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Hospital MedicineIs quality improvement
The Journey of Hospital Medicine
The US Perspective
The Journey of Hospital Medicine
The US Perspective
Jeanne M. Huddleston, MD, FACPJeanne M. Huddleston, MD, FACPPast-President, Society of Hospital MedicinePast-President, Society of Hospital Medicine
National Institutes of Health Scholar (KL2)National Institutes of Health Scholar (KL2)
Research Chair, Division of Hospital MedicineResearch Chair, Division of Hospital Medicine
Program Director, Hospital Medicine FellowshipProgram Director, Hospital Medicine Fellowship
Chair, Mortality Review Subcommittee of Hospital PracticeChair, Mortality Review Subcommittee of Hospital Practice
Mayo Clinic, Rochester, MinnesotaMayo Clinic, Rochester, Minnesota
Jeanne M. Huddleston, MD, FACPJeanne M. Huddleston, MD, FACPPast-President, Society of Hospital MedicinePast-President, Society of Hospital Medicine
National Institutes of Health Scholar (KL2)National Institutes of Health Scholar (KL2)
Research Chair, Division of Hospital MedicineResearch Chair, Division of Hospital Medicine
Program Director, Hospital Medicine FellowshipProgram Director, Hospital Medicine Fellowship
Chair, Mortality Review Subcommittee of Hospital PracticeChair, Mortality Review Subcommittee of Hospital Practice
Mayo Clinic, Rochester, MinnesotaMayo Clinic, Rochester, Minnesota
Hospital MedicineIs quality improvement CP1150888-3
A hospitalist is a physician A hospitalist is a physician whose primary professional whose primary professional focus is the medical care of focus is the medical care of hospitalized patientshospitalized patients
A hospitalist is a physician A hospitalist is a physician whose primary professional whose primary professional focus is the medical care of focus is the medical care of hospitalized patientshospitalized patients
SHM Board of Directors,April 13, 2000
SHM Board of Directors,April 13, 2000
Hospital MedicineIs quality improvement
4 years medical school4 years college
12 years primary education
Internal Medicine3 years
Peds3 yrs
FM3yrs
Surgical Specialties5-7 years
EM3 yrs
Board Exams
Subspecialty MedicineCardiology, Pulmonology, Gastroenterology, Geriatrics,
Critical Care, Endocrinology, Nephrology
GeneralMedicine
Care of the complex adult patient with chronic disease and significant number of
comorbidities across the continuum through time
Hospital Medicine
Subspecialty MedicineCardiology, Pulmonology, Gastroenterology, Geriatrics,
Critical Care, Endocrinology, Nephrology, HOSPITAL MEDICINE
GeneralMedicine
Hospital MedicineIs quality improvement
Forces Driving the Hospitalist Movement, Circa 2006
Forces Driving the Hospitalist Movement, Circa 2006
CP1150888-7
• Mandate to improve quality and safety
• Introduction of complex clinical systems
• Regulatory requirements intrusive and onerous
• Residency work hour restrictions
• Cost pressure and potential revenue reduction
• Mandate to improve quality and safety
• Introduction of complex clinical systems
• Regulatory requirements intrusive and onerous
• Residency work hour restrictions
• Cost pressure and potential revenue reduction
Hospital MedicineIs quality improvement
• Hospital Advocate and Physician Leader - Senior management level of hospital- Innovative patient care models/management- QI teams- Standardized, evidence-based practice- Critically evaluate and improve expense management- Co-manage perioperative and medical specialty pts
• Rapid adoption of medical informatics/technology
• Disease management strategies for chronic illness
Forces Driving the Hospitalist Movement, Circa 2010
Forces Driving the Hospitalist Movement, Circa 2010
Hospital MedicineIs quality improvement
Hospital Medicine Hospital Medicine
Growing Faster than Any of Growing Faster than Any of Us DreamedUs Dreamed
Hospital MedicineIs quality improvement
Number of U.S. Physicians in Various Specialties
0
5,000
10,000
15,000
20,000
25,000
30,000Cards
ID
Allergy
Geriatrics
EPS
Hospitalists, 2000
Hospitalists, 1stprediction
Hospitalists, 2004prediction
*Lurie, Am J Med, 1999
Hospital MedicineIs quality improvement
UHC – The Role of Hospitalists in UHC – The Role of Hospitalists in Academic Institutions: 2006 StudyAcademic Institutions: 2006 Study
Of Academic Medical Centers use hospitalistsOf Academic Medical Centers use hospitalists86%86%
Average number of years Hospitalist Program has been in placeAverage number of years Hospitalist Program has been in place4.64.6
Average number of hospitalist FTEs added in response to ACGME resident requirements
Average number of hospitalist FTEs added in response to ACGME resident requirements
9.59.5
Of AMCs have hospitalists managing speciality patientsOf AMCs have hospitalists managing speciality patients57%57%
Average number of hospitalists per institutionAverage number of hospitalists per institution8.78.7
Average number of patient encounters per dayAverage number of patient encounters per day1212
Hospital MedicineIs quality improvement
“There are hospitalist programs and there are hospitalist programs.”
Maureen Bisignano, IHIMaureen Bisignano, IHI
Hospital MedicineIs quality improvement
Areas of FocusAreas of Focus
Core Clinical AreasCore Clinical Areas
•Perioperative care
•Geriatrics
•Palliative care
•General medical care
Core Research AreasCore Research Areas
•Perioperative medicine
•Safety and QI
•Model and curriculum development
Core interestsCore interests
• Quality improvement
• Safety
• Systems and processes of care
• Medical education
Hospital MedicineIs quality improvement
Hospitalists’ roles in the hospital
Clinical RolesClinical Roles
Surgical Co-management 85%Surgical Co-management 85%
Critical Care Critical Care 75%75%
ProceduresProcedures 69%69%
Cardiac ArrestsCardiac Arrests 43%43%
Rapid Response TeamsRapid Response Teams 35%35%
Non-clinical RolesNon-clinical Roles
Committee ParticipationCommittee Participation 92%92%
Quality ImprovementQuality Improvement 86%86%
P/T CommitteeP/T Committee 64%64%
IT Application IT Application 54%54%
TeachingTeaching 51%51%
SHM 2005-2006 Survey
Hospital MedicineIs quality improvement
Factors ImpactingFactors ImpactingEncounter ProductionEncounter Production
1500
1700
1900
2100
2300
2500
0% 1-14% 15-29% 30-44% 45-100%
Tot encounters-Mean Tot encounters-Median
1200
1400
1600
1800
2000
2200
2400
2600
0% 1-9% 10-19% 20-49% 50-100%
Tot encounters-Mean Tot encounters-Median
% of time covering nights
% non-clinical time
1000
1400
1800
2200
2600
3000
3400
<1500Hours
1500-1999Hours
2000-2249Hours
2250-2499Hours
2500-2999Hours
3000+Hours
Tot encounters-Mean Tot encounters-Median
Hours worked/year
Production is correlated with hours worked and somewhat
related to % non-clinical time and % of time covering nights
Hospital MedicineIs quality improvement
Role of Physician Experience in Improved Outcomes
Role of Physician Experience in Improved Outcomes
CP1150888-21
• One year to improve outcomesEfficiency
Clinical
• Disease-specific volume
• Medical patients
• One year to improve outcomesEfficiency
Clinical
• Disease-specific volume
• Medical patients
Meltzer and Auerbach articles: Ann Intern Med, Jan 2003Meltzer and Auerbach articles: Ann Intern Med, Jan 2003Meltzer and Auerbach articles: Ann Intern Med, Jan 2003Meltzer and Auerbach articles: Ann Intern Med, Jan 2003
Hospital MedicineIs quality improvement
Hospitalists Alignment Hospitalists Alignment with Local Culture and with Local Culture and Design Brings ValueDesign Brings Value
Hospital MedicineIs quality improvement
““Seek first to understand…”Seek first to understand…”
• Typical day for providersTypical day for providers
• Providers’ needsProviders’ needs
• Patients’ needsPatients’ needs
Start where the need is greatest:Start where the need is greatest:- patients without providers- patients without providers- complex, frail elderly- complex, frail elderly- co-management specialty patients- co-management specialty patients
Hospital MedicineIs quality improvement
Setting Clear Expectations
““The The
needs ofneeds of
the patient the patient
come first” come first”
CP1150844-28
… … by serving by serving everyone elseeveryone else
… … by serving by serving everyone elseeveryone else
Hospital MedicineIs quality improvement
Partnering for OptimalPartnering for OptimalPatient CarePatient Care
CP1150844-34
Improves Patient OutcomesImproves Patient Outcomes
Hospital MedicineIs quality improvement
Hospitalist-Orthopedic Team Hospitalist-Orthopedic Team ModelModel
““Continuity of medical care throughout a Continuity of medical care throughout a surgical episode for high risk patients.”surgical episode for high risk patients.”
ComanagementComanagement
• Preoperative evaluationPreoperative evaluation
• Immediate post-operative evaluationImmediate post-operative evaluation
• ‘‘Daily’ visits during hospitalizationDaily’ visits during hospitalization
• Post-operative follow-up as indicatedPost-operative follow-up as indicated
Hospital MedicineIs quality improvement
Changes in PracticeChanges in Practice Standard Care HOT
Perioperative medical care
Orthopedic surgical team Faculty, resident/s,
PA
Faculty hospitalist no residents
Ordering of tests, labs, subspecialty consultations
Orthopedic surgical team
Faculty hospitalist
Follow up tests and implementation of consult suggestions
Orthopedic surgical team
Faculty hospitalist
Nursing questions All questions to surgical team
Medical questions: hospitalist
Surgical questions: surgical team
Dismissal planning and summary preparation
Orthopedic surgical team
Surgical team and hospitalist
Hospitalist edits medical information
Hospital MedicineIs quality improvement
What is the evidence that this rapid growth of a new
specialty will make a difference?
What is the evidence that this rapid growth of a new
specialty will make a difference?
CP1150888-22
Hospital MedicineIs quality improvement
Hospitalist – Orthopedic TeamImpact on elective and urgent orthopedic patients
4
5
6
7
8
9
10
11L
OS
(d
ays)
overall ASA 1-2 ASA 3-4 overall
DRG209 – elective LE joints DRG210 – hip fx
Hospital MedicineIs quality improvement CP1150888-14
0 20 40 60 80 100 120 140
"Old" much better
"Old" somewhat better
Same
HOT somewhat better
HOT much better
Respondents (no.)Respondents (no.)
Patient receives better carePatient receives better care
Follow-up of testsFollow-up of tests
Promptness in response to patient needsPromptness in response to patient needs
Recognition of postop medical needsRecognition of postop medical needs
Coordination of careCoordination of care
Ease of providing high-quality careEase of providing high-quality care
ApproachabilityApproachability
Clarity of medical recommendationsClarity of medical recommendations
Level of communicationLevel of communication
Hospital MedicineIs quality improvement
Evidence to Date on Hospital MedicineThe Bottom Line
Evidence to Date on Hospital MedicineThe Bottom Line
CP1150888-20
• Reduced hospital costs and LOS (~15%)
• Decreased readmissions and mortality
• No change in consultation (Mayo and UCSF)Some have found significant drops (~20%)
• Inpatient satisfaction preserved
• Provider satisfaction high Hospitalist, specialist, surgeons, nurses
• Reduced hospital costs and LOS (~15%)
• Decreased readmissions and mortality
• No change in consultation (Mayo and UCSF)Some have found significant drops (~20%)
• Inpatient satisfaction preserved
• Provider satisfaction high Hospitalist, specialist, surgeons, nurses
Hospital MedicineIs quality improvement
What is the “disease” for hospital medicine?
• delivery of clinical care
• flow through hospital
• adverse events
• transitions of care
Hospital MedicineIs quality improvement
Resources for HospitalistsResources for Hospitalists
Hospital MedicineIs quality improvement
Societies of Societies of Hospital Hospital MedicineMedicine
Hospital MedicineIs quality improvement
Text Books
New text 2006:Comprehensive Hospital
Medicine
Hospital MedicineIs quality improvement
Journal of Hospital Journal of Hospital MedicineMedicine
1st issue: February 20061st issue: February 2006
www.hospitalmedicine.org
Hospital MedicineIs quality improvement
Speed BumpsSpeed Bumps
andand
Pot HolesPot Holes
Hospital MedicineIs quality improvement
Current U.S. Threats• Burn outBurn out
• Local expectationsLocal expectations• PhysiciansPhysicians• AdministrationAdministration
• Academic credibilityAcademic credibility
• Recruitment patternsRecruitment patterns
• Continuity of careContinuity of care
• Variability of care deliveryVariability of care delivery
• Autonomy vs. adherence to quality and safety protocolsAutonomy vs. adherence to quality and safety protocols
• The answer for everythingThe answer for everything
Hospital MedicineIs quality improvement
Benefits of Being a Hospitalist
• Flexibility - type of patientsFlexibility - type of patients• Service weightingService weighting
• Flexibility in the work dayFlexibility in the work day
• Flexibility in the work yearFlexibility in the work year
• Improve operations of careImprove operations of care
• Save livesSave lives
• TeamworkTeamwork
• Career and leadership developmentCareer and leadership development
Hospital MedicineIs quality improvement
Systems Approach to Patient Care:
Public health for inpatient care
• How can we best manage the 200 How can we best manage the 200 pneumonias that will be admitted this year?pneumonias that will be admitted this year?
• Should every patient receive their IV Should every patient receive their IV antibiotics within the first hour?antibiotics within the first hour?
• How should nursing, pharmacy, the ER and How should nursing, pharmacy, the ER and physicians be staffed and organized to physicians be staffed and organized to accomplish this?accomplish this?
Hospital MedicineIs quality improvement
Defining Features of Hospital Medicine
Hospital MedicineIs quality improvement
Defining Features of Hospital Medicine
• Dedicated to the hospitalDedicated to the hospital
• TeamworkTeamwork
• Systems orientedSystems oriented
• Expect to be measuredExpect to be measured
Hospital MedicineIs quality improvement CP1150888-40