enhance their careerssafe and effective sedation.

Balancing the volume of cases is another issue to consider. Our goal is to provide safe and timely sedation, therefore we need to have enough scheduled cases to maintain competency and financial viability, but we must also leave adequate flexibility in the schedule for urgent cases.

In addition to the operating room training, we are beginning to incorporate pediatric simulation as an adjunct to our training. We have designed simulation scenarios which address issues of obstruction, apnea, hypotension, bronchospasm, and aspiration. However, OR training remains a mandatory requirement for sedation training and, at times, can be challenging to schedule.

We complete a post‐sedation assessment on all patients; we are currently performing a chart review of over 1600 patients sedated with propofol, to look at the rate of planned and unplanned interventions. We believe this data will show that our training has been successful, and that with analysis of our Quality Improvement data, we can improve the safety and efficacy of our sedation program even further.

CONCLUSIONS

A pediatric hospitalist sedation service, with proper training and oversight, can successfully augment sedation services provided by anesthesiologists. As has been stated in prior publications, a defined system, and the use of a dedicated well‐trained team makes a sedation service a success.1719 A collegial and mutually respectful relationship between Anesthesia and non‐Anesthesia sedation providers is critical in developing and maintaining a successful sedation program.

There is growing demand for safe and effective procedural sedation in pediatric facilities around the country. Multiple articles published in the last 10 years have addressed the shortage of pediatric anesthesiologists to meet this rising need.14 In 2005, Lalwani and Michel published results of a survey of North American children's hospitals that showed 87% of institutions reporting barriers to development of a pediatric sedation service, and that the most common barrier was shortage of anesthesiologists.5 In our hospital, the wait time for an outpatient sedated pediatric magnetic resonance imaging (MRI) grew to as long as 6 weeks. Many institutions have had to look for unique ways to solve this problem. Pediatric sedation programs have been developed which utilize intensivists, emergency medicine physicians, nurse anesthetists, or trained sedation nurses to provide safe pediatric sedation.611 Each of these programs has grown from the particular strengths and needs at each institution. In many institutions, hospitalists are the best candidates to meet this need because of their knowledge of patient needs and safety. They are accessible and receptive to obtaining additional training and, therefore, are a natural fit to provide this service.

As more non‐anesthesiologists are called upon to meet this growing need, the principles and practice of safe sedation must be followed. The Pediatric Sedation Research Consortium, a collaborative group of 37 locations that provide data on pediatric sedations, has published their findings on the safety of pediatric sedation/anesthesia outside of the operating room (OR) performed by anesthesiologists and non‐anesthesiologists.1213 This data has been very valuable, given that studies from single institutions will often lack the power to investigate the rare, but potentially devastating, adverse events which can occur in pediatric sedation/anesthesia.

Despite the widespread use of propofol by non‐anesthesiologists, the lack of substantial data regarding safety by these providers makes its use controversial. A search of the literature finds only 1 prior article that describes the use of propofol by general pediatricians. This was sedation for endoscopy, and the sedation was performed by specially trained pediatric residents in Italy.14 A recently published study from the Consortium regarding the use of propofol showed that the majority of propofol sedations were being performed by intensivists (49%), emergency medicine physicians (36%), or anesthesiologists (10%). General pediatricians or hospitalists performed just 2% of the cases in this series.13

In 2003, a large group of experienced pediatric hospitalists were already providing sedation in the Emergency Unit (EU) and Center for After‐hours Referrals for Emergency Services (CARES) at St Louis Children's Hospital. The Division of Hospital Medicine was approached to meet the demand for increased sedation services at our institution. The Division of Pediatric Anesthesia agreed to provide our physicians with the appropriate training to provide safe, effective, and efficient sedations for painful and non‐painful procedures outside of the OR. One of our sedation units, the Ambulatory Procedure Center (APC), has been described in detail in a prior publication by Strauser Sterni et al.15 Here, we will describe the operations of our sedation services, and specifically describe the training required for our hospitalists to provide sedation services.

METHODS

St Louis Children's Hospital is a 250‐bed tertiary‐care teaching hospital affiliated with Washington University School of Medicine. The Division of Hospitalist Medicine is today comprised of 43 physicians who provide care in the EU, CARES, inpatient units, Transport, and Sedation Services at St Louis Children's Hospital. Our division also provides pediatric care in the EU, inpatient units, newborn nursery, and labor and delivery at 3 affiliated hospitals. In 2003, we developed a dedicated program in our division to meet our institutional need for sedation, with training and oversight by the Division of Pediatric Anesthesia. We developed a structured 3‐tiered program of sedation providers to manage all of our sedation needs. We then designed a training program for these 3 tiers of sedation providers. The 3‐tired program is based on the level of sedation training of each member.

Current American Academy of Pediatrics (AAP) guidelines state:

The practitioner responsible for the treatment of the patient and/or the administration of drugs for sedation must be competent to use such techniques, provide the level of monitoring provided in these guidelines, and manage complications of these techniques (ie, to be able to rescue the patient). Because the level of intended sedation may be exceeded, the practitioner must be sufficiently skilled to provide rescue should the child progress to a level of deep sedation. The practitioner must be trained in, and capable of providing, at the minimum, bag‐valve‐mask ventilation to be able to oxygenate a child who develops airway obstruction or apnea. Training in, and maintenance of, advanced pediatric airway skills is required; regular skills reinforcement is strongly encouraged.16

Our first‐tier sedation providers are junior faculty who provide sedation in the EU and CARES, and in the EU at our community hospitals. The first tier completes sedation training as part of overall hospitalist orientation in order to provide this service. The second tier goes through an advanced sedation provider program to provide sedation in the APC, Pediatric Acute Wound Service (PAWS), inpatient units, and After Hours sedation call, as well as the locations from the first tier. The third tier completes a more complex advanced sedation training program, specifically using propofol, and provides propofol sedation in the APC only, as well as providing sedation in all of the units from the first and second tiers. The responsibilities of the hospitalist providing sedation are described in detail by tier below, including the specific training requirements necessary for each tier (Table 1).

RESULTS

Utilizing this design and training method, we have developed a successful pediatric hospitalist sedation program. Based on fiscal year 2009 billing data, the Division of Hospital Medicine performed 2471 sedations. There were 2069 sedations performed in APC or PAWS; of those, 1017 were performed on inpatients and 1052 were performed on outpatients. Hospitalists performed 402 sedations on patients in the EU. The EU numbers are likely much larger given that, for over half the year, billing data was not collected from the EU. Unfortunately, we did not have billing data regarding night and weekend sedations, but our best estimate is 1 to 2 per week. The wait time for an outpatient sedated pediatric MRI has gone from 6 weeks to 2 days or less. As of July 2010, we have trained 90 providers at Tier One, 32 at Tier Two, and 11 at Tier Three. We currently have 43 hospitalists providing Tier‐One sedation, 18 providing Tier‐Two, and 6 providing Tier‐Three. Average cumulative hospitalist experience is 1 year for Tier One, 5 years for Tier Two, and 10 years for Tier Three.

DISCUSSION

We believe this is the first description of a pediatric hospitalist training program for a sedation service. However, it is clear that many other pediatric hospitalists are performing sedation and developing similar training programs. When starting a program such as this, there are many things to consider. First, patient volume/demand must allow for each hospitalist to perform sedations on a regular basis, both for training and Maintenance of Certification. Second, Anesthesia must be willing to provide training and oversight. Third, the hospital or university must be willing to support the cost associated with the training period. Finally, negotiating with third party payers for reimbursement is critical to financial sustainability.

The success of our program hinged upon the ability to develop a strong and collaborative relationship with Anesthesiology. Many factors played into making this relationship work. Initially, Anesthesia approached us to help them meet an unmet clinical need. Because of this, we were viewed as helpful and as problem solvers, rather than as a threat. Additionally, each division had a sedation service champion that pushed for the development of a hospitalist sedation service. Lastly, regular meetings with Anesthesia, and the intense training program itself, helped to develop a sense of collegiality between the divisions.

We have faced many challenges and learned many lessons while developing this program. There is a significant cost to training sedation providers; 47 hospitalists trained to provide Tier‐One sedation have left the program. Of those, 16 hospitalists completed training for Tier‐Two sedation, and 5 completed Tier Three. The Tier‐Two training described earlier requires approximately 50 hours of dedicated time away from other hospitalist duties, while Tier Three requires an additional 125 hours. The majority of our turnover occurred in the first few years of the program. From a financial perspective, we have had to reserve sedation training beyond Tier One to hospitalists who are able to demonstrate evidence of a long‐term commitment to our division. Every person providing Tier‐Three sedation has been with the division over 6 years. From a broader perspective, we are providing hospitalists with an important and useful skill that may enhance their careerssafe and effective sedation.

Balancing the volume of cases is another issue to consider. Our goal is to provide safe and timely sedation, therefore we need to have enough scheduled cases to maintain competency and financial viability, but we must also leave adequate flexibility in the schedule for urgent cases.

In addition to the operating room training, we are beginning to incorporate pediatric simulation as an adjunct to our training. We have designed simulation scenarios which address issues of obstruction, apnea, hypotension, bronchospasm, and aspiration. However, OR training remains a mandatory requirement for sedation training and, at times, can be challenging to schedule.

We complete a post‐sedation assessment on all patients; we are currently performing a chart review of over 1600 patients sedated with propofol, to look at the rate of planned and unplanned interventions. We believe this data will show that our training has been successful, and that with analysis of our Quality Improvement data, we can improve the safety and efficacy of our sedation program even further.

CONCLUSIONS

A pediatric hospitalist sedation service, with proper training and oversight, can successfully augment sedation services provided by anesthesiologists. As has been stated in prior publications, a defined system, and the use of a dedicated well‐trained team makes a sedation service a success.1719 A collegial and mutually respectful relationship between Anesthesia and non‐Anesthesia sedation providers is critical in developing and maintaining a successful sedation program.

There is growing demand for safe and effective procedural sedation in pediatric facilities around the country. Multiple articles published in the last 10 years have addressed the shortage of pediatric anesthesiologists to meet this rising need.14 In 2005, Lalwani and Michel published results of a survey of North American children's hospitals that showed 87% of institutions reporting barriers to development of a pediatric sedation service, and that the most common barrier was shortage of anesthesiologists.5 In our hospital, the wait time for an outpatient sedated pediatric magnetic resonance imaging (MRI) grew to as long as 6 weeks. Many institutions have had to look for unique ways to solve this problem. Pediatric sedation programs have been developed which utilize intensivists, emergency medicine physicians, nurse anesthetists, or trained sedation nurses to provide safe pediatric sedation.611 Each of these programs has grown from the particular strengths and needs at each institution. In many institutions, hospitalists are the best candidates to meet this need because of their knowledge of patient needs and safety. They are accessible and receptive to obtaining additional training and, therefore, are a natural fit to provide this service.

As more non‐anesthesiologists are called upon to meet this growing need, the principles and practice of safe sedation must be followed. The Pediatric Sedation Research Consortium, a collaborative group of 37 locations that provide data on pediatric sedations, has published their findings on the safety of pediatric sedation/anesthesia outside of the operating room (OR) performed by anesthesiologists and non‐anesthesiologists.1213 This data has been very valuable, given that studies from single institutions will often lack the power to investigate the rare, but potentially devastating, adverse events which can occur in pediatric sedation/anesthesia.

Despite the widespread use of propofol by non‐anesthesiologists, the lack of substantial data regarding safety by these providers makes its use controversial. A search of the literature finds only 1 prior article that describes the use of propofol by general pediatricians. This was sedation for endoscopy, and the sedation was performed by specially trained pediatric residents in Italy.14 A recently published study from the Consortium regarding the use of propofol showed that the majority of propofol sedations were being performed by intensivists (49%), emergency medicine physicians (36%), or anesthesiologists (10%). General pediatricians or hospitalists performed just 2% of the cases in this series.13

In 2003, a large group of experienced pediatric hospitalists were already providing sedation in the Emergency Unit (EU) and Center for After‐hours Referrals for Emergency Services (CARES) at St Louis Children's Hospital. The Division of Hospital Medicine was approached to meet the demand for increased sedation services at our institution. The Division of Pediatric Anesthesia agreed to provide our physicians with the appropriate training to provide safe, effective, and efficient sedations for painful and non‐painful procedures outside of the OR. One of our sedation units, the Ambulatory Procedure Center (APC), has been described in detail in a prior publication by Strauser Sterni et al.15 Here, we will describe the operations of our sedation services, and specifically describe the training required for our hospitalists to provide sedation services.

METHODS

St Louis Children's Hospital is a 250‐bed tertiary‐care teaching hospital affiliated with Washington University School of Medicine. The Division of Hospitalist Medicine is today comprised of 43 physicians who provide care in the EU, CARES, inpatient units, Transport, and Sedation Services at St Louis Children's Hospital. Our division also provides pediatric care in the EU, inpatient units, newborn nursery, and labor and delivery at 3 affiliated hospitals. In 2003, we developed a dedicated program in our division to meet our institutional need for sedation, with training and oversight by the Division of Pediatric Anesthesia. We developed a structured 3‐tiered program of sedation providers to manage all of our sedation needs. We then designed a training program for these 3 tiers of sedation providers. The 3‐tired program is based on the level of sedation training of each member.

Current American Academy of Pediatrics (AAP) guidelines state:

The practitioner responsible for the treatment of the patient and/or the administration of drugs for sedation must be competent to use such techniques, provide the level of monitoring provided in these guidelines, and manage complications of these techniques (ie, to be able to rescue the patient). Because the level of intended sedation may be exceeded, the practitioner must be sufficiently skilled to provide rescue should the child progress to a level of deep sedation. The practitioner must be trained in, and capable of providing, at the minimum, bag‐valve‐mask ventilation to be able to oxygenate a child who develops airway obstruction or apnea. Training in, and maintenance of, advanced pediatric airway skills is required; regular skills reinforcement is strongly encouraged.16

Our first‐tier sedation providers are junior faculty who provide sedation in the EU and CARES, and in the EU at our community hospitals. The first tier completes sedation training as part of overall hospitalist orientation in order to provide this service. The second tier goes through an advanced sedation provider program to provide sedation in the APC, Pediatric Acute Wound Service (PAWS), inpatient units, and After Hours sedation call, as well as the locations from the first tier. The third tier completes a more complex advanced sedation training program, specifically using propofol, and provides propofol sedation in the APC only, as well as providing sedation in all of the units from the first and second tiers. The responsibilities of the hospitalist providing sedation are described in detail by tier below, including the specific training requirements necessary for each tier (Table 1).

RESULTS

Utilizing this design and training method, we have developed a successful pediatric hospitalist sedation program. Based on fiscal year 2009 billing data, the Division of Hospital Medicine performed 2471 sedations. There were 2069 sedations performed in APC or PAWS; of those, 1017 were performed on inpatients and 1052 were performed on outpatients. Hospitalists performed 402 sedations on patients in the EU. The EU numbers are likely much larger given that, for over half the year, billing data was not collected from the EU. Unfortunately, we did not have billing data regarding night and weekend sedations, but our best estimate is 1 to 2 per week. The wait time for an outpatient sedated pediatric MRI has gone from 6 weeks to 2 days or less. As of July 2010, we have trained 90 providers at Tier One, 32 at Tier Two, and 11 at Tier Three. We currently have 43 hospitalists providing Tier‐One sedation, 18 providing Tier‐Two, and 6 providing Tier‐Three. Average cumulative hospitalist experience is 1 year for Tier One, 5 years for Tier Two, and 10 years for Tier Three.

DISCUSSION

We believe this is the first description of a pediatric hospitalist training program for a sedation service. However, it is clear that many other pediatric hospitalists are performing sedation and developing similar training programs. When starting a program such as this, there are many things to consider. First, patient volume/demand must allow for each hospitalist to perform sedations on a regular basis, both for training and Maintenance of Certification. Second, Anesthesia must be willing to provide training and oversight. Third, the hospital or university must be willing to support the cost associated with the training period. Finally, negotiating with third party payers for reimbursement is critical to financial sustainability.

The success of our program hinged upon the ability to develop a strong and collaborative relationship with Anesthesiology. Many factors played into making this relationship work. Initially, Anesthesia approached us to help them meet an unmet clinical need. Because of this, we were viewed as helpful and as problem solvers, rather than as a threat. Additionally, each division had a sedation service champion that pushed for the development of a hospitalist sedation service. Lastly, regular meetings with Anesthesia, and the intense training program itself, helped to develop a sense of collegiality between the divisions.

We have faced many challenges and learned many lessons while developing this program. There is a significant cost to training sedation providers; 47 hospitalists trained to provide Tier‐One sedation have left the program. Of those, 16 hospitalists completed training for Tier‐Two sedation, and 5 completed Tier Three. The Tier‐Two training described earlier requires approximately 50 hours of dedicated time away from other hospitalist duties, while Tier Three requires an additional 125 hours. The majority of our turnover occurred in the first few years of the program. From a financial perspective, we have had to reserve sedation training beyond Tier One to hospitalists who are able to demonstrate evidence of a long‐term commitment to our division. Every person providing Tier‐Three sedation has been with the division over 6 years. From a broader perspective, we are providing hospitalists with an important and useful skill that may enhance their careerssafe and effective sedation.

Balancing the volume of cases is another issue to consider. Our goal is to provide safe and timely sedation, therefore we need to have enough scheduled cases to maintain competency and financial viability, but we must also leave adequate flexibility in the schedule for urgent cases.

In addition to the operating room training, we are beginning to incorporate pediatric simulation as an adjunct to our training. We have designed simulation scenarios which address issues of obstruction, apnea, hypotension, bronchospasm, and aspiration. However, OR training remains a mandatory requirement for sedation training and, at times, can be challenging to schedule.

We complete a post‐sedation assessment on all patients; we are currently performing a chart review of over 1600 patients sedated with propofol, to look at the rate of planned and unplanned interventions. We believe this data will show that our training has been successful, and that with analysis of our Quality Improvement data, we can improve the safety and efficacy of our sedation program even further.

CONCLUSIONS

A pediatric hospitalist sedation service, with proper training and oversight, can successfully augment sedation services provided by anesthesiologists. As has been stated in prior publications, a defined system, and the use of a dedicated well‐trained team makes a sedation service a success.1719 A collegial and mutually respectful relationship between Anesthesia and non‐Anesthesia sedation providers is critical in developing and maintaining a successful sedation program.

Recognition that healthcare carries considerable risks of patient injury has focused efforts on identifying problems before they occur, and understanding the root causes of those problems that do occur to prevent them from happening again.1 To further these efforts, a Joint Commission (JC) standard requires hospitals to review sentinel events (SE).2 Reviews must develop a timely, thorough, and credible root cause analysis (RCA), implement action plans to reduce risk, and monitor the effectiveness of implemented improvements.3

Ideally, hospitals would summarize their experiences with SE reviews, identify high‐risk activities and patients, institute system changes to prevent SE recurrences, and share their findings with other healthcare organizations to help them avoid similar patient injuries.1 In support of this last goal, the JC maintains a voluntary database system that allows hospitals to report their SE analyses for other facilities to review and institute preventative actions.

Unfortunately, the reality of SE reviews does not match their ideals for improving patient safety.4 Healthcare organizations often describe their review process as less than credible and note a need for ongoing oversight to maintain the reviews' effectiveness.5 The JC voluntary reporting system captures less than 1% of the SEs that occur nationally,2 because hospitals perceive barriers to external reporting.1 If healthcare organizations decide against reporting externally, they can create their own internal systems to aggregate and summarize SEs, but few such systems exist. A major impediment to designing internal systems is the absence of universally endorsed nomenclature for safety‐related events.6, 7 Poorly aligned terminology and subjective conceptualizations for safety incidents impede the aggregation of SEs, comparisons between facilities, and trend analyses for tracking SE patterns.

In 2005, the World Health Organization (WHO) World Alliance for Patient Safety, in collaboration with the JC, began developing an International Classification for Patient Safety (ICPS) to provide healthcare organizations a consistent conceptual model for safety incidents and promote their classification by a standardized taxonomy.810 Although this system has promise for allowing standardization, data aggregation, analysis, and learning between institutions,11 integration of the ICPS conceptual model into an SE decision support tool with summarizing and reporting features has not been reported.

This report describes our development of an intranet‐based SE reporting system, called Incident Tracker (I‐Tracker), based on the ICPS model. For our SE review groups from the 4 Providence Health Systems (PHS) Portland Service Area (PSA) hospitals, the I‐Tracker system offers a tool to guide efforts in developing RCAs and action plans in alignment with the ICPS framework. The system includes scripts that automatically generate and distribute standardized reports of individual and aggregated SEs. The objectives of this project were to report our experience with developing a flexible and accessible intranet‐based system that assists RCA participants in conforming to the ICPS framework and oversight safety staff in summarizing and reporting root cause analyses.

METHODS

The 4 PSA hospitals have 1083 licensed beds and perform SE reviews with a centralized process that reports results to a Community Governing Board. An ad hoc team for each SE performs the RCAs. The SE groups report RCAs and action plans in an unstructured format that varies for each event. A paper file is maintained for each SE report, but a system for aggregating reports to track trends, disseminating SE trends, or monitoring the completion or effectiveness of action plans is not available.

We designed a system to achieve the following objectives:

• 1

  Apply the ICPS framework (Figure 1) and taxonomy of terms to SE analyses;

• 2

  Provide a computer‐based tool to assist review groups and quality staff to perform their SE reviews and data collection in alignment with the ICPS framework;

• 3

  Create an intranet‐based database that captures elements of the reviews, RCAs, and action plans with the use of drop‐down lists, help windows, windows with live access to Internet educational resources and tools, decision support tools, default entries, and audio prompts to streamline data entry;

• 4

  Generate a suite of standardized reports customized for different audiences that can be accessed online and printed from the database with automated scripts;

• 5

  Produce intranet‐based summaries of aggregated events to identify common causes and disseminate observed patterns and action plans to other PSA hospitals.

Figure 1

We selected FileMaker Pro 11 Advanced (FMP11) for authoring and maintaining the decision support tool and database, and FileMaker Pro Server 11 Advanced (FMPS11) (Filemaker, Inc, Santa Clara, CA) for hosting the system, because it provides intranet access and tools for updating the system by personnel with minimal programming experience. End users can view and enter data through layouts that display only the information allowed by the user's login password and access privileges, with external authentication by Active Directory and Open Directory technology. Staff who author and manage the database do so through client FMP11 software loaded on a computer that provides remote server access.

The I‐Tracker system was authored using the ICPS definitions for the 48 preferred terms for safety incidents and the ICPS conceptual framework.8 The conceptual framework consists of 10 major incident domains, that include incident type, patient outcomes, patient characteristics, incident characteristics, contributing factors and hazards, organizational outcomes, detection, mitigating factors, ameliorating actions, and actions taken to reduce risk (Figure 1).11 The framework is applicable to all hospital safety incidents, but we limited I‐Tracker to SEs because our hospitals had completed comprehensive reviews and action plans only for these more serious events. The literature on the ICPS framework812 was carefully reviewed to identify the specific data fields that were recommended by ICPS developers to be included under each of the 10 major classification domains. In most instances, data fields existed only in the body of these reports. Article texts, however, provided sufficient descriptions of these data fields to allow their translation into data entry fields in I‐Tracker with accompanying help windows and explanations to guide I‐Tracker users. Sixty ICPS data fields were programmed into I‐Tracker, with another 120 fields that allowed entry of descriptions and explanations of the ICPS data field entries. For instance, an entry of Yes into an ICPS data field that queried Was there a systems problem of an external organization other than a Providence entity opens a Describe field that allows a brief description of the problem, and an additional Details field that allows a longer explanation of the problem if necessary. The brief Describe field contents populate an automatically generated fishbone diagram.

The authors and quality staff translated the most recent 15 SE reviews into ICPS terms and classifications, and entered the results into I‐Tracker as it was being developed, to assist system design and programming of the system. The authors noted during data entry which of the 10 ICPS major domains had not been analyzed by the previous 15 reviews. Because existing reports were unstructured with considerable variation in style and usage of terms, the authors and quality staff made group decisions regarding how to cross‐walk existing information into the standardized ICPS data fields.

RESULTS

In developing I‐Tracker, the authors and quality staff observed that the ICPS framework and recommended data fields were logical and straightforward to learn. Although it was difficult to find the definitions of specific ICPS data fields within the 10 major domains in the text of retrieved articles, these fields could be readily cross‐walked into I‐Tracker data entry fields. Translating existing SE reports into I‐Tracker classifications, however, presented considerable challenges because of the unstructured, discursive, and variable nature of our SE review and reports. The authors and staff spent 1 to 2 hours conferring over each report to make judgments as to which elements of the review would be entered into which I‐Tracker data fields. Once the authors and staff translated existing reports into ICPS terms, actual data entry into I‐Tracker took typically less than 30 minutes for each review. We found that none of our 15 SE reviews included information on the following ICPS major domains: detection, mitigating factors, and ameliorating actions. We also observed that many ICPS data fields were not assessed, such as patient contributions to errors and external organization's contributions to a safety incident.

The latest version of I‐Tracker receives and displays information at the individual patient level. Records are shown onscreen with different screen layouts depending on the viewer's login security clearance. Hospital safety staff have full access to view and enter data on the initial layout, which displays patient demographic information and folder tabs that navigate when clicked to other database fields (Figure 2). Viewers with lower security clearance either view the same opening screen, but have limited access to other screens, or view a different opening screen designed to meet their specific needs. All screens provide definitions of terms and information to assist data entry, buttons that navigate to help pages, pop‐up windows that provide tips, and buttons that trigger brief audio explanations. Most fields use drop‐down lists to standardize data entry around the ICPS definitions, with default values entered into many fields to streamline data entry. A list view allows review of all patients and quick access to an individual patient's record. All fields and combinations of fields with Boolean rules are searchable within the database.

Figure 2

I‐Tracker has features that support SE review groups in beginning an SE review by providing them a paper form or electronic interface by way of a portable computer or tablet device, that guides their discussions and analyses toward providing conclusions that can be entered into the database fields, thereby aligning their deliberations with the ICPS conceptual framework. The same resource is available within the database online for those groups who would prefer to use computer prompts and enter data directly into the database as they proceed through their analyses. Some layouts contain windows that port live views from external Web sites (eg, JC RCA resources) that provide participants of RCA groups with tools to assist their work. FMP11 allows users to access the database by portable computers or handheld tablet devices using the hospitals' WiFi network.

A report screen allows automatic generation of different printouts of individual or aggregate summary reports. A Comprehensive Report includes all of the data fields included in the ICPS conceptual framework. Other reports present subsets of data depending on the user's needs and access privileges. The FMPS11 database allows printing the reports to paper or Portable Document Format (pdf), exporting data into an Excel spreadsheet, or e‐mailing reports to recipients from within I‐Tracker.

Additionally, I‐Tracker functionality facilitates follow‐up and monitoring of action items developed during the RCA process in a manner that conforms to the ICPS framework. We are now developing educational resources for RCA team members to investigate the implementation of I‐Tracker into future RCAs.

DISCUSSION

I‐Tracker provides an intranet‐based tool that met the objectives of the present project. The process of entering 15 existing SE reviews and action plans from our healthcare system into I‐Tracker allowed an incremental development of the database and identified gaps in our existing RCA process. For instance, none of the previous RCAs critically appraised detection, mitigating factors, or ameliorating actions; defined the specific nature or quantified severity of patient injuries using standardized terms; distinguished between human errors and negligence; or comprehensively reported the full spectrum of underlying causes of Tracker's use of standardized terms based on the ICPS conceptual framework provided a potential resource for focusing SE reviews and producing more comprehensive RCAs and action plans in the future. I‐Tracker has additional potential to facilitate dissemination of RCAs to other facilities, both as individual incident reports and aggregated summaries as recommended by experts in patient safety.13

The deficiencies in our existing RCA analyses, identified during data entry into I‐Tracker, represent common shortcomings experienced by other healthcare organizations and summarized in a report by the Agency for Healthcare Research and Quality.4 Considerable hindsight bias and prevailing concerns of the day taint the RCA process, which is time‐consuming and labor intensive, and thereby hinders comprehensive reviews. Also, our SE reviews, like others reviewed in the literature,14 focused on biologic injury to patients and omitted assessment of psychologic, organizational, social, and economic injury domains. Although SE review teams benefit from involvement of quality improvement staff who are trained in techniques and goals of RCA,15 many hospitals like ours have limited resources for fully staffing all SE reviews with trained facilitators. These SE reviews generate both quantitative and qualitative data, the latter of which hinders standardized data entry in the absence of a conceptual framework. A structured database with formative tools to guide RCAs in conformance with the ICPS framework in organizations without sufficient numbers of trained facilitators offers opportunities to produce more comprehensive, standardized, and actionable reports. To date, our quality staff and leadership have responded positively to presentations of the functional features of I‐Tracker (Table 1).

Limitations of our report include its focus solely on the development and programming phase of I‐Tracker and the absence of information on its actual implementation. We believe, however, the development phase is important to report because it demonstrates that the ICPS framework and specific ICPS data fields are amenable to incorporation into a decision support and reporting tool, which to our knowledge has not been previously reported. We begin implementation of I‐Tracker within our organization this year and will have observations on its feasibility, acceptability, and staff training needs. As an additional limitation, we emphasize that we do not propose I‐Tracker as a solution for other organizations, because we have no plans for its commercial or public domain development. This report is intended to demonstrate, however, that commercially available software, such as FileMaker, can readily support the ICPS Framework and thereby has potential to assist RCAs and SE reporting. Other organizations may develop similar systems on other database platforms that incorporate the ICPS system into their reviews.

To implement I‐Tracker, we are now working with nursing and pharmacy leadership focus groups to develop formative tools, data collection forms, and other resources to assist their RCA efforts and data entry into the database. We also plan to apply the database tool to our residency training program to promote resident involvement in SE reviews by providing standardized, reproducible, and structured processes.16 Our 5‐state healthcare system has funded an evaluation of the implementation phase of I‐Tracker to other Providence facilities. Because the ICPS framework applies to all safety incidents beyond SEs (Table 2), a successful implementation of I‐Tracker for SEs will allow its eventual application to other types of critical incidents.

The strength of this project derives from its innovative development of an intranet‐based tool that allows groups to conform their RCAs to the ICPS framework. Because the absence of a standardized classification for patient safety concepts has hindered advances in patient safety,11 we believe I‐Tracker, or decision support tools like it that use the ICPS framework, can standardize RCAs and promote dissemination and adoption of action plans.

Recognition that healthcare carries considerable risks of patient injury has focused efforts on identifying problems before they occur, and understanding the root causes of those problems that do occur to prevent them from happening again.1 To further these efforts, a Joint Commission (JC) standard requires hospitals to review sentinel events (SE).2 Reviews must develop a timely, thorough, and credible root cause analysis (RCA), implement action plans to reduce risk, and monitor the effectiveness of implemented improvements.3

Ideally, hospitals would summarize their experiences with SE reviews, identify high‐risk activities and patients, institute system changes to prevent SE recurrences, and share their findings with other healthcare organizations to help them avoid similar patient injuries.1 In support of this last goal, the JC maintains a voluntary database system that allows hospitals to report their SE analyses for other facilities to review and institute preventative actions.

Unfortunately, the reality of SE reviews does not match their ideals for improving patient safety.4 Healthcare organizations often describe their review process as less than credible and note a need for ongoing oversight to maintain the reviews' effectiveness.5 The JC voluntary reporting system captures less than 1% of the SEs that occur nationally,2 because hospitals perceive barriers to external reporting.1 If healthcare organizations decide against reporting externally, they can create their own internal systems to aggregate and summarize SEs, but few such systems exist. A major impediment to designing internal systems is the absence of universally endorsed nomenclature for safety‐related events.6, 7 Poorly aligned terminology and subjective conceptualizations for safety incidents impede the aggregation of SEs, comparisons between facilities, and trend analyses for tracking SE patterns.

In 2005, the World Health Organization (WHO) World Alliance for Patient Safety, in collaboration with the JC, began developing an International Classification for Patient Safety (ICPS) to provide healthcare organizations a consistent conceptual model for safety incidents and promote their classification by a standardized taxonomy.810 Although this system has promise for allowing standardization, data aggregation, analysis, and learning between institutions,11 integration of the ICPS conceptual model into an SE decision support tool with summarizing and reporting features has not been reported.

This report describes our development of an intranet‐based SE reporting system, called Incident Tracker (I‐Tracker), based on the ICPS model. For our SE review groups from the 4 Providence Health Systems (PHS) Portland Service Area (PSA) hospitals, the I‐Tracker system offers a tool to guide efforts in developing RCAs and action plans in alignment with the ICPS framework. The system includes scripts that automatically generate and distribute standardized reports of individual and aggregated SEs. The objectives of this project were to report our experience with developing a flexible and accessible intranet‐based system that assists RCA participants in conforming to the ICPS framework and oversight safety staff in summarizing and reporting root cause analyses.

METHODS

The 4 PSA hospitals have 1083 licensed beds and perform SE reviews with a centralized process that reports results to a Community Governing Board. An ad hoc team for each SE performs the RCAs. The SE groups report RCAs and action plans in an unstructured format that varies for each event. A paper file is maintained for each SE report, but a system for aggregating reports to track trends, disseminating SE trends, or monitoring the completion or effectiveness of action plans is not available.

We designed a system to achieve the following objectives:

• 1

  Apply the ICPS framework (Figure 1) and taxonomy of terms to SE analyses;

• 2

  Provide a computer‐based tool to assist review groups and quality staff to perform their SE reviews and data collection in alignment with the ICPS framework;

• 3

  Create an intranet‐based database that captures elements of the reviews, RCAs, and action plans with the use of drop‐down lists, help windows, windows with live access to Internet educational resources and tools, decision support tools, default entries, and audio prompts to streamline data entry;

• 4

  Generate a suite of standardized reports customized for different audiences that can be accessed online and printed from the database with automated scripts;

• 5

  Produce intranet‐based summaries of aggregated events to identify common causes and disseminate observed patterns and action plans to other PSA hospitals.

Figure 1

We selected FileMaker Pro 11 Advanced (FMP11) for authoring and maintaining the decision support tool and database, and FileMaker Pro Server 11 Advanced (FMPS11) (Filemaker, Inc, Santa Clara, CA) for hosting the system, because it provides intranet access and tools for updating the system by personnel with minimal programming experience. End users can view and enter data through layouts that display only the information allowed by the user's login password and access privileges, with external authentication by Active Directory and Open Directory technology. Staff who author and manage the database do so through client FMP11 software loaded on a computer that provides remote server access.

The I‐Tracker system was authored using the ICPS definitions for the 48 preferred terms for safety incidents and the ICPS conceptual framework.8 The conceptual framework consists of 10 major incident domains, that include incident type, patient outcomes, patient characteristics, incident characteristics, contributing factors and hazards, organizational outcomes, detection, mitigating factors, ameliorating actions, and actions taken to reduce risk (Figure 1).11 The framework is applicable to all hospital safety incidents, but we limited I‐Tracker to SEs because our hospitals had completed comprehensive reviews and action plans only for these more serious events. The literature on the ICPS framework812 was carefully reviewed to identify the specific data fields that were recommended by ICPS developers to be included under each of the 10 major classification domains. In most instances, data fields existed only in the body of these reports. Article texts, however, provided sufficient descriptions of these data fields to allow their translation into data entry fields in I‐Tracker with accompanying help windows and explanations to guide I‐Tracker users. Sixty ICPS data fields were programmed into I‐Tracker, with another 120 fields that allowed entry of descriptions and explanations of the ICPS data field entries. For instance, an entry of Yes into an ICPS data field that queried Was there a systems problem of an external organization other than a Providence entity opens a Describe field that allows a brief description of the problem, and an additional Details field that allows a longer explanation of the problem if necessary. The brief Describe field contents populate an automatically generated fishbone diagram.

The authors and quality staff translated the most recent 15 SE reviews into ICPS terms and classifications, and entered the results into I‐Tracker as it was being developed, to assist system design and programming of the system. The authors noted during data entry which of the 10 ICPS major domains had not been analyzed by the previous 15 reviews. Because existing reports were unstructured with considerable variation in style and usage of terms, the authors and quality staff made group decisions regarding how to cross‐walk existing information into the standardized ICPS data fields.

RESULTS

In developing I‐Tracker, the authors and quality staff observed that the ICPS framework and recommended data fields were logical and straightforward to learn. Although it was difficult to find the definitions of specific ICPS data fields within the 10 major domains in the text of retrieved articles, these fields could be readily cross‐walked into I‐Tracker data entry fields. Translating existing SE reports into I‐Tracker classifications, however, presented considerable challenges because of the unstructured, discursive, and variable nature of our SE review and reports. The authors and staff spent 1 to 2 hours conferring over each report to make judgments as to which elements of the review would be entered into which I‐Tracker data fields. Once the authors and staff translated existing reports into ICPS terms, actual data entry into I‐Tracker took typically less than 30 minutes for each review. We found that none of our 15 SE reviews included information on the following ICPS major domains: detection, mitigating factors, and ameliorating actions. We also observed that many ICPS data fields were not assessed, such as patient contributions to errors and external organization's contributions to a safety incident.

The latest version of I‐Tracker receives and displays information at the individual patient level. Records are shown onscreen with different screen layouts depending on the viewer's login security clearance. Hospital safety staff have full access to view and enter data on the initial layout, which displays patient demographic information and folder tabs that navigate when clicked to other database fields (Figure 2). Viewers with lower security clearance either view the same opening screen, but have limited access to other screens, or view a different opening screen designed to meet their specific needs. All screens provide definitions of terms and information to assist data entry, buttons that navigate to help pages, pop‐up windows that provide tips, and buttons that trigger brief audio explanations. Most fields use drop‐down lists to standardize data entry around the ICPS definitions, with default values entered into many fields to streamline data entry. A list view allows review of all patients and quick access to an individual patient's record. All fields and combinations of fields with Boolean rules are searchable within the database.

Figure 2

I‐Tracker has features that support SE review groups in beginning an SE review by providing them a paper form or electronic interface by way of a portable computer or tablet device, that guides their discussions and analyses toward providing conclusions that can be entered into the database fields, thereby aligning their deliberations with the ICPS conceptual framework. The same resource is available within the database online for those groups who would prefer to use computer prompts and enter data directly into the database as they proceed through their analyses. Some layouts contain windows that port live views from external Web sites (eg, JC RCA resources) that provide participants of RCA groups with tools to assist their work. FMP11 allows users to access the database by portable computers or handheld tablet devices using the hospitals' WiFi network.

A report screen allows automatic generation of different printouts of individual or aggregate summary reports. A Comprehensive Report includes all of the data fields included in the ICPS conceptual framework. Other reports present subsets of data depending on the user's needs and access privileges. The FMPS11 database allows printing the reports to paper or Portable Document Format (pdf), exporting data into an Excel spreadsheet, or e‐mailing reports to recipients from within I‐Tracker.

Additionally, I‐Tracker functionality facilitates follow‐up and monitoring of action items developed during the RCA process in a manner that conforms to the ICPS framework. We are now developing educational resources for RCA team members to investigate the implementation of I‐Tracker into future RCAs.

DISCUSSION

I‐Tracker provides an intranet‐based tool that met the objectives of the present project. The process of entering 15 existing SE reviews and action plans from our healthcare system into I‐Tracker allowed an incremental development of the database and identified gaps in our existing RCA process. For instance, none of the previous RCAs critically appraised detection, mitigating factors, or ameliorating actions; defined the specific nature or quantified severity of patient injuries using standardized terms; distinguished between human errors and negligence; or comprehensively reported the full spectrum of underlying causes of Tracker's use of standardized terms based on the ICPS conceptual framework provided a potential resource for focusing SE reviews and producing more comprehensive RCAs and action plans in the future. I‐Tracker has additional potential to facilitate dissemination of RCAs to other facilities, both as individual incident reports and aggregated summaries as recommended by experts in patient safety.13

The deficiencies in our existing RCA analyses, identified during data entry into I‐Tracker, represent common shortcomings experienced by other healthcare organizations and summarized in a report by the Agency for Healthcare Research and Quality.4 Considerable hindsight bias and prevailing concerns of the day taint the RCA process, which is time‐consuming and labor intensive, and thereby hinders comprehensive reviews. Also, our SE reviews, like others reviewed in the literature,14 focused on biologic injury to patients and omitted assessment of psychologic, organizational, social, and economic injury domains. Although SE review teams benefit from involvement of quality improvement staff who are trained in techniques and goals of RCA,15 many hospitals like ours have limited resources for fully staffing all SE reviews with trained facilitators. These SE reviews generate both quantitative and qualitative data, the latter of which hinders standardized data entry in the absence of a conceptual framework. A structured database with formative tools to guide RCAs in conformance with the ICPS framework in organizations without sufficient numbers of trained facilitators offers opportunities to produce more comprehensive, standardized, and actionable reports. To date, our quality staff and leadership have responded positively to presentations of the functional features of I‐Tracker (Table 1).

Limitations of our report include its focus solely on the development and programming phase of I‐Tracker and the absence of information on its actual implementation. We believe, however, the development phase is important to report because it demonstrates that the ICPS framework and specific ICPS data fields are amenable to incorporation into a decision support and reporting tool, which to our knowledge has not been previously reported. We begin implementation of I‐Tracker within our organization this year and will have observations on its feasibility, acceptability, and staff training needs. As an additional limitation, we emphasize that we do not propose I‐Tracker as a solution for other organizations, because we have no plans for its commercial or public domain development. This report is intended to demonstrate, however, that commercially available software, such as FileMaker, can readily support the ICPS Framework and thereby has potential to assist RCAs and SE reporting. Other organizations may develop similar systems on other database platforms that incorporate the ICPS system into their reviews.

To implement I‐Tracker, we are now working with nursing and pharmacy leadership focus groups to develop formative tools, data collection forms, and other resources to assist their RCA efforts and data entry into the database. We also plan to apply the database tool to our residency training program to promote resident involvement in SE reviews by providing standardized, reproducible, and structured processes.16 Our 5‐state healthcare system has funded an evaluation of the implementation phase of I‐Tracker to other Providence facilities. Because the ICPS framework applies to all safety incidents beyond SEs (Table 2), a successful implementation of I‐Tracker for SEs will allow its eventual application to other types of critical incidents.

The strength of this project derives from its innovative development of an intranet‐based tool that allows groups to conform their RCAs to the ICPS framework. Because the absence of a standardized classification for patient safety concepts has hindered advances in patient safety,11 we believe I‐Tracker, or decision support tools like it that use the ICPS framework, can standardize RCAs and promote dissemination and adoption of action plans.

Recognition that healthcare carries considerable risks of patient injury has focused efforts on identifying problems before they occur, and understanding the root causes of those problems that do occur to prevent them from happening again.1 To further these efforts, a Joint Commission (JC) standard requires hospitals to review sentinel events (SE).2 Reviews must develop a timely, thorough, and credible root cause analysis (RCA), implement action plans to reduce risk, and monitor the effectiveness of implemented improvements.3

Ideally, hospitals would summarize their experiences with SE reviews, identify high‐risk activities and patients, institute system changes to prevent SE recurrences, and share their findings with other healthcare organizations to help them avoid similar patient injuries.1 In support of this last goal, the JC maintains a voluntary database system that allows hospitals to report their SE analyses for other facilities to review and institute preventative actions.

Unfortunately, the reality of SE reviews does not match their ideals for improving patient safety.4 Healthcare organizations often describe their review process as less than credible and note a need for ongoing oversight to maintain the reviews' effectiveness.5 The JC voluntary reporting system captures less than 1% of the SEs that occur nationally,2 because hospitals perceive barriers to external reporting.1 If healthcare organizations decide against reporting externally, they can create their own internal systems to aggregate and summarize SEs, but few such systems exist. A major impediment to designing internal systems is the absence of universally endorsed nomenclature for safety‐related events.6, 7 Poorly aligned terminology and subjective conceptualizations for safety incidents impede the aggregation of SEs, comparisons between facilities, and trend analyses for tracking SE patterns.

In 2005, the World Health Organization (WHO) World Alliance for Patient Safety, in collaboration with the JC, began developing an International Classification for Patient Safety (ICPS) to provide healthcare organizations a consistent conceptual model for safety incidents and promote their classification by a standardized taxonomy.810 Although this system has promise for allowing standardization, data aggregation, analysis, and learning between institutions,11 integration of the ICPS conceptual model into an SE decision support tool with summarizing and reporting features has not been reported.

This report describes our development of an intranet‐based SE reporting system, called Incident Tracker (I‐Tracker), based on the ICPS model. For our SE review groups from the 4 Providence Health Systems (PHS) Portland Service Area (PSA) hospitals, the I‐Tracker system offers a tool to guide efforts in developing RCAs and action plans in alignment with the ICPS framework. The system includes scripts that automatically generate and distribute standardized reports of individual and aggregated SEs. The objectives of this project were to report our experience with developing a flexible and accessible intranet‐based system that assists RCA participants in conforming to the ICPS framework and oversight safety staff in summarizing and reporting root cause analyses.

METHODS

The 4 PSA hospitals have 1083 licensed beds and perform SE reviews with a centralized process that reports results to a Community Governing Board. An ad hoc team for each SE performs the RCAs. The SE groups report RCAs and action plans in an unstructured format that varies for each event. A paper file is maintained for each SE report, but a system for aggregating reports to track trends, disseminating SE trends, or monitoring the completion or effectiveness of action plans is not available.

We designed a system to achieve the following objectives:

• 1

  Apply the ICPS framework (Figure 1) and taxonomy of terms to SE analyses;

• 2

  Provide a computer‐based tool to assist review groups and quality staff to perform their SE reviews and data collection in alignment with the ICPS framework;

• 3

  Create an intranet‐based database that captures elements of the reviews, RCAs, and action plans with the use of drop‐down lists, help windows, windows with live access to Internet educational resources and tools, decision support tools, default entries, and audio prompts to streamline data entry;

• 4

  Generate a suite of standardized reports customized for different audiences that can be accessed online and printed from the database with automated scripts;

• 5

  Produce intranet‐based summaries of aggregated events to identify common causes and disseminate observed patterns and action plans to other PSA hospitals.

Figure 1

We selected FileMaker Pro 11 Advanced (FMP11) for authoring and maintaining the decision support tool and database, and FileMaker Pro Server 11 Advanced (FMPS11) (Filemaker, Inc, Santa Clara, CA) for hosting the system, because it provides intranet access and tools for updating the system by personnel with minimal programming experience. End users can view and enter data through layouts that display only the information allowed by the user's login password and access privileges, with external authentication by Active Directory and Open Directory technology. Staff who author and manage the database do so through client FMP11 software loaded on a computer that provides remote server access.

The I‐Tracker system was authored using the ICPS definitions for the 48 preferred terms for safety incidents and the ICPS conceptual framework.8 The conceptual framework consists of 10 major incident domains, that include incident type, patient outcomes, patient characteristics, incident characteristics, contributing factors and hazards, organizational outcomes, detection, mitigating factors, ameliorating actions, and actions taken to reduce risk (Figure 1).11 The framework is applicable to all hospital safety incidents, but we limited I‐Tracker to SEs because our hospitals had completed comprehensive reviews and action plans only for these more serious events. The literature on the ICPS framework812 was carefully reviewed to identify the specific data fields that were recommended by ICPS developers to be included under each of the 10 major classification domains. In most instances, data fields existed only in the body of these reports. Article texts, however, provided sufficient descriptions of these data fields to allow their translation into data entry fields in I‐Tracker with accompanying help windows and explanations to guide I‐Tracker users. Sixty ICPS data fields were programmed into I‐Tracker, with another 120 fields that allowed entry of descriptions and explanations of the ICPS data field entries. For instance, an entry of Yes into an ICPS data field that queried Was there a systems problem of an external organization other than a Providence entity opens a Describe field that allows a brief description of the problem, and an additional Details field that allows a longer explanation of the problem if necessary. The brief Describe field contents populate an automatically generated fishbone diagram.

The authors and quality staff translated the most recent 15 SE reviews into ICPS terms and classifications, and entered the results into I‐Tracker as it was being developed, to assist system design and programming of the system. The authors noted during data entry which of the 10 ICPS major domains had not been analyzed by the previous 15 reviews. Because existing reports were unstructured with considerable variation in style and usage of terms, the authors and quality staff made group decisions regarding how to cross‐walk existing information into the standardized ICPS data fields.

RESULTS

In developing I‐Tracker, the authors and quality staff observed that the ICPS framework and recommended data fields were logical and straightforward to learn. Although it was difficult to find the definitions of specific ICPS data fields within the 10 major domains in the text of retrieved articles, these fields could be readily cross‐walked into I‐Tracker data entry fields. Translating existing SE reports into I‐Tracker classifications, however, presented considerable challenges because of the unstructured, discursive, and variable nature of our SE review and reports. The authors and staff spent 1 to 2 hours conferring over each report to make judgments as to which elements of the review would be entered into which I‐Tracker data fields. Once the authors and staff translated existing reports into ICPS terms, actual data entry into I‐Tracker took typically less than 30 minutes for each review. We found that none of our 15 SE reviews included information on the following ICPS major domains: detection, mitigating factors, and ameliorating actions. We also observed that many ICPS data fields were not assessed, such as patient contributions to errors and external organization's contributions to a safety incident.

The latest version of I‐Tracker receives and displays information at the individual patient level. Records are shown onscreen with different screen layouts depending on the viewer's login security clearance. Hospital safety staff have full access to view and enter data on the initial layout, which displays patient demographic information and folder tabs that navigate when clicked to other database fields (Figure 2). Viewers with lower security clearance either view the same opening screen, but have limited access to other screens, or view a different opening screen designed to meet their specific needs. All screens provide definitions of terms and information to assist data entry, buttons that navigate to help pages, pop‐up windows that provide tips, and buttons that trigger brief audio explanations. Most fields use drop‐down lists to standardize data entry around the ICPS definitions, with default values entered into many fields to streamline data entry. A list view allows review of all patients and quick access to an individual patient's record. All fields and combinations of fields with Boolean rules are searchable within the database.

Figure 2

I‐Tracker has features that support SE review groups in beginning an SE review by providing them a paper form or electronic interface by way of a portable computer or tablet device, that guides their discussions and analyses toward providing conclusions that can be entered into the database fields, thereby aligning their deliberations with the ICPS conceptual framework. The same resource is available within the database online for those groups who would prefer to use computer prompts and enter data directly into the database as they proceed through their analyses. Some layouts contain windows that port live views from external Web sites (eg, JC RCA resources) that provide participants of RCA groups with tools to assist their work. FMP11 allows users to access the database by portable computers or handheld tablet devices using the hospitals' WiFi network.

A report screen allows automatic generation of different printouts of individual or aggregate summary reports. A Comprehensive Report includes all of the data fields included in the ICPS conceptual framework. Other reports present subsets of data depending on the user's needs and access privileges. The FMPS11 database allows printing the reports to paper or Portable Document Format (pdf), exporting data into an Excel spreadsheet, or e‐mailing reports to recipients from within I‐Tracker.

Additionally, I‐Tracker functionality facilitates follow‐up and monitoring of action items developed during the RCA process in a manner that conforms to the ICPS framework. We are now developing educational resources for RCA team members to investigate the implementation of I‐Tracker into future RCAs.

DISCUSSION

I‐Tracker provides an intranet‐based tool that met the objectives of the present project. The process of entering 15 existing SE reviews and action plans from our healthcare system into I‐Tracker allowed an incremental development of the database and identified gaps in our existing RCA process. For instance, none of the previous RCAs critically appraised detection, mitigating factors, or ameliorating actions; defined the specific nature or quantified severity of patient injuries using standardized terms; distinguished between human errors and negligence; or comprehensively reported the full spectrum of underlying causes of Tracker's use of standardized terms based on the ICPS conceptual framework provided a potential resource for focusing SE reviews and producing more comprehensive RCAs and action plans in the future. I‐Tracker has additional potential to facilitate dissemination of RCAs to other facilities, both as individual incident reports and aggregated summaries as recommended by experts in patient safety.13

The deficiencies in our existing RCA analyses, identified during data entry into I‐Tracker, represent common shortcomings experienced by other healthcare organizations and summarized in a report by the Agency for Healthcare Research and Quality.4 Considerable hindsight bias and prevailing concerns of the day taint the RCA process, which is time‐consuming and labor intensive, and thereby hinders comprehensive reviews. Also, our SE reviews, like others reviewed in the literature,14 focused on biologic injury to patients and omitted assessment of psychologic, organizational, social, and economic injury domains. Although SE review teams benefit from involvement of quality improvement staff who are trained in techniques and goals of RCA,15 many hospitals like ours have limited resources for fully staffing all SE reviews with trained facilitators. These SE reviews generate both quantitative and qualitative data, the latter of which hinders standardized data entry in the absence of a conceptual framework. A structured database with formative tools to guide RCAs in conformance with the ICPS framework in organizations without sufficient numbers of trained facilitators offers opportunities to produce more comprehensive, standardized, and actionable reports. To date, our quality staff and leadership have responded positively to presentations of the functional features of I‐Tracker (Table 1).

Limitations of our report include its focus solely on the development and programming phase of I‐Tracker and the absence of information on its actual implementation. We believe, however, the development phase is important to report because it demonstrates that the ICPS framework and specific ICPS data fields are amenable to incorporation into a decision support and reporting tool, which to our knowledge has not been previously reported. We begin implementation of I‐Tracker within our organization this year and will have observations on its feasibility, acceptability, and staff training needs. As an additional limitation, we emphasize that we do not propose I‐Tracker as a solution for other organizations, because we have no plans for its commercial or public domain development. This report is intended to demonstrate, however, that commercially available software, such as FileMaker, can readily support the ICPS Framework and thereby has potential to assist RCAs and SE reporting. Other organizations may develop similar systems on other database platforms that incorporate the ICPS system into their reviews.

To implement I‐Tracker, we are now working with nursing and pharmacy leadership focus groups to develop formative tools, data collection forms, and other resources to assist their RCA efforts and data entry into the database. We also plan to apply the database tool to our residency training program to promote resident involvement in SE reviews by providing standardized, reproducible, and structured processes.16 Our 5‐state healthcare system has funded an evaluation of the implementation phase of I‐Tracker to other Providence facilities. Because the ICPS framework applies to all safety incidents beyond SEs (Table 2), a successful implementation of I‐Tracker for SEs will allow its eventual application to other types of critical incidents.

The strength of this project derives from its innovative development of an intranet‐based tool that allows groups to conform their RCAs to the ICPS framework. Because the absence of a standardized classification for patient safety concepts has hindered advances in patient safety,11 we believe I‐Tracker, or decision support tools like it that use the ICPS framework, can standardize RCAs and promote dissemination and adoption of action plans.

Hospitalists are the fastest growing segment of physicians in the United States.1 Given the growing field of Pediatric Hospital Medicine (PHM) and the need to define strategic direction, the Society of Hospital Medicine (SHM), the American Academy of Pediatrics (AAP), and the Academic Pediatric Association (APA) sponsored a strategic planning meeting in February 2009 that brought together 22 PHM leaders to discuss the future of the field.

PHM is at a critical juncture in terms of clinical practice, research, workforce issues, and quality improvement. The field has developed sufficiently to produce leaders capable of setting an agenda and moving forward. A discussion with the American Board of Pediatrics (ABP) by PHM leaders from the AAP, APA, and SHM at the Pediatric Hospital Medicine 2007 Conference regarding subspecialty designation stimulated convening the PHM Strategic Planning Roundtable to address the task of coordinating further development of PHM (Table 1).

The objective of this article is to describe: (1) the Strategic Planning Roundtable's vision for the field of pediatric hospital medicine; (2) the generation and progress on specific initiatives in clinical practice, quality, research, and workforce identified by the Strategic Planning Roundtable; and (3) issues in the designation of PHM as a subspecialty.

METHODS

The PHM Strategic Planning Roundtable was conducted by a facilitator (S.M.) during a 2‐day retreat using established healthcare strategic planning methods.2

Participants were the existing PHM leaders from the AAP, APA, and SHM, as well as other national leaders in clinical practice, quality, research, and workforce. Development of the vision statement was a key step in which the participants developed a consensus‐based aspirational view of the future. The draft version of the vision statement was initially developed after extensive interviews with key stakeholders and experts in PHM, and was revised by the participants in the course of a facilitated group discussion during the retreat. Following creation of the vision statement, the group then defined the elements of transformation pertaining to PHM and detailed the components of the vision.

Analysis of internal and external environmental factors was critical in the strategic planning process. This type of analysis, detailing the current state of PHM practice, permitted the strategic planners to understand the gaps that existed between the aspirational vision statement and today's reality, and set the stage to identify and implement initiatives to achieve the vision. Several months before the meeting, 4 expert panels comprised of PHM specialists representing a variety of academic and clinical practice settings were brought together via e‐mail and conference calls to focus on 4 domains of PHM: clinical practice, quality of care, research, and workforce. These groups were asked to describe the current status, challenges, and opportunities in these areas. Combining literature review and key stakeholder interviews, their findings and recommendations were distilled into brief summaries that were presented at the Roundtable meeting. Following the presentations, the participants, working in small groups representing all areas of focus,provided additional feedback.

Following the creation of a consensus vision statement and review of internal and external factors, the participants worked to identify specific initiatives in the 4 domains that would advance the field towards the goals contained in the vision statement. These initiatives were grouped into categories. Initiatives by category were scored and prioritized according to predetermined criteria including potential impact, cost, operational complexity, and achievability.

For each initiative selected, the group developed targets and metrics that would be used to track progress. Assigning leadership, accountability, and a timeline to each of the selected projects completed the implementation plan. In addition, the group developed an organizational structure to provide oversight for the overall process, and designated individuals representing the sponsoring organizations into those roles. In conclusion, the group discussed potential structures to guide the future of PHM.

CLINICAL PRACTICE

The Roundtable defined clinical practice for PHM as the general medical care of the hospitalized child, including direct patient care and leadership of the inpatient service. Clinical practice is affected by a number of current national trends including: fewer primary care providers interested in, or with the time to provide, inpatient care; resident work hour restrictions; increasing complexity of clinical issues; and increasing availability of pediatric hospitalists. At the hospital level, clinical practice is affected by increasing need for quality and safety measures, electronic health records and computerized physician order entry, and mounting financial pressures on the hospital system. Hospitalists are assuming more roles in leading quality and safety initiatives, creating computerized systems that address children's needs, and creating financially viable systems of quality pediatric care.3 Hospitalists' clinical care and leadership roles are emerging, and therefore the field faces training and mentorship issues.

Progress to date in this area includes 2 textbooks that define a scope of knowledge and practice, and a newly developed journal in PHM. Core competencies in PHM have been published and provide further refinement of scope and a template for future training.4

Multiple opportunities exist for hospitalists to establish themselves as clinical leaders. Hospitalists can become the preferred providers for hospitalized chronically ill children, with specific initiatives to improve care coordination and multidisciplinary communication. In addition to care coordination and decreasing length of stay, hospitalists, with their intimate knowledge of hospital operations, can be leaders in hospital capacity management and patient flow to increase operational efficiency. Hospitalists can expand evidence‐based guidelines for, and data about, inpatient conditions, and explore the effect of workload and hours on patient care. In addition, there is an expanding role into administrative areas, as well as alternate care arenas, such as: intensive care support (pediatric and neonatal), transport, sedation, palliative care, and pain management. Activities in administrative and alternate care areas have profound direct affects on patient care, as well as providing value added services and additional revenue streams which can further support clinical needs. Finally, achieving quality targets will likely be increasingly linked to payment, so hospitalists may play a key role in the incentives paid to their hospitals. Meeting these challenges will further solidify the standing of hospitalists in the clinical realm.

QUALITY

National and governmental agencies have influenced quality and performance improvement measurements in adult healthcare, resulting in improvements in adult healthcare quality measurement.5 There is limited similar influence or measure development in pediatric medicine, so the quality chasm between adult and child healthcare has widened. Few resources are invested in improving quality and safety of pediatric inpatient care. Of the 18 private health insurance plans' quality and pay for performance programs identified by Leapfrog, only 17% developed pediatric‐specific inpatient measures.6 Only 5 of 40 controlled trials of quality improvement efforts for children published between 1980 and 1998 addressed inpatient problems.7

There have been recent efforts at the national level addressing these issues, highlighted by the introduction of The Children's Health Care Quality Act, in 2007. Early studies in PHM systems focused on overall operational efficiency, documenting 9% to 16% decreases in length of stay and cost compared to traditional models of care.8 Conway et al. identified higher reported adherence to evidence‐based care for hospitalists compared to community pediatricians.9 However, Landrigan et al. demonstrated that there is still large variation in care that exists in the management of common inpatient diagnoses, lacking strong evidence‐based guidelines even among pediatric hospitalists.10 Moreover, there have been no significant studies reviewing the impact of pediatric hospitalists on safety of inpatient care. Magnifying these challenges is the reality that our healthcare system is fragmented with various entities scrambling to define, measure, and compare the effectiveness and safety of pediatric healthcare.

These challenges create an opportunity for PHM to develop a model of how to deliver the highest quality and safest care to our patients. The solution is complex and will take cooperation at many levels of our healthcare system. Improving the safety and quality of care for children in all settings of inpatient care in the United States may best be accomplished via an effective collaborative. This collaborative should be comprehensive and inclusive, and focused on demonstrating and disseminating how standardized, evidence‐based care in both clinical and safety domains can lead to high‐value and high‐quality outcomes. The success of PHM will be measured by its ability to deliver a clear value proposition to all consumers and payers of healthcare. The creation of a robust national collaborative network is a first step towards meeting this goal and will take an extraordinary effort. A PHM Quality Improvement (QI) Collaborative workgroup was created in August 2009. Three collaboratives have been commissioned: (1) Reduction of patient identification errors; (2) Improving discharge communication to referring primary care providers for pediatric hospitalist programs, and (3) Reducing the misuse and overuse of bronchodilators for bronchiolitis. All the collaborative groups have effectively engaged key groups of stakeholders and utilized standard QI tools, demonstrating improvement by the fall of 2010 (unpublished data, S.N.).

RESEARCH

Despite being a relatively young field, there is a critical mass of pediatric hospitalist‐investigators who are establishing research career paths for themselves by securing external grant funding for their work, publishing, and receiving mentorship from largely non‐hospitalist mentors. Some hospitalists are now in a position to mentor junior investigators. These hospitalist‐investigators identified a collective goal of working together across multiple sites in a clinical research network. The goal is to conduct high‐quality studies and provide the necessary clinical information to allow practicing hospitalists to make better decisions regarding patient care. This new inpatient evidence‐base will have the added advantage of helping further define the field of PHM.

The Pediatric Research in Inpatient Settings Network (PRIS) was identified as the vehicle to accomplish these goals. A series of objectives were identified to redesign PRIS in order to accommodate and organize this new influx of hospitalist‐investigators. These objectives included having hospitalist‐investigators commit their time to the prioritization, design, and execution of multicenter studies, drafting new governance documents for PRIS, securing external funding, redefining the relationships of the 3 existing organizations that formed PRIS (AAP, APA, SHM), defining how new clinical sites could be added to PRIS, creating a pipeline for junior hospitalist‐investigators to transition to leadership roles, securing a data coordinating center with established expertise in conducting multicenter studies, and establishing an external research advisory committee of leaders in pediatric clinical research and QI.

Several critical issues were identified, but funding remained a priority for the sustainability of PRIS. Comparative effectiveness (CE) was recognized as a potential important source of future funding. Pediatric studies on CE (eg, surgery vs medical management) conducted by PRIS would provide important new data to allow hospitalists to practice evidence‐based medicine and to improve quality.

A Research Leadership Task Force was created with 4 members of the PHM Strategic Planning Roundtable to work on the identified issues. The APA leadership worked with PRIS to establish a new Executive Council (comprised of additional qualified hospitalist‐investigators). The Executive Council was charged with accomplishing the tasks outlined from the Strategic Planning Roundtable. They have created the governance documents and standard operating procedures necessary for PRIS to conduct multicenter studies, defined a strategic framework for PRIS including the mission, vision and values, and funding strategy. In February 2010, PRIS received a 3‐year award for over $1 million from the Child Health Corporation of America to both fund the infrastructure of PRIS and to conduct a Prioritization Project. The Prioritization Project seeks to identify the conditions that are costly, prevalent, and demonstrate high inter‐hospital variation in resource utilization, which signals either lack of high‐quality data upon which to base medical decisions, and/or an opportunity to standardize care across hospitals. Some of these conditions will warrant further investigation to define the evidence base, whereas other conditions may require implementation studies to reliably introduce evidence into practice. Members of the Executive Council received additional funding to investigate community settings, as most children are hospitalized outside of large children's hospitals. PRIS also reengaged all 3 societies (APA, AAP, and SHM) for support for the first face‐to‐face meeting of the Executive Council. PRIS applied for 2 Recovery Act stimulus grants, and received funding for both of approximately $12 million. The processes used to design, provide feedback, and shepherd these initial studies formed the basis for the standard operating procedures for the Network. PRIS is now reengaging its membership to establish how sites may be able to conduct research, and receive new ideas to be considered for study in PRIS.

Although much work remains to be done, the Executive Council is continuing the charge with quarterly face‐to‐face meetings, hiring of a full‐time PRIS Coordinator, and carrying out these initial projects, while maintaining the goal of meeting the needs of the membership and PHM. If PRIS is to accomplish its mission of improving the health of, and healthcare delivery to, hospitalized children and their families, then the types of studies undertaken will include not only original research questions, but also comparative implementation methods to better understand how hospitalists in a variety of settings can best translate research findings into clinical practice and ultimately improve patient outcomes.

WORKFORCE

The current number of pediatric hospitalists is difficult to gauge11; estimates range from 1500 to 3000 physicians. There are groups of pediatric hospitalists within several national organizations including the AAP, APA, and SHM, in addition to a very active listserve community. It is likely that only a portion of pediatric hospitalists are represented by membership in these organizations.

Most physicians entering the field of PHM come directly out of residency. A recent survey by Freed et al.12 reported that 3% of current pediatric residents are interested in PHM as a career. In another survey by Freed et al., about 6% of recent pediatric residency graduates reported currently practicing as pediatric hospitalists.13 This difference may indicate a number of pediatricians practicing transiently as pediatric hospitalists.

There are numerous issues that will affect the growth and sustainability of PHM. A large number of pediatric residents entering the field will be needed to maintain current numbers. With 45% of hospitalists in practice less than 3 years,11 the growth of PHM in both numbers and influence will require an increasing number of hospitalists with sustained careers in the field. Recognition as experts in inpatient care, as well as expansion of the role of hospitalists beyond the clinical realm to education, research, and hospital leadership, will foster long‐term career satisfaction. The increasingly common stature of hospital medicine as an independent division, equivalent to general pediatrics and subspecialty divisions within a department, may further bolster the perception of hospital medicine as a career.

The majority of pediatric hospitalists believe that current pediatric residency training does not provide all of the skills necessary to practice as a pediatric hospitalist,14 though there is disagreement regarding how additional training in pediatric hospital medicine should be achieved: a dedicated fellowship versus continuing medical education (CME). There are several initiatives with the potential to transform the way pediatric hospitalists are trained and certified. The Residency Review and Redesign Project indicates that pediatric residency is likely to be reformed to better meet the training demands of the individual resident's chosen career path. Changing residency to better prepare pediatric residents to take positions in pediatric hospital medicine will certainly affect the workforce emerging from residency programs and their subsequent training needs.15 The American Board of Internal Medicine and the American Board of Family Medicine have approved a Recognition of Focused Practice in Hospital Medicine. This recognition is gained through the Maintenance of Certification (MOC) Program of the respective boards after a minimum of 3 years of practice. SHM is offering fellow recognition in tiered designations of Fellow of Hospital Medicine (FHM), Senior Fellow of Hospital Medicine, and Master of Hospital Medicine. Five hundred hospitalists, including many pediatric hospitalists, received the inaugural FHM designation in 2009. Organizational recognition is a common process in many other medical fields, although previously limited in pediatrics to Fellow of the AAP. FHM is an important step, but cannot substitute for specific training and certification.

Academic fellowships in PHM will aid in the training of hospitalists with scholarly skills and will help produce more pediatric hospitalists with clinical, quality, administrative, and leadership skills. A model of subspecialty fellowship training and certification of all PHM physicians would require a several‐fold increase in available fellowships, currently approximately 15.

Ongoing CME offerings are also critical to sustaining and developing the workforce. The annual national meetings of the APA, AAP, and SHM all offer PHM‐dedicated content, and there is an annual PHM conference sponsored by these 3 organizations. There are now multiple additional national and regional meetings focused on PHM, reflecting the growing audience for PHM CME content. The AAP offers a PHM study guide and an Education in quality improvement for pediatric practice (eQIPP) module on inpatient asthma, specifically designed to facilitate the MOC process for pediatric hospitalists.

Some form of ABP recognition may be necessary to provide the status for PHM to be widely recognized as a viable academic career in the larger pediatric community. This would entail standardized fellowships that will ensure graduates have demonstrated proficiency in the core competencies. PHM leaders have engaged the ABP to better understand the subspecialty approval process and thoughtfully examine the ramifications of subspecialty status, specifically what subspecialty certification would mean for PHM providers and hospitals. Achieving ABP certification may create a new standard of care meaning that noncertified PHM providers will be at a disadvantage. It is unknown what the impact on pediatric inpatient care would be if a PHM standard was set without the supply of practitioners to provide that care.

STRUCTURE

The efforts of the Roundtable demonstrate the potential effectiveness of the current structure that guides the field: that of the cooperative interchange between the PHM leaders within the APA, AAP, and SHM. It may be that, similar to Pediatric Emergency Medicine (PEM), no formal, unifying structure is necessary. Alternatively, both Adolescent Medicine and Behavioral and Developmental Pediatrics (BDP) have their own organizations that guide their respective fields. A hybrid model is that of Pediatric Cardiology which has the Joint Council on Congenital Heart Disease. This structure assures that the leaders of the various organizations concerned with congenital heart disease meet at least annually to report on their activities and coordinate future efforts. Its makeup is similar to how the planning committee of the annual national PHM conference is constructed. Although PHM has largely succeeded with the current organizational structure, it is possible that a more formal structure is needed to continue forward.

CONCLUSION

The Roundtable members developed the following vision for PHM: Pediatric hospitalists will transform the delivery of hospital care for children. This will be done by achieving 7 goals (Table 2).

Attaining this vision will take tremendous dedication, effort, and collaboration. As a starting point, the following initiatives were proposed and implemented as noted:

Hospitalists are the fastest growing segment of physicians in the United States.1 Given the growing field of Pediatric Hospital Medicine (PHM) and the need to define strategic direction, the Society of Hospital Medicine (SHM), the American Academy of Pediatrics (AAP), and the Academic Pediatric Association (APA) sponsored a strategic planning meeting in February 2009 that brought together 22 PHM leaders to discuss the future of the field.

PHM is at a critical juncture in terms of clinical practice, research, workforce issues, and quality improvement. The field has developed sufficiently to produce leaders capable of setting an agenda and moving forward. A discussion with the American Board of Pediatrics (ABP) by PHM leaders from the AAP, APA, and SHM at the Pediatric Hospital Medicine 2007 Conference regarding subspecialty designation stimulated convening the PHM Strategic Planning Roundtable to address the task of coordinating further development of PHM (Table 1).

The objective of this article is to describe: (1) the Strategic Planning Roundtable's vision for the field of pediatric hospital medicine; (2) the generation and progress on specific initiatives in clinical practice, quality, research, and workforce identified by the Strategic Planning Roundtable; and (3) issues in the designation of PHM as a subspecialty.

METHODS

The PHM Strategic Planning Roundtable was conducted by a facilitator (S.M.) during a 2‐day retreat using established healthcare strategic planning methods.2

Participants were the existing PHM leaders from the AAP, APA, and SHM, as well as other national leaders in clinical practice, quality, research, and workforce. Development of the vision statement was a key step in which the participants developed a consensus‐based aspirational view of the future. The draft version of the vision statement was initially developed after extensive interviews with key stakeholders and experts in PHM, and was revised by the participants in the course of a facilitated group discussion during the retreat. Following creation of the vision statement, the group then defined the elements of transformation pertaining to PHM and detailed the components of the vision.

Analysis of internal and external environmental factors was critical in the strategic planning process. This type of analysis, detailing the current state of PHM practice, permitted the strategic planners to understand the gaps that existed between the aspirational vision statement and today's reality, and set the stage to identify and implement initiatives to achieve the vision. Several months before the meeting, 4 expert panels comprised of PHM specialists representing a variety of academic and clinical practice settings were brought together via e‐mail and conference calls to focus on 4 domains of PHM: clinical practice, quality of care, research, and workforce. These groups were asked to describe the current status, challenges, and opportunities in these areas. Combining literature review and key stakeholder interviews, their findings and recommendations were distilled into brief summaries that were presented at the Roundtable meeting. Following the presentations, the participants, working in small groups representing all areas of focus,provided additional feedback.

Following the creation of a consensus vision statement and review of internal and external factors, the participants worked to identify specific initiatives in the 4 domains that would advance the field towards the goals contained in the vision statement. These initiatives were grouped into categories. Initiatives by category were scored and prioritized according to predetermined criteria including potential impact, cost, operational complexity, and achievability.

For each initiative selected, the group developed targets and metrics that would be used to track progress. Assigning leadership, accountability, and a timeline to each of the selected projects completed the implementation plan. In addition, the group developed an organizational structure to provide oversight for the overall process, and designated individuals representing the sponsoring organizations into those roles. In conclusion, the group discussed potential structures to guide the future of PHM.

CLINICAL PRACTICE

The Roundtable defined clinical practice for PHM as the general medical care of the hospitalized child, including direct patient care and leadership of the inpatient service. Clinical practice is affected by a number of current national trends including: fewer primary care providers interested in, or with the time to provide, inpatient care; resident work hour restrictions; increasing complexity of clinical issues; and increasing availability of pediatric hospitalists. At the hospital level, clinical practice is affected by increasing need for quality and safety measures, electronic health records and computerized physician order entry, and mounting financial pressures on the hospital system. Hospitalists are assuming more roles in leading quality and safety initiatives, creating computerized systems that address children's needs, and creating financially viable systems of quality pediatric care.3 Hospitalists' clinical care and leadership roles are emerging, and therefore the field faces training and mentorship issues.

Progress to date in this area includes 2 textbooks that define a scope of knowledge and practice, and a newly developed journal in PHM. Core competencies in PHM have been published and provide further refinement of scope and a template for future training.4

Multiple opportunities exist for hospitalists to establish themselves as clinical leaders. Hospitalists can become the preferred providers for hospitalized chronically ill children, with specific initiatives to improve care coordination and multidisciplinary communication. In addition to care coordination and decreasing length of stay, hospitalists, with their intimate knowledge of hospital operations, can be leaders in hospital capacity management and patient flow to increase operational efficiency. Hospitalists can expand evidence‐based guidelines for, and data about, inpatient conditions, and explore the effect of workload and hours on patient care. In addition, there is an expanding role into administrative areas, as well as alternate care arenas, such as: intensive care support (pediatric and neonatal), transport, sedation, palliative care, and pain management. Activities in administrative and alternate care areas have profound direct affects on patient care, as well as providing value added services and additional revenue streams which can further support clinical needs. Finally, achieving quality targets will likely be increasingly linked to payment, so hospitalists may play a key role in the incentives paid to their hospitals. Meeting these challenges will further solidify the standing of hospitalists in the clinical realm.

QUALITY

National and governmental agencies have influenced quality and performance improvement measurements in adult healthcare, resulting in improvements in adult healthcare quality measurement.5 There is limited similar influence or measure development in pediatric medicine, so the quality chasm between adult and child healthcare has widened. Few resources are invested in improving quality and safety of pediatric inpatient care. Of the 18 private health insurance plans' quality and pay for performance programs identified by Leapfrog, only 17% developed pediatric‐specific inpatient measures.6 Only 5 of 40 controlled trials of quality improvement efforts for children published between 1980 and 1998 addressed inpatient problems.7

There have been recent efforts at the national level addressing these issues, highlighted by the introduction of The Children's Health Care Quality Act, in 2007. Early studies in PHM systems focused on overall operational efficiency, documenting 9% to 16% decreases in length of stay and cost compared to traditional models of care.8 Conway et al. identified higher reported adherence to evidence‐based care for hospitalists compared to community pediatricians.9 However, Landrigan et al. demonstrated that there is still large variation in care that exists in the management of common inpatient diagnoses, lacking strong evidence‐based guidelines even among pediatric hospitalists.10 Moreover, there have been no significant studies reviewing the impact of pediatric hospitalists on safety of inpatient care. Magnifying these challenges is the reality that our healthcare system is fragmented with various entities scrambling to define, measure, and compare the effectiveness and safety of pediatric healthcare.

These challenges create an opportunity for PHM to develop a model of how to deliver the highest quality and safest care to our patients. The solution is complex and will take cooperation at many levels of our healthcare system. Improving the safety and quality of care for children in all settings of inpatient care in the United States may best be accomplished via an effective collaborative. This collaborative should be comprehensive and inclusive, and focused on demonstrating and disseminating how standardized, evidence‐based care in both clinical and safety domains can lead to high‐value and high‐quality outcomes. The success of PHM will be measured by its ability to deliver a clear value proposition to all consumers and payers of healthcare. The creation of a robust national collaborative network is a first step towards meeting this goal and will take an extraordinary effort. A PHM Quality Improvement (QI) Collaborative workgroup was created in August 2009. Three collaboratives have been commissioned: (1) Reduction of patient identification errors; (2) Improving discharge communication to referring primary care providers for pediatric hospitalist programs, and (3) Reducing the misuse and overuse of bronchodilators for bronchiolitis. All the collaborative groups have effectively engaged key groups of stakeholders and utilized standard QI tools, demonstrating improvement by the fall of 2010 (unpublished data, S.N.).

RESEARCH

Despite being a relatively young field, there is a critical mass of pediatric hospitalist‐investigators who are establishing research career paths for themselves by securing external grant funding for their work, publishing, and receiving mentorship from largely non‐hospitalist mentors. Some hospitalists are now in a position to mentor junior investigators. These hospitalist‐investigators identified a collective goal of working together across multiple sites in a clinical research network. The goal is to conduct high‐quality studies and provide the necessary clinical information to allow practicing hospitalists to make better decisions regarding patient care. This new inpatient evidence‐base will have the added advantage of helping further define the field of PHM.

The Pediatric Research in Inpatient Settings Network (PRIS) was identified as the vehicle to accomplish these goals. A series of objectives were identified to redesign PRIS in order to accommodate and organize this new influx of hospitalist‐investigators. These objectives included having hospitalist‐investigators commit their time to the prioritization, design, and execution of multicenter studies, drafting new governance documents for PRIS, securing external funding, redefining the relationships of the 3 existing organizations that formed PRIS (AAP, APA, SHM), defining how new clinical sites could be added to PRIS, creating a pipeline for junior hospitalist‐investigators to transition to leadership roles, securing a data coordinating center with established expertise in conducting multicenter studies, and establishing an external research advisory committee of leaders in pediatric clinical research and QI.

Several critical issues were identified, but funding remained a priority for the sustainability of PRIS. Comparative effectiveness (CE) was recognized as a potential important source of future funding. Pediatric studies on CE (eg, surgery vs medical management) conducted by PRIS would provide important new data to allow hospitalists to practice evidence‐based medicine and to improve quality.

A Research Leadership Task Force was created with 4 members of the PHM Strategic Planning Roundtable to work on the identified issues. The APA leadership worked with PRIS to establish a new Executive Council (comprised of additional qualified hospitalist‐investigators). The Executive Council was charged with accomplishing the tasks outlined from the Strategic Planning Roundtable. They have created the governance documents and standard operating procedures necessary for PRIS to conduct multicenter studies, defined a strategic framework for PRIS including the mission, vision and values, and funding strategy. In February 2010, PRIS received a 3‐year award for over $1 million from the Child Health Corporation of America to both fund the infrastructure of PRIS and to conduct a Prioritization Project. The Prioritization Project seeks to identify the conditions that are costly, prevalent, and demonstrate high inter‐hospital variation in resource utilization, which signals either lack of high‐quality data upon which to base medical decisions, and/or an opportunity to standardize care across hospitals. Some of these conditions will warrant further investigation to define the evidence base, whereas other conditions may require implementation studies to reliably introduce evidence into practice. Members of the Executive Council received additional funding to investigate community settings, as most children are hospitalized outside of large children's hospitals. PRIS also reengaged all 3 societies (APA, AAP, and SHM) for support for the first face‐to‐face meeting of the Executive Council. PRIS applied for 2 Recovery Act stimulus grants, and received funding for both of approximately $12 million. The processes used to design, provide feedback, and shepherd these initial studies formed the basis for the standard operating procedures for the Network. PRIS is now reengaging its membership to establish how sites may be able to conduct research, and receive new ideas to be considered for study in PRIS.

Although much work remains to be done, the Executive Council is continuing the charge with quarterly face‐to‐face meetings, hiring of a full‐time PRIS Coordinator, and carrying out these initial projects, while maintaining the goal of meeting the needs of the membership and PHM. If PRIS is to accomplish its mission of improving the health of, and healthcare delivery to, hospitalized children and their families, then the types of studies undertaken will include not only original research questions, but also comparative implementation methods to better understand how hospitalists in a variety of settings can best translate research findings into clinical practice and ultimately improve patient outcomes.

WORKFORCE

The current number of pediatric hospitalists is difficult to gauge11; estimates range from 1500 to 3000 physicians. There are groups of pediatric hospitalists within several national organizations including the AAP, APA, and SHM, in addition to a very active listserve community. It is likely that only a portion of pediatric hospitalists are represented by membership in these organizations.

Most physicians entering the field of PHM come directly out of residency. A recent survey by Freed et al.12 reported that 3% of current pediatric residents are interested in PHM as a career. In another survey by Freed et al., about 6% of recent pediatric residency graduates reported currently practicing as pediatric hospitalists.13 This difference may indicate a number of pediatricians practicing transiently as pediatric hospitalists.

There are numerous issues that will affect the growth and sustainability of PHM. A large number of pediatric residents entering the field will be needed to maintain current numbers. With 45% of hospitalists in practice less than 3 years,11 the growth of PHM in both numbers and influence will require an increasing number of hospitalists with sustained careers in the field. Recognition as experts in inpatient care, as well as expansion of the role of hospitalists beyond the clinical realm to education, research, and hospital leadership, will foster long‐term career satisfaction. The increasingly common stature of hospital medicine as an independent division, equivalent to general pediatrics and subspecialty divisions within a department, may further bolster the perception of hospital medicine as a career.

The majority of pediatric hospitalists believe that current pediatric residency training does not provide all of the skills necessary to practice as a pediatric hospitalist,14 though there is disagreement regarding how additional training in pediatric hospital medicine should be achieved: a dedicated fellowship versus continuing medical education (CME). There are several initiatives with the potential to transform the way pediatric hospitalists are trained and certified. The Residency Review and Redesign Project indicates that pediatric residency is likely to be reformed to better meet the training demands of the individual resident's chosen career path. Changing residency to better prepare pediatric residents to take positions in pediatric hospital medicine will certainly affect the workforce emerging from residency programs and their subsequent training needs.15 The American Board of Internal Medicine and the American Board of Family Medicine have approved a Recognition of Focused Practice in Hospital Medicine. This recognition is gained through the Maintenance of Certification (MOC) Program of the respective boards after a minimum of 3 years of practice. SHM is offering fellow recognition in tiered designations of Fellow of Hospital Medicine (FHM), Senior Fellow of Hospital Medicine, and Master of Hospital Medicine. Five hundred hospitalists, including many pediatric hospitalists, received the inaugural FHM designation in 2009. Organizational recognition is a common process in many other medical fields, although previously limited in pediatrics to Fellow of the AAP. FHM is an important step, but cannot substitute for specific training and certification.

Academic fellowships in PHM will aid in the training of hospitalists with scholarly skills and will help produce more pediatric hospitalists with clinical, quality, administrative, and leadership skills. A model of subspecialty fellowship training and certification of all PHM physicians would require a several‐fold increase in available fellowships, currently approximately 15.

Ongoing CME offerings are also critical to sustaining and developing the workforce. The annual national meetings of the APA, AAP, and SHM all offer PHM‐dedicated content, and there is an annual PHM conference sponsored by these 3 organizations. There are now multiple additional national and regional meetings focused on PHM, reflecting the growing audience for PHM CME content. The AAP offers a PHM study guide and an Education in quality improvement for pediatric practice (eQIPP) module on inpatient asthma, specifically designed to facilitate the MOC process for pediatric hospitalists.

Some form of ABP recognition may be necessary to provide the status for PHM to be widely recognized as a viable academic career in the larger pediatric community. This would entail standardized fellowships that will ensure graduates have demonstrated proficiency in the core competencies. PHM leaders have engaged the ABP to better understand the subspecialty approval process and thoughtfully examine the ramifications of subspecialty status, specifically what subspecialty certification would mean for PHM providers and hospitals. Achieving ABP certification may create a new standard of care meaning that noncertified PHM providers will be at a disadvantage. It is unknown what the impact on pediatric inpatient care would be if a PHM standard was set without the supply of practitioners to provide that care.

STRUCTURE

The efforts of the Roundtable demonstrate the potential effectiveness of the current structure that guides the field: that of the cooperative interchange between the PHM leaders within the APA, AAP, and SHM. It may be that, similar to Pediatric Emergency Medicine (PEM), no formal, unifying structure is necessary. Alternatively, both Adolescent Medicine and Behavioral and Developmental Pediatrics (BDP) have their own organizations that guide their respective fields. A hybrid model is that of Pediatric Cardiology which has the Joint Council on Congenital Heart Disease. This structure assures that the leaders of the various organizations concerned with congenital heart disease meet at least annually to report on their activities and coordinate future efforts. Its makeup is similar to how the planning committee of the annual national PHM conference is constructed. Although PHM has largely succeeded with the current organizational structure, it is possible that a more formal structure is needed to continue forward.

CONCLUSION

The Roundtable members developed the following vision for PHM: Pediatric hospitalists will transform the delivery of hospital care for children. This will be done by achieving 7 goals (Table 2).

Attaining this vision will take tremendous dedication, effort, and collaboration. As a starting point, the following initiatives were proposed and implemented as noted:

Hospitalists are the fastest growing segment of physicians in the United States.1 Given the growing field of Pediatric Hospital Medicine (PHM) and the need to define strategic direction, the Society of Hospital Medicine (SHM), the American Academy of Pediatrics (AAP), and the Academic Pediatric Association (APA) sponsored a strategic planning meeting in February 2009 that brought together 22 PHM leaders to discuss the future of the field.

PHM is at a critical juncture in terms of clinical practice, research, workforce issues, and quality improvement. The field has developed sufficiently to produce leaders capable of setting an agenda and moving forward. A discussion with the American Board of Pediatrics (ABP) by PHM leaders from the AAP, APA, and SHM at the Pediatric Hospital Medicine 2007 Conference regarding subspecialty designation stimulated convening the PHM Strategic Planning Roundtable to address the task of coordinating further development of PHM (Table 1).

The objective of this article is to describe: (1) the Strategic Planning Roundtable's vision for the field of pediatric hospital medicine; (2) the generation and progress on specific initiatives in clinical practice, quality, research, and workforce identified by the Strategic Planning Roundtable; and (3) issues in the designation of PHM as a subspecialty.

METHODS

The PHM Strategic Planning Roundtable was conducted by a facilitator (S.M.) during a 2‐day retreat using established healthcare strategic planning methods.2

Participants were the existing PHM leaders from the AAP, APA, and SHM, as well as other national leaders in clinical practice, quality, research, and workforce. Development of the vision statement was a key step in which the participants developed a consensus‐based aspirational view of the future. The draft version of the vision statement was initially developed after extensive interviews with key stakeholders and experts in PHM, and was revised by the participants in the course of a facilitated group discussion during the retreat. Following creation of the vision statement, the group then defined the elements of transformation pertaining to PHM and detailed the components of the vision.

Analysis of internal and external environmental factors was critical in the strategic planning process. This type of analysis, detailing the current state of PHM practice, permitted the strategic planners to understand the gaps that existed between the aspirational vision statement and today's reality, and set the stage to identify and implement initiatives to achieve the vision. Several months before the meeting, 4 expert panels comprised of PHM specialists representing a variety of academic and clinical practice settings were brought together via e‐mail and conference calls to focus on 4 domains of PHM: clinical practice, quality of care, research, and workforce. These groups were asked to describe the current status, challenges, and opportunities in these areas. Combining literature review and key stakeholder interviews, their findings and recommendations were distilled into brief summaries that were presented at the Roundtable meeting. Following the presentations, the participants, working in small groups representing all areas of focus,provided additional feedback.

Following the creation of a consensus vision statement and review of internal and external factors, the participants worked to identify specific initiatives in the 4 domains that would advance the field towards the goals contained in the vision statement. These initiatives were grouped into categories. Initiatives by category were scored and prioritized according to predetermined criteria including potential impact, cost, operational complexity, and achievability.

For each initiative selected, the group developed targets and metrics that would be used to track progress. Assigning leadership, accountability, and a timeline to each of the selected projects completed the implementation plan. In addition, the group developed an organizational structure to provide oversight for the overall process, and designated individuals representing the sponsoring organizations into those roles. In conclusion, the group discussed potential structures to guide the future of PHM.

CLINICAL PRACTICE

The Roundtable defined clinical practice for PHM as the general medical care of the hospitalized child, including direct patient care and leadership of the inpatient service. Clinical practice is affected by a number of current national trends including: fewer primary care providers interested in, or with the time to provide, inpatient care; resident work hour restrictions; increasing complexity of clinical issues; and increasing availability of pediatric hospitalists. At the hospital level, clinical practice is affected by increasing need for quality and safety measures, electronic health records and computerized physician order entry, and mounting financial pressures on the hospital system. Hospitalists are assuming more roles in leading quality and safety initiatives, creating computerized systems that address children's needs, and creating financially viable systems of quality pediatric care.3 Hospitalists' clinical care and leadership roles are emerging, and therefore the field faces training and mentorship issues.

Progress to date in this area includes 2 textbooks that define a scope of knowledge and practice, and a newly developed journal in PHM. Core competencies in PHM have been published and provide further refinement of scope and a template for future training.4

Multiple opportunities exist for hospitalists to establish themselves as clinical leaders. Hospitalists can become the preferred providers for hospitalized chronically ill children, with specific initiatives to improve care coordination and multidisciplinary communication. In addition to care coordination and decreasing length of stay, hospitalists, with their intimate knowledge of hospital operations, can be leaders in hospital capacity management and patient flow to increase operational efficiency. Hospitalists can expand evidence‐based guidelines for, and data about, inpatient conditions, and explore the effect of workload and hours on patient care. In addition, there is an expanding role into administrative areas, as well as alternate care arenas, such as: intensive care support (pediatric and neonatal), transport, sedation, palliative care, and pain management. Activities in administrative and alternate care areas have profound direct affects on patient care, as well as providing value added services and additional revenue streams which can further support clinical needs. Finally, achieving quality targets will likely be increasingly linked to payment, so hospitalists may play a key role in the incentives paid to their hospitals. Meeting these challenges will further solidify the standing of hospitalists in the clinical realm.

QUALITY

National and governmental agencies have influenced quality and performance improvement measurements in adult healthcare, resulting in improvements in adult healthcare quality measurement.5 There is limited similar influence or measure development in pediatric medicine, so the quality chasm between adult and child healthcare has widened. Few resources are invested in improving quality and safety of pediatric inpatient care. Of the 18 private health insurance plans' quality and pay for performance programs identified by Leapfrog, only 17% developed pediatric‐specific inpatient measures.6 Only 5 of 40 controlled trials of quality improvement efforts for children published between 1980 and 1998 addressed inpatient problems.7

There have been recent efforts at the national level addressing these issues, highlighted by the introduction of The Children's Health Care Quality Act, in 2007. Early studies in PHM systems focused on overall operational efficiency, documenting 9% to 16% decreases in length of stay and cost compared to traditional models of care.8 Conway et al. identified higher reported adherence to evidence‐based care for hospitalists compared to community pediatricians.9 However, Landrigan et al. demonstrated that there is still large variation in care that exists in the management of common inpatient diagnoses, lacking strong evidence‐based guidelines even among pediatric hospitalists.10 Moreover, there have been no significant studies reviewing the impact of pediatric hospitalists on safety of inpatient care. Magnifying these challenges is the reality that our healthcare system is fragmented with various entities scrambling to define, measure, and compare the effectiveness and safety of pediatric healthcare.

These challenges create an opportunity for PHM to develop a model of how to deliver the highest quality and safest care to our patients. The solution is complex and will take cooperation at many levels of our healthcare system. Improving the safety and quality of care for children in all settings of inpatient care in the United States may best be accomplished via an effective collaborative. This collaborative should be comprehensive and inclusive, and focused on demonstrating and disseminating how standardized, evidence‐based care in both clinical and safety domains can lead to high‐value and high‐quality outcomes. The success of PHM will be measured by its ability to deliver a clear value proposition to all consumers and payers of healthcare. The creation of a robust national collaborative network is a first step towards meeting this goal and will take an extraordinary effort. A PHM Quality Improvement (QI) Collaborative workgroup was created in August 2009. Three collaboratives have been commissioned: (1) Reduction of patient identification errors; (2) Improving discharge communication to referring primary care providers for pediatric hospitalist programs, and (3) Reducing the misuse and overuse of bronchodilators for bronchiolitis. All the collaborative groups have effectively engaged key groups of stakeholders and utilized standard QI tools, demonstrating improvement by the fall of 2010 (unpublished data, S.N.).

RESEARCH

Despite being a relatively young field, there is a critical mass of pediatric hospitalist‐investigators who are establishing research career paths for themselves by securing external grant funding for their work, publishing, and receiving mentorship from largely non‐hospitalist mentors. Some hospitalists are now in a position to mentor junior investigators. These hospitalist‐investigators identified a collective goal of working together across multiple sites in a clinical research network. The goal is to conduct high‐quality studies and provide the necessary clinical information to allow practicing hospitalists to make better decisions regarding patient care. This new inpatient evidence‐base will have the added advantage of helping further define the field of PHM.

The Pediatric Research in Inpatient Settings Network (PRIS) was identified as the vehicle to accomplish these goals. A series of objectives were identified to redesign PRIS in order to accommodate and organize this new influx of hospitalist‐investigators. These objectives included having hospitalist‐investigators commit their time to the prioritization, design, and execution of multicenter studies, drafting new governance documents for PRIS, securing external funding, redefining the relationships of the 3 existing organizations that formed PRIS (AAP, APA, SHM), defining how new clinical sites could be added to PRIS, creating a pipeline for junior hospitalist‐investigators to transition to leadership roles, securing a data coordinating center with established expertise in conducting multicenter studies, and establishing an external research advisory committee of leaders in pediatric clinical research and QI.

Several critical issues were identified, but funding remained a priority for the sustainability of PRIS. Comparative effectiveness (CE) was recognized as a potential important source of future funding. Pediatric studies on CE (eg, surgery vs medical management) conducted by PRIS would provide important new data to allow hospitalists to practice evidence‐based medicine and to improve quality.

A Research Leadership Task Force was created with 4 members of the PHM Strategic Planning Roundtable to work on the identified issues. The APA leadership worked with PRIS to establish a new Executive Council (comprised of additional qualified hospitalist‐investigators). The Executive Council was charged with accomplishing the tasks outlined from the Strategic Planning Roundtable. They have created the governance documents and standard operating procedures necessary for PRIS to conduct multicenter studies, defined a strategic framework for PRIS including the mission, vision and values, and funding strategy. In February 2010, PRIS received a 3‐year award for over $1 million from the Child Health Corporation of America to both fund the infrastructure of PRIS and to conduct a Prioritization Project. The Prioritization Project seeks to identify the conditions that are costly, prevalent, and demonstrate high inter‐hospital variation in resource utilization, which signals either lack of high‐quality data upon which to base medical decisions, and/or an opportunity to standardize care across hospitals. Some of these conditions will warrant further investigation to define the evidence base, whereas other conditions may require implementation studies to reliably introduce evidence into practice. Members of the Executive Council received additional funding to investigate community settings, as most children are hospitalized outside of large children's hospitals. PRIS also reengaged all 3 societies (APA, AAP, and SHM) for support for the first face‐to‐face meeting of the Executive Council. PRIS applied for 2 Recovery Act stimulus grants, and received funding for both of approximately $12 million. The processes used to design, provide feedback, and shepherd these initial studies formed the basis for the standard operating procedures for the Network. PRIS is now reengaging its membership to establish how sites may be able to conduct research, and receive new ideas to be considered for study in PRIS.

Although much work remains to be done, the Executive Council is continuing the charge with quarterly face‐to‐face meetings, hiring of a full‐time PRIS Coordinator, and carrying out these initial projects, while maintaining the goal of meeting the needs of the membership and PHM. If PRIS is to accomplish its mission of improving the health of, and healthcare delivery to, hospitalized children and their families, then the types of studies undertaken will include not only original research questions, but also comparative implementation methods to better understand how hospitalists in a variety of settings can best translate research findings into clinical practice and ultimately improve patient outcomes.

WORKFORCE

The current number of pediatric hospitalists is difficult to gauge11; estimates range from 1500 to 3000 physicians. There are groups of pediatric hospitalists within several national organizations including the AAP, APA, and SHM, in addition to a very active listserve community. It is likely that only a portion of pediatric hospitalists are represented by membership in these organizations.

Most physicians entering the field of PHM come directly out of residency. A recent survey by Freed et al.12 reported that 3% of current pediatric residents are interested in PHM as a career. In another survey by Freed et al., about 6% of recent pediatric residency graduates reported currently practicing as pediatric hospitalists.13 This difference may indicate a number of pediatricians practicing transiently as pediatric hospitalists.

There are numerous issues that will affect the growth and sustainability of PHM. A large number of pediatric residents entering the field will be needed to maintain current numbers. With 45% of hospitalists in practice less than 3 years,11 the growth of PHM in both numbers and influence will require an increasing number of hospitalists with sustained careers in the field. Recognition as experts in inpatient care, as well as expansion of the role of hospitalists beyond the clinical realm to education, research, and hospital leadership, will foster long‐term career satisfaction. The increasingly common stature of hospital medicine as an independent division, equivalent to general pediatrics and subspecialty divisions within a department, may further bolster the perception of hospital medicine as a career.

The majority of pediatric hospitalists believe that current pediatric residency training does not provide all of the skills necessary to practice as a pediatric hospitalist,14 though there is disagreement regarding how additional training in pediatric hospital medicine should be achieved: a dedicated fellowship versus continuing medical education (CME). There are several initiatives with the potential to transform the way pediatric hospitalists are trained and certified. The Residency Review and Redesign Project indicates that pediatric residency is likely to be reformed to better meet the training demands of the individual resident's chosen career path. Changing residency to better prepare pediatric residents to take positions in pediatric hospital medicine will certainly affect the workforce emerging from residency programs and their subsequent training needs.15 The American Board of Internal Medicine and the American Board of Family Medicine have approved a Recognition of Focused Practice in Hospital Medicine. This recognition is gained through the Maintenance of Certification (MOC) Program of the respective boards after a minimum of 3 years of practice. SHM is offering fellow recognition in tiered designations of Fellow of Hospital Medicine (FHM), Senior Fellow of Hospital Medicine, and Master of Hospital Medicine. Five hundred hospitalists, including many pediatric hospitalists, received the inaugural FHM designation in 2009. Organizational recognition is a common process in many other medical fields, although previously limited in pediatrics to Fellow of the AAP. FHM is an important step, but cannot substitute for specific training and certification.

Academic fellowships in PHM will aid in the training of hospitalists with scholarly skills and will help produce more pediatric hospitalists with clinical, quality, administrative, and leadership skills. A model of subspecialty fellowship training and certification of all PHM physicians would require a several‐fold increase in available fellowships, currently approximately 15.

Ongoing CME offerings are also critical to sustaining and developing the workforce. The annual national meetings of the APA, AAP, and SHM all offer PHM‐dedicated content, and there is an annual PHM conference sponsored by these 3 organizations. There are now multiple additional national and regional meetings focused on PHM, reflecting the growing audience for PHM CME content. The AAP offers a PHM study guide and an Education in quality improvement for pediatric practice (eQIPP) module on inpatient asthma, specifically designed to facilitate the MOC process for pediatric hospitalists.

Some form of ABP recognition may be necessary to provide the status for PHM to be widely recognized as a viable academic career in the larger pediatric community. This would entail standardized fellowships that will ensure graduates have demonstrated proficiency in the core competencies. PHM leaders have engaged the ABP to better understand the subspecialty approval process and thoughtfully examine the ramifications of subspecialty status, specifically what subspecialty certification would mean for PHM providers and hospitals. Achieving ABP certification may create a new standard of care meaning that noncertified PHM providers will be at a disadvantage. It is unknown what the impact on pediatric inpatient care would be if a PHM standard was set without the supply of practitioners to provide that care.

STRUCTURE

The efforts of the Roundtable demonstrate the potential effectiveness of the current structure that guides the field: that of the cooperative interchange between the PHM leaders within the APA, AAP, and SHM. It may be that, similar to Pediatric Emergency Medicine (PEM), no formal, unifying structure is necessary. Alternatively, both Adolescent Medicine and Behavioral and Developmental Pediatrics (BDP) have their own organizations that guide their respective fields. A hybrid model is that of Pediatric Cardiology which has the Joint Council on Congenital Heart Disease. This structure assures that the leaders of the various organizations concerned with congenital heart disease meet at least annually to report on their activities and coordinate future efforts. Its makeup is similar to how the planning committee of the annual national PHM conference is constructed. Although PHM has largely succeeded with the current organizational structure, it is possible that a more formal structure is needed to continue forward.

CONCLUSION

The Roundtable members developed the following vision for PHM: Pediatric hospitalists will transform the delivery of hospital care for children. This will be done by achieving 7 goals (Table 2).

Attaining this vision will take tremendous dedication, effort, and collaboration. As a starting point, the following initiatives were proposed and implemented as noted:

Smooth and timely hospital patient flow can have multiple positive effects including reduced wait times for services, decreased congestion in the Emergency Department (ED), and increased patient and staff satisfaction.14 One way to improve patient flow is to remove variation along the care pathway.57

For teaching hospitals that provide team‐based care, 1 significant source of variation involves the emergent admission process.8, 9 Typically, for services that admit the majority of their patients from the ED, 1 team is assigned to all admitting duties on a particular day; the on‐call team. While teams rotate between designations of on‐call, post‐call, and pre‐call over the course of the week, only the team designated on‐call accepts new admissions. This bolus call structure creates the need for extensive cross‐coverage, large variations in team admissions, and disparate team workloads.1012 Moreover, the effects of these variations may persist and extend along the care pathway, ultimately impacting timely patient discharge. Therefore, interventions aimed at improving the admission process may be candidates for improved patient flow.

The objective of this study is to evaluate the effect of changing the admission process from a bolus admission system to a trickle system that evenly distributes newly admitted patients to each of the physician‐led care teams. We hypothesize that by removing variation within the team admission process, team workload will be smoothed and ultimately result in patients being discharged by the team in a more uniform pattern. We evaluate this hypothesis by measuring length of stay and daily discharge rate.

METHODS

Setting

This retrospective study was conducted on the General Internal Medicine clinical teaching unit (GIM CTU) at a large academic tertiary care center in Toronto, Canada. GIM provides acute, nonsurgical care to a patient population composed primarily of elderly patients with complex chronic illnesses. GIM receives 98% of its inpatient admissions from the ED. On a daily basis, the ED sees approximately 100 patients, of which nearly 20% are admitted to hospital. GIM constitutes the single largest admitting service in the ED, admitting nearly half of all emergent admissions. Surgical and specialized medical services (eg, Cardiology, Oncology, Nephrology) admit the remaining half.

On March 2, 2009, the GIM CTU underwent a structural change from a bolus admission system to a trickle system of admissions to each care team. Figure 1 depicts a typical pre‐change admission pattern where each of the 4 care teams would admit a bolus of patients on a given day (left panel), and a typical post‐change admission pattern where the variation in daily admissions is smoothed out as a result of the trickle admission system (right panel). No change was made to care team members; each team consisted of an attending physician, 1 senior resident, 2 to 3 junior residents, 1 social worker, 1 physiotherapist, 1 occupational therapist, and 1 pharmacist. The Appendix provides a detailed description of the structural change.

Figure 1

RESULTS

During the 2 study periods, a total of 2734 patients were discharged, 1446 in the pre‐change period (1535 admitted), and 1288 in the post‐change period (1363 admitted). Table 1 presents mean age and primary CMG diagnosis.

Figure 2 shows the estimated average team‐specific DDR's according to call schedule status, along with 95% credible intervals. With the exception of the postpost‐call day, each black point (2009, post‐change period) is closer to the overall average DDR of 9.9% than each corresponding gray point (2008, pre‐change period). In our Bayesian model, there was a 96.9% probability that the variability across call schedule status was reduced in the post‐change period, substantial evidence of smoother discharge rates across different types of call days.

Figure 2

Summary statistics for the LOS for both groups can be seen in Table 2. The median LOS in the post‐change period was statistically significantly shorter than in the pre‐change period (4.8 days vs 5.1 days, P < 0.001).

Figure 3 shows the estimated KaplanMeier curves of time to discharge (LOS) in both time periods. Differences between the 2 study periods in the proportion of patients that had been discharged at each time point (the vertical distance between the curves) can be observed, particularly in the shorter LOS times.

Figure 3

DISCUSSION

Previous studies have suggested that systems become more efficient when every day runs the same way.15 Achieving this for the number of daily discharges from the ward should have a positive effect on the flow of patients through the GIM service.16 Wong et al. showed how the on call schedule of medical personnel had a strong effect on the variation in daily discharges.17 A more recent study by the same authors demonstrated, through a computer simulation model, that smoothing patient discharges over the course of the week decreases the number of ED beds occupied by admitted patients.18 After introducing a structural change to our admission system that made the daily admissions of patients to each care team uniform, we showed a significant reduction in the variation of discharge rates from day to day, and the expected improvement in patient flow as shown by a decrease in the median LOS.

This intervention changed only 1 component of a complex patient care process, of which the resident on‐call schedule is only a small part. Nevertheless, this small change, designed to optimize the doctors' contribution to patient flow, was sufficient in effecting a significant reduction in the variation of the DDR. Inpatients follow a usual course in the hospital, requiring an average LOS of 4 to 5 days. In the bolus system of admissions, we observed what was essentially a cohort effect where the same bolus of patients was discharged on roughly the same day, an average of 4 to 5 days after admission. If the daily variation in discharges were only dependent on the daily variation in admissions, by making the influx of inpatients constant, we should have eliminated this cohort effect. Although the variation in discharges was reduced, it was not completely eliminated, suggesting that elements of the old system are retained. It is possible that the senior resident's management of the patients on the team has a stronger influence than that of other members of the team, and the flow of patients may still be affected by their call schedule.

We observed a significant reduction (0.3 days) in median LOS. By making each day look the same for admissions to each care team, and by making each day look more uniform for discharges from each care team, we were able to improve our unit's operational efficiency. Other benefits of the new system included: less cross‐coverage, since after‐hours there was always a member of each team to look after their own patients; the elimination of the post‐call day for the entire team; and the relatively decreased average daily workload.

The bulk of the reduction in median LOS was attributed to short‐stay patients. The flow of very sick patients who require prolonged inpatient treatment, or those waiting for post‐acute care beds (rehabilitation, long‐term care, convalescence, etc) may be less sensitive to improvements in internal efficiencies.

Although the improvement in LOS was modest, it was certainly no worse than in the older system, and the change was accompanied by the many other benefits already mentioned. In fact, ours is not the only hospital in the city that has made this change. Early results of a qualitative study exploring the perceptions of attending staff, residents, and students of the new systemparticularly its effects on the educational experienceare encouraging, showing overall positive opinions about the change. Further studies aimed at analyzing the barriers to efficient patient discharges may help identify important factors, such as those already mentioned, that this change in structure did not address. Policymakers could address other components of the discharge process, particularly the chronic shortage of post‐acute care beds. Finally, an economic analysis could provide insights about the potential savings that such structural changes could represent.

This study has several limitations. It took place in a single teaching hospital in Canada and, therefore, may not be generalizable to community hospitals or to settings that do not provide single‐payer free public healthcare. Nevertheless, most hospital units are subject to the effects of medical personnel scheduling, and the variation in patient flow processes that this produces. The current resident association collective agreement in Ontario still allows trainees to be scheduled for continuous 24‐hour duty periods. An exact replication of our structure would not be possible in settings with more stringent duty‐hour restrictions. Nevertheless, the goal of the structural change was to make the influx of patients to each care team constant, and this is achievable regardless of the length of the trainee call period. Although there is no reason to suspect a systematic difference in the mix of patients from 2008 to 2009, it would have been preferable to use a propensity score to compare clinical characteristics of the 2 patient groups. We used a relatively new metric, DDR, which was created in our institution and already has been used in several studies. However, it has not yet been validated in other centers.

One of the limitations of a before‐and‐after analysis is our inability to adjust for other changes that may have occurred during the study periods. These known and unknown factors may have had effects on the findings.

CONCLUSIONS

A new admission structure was introduced to the GIM CTU in March 2009, with the intention of changing the admissions to each care team from a bolus to a trickle system. This study was a real‐world demonstration of a concept that had, until this point, only been observed in robust simulation models. When the daily influx of patients to a care team becomes constant, the number of discharges from that team experience less daily variation, and the overall efficiency of the team improves, as measured by a reduction in the median LOS. Standardizing the care processes on the GIM inpatient ward improves overall efficiency and capacity.

Smooth and timely hospital patient flow can have multiple positive effects including reduced wait times for services, decreased congestion in the Emergency Department (ED), and increased patient and staff satisfaction.14 One way to improve patient flow is to remove variation along the care pathway.57

For teaching hospitals that provide team‐based care, 1 significant source of variation involves the emergent admission process.8, 9 Typically, for services that admit the majority of their patients from the ED, 1 team is assigned to all admitting duties on a particular day; the on‐call team. While teams rotate between designations of on‐call, post‐call, and pre‐call over the course of the week, only the team designated on‐call accepts new admissions. This bolus call structure creates the need for extensive cross‐coverage, large variations in team admissions, and disparate team workloads.1012 Moreover, the effects of these variations may persist and extend along the care pathway, ultimately impacting timely patient discharge. Therefore, interventions aimed at improving the admission process may be candidates for improved patient flow.

The objective of this study is to evaluate the effect of changing the admission process from a bolus admission system to a trickle system that evenly distributes newly admitted patients to each of the physician‐led care teams. We hypothesize that by removing variation within the team admission process, team workload will be smoothed and ultimately result in patients being discharged by the team in a more uniform pattern. We evaluate this hypothesis by measuring length of stay and daily discharge rate.

METHODS

Setting

This retrospective study was conducted on the General Internal Medicine clinical teaching unit (GIM CTU) at a large academic tertiary care center in Toronto, Canada. GIM provides acute, nonsurgical care to a patient population composed primarily of elderly patients with complex chronic illnesses. GIM receives 98% of its inpatient admissions from the ED. On a daily basis, the ED sees approximately 100 patients, of which nearly 20% are admitted to hospital. GIM constitutes the single largest admitting service in the ED, admitting nearly half of all emergent admissions. Surgical and specialized medical services (eg, Cardiology, Oncology, Nephrology) admit the remaining half.

On March 2, 2009, the GIM CTU underwent a structural change from a bolus admission system to a trickle system of admissions to each care team. Figure 1 depicts a typical pre‐change admission pattern where each of the 4 care teams would admit a bolus of patients on a given day (left panel), and a typical post‐change admission pattern where the variation in daily admissions is smoothed out as a result of the trickle admission system (right panel). No change was made to care team members; each team consisted of an attending physician, 1 senior resident, 2 to 3 junior residents, 1 social worker, 1 physiotherapist, 1 occupational therapist, and 1 pharmacist. The Appendix provides a detailed description of the structural change.

Figure 1

RESULTS

During the 2 study periods, a total of 2734 patients were discharged, 1446 in the pre‐change period (1535 admitted), and 1288 in the post‐change period (1363 admitted). Table 1 presents mean age and primary CMG diagnosis.

Figure 2 shows the estimated average team‐specific DDR's according to call schedule status, along with 95% credible intervals. With the exception of the postpost‐call day, each black point (2009, post‐change period) is closer to the overall average DDR of 9.9% than each corresponding gray point (2008, pre‐change period). In our Bayesian model, there was a 96.9% probability that the variability across call schedule status was reduced in the post‐change period, substantial evidence of smoother discharge rates across different types of call days.

Figure 2

Summary statistics for the LOS for both groups can be seen in Table 2. The median LOS in the post‐change period was statistically significantly shorter than in the pre‐change period (4.8 days vs 5.1 days, P < 0.001).

Figure 3 shows the estimated KaplanMeier curves of time to discharge (LOS) in both time periods. Differences between the 2 study periods in the proportion of patients that had been discharged at each time point (the vertical distance between the curves) can be observed, particularly in the shorter LOS times.

Figure 3

DISCUSSION

Previous studies have suggested that systems become more efficient when every day runs the same way.15 Achieving this for the number of daily discharges from the ward should have a positive effect on the flow of patients through the GIM service.16 Wong et al. showed how the on call schedule of medical personnel had a strong effect on the variation in daily discharges.17 A more recent study by the same authors demonstrated, through a computer simulation model, that smoothing patient discharges over the course of the week decreases the number of ED beds occupied by admitted patients.18 After introducing a structural change to our admission system that made the daily admissions of patients to each care team uniform, we showed a significant reduction in the variation of discharge rates from day to day, and the expected improvement in patient flow as shown by a decrease in the median LOS.

This intervention changed only 1 component of a complex patient care process, of which the resident on‐call schedule is only a small part. Nevertheless, this small change, designed to optimize the doctors' contribution to patient flow, was sufficient in effecting a significant reduction in the variation of the DDR. Inpatients follow a usual course in the hospital, requiring an average LOS of 4 to 5 days. In the bolus system of admissions, we observed what was essentially a cohort effect where the same bolus of patients was discharged on roughly the same day, an average of 4 to 5 days after admission. If the daily variation in discharges were only dependent on the daily variation in admissions, by making the influx of inpatients constant, we should have eliminated this cohort effect. Although the variation in discharges was reduced, it was not completely eliminated, suggesting that elements of the old system are retained. It is possible that the senior resident's management of the patients on the team has a stronger influence than that of other members of the team, and the flow of patients may still be affected by their call schedule.

We observed a significant reduction (0.3 days) in median LOS. By making each day look the same for admissions to each care team, and by making each day look more uniform for discharges from each care team, we were able to improve our unit's operational efficiency. Other benefits of the new system included: less cross‐coverage, since after‐hours there was always a member of each team to look after their own patients; the elimination of the post‐call day for the entire team; and the relatively decreased average daily workload.

The bulk of the reduction in median LOS was attributed to short‐stay patients. The flow of very sick patients who require prolonged inpatient treatment, or those waiting for post‐acute care beds (rehabilitation, long‐term care, convalescence, etc) may be less sensitive to improvements in internal efficiencies.

Although the improvement in LOS was modest, it was certainly no worse than in the older system, and the change was accompanied by the many other benefits already mentioned. In fact, ours is not the only hospital in the city that has made this change. Early results of a qualitative study exploring the perceptions of attending staff, residents, and students of the new systemparticularly its effects on the educational experienceare encouraging, showing overall positive opinions about the change. Further studies aimed at analyzing the barriers to efficient patient discharges may help identify important factors, such as those already mentioned, that this change in structure did not address. Policymakers could address other components of the discharge process, particularly the chronic shortage of post‐acute care beds. Finally, an economic analysis could provide insights about the potential savings that such structural changes could represent.

This study has several limitations. It took place in a single teaching hospital in Canada and, therefore, may not be generalizable to community hospitals or to settings that do not provide single‐payer free public healthcare. Nevertheless, most hospital units are subject to the effects of medical personnel scheduling, and the variation in patient flow processes that this produces. The current resident association collective agreement in Ontario still allows trainees to be scheduled for continuous 24‐hour duty periods. An exact replication of our structure would not be possible in settings with more stringent duty‐hour restrictions. Nevertheless, the goal of the structural change was to make the influx of patients to each care team constant, and this is achievable regardless of the length of the trainee call period. Although there is no reason to suspect a systematic difference in the mix of patients from 2008 to 2009, it would have been preferable to use a propensity score to compare clinical characteristics of the 2 patient groups. We used a relatively new metric, DDR, which was created in our institution and already has been used in several studies. However, it has not yet been validated in other centers.

One of the limitations of a before‐and‐after analysis is our inability to adjust for other changes that may have occurred during the study periods. These known and unknown factors may have had effects on the findings.

CONCLUSIONS

A new admission structure was introduced to the GIM CTU in March 2009, with the intention of changing the admissions to each care team from a bolus to a trickle system. This study was a real‐world demonstration of a concept that had, until this point, only been observed in robust simulation models. When the daily influx of patients to a care team becomes constant, the number of discharges from that team experience less daily variation, and the overall efficiency of the team improves, as measured by a reduction in the median LOS. Standardizing the care processes on the GIM inpatient ward improves overall efficiency and capacity.

Smooth and timely hospital patient flow can have multiple positive effects including reduced wait times for services, decreased congestion in the Emergency Department (ED), and increased patient and staff satisfaction.14 One way to improve patient flow is to remove variation along the care pathway.57

For teaching hospitals that provide team‐based care, 1 significant source of variation involves the emergent admission process.8, 9 Typically, for services that admit the majority of their patients from the ED, 1 team is assigned to all admitting duties on a particular day; the on‐call team. While teams rotate between designations of on‐call, post‐call, and pre‐call over the course of the week, only the team designated on‐call accepts new admissions. This bolus call structure creates the need for extensive cross‐coverage, large variations in team admissions, and disparate team workloads.1012 Moreover, the effects of these variations may persist and extend along the care pathway, ultimately impacting timely patient discharge. Therefore, interventions aimed at improving the admission process may be candidates for improved patient flow.

The objective of this study is to evaluate the effect of changing the admission process from a bolus admission system to a trickle system that evenly distributes newly admitted patients to each of the physician‐led care teams. We hypothesize that by removing variation within the team admission process, team workload will be smoothed and ultimately result in patients being discharged by the team in a more uniform pattern. We evaluate this hypothesis by measuring length of stay and daily discharge rate.

METHODS

Setting

This retrospective study was conducted on the General Internal Medicine clinical teaching unit (GIM CTU) at a large academic tertiary care center in Toronto, Canada. GIM provides acute, nonsurgical care to a patient population composed primarily of elderly patients with complex chronic illnesses. GIM receives 98% of its inpatient admissions from the ED. On a daily basis, the ED sees approximately 100 patients, of which nearly 20% are admitted to hospital. GIM constitutes the single largest admitting service in the ED, admitting nearly half of all emergent admissions. Surgical and specialized medical services (eg, Cardiology, Oncology, Nephrology) admit the remaining half.

On March 2, 2009, the GIM CTU underwent a structural change from a bolus admission system to a trickle system of admissions to each care team. Figure 1 depicts a typical pre‐change admission pattern where each of the 4 care teams would admit a bolus of patients on a given day (left panel), and a typical post‐change admission pattern where the variation in daily admissions is smoothed out as a result of the trickle admission system (right panel). No change was made to care team members; each team consisted of an attending physician, 1 senior resident, 2 to 3 junior residents, 1 social worker, 1 physiotherapist, 1 occupational therapist, and 1 pharmacist. The Appendix provides a detailed description of the structural change.

Figure 1

RESULTS

During the 2 study periods, a total of 2734 patients were discharged, 1446 in the pre‐change period (1535 admitted), and 1288 in the post‐change period (1363 admitted). Table 1 presents mean age and primary CMG diagnosis.

Figure 2 shows the estimated average team‐specific DDR's according to call schedule status, along with 95% credible intervals. With the exception of the postpost‐call day, each black point (2009, post‐change period) is closer to the overall average DDR of 9.9% than each corresponding gray point (2008, pre‐change period). In our Bayesian model, there was a 96.9% probability that the variability across call schedule status was reduced in the post‐change period, substantial evidence of smoother discharge rates across different types of call days.

Figure 2

Summary statistics for the LOS for both groups can be seen in Table 2. The median LOS in the post‐change period was statistically significantly shorter than in the pre‐change period (4.8 days vs 5.1 days, P < 0.001).

Figure 3 shows the estimated KaplanMeier curves of time to discharge (LOS) in both time periods. Differences between the 2 study periods in the proportion of patients that had been discharged at each time point (the vertical distance between the curves) can be observed, particularly in the shorter LOS times.

Figure 3

DISCUSSION

Previous studies have suggested that systems become more efficient when every day runs the same way.15 Achieving this for the number of daily discharges from the ward should have a positive effect on the flow of patients through the GIM service.16 Wong et al. showed how the on call schedule of medical personnel had a strong effect on the variation in daily discharges.17 A more recent study by the same authors demonstrated, through a computer simulation model, that smoothing patient discharges over the course of the week decreases the number of ED beds occupied by admitted patients.18 After introducing a structural change to our admission system that made the daily admissions of patients to each care team uniform, we showed a significant reduction in the variation of discharge rates from day to day, and the expected improvement in patient flow as shown by a decrease in the median LOS.

This intervention changed only 1 component of a complex patient care process, of which the resident on‐call schedule is only a small part. Nevertheless, this small change, designed to optimize the doctors' contribution to patient flow, was sufficient in effecting a significant reduction in the variation of the DDR. Inpatients follow a usual course in the hospital, requiring an average LOS of 4 to 5 days. In the bolus system of admissions, we observed what was essentially a cohort effect where the same bolus of patients was discharged on roughly the same day, an average of 4 to 5 days after admission. If the daily variation in discharges were only dependent on the daily variation in admissions, by making the influx of inpatients constant, we should have eliminated this cohort effect. Although the variation in discharges was reduced, it was not completely eliminated, suggesting that elements of the old system are retained. It is possible that the senior resident's management of the patients on the team has a stronger influence than that of other members of the team, and the flow of patients may still be affected by their call schedule.

We observed a significant reduction (0.3 days) in median LOS. By making each day look the same for admissions to each care team, and by making each day look more uniform for discharges from each care team, we were able to improve our unit's operational efficiency. Other benefits of the new system included: less cross‐coverage, since after‐hours there was always a member of each team to look after their own patients; the elimination of the post‐call day for the entire team; and the relatively decreased average daily workload.

The bulk of the reduction in median LOS was attributed to short‐stay patients. The flow of very sick patients who require prolonged inpatient treatment, or those waiting for post‐acute care beds (rehabilitation, long‐term care, convalescence, etc) may be less sensitive to improvements in internal efficiencies.

Although the improvement in LOS was modest, it was certainly no worse than in the older system, and the change was accompanied by the many other benefits already mentioned. In fact, ours is not the only hospital in the city that has made this change. Early results of a qualitative study exploring the perceptions of attending staff, residents, and students of the new systemparticularly its effects on the educational experienceare encouraging, showing overall positive opinions about the change. Further studies aimed at analyzing the barriers to efficient patient discharges may help identify important factors, such as those already mentioned, that this change in structure did not address. Policymakers could address other components of the discharge process, particularly the chronic shortage of post‐acute care beds. Finally, an economic analysis could provide insights about the potential savings that such structural changes could represent.

This study has several limitations. It took place in a single teaching hospital in Canada and, therefore, may not be generalizable to community hospitals or to settings that do not provide single‐payer free public healthcare. Nevertheless, most hospital units are subject to the effects of medical personnel scheduling, and the variation in patient flow processes that this produces. The current resident association collective agreement in Ontario still allows trainees to be scheduled for continuous 24‐hour duty periods. An exact replication of our structure would not be possible in settings with more stringent duty‐hour restrictions. Nevertheless, the goal of the structural change was to make the influx of patients to each care team constant, and this is achievable regardless of the length of the trainee call period. Although there is no reason to suspect a systematic difference in the mix of patients from 2008 to 2009, it would have been preferable to use a propensity score to compare clinical characteristics of the 2 patient groups. We used a relatively new metric, DDR, which was created in our institution and already has been used in several studies. However, it has not yet been validated in other centers.

One of the limitations of a before‐and‐after analysis is our inability to adjust for other changes that may have occurred during the study periods. These known and unknown factors may have had effects on the findings.

CONCLUSIONS

A new admission structure was introduced to the GIM CTU in March 2009, with the intention of changing the admissions to each care team from a bolus to a trickle system. This study was a real‐world demonstration of a concept that had, until this point, only been observed in robust simulation models. When the daily influx of patients to a care team becomes constant, the number of discharges from that team experience less daily variation, and the overall efficiency of the team improves, as measured by a reduction in the median LOS. Standardizing the care processes on the GIM inpatient ward improves overall efficiency and capacity.

The traditional acute care for the elderly (ACE) unit has demonstrated improved functional outcomes without increased costs or changes in length of stay (LOS).15 It is, however, limited in scope to only those patients cared for on a fixed geographical unit. This structural limitation is of increasing relevance in times of high hospital bed occupancy rates, as during such times, many appropriate older patients are admitted elsewhere. In our experience with a traditional ACE unit‐based model, only 52% of our geriatrics practice patients were admitted to an ACE unit bed, while the remainder were admitted to various medical units throughout the hospital. We therefore abandoned our traditional unit‐based ACE service in July 2007 in favor of a mobile ACE (MACE) service, bringing the interdisciplinary, patient‐centered team approach to our hospitalized older adult patients admitted throughout the hospital.

The purpose of this study is to compare the operational and quality outcomes for patients cared for on the MACE service to those cared for on a unit‐based ACE service and matched controls cared for on other general medical services. We hypothesized that the MACE service would be associated with lower lengths of stay, reduced costs, and decreased rehospitalization rates.

METHODS

The MACE team was composed of a geriatrician‐hospitalist, geriatric medicine fellow, social worker, and nurse coordinator. The geriatric medicine attending on the MACE service was in the hospital providing patient care during regular working hours from Monday through Friday, while the weekends were covered by a rotating group of all geriatric medicine faculty. During the first and second years of MACE, there were 7 and 4 attendings, respectively; all fellowship‐trained geriatricians. Three of the 4 geriatric medicine hospitalists during year 2 had been in practice between 1 and 3 years postfellowship and also had training in palliative medicine, although were not board‐certified in the latter. The fourth hospitalist had been in practice for 5 years postfellowship. The interdisciplinary team met daily to discuss the care of all patients and used a transitional care model based on The Care Transitions Program⁶ adapted to our institution, with a focus on reducing the risks of hazards of hospitalization. Care coordination with the outpatient practice, early family meetings, discharge planning, patient and caregiver education, and postdischarge follow‐up phone calls were some of the key hallmarks of the service (Table 1).

We conducted a retrospective cohort study with propensity‐score matching in an urban academic medical center. Study subjects comprised 5 distinct groups. First were community‐dwelling older adults cared for at our outpatient geriatrics ambulatory practice who were discharged from our traditional ACE unit‐based acute care service at the Mount Sinai Hospital from July 1, 2006 through June 30, 2007 (N = 450). Second and third were patients from the same practice discharged from our MACE service during the first 2 years of operation (N = 556 from July 1, 2007 through June 30, 2008, and N = 501 from July 1, 2008 through June 30, 2009). Fourth and fifth were control cohorts of hospitalized older adults discharged from other medical services at the Mount Sinai Hospital during these same 2 years (N = 4863 and N = 4777, respectively). The average daily census on all services was 1012 patients.

Some patients on all 3 services are co‐managed with house staff, who are responsible for writing physician orders. Control cohort patients were cared for by a mix of private attendings (approximately 75%) or hospitalists (25%), and in contradistinction to MACE patients, their typical care did not include daily interdisciplinary team rounds, a nurse coordinator, or geriatrics fellow. Social work and case management were unit‐ as opposed to team‐based. Care on the ACE unit‐based service differed from care for matched control patients by having daily interdisciplinary team rounds, a prepared environment, and nursing‐led protocols for the patients on the ACE unit.

Because the ACE unit‐based service admitted both patients who were and were not cared for in our ambulatory practice, while the MACE service admitted only patients cared for in the ambulatory practice, we deleted from the study sample the patients who did not have a visit to our outpatient practice before the index hospitalization. This allowed us to isolate the effect of the model of care itself as opposed to the effect of simply changing the patient base for admissions. We then merged the files with the hospital's administrative database and electronic billing system to obtain demographic and claims data.

Additional demographic data were obtained through chart review of the MACE patients during year 1. The chart review process was standardized using a data abstraction instrument and by determining inter‐rater reliability of the individual data abstractors (comprised of author B.K. and 4 MACE team members).

Costs were assigned to individual admissions by the hospital's cost reporting system and include a combination of traceable costs (such as imaging, laboratory, and pharmacy) and applied costs (nursing; allocated based on geographic location in the hospital) to arrive at direct and total costs.

We made 3 distinct comparisons of operational and quality outcomes using the above 5 groups, first comparing patients cared for on our traditional ACE unit‐based service to those cared for on the MACE service, and second and third comparing patients on the MACE service to propensity score‐matched controls during the first and second year of operations. Specifically, we hypothesized that the MACE service would be associated with reduced LOS, costs, and readmission rates compared with the ACE unit‐based service and the matched control groups. We used multivariate logistic regression to estimate the association of binary quality outcomes (mortality during the hospital stay, 7‐ and 30‐day readmission rates) with the existence of MACE while adjusting for confounding variables which included patient demographic and clinical characteristics such as age, gender, race, total number of comorbidities (calculated by Elixhauser method that includes 30 categories of comorbid illnesses identified by secondary diagnosis codes and discharge diagnosis‐related groups [DRGs]).7 We considered the clustering effect due to the same attending physician into the model as well. While adjusting for the same covariates, we used generalized linear models with a gamma distribution and log link to estimate the association of continuous variables (costs and LOS) with the existence of MACE.

The same statistical methods were applied to the second and third comparisons between patients cared for on the MACE and the propensity score‐matched cohorts for the first and second year of the MACE service. First, 2 control cohorts (N = 6148 and 5803 of our hospital discharges from July 1, 2007 to June 30, 2008, and July 1, 2008 to June 30, 2009, respectively, with age > 64 and with the identical DRG and All Patient Refined DRG (APR DRG) Severity of Illness (SOI) score as those of the MACE groups were obtained from our hospital's administrative database to reduce the selection bias. Then, 4863 patients within the first cohort (N = 6148) and 4777 patients within the second cohort (N = 5,803) with the closest propensity score were matched to 545 of 556 MACE patients and 494 of 501 MACE patients, respectively, in which the logit of their propensity score was within 0.02 standard deviations of the logit of the MACE patient's score.

Propensity scores were determined by logistic regression on whether patients were admitted to the MACE. The covariates for the propensity model were the same as the previously stated adjusting variables. Usual care patients' data were weighted to account for the one‐to‐many propensity score‐matching algorithm.

We similarly conducted a post hoc analysis of MACE compared with a subgroup control cohort of patients cared for by medicine hospitalists in year 1 (N = 1175) and year 2 (N = 1564), with age > 64 and with the identical DRG and APR DRG SOI as those of the MACE group. We then matched 1012 of the 1175 discharges with the closest propensity score to 389 of the 411 MACE discharges who were cared for by 1 of the 4 geriatric medicine hospitalists in year 1 and 1308 of the 1564 discharges to 471 of the 501 MACE discharges in year 2, in which the logit of their propensity score was within 0.02 standard deviations of the logit of the MACE patient's score, using the same covariates described above.

All analyses were done using Stata software, version 9.2 (StataCorp LP, College Station, TX). This project was exempted by the Institutional Review Board at Mount Sinai School of Medicine, New York, New York.

RESULTS

Table 2 presents the characteristics of the study subjects in all 5 groups. Patients cared for on the ACE unit‐based service and the MACE service in years 1 and 2 were very similar, with a mean age of 82.6, 83.2, and 83.6 years; 74.4%, 75.9%, and 76.7% were female; and mean Elixhauser comorbidity scores were 3.4, 3.3, and 3.5, respectively. Patients in the 2 matched control groups were likewise very similar to those in the matched MACE groups with regard to all demographic variables.

Chart review of the year 1 MACE discharges revealed that 70% spoke English as their primary language and 46% had cognitive impairment. Most lived at home alone (49%) or with family members (41%) while receiving some paid caregiver help (59%). The remaining 10% were admitted from either an assisted living facility (5%) or subacute rehabilitation (5%). Only 12% were wheelchair or bed‐bound, while 21% ambulated without and 67% with an assistive device. Their functional status was limited, with 58% dependent for both ADLs and IADLs, 22% dependent for IADLs only, and 20% independent in both. They had relatively high prescription medication burdens, with 10% taking 05, 34% taking 610, 38% taking 1115, and 18% taking >15 medications.

Patients cared for by the MACE service had an adjusted 2.1 days shorter LOS (P < 0.001) when compared with patients cared for on the ACE unit service. Additionally, there was a net savings of $2872 in total costs per hospitalization (P = 0.002), $1094 in direct costs (P = 0.016), $849 in nursing costs (P < 0.001), and $237 in pharmacy costs (P = 0.002). Imaging and laboratory costs between the 2 groups were not statistically different. There was no significant differences in in‐hospital mortality, 7‐day, 30‐day, or 90‐day readmission rates between the 2 groups (Table 3).