Hospital Medicine

An Evolution in Changing Paradigms

Jeff Wiese, MD, FACP, FHM

Professor of Medicine

Tulane University Health Sciences Center

What is a Hospitalist?

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%

Hospitalist Specialties

The Society of Hospital Medicine National Survey; 2008

Hospital/Hosp. Corporation,

40%

Academic, 24%

Multi-state group/mgt. co.,

8%

Multi-spec/PCP med. group,

11%

Local hospitalist only group,

14%

Other, 3%

Employment Model of Hospital Medicine Groups

The Society of Hospital Medicine National Survey; 2008

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%

Hospitalist Characteristics

The Society of Hospital Medicine National Survey; 2008

• 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 Work of Hospitalists

The Society of Hospital Medicine National Survey; 2008

Non-clinical Roles

Committee Participation 92%

Quality Improvement 86%

P&T Committees 64%

CPOE/Information Systems 54%

Teaching 51%

The Expanding Role of the Hospitalist

26,634

22,302

19,271

13,293

11,704

9,791

4,156

0 5,000 10,000 15,000 20,000 25,000 30,000

Emergency Medicine

Cardiology

Hospital Medicine

Neurology

Gastroenterology

Pulmonary

Allergy

# of physicians

AHA 2006 Survey

Society of Hospital Medicine Membership#

of M

emb

ers

What drove the hospitalist movement?

The physician The hospitalized patient

Increasing disease severity * Inpatient * Outpatient

Higher standards of careClinic reliability

Patient issuesPhysician Issues

Complexity of documentationBusy clinic schedulePhysician quality of lifeQuality of care standards

Third party issues

Joint CommissionQuality improvement Supervision requirementsCost-containment * Admissions * Resource utilization * Discharge

Hospital Medicine in 2009

The Seven Deadly Sins

Seven Deadly* Sins of Hospital Medicine

* Potentially

Sin 1: Failure to Advance

Quality and Patient Safety

Quality:

1.Desired Outcomes Occur2.Evidenced-Based Standard of Care Leads to the Outcome

Institute of Medicine Six Components of Quality Health Care

Time

Quality

Time

Quality

SafeTimelyEffectiveEfficientPatient-CenteredEquitable

Institute of Medicine Six Components of Quality Health 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

The rational behind hospitalists and quality of care

SafeTimelyEffectiveEfficientPatient-CenteredEquitable

Hospitalists vs Gen Internists

Length of Stay -0.4 daysCosts -$268Same mortalitySame re-admit rate

Chan PS, et al.N Engl J Med 2008;358:9-17.

Gray A, et al.N Engl J Med 2008;359:142-51

Wachter R, et al.,Ann Intern Med. 2008;149:29-32.

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.

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

• 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

SHM-Developed Quality Improvement Initiatives

Sin 2: Living in a Silo

1. Hospital Value-based Purchasing2. Physician Quality Reporting Initiative (PQRI)3. Expansion of Physician Feedback Program (Resource Use) 4. Value-Based Modifier for Physician Payment Formula5. Reducing Hospital Acquired Conditions6. Improving Quality7. Accountable Care Organizations8. CMS Payment Innovation Center9. National Pilot Program on Bundling Acute &Post Acute Payments10. Readmissions11. Community Care Transitions Program12. Medicare Physician Payment Update (SGR)13. Medical Liability Reform14. Provider Screening 15. Provider Compliance and Penalties (High Risk Referrals)16. Primary Care Bonus Payment

Sin 3: Failure to Maintain Patient-Centered Care

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 patient’s family, and the patient’s primary care provider is necessary for maintaining this standard.

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.

Weissman JS, et al.,Ann Intern Med. 2008;149:100-108.

Sin 4: Failure to Sustain Quality & Patient Safety:

Transitions of Care

Transitions of Care

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

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

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 2006:354.

• Resource Room

• Safe STEPs

• Project BOOST

– Better Outcomes for Older adults through Safe Transitions

– John A. Hartford Foundation $1.4 million

BOOST Toolkit: Primary Components1. Tool for Identification of High-Risk Patients

2. Patient and Family/Caregiver Preparation– Diagnosis – primary cause for hospitalization and other Dx– Test results and interpretation– Treatment Plan during and after hospitalization

• Contextualize

3. 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

Other Transitions

The Seven Organizational Sins

1. Overproduction2. Waiting3. Transporting4. Inappropriate Processing 5. Unnecessary Inventory6. Unnecessary Motion7. Defects

Howell E, et al.,Ann Intern Med. 2008;149:804-810.

Sin 5: Failure to Sustain The Art:

Instruction of Quality and Patient Safety

Before the Work Hours

After the Work Hours

Extra Work

Before the Work Hours

Solution 1: Shift the work to others (i.e., other residents/ hospitalists)

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

Before the Work Hours

Solution 2: Go To Shifts

Before the Work Hours

Solution 2: Go To Shifts

Problem: Efficiency in the system is lost generating extra work

How We Learn: SurgeryA clinical decision is made:

“Cut that”

Patient Bleeds Patient does not bleed

An outcome occurs

Response: Bovi

Response: Continue

Lesson Learned:

OK to cut thatDon’t cut that

How We Learn: MedicineA clinical decision is made:

“Give the patient insulin”

Patient has ARF; becomes hypoglycemic

Patient does not have ARF; remains normoglycemic

An outcome occurs

Response: Glucose needed

to correct

Response: Continue

Lesson Learned:

Don’t give patients with ARF insulin.

OK to give patients without ARF insulin.

How We Learn (Multiple Shifts)

A clinical decision is made: “Give the patient insulin”

Patient has ARF; becomes hypoglycemic

Patient does not have ARF; remains normoglycemic

An outcome occurs

Response: Glucose needed

to correct

Response: Continue

Lesson Learned:

OK to give patientswith ARF insulin.

OK to give patients without ARF insulin.

New shift

Before the Work Hours

Solution 3: Assume the Work, Deal with the Intensity

Before the Work Hours

Solution 1: Assume the Work, Eliminate the MUDA

Papadakis M, et al.Ann Intern Med. 2008;148:869-876.

Sin 6: Failure to Sustain the Career

Sustainability

Fulfillment proportional to work invested

Empowerment to change systems Leadership opportunities for career

growth

Sustainability Part A: Matching Compensation to Effort

1800

1900

2000

2100

2200

2300

2400

2500

Hosp Empl Academic Multi-stateHosp Only

Group/Mgt Co

Local HospOnly Group

Multi-spec/Prim.

Care Med Grp

Hours worked

0

500

1000

1500

2000

2500

3000

3500

Hosp Empl Academic Multi-stateHosp Only

Group/Mgt Co

Local HospOnly Group

Multi-spec/Prim.

Care Med Grp

Encounters

Work Intensity

$189,400$198,600 $198,500

$186,700

$100,000

$125,000

$150,000

$175,000

$200,000

$225,000

East South Midwest West

Tot. compensation

$173,000$185,000

$202,000

$100,000

$125,000

$150,000

$175,000

$200,000

$225,000

100% Salary Mix Salary/Bonus 100% Production-based

Tot. compensation

Compensation

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?

At the End of the Day, Compensation= Value Added Service

Value = Quality Cost

Sustainability Part B: Fulfillment

Emergency DepartmentClinics

Ward Team

Emergency DepartmentClinics

Ward TeamNon-Teaching Service

Option A: Non-teaching ServiceRandom or Alternating Assignment

Emergency DepartmentClinics

Ward TeamNon-Teaching Service

Option B: Non-teaching ServicePre-determinedAssignments

Sustainability Part C: Promotion & Reputation

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 picks2000-present 30 71990-1999 37 21980-1989 27 41970-1979 25 4

What the NFL Knows, That We Don’t

Sin 7: Failure to Maintain Public Accountability:

Maintenance of Certification

Maintenance of Certification Process

Part I. Pre-RequisitesA. Valid, unrestricted medical license and confirmation of good standingB. ABIM certification in internal medicineC. 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

Maintenance of Certification

Part II. Self-Evaluation Programs A.Complete self-evaluation modules to earn 100 points:

1. Patient Safety2. Systems Improvements to Advance Timely & Efficient Care3. Evidence-Based Hospital Care4. Measures to Improve Patient-Centered Care5. Measures to Improve Equitable Access to Care

Current IM MOC Hospital Medicine MOC

In-Patient Content In-Patient Content

Ambulatory Content

Ambulatory Content

Systems/ QI

 Part III. The Secure Exam

 Part IV. Practice Improvement Module

A. Longitudinal Self-reflection ModulesB. Practice Improvement ProjectC. On-Going (every three years)