Section 1: The Value and Values of Hospital Medicine

INTRODUCTION

Hospital medicine is entering its third decade since the term “hospitalist” was first created by Wachter and Goldman. There are now approximately 40,000 hospitalists and the number is likely to reach 50,000 in the next decade. The specialty has emerged from vigorous early debate about whether there was sufficient evidence to justify the role of hospitalists to a point where hospital medicine programs are hard-wired and indispensable in the majority of US hospitals. Early leaders and pioneers in hospital medicine were frequently two to three physician programs with heavy call burdens. Current hospital medicine groups, particularly in larger hospitals, average approximately 15 clinicians and have complicated alternating schedules with clear time off. Early hospitalists often served in hospital leadership roles with no dedicated time. They were often the only source of quality and safety leadership across the hospital. Today, hospitalists frequently have committed time to serve in quality and safety positions as well as other medical leadership roles. Most hospitals now have numerous staff that oversee various quality functions and ably assist these hospitalist leaders. While some aspects have greatly advanced for hospital medicine, two things have not changed:

• Pressure to care for sick patients requiring hospitalization—In many hospitals, the severity of illness across the patients cared for by hospitalists continues to rise. The number of patients covered by hospitalists grows in most hospitals and it is not unheard of for all medical inpatients to be cared for by hospitalists.

• Juggling time between clinical care and hospital leadership— While there are greater numbers of hospitalists and more hospital staff focused on quality and safety, the need for clinician leadership has never been more necessary. The vacuum caused by physicians no longer seeking hospital staff privileges as well as the overall urgent need for a new paradigm in health care to increase quality and decrease the cost of care has only resulted in greater need for hospitalists and physician leadership. Hospitalists are quickly expected to assume formal leader roles as well as clinical team leaders.

The need for inpatient care will not go away but how we care for the acutely ill may change. The demand for physician leadership does not diminish, but our focus on certain issues will vary. So what are the issues facing hospitalists in the next decade? Based on careful study of patients, families, hospitalists, hospitals, and health systems, we can predict the likely emerging issues.

“VALUE”

Similar to history, certain issues in health care predominate during a particular era because of timing related to unique discovery, emerging evidence, or simply greater knowledge by the masses of a problem. In the late 1990s, quality began its emergence as the principal concern in health care. This started in the 1980s with early studies examining inconsistency and errors as well as problems associated with overuse, misuse, and underuse of health care services. The Institute of Medicine released reports about the quality of health care in the United States in 1994, 1999, and 2001. Each of these had a slightly different focus, and over the next decade, improving quality became a common theme in health care. American hospitals, health systems, and clinicians responded, albeit slowly and deliberately, but by 2010, no area of medicine had failed to grasp the fundamentals of the quality movement and make changes for the better. During this same decade, another concept gained broad consensus—improved quality is usually less expensive. This first began as outcomes that were seen alongside quality improvement, but steadily it became clearer and today there is wide spread evidence that quality and cost are closely interconnected. The best quality is often the least expensive. As the linkage grew, the focus on value in clinical care emerged to a significant degree among the large numbers of leaders in health care. The value equation (value = quality/cost) in health care is certainly not new. One can go back decades and read numerous references in the health care literature. There have been many proposed versions of the value equation depending largely on how one defines quality. The early concept of value was mainly in reference to the health care system and the overall approach to strategically improving health care. Today, after almost two decades of quality improvement along with the more recently acceptance of cost containment as an independent quality measure, the concept of value is rapidly approaching majority acceptance by physicians and health care leaders. The next decade will see value broadly and deeply pushed into the health care system. Forward thinking hospitalists and hospital medicine groups will be ready for the emergence of value as an outcome by which they will be measured.

HIGH RELIABILITY

As quality and safety improvement has been embraced by health care, it has become abundantly clear that more radical transformation is necessary in order to accomplish a greater magnitude of error reduction and quality consistency. This need for transformation led health care to an examination of how other industries such as nuclear power and aviation have achieved a higher degree of reliability resulting in safety improvement and avoidance of potentially catastrophic events. Subsequent research revealed that successful organizations in high-risk industries achieve high reliability by maintaining a cultural mindfulness that allows them to continually reinvent themselves in the face of highly complex environments.

As high-reliability organizations (HRO) were studied, it became clear that there are common challenges across organizations pursuing high reliability:

• Hypercomplex environment

• Tight coupling teams where members depend on tasks performed across their team

• Extreme hierarchical differentiation

• Multiple decision makers in a complex communication network

• Need for frequent, immediate feedback

• Compressed time constraints

Many of these challenges exist in hospitals, and as a result the concept of high-reliability organizations in health care has been broadly embraced as potentially the transforming approach needed to vastly improve quality and safety.

As health care incorporates the methodology of HRO, it is important to study the work of Weick and Sutcliffe who have identified five organizing characteristics that need to guide the thinking of people in a high-reliable organization:

• Preoccupation with failure—Everyone in the organization is focused on errors and near-misses in order to learn from them and figure out how to prevent recurrence. Finding and fixing problems is everyone’s responsibility. Leaders support and encourage this approach.

• Reluctance to simplify interpretations—Everyone in the organization is driven to ask why something happens and do not rely on the first or easiest explanation.

• Sensitivity to operations—Everyone in the organization is focused on ways their work processes might break down and are then encouraged to share potential failures and create best practices. Situational awareness is part of the organizational culture.

• Commitment to resilience—Everyone in the organization works quickly to contain errors that do occur in order to minimize potential harm. Additionally, errors do not disable the organization. The organization responds robustly and looks for new solutions to prevent catastrophes.

• Deference to expertise—Everyone in the organization listens to people who have the most developed knowledge of the task at hand and empowers them to make decisions in order to quickly mitigate harm. Sometimes, those individuals might not have the most seniority, but they are still encouraged to voice their concerns, ideas, and input—regardless of hierarchy.

These organizing processes are essential to the development of a highly reliable organization and all leaders and physicians in an organization attempting to achieve high reliability should understand the theory and application of each characteristic.

PATIENT-CENTERED CARE/CONSUMERISM

The word “consumer” turns off many physicians, but the movement cannot be underestimated in how it is changing health care. The most strident opponents to the word frequently become some of the most vocal advocates for a more patient-centric approach when they become users of the health care system.

The history of patient-centered care can be directly traced to the civil and human rights activism in the 1960s. In 1978, Angelica Thieriot started the Planetree organization after a series of upsetting personal health care experiences. The organization “vowed to reclaim for patients the holistic, patient-centered focus that medicine had lost.” Harvey Picker founded the Picker Institute in 1986 for similar reasons and then teamed up with the Commonwealth Fund to research a patient-centric approach. The term “patient centered” was coined and then later changed to “patient and family centered” by the Institute for Family Centered Care which was founded in 1992, subsequently becoming the Institute for Patient and Family Centered Care in 2010. Through the Picker/Commonwealth Fund research, we began to see differences in what patients noted as important versus physicians. Surveying patients about patient experience with the health care system started. This led to the Institute of Medicine emphasizing the concept of patient-centered care in its reports on quality care in the United States. Patient-centered care was defined as providing care that is respectful of and responsive to individual patient preferences, needs, and values and ensuring that patient values guide all clinical decisions.

In addition to patient-centered care, two additional notions are important to understand. Both are subsets of patient-centered care, which as an expression has come to mean a lot of different things, and it is important to differentiate.

Patient experience is the sum of all interactions, shaped by an organization’s culture, that influence patient perceptions across a continuum of care. It is measured by patient surveys. For hospitalists, the most frequent measurement method is the HCAHPS (Hospital Consumer Assessment of Healthcare Providers and Systems) survey which is used for adult inpatients and measures patients perceptions about communication with nurses, communication about medicines, communication with doctors, pain management, cleanliness and quietness of the hospital environment, responsiveness of hospital staff, discharge information, and the overall rating of the hospital. Patient experience and satisfaction surveys are common to all hospitals and are important as a method of understanding the patient viewpoint. They are used as quality measure to be continuously improved, but they are only one element of patient-centered care and should be understood as that.

Patient engagement are actions taken by individuals to obtain the greatest benefit from the health care services available to them. Patient engagement occurs when patients feel empowered to move to a state of active participation and self-efficacy in managing their health. This does not mean just obeying directives from health care providers, but rather moving to a higher plain of involvement, interest, and self-awareness.

Why is patient engagement so important? Engaged patients have better health outcomes, incur less costs, and enjoy greatest value (quality/cost) from health care system. A patient can conceivably be satisfied with their health care experience while having minimal engagement.

In order to optimize patient engagement, there are key patient concepts to understand and incorporate into the health care experience such as literacy level, readiness to learn, readiness to change, learning style, and patient activation.

TRANSITIONS OF CARE

Since the dawn of hospital medicine, there has been a focus on care transitions, which are the movement patients make between health care practitioners during the course of a chronic or acute illness. Early in the hospital medicine movement, this time period was often referred to as the “voltage drop.” Because of the discontinuity introduced when a patient’s outpatient physician is different than their inpatient physician, the importance of care transition in terms of patient quality and safety is paramount. One of the professional organizations of hospital medicine, the Society of Hospital Medicine, was an early adopter in promulgating the study of transitions and the determination of best practices by hospitalists and hospitals. Many potential models have been developed to improve hospital to home transitions including BOOST, Care Transition Intervention, Project Red, and the Naylor Model. Health care payers are developing financial incentives for hospitalists as well primary care physicians to focus on care transitions. The wider use of electronic health records (EHR) by physicians and hospitals holds great promise as a tactic to improve information transfer as patients move between providers. However, EHR issues such as how information is displayed as well as the lack of linkage between different EHR systems limit the effectiveness of EHRs in fully improving the knowledge “voltage drop.”

In the last several years, the focus on thirty-day hospital readmission rates has become a significant driver of the emphasis on care transitions. This is largely driven by the Centers for Medicare and Medicaid penalties to hospitals with poor performance effective October 1, 2012. Readmission rates are seen as a potential outcome measure for poor care transitioning. There is increasing evidence that socioeconomic factors play a large role in determining readmission rates, so one should be care in completely linking readmission rates to poor transition efforts by hospitals and hospitalists. As the link to socioeconomic factors is further understood, this will likely require hospitals and health systems to work closely with community programs and governments to address these factors if more transformative improvement is to be made in readmission rates.

TELEHEALTH/TELEMEDICINE

Telehealth is a broad term used to refer to the process of providing health care services at a distance. It is increasingly performed via synchronous or asynchronous video connection. Telemedicine is a component of telehealth and refers to the delivery of clinical services to patients in other locations. Examples of telemedicine include video consultations with physicians, digital transmission of medical imaging, and remote monitoring of intensive care unit patients.

The delivery of clinical care via video is rapidly improving. Early issues such as network availability, capability, and delivery cost continue to progress on an annual basis. Open, secure software platforms are replacing closed proprietary systems. This brings in an era of ease of use as well as significant cost decrease. Patients are increasingly accepting telehealth visits. The growing use of smartphones and tablets by patients and families present a potential platform for the provision of enhanced communication and clinical care.

Regulators of the practice of medicine such as state boards of medicine have been slow to fully accept and grant unrestricted licensure, but public demands for telehealth are likely to pressure regulators to relax constraints. Similarly, 2015 was a landmark year for telemedicine in that over half of the states now require health plans to cover and reimburse for telemedicine in the same manner and at the same rate as in-person services. Telehealth parity in the remaining states or via federal mandate is only a matter of time.

Provider acceptance has been limited at first and mainly related to early adopters and innovators trialing new methods and systems. As telehealth visits have increased, the need for more dedicated provider time and systems to schedule, record, and follow-up visits has increased.

TRANSPARENCY

There are multiple major approaches to improving quality and safety in health including adherence to a quality improvement methodology, outcomes transparency or public reporting, financial incentives, regulation or accreditation, and competition. Outcomes transparency is the one which most physicians and organizations have the least expertise, but it is very high on the list of importance for patients and families. There is not a long history of transparency in health care and one of the earliest was the publication of hospital mortality rates and outliers by the Healthcare Financing Administration (HCFA) in the 1980s. This resulted in backlash from hospital executives who when surveyed overwhelmingly found the data of little use. Since then, there has been persistent and increasing outcomes transparency including severity adjusted mortality rates for coronary artery bypass grafts survey in New York and Pennsylvania in the late 1980s and early 1990s, and National Committee for Quality Assurance reporting in 1993 of managed care plans and Healthcare Effectiveness Data and Information Set (HEDIS) indicators. In 2002, the Joint Commission began reporting outcomes and the National Quality Foundation developed the serious reportable events classification. By the mid-2000, many companies such as HealthGrades and Consumer Report as well as multiple states were releasing a variety of health care outcome reports on a regular basis. Price transparency in health care also began to rise. In 2006, President Bush signed a Transparency Executive Order, which further opened avenues for pricing and quality transparency. In 2015, the Robert Wood Johnson Foundation held its second transparency summit with the following conclusions:

1. Transparency may not be ubiquitous, but it is now a permanent feature of the health care landscape.

2. For all the progress made in transparency, there is much more work to be done.

3. There is a paradox: The more transparency we have in health care, the more we expose how little we actually know or understand.

Health care transparency is part of a larger transparency trend due to the rise in global market economics and its resultant demand for data, an increase in communication technology which facilities transparency, and an “internet culture” which demands a more open interaction. Health care transparency is clearly growing and not a fad. The OpenNotes project, in which patients are able to see their doctors’ visit notes, found that patients become more engaged with such access. This is likely to become routine in the near future. While transparency in health care is largely viewed positively, for patients to achieve optimal engagement from transparency will require better design principles into public reports.

GENOMICS/GENETICS

The past two decades has birthed a dizzying array of genomic technologies that ranges from rapid genome sequencing to the ability to evaluate genomes across large populations to the discovery of genetic basis of certain diseases as well drug responsiveness. The combination of these genomic technologies is resulting in new types of genetic testing which will increasingly result in clinical relevance. In addition, genetic tests are now directly marketing to the consumer who comes to the physician seeking additional knowledge.

The combination of genomic technologies and the electronic health record holds great promise for medical care to become more precise and individualized, however many record systems are often lacking core data to optimize this connection. To fully permeate these technologies into medical care, health care leaders and physicians must ensure that electronic health records are built to obtain appropriate information, such as demographics, medications, diagnosis, vital signs, and other information.

Pioneers of learning health care systems have established streamlined consenting processes and data warehouses. However, systems are not consistently incentivized to build these capacities. Health leaders want evidence before investing resources, yet without those investments such evidence is hard to gather.

TEAMWORK TRANSFORMATION

The acceptance and rapid growth of hospitalists, based on personal observation, in many hospitals and health systems is tied to the team approach by early hospitalists. These hospitalists were available to hospital personnel to a great degree than nonhospitalists and this often resulted in close relationships and greater teamwork. Studies of nursing satisfaction showed higher results in hospitals with hospitalists. Today, many hospitalist leaders have typically been trained in the mechanics of teamwork and advocate for greater interaction and voice across the hospital medicine team.

The focus on value in the coming decade will force a reexamination of the hospital medicine team. The typical hospitalist is likely to assume the care of much greater numbers of patients on a daily basis and this will only be achieved through a transformation of the hospital medicine team. To alter the present system will require first and foremost a willingness of both hospitalists and hospital leaders to modify it. This is not an easy task as significant change management skills are required as well as a commitment to a higher level of team reliance, communication, and trust. There will need to be a diligent focus on patient satisfaction, each team member’s satisfaction, and clinical outcomes. It can be achieved faster if there is payer flexibility in professional and hospital reimbursement.

HOSPITALIST/PHYSICIAN STRESS

The health care system is undergoing tremendous change and because of the central role in the health care system physicians will experience significant change. In addition, there are professional reimbursement challenges, increased scrutiny in terms of quality outcomes, cultural transparency, and increasing demands for physician time and presence. Incorporating new electronic health records into the daily work of physicians requires retraining and optimization. Medical knowledge and techniques advance requiring constant relearning. Administrative burdens related to reimbursement continue to rise. There are simply many pressure points on the individual physician. For hospitalists, who interact with patients and families at a very stressful time—acute illness requiring hospitalization, this can lead to tense and demanding interactions and communications. On the leadership side, there is pressure for hospitals to deliver greater value and all hospital leaders, including hospitalists, will experience great demands to develop and lead innovations. The list of stress points seems endless and overwhelming on the individual hospitalist.

However, the ability to positively impact patients and families has never been greater in the history of medicine. Hospitalists should recognize that despite the numerous stressors as well as ambiguity of the future, the ability to help patients and families is tremendously satisfying and professionally fulfilling.

Professional dissatisfaction and burnout is treatable if recognized and managed appropriately. There are personal and organizational approaches to prevent physician distress as well as optimize physical, emotional, and psychological wellness. Hospitalists and particularly hospital medicine leaders should fully understand the signs and symptoms of distress and have options for referral.

LEADERSHIP

The need for hospital medicine leadership has never been greater. It was there at the dawn of hospital medicine and it will not wane in the coming years. The demand spans from clinical team leadership to program leadership to hospital and health system senior executive levels. If you have been a user of the health care system, you understand the need immediately. We can do great things in medicine, but it can be undone by some of the most trivial issues. To rectify this, particularly in the hospital setting, requires focus and leadership as well as the right emotional commitment by hospitalists. William Welch, the first dean of the Johns Hopkins School of Medicine, said it eloquently in his reference to a new approach to medical training—”I can think of but one motive which might influence you to come here with us and that is …our ideals and our future…This will not appeal to the great mass of the public, not even to the medical public, for a considerable time. What we shall consider success, the mass of doctors will not consider a success.”

As hospitalists, we should keep the patient in our focus at all times and continue to lead the transformation in quality and safety across health care.

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INTRODUCTION

The field of hospital medicine was built on the premise that hospitalists would promote and deliver more efficient, safer, and higher-quality inpatient care. Indeed, over the past decade hospitalist care has led to shorter lengths of stay and relatively lower hospital costs. However, as national health care costs have continued to rise unabated, on track to consume approximately 20% of the United States gross domestic product by 2020, the government, payers, and the public have all focused renewed efforts on improving health care value—commonly defined as

Hospital costs represent the single largest segment of the nearly $3 trillion annual US health care expenditure. Thus, hospitalists are vital to any effort to rein in health care costs. This chapter reviews concepts and strategies critical for hospitalists to understand in the emerging world of value-based health care.

HOSPITAL COSTS IN THE NATIONAL SPOTLIGHT

In February 2013, Time magazine published an expose on health care costs, “Bitter Pill: Why Medical Bills Are Killing Us,” which was trumpeted across popular media and helped the hospital “chargemaster” become nearly a household term. The chargemaster (also known as the charge description master or “CDM”) is the list of prices for the tens of thousands of billable items at a given hospital. Shortly following the Time article, the Centers for Medicare and Medicaid Services (CMS) publicly released a database of how hospitals billed Medicare for the 100 most common inpatient procedures, revealing in stark relief the baffling amount of variation in charges and reimbursements for the same procedures between similar hospitals. Later that same year, the New York Times published a front-page article with the headline, “As Hospital Prices Soar, a Stitch Tops $500,” continuing to shine a bright national spotlight on the issue of hospital costs. As the “Bitter Pill” and the “$500 stitch” highlighted, charges found on hospital bills usually appear arbitrary and grossly inflated.

Despite the pressures to increase transparency, health care costs have largely remained hidden from the public and medical professionals. As a result, hospitalists are generally not aware of the costs associated with their care. In addition, most clinicians find the concepts of “charge,” “price,” “cost,” and “reimbursement” confusing (Table 2-1). In most medical centers, the majority of health care transactions occur between the organization and large payer organizations, such as insurance companies or Medicare. The price or charge refers to the amount reported on the bill to each of these payers. The cost depends on perspective; providers, payers, and patients each evaluate costs differently:

• To providers, costs are the expense incurred to deliver health care services to patients.

• To payers, costs are the amount payable to the provider for services rendered.

• To patients, costs are the amount payable out-of-pocket for health care services.

The chargemaster is theoretically meant to relate to both costs and payments, but since there is tremendous inexplicable variation in prices between similar organizations and because the prices are highly inflated, the chargemaster routinely fails at this function. Instead, the chargemaster is generally used as a starting point for closed-door bargaining with different payers. While insurance companies pay a relatively small fraction of the charge on the chargemaster, uninsured patients have often been stuck with full chargemaster prices.

The Affordable Care Act (ACA) now formally requires all providers to publish their chargemasters, and some states are requiring hospitals to also disclose the “allowed amount” (contractually agreed amount paid by a private insurance company) to any patient who asks. In California, health care providers cannot bill uninsured patients an amount greater than the reimbursement the hospital would receive from a government payer.

Newer methods for determining more accurate measurements of actual costs are now increasingly being applied in health care. For example, Michael Porter and Robert Kaplan from Harvard Business School have advocated for the use of time-driven activity-based costing (TDABC). With TDABC, the costs of space, nonconsumable equipment, and administrative overhead are all assigned minute-to-minute cost rates that are relevant to specific processes of care. The care that is delivered over an entire episode of care is broken down into discrete activities or process steps, such as check-in, vitals and intake, physician evaluation, nursing care, and so on. A cost is assigned to each step by tracking who is doing the activity, what resources they use, which space they are in, and how long it takes them. Each item (personnel, resources, and space) is assigned a per-minute cost rate by bundling together all costs (fixed and variable) and then dividing by the total amount available for patient care. For a more detailed explanation of TDABC, one can refer to “How to Solve the Cost Crisis in Health Care” by Kaplan and Porter in the Harvard Business Review (2011). Using TDABC, some progressive medical centers have begun to establish a true “cost-master” to replace the controversial charge-master.

THE EFFECT OF PRICE TRANSPARENCY ON HOSPITALIST ORDERING PRACTICES

One seemingly obvious solution to hospitalists’ lack of knowledge about costs is to provide diagnostic test prices at the point of ordering. After all, many have remarked that when ordering off a menu without prices, it is easy to unwittingly order the filet mignon every time. So, why not just put the prices back on the menu?

Initial studies on this strategy showed mixed results, and the conventional wisdom evolved that displaying price information had limited effect, with prices often becoming “white noise” and being quickly disregarded. More recent studies, however, including a controlled trial at Johns Hopkins suggest that, perhaps due to the recent global attention to the importance of health care costs, clinicians are now more likely to react to price information. Displaying the Medicare Allowable Rates of lab tests to hospital physicians led to substantial decreases in certain higher-cost lab tests and resulted in a more than $400,000 net cost reduction over the course of a 6-month intervention period. It is not clear if this effect too will abate over time.

Similarly, a study using dollar signs () to translate relative costs of antibiotics on culture and susceptibility testing reports resulted in a significant decrease in prescriptions for high-cost antibiotics.

Taken as a whole, a 2015 systematic review on the topic of providing price information for diagnostic testing concluded that “charge information changed ordering and prescribing behavior” in the majority of studies.

Remaining challenges include determining which price to display (the charge, the Medicare allowable fee, the estimated marginal cost, or some other measure), as well as whether prices should be displayed for all orders or rather be limited to only specific orders that may be ordered frequently or that are associated with high cost or marginal benefit.

HOSPITAL PAYMENTS SHIFTING FROM VOLUME TO VALUE

If there is one thing that most policymakers can agree on, it is that the payment system, which currently rewards volume of services delivered, should be realigned to compel the delivery of value. Not all policymakers, however, agree exactly how to best do that.

Medicare’s Value-Based Purchasing (VBP) program has already tied a percentage of hospital payments to metrics of quality, patient satisfaction, and cost. In addition, with the proliferation of accountable care organizations (ACOs) and other bundled payment models, hospitals will continue to have an increasing share of reimbursement at risk related to the value of care that they deliver. According to the US Health and Human Services Secretary, Medicare aims to have at least 50% of all payments tied to quality or value through alternative payment models by the end of 2018.

MEDICARE’S HOSPITAL VALUE-BASED PURCHASING PROGRAM

The federal government introduced their hospital VBP program in 2012, initially with 1% of Medicare hospital payments based on some measures of quality. This percentage will continue to rise. The first quality indicators included process measures for pneumonia, acute myocardial infarction, congestive heart failure, health care-associated infections, and patient experience (largely based on patient survey responses to the Hospital Consumer Assessment of Healthcare Providers and Systems Hospital survey [HCAHPS]). Subsequently, risk-adjusted mortality, hospital-acquired conditions, and patient safety were added. The 2016 VBP metrics include eight clinical process of care measures, eight patient experience dimensions, three 30-day mortality outcome measures, one Agency for Healthcare Research and Quality composite score, four health care-associated infection rates, and one efficiency measure based on Medicare spending per beneficiary (Table 2-2).

Payment for achieving higher-quality metrics seems to be a step in the right direction for our health care system, but there are criticisms that the current mechanism will unfairly punish safety net hospitals and clinicians caring for the most vulnerable populations.

HOSPITAL COMPARE

CMS hopes to also drive value through better public transparency of quality and cost data via their Hospital Compare website (www.medicare.gov/hospitalcompare). Hospital Compare provides data on a large number of metrics and even allows the public to select up to three hospitals at a time to compare head to head. In an effort to make the website more user-friendly for public consumers, CMS recently borrowed a strategy from the vast majority of popular rating websites and added a “star rating.” The star rating, from one to five stars, is initially based on validated patient experience metrics.

BUNDLED PAYMENTS AND ACCOUNTABLE CARE ORGANIZATIONS

Whereas the VBP program is based on annual rewards and penalties, other payment models including bundled payments aim to more directly incentivize quality and efficiency. Strategies for payments exist on a spectrum from straight fee-for-service to fixed global budgets. If we consider reimbursements to a hospital, a payer may pay a specific amount for every service delivered (fee-for-service), for each day in the hospital (Per Diem), for each episode of hospitalization (eg, Diagnosis Related Groups [DRGs]), or for each patient in their community considered to be under their care (Capitation). Alternatively, the hospital could be given a fixed fee for all services performed on every patient during a full year (Global Budget). Currently, the majority of payments are still primarily based on fee-for-service, but this is projected to rapidly change (Figure 2-1).

Bundled payments could theoretically encourage improved efficiency and reductions in hospital-acquired complications as these would lead to increased costs, length of stay, and spent resources. For example, a hospital could be paid one fee for pneumonia, regardless of the number and type of interventions or resources used. CMS has used a prospective flat fee per inpatient episode of care, based on a diagnosis-related group (DRG) system, since 1983. CMS sets the base payment amounts “for the operating and capital costs that efficient facilities would be expected to incur in furnishing covered inpatient services.” This rate is then weighted by DRG (which accounts for relative severity of a given condition), and then adjusted according to an algorithm that accounts for a number of factors such as the regional cost of labor, and whether the hospital is a teaching facility. Medicare also provides higher payments for patients with “complicating or comorbid conditions,” or with “major complicating or comorbid conditions.” For particularly complex patients, Medicare provides “outlier payments” that are calculated based on an imprecise ratio of costs to charges.

Global or bundle payments could potentially combine payments across different providers and settings, encouraging better coordination and communication between hospitals, postacute care facilities (eg, a skilled nursing facility [SNF]), and outpatient providers. This is some of the logic behind the emergence of ACOs, which were included as part of the ACA to provide an experiment in global payments and shared risk. According to the CMS definition, ACOs are “groups of doctors, hospitals, and other health care providers, who come together voluntarily to give coordinated high quality care to their Medicare patients.” When an ACO delivers high quality care at low costs, the organization shares in the savings that the ACO achieves.

Interpretations of the early results of ACOs have been mixed. The pilot Pioneer ACO program, which included 32 medical care organizations, was estimated to save 1.2% of health care spending, translating to about $400 million, over the first 2 years. Critics point out that the pilot programs were highly selected and unlikely to represent the abilities of the rest of the health care system once the model is more widely deployed. Moreover, 13 of the 32 pilot programs had dropped out due to not achieving savings in the first year or because they felt that the program was too complex with too many quality metrics to track. While we await additional research evidence on the true potential impact of ACOs, their premise in improving efficiency and coordinated care is strong, and their numbers will likely expand in the near future.

HEALTH CARE WASTE

The Institute of Medicine (IOM) estimated that over $750 billion annually spent on health care does not make anyone healthier, and thus is considered waste. This represents up to more than 30 cents on every health care dollar spent. Although there are many contributors to health care waste including prices that are excessively high, unwarranted administrative costs, fraud, and inefficiencies due to system errors and failures of coordination, the largest component is unnecessary services, which includes overuse, discretionary use beyond benchmarks, and unnecessary choice of higher-cost services (Table 2-3). Unnecessary services account for $210 billion of waste annually. This is the area of waste that individual hospitalists have the most direct control over.

OVERUSE IS A PATIENT SAFETY PROBLEM

The 1998 IOM National Roundtable on Healthcare Quality classified three types of health care quality problems: underuse, overuse, and misuse. However, the following decade of the patient safety movement focused nearly exclusively on preventable complications related to misuse. Only recently has overuse of medical care—which refers to providing care in circumstances where the potential for harm exceeds the potential benefits—gained attention as an important patient safety hazard.

Overuse of medical care is a widespread problem in the US health care system. According to a 2011 study, nearly half of primary care physicians in the United States believe that their patients are receiving too much care. Overuse of medical care can directly lead to patient harm as a result of the known risks or adverse effects of the provided test, procedure, or medication. There are numerous frequently cited instances of overuse, including inappropriate imaging, laboratory tests, antibiotics, and catheter usage (Table 2-4). For example, despite evidence and clear guidelines that suggest imaging is unhelpful for patients with acute low back pain who lack specific clinical findings, routine diagnostic imaging is frequently obtained for these patients. This places patients at risk for excessive radiation, costs, and substantial downstream effects, including ineffective spine operations and perceptions of lessened overall health status.

Antibiotic prescribing is another area rife with overuse, which has led to the emergence of a number of antibiotic-resistant pathogens, making infections more difficult to treat. When prescribed incorrectly, antibiotics pose serious risks to both individual patients and the public health at large. Antibiotic overuse can place patients at risk for allergic reactions, antibiotic-associated diarrhea, and other dangerous adverse effects.

More medical care may also lead to overdiagnosis and overtreatment, which may result in a cascade effect of potential harms, including adverse events, mistakes, anxiety and disability, and additional unnecessary treatments. With patients bearing more and more of the cost of care themselves, some have further argued that clinicians should also consider the potential financial harm to individual patients due to excessive medical evaluations and subsequent overtreatments.

The many drivers of overuse include medical culture, fee-for-service payments, patient expectations, and fear of malpractice litigation. A survey study using clinical vignettes of common hospital clinical situations revealed a large amount of overuse of testing among practicing hospitalists, with 52% to 65% of respondents requesting unnecessary testing in a preoperative evaluation scenario, and 82% to 85% in a syncope work-up scenario. The majority of physicians reported that they knew the testing was not clinically indicated based on evidence or guidelines, but were ordering the test due to a desire to reassure the patients or themselves. This finding suggests efforts to decrease overuse will need to engage clinicians and patients in ways that help overcome the attitude that more testing is required to provide reassurance.

STRATEGIES FOR HOSPITALISTS TO PROVIDE HIGH-VALUE CARE

As payment systems and health care organizations shift toward rewarding and supporting a focus on value, individual hospitalists can help deliver higher value care for their patients through: (1) providing appropriate care, (2) ensuring care coordination, (3) considering patient affordability in customizing treatment plans, and (4) leading local value improvement initiatives.

PROVIDING APPROPRIATE CARE

Hospitalists should address the problem of overuse by directly practicing appropriate care for their patients. Emerging resources for identifying specific targets of common overuse include the Choosing Wisely lists, guidelines, and appropriateness criteria. The Choosing Wisely campaign (www.choosingwisely.org) is an effort organized by the ABIM Foundation to engage specialty societies in identifying lists of commonly overused medical services “that physicians and patients should question.” In 2013, the Society of Hospital Medicine published an initial Choosing Wisely list for both adult and pediatric hospital medicine (Table 2-5), and many other professional organizations’ Choosing Wisely lists (eg, American College of Physicians, American Academy of Neurology, etc) have components that apply directly or indirectly to hospital medicine practice.

One strategy for encouraging and communicating appropriate care is to create a cognitive forcing function by explicitly documenting these types of decisions in daily progress notes. For example, hospitalists Drs Scott Flanders and Sanjay Saint recommend including the indication, day of administration, and expected duration of therapy for all antimicrobial therapies in all progress notes and sign-outs, as an approach for curbing inpatient antibiotic overuse. Likewise, hospitalists may eliminate use of routine labs, telemetry, continuous pulse oximetry, or other recurrent interventions or monitoring by documenting daily the patient needs and reasons for continued use or ordering.

THE IMPORTANCE OF CARE COORDINATION

The typical hospital patient is handed off from one physician to another more than 15 times during a single 5-day hospital stay, a rate that has been increasing with new duty hour restrictions and hospitalist staffing models. Not surprisingly, studies show the majority of hospital patients are unable to identify the clinician in charge of their care. Hospital physician discontinuity may lead to increased resource utilization and lower patient satisfaction. Coordinating structured handoffs between inpatient providers and with outpatient providers during transitions in care is critical to delivering high-value care.

Currently, about one-fifth of Medicare patients are readmitted within 30 days of hospitalization, and more than half of these patients do not see any outpatient health care provider between these visits. This population of frequently readmitted patients is particularly important for hospitalists. Some care coordination programs have been experimenting with the use of hospitalists that care for a subset of the highest risk patients both during hospitalization and following discharge, either in a high-risk clinic or at postacute care facilities such as skilled nursing facilities. These physicians are increasingly becoming known as “extensivists.” The early data on the cost-effectiveness of these types of programs have been mixed, but, much like ACOs, it may be too early to draw conclusions.

CONSIDERING PATIENT AFFORDABILITY

More Americans than ever before are on high-deductible insurance plans, making them responsible for an increasing share of health care costs. As “financial harms” for individual patients become increasingly recognized, and more patients forgo recommended medical treatments due to out-of-pocket costs, hospitalists must customize care plans to help patients afford their care.

Hospitalists may be able to improve their prescribing practices, particularly at the time of discharge. Nearly one-quarter of hospitalized adults in a survey reported cost-related underuse in the year prior to admission, and only 16% of patients knew how much their prescribed medications at discharge would cost them. Virtually nobody had spoken to their inpatient providers about the cost of the newly prescribed drugs.

Discussing drug costs with patients has been shown to be strongly associated with providing individualized lower-cost medication options. Health care professionals and patients can rely on an increasing number of freely available resources that provide price information and cheaper alternatives for most medications (Table 2-6). High-value prescribing has been defined as “providing the simplest medication regimen that minimizes physical and financial risk to the patient while achieving the best outcome.”

IMPLEMENTING VALUE-BASED INITIATIVES

Hospitalists across the country have largely taken the lead on designing value improvement pilots, programs, and groups within hospitals. Although value improvement projects may be built upon the established structures and techniques for quality improvement (see Section IV: Patient Safety and Quality Improvement, Chapter 21: Quality Improvement Methodologies), importantly these programs should include expertise in cost analyses. Furthermore, some traditional quality improvement programs have failed to result in actual cost savings; thus it is not enough to simply re-brand quality improvement with a banner of “value.” Value improvement efforts must overcome the cultural hurdle of “more care as better care,” as well as pay careful attention to the diplomacy required with value improvement since reducing costs may result in decreased revenue for certain departments or even decreases in individuals’ wages.

The national nonprofit group Costs of Care has proposed a “COST” framework to guide value improvement project design. COST stands for culture, oversight accountability, system support, and training. This approach leverages principles from implementation science to ensure that value improvement projects successfully provide multipronged tactics for overcoming the many barriers to high-value care delivery.

APPLYING LEAN AND REDESIGNING CARE PATHWAYS

On a health system level, methods for ensuring better value may focus on techniques to improve efficiency and decrease “defects.” To achieve this goal, an increasing number of hospitals are now adopting lean methodologies and systems. Lean principles stem from the Toyota Production System developed by the automaker in Japan to focus on improving quality while reducing waste. In 2002, Virginia Mason Medical Center in Seattle famously began applying to health care the five general principles of lean: (1) define value from the customer’s perspective, (2) identify the value stream and remove any waste, (3) make value flow without interruption, (4) help customers pull value, and (5) pursue perfection.

Some lean tools have quickly been adapted to health care, including value stream maps that depict all of the individual steps in a process from beginning to end, and provides a graphical tool for identifying any non–value-added steps, delays, waiting times, and inefficiencies, as well as the commitment to rapid improvement cycles that are built around “small tests of change.” Lean programs have led to remarkable improvements in hospital processes and outcomes across the country from safety net hospitals like Denver Health to Veteran’s Affairs hospitals to the University of Michigan.

Similar in concept to lean are efforts to design and hone specific care pathways for certain patients and conditions. For example, many joint-replacement programs have created care pathways that standardize when patients will have catheters removed, mobilize with physical therapy, and be discharged to a specific disposition. Hospitalists are increasingly creating similar models for patients with pneumonia, chronic obstructive pulmonary disease (COPD) exacerbations, syncope, or other common clinical conditions. Intermountain Healthcare in Utah has applied evidence-based protocols to more than 60 clinical processes, re-engineering roughly 80% of all care that they deliver. Cincinnati Children’s Hospital partnered with local physicians to create large-scale improvements in the care of children with asthma, resulting in 92% adherence to best practices for asthma care, which has yielded many avoided hospital admissions and emergency department visits. These types of care redesigns and standardization promise to provide better, more efficient, and often safer care for more patients.

CONCLUSION

Hospitalists are now faced with the massive responsibility of providing better health care value. Based on the history of the hospitalist movement, we are up to the task. Value is defined as providing the highest quality care at lower costs, and should include components of patient outcomes, safety, and experience. To achieve this goal, measuring and understanding metrics related to quality and costs will be vitally important. There is an inexorable trend toward greater transparency in health care and it is likely soon that true health care costs will be publicly accessible across the country. Evidence is mounting that providing some cost information at the point-of-care may help support behavior changes and decrease unnecessarily expensive test ordering.

The most potent strategy for simultaneously improving care and decreasing costs is to reduce waste and overuse, which accounts for more than $200 billion in health care costs annually in the United States and causes significant patient harms. There are many common areas of overuse in hospital care, including the use of antibiotics, telemetry monitoring, transfusions, imaging, catheter usage, and routine lab draws. Many of these are highlighted in Choosing Wisely lists and other emerging appropriateness criteria.

Hospitalists can deliver high-value care to their patients by specifically considering appropriateness of care, care coordination, patient affordability, and value-based initiatives and care pathways.

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INTRODUCTION

Racial and ethnic disparities in care have been consistently documented in the treatment and outcomes of many common clinical diseases. The 2003 Institute of Medicine (IOM) report, “Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care,” defines disparities as differences in the treatment that are not directly attributable to access-related factors, clinical needs, patient preferences, or appropriateness of intervention (Figure 3-1). The elimination of health care disparities is a high priority for the federal government and several academic organizations.

Documented disparities of disease prevention and treatment include rates of vaccination, cancer screening, secondary prevention of myocardial infarction (MI), transplant surgery, curative surgery, and angioplasty. Disparities in health outcomes include cardiovascular disease, HIV/AIDS, diabetes, cancer, asthma, pregnancy outcomes, mental health, and hospitalization.

Specific examples include the following (Table 3-1):

• A higher risk of stroke, heart failure, and renal failure associated with hypertension (African Americans)

• A higher rate of complications from diabetes (African Americans and Native Americans)

• Later-stage colon, breast, and prostate cancer at presentation (African Americans)

• Less aggressive evaluation and treatment: curative lung cancer resection, cardiac catheterization, peripheral angioplasty, and renal transplantation (African Americans)

• Diabetic more likely to receive amputations (African Americans)

• Higher death rates per 1000 hospital admissions in low-mortality diagnosis-related groups (African Americans, Hispanics, and the uninsured)

The observed racial/ethnic health care disparities have multifactorial etiologies. Patients face multiple barriers as they engage the health care system: (1) personal and family; (2) access to the health care system (structural, financial, types of services); and (3) the quality of the available providers (Figure 3-2). These barriers can occur individually or in combination to have an additive effect on health outcomes.

Historically, disparities in hospital care originated in the policy of hospital segregation during the first 66 years of the 20th century. Before the creation of Medicare, the Hospital Survey and Construction Act of 1946, commonly known as “Hill-Burton,” was the largest federal grant program in health care. This law was intended to increase the number of hospital beds throughout the country. However, this was the only federal legislation in the 20th century that explicitly permitted use of federal funds to provide racially exclusionary services (“separate but equal”) thus augmenting the wide divide in poor-quality hospital services and facilities for African Americans. Hospital segregation ended with President Johnson signing into law the Medicare bill on July 9, 1965. The Medicare bill was tied to Title VI of the Civil Rights Act of 1964, which banned discrimination in any activities that used federal funds for training, employment, or construction. Because of this legal requirement, more than 95% of hospitals desegregated their facilities by the first day Medicare was implemented on July 1, 1966, in order to receive Medicare reimbursement.

The elimination of health care disparities is a high priority for the federal government, and many academic organizations are beginning to take steps to educate physicians about this problem. To date, existing data suggest that the type of hospital facility and its location explain some of the observed racial and ethnic disparities in health care services; less is known, however, about disparities in hospital care. This chapter reviews the racial disparities in hospital care that can be impacted by hospitalists and proposes directions for future research.

MECHANISMS AND ETIOLOGY

INTERINSTITUTIONAL AND INTRAINSTITUTIONAL VARIATIONS IN CARE

Although where patients receive care likely explains some of the observed racial and ethnic disparities in health care service, prior studies suggest that hospital-level factors may play an important role in creating disparities in care. In addition, minorities live disproportionately in parts of the country that have lower-quality hospitals and fewer primary care physicians.

Safety-net hospitals predominantly serve poor and underserved patients and provide care for a disproportionate number of racial and ethnic minorities in the United States. Multiple studies have shown that these hospitals often provide a lower quality of care. This decreased quality is likely due to shortages of resources, nurse staff, technical support such as health information systems, and capital to make improvements. These hospitals have increased post-MI mortality rates and decreased performance measure scores for acute MI, lower performance on national quality process indicators for acute myocardial infarction (AMI), congestive heart failure (CHF), and pneumonia, and higher postoperative colon cancer mortality rates. In addition, they tend to have smaller gains over time on process measures for AMI, CHF, and pneumonia, and are less likely to achieve high-performing status.

A large proportion of minority patients receive their care in a small number of hospitals and these facilities seem to provide a lower quality of care for common medical and surgical conditions. One study demonstrated that 90% of Hispanic and black Medicare beneficiaries receive their care at 25% of the 4500 acute care hospitals in the United States. Another study found significant racial/ethnic disparities in clinical processes for AMI, CHF, and pneumonia explained primarily by hospital factors and not individual patient characteristics. They also found that lower-performing hospitals tended to serve a larger proportion of minority patients. Similar findings have been demonstrated using national Hospital Quality Alliance (HQA) patient-level data. Other national studies demonstrate that African Americans go to hospitals that have lower rates of evidence-based medical treatments and worse risk-adjusted mortality after AMI, are less likely to receive optimal care for pneumonia as measured by national HQA measures, and have higher operative mortality risks for eight different procedures because the hospitals they attend have higher mortality rates for all patients.

In addition to differences in quality of care based on institution, data suggest that among patients hospitalized in the same institutions, racial and ethnic disparities in care often exist. Several studies have demonstrated significant racial and ethnic differences in utilization of cardiovascular procedures for patients hospitalized within the same institutions. For example, African Americans have a lower rate of coronary artery bypass procedures than whites, even with similar presentation and clinical features.

DIFFERENTIAL UTILIZATION OF MEDICAL PROCEDURES AND TECHNOLOGY AVAILABILITY

Racial differences in the utilization of medical procedures are well documented, especially for “referral-sensitive” procedures and invasive, costly procedures such as coronary revascularization. The reasons for these differences are complex and may reflect differences in clinical presentation, medical decision making, differential access to providers and institutions providing procedures, and differential care at hospitals.

Studies have demonstrated that Caucasian patients more often receive renal transplantation, cardiac surgical procedures, total joint replacement, and other procedures than do African Americans. African Americans are less likely to receive coronary revascularization compared to whites, even in hospitals with revascularization services. Additionally, African Americans are less likely to be transferred from hospitals without revascularization services to those with these cardiac services, and, even when they are transferred, they are still less likely to receive revascularization as compared to Caucasians. These differences in procedure use have been associated with increased African American mortality rates. Finally, procedure volume has been shown to be a proxy for quality of care. African Americans and Hispanics tend to get care at low-procedure-volume hospitals with low-volume surgeons and cardiologists. A study of coronary artery bypass surgery (CABG) surgery outcomes in New York State found that African Americans and Asians were more likely to receive care from surgeons with higher risk-adjusted mortality. African Americans at low-volume hospitals have greater risk-adjusted mortality than Caucasian patients after elective aortic abdominal aneurysm (AAA) repair, CABG, and carotid endarterectomy (CEA).

Technology availability likely contributes to low performance. Hospitals with a high proportion of African American inpatients may have lower rates of adoption of new technologies. In general, safety-net providers are slower to adopt new technologies than non–safety-net providers. Providers and hospitals that invest in technology score higher on standard quality measures. However, national studies have demonstrated that providers who cared for uninsured and Medicaid African American and Hispanic patients are less likely to use electronic health records. These differences underscore the need to provide higher funding of public and other safety-net hospitals in order to reduce disparities in health care by ensuring the delivery of high-quality care for all patients.

PATIENT EXPERIENCES

Perceived provider attitude (both physicians and nonphysicians), including perceptions of provider prejudice, by minority patients has been shown to have a direct relationship to patient decision making and perceived quality and satisfaction. Reports of patient experiences with health care are therefore important correlates with quality. There are significant differences in hospitalized patients’ self-reported experiences among different groups. African American and Latino patients are less satisfied with their hospital care, particularly in the dimension of having their preferences respected consistent with prior studies demonstrating racial/ethnic differences in satisfaction with provider communication and management. Both African American and Hispanic patients report that perceived attitudes of social workers and nursing staff have an important direct relationship with their perceived satisfaction and quality. Hispanic patients correlate high satisfaction with care when well-qualified medical interpreters are available.

These findings have several important implications for prioritizing quality improvement efforts in improving patient satisfaction with care. First, physicians and hospital staff should strive to better understand and address the expectations of African American and Latino patients. Second, hospital administrators should include allied health professionals and social workers in addition to nurses and physicians in training on patient-centered and culturally appropriate counseling techniques and communication. All clinicians should use medical interpreters when English is not the first language. Finally, hospitals should collect satisfaction data stratified by race and ethnicity in order to better tailor quality improvement (QI) efforts.

ROLE OF HOSPITALISTS

Hospitalists are specialists in the general medical care of hospitalized patients. Their activities include patient care, teaching, research, and leadership related to inpatient care. The number of hospitalists continues to grow significantly across the nation; as a result, this specialty will care for increasing numbers of hospitalized underserved patients. Existing literature has demonstrated that hospitalists are associated with lower inpatient costs and shorter lengths of stay compared to general internists and family physicians, and such savings did not have a detrimental effect on rates of death or readmission. Importantly, hospitalists are associated with providing higher-quality inpatient care because of closer adherence to treatment guidelines and better post discharge follow-up. A recent national study has demonstrated that hospitals with hospitalists were associated with better performance on quality indicators for AMI, pneumonia, and the composite domains of disease treatment, diagnosis, counseling, and prevention controlling for hospital characteristics such as size, location, ownership type, and staffing availability. There are, however, no data reported on the performance of hospitalists compared to other providers relating to their care of different ethnic groups.

Previous research using national quality measures has found substantial variability and room for improvement in the care of hospitalized patients across medical conditions. With the continued growth of the hospitalist inpatient care model, further research is needed to delineate the specific hospitalist model characteristics associated with improved quality and outcomes of care. The hospitalist model of inpatient care should be considered an essential component of quality improvement for hospitals seeking to improve inpatient care. This is especially true for public/municipal hospitals and smaller hospitals, which have been shown to be consistently associated with lower quality and provide care for the disproportionate number of racial/ethnic minority patients.

HOSPITALISTS AND THE USE OF INTERPRETERS IN THE CLINICAL ENCOUNTER

In 2011, over 25 million Americans rated themselves as speaking English less than “very well,” and as a result, health care providers increasingly encounter patients with limited English proficiency (LEP). The use of professional medical interpreters is associated with increased patient satisfaction, quality of care, and improved disease-specific process measures and outcomes. The Institute of Medicine report Crossing the Quality Chasm states that the use of an interpreter is not only a quality but also a patient safety imperative. Patients with communication problems due to language barriers are at high risk for preventable adverse events. Recent research has documented that patient safety events affecting hospitalized LEP patients are more severe and more frequently due to communication errors compared to English-speaking patients. Similarly, drug complications in outpatients are more common in patients who speak a primary language other than English. Hospitals should stratify their adverse events data by language in order to improve patient safety.

Although Federal law, the Institute of Medicine, and hospital guidelines, including the Joint Commission standards, all recommend the routine use of professional interpreters during clinical encounters, many LEP patients do not have access to interpreters and some clinicians continue to “get by” without using interpreters consistently. In addition, nonprofessional interpreters cause an increase in interpretation errors that may potentially harm the patient through the misinterpretation of information and alteration of key patient details. Language barriers between patients and their clinical providers are not only an inconvenience to workflow but are also a patient safety hazard.

Inpatient care is a continuum of clinical care encounters with both clinical and nonclinical staff. All patient interactions with clinical providers should document whether an interpreter or a bilingual clinician was used in order to allow quality assessment both in real time and retrospectively. It is likely not enough to have interpreter use only at the time of admission or possibly only at discharge given that the clinical care received by patients’ change may change rapidly during admission. Increasing the availability and use of professional interpreters throughout the hospital stay is essential. This will also require educating physicians about the quality of available interpretation modalities. Recent studies have demonstrated that remote telephone or video conferencing modes are as effective as in-person interpretation as measured by communication quality and patient satisfaction. Use of these non–in-person methods should be encouraged in the hospital setting where in-person interpretation may not be readily available throughout the 24-hour hospital continuum of care.

CONCLUSION

Racial/ethnic disparities in hospital care and outcomes are based in a tradition of hospital segregation that has residual, significant, and persistent effects. A growing body of literature has demonstrated disparities in processes of care, utilization of procedures, clinical outcomes, and patients’ experiences. These disparities are due in large part to differences in access to higher-quality hospitals; however, variation in intrainstitutional care has also been documented.

A small number of hospitals nationwide serve a high number of minorities. Ameliorating health care disparities includes improving hospital quality of care. The hospitalist model of inpatient care provides a vehicle for driving high quality by engaging hospitalists as quality improvement and patient safety leaders. All clinicians should strive to improve quality and patient safety through the consistent use of certified interpreters during clinical encounters involving patients with limited English proficiency.

It is incumbent among policy makers, hospital administrators, and clinicians to develop strategies to achieve racial/ethnic equity in care. These strategies should include (1) examining within-institution differences in care, outcomes, and patient experience based on patients’ race/ethnicity; (2) improving infrastructure and quality within largely minority-servicing institutions; and (3) developing QI initiatives focused on cultural competency and targeting high-risk racial and ethnic groups such as those with limited English proficiency.

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INTRODUCTION

From the beginning of the hospitalist movement, hospitalists have filled a collaborative role in assuming care of primary care physicians’ patients in the hospital. Just as primary care physicians (PCPs) cannot feasibly be in two places at once (the office and the hospital), surgeons and medical subspecialists cannot simultaneously manage complex inpatients and perform procedures and other specialty services. The limited surgical availability with restricted surgical resident work hours creates added pressure on surgical residents to maximize operating room time. Likewise, medical subspecialties face similar pressures with limited fellow work hours. The active involvement of a medical comanager may make practical and economic sense if it is planned well and actively managed. In addition, co-management may improve the quality of care by having a generalist on site to anticipate and address common problems that arise during hospitalization without the delays that may occur with traditional medical consultation.

Comanagement is now a prominent practice pattern as an integrated part of hospitalist practice. Comanagement practices have now been described in collaboration with orthopedic surgery, neurosurgery, vascular surgery, otolaryngology, hepatology, and pediatrics. Thus, in all likelihood, the practice of comanagement by hospitalists will not wane, and both surgeons and medical subspecialists will call on hospitalists in this collaborative spirit. Some authors express concerns for exacerbating the workforce shortage of internists by increasing overall workload with comanagement and increasing the “silo” delineations in medicine. However, comanagement may provide value if there is a clear delineation of roles and responsibilities and the value equation is articulated for all parties—hospitalists, surgeons, patients, and hospital leadership. Based on the author’s experience with orthopedic comanagement and on other hospitalists’ successful collaborations, this chapter will suggest specific steps that can be taken to initiate a potential comanagement effort and avoid common pitfalls.

ANTICIPATE THE GROWTH OF THE SPECIALTY IN THE HOSPITAL SETTING

Musculoskeletal disorders and diseases are the leading cause of disability in the United States and account for more than one-half of all chronic conditions in people over 50 years of age in developed countries. One in two Americans has a musculoskeletal condition requiring medical attention, twice the rate of chronic heart and lung conditions. Annual direct and indirect costs for bone and joint health are $874 billion, 5.7% of the gross domestic product.

Based on these data, it is little wonder that orthopedic surgeons will have increasing volumes of patient visits and operative interventions in the coming years, especially in the setting of an aging population with increasing expectations for functional recovery and quality of life. The challenge associated with this growth will be the increasing number of medical comorbidities in these older patients and the need for systematic evaluation of these comorbidities to optimize the perioperative course. It is estimated that surgery-related costs will rise 50% and surgical complications 100% in the United States in the next two decades.

REVIEW AVAILABLE LITERATURE ON COMANAGEMENT

Early literature on orthopedic comanagement focused on geriatrician collaboration with surgeons. Despite inconsistent data on length of hospital stay and mortality, these studies and more recent ones demonstrate that systematic geriatric evaluation and management can decrease the incidence of common postoperative medical complications such as congestive heart failure, arrhythmias, venous thromboembolism (VTE), and delirium, and improve compliance with antiosteoporotic therapy and VTE prophylaxis. More recent literature has focused on hospitalist collaboration with orthopedics and has shown lower adjusted length of hospital stay and decreased complication rates in some studies, although mortality and readmission rates were not changed. In one study of hip fracture patients, delirium was diagnosed more often in the comanagement group, and this was associated with an earlier discharge after surgery. This may reflect greater attention to the presence of delirium, better documentation, and more prompt treatment. A single-center retrospective cohort study of 501 patients who experienced at least one postoperative complication found that comanagement was associated with a lower mortality rate and a shorter length of stay, suggesting that this was a “rescue” phenomenon of the medically complex surgical patient.

ASK KEY QUESTIONS SPECIFIC TO YOUR HOSPITAL

Comanagement of surgical (and medical subspecialty) patients has rapidly evolved with much initial enthusiasm. However, when proposals do not clearly delineate the nature of these relationships, great potential for confusion of roles, miscommunication, suboptimal patient care, and dissatisfaction of both parties can result as the service expands and staffing becomes more of an issue. Institutional support for this activity is paramount and the medical administration should be involved in these initial meetings from the outset.

Initially, ask the following questions:

1. Why are we doing this?

   To start out, it is best to explicitly clarify the motivation for starting such a program: Are the surgeons stretched thin between operating room time and patient care responsibilities on the floors and in the office? Are orthopedic residents more limited by duty hour restrictions and therefore less able to focus on patient care on the floors? Are there concerns with care quality within the standard structure of medical subspecialty consultation? Are nursing and ancillary staff having issues with access to practitioners for patient medical needs and issues? Do they want someone to take on the role and responsibility of completing histories and physicals and discharge notes and summaries? These are just a few questions that might help to focus the expectations of the proposing surgeons.

2. Is the hospitalist service the best solution to this problem?

   Once it becomes clear what your surgical or medical colleagues desire, then clarify how hospitalist services and skills can (or should) address these issues. Is a hospitalist the best solution to this problem? Certainly hospitalists are adept at addressing medical issues in hospitalized patients as medical consultants, but to what degree should they assume the detailed minutia of patient care (ie, acetaminophen orders, renewing intravenous fluids)? This presents the potential to become a “glorified resident” in the care of these patients, which many hospitalists abhor. In addition, expectations for surgical wound care and drain management may be tasked to hospitalists despite concerns that this may extend outside the scope of practice of their internal medicine training. Similar concerns have been raised when hospitalists assume primary responsibility for patients with intracranial bleeds for neurosurgeons.

3. What other options have been considered?

   If the first call from nursing for a problem traditionally has gone to orthopedic residents and/or staff who now are tied up elsewhere, is the hospitalist the next logical call in an equitable “comanagement” relationship? Some newer hospitalists or hospitalist groups may accept this as part of their growth and cultivation of their practice, whereas others fear the mission creep to becoming a “glorified resident” as described previously. In our institution, nurses channel most first calls for a variety of issues to one nurse practitioner (NP) and one physician’s assistant (PA), both stationed on the dedicated orthopedic ward. If relevant medical issues arise that require hospitalist involvement, they will find us on the ward and relay the information to us. This allows us as hospitalists to focus on the more sophisticated medical issues that are more consistent with our scope of practice; in addition, we can also serve as the gatekeeper to further subspecialty consultation when needed, avoiding superfluous consultations and testing.

4. How would a comanagement service affect other relationships? For example, consultants or other medical groups who traditionally round on their own patients may lose revenue as a result of this service.

5. Does the hospitalist service have adequate staffing to expand services? Initially, comanagement may be limited to certain groups who admit to the hospitalist service, or to specific diagnoses, or time of day.

ANALYZE THE CURRENT STRUCTURE

Analysis of the current structure of care delivery in orthopedics serves a useful measurement both as a baseline and after the intervention. In our analysis at the Cleveland Clinic, we found that there were significant differences in the delivery of care on medical services and orthopedic services due to the following factors:

• Limited supervision of medical care provided by the NP and PA.

• Competing responsibilities of orthopedic residents providing backup for other providers or assisting in the operating room.

• Lack of internal medicine training of orthopedic residents to address complicated medical issues.

• Significant medical comorbidities of patients requiring routine medical surveillance to prevent, detect, and intervene during their hospitalization.

• Limitations of general medical consultation service that typically “reacts” to consultation requests when problems have already been identified and lacks the capacity to prospectively affirm or develop a medical plan of care for high-risk or complicated medical patients.

CLARIFY ROLES AND EXPECTATIONS

At this point clarifying and documenting roles and expectations may avoid the potential for confusion and divisiveness. Table 4-1 outlines our expectations for our hospitalist roles and responsibilities and the ongoing orthopedic roles and responsibilities. Table 4-2 lists the conditions that should trigger referral to the hospitalist comanagement service.

These are not firm and inflexible rules; other comanagement relationships may opt to take on some of the responsibilities listed above in the orthopedic section, such as blood and fluid management, pain management, and communication with patients and families regarding medical issues, all of which are in a reasonable scope of hospitalist practice. However, it is critical to delineate who will take on these tasks and to have a mechanism for resolution of disagreements. Some hospitalists may wish to “specialize” in comanagement and become more familiar with the specialty. See Part II (Medical Consultation), Section V (Specialty Consultation: What the Consulting Hospitalist Needs to Know).

Periodic meetings between hospitalist and orthopedic champions as well as nursing, other members of the comanagement team, and administration should review program functioning and processes of care; address specific problems in direct patient care; and further define roles and expectations. In addition, this group may assess the impact of the comanagement service on teaching of medical and surgical trainees and explore future directions. Our medicine residents rotate with our hospitalist comanager as part of their medical consultation experience, and our relationship provides opportunities for creating academic value such as the potential for publication of outcomes data, collaboration in research, and orthopedic quality improvement projects. Table 4-3 delineates the development timeline of our comanagement service.

PATIENT SELECTION AND TRIAGE

Decisions about which patients should be followed by the comanager should be based on patient needs and provider capacity. Patients with minimal or no medical comorbidities rarely benefit from hospitalist input and may only serve to direct clinician efforts away from the patients that need more intensive medical attention. Patients with acutely decompensated problems and/or multiple chronic comorbidities will more likely benefit from comanagement attention; in some circumstances, admission to a medical service with orthopedic consultation may be the most appropriate path. Figure 4-1 delineates the decision process for triage at our institution.

ROLE OF A PREOPERATIVE ASSESSMENT CLINIC

Some institutions (including ours) have an internist- or hospitalist-run preoperative assessment clinic that works in conjunction with the surgeon and anesthesiologist to provide a broad systematic evaluation of readiness for surgery and to facilitate optimization of key medical conditions. Instead of being seen in the hospital or by the patient’s primary care provider, clinicians with more concentrated expertise in assessing and preparing patients for surgery see the patient in advance and then communicate their findings and recommendations to the surgeon and anesthesiologist. In our case, we also communicate with the orthopedic comanager via e-mail, page, or shared EMR (electronic medical record) patient list about planned admissions of surgical patients with relevant comorbidities. The preoperative clinic model may reduce cancellation rates and may identify decompensated medical problems that might lead to increased perioperative morbidity and mortality, as well as identify conditions that could easily decompensate if not scrutinized (eg, excessive intravenous fluids postoperatively in a patient with systolic heart failure).

MEASURING SUCCESS

Defining what constitutes success of the program in measurable terms is an essential piece of the puzzle, as it may provide information about practice changes, variability of practice patterns, outcome changes, and financial benefits or risks of the relationship.

Table 4-4 lists some suggested metrics to consider at the outset. It would also help to obtain data on these metrics prior to the initiation of comanagement to determine the influence of the program.

Especially challenging for the modern orthopedic surgeon is that since August 2008 the U.S. Centers for Medicare and Medicaid Services (CMS) has included deep venous thrombosis and pulmonary embolism after total knee arthroplasty and total hip arthroplasty on the list of nonreimbursed Hospital Acquired Conditions. A portion of the payment made by CMS to hospitals is withheld if a patient experiences deep venous thrombosis or pulmonary embolism following one of these procedures. While this decision has been criticized because prophylaxis is neither perfect nor risk free, it is a reality of practice, and the hospitalist comanager must be aware of this and engage the orthopedist regarding appropriate evidence-based prophylaxis methods.

One must keep in mind that not all metrics can be expected to improve in a “positive” way; in the study described previously about hip fractures, the rates of delirium were increased, which traditionally would be perceived as a negative result. However, this was due to increased recognition, documentation, and treatment of delirium by physicians, which many would agree is a beneficial intervention. Also, these individual metrics are not in a vacuum; an increase in length of hospital stay coupled with decreased readmission rates might reflect the hospitalist taking an extra half to full day to optimize certain medical conditions, which results in fewer readmissions for decompensation.

Early results revealed that our program provided a net cost savings to the orthopedic department in terms of reduced surgical cancellations and improved patient satisfaction with care delivery.

CONCLUSION

Comanagement of specialty patients provides a novel diversity of practice to hospitalists and may be professional rewarding with improved collegiality with surgical specialties, opportunities for leadership, and quality improvement research. Engaging in a new comanagement relationship requires forethought and planning, and clarifying expectations, responsibilities, and metrics of success. However, when designed and managed well, a comanagement service can benefit hospitalists, orthopedists, and, most importantly, the patients who trust us with their care.

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ONLINE RESOURCES

PROFESSIONALISM

Professionalism in medicine has long focused on the tenets of patient welfare, patient autonomy and social justice. As health care has evolved, our definitions and value statements have broadened. Evidence-based medicine, quality improvement, access to care, cost-effective practices, and conflicts of interest are now at the forefront of these discussions—all of which are salient in hospital medicine.

The 2002 jointly published Medical Professionalism in the New Millennium: A Physician Charter articulated fundamental principles and responsibilities to which all physicians should aim to maintain. The ABIM Foundation, The European Federation of Internal Medicine, and the ACP Foundation worked together to develop a charter that reconciled the selfless expectations of the physician with the ever-changing landscape of health care delivery. The American Academy of Pediatrics’ Committee on Bioethics followed with their policy statement on professionalism in pediatrics, which addressed some of the unique considerations for those caring for children.

Hospitalists are trusted with the well being of some of the most vulnerable patients. This distinctive contract with society calls for some variation in our emphasis when discussing professionalism. Here we will define professionalism in hospital medicine, clarify concepts most applicable to those caring for hospitalized patients, and translate this into clinical practice. These concepts apply to all clinicians at all levels, team members, and hospital systems caring for patients admitted to the hospital.

WHAT DOES “PROFESSIONALISM” MEAN IN HOSPITAL MEDICINE?

Members of any profession are expected to have acquired a body of knowledge and skills specific to their chosen field. Through a shared commitment, there is self-regulation and a contract with society to judiciously apply skills and expertise. Hospitalists, like all physicians, have made an agreement to heal. This pact requires an establishment of trust and a willingness to place patient needs above all other considerations. Self-regulation is administered through state medical boards, clinical leadership, and ethical codes. Professionalism is what binds this treaty to our profession.

The high stakes and lack of predictability in caring for inpatients creates unique challenges for hospitalists. Beyond the standard definitions of medical professionalism, special emphasis on patient safety, provider interdependency and communication, financial reimbursement and patient satisfaction reshape our understanding and must always be considered. Finally, with a substantial component of undergraduate, graduate and interprofessional training taking place in the hospital setting, the impact of hidden curricula in medical education is arguably greatest in hospital medicine. Given this, the ripple effects of our behaviors are far reaching. Professionalism for the hospitalist translates to more than outcomes for patients—it has the potential to define generational culture in medicine.

PROFESSIONALISM AND PATIENT SAFETY

Safety for hospitalized patient relies upon a collaborative work climate, teamwork, and effective communication. Intimidating and disruptive behaviors have been linked to increases in medical errors, poor patient satisfaction, cost of care and higher rates of attrition for staff. Behaviors that threaten the performance of the health care team create significant barriers to quality.

In 2008, the Joint Commission released a sentinel event alert addressing behaviors that undermine a culture of safety. From this came new requirements:

1. Every hospital or patient care organization should have a code of conduct defining acceptable and disruptive behaviors.

2. Hospital leadership must have processes in place for managing inappropriate or disruptive behaviors.

Disruptive behaviors have been described as a spectrum of actions such as egregious verbal and physical actions to subtle refusals to cooperate within a system. Specifically, this could manifest as reluctance to answer phone calls or pages, condescending intonation with nurses, colleagues and patients and impatience with queries. These behaviors are not rare in health care organizations. In a survey conducted by the Institution of Safe Medication Practices on intimidation, as many as 40% of clinicians reported keeping quiet or remaining passive rather than confront an intimidating person. Other surveys have revealed that such behaviors are not limited to one gender or a specific discipline. In hospital medicine, which relies upon frequent transitions of care and heavy collaboration with nurses and colleagues, this can pose significant threats to patients.

The standard in hospital organizations should also include (but are not limited to) these additional recommendations from the Joint Commission:

1. Education of all team members defined by the organization’s code of conduct with particular emphasis on respect.

2. Accountability of all team members to model desirable behaviors regardless of hierarchal rank with equitable consequences and reinforcement.

3. “Zero tolerance” for intimidating and/or disruptive behaviors with incorporation of specific verbiage into by-laws and employee agreements.

4. Protection of those who report witnessing or experiencing disruptive behaviors through nonretaliation clauses in policy statements.

5. Timely and thorough responses to all patients and/or families with emphasis on acknowledgement, empathy, and apology.

6. Development of organizational processes that solicit input from a broad representation of team members when addressing intimidating and disruptive behaviors including encouragement of ongoing interprofessional dialogue.

7. Offering training for all leaders and managers of hospital groups to build skills in team building, conflict resolution, and feedback on unprofessional behavior.

8. Assessment of the working climate to assess perceptions of unprofessional behaviors and risk of harm to patients.

9. Provision of anonymous and confidential surveillance and reporting systems for detecting unprofessional behavior.

10. Clear documentation of all attempts to address intimidating and disruptive behaviors with outcomes.

PROFESSIONALISM ISSUES AMONG HOSPITALISTS

Hospitalists strive to provide uninterrupted care to hospitalized patients. Given this, transitions of care and responsibility are dependent upon respectful interactions between providers. Provider interdependency also plays a role in patient satisfaction, burnout risk, and quality. Healthy relationships and working climates are essential though challenging to maintain.

In a study published in the Journal of Hospital Medicine, Reddy and colleagues looked at participation in unprofessional behaviors among internal medicine hospitalists. They found that factors most likely to underlie such behaviors were: making fun of others, learning environment, workload management and time pressure. Additionally, from this study we glean that certain job and provider characteristics increased this likelihood.

Hospitalists with less clinical time were more likely to make fun of other colleagues. It is postulated that those with heavier clinical loads have more opportunities to form relationships and are thus more apt to avoid unflattering commentary of others. Moreover, more clinical time could also cause hospitalists to be less easily influenced by the opinions of others. Night work and age also seemed to be factors in unprofessional behaviors. Those working at night felt more pressure to wrap up work. Hasty handovers and celebration of intercepted admissions are just a few things that could happen as a result.

Given the understanding that unique characteristics increase the incidence of unprofessional behaviors, special attention should be given to more junior hospitalists as well as those with night shifts, limited clinical duties due to competing priorities, and at sites known for heavier workloads. Efforts to better understand the reasons for participating in these behaviors should continue to be explored.

PROFESSIONALISM AND PATIENT SATISFACTION

Patient satisfaction is linked to reimbursements and is a key factor in determining quality of care. Interestingly, the technical dimensions of quality of care are rarely called into question with regards to hospitalized patients. Instead, perception of quality for patients is most connected to what is personally valued by patients and their families. Among those things being treated with respect and dignity coupled with clear communication around treatment decisions are areas that have been identified to be of paramount importance to patients. Professional behaviors are generally the defining features of these perceptions.

Surveys have been developed to best ascertain patient satisfaction in hospitals. The Hospital Consumer Assessment of Healthcare Provider and Systems (HCAHPS) is now the core metric against which health care systems are evaluated. As the first national, standardized and publicly reported survey of patients’ viewpoints on hospital care, HCAHPS now serves as a tool for valid comparisons between hospitals locally, regionally and nationally.

A random sample of patients receives this survey between 48 hours and 6 weeks after discharge. Among the 32 questions about their hospitalization, patients are asked to recall their perceptions of physician and nurse communication, responsiveness of hospital staff, communication about medications and care transition. Though HCAHPS data are not limited to hospitalists, as the “face” of the hospitalization for many patients their impact can be substantial. Special attention to communication skills training, strategic planning around availability to patients and enhanced discharge paperwork and medication reconciliation are just a few measures that have been shown to improve potential areas of weakness. Other simple tips have been offered to enhance patient satisfaction and experience include:

• Make a positive patient experience a part of the culture.

• Adopt patient-centered, multidisciplinary rounds with transparent discussions that include patients.

• Avoid giving off cues of indifference or uncaring (eg, rushing, lack of eye contact, standing instead of sitting).

• Encourage every employee to think about purpose and people, not just tasks.

• Equip every team member with skills for handling patient or family member complaints.

• Recognize that system inadequacies can be responsible for individual lapses in professionalism. Unreasonable scheduling algorithms and workloads are examples of system issues that can undermine professional behavior.

• Collect and act on data related to patient satisfaction.

Hospitalists are poised to have great impact in all of these areas through their continuum of contact throughout the hospitalization. Intentional approaches to both individual behaviors and the systems in which hospitalists work are essential.

PROFESSIONALISM AND THE ACADEMIC ENVIRONMENT

The Accreditation Council of Graduate Medical Education (ACGME) and the Liaison Committee on Medical Education (LCME) have identified professionalism as a crucial competency for developing physicians and have labored to build program requirements around this expectation. For example, the LCME uses this verbiage in their accreditation data collection tools for medical schools:

The hospital setting accounts for a substantial proportion of learning environments in undergraduate and graduate medical education. Given this fact, the importance of professionalism must be emphasized for hospitalists through institutional efforts and programs.

Medical education literature informs us that learners report that values exhibited by their teachers and institutions directly impact their own professionalism. Regrettably, a majority of medical students endorse witnessing peers and supervising physicians speaking of patients and/or other health care professionals in unflattering, cynical or derogatory ways. Multiple studies have shown that the humanistic attitudes essential to patient-centered care unravel during medical school and residency, increasing the risk of burnout and depression.

Hospital medicine provides much of the backdrop for this “hidden curriculum,” originally described by Hafferty as “a set of influences that function at the level of organizational structure and culture.” There can be profound dichotomy between the negative behaviors exhibited by some physician role models and the desired attributes described in formal curricula. The insidious nature of a hidden curriculum is powerful enough to become institutional culture. Newer mandates through accreditation organizations call for more honest appraisals of the informal influences on learners. They also charge institutions with building ongoing strategies to reshape and mitigate their untoward effects.

NEW CONSIDERATIONS

PROFESSIONALISM AND DIRECT PHARMACEUTICAL MARKETING

The interaction between physicians and the pharmaceutical industry and its sales representatives remains controversial. Though lessening in frequency, direct marketing (usually trade name drugs) promoted to providers and groups through gifts, sponsored meals and lectures, travel and symposia are not foreign to most physicians. Though clinicians do not typically report that such interactions influence their prescribing practices, evidence supports otherwise. A large meta-analysis of over 500 studies revealed that attending sponsored CME events, accepting funding for travel, and participating in pharmaceutical sponsored lectures were associated with certain prescribing and professional behavior. Institutional policies are in place at many hospitals regarding disclosure of conflicts of interest. This continues to be an important discussion at the level of policy and education, as well as among professional organizations such as Society of Hospital Medicine (SHM), American College of Physicians (ACP), and Society of General Internal Medicine (SGIM).

PROFESSIONALISM AND SOCIAL MEDIA

Social media has redefined the interface between physicians, patients, learners, and the public. The once passive viewing of content on early iterations of the websites has exploded over the last decade to include interactive exchanging, sharing and communication in real time. Facebook, Twitter, Instagram, and LinkedIn are among the most widely used social media platforms, all made even more accessible by recent advances in mobile smartphone technology and their near universal use by the public. As of 2014, it was estimated that more than 1 billion people were on Facebook and, of these individuals, nearly 400 million only log in using mobile smartphones. Tablets, Internet ready televisions and even smart watches, all with capability to access these same social media platforms, have also emerged in very recent years. These developments, along with more unrestricted Wi-Fi “hotspots” (even in most hospitals) and robust search engines using collective intelligence tools, have closed the gaps that once stood between the professional and private personas of physicians.

Though social media presents new challenges to the landscape of medical professionalism, it also presents opportunities. Specific health information can be quickly disseminated to large groups of individuals in moments. Platforms aimed toward health professionals such as Doximity offer encrypted, HIPAA compliant privacy settings for idea sharing, consultation, and collaboration in ways previously unforeseen. Moreover, Twitter use at professional meetings keeps attendees and allows those unable to leave the hospital to stay abreast of ongoing activities as they are happening. In less than half of a decade this culture of “tweeting” professional meetings in real time has become not only a welcomed feature but an expected one as well.

A growing number of academic institutions and organizations have begun to develop policies about judicious use of social media, most of which emphasize confidentiality. Professional development centered on social media is becoming more frequent on meeting agendas. From concrete tips on privacy settings to abstract ways to seize collaborative opportunities, hospitalists and other health care providers should all gain some proficiency with social media and its potential impact on the care of patients.

CONCLUSION

Hospitalists, with their large imprint in medical education and contract to care for a diverse and vulnerable patient population, must approach professionalism with intentionality. New considerations such as direct pharmaceutical marketing and social media have shifted prior understandings of what it means to be a medical professional. Thoughtful consideration of professional behaviors along with their impact on patient safety, patient satisfaction, and the hidden curriculum should guide ongoing individual, institutional and organizational development.

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INTRODUCTION

Physicians are frequently called upon to take on leadership roles. These roles can come in various forms, ranging from academic leadership roles (eg, division or department chief or chair) to educational leadership roles (eg, clerkship or residency program director) to leadership roles in a practice setting (eg, director of a practice group). Although some of the desired skills and competencies for the leader may be specific to particular roles and responsibilities, others are more generic and applicable to any of these leadership positions. This chapter concentrates initially on the generic aspects of leadership and concludes by discussing some of the challenges that are more specific to hospitalists and to the hospital environment. In addition, instead of trying to review the voluminous leadership literature, presented here will be a personal perspective, based upon experiences in a variety of leadership positions over many years. Discussion of leadership will be divided into four primary components: the personal attributes that a leader should demonstrate, the skills that should be acquired, a suggested approach to reach a goal, and leadership challenges for hospitalists in the hospital environment.

LEADERS VERSUS MANAGERS

Before considering the important attributes of a leader, it is worthwhile to understand the distinction between a leader and a manager. Much has been written about these differences, which can be readily summarized and understood by any of several descriptions or aphorisms:

• Leaders have followers; managers have subordinates. Individuals voluntarily follow a leader because of the qualities of the leader; subordinates work for managers because of the reporting relationship and the organizational authority vested in the manager.

• Leaders lead people; managers manage tasks.

• Leadership is doing the right thing; management is doing things right.

• Managers focus on tactics and tasks; leaders focus on strategy and direction.

In fact, however, these distinctions often blur in the setting of actual roles and responsibilities in the workplace. The individuals who are most successful in assuming roles with greater authority and responsibility are those who are both effective leaders and effective managers. A leader who does not have good management skills can generate visionary ideas but will be unable to implement or operationalize them. A manager who does not have good leadership skills will be unable to mobilize and motivate a supportive team.

Some activities and responsibilities of a physician leading a group of hospitalists can readily illustrate the differences between leadership and management. “Managing” the group means assuring that the patients are covered, that transitions of care are effectively handled, that chart and billing documentation is complete and accurate, and that teaching responsibilities are assigned and well integrated with patient care responsibilities. In contrast, “leading” the group means exploring and developing ideas for improving the system and its productivity, improving quality of care, developing the skills of the team, and facilitating the professional development of the team members.

For the purposes of this chapter, I will primarily use the terms “leadership” and “leadership skills,” recognizing, however, that we are really considering both leadership and management skills. In the medical leadership positions that are likely to be assumed by readers of this chapter, success will hinge upon both leadership and managerial qualities and the importance of each in reinforcing the other. Therefore, the approach here to discussing leadership and management qualities will be one of lumping rather than splitting.

DESIRABLE ATTRIBUTES OF THE LEADER

A leader must demonstrate professional integrity, including honesty. High standards of integrity and honesty are a prerequisite for obtaining the respect of colleagues, superiors, and subordinates. The leader sets the model of behavior for the rest of the team, and lack of professional integrity exhibited by the leader will soon be mirrored by cracks in professionalism among others.

The leader needs to be an effective communicator; openness and transparency in communicating to all constituencies assure that everyone is on the same page. A commonly held perception of a talented leader is often someone who can communicate both values and vision, including a set of goals and how those goals might be achieved. However, that is only part of the communication equation, which also involves establishing and transmitting expectations for others. It is critical that subordinates, trainees, and team members understand the expectations being placed on them, including how and on what basis they are being judged.

Communication must also occur on a two-way street, that is, the leader must be an excellent listener as well. If the leader is unable or unwilling to hear what others have to say, he or she will be doomed to failure. Without ideas and feedback from others, the leader will invariably make mistakes of both commission and omission that can be avoided by hearing the ideas and opinions of others and considering all perspectives when making important decisions.

Another important aspect of communication relates to feedback. The effective leader provides feedback in a constructive, professional manner. This feedback must be based on established expectations, not on the subordinate’s or trainee’s ability to read the leader’s mind and guess what s/he wants. In addition, the feedback should be done in a way that is formative, that is, giving the receiver of the feedback an opportunity to, and advice on how to improve performance. Providing only summative feedback at the end of a responsibility or task allows no room for improvement and often proves frustrating to the person receiving the feedback.

An effective leader remembers that success is determined by the contributions or development of the people s/he leads or trains. The leader must acknowledge the contributions of others and not always take credit for success. Nothing is as demoralizing to a team member as the feeling that his contributions are not being recognized and that someone else is taking credit for his work or accomplishments. At the same time, a successful leader is cognizant of, and aims to promote the professional development of the individuals for which she is responsible. For example, true success for an academic leader is often determined as much by the ultimate careers of the individuals trained by the leader, as it is by the academic contributions of the leader himself. Supporting the professional development of one’s trainees is one of the most important and enduring legacies that a leader can leave to the profession.

Finally, an intangible but critical quality of a successful leader is the ability to create and maintain a positive work environment. The leader needs to establish a workplace tone that is positive, in which people feel they are supported and a “can do” attitude prevails. Productivity of the individuals for whom a leader is responsible is dependent upon their interest in, and commitment to the team and to the shared goals and vision that have been defined by the leader. A setting in which individuals are competitive with each other, where back-biting is common, and people feel they do not respect and share the values of their colleagues and the leader, is not an enjoyable workplace. It is also one that will never reach its true potential.

LEADERSHIP SKILLS

An important prerequisite for a successful leader is a high level of competence in the particular field related to the leadership role. For example, an educational leader must be accomplished as a teacher and educator in order to command the necessary respect of trainees and other educational colleagues. Similarly, a clinical leader must be highly regarded as an excellent clinician in order to have credibility with other clinicians.

Another important skill that leaders must acquire is the ability to negotiate effectively. This topic is covered extensively in a later chapter (Chapter 26, Negotiation and Conflict Resolution), but it is important to stress that leaders must exercise their negotiation skills in many settings—when dealing with superiors, dealing with subordinates, or dealing with third parties with whom there is no reporting relationship. Physicians typically have not been trained in negotiation, but fortunately a number of excellent and readily accessible resources can provide valuable guidance to the previously untrained leader.

Many leaders have responsibility for budgets, and a working familiarity with balance sheets and with revenue and expense statements is therefore useful. Although providing such financial training is beyond the scope of this chapter, a valuable resource that can provide basic training in the principles of accounting is a short, easy to read, programmed text used in many business schools.

Finally, the responsibility of running meetings often accompanies leadership roles. Everyone has participated in meetings that run effectively, where the participants feel they have not wasted their time, and they leave the meeting with a well-defined action plan. On the other hand, everyone has also participated in meetings that are poorly organized, do not make best use of participants’ time, and do not have a well-defined purpose or outcome. Several important aspects of well-designed meetings include:

• Sending an advance agenda to the participants, so that they can prepare appropriately.

• Starting on time and finishing on time (or early). Time is an incredibly valuable commodity, and meeting participants become distracted and resentful when time is wasted at the beginning of a meeting or when a meeting runs overtime and potentially affects their subsequent commitments.

• Assuring that the meeting is interactive and makes good use of the participants’ time and expertise. A successful meeting is not a monologue provided by the meeting coordinator. Rather, it involves active engagement and participation by all attendees, so that the participants feel they have contributed to the meeting and have not just been wasting their time.

• Wrapping up the meeting with a summary and a well-defined action plan. Everyone should understand the outcome of the meeting and the expected action plan, including the assignments that have been meted out to individuals and the timeline according to which they should be completed.

REACHING A GOAL

In trying to generate ideas and complete desired tasks necessary to reach a goal, the successful leader may find it helpful to use a set of principles: (1) establish the goal, (2) identify and include stakeholders, (3) assemble a team, (4) engage all team members to generate ideas, (5) accept ideas from outside the team or organization, (6) delegate responsibility, and (7) assess interim outcomes and reassess the plan.

At the outset, the leader needs to establish the goal and communicate it to others. In other words, the leader must define the destination before anyone can plot the route of how to get there. Success in achieving a goal depends critically upon the process of engaging others at least as much as the goal itself. This process involves identifying stakeholders who are either impacted by the goal, or who will feel disenfranchised if they have not been included in developing or working to achieve the goal. For example, if a residency program director needs to restructure a schedule for the residents based upon changing regulatory requirements, s/he is much more likely to be successful when including residents in developing the new model, rather than imposing it upon them without their input. No matter how sound an idea or plan, its acceptance and implementation can be obstructed by those who were not included or engaged—but feel they should have been—in its generation and development.

In making plans for a project or reaching a goal, the leader often needs to establish a team of individuals who can work together. Assembling the right people is critical for a successful outcome. Team members need to be chosen based upon their skills, their interest in and enthusiasm for the project, their ability to work well with others on the team, and their openness in providing ideas and feedback about how things are going.

Once the goal is established, stakeholders are identified, and the team is assembled, the leader must recognize that s/he does not need to generate all the ideas. Great work is typically done in teams in which everyone is encouraged to share ideas, no matter how crazy or far-fetched they may initially seem. In addition, not all good ideas need to come from within the team. One can adopt and build upon ideas and successful initiatives that have been developed by individuals outside the organization. The “not invented here” attitude often precludes an open mind to accepting ideas that have worked successfully in other settings.

The ideas necessary to reach a goal are often not grand and sweeping ones. A series of small steps, each of which can be judged and modified as necessary based upon the outcome achieved, is often more successful than a single, revolutionary idea that does not allow for opportunities to provide mid-course assessment and correction.

In making the best use of the team members, the leader must be willing to delegate responsibility appropriately. From the time of their training, physicians are often used to feeling that they need to take full responsibility for a patient, and this attitude of individual responsibility and accountability should often be modified when one assumes leadership responsibilities. Members of a team work best when they feel that responsibility has been bestowed upon them. Delegating responsibility is not a sign of weakness; rather, appropriate delegation demonstrates an understanding of how to share responsibility, engage others, make best use of available resources, and capitalize on each person’s strengths.

As a project progresses, the leader must critically assess interim outcomes. Based upon these outcomes, the leader must be willing to reassess the plan and adjust accordingly. The leader and the team members should also recognize that not all plans will be successful. A plan that does not succeed should not necessarily be viewed as a failure. Important lessons are often learned and new ideas generated based upon unanticipated problems or unexpected results.

LEADERSHIP CHALLENGES IN THE HOSPITAL ENVIRONMENT

Hospitalists who are in leadership positions or who are expected to effect change are often confronted with challenges that arise specifically from working in the hospital environment. Besides dealing with physicians, hospitalists are constantly working with nonphysician personnel and administrators whose management and reporting structure is quite independent of the physicians at the institution. A hospitalist leader who is trying to effect change but is not part of the hospital’s administrative hierarchy may have difficulty shaping opinions and getting buy-in from a group of nursing leaders or from nonphysician hospital administrators. Even among physician leaders at the hospital, challenges arise often centered around a competition for resources, so that the interpersonal relationships become adversarial rather than cooperative.

An additional challenge confronted by hospitalists stems from their basic demographic characteristics. Age, gender and even race could impact abilities to break into a hospital hierarchy that tends to be older, male, and Caucasian. A young physician who goes on staff as a hospitalist at the institution where s/he completed residency may find it difficult to shake the image of being a resident rather than a staff member and colleague. On the other hand, a young hospitalist who takes a position at an institution where s/he did not train may find it difficult to parachute in as a newcomer unfamiliar with a particular hospital’s culture and personalities.

Although there are no proven methods to overcome such challenges, some strategies may be helpful. First, it is extremely valuable to obtain the trust and support of a more senior, well-respected person, ideally a current physician leader at the institution. Such an individual not only can serve as a mentor and advisor to guide the hospitalist in charting a path through unfamiliar territory, but s/he can also smooth the way for the young hospitalist to become accepted by the more established hospital hierarchy. For example, the support and trust from a well-respected division chief or department chair can be invaluable in easing the way for a hospitalist to deal with an older, potentially intimidating chief of surgery or hospital’s chief operating officer.

Second, as mentioned earlier in this chapter, it is critical for any clinician leader, particularly a hospitalist leader, to be viewed by both physician and nonphysician staff as an outstanding clinician. It is very difficult to have credibility in the hospital environment, particularly from physician colleagues and from nursing staff, if one is viewed as a “clinical lightweight.” The hospitalist’s conscientiousness, clinical skills, decision-making ability, communications skills, and professionalism all contribute to the individual’s reputation and ability to command respect from others at the institution.

Third, when trying to effect change and garner support from both physician and nonphysician staff, the hospitalist leaders must initially establish, promote, and focus on the principles underlying any proposed plan. Although it is easy for a hospital administrator to argue with a specific proposal, it is much more difficult to take a position against an ultimate goal of improving the quality and safety of patient care, improving hospital systems and efficiency, or improving the financial performance of the hospital.

Finally, it is important for the hospitalist to seek out defined leadership roles. Such roles can obviously be within the hospital community, for example, by serving on committees. However, establishing a presence and reputation outside the institution, for example, through involvement at regional and national levels, can only help the hospitalist’s reputation and credibility within her own hospital setting.

FINAL WORDS

The concept of being a “born leader” has clearly given way to a philosophy that leadership skills can be learned. It is perhaps based on this premise that so many books and articles have been written about every possible aspect of leadership. Yet, it is fair to say that many personal qualities and aspects of personality do have an impact on potential success as a leader. When placed in a position with leadership responsibilities, it is valuable to take some time to self-reflect upon personality traits and how they will likely influence leadership style. In addition, one should try to assess what additional skills s/he needs to acquire to be an effective leader. Even though physicians are often placed in either clinical or academic leadership positions, they have not typically received leadership training. Recognizing the interplay between personal style and leadership skills, and acknowledging the importance of self-reflection on successes and failures as a leader will serve to make one an increasingly effective leader over time.

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