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Check out our new resource for medical staff leaders

Medical Staff Leadership Essentials: A Guide to Developing Leadership Skills and Recruiting the Next Generation provides valuable insight to help new and veteran medical staff leaders develop, retain, and recruit a legacy of effective future physician leaders. Written by 35-year medical staff veteran R. Dean White, DDS, MS, a medical staff consultant in Granbury, TX, and reviewed by The Greeley Company’s Jonathan H. Burroughs, MD, MBA, FACPE, CMSL, this book is a complete training resource for any medical staff leader who may have been elected (or thrown)  his or her position with little experience. It’s also great for veteran leaders who wish to train incoming leaders. Check out table of contents:

  • Chapter 1: Principles of leadership
  • Chapter 2: Foundational leadership skills that can be learned
  • Chapter 3: Roles and responsibilities of medical staff leaders
  • Chapter 4: Identifying and recruiting medical staff leaders
  • Chapter 5: Educating medical staff leaders
  • Chapter 6: Nominating and selecting medical staff leaders
  • Chapter 7: Succession planning and leadership retention
  • Chapter 8: Understanding the medical staff culture to meet future challenges
  • Chapter 9: Reflections and resources
  • Chapter 10: From the field: Medical staff leaders share their thoughts on what it means to lead

To order, click here.

Authors explore the ethics of physicians participating in capital punishment

The Hastings Center Report this month explores the ethics involved with physicians participating in lethal injection. On one hand, allowing physicians to participate may make deaths swifter and more humane for patients, but on the other hand, killing patients goes against physicians’ code of ethics to “first, do no harm.” In 2010, the American Board of Anesthesiologists decided to revoke the certification of any physician who participated in capital punishment, following the AMA’s lead.

Free-standing emergency departments on the rise

Free-standing emergency departments are on the rise, according to Physician News Digest. The majority of patients currently visit emergency departments for non-urgent and semi-urgent care, and visiting a free-standing emergency department, which is not attached or associated with a hospital, can save them money and reduce wait times in hospital-associated emergency departments. They aren’t the best choice, however, for true emergencies, such as heart attacks, and it’s difficult for patients to know which facilities offer which services, say critics.

ACGME-compliant staffing model reduces costs for hospital

When the ACGME released its new Common Program Requirements, many balked at the estimated cost of implementing and remaining compliant with the new rules. However, the University of California, San Francisco’s (UCSF) Benioff Children’s Hospital found that the right staffing model can reduce hospitalization costs by 11% and shorten lengths of stay by 18%, reports Hospitalist News Digital Network.

“In September 2008, UCSF expanded and reorganized its pediatric inpatient hospitalist service, moving from a traditional call model to a shift-based staffing model. In the process, the hospital eliminated cross-coverage of different teams in favor of dedicated night teams that were subsets of their day teams,” the article states.

Hospitalist-nurse partnerships

I have written in previous posts about the importance of developing partnerships between hospitalists and nurses. The quality of those relationships may determine the difference between a hospital that succeeds and one that fails. The key to a successful partnership is rapid flow of information between the parties and the ability to trust each other. Consider the needs of each side: hospitalists need nurses who can make accurate patient assessments and provide timely alerts to changes in condition, while nurses need physicians who provide clear instructions and provide rapid and respectful responses to contacts from the nurses.

Let’s start with the basics. Nurses need to know at all times which doctor is responsible for each of their patients. It is not acceptable for nurses to have to guess, try several doctors, or call an office to figure out which hospitalist is caring for a patient. When patient responsibility is transferred from one physician to another, the primary nurse needs to have that information promptly, and every hospitalist program needs a system to relay that information. If a nurse is confused and calls the incorrect physician, hospitalists should not dismiss the call with a brusque “Call Dr. X.” If the problem is simple and does not require detailed knowledge of the patient, handle it yourself and then refer the nurse to the appropriate physician for additional assistance.

The next level involves changing the work dynamics between hospitalists and nurses. Nurses document reams of information about patients throughout the course of a day, most of which physicians ignore. Unlock that information by holding a daily meeting in which physicians and nurses share their knowledge about patients. Formal rounding is great if you can do it, but a quick huddle with the nurse to go over the nurse’s observations about the patient and the doctor’s plan for diagnosis and treatment can be tremendously valuable in speeding treatment plans and in reducing phone calls during the remainder of the day.

The final level involves breaking down the wall between the professional status of doctors and nurses. If the patient asks for a cup of water, do you need to ring for a nurse? Would it kill you to fill a cup from the sink and bring it to the bedside? If you do a bedside procedure, how about taking the used items and placing them in the proper receptacles? A little bit of humility goes a long way in helping nurses feel that they are valued colleagues, rather than servants.

Autopsies: A dying procedure?

A May 16, 2011 article in the Washington Post reports that autopsies are now performed on only approximately 5% percent of patients who die, compared to roughly 50%  in the 1960s.  According to some experts, this decline is unfortunate because “details about the cause of death can be illuminating for both families and hospitals, even if they don’t turn up an undiagnosed ailment or other new information about the cause of death.” A 1998 JAMA article (JAMA. 1998;280 [14]:1273-1274) reported that autopsy results showed that clinicians misdiagnosed the cause of death up to 40% of the time. How do you and your hospitals balance academic curiosity, research, family needs for closure, and the risk of medical liability? At our institutions, we perform very few autopsies. When asked, the majority of physicians working in the community believe they “know” the cause of death, and therefore an autopsy is an unnecessary burden on an already fragile healthcare system. But when pushed, they often answer that they don’t want to know if they missed anything for fear of a malpractice suit. Is that wrong? Are we letting fear of malpractice stifle our pursuit of excellence and knowledge? 

Do pharmaceutical and device manufacturers create biased CME?

A recent article in the Archives of Internal Medicine, Clinician Attitudes About Commercial Support of Continuing Medical Education,” addresses whether physicians think that funding from pharmaceutical and medical device companies injects bias into continuing medical education presentations (these companies provide up to 60% of CME funding in the United States). Of the 1347 surveyed, 770 responded to a structured questionnaire. The results showed that 88% of respondents thought some bias was introduced into the presentation, but only 15% thought commercial sponsorship should be eliminated. Only 42% were willing to pay higher registration fees to eliminate commercial support.

Our hospitals do not allow vendors to set up shop to present their wares or provide education for fear of a biased presentation. This, however, doesn’t stop them from doing this outside the hospital. The question is whether we should stop them. After so many years of schooling, are physicians not intelligent enough to know that commercial support can lead to bias? Are we not able to look at the science behind the product and make a determination of utility? If all commercial support is banned, will physicians pay the increased fees to learn about new products and technologies, or will they just continue to practice the way they always have? The slope has always been slippery, but most physicians have been able to discern marketing hype from science.  Have we changed?  What do you think?

Does unhappy = underpaid?

An April 28, 2011 piece in The Washington Post raises the issue of patient satisfaction as it relates to the value based performance initiative from the Centers for Medicare & Medicaid Services (CMS). CMS’ recent proposal will allow Medicare to withhold 1% of its payments to hospitals starting in October 2012—for those of you who are counting, that is $850 million in the first year. That money will go into a pool and be doled out to hospitals that perform better than average on patient satisfaction and quality care measures. Only 30% of the withhold is based patient satisfaction; the other 70% is related to quality metrics.

Given these upcoming changes, what do you think about physicians’ role in patient satisfaction? Should hospitals allow physicians who have below-average satisfaction scores to remain on staff? Is it not the right and responsibility of a hospital’s board to do whatever it can to maintain financial stability, even if it negatively affects physicians?  Should the credentials committee review patient satisfaction in a similar fashion that it reviews physician quality metrics?  Is there a correlation between quality and satisfaction?  Our hospitals are now reviewing patient satisfaction scores at the time of reappointment, and a subgroup is evaluating what should be the acceptable score and what should be done about physicians who fall below that target.  Isn’t it time we really took patient satisfaction seriously? How about your hospital? What are you going to do?

Alligators in the hospital: Part II

My last two posts have dealt with the analogy between hospitalist program managers and civil engineers who find that they cannot drain the swamp as contracted because they are occupied with fighting off alligators. I want to discuss now the most prevalent type of alligators in hospitals—the nurses. Doctor-nurse relationships run deep and may well be the prime determinant between hospitals that fail and those that succeed. The nurse was historically a handmaiden to the physician and maintained extreme deference. Advances in nursing education have prepared nurses for a professional role that is still subordinate to the physician, but the relationship between the two varies from cooperative to antagonistic.

What makes a nurse into an alligator? Nurses are expected to carry out a daily care plan for a group of patients that may number from one (in the ICU) to 30 or more (typically on a night shift). They are expected to respond promptly to call buttons, answer calls from doctors and families, send patients off to scheduled tests and procedures, administer complex medication regimens correctly, and document their activities thoroughly. There is a lot to do in the course of a day and not quite enough time to do it. Years ago, all of a nurse’s patients might be in a single room and she (no male nurses back then) could see them all and shift attention quickly to those that needed it. Today’s nurse may have each patient in a different room and the rooms may be at opposite ends of the floor.


The ACO proposed rules: A party starter or a party killer?

We all anxiously, and many hopefully, waited and watched as the CMS proposed rules for the accountable care organizations (ACO) were being prepared. Now that the rules have been released and many have had a chance to read them, what I’m hearing from hospitalists and administrators alike is a collective state of disappointment.

Some common observations that surround the ACO new rules: too much regulation, not enough potential or risk sharing and too much investment involved. The general feeling among those I’ve been talking to is that there will be muted participation in the ACO program because of all the barriers to entry.

For example, there are 65 quality measures that all must be met to qualify for any shared savings. How many practices can accurately collect and report data on even just a few Physician Quality Reporting Initiative (PQRI) metric? Another challenge is that 50% of providers in an ACO must meet the meaningful use definition for electronic health records. This represents a very large investment by physician practices regardless of size, many of which are not prepared to take on this burden. In addition, the rules call for a 25% holdback on funds earned in the shared savings program. This withhold is to protect against underperformance in future years when a repayment might be required of the ACO. However, as currently written, the withhold is never released! A successful ACO could accumulate several years of shared savings that they will never receive.

These are just a few of the elements of the proposed ACO rules that are taking the wind out of the sails of some in hospital medicine. It seems that the rules have not energized or empowered the potential participant organizations to embark on the effort to create ACOs. Instead, they seem to create barriers and skepticism. I am certain that large health systems that have already made most of the required investment in EHR, etc., will proceed with their plans, but I wonder how many smaller systems will view the return as being worth the risk and take the plunge.

What to do you think? What have you heard? Have the proposed rules put a damper on the ACO party? I am eager to hear from others on this topic.

Case review form and peer review referral form

In the May issue of Credentialing & Peer Review Legal Insider, we discuss with Linda Van Winkle, CPCS, CPMSM,  manager of medical staff services at Christus St. Patrick in Lake Charles, LA, the chart review form and the peer review referral form that she submitted to the Credentialing Resource Center Symposium contest. These two forms have helped in Christus St. Patrick’s quest to reduce the number of peer review cases that are sent to the multi-disciplinary peer review committee unncessarily and have helped Van Winkle  sail through the OPPE process. In the newsletter, Linda explains why she developed the forms and how to use them. Check them out and see if your facility can adapt them.

Thanks for sharing, Linda!

For better or for worse: Waivers for patient online reviews

When I first moved to a new city, I knew no one, including a primary care physician (PCP), gynecologist, dentist, no one. I asked friends of friends and my PCP from my old city for recommendations, but unfortunately, they didn’t have any for me. As a patient, I did the next logical step in my research and Googled physicians who belonged to my insurance network. I came across glowing reviews, as well as a few sour ones. Those online reviews were extremely helpful in selecting who my physicians would be.

A new trend, however, is putting a stop to those online reviews. More physicians are asking their patients to sign waivers restricting them from posting reviews online. Known as mutual privacy agreements, these documents are typically batched with other HIPAA agreements and initial patient paperwork that patients fill out before their examination.

User-generated reviews, written by patients, themselves, are open for public view. Patients can rate their physicians and appointment experience, both positively and negatively. Ratings and comments can include information about the physician’s licensure, schools attended, office location, disciplinary records, and even bedside manner. Some user-generated review websites include the following: