RSSAll Entries in the "Quality improvement" Category

Where the money is

Subsidies are a hot topic in hospital medicine right now. The latest SHM-MGMA survey indicates that the average hospitalist receives about $136,000 in support from hospital funds other than fee collections. The Affordable Care Act (aka Obamacare) requires an annual 1.4%, reduction in Medicare payments to hospitals, and a CMS actuary recently told a congressional committee that 40% of hospitals will be insolvent by 2050. The day of reckoning for hospitalists will come much sooner than that because nearly every physician who treats hospital patients is standing in line for a handout from the institution. The surgeons and cardiologists will be paid because they bring in patients for well-reimbursed procedures. What’s the business case for supporting hospitalists? The early growth in hospital medicine came after administrators found that hospitalists help reduce average length of stay by about one day. The average subsidy has doubled since then, so we need to come up with something else. SHM leaders tout quality improvement (QI) and patient safety as the new business case for hospital medicine, but the numbers don’t add up. If you value a hospitalist’s time at $130 per hour, then the physician would have to devote more than 1000 hours a year to this activity, on top of clinical time, to justify the subsidy.  Even if it were possible to do this, the hospital could hire two nurses with formal training in QI and get 4000 hours a year of work for the same price.

The best hope for justifying hospitalist salaries is in reducing the cost of care. The average hospitalist treats about 500 patients a year, so a mean reduction of $260 in cost per case is needed. Antibiotics are an obvious target for cost control, but what about the indiscriminate use of PPIs that are not needed for the routine medical admission? There is no justification for broad spectrum antibiotic therapy once culture results are known. Oxygen is another item used profligately. Most hospitals assign the responsibility for tapering oxygen to the respiratory therapists, but it is not done consistently. Unnecessary testing is another opportunity for savings, though the accounting here is tricky. Much of the cost is in the labor of technologists. Unless the test volume reduces enough to eliminate a position, the savings will be limited to the cost of the materials used. This is not easy stuff, but hospitalists can sit down with the finance staff in the hospital to find opportunities for savings. This kind of cost accounting has not been done very much in hospitals, so don’t expect an enthusiastic reception from management, but with few other opportunities for savings, this is an opportunity for leadership.

The sleep doctor question

An article in the July 1, 2011 Los Angeles Times, titled “Limiting resident physicians’ work hours to save lives” again raises the question of whether resident fatigue affects patient care. I assume there is no coincidence that the article appeared the day that the newly minted physicians began training. The article, co-authored by Lucian Leape, MD, chair of the Lucian Leape Institute and adjunct professor of health policy at Harvard School of Public Health and Helen Haskell, founder of Mothers Against Medical Error, cites studies that go back at least 40 years demonstrating that fatigued residents make more mistakes than well-rested residents.

New rules limit first year residents to shifts no longer than 16 hours, and more senior residents to 28-hour shifts. When I was in training, my surgical brethren and I thought that if you were only on call every other night, you missed half of the interesting cases. I wonder whether today’s residents are as “tough” as we were back in the day. Should slave labor be reintroduced? Or are folks like Dr. Leape right?  Back in the day, we assumed our patients were safe and received quality care—were we right?  I don’t think so. So is 16 hours right?  Should it be 12?  Should it be less?  Should residency programs add a year to training programs so that residents can get the necessary experience, and still get some sleep?  What do you think?

Draining the swamp

I have been chided for the downbeat tone of some of my recent posts. You need to understand the financial challenges ahead, but having said that, it is time to refocus on what is good and positive about hospital medicine. The difficulty in doing so reminds me of a saying among civil engineers: When you are up to your buttocks in alligators, it is hard to remember that you were hired to drain the swamp. The swamp contains all the things that prevent hospital care from being perfect—readmissions, medical errors, quality deficiencies, delays, excess costs, inadequate communication, poor patient satisfaction, to name some.

Hospital medicine has made definite strides in solving some of these problems, yet most hospitals have each of these problems to some extent. Hospital medicine programs have been sold to administrators as a solution to these problems, but most smaller and nonacademic programs have trouble delivering the goods. The reason is that medical directors are given few resources to drain the swamp and spend most of their time wrestling with alligators. The alligators are most of the hospital stakeholders, nurses, emergency doctors, specialists, primary doctors, patients, families, insurers, and, regrettably, hospitalists.

What makes an alligator? A stakeholder becomes an alligator when the hospital medicine program fails to deliver some portion of the desired benefit, and the stakeholder becomes angry and demanding.

I have been a physician for more than 30 years, and I have never seen so many angry people in hospitals as there are today. I got into hospital medicine because it offered an opportunity to make hospital care work, but after 15 years in the field, the goals seem more elusive than when I started. Whoops, there goes the downbeat tone again.

The problem is in getting enough resources to perform effective quality improvement work. Pronovost and Marsteller, writing in the February 2 issue of JAMA, note the peripheral role of physicians in quality improvement (QI) work. They call for physician managers with dedicated time and salary support for quality work. Most hospital medicine program directors have little or no salary support for activities other than direct patient care. A few larger hospital systems are creating true executive positions for hospital medicine, but this is still a rarity. Some academic hospitalists are able to do QI work as part of their scholarly activity. We clearly need to find ways to make things better within the time available to us. I’ll explore that in subsequent posts.

What’s on your to-do list? Discharge planning improvement should be

Yes, it’s almost the end of January, and I shamefully still have my Christmas tree up and my luggage all over my living room floor. Why? My to-do lists seem endless.

I have two lists—one for personal life, full of items, such as pay bills and write thank-you cards, and one for work life, a long list of people I need to e-mail or calls to make.

As with most people’s, the to-do list seems to grow by the minute. Today’s Hospitalist featured an article on uncovering the cause of hospitalists’ readmission rates, in other words, a must for the to-do list.
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Should hospitalist program dashboards measure individual performance?

Hospitalist program dashboards often measure the group’s performance as a whole, but they can also measure individual hospitalists’ performance. The field is torn over which is best practice. According to a poll on MedicalStaffLeader.com, of the 104 respondents, 28% indicated that their dashboards only contain information regarding the group’s performance as a whole, and 49% indicated that they include some individual measures on their dashboards. Twenty-three percent said that their hospitalist programs did not use dashboards.

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The Commonwealth Fund and HRET highlight best practices that result in high quality care

The Commonwealth Fund recently released a study examining what successful health systems do that make them, well…successful. By interviewing leaders of 45 multi-hospital health systems and evaluating publicly available quality data, The Commonwealth Fund and the Health Research & Educational Trust identified three major themes, four best practices areas, and 17 specific best practices related to high performance.

The organization identifies health systems as organizations that have two or more general acute care hospitals and says that the 200 largest hospital systems account for half of all hospital admissions in the U.S.

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Heads up: Physicians are people, too

Meditation-5Two new studies support mysterious rumors that doctors are people, too. According to a study in the Sept. 23/30 issue of JAMA, fatigue isn’t the only factor that increases the likelihood that a physician will make a medical error. Other factors, such as financial and familial distress, also contribute. When developing a burnout prevention program, it is important to separate fatigue from other stress factors, the study suggests.

On a similar note, another study in the same issue of JAMA says that meditation may help relieve symptoms of burnout caused by fatigue and personal problems, as well as improve physicians’ relationships with patients. Physicians who participated in a mindful communication education program demonstrated sustained improvements in well-being, and their attitudes associated with patient-centered care improved.

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Contest entry: Hospital quality summit

Meeting-podiumHere’s another helpful hint about quality from one contest entry submission.

Director of Quality, Rosemary O’Gara, RN, CPHQ, CPHRM, of East Orange General Hospital developed a nursing quality summit, which is a monthly meeting in which managers address quality variances in the same way that budget variances are discussed and reviewed.

At the meeting, they review the following items:

  • Falls
  • Restraints
  • Pressure ulcers
  • Pain managements
  • Medication reconciliation

Rosemary says, “Quality outcomes have significantly improved since inception of the summit in September 2008.”

Keep those contest entries coming, and you could win the free registration to The Greeley Medical Staff Institute Symposium (Nov. 8-9, Naples, Fl)!

We’ll share the entries on the blog and select the best one at the end of the month.

To enter the drawing, submit your best practice, tool, or tip to us. Find more details here!

Contest entry: Physician hotline for patient and physician satisfaction

phone-on-deskKeeping patients and physicians happy sometimes requires some creative thinking. We liked this tip that came from Gloria Ziegler, CPCS, medical staff services director of Val Verde Regional Medical Center.

Gloria says that her institution strives to improve patient and physician satisfaction. How do they accomplish that goal?

The Val Verde Regional Medical Center currently uses a physician hotline for physicians to call reference any complaints, praises, or new ideas that might be helpful in improving patient/physician satisfaction.

She says,

“We also have established a patient/customer hot line to deal with any concerns that our community might have dealing with their care at our facility. Our administration works extra hard to assure that anyone having concerns or issues which need to be resolved are addressed in a timely manner. We are the only facility in town within a 300-mile radius and must work extra hard to keep our patients from going to San Antonio or San Angelo for care.”

Thanks for sharing!

Keep those contest entries coming, and you could win the free registration to The Greeley Medical Staff Institute Symposium (Nov. 8-9, Naples, Fl)!

We’ll share the entries on the blog and select the best one at the end of the month.

To enter the drawing, submit your best practice, tool, or tip to us. Find more details here!

What’s the number one duty of a hospitalist? Patient safety?

When Robert M. Centor, MD, did his morning rounds, he found one patient named Jones in one room, and another patient also named Jones in the next room. That was a mistake waiting to happen, said Centor, associate dean for the Huntsville Regional Medical Campus of the University of Alabama, School of Medicine, in Birmingham, in an interview with HealthLeaders Media I conducted last week.

That’s where the true value of the hospitalist comes in.

“Hospitalists will help the C-suite improve patient safety,” said Centor, who is the voice behind the DB’s Medical Rants blog. Given that hospitalists practically live in the hospital, they are the go-to people for consistency of care and operations.
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Do hospitalists improve the quality of care? YES!

I read, with great interest, two newspaper stories from The Wall Street Journal and the Los Angeles Times that reference a research piece published in the regarding Archives of Internal Medicine hospitalists and quality of care. The study concluded that after adjusting for several factors, care was 21% better for heart attack patients when hospitalists were involved, 11% for pneumonia patients, and no statistically significant difference for congestive heart failure patients.

However, the research could not prove a direct cause and effect relationship between the use of hospitalists and the better quality of care. Other factors such as ratio of nurses to patients (the more nurses, the better the care) clouded the ability to isolate one factor as the cause of the improved care.

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Hospitalists are quality rockstars, according to new study

The healthcare community has long been questioning the value of hospitalists—do hospitalists really improve quality of care? A new study by researchers at Massachusetts General Hospital, Brigham and Women’s Hospital, and Harvard University says yes.

The study, which has been making headlines across the country was called “Hospitalists and the Quality of Care in Hospitals,” published in the August issue of Archives of Internal Medicine. The study linked data from the Hospital Quality Alliance (HQA) with data from the American Hospital Association in three quality measures: acute myocardial infarction (AMI), congestive heart failure, and pneumonia. Researchers found that hospitals with hospitalists—which were usually nonprofit, large, teaching facilities—performed better than hospitals without hospitalists.

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