how hospitalists can lead on quality

WEBINAR WELCOME!How hospitalists can lead on quality

Dr. Kevin O’Leary Chief of the Division of

Hospital Medicine Northwestern University

Feinberg School of Medicine

Dr. Vercin Ephrem Chief of Hospital

Medicine LRGHealthcare

Maureen McKinney Editorial Programs

Manager Modern Healthcare

During today’s discussion, feel free to submit questions at any time by using the questions box.

A follow-up e-mail will be sent to all attendees with links to the presentation materials online.

Dr. Robert Wachter Chief of the Division of Hospital Medicine UCSF Medical Center

Panelists:

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How hospitalists can lead on quality

Please use the questions box on your webinar dashboard to submit questions to our moderator

Maureen McKinneyEditorial Programs


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Dr. Robert WachterChief of the Division of

Hospital Medicine UCSF Medical Center

Wachter RM, Goldman L. NEJM 1996

An SAT Question

Is to The…

As Is to …

Hospitalist Growth, 1996-present

Society of Hospital Medicine

29% of US

hospitals

61% of US

hospitals

Fastest Growing MD Specialty in US History

Why We’re Being Pressured to Change

“The Challenge That Will

Dominate Your Career…”

Do Data Support Hospitalists’’’’ ““““Value””””?

Yes (generally)

Wachter, JAMA 2002 & many others

Key organizational question: do the advantages of

focused practice and on-site presence outweigh the

disadvantages of ““““purposeful discontinuity””””

Vast majority of published studies show ~15% fall

in costs and LOS; many now show better quality

The Fundamental Economic

Truths of the Hospitalist Field

�Non-procedural E&M hospital codes are a tough way to make a living

�90% of hospitalist groups receive support– > $20B (40K hospitalists x $150K/MD x 90%) in

new hospital -> MD dollars since field began

�This isn’t charity: there must be a ROI – Initially, this was cost and LOS reduction

– Now increasingly quality, safety, pt experience, IT

�A positive side-effect: unique hospital-MD alignment/synergy; perhaps a model for others

50-60% comes

from the hospital

My Decision as SHM Prez in 1999

�Risk that hospitalists were being branded as

being all about efficiency, LOS

�No physician wants to be “about”

getting grandma out of the

building a day earlier

�To Err is Human published:

opportunity for hospital

medicine to “own” safety, quality

�The “two sick patients” mantra

Business Case for Quality and

Safety has Grown

�Percent of hospital dollars at risk based on

performance in 2000: zero

�Percent at risk in 2008: zero (but stricter

accreditation requirements, public reporting)

�Percent at risk in 2014: 3-4%

�Percent at risk in 2017: 7-8%

�Percent at risk in 2020: who knows, but more

Value Oversight Committee

Quality Improvement(ie, Evidence-

based Practices)

Pt Experience(ie, HCAHPS scores, patient complaints)

Patient Safety(ie, Case revus, Safety Culture,

“Never Events”)

Cost/Waste Reduction

Targeted Initiatives

(ie, Nebs to MDIs, less labs)

Lean Initiatives (ie, Improving

discharge process)

Numerator of the Value Equation Denominator of the Value Equation

UCSF’s Model Organizational Chart

for a “Value Improvement” Program

Hospitalists as System Leaders

The Bottom Line and a Few Predictions

� Hospitalists are now the major U.S. providers of hospital

care

� Studies will continue to show improved value

� The Swiss-army-knife-nature of the field will make it a

perpetually exciting (and challenging) place to be

– Uniquely context dependent

� Often an island of MD-hospital integration in a non-ACO

world (and doesn’t take 50 yrs to build)

� The U.S. healthcare marketplace will

not tolerate failure to innovate in the

name of tradition

Could this be worse?

“We think that the anxiety, demoralization, and sense of loss of control that afflict all too many healthcare

professionals today comes not from finding themselves to be participants in systems of care, but rather from

finding themselves lacking the skills and knowledge to thrive as effective, proud, and well-oriented agents of

change in those systems…. A physician equipped to help improve healthcare will be not demoralized, but

optimistic; not helpless in the face of complexity, but empowered; not frightened by measurement, but made curious and more interested; not forced by culture to

wear the mask of the lonely hero, but armed with confidence to make a better contribution to the whole.”

Berwick & Finkelstein, Acad Med 2010

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Dr. Vercin EphremChief of Hospital Medicine

LRGHealthcare

LRGHealthcare

• Lakes Region General Hospital-137 Bed Rural Community Hospital

• Franklin Regional Hospital-25 Bed Critical Access Hospital

• Two Ambulatory Surgery Centers

• 100+ Provider Practices including 2 Rural Health Clinics

• 13 Hospitalists & 6 APRNs for 2 hospitals & 4 Nursing Homes

• 32,597 ED Visits/Year, 16 % ED Admits

Hospitalists in Community Hospital

Leading Quality

• Ideal Position, Since Hospitalist is Knowledgeable about the Entire

Patient Care Continuum

• Working with Same Team on a Daily Basis to Ensure Best Practices

Are Followed

• Easier to Implement Quality Improvements projects & Ensure that

they are Being Followed

• Ability to Involve Other Community Partners in Quality Projects

Challenges to Hospitalists in Community

Hospital Leading Quality

• Financial Support

• Staff Support

• Few Resources

• Launched in 2010, BOOST Implementation Team included

other Health Care Related Agencies including Home Health,

Mental Health, Long Term Care

•Common Goals

•Developed Systems to Communicate & Coordinate in

Caring for Patients

•Used all the BOOST Tools such Risk Identification, Teach-

Back, etc.

Implementation of BOOST-Better Outcomes By

Optimizing Safe Transitions

• Patient Flow Meetings:

• Co-Chairs Hospitalist/ ER

• Bed “Czar” Concept

• “Bed Ahead” Process

• Bridge Orders to Facilitate Admission

• Hall Beds

Process Improvements in Transitioning Patients from

ED to Bed

Transitioning Patients from ED to Bed

Admit Decision to Floor

•Daily Rounding with Hospitalist and the Entire

Multidisciplinary Team

•Medication Reconciliation with Hospitalist and Clinical

Pharmacist Day Prior to Discharged

•Weekly Meeting to Discuss “Challenging Discharges” &

Review of Readmissions for Learning by Team

•“Almost Home” to Teach Patients/Families to Care for

Themselves at Home

•As of Feb, 2015, Bedside Medication Delivery Prior to

Discharge

Process Improvements in Transitioning Patients from

Bed to Discharge

• Home Care, Embedded Care Coordinator, Long Term

Care Staff at Discharge Planning Meeting Helping to

Facilitate Communication About Patient

• Hospitalist contacting PCP Prior to Discharge

• Follow up Appointment with PCP within 3 to 7 Days

• Embedded Care Coordinators making follow up

phone calls to patients within 48 hours of Discharge

• Hospitalists caring for patients in the Nursing Homes

Transitioning Patients from Discharge to

Nursing Home or Home

The Rate for the Top 10% of US Hospitals is 16.9%-We are 16.9%We are 221 out of 2331 Hospitals

LRGH

LRGH

The Top 10% of US Hospital Rate is 20.9%- We are 21.7% We are 785 out of 3996 Hospitals & went from 18 in NH to 8

LRGH LRGH

Top 10% of US Hospital Rate is 15.9%-- We are 16.6%We have to reduce readmissions by 0.7%-top 10% of Hospitals

LRGHLRGH

LRGHealthcare

WEBINAR

NOW SPEAKING



Dr. Kevin O’LearyChief of the Division of



How Hospitalists can Lead

Quality

Kevin O’Leary MD, MS

Northwestern Medicine

Recognize trends that affect both

hospitals and hospital medicine

ACA Impact on Hospitals

• Will expand the base of insured patients

• Decrease overall payment rates to hospitals

• Incentives and penalties

– Readmission Reduction Program

– Value Based Purchasing

– HAC Reduction Program

– Bundled payments

– Accountable Care Organizations

Source: New York Times

What does consolidation mean for

hospitalists?

• Hospitals will prefer single group per hospital

• Lays foundation for true partnership

• Potential for collaboration across sites

– Joint recruitment, credentialing

– Share best practices, innovate on larger scale

• Pressure to address population health (high

utilizers, recidivist patients)

Create innovative partnerships

between hospitalists and hospital

Collaboration Between Nurses &

Physicians on Medical Services

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Hospitalists rate

RNs

RNs rate

Hospitalists

Graphs show % rating collaboration as high or very high

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Housestaff rate

RNs

RNs rate

Housestaff

Teaching Service Hospitalist Service

O'Leary KJ et al. Qual Saf Healthcare. 2010.

FEINBERG 15W

EMERGENCY

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• Unit Based Co-leadership

– Nurse manager and unit medical director

– Co-leadership training

• Structured Inter-Disciplinary Rounds (SIDR)

– Designed by frontline professionals

– Uses a structured communication tool

– Nurse manager & medical director co-facilitate

– All RNs, physicians, pharmacists, social work, and case management attend

INTERACT Intervention:

Unit Based Co-leadership and SIDR

INTERACT Results

• Significant improvements in collaboration & teamwork

• Significant reduction in rate of adverse events

O’Leary KJ et al. J Hosp Med. 2010. O’Leary KJ et al. Arch Intern Med. 2011.

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Physicians rateRNs

RNs ratePhysicians

90

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Physicians rateRNs

RNs ratePhysicians

Control Units Intervention Units

Graphs show % rating collaboration as high or very high

Develop Quality Improvement

Leaders

Professional Development

Opportunities in QI

• Internal programs

• Certificate programs

– Intermountain Healthcare ATP, IHI, NAHQ

• Masters programs

– Northwestern, Thomas Jefferson University

Hospitals should invest in professional development

Hospitalists and Hospital QI: You

complete me

You had me at hello!

WEBINAR

TODAY’S PANELISTS


During today’s discussion, feel free to submit questions at any time by using the questions box

Dr. Kevin O’Leary Chief of the Division of



Dr. Vercin Ephrem Chief of Hospital

Medicine LRGHealthcare

Maureen McKinney Editorial Programs



Expect a follow-up email within two weeks with links to presentation materials and information about how to offer feedback.

For more information about upcoming webinars, please visit ModernHealthcare.com/webinars

WEBINAR THANK YOU FOR ATTENDINGHow hospitalists can lead on qualityThanks also to our panelists:

Dr. Kevin O’Leary Chief of the Division of Hospital Medicine Northwestern University Feinberg School of Medicine

Dr. Vercin Ephrem Chief of Hospital Medicine LRGHealthcare

Maureen McKinney Editorial Programs Manager Modern Healthcare
