hospital medicine is quality improvement the journey of hospital medicine the us perspective jeanne...

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


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


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 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




Hospital Medicine Hospital Medicine

Growing Faster than Any of Growing Faster than Any of Us DreamedUs Dreamed


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


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


“There are hospitalist programs and there are hospitalist programs.”

Maureen Bisignano, IHIMaureen Bisignano, IHI


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


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


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%


% 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


Hours worked/year

Production is correlated with hours worked and somewhat

related to % non-clinical time and % of time covering nights


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


Hospitalists Alignment Hospitalists Alignment with Local Culture and with Local Culture and Design Brings ValueDesign Brings Value


““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


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


Partnering for OptimalPartnering for OptimalPatient CarePatient Care

CP1150844-34

Improves Patient OutcomesImproves Patient Outcomes


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


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


Faculty hospitalist

Nursing questions All questions to surgical team

Medical questions: hospitalist

Surgical questions: surgical team

Dismissal planning and summary preparation


Surgical team and hospitalist

Hospitalist edits medical information


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


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


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


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


What is the “disease” for hospital medicine?

• delivery of clinical care

• flow through hospital

• adverse events

• transitions of care


Resources for HospitalistsResources for Hospitalists


Societies of Societies of Hospital Hospital MedicineMedicine


Text Books

New text 2006:Comprehensive Hospital

Medicine


Journal of Hospital Journal of Hospital MedicineMedicine

1st issue: February 20061st issue: February 2006

www.hospitalmedicine.org


Speed BumpsSpeed Bumps

andand

Pot HolesPot Holes


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


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


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?


Defining Features of Hospital Medicine


Defining Features of Hospital Medicine

• Dedicated to the hospitalDedicated to the hospital

• TeamworkTeamwork

• Systems orientedSystems oriented

• Expect to be measuredExpect to be measured

hospital medicine is quality improvement the journey of hospital medicine the us perspective jeanne...

Documents