Hospital Medicine An Evolution in Changing Paradigms

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Hospital MedicineAn Evolution in Changing
Paradigms

• Jeff Wiese, MD, FACP, FHM
• Professor of Medicine
• Tulane University Health Sciences Center

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What is a Hospitalist?
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Hospitalist Specialties
General Internal Medicine 82.3
General Pediatrics 6.5
Internal Medicine Sub-specialty 4.0
Family Practice 3.7
Internal Medicine Pediatrics 3.1
Pediatrics Sub-specialty 0.4
The Society of Hospital Medicine National Survey
2008
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Employment Model of Hospital Medicine Groups
The Society of Hospital Medicine National Survey
2008
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Hospitalist Characteristics
HMG Leaders Non-leader physicians
Median Age 41 years 37 years
Male 80 63
Mean experience 6.7 years 3.7 years
IMG 15 29
The Society of Hospital Medicine National Survey
2008
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The Work of Hospitalists

• Admissions, Follow-ups, Discharges 73.6
• Consultations 8.2
• Observation Days 8.0
• Critical Care 4.0
• Procedures 2.0
• Office Encounters/Consultations 1.1
• SNF/Rest Home Visits 1.0
• ED Encounters 0.9
• Other Encounters 1.1

The Society of Hospital Medicine National Survey
2008
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The Expanding Role of the Hospitalist
Non-clinical Roles Committee Participation
92 Quality Improvement 86 PT Committees
64 CPOE/Information Systems 54 Teaching
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AHA 2006 Survey
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Society of Hospital Medicine Membership
of Members
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What drove the hospitalist movement?

The physician
The hospitalized patient
Patient issues
Physician Issues
Third party issues
Increasing disease severity Inpatient
Outpatient Higher standards of
care Clinic reliability
Complexity of documentation Busy clinic
schedule Physician quality of life Quality of
care standards
Joint Commission Quality improvement Supervision
requirements Cost-containment Admissions
Resource utilization Discharge
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Hospital Medicine in 2009
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The Seven Deadly Sins
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Seven Deadly Sins of Hospital Medicine
Potentially
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Sin 1 Failure to Advance Quality and Patient
Safety
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• Quality
• Desired Outcomes Occur
• Evidenced-Based Standard of Care Leads to the
  Outcome

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Institute of Medicine Six Components of Quality
Health Care
Quality
Time
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Institute of Medicine Six Components of Quality
Health Care
Safe Timely Effective Efficient Patient-Centered E
quitable
Quality
Time
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The rational behind hospitalists and quality of
care

• Familiarity with the intricacies of inpatient
  disease management (specialization)
• Familiarity with many different sub-specialties
• Familiarity with non-medical services
• Closer relationship with nurses, administration,
  and technicians
• Greater availability to patients

Safe Timely Effective Efficient Patient-Centered E
quitable
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Hospitalists vs Gen Internists Length of Stay
-0.4 days Costs -268 Same mortality Same
re-admit rate
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Chan PS, et al. N Engl J Med 20083589-17.
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Gray A, et al. N Engl J Med 2008359142-51
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Wachter R, et al., Ann Intern Med. 200814929-32.
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Quality and Patient Safety

• Quality Patients received the highest standard
  of care such that expected outcomes are routinely
  achieved.
• Patient Safety Adverse consequences of
  diagnostic and therapeutic interventions,
  including medical errors, are avoided.

Committee on Quality Healthcare in America,
Institute of Medicine. (2001). Crossing the
Quality Chasm A New Health System for the 21st
Century.
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Overriding Aims of Patient Safety
1. Education   2. Raise Awareness   3.
Accountability/Metrics   4. QI Projects/Research
to change the system
Wachter, R.M. Understanding Patient Safety. 2008
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SHM-Developed Quality Improvement Initiatives

• Quality Improvement Resource Rooms
• www.hospitalmedicine.org/rrs
• Acute Coronary Syndrome
• Antimicrobial Resistance
• BOOSTing Care Transitions
• Glycemic Control
• Heart Failure
• Veneous Thromboembolism
• Stroke
• Peer-Submitted Quality Improvement Tools

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Sin 2 Living in a Silo
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• Hospital Value-based Purchasing
• Physician Quality Reporting Initiative (PQRI)
• Expansion of Physician Feedback Program (Resource
  Use)
• Value-Based Modifier for Physician Payment
  Formula
• Reducing Hospital Acquired Conditions
• Improving Quality
• Accountable Care Organizations
• CMS Payment Innovation Center
• National Pilot Program on Bundling Acute Post
  Acute Payments
• Readmissions
• Community Care Transitions Program
• Medicare Physician Payment Update (SGR)
• Medical Liability Reform
• Provider Screening
• Provider Compliance and Penalties (High Risk
  Referrals)
• Primary Care Bonus Payment

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Sin 3 Failure to Maintain Patient-Centered Care
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3. Patient-Centered Care

• Pay for hospitalists may, and likely will is,
  derived from hospitals.
• The fiduciary responsibility must remain with the
  patient.
• A strong connection to the patient, the patients
  family, and the patients primary care provider
  is necessary for maintaining this standard.

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Patient Satisfaction

• Patients prefer to receive care from their
  primary care provider if
• The primary care MD is consistently available
• The primary care relationship has been
  well-established.
• Patients prefer hospitalist care if
• The hospitalist regularly sees the patient
  (accessability)
• The hospitalist is in frequent communication with
  the patients primary physician.

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Weissman JS, et al., Ann Intern Med.
2008149100-108.
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Sin 4 Failure to Sustain Quality Patient
Safety Transitions of Care
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Transitions of Care

• Transfer of Information
• Transfer of Choice
• Transfer of Decision-Making
• Enabling Communications/Decisions
• Preservation of Patient-Centered Care

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Transitions of Care

• - Inflow to Hospital Medicine
• - Primary Care Identification
• - Past Medical History
• - Patient wishes/personal history
• - Diagnostic coordination
• - Outflow to Primary Care
• - Primary Care Entry
• - Synching inpatient to outpatient continuum
• - Setting up the perfect first visit

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SHM Initiatives Care Transitions

• Discharge Checklist
• Halasyamani L et al. Transition of care for
  hospitalized elderly patients--development of a
  discharge checklist for hospitalists. J of Hosp
  Med 2006354.
• Resource Room
• Safe STEPs
• Project BOOST
• Better Outcomes for Older adults through Safe
  Transitions
• John A. Hartford Foundation 1.4 million

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BOOST Toolkit Primary Components

• Tool for Identification of High-Risk Patients
• Patient and Family/Caregiver Preparation
• Diagnosis primary cause for hospitalization and
  other Dx
• Test results and interpretation
• Treatment Plan during and after hospitalization
• Contextualize
• Follow-up Plans
• Principal Care Provider identification
• Who to contact with questions/concerns
• Warning signs/symptoms and how to respond
• Outpatient appointments
• Pending tests
• 4. Medication Reconciliation
• 5. Discharge Summary Communication

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Other Transitions
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The Seven Organizational Sins

1. Overproduction
2. Waiting
3. Transporting
4. Inappropriate Processing
5. Unnecessary Inventory
6. Unnecessary Motion
7. Defects

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Howell E, et al., Ann Intern Med.
2008149804-810.
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Sin 5 Failure to Sustain The Art Instruction
of Quality and Patient Safety
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Before the Work Hours
After the Work Hours
Extra Work
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Before the Work Hours
Solution 1 Shift the work to others (i.e., other
residents/ hospitalists)
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Before the Work Hours
Solution 1 Shift the work to others
Problem 1) A proportion of the good work is
lost ( ), or 2) You induce a system of
high-output heartfailure
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Before the Work Hours
Solution 2 Go To Shifts
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Before the Work Hours
Solution 2 Go To Shifts
Problem Efficiency in the system is lost
generating extra work
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How We Learn Surgery
A clinical decision is made Cut that
An outcome occurs
Patient Bleeds
Patient does not bleed
Response Bovi
Response Continue
Lesson Learned
OK to cut that
Dont cut that
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How We Learn Medicine
A clinical decision is made Give the patient
insulin
An outcome occurs
Patient has ARF becomes hypoglycemic
Patient does not have ARF remains normoglycemic
Response Glucose needed to correct
Response Continue
Lesson Learned
Dont give patients with ARF insulin.
OK to give patients without ARF insulin.
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How We Learn (Multiple Shifts)
A clinical decision is made Give the patient
insulin
An outcome occurs
Patient has ARF becomes hypoglycemic
Patient does not have ARF remains normoglycemic
New shift
Response Glucose needed to correct
Response Continue
Lesson Learned
OK to give patients with ARF insulin.
OK to give patients without ARF insulin.
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Before the Work Hours
Solution 3 Assume the Work, Deal with the
Intensity
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Before the Work Hours
Solution 1 Assume the Work, Eliminate the MUDA
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Papadakis M, et al. Ann Intern Med.
2008148869-876.
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Sin 6 Failure to Sustain the Career
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Sustainability

• Fulfillment proportional to work invested
• Empowerment to change systems
• Leadership opportunities for career growth

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Sustainability Part A Matching Compensation to
Effort
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Work Intensity
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Compensation
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Potential Threats to Compensation

• Pay for Performance
• Value Based Purchasing
• Bundling
• DRG for facility and professional charges
• Who will control these dollars?
• What about the Uninsured/Underinsured?

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At the End of the Day, Compensation Value Added
Service
Value Quality Cost
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Sustainability Part B Fulfillment
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Emergency Department Clinics
Ward Team
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Emergency Department Clinics
Option A Non-teaching Service Random or
Alternating Assignment
Ward Team
Non-Teaching Service
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Emergency Department Clinics
Option B Non-teaching Service Pre-determined Ass
ignments
Ward Team
Non-Teaching Service
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Sustainability Part C Promotion Reputation
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What the NFL Knows, That We Dont
On offense, only the quarterbacks make more on
average than left tackles, but it's not just
salaries that spell out the bottom line. Tackles
have become more coveted at the top of the draft
order 1st-round picks Top-five
picks 2000-present 30 7 1990-1999 37 2 19
80-1989 27 4 1970-1979 25 4
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Sin 7 Failure to Maintain Public
Accountability Maintenance of Certification
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Maintenance of Certification Process Part I.
Pre-Requisites A. Valid, unrestricted medical
license and confirmation of good standing B. ABIM
certification in internal medicine C. Minimum of
three years hospital medicine practice
experience (hospital medicine practice experience
acquired during training cannot be counted unless
it is part of a hospital medicine fellowship)
. D. Attestation of significant commitment to
focused practice in hospital medicine, through
meeting requirements for either of the following
two pathways 1. Direct Patient Care (i.e.,
full-time hospital practice) minimum of 1000
hospital patient encounters (limited to one
encounter per patient-day) per year for three
years, or 3000 over three years. 2. Clinical
Systems (i.e., full time hospital medicine
professional activity with part-time hospital
practice) minimum of 250 hospital patient
encounters (limited to one encounter per patient
day) per year for three years, of 750 over three
years these encounters must comprise at least
75 of total clinical activity. E. ACLS
Certification
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• Maintenance of Certification
• Part II. Self-Evaluation Programs
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• Complete self-evaluation modules to earn 100
  points
• 1. Patient Safety
• 2. Systems Improvements to Advance Timely
  Efficient Care
• 3. Evidence-Based Hospital Care
• 4. Measures to Improve Patient-Centered Care
• 5. Measures to Improve Equitable Access to Care

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 Part III. The Secure Exam
Current IM MOC Hospital Medicine MOC
Ambulatory Content
Ambulatory Content
Systems/ QI
In-Patient Content
In-Patient Content
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  Part IV. Practice Improvement Module A.
Longitudinal Self-reflection Modules B. Practice
Improvement Project C. On-Going (every three
years)
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