hospital medicine an evolution in changing paradigms jeff wiese, md, facp, fhm professor of medicine...
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Hospital Medicine
An Evolution in Changing Paradigms
Jeff Wiese, MD, FACP, FHM
Professor of Medicine
Tulane University Health Sciences Center
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What is a Hospitalist?
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General Internal Medicine 82.3%
General Pediatrics 6.5%
Internal Medicine Sub-specialty 4.0%
Family Practice 3.7%
Internal Medicine Pediatrics 3.1%
Pediatrics Sub-specialty 0.4%
Hospitalist Specialties
The Society of Hospital Medicine National Survey; 2008
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Hospital/Hosp. Corporation,
40%
Academic, 24%
Multi-state group/mgt. co.,
8%
Multi-spec/PCP med. group,
11%
Local hospitalist only group,
14%
Other, 3%
Employment Model of Hospital Medicine Groups
The Society of Hospital Medicine National Survey; 2008
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HMG Leaders Non-leader physicians
Median Age 41 years 37 years
% Male 80% 63%
Mean experience 6.7 years 3.7 years
% IMG 15% 29%
Hospitalist Characteristics
The Society of Hospital Medicine National Survey; 2008
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• Admissions, Follow-ups, Discharges: 73.6%
• Consultations: 8.2%
• Observation Days: 8.0%
• Critical Care: 4.0%
• Procedures: 2.0%
• Office Encounters/Consultations: 1.1%
• SNF/Rest Home Visits: 1.0%
• ED Encounters: 0.9%
• Other Encounters: 1.1%
The Work of Hospitalists
The Society of Hospital Medicine National Survey; 2008
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Non-clinical Roles
Committee Participation 92%
Quality Improvement 86%
P&T Committees 64%
CPOE/Information Systems 54%
Teaching 51%
The Expanding Role of the Hospitalist
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26,634
22,302
19,271
13,293
11,704
9,791
4,156
0 5,000 10,000 15,000 20,000 25,000 30,000
Emergency Medicine
Cardiology
Hospital Medicine
Neurology
Gastroenterology
Pulmonary
Allergy
# of physicians
AHA 2006 Survey
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Society of Hospital Medicine Membership#
of M
emb
ers
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What drove the hospitalist movement?
The physician The hospitalized patient
Increasing disease severity * Inpatient * Outpatient
Higher standards of careClinic reliability
Patient issuesPhysician Issues
Complexity of documentationBusy clinic schedulePhysician quality of lifeQuality of care standards
Third party issues
Joint CommissionQuality improvement Supervision requirementsCost-containment * Admissions * Resource utilization * Discharge
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Hospital Medicine in 2009
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The Seven Deadly Sins
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Seven Deadly* Sins of Hospital Medicine
* Potentially
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Sin 1: Failure to Advance
Quality and Patient Safety
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Quality:
1.Desired Outcomes Occur2.Evidenced-Based Standard of Care Leads to the Outcome
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Institute of Medicine Six Components of Quality Health Care
Time
Quality
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Time
Quality
SafeTimelyEffectiveEfficientPatient-CenteredEquitable
Institute of Medicine Six Components of Quality Health Care
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Familiarity with the intricacies of inpatient disease management (specialization)
Familiarity with many different sub-specialties Familiarity with non-medical services Closer relationship with nurses, administration,
and technicians Greater availability to patients
The rational behind hospitalists and quality of care
SafeTimelyEffectiveEfficientPatient-CenteredEquitable
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Hospitalists vs Gen Internists
Length of Stay -0.4 daysCosts -$268Same mortalitySame re-admit rate
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Chan PS, et al.N Engl J Med 2008;358:9-17.
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Gray A, et al.N Engl J Med 2008;359:142-51
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Wachter R, et al.,Ann Intern Med. 2008;149:29-32.
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Quality and Patient Safety
Quality: Patients received the highest standard of care such that expected outcomes are routinely achieved.
Patient Safety: Adverse consequences of diagnostic and therapeutic interventions, including medical errors, are avoided.
Committee on Quality Healthcare in America, Institute of Medicine. (2001). Crossing the Quality Chasm: A New Health System for the 21st Century.
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Overriding Aims of Patient Safety
1. Education 2. Raise Awareness 3. Accountability/Metrics 4. QI Projects/Research to change the system
Wachter, R.M. Understanding Patient Safety. 2008
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• Quality Improvement Resource Rooms
www.hospitalmedicine.org/rrs
•Acute Coronary Syndrome
•Antimicrobial Resistance
•BOOSTing Care Transitions
•Glycemic Control
•Heart Failure
•Veneous Thromboembolism
•Stroke
• Peer-Submitted Quality Improvement Tools
SHM-Developed Quality Improvement Initiatives
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Sin 2: Living in a Silo
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1. Hospital Value-based Purchasing2. Physician Quality Reporting Initiative (PQRI)3. Expansion of Physician Feedback Program (Resource Use) 4. Value-Based Modifier for Physician Payment Formula5. Reducing Hospital Acquired Conditions6. Improving Quality7. Accountable Care Organizations8. CMS Payment Innovation Center9. National Pilot Program on Bundling Acute &Post Acute Payments10. Readmissions11. Community Care Transitions Program12. Medicare Physician Payment Update (SGR)13. Medical Liability Reform14. Provider Screening 15. Provider Compliance and Penalties (High Risk Referrals)16. Primary Care Bonus Payment
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Sin 3: Failure to Maintain Patient-Centered Care
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3. Patient-Centered Care
Pay for hospitalists may, and likely will is, derived from hospitals.
The fiduciary responsibility must remain with the patient.
A strong connection to the patient, the patient’s family, and the patient’s primary care provider is necessary for maintaining this standard.
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Patient Satisfaction Patients prefer to receive care from their
primary care provider if: The primary care MD is consistently available The primary care relationship has been well-
established.
Patients prefer hospitalist care if The hospitalist regularly sees the patient
(accessability) The hospitalist is in frequent communication with
the patients primary physician.
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Weissman JS, et al.,Ann Intern Med. 2008;149:100-108.
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Sin 4: Failure to Sustain Quality & Patient Safety:
Transitions of Care
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Transitions of Care
- Transfer of Information- Transfer of Choice- Transfer of Decision-Making- “Enabling” Communications/Decisions- Preservation of Patient-Centered Care
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Transitions of Care- Inflow to Hospital Medicine
- Primary Care Identification- Past Medical History- Patient wishes/personal history- Diagnostic coordination
- Outflow to Primary Care
- Primary Care Entry- Synching inpatient to outpatient continuum- Setting up the perfect first visit
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SHM Initiatives – Care Transitions• Discharge Checklist
• Halasyamani L et al. Transition of care for hospitalized elderly patients--development of a discharge checklist for hospitalists. J of Hosp Med 2006:354.
• Resource Room
• Safe STEPs
• Project BOOST
– Better Outcomes for Older adults through Safe Transitions
– John A. Hartford Foundation $1.4 million
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BOOST Toolkit: Primary Components1. Tool for Identification of High-Risk Patients
2. Patient and Family/Caregiver Preparation– Diagnosis – primary cause for hospitalization and other Dx– Test results and interpretation– Treatment Plan during and after hospitalization
• Contextualize
3. Follow-up Plans• Principal Care Provider identification
– Who to contact with questions/concerns• Warning signs/symptoms and how to respond• Outpatient appointments• Pending tests
4. Medication Reconciliation
5. Discharge Summary Communication
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Other Transitions
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The Seven Organizational Sins
1. Overproduction2. Waiting3. Transporting4. Inappropriate Processing 5. Unnecessary Inventory6. Unnecessary Motion7. Defects
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Howell E, et al.,Ann Intern Med. 2008;149:804-810.
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Sin 5: Failure to Sustain The Art:
Instruction of Quality and Patient Safety
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Before the Work Hours
After the Work Hours
Extra Work
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Before the Work Hours
Solution 1: Shift the work to others (i.e., other residents/ hospitalists)
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Before the Work Hours
Solution 1: Shift the work to others
Problem: 1) A proportion of the “good work” is lost ( ), or 2) You induce a system of high-output heartfailure
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Before the Work Hours
Solution 2: Go To Shifts
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Before the Work Hours
Solution 2: Go To Shifts
Problem: Efficiency in the system is lost generating extra work
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How We Learn: SurgeryA clinical decision is made:
“Cut that”
Patient Bleeds Patient does not bleed
An outcome occurs
Response: Bovi
Response: Continue
Lesson Learned:
OK to cut thatDon’t cut that
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How We Learn: MedicineA clinical decision is made:
“Give the patient insulin”
Patient has ARF; becomes hypoglycemic
Patient does not have ARF; remains normoglycemic
An outcome occurs
Response: Glucose needed
to correct
Response: Continue
Lesson Learned:
Don’t give patients with ARF insulin.
OK to give patients without ARF insulin.
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How We Learn (Multiple Shifts)
A clinical decision is made: “Give the patient insulin”
Patient has ARF; becomes hypoglycemic
Patient does not have ARF; remains normoglycemic
An outcome occurs
Response: Glucose needed
to correct
Response: Continue
Lesson Learned:
OK to give patientswith ARF insulin.
OK to give patients without ARF insulin.
New shift
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Before the Work Hours
Solution 3: Assume the Work, Deal with the Intensity
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Before the Work Hours
Solution 1: Assume the Work, Eliminate the MUDA
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Papadakis M, et al.Ann Intern Med. 2008;148:869-876.
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Sin 6: Failure to Sustain the Career
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Sustainability
Fulfillment proportional to work invested
Empowerment to change systems Leadership opportunities for career
growth
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Sustainability Part A: Matching Compensation to Effort
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1800
1900
2000
2100
2200
2300
2400
2500
Hosp Empl Academic Multi-stateHosp Only
Group/Mgt Co
Local HospOnly Group
Multi-spec/Prim.
Care Med Grp
Hours worked
0
500
1000
1500
2000
2500
3000
3500
Hosp Empl Academic Multi-stateHosp Only
Group/Mgt Co
Local HospOnly Group
Multi-spec/Prim.
Care Med Grp
Encounters
Work Intensity
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$189,400$198,600 $198,500
$186,700
$100,000
$125,000
$150,000
$175,000
$200,000
$225,000
East South Midwest West
Tot. compensation
$173,000$185,000
$202,000
$100,000
$125,000
$150,000
$175,000
$200,000
$225,000
100% Salary Mix Salary/Bonus 100% Production-based
Tot. compensation
Compensation
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Potential Threats to Compensation
• Pay for Performance
• Value Based Purchasing
• Bundling
– DRG for facility and professional charges
– Who will control these dollars?
• What about the Uninsured/Underinsured?
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At the End of the Day, Compensation= Value Added Service
Value = Quality Cost
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Sustainability Part B: Fulfillment
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Emergency DepartmentClinics
Ward Team
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Emergency DepartmentClinics
Ward TeamNon-Teaching Service
Option A: Non-teaching ServiceRandom or Alternating Assignment
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Emergency DepartmentClinics
Ward TeamNon-Teaching Service
Option B: Non-teaching ServicePre-determinedAssignments
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Sustainability Part C: Promotion & Reputation
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On offense, only the quarterbacks make more on average than left tackles, but it's not just salaries that spell out the bottom line. Tackles have become more coveted at the top of the draft order:
1st-round picks Top-five picks2000-present 30 71990-1999 37 21980-1989 27 41970-1979 25 4
What the NFL Knows, That We Don’t
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Sin 7: Failure to Maintain Public Accountability:
Maintenance of Certification
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Maintenance of Certification Process
Part I. Pre-RequisitesA. Valid, unrestricted medical license and confirmation of good standingB. ABIM certification in internal medicineC. Minimum of three years’ hospital medicine practice experience (hospital medicine practice experience acquired during training cannot be counted unless it is part of a hospital medicine fellowship) .D. Attestation of significant commitment to focused practice in hospital medicine, through meeting requirements for either of the following two pathways:
1. Direct Patient Care (i.e., full-time hospital practice): minimum of 1000 hospital patient encounters (limited to one encounter per patient-day) per year for three years, or 3000 over three years.2. Clinical Systems (i.e., full time hospital medicine professional activity with part-time hospital practice): minimum of 250 hospital patient encounters (limited to one encounter per patient day) per year for three years, of 750 over three years; these encounters must comprise at least 75% of total clinical activity.
E. ACLS Certification
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Maintenance of Certification
Part II. Self-Evaluation Programs A.Complete self-evaluation modules to earn 100 points:
1. Patient Safety2. Systems Improvements to Advance Timely & Efficient Care3. Evidence-Based Hospital Care4. Measures to Improve Patient-Centered Care5. Measures to Improve Equitable Access to Care
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Current IM MOC Hospital Medicine MOC
In-Patient Content In-Patient Content
Ambulatory Content
Ambulatory Content
Systems/ QI
Part III. The Secure Exam
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Part IV. Practice Improvement Module
A. Longitudinal Self-reflection ModulesB. Practice Improvement ProjectC. On-Going (every three years)
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