Welcome to our third annual Top Hospitalists issue. Our requests for nominations—sent out last spring and summer—asked for hospitalists who are making notable contributions to the field, whether through clinical skills, innovation, community involvement, improved work flow, patient safety, research, teamwork, leadership, mentorship or quality improvement. Readers enthusiastically responded to the charge: This year we had the largest number of nominations yet. We heard from supervisors and peers, administrators and mentors. The breadth and depth of candidates spoke to the impressive work being done in U.S. hospital medicine, making the decision to pick only 10 far from easy.
ACP Hospitalist's editorial board members reviewed the nominations and selected the Top Hospitalists, who are profiled on the following pages. These physicians are innovators and teachers, mentors and researchers, leaders and hospital medicine pioneers. Some have distinguished themselves by helping younger physicians get ahead, while others are making great strides in patient safety and care transitions. All have contributed enormously to the field of hospital medicine. We're excited to recognize the work of these extraordinary individuals. We hope you enjoy reading about them—and we look forward to receiving your nominations for next year's honorees.
(ACP Hospitalist's Top Hospitalist feature is not considered part of the ACP National Awards Program.)
Successful office practice opens door to second career as hospitalist
Thomas M. Braithwaite, FACP
Medical school: University of South Dakota School of Medicine, Sioux Falls, S.D.
Residency: University of Iowa, Iowa City
Current titles: Associate professor of medicine, Sanford School of Medicine, University of South Dakota (USD), and medical director, Sanford Clinic Hospitalists, Sanford USD Medical Center, Sioux Falls
If hospital medicine had been a career option in 1985, Thomas M. Braithwaite, FACP, would have signed up right out of residency. As it turned out, he's confident he's had the best of both worlds—18 years of private practice followed by a chance to build a hospitalist program from the ground up.
“I loved general medicine; I didn't leave because I was burned out or frustrated,” said Dr. Braithwaite, who left his Sioux Falls internal medicine practice in 2003 to help develop and run a hospitalist program at Sanford USD Medical Center with then-colleague Robert Houser, ACP Member. “I was just very excited and intrigued by the hospital environment. I loved the acuity and working with patients and families in crisis. That's my fuel.”
Under Dr. Braithwaite's leadership, Sanford's program has grown to 12 hospitalists with plans to expand to 16 by the end of this year. While working a full clinical schedule, Dr. Braithwaite created compensation and incentive programs, modified work schedules and established the hospitalist program as the primary teaching service for USD.
“He worked tirelessly to develop the foundations of the program as it currently exists,” said Ken Aspaas, ACP Member and Sanford's chief medical officer, who recruited Dr. Braithwaite to start the hospitalist program. The two were once partners in the same private practice.
One of his first priorities as medical director was to “cement the group's value to the hospital and the region,” said Dr. Braithwaite. That meant integrating hospitalists into the strategic structure of the hospital and establishing a leadership role in quality efforts and protocol development.
Dr. Braithwaite now chairs the hospital's clinical practice committee, a multidisciplinary group whose past initiatives include developing an inpatient anticoagulation service to standardize practice across the hospital.
“We now have written, set protocols so that patients are treated in the same way,” said Dr. Braithwaite. “By having one team managing the majority of anticoagulation, we are beginning to reduce complications.”
At the same time that Dr. Braithwaite was working overtime to build a sustainable program, he faced even tougher challenges in his personal life. Seven years ago, he was diagnosed with non-Hodgkin's lymphoma. Chemotherapy pushed the disease into remission for five years but he's since relapsed twice and last summer underwent a stem-cell transplant, forcing him to step down as director and take a medical leave of absence.
Years of dealing with a serious illness changes the way you practice medicine, even if you have always been a caring physician, he said. He's become sensitized, in particular, to “the difficult and excruciating nature of waiting” and to the pain and discomfort caused by many common tests and procedures.
“When you've gone through countless bone marrows and CAT scans and biopsies and procedures you understand, because you've laid there on that cold table, you've had to sit there for hours with your arms above your head in an uncomfortable position, you've had your backside plunged with a needle to have a bone marrow or a spinal tap done,” he explained. “All these things that I've ordered countless times, I've been through to some extent.”
Working at the hospital has been difficult or impossible at times when his disease flares up, but it is also one of the things that keep him going.
“Having something you feel called to do in front of you is a powerful force,” said Dr. Braithwaite. “It's one thing that lets me look ahead when what I'm going through at present is a little dreary and difficult.”
Changing behaviors with evidence and information
Damanjeet K. Chaubey, FACP
Medical school: Lady Harding Medical College, Delhi, India
Residency: Danbury Hospital, Danbury, Conn.
Current title: Chief of hospital medicine, Danbury Hospital
Damanjeet K. Chaubey, FACP, is a strong proponent of checklists, but takes issue with how they are often used to treat common conditions like pneumonia, stroke or chronic heart failure. Doctors tend to want to just check all of the boxes, even when it's not necessary, she said.
“Care plan pathways and order sets are not mandatory tests, but are what a patient with pneumonia, for example, might need,” said Dr. Chaubey, chief of hospital medicine at Danbury, a 371-bed regional facility and teaching hospital affiliated with medical schools at Yale University, the University of Connecticut and the University of Vermont. “What often happens is you check all the boxes without looking at what really needs to be done or what a patient really needs.”
Dr. Chaubey teaches her staff of 23 hospitalists to resist that kind of thinking in order to prevent unnecessary testing and keep costs in check. Along with the hospital's chief medical officer, she was a key member of a Diagnosis-Related Groups (DRGs) cost-efficiency council to delve into what drives the cost of care. By comparing evidence-based recommendations with what was actually ordered for individual patients, the council determined that physicians often order tests reflexively.
“We found that the physicians, including the house staff, were ordering unnecessary testing or blood work,” said Dr. Chaubey. “If they wanted to know what a patient's potassium was, for example, they would recheck it even if it was normal the day before. We're subjecting patients to things they don't need.”
Better communication and collaboration supported by easily accessible information are key to changing that mindset, said Dr. Chaubey, who is known among colleagues for her ability to build consensus on quality and safety measures.
“We need to train our physicians to think more judiciously and review data, which may be available but scattered around. You have to strengthen systems and make information available to help doctors in their decision making,” she said.
Dr. Chaubey worked with the hospital's information technology department to help develop a regional health information exchange that links primary care physicians, specialists and hospitalists across the community. Its aim is to strengthen information exchange during transitions of care.
“If I admit a patient, I can view which prior as well as outpatient testing has been done,” she explained. “If this patient just had an echocardiogram or CAT scan, even if it wasn't at our hospital, that information will help in reducing unnecessary testing.”
To reduce other physicians' unnecessary use of tests, Dr. Chaubey and her colleagues collected historic data, research evidence and input from specialists. They then solicited feedback from frontline physicians on their prescribing and ordering patterns and provided them with corresponding data on whether or not their decisions were supported by evidence.
“When we provided data and showed them a reason for doing or not doing something, they started to question the relevance of the status quo and became receptive to new ideas,” said Dr. Chaubey.
Still, change happens gradually, she conceded. Some physicians resist taking the extra time to think through whether a test is really needed, but most eventually come around, she said: “If you understand the rationale, it will eventually become your normal process.”
Dr. Chaubey's quality and safety projects are numerous and varied. Recent initiatives include developing treatment protocols for the hospital's observation unit, which sees about 2,300 patients per year, and developing a new model of work rounds where hospitalists lead interdisciplinary teams of residents, interns, medical students, nurses and case managers in using safety checklists. She also implemented a model for night coverage involving collaboration among hospitalists, physician assistants and house staff, and leads the team providing palliative care services at her hospital.
“I am involved in many safety and quality improvement measures in the hospital,” she said. “How to deliver high-quality care in a safe environment in a cost-efficient way is truly what hospital medicine is about.”
Instilling appreciation for art of the physical exam
Jasminka M. Criley, FACP
Medical school: University of Rijeka, Croatia
Residency: Vanderbilt University, Nashville, Tenn.
Current titles: Associate residency program director for internal medicine residents and director of inpatient services for graduate medical education, St. Mary's Medical Center, Long Beach, Calif., and associate clinical professor of medicine, University of California Los Angeles School of Medicine
Jasminka M. Criley, FACP, was nearing the end of a busy shift when a 52-year-old man was admitted to the emergency department after being treated for five days at another hospital for asthma exacerbation. Further examination revealed that the patient had acute aortic regurgitation, but doctors had missed the signs early on—apparently because no one had performed a careful bedside exam.
Dr. Criley came to a correct diagnosis by questioning the patient, who admitted that he had felt chest pain. Removing his shirt to perform a chest exam, he revealed a midline chest scar and a diastolic murmur. What had started as a routine asthma case turned into a much more serious dissecting aortic aneurysm requiring immediate surgery—but too late to save the patient's life.
“Once you see something like that you never forget it,” said Dr. Criley, who was a young hospitalist at St. Thomas Hospital in Nashville at the time. “It captured for me why I am interested in clinical skills teaching and particularly the cardiac exam.”
Years later, Dr. Criley often tells the story during rounds with medical students and residents at St. Mary's Medical Center as a cautionary tale about taking shortcuts, like failing to remove a patient's shirt for a chest exam. She is a strong advocate of bedside rounds and using virtual patients as tools in teaching students how to identify and interpret clinical bedside findings.
Students who witness an unusual case during bedside rounds are much more likely to remember it than if they had read about it in a book, she said.
A recent teaching session was a case in point. Dr. Criley asked a group of residents to find a patient's point of maximal impulse. Two teams of students and residents pointed to the area where the heart should be on the left side of the chest but were surprised when they were told to examine the prominent pulsation on the patient's right side. It turned out that the patient had advanced lung disease causing right ventricular hypertrophy, an enlarged right heart, and right parasternal and subxiphoid heave.
“Often in medicine we think something should be there so we assume it is,” said Dr. Criley. “Showing this case at the bedside was extremely useful. A thousand words could not explain what it was teaching, and it will stay with those trainees forever.”
Students in Dr. Criley's cardiac examination course also learn that a careful exam sometimes eliminates the need for additional—and costly—tests.
“For a heart exam there are two forks: Figure out if it is benign and doesn't require further testing, or detect and direct the patient on the right road to being diagnosed,” she said. “If you spend a little more time, you may not need that chest X-ray or echocardiogram.”
Dr. Criley has been involved in many quality improvement projects, including efforts to decrease falls, improve medication reconciliation at discharge, and facilitate handoff communication. She also serves on the hospital's patient safety and utilization committees and helped evaluate and implement a more evidence-based process for ordering brain natriuretic peptide tests.
The best part of her job, however, is the opportunity to teach and mentor students and residents, she said.
“Mentoring is listening and learning what a person's goals are and pulling in resources to help them where they want to go,” said Dr. Criley. “It's a lot like patient care—listening and finding out what's important to the patient helps you craft a better plan of care.”
Teacher's best reward is seeing students succeed
Jeanne M. Farnan, ACP Member
Medical school: University of Chicago
Residency: University of Chicago
Current title: Assistant professor of medicine and course director for clinical skills and transitions to internship, Pritzker School of Medicine, University of Chicago
Jeanne M. Farnan, ACP Member, feels a surge of pride whenever one of her first-year medical students interviews a patient for the first time or delivers his or her first research presentation. For a clinician-educator like Dr. Farnan, student achievements are tangible proof of a job well done.
“As physicians, the one thing we don't have is a product,” said Dr. Farnan, a hospitalist at the University of Chicago (UC) Medical Center. “What is so wonderful about teaching and mentoring is being able to work with someone over the course of time and watch them grow and change and accomplish things.”
Since joining the faculty at the University of Chicago's Pritzker School of Medicine in 2006, Dr. Farnan has established a reputation as a valued teacher and mentor for students and residents. One recent student review described her as “one of the best attendings I have worked with on general medicine ... she provided me with the autonomy to make my own decisions while being quietly available at any time if needed.”
“I've always had an interest in education,” said Dr. Farnan, who started at UC as an undergraduate. While drawn to inpatient care during residency, she wanted to develop a niche in education so enrolled in a two-year hospitalist scholars program in order to combine a fellowship in hospital medicine with a master's degree in health profession education.
She is now course director for the clinical skills curriculum, which is required coursework for first- and second-year medical students on doctor-patient communication and physical examination skills, and the fourth-year transitions to internship curriculum. She co-directs two fourth-year electives: case studies in cross-cover, and the sub-internship clinical case conference. She is also a clinical preceptor for second- and third-year medical students and supervises residents and students on the general medicine ward, among other roles.
In addition, Dr. Farnan is a member of an accomplished research group, collaborating with other faculty at UC including Vineet Arora, FACP, and Holly Humphrey, MACP, in the areas of handoffs and clinical supervision. Their research on resident supervision is the basis for a training workshop for attending physicians on how to be more effective supervisors, which was presented at the 2010 Society of Hospital Medicine and Accreditation Council of Graduate Medical Education annual meetings. They have also created and implemented an innovative curriculum on handoff education and designed a handoff simulation for fourth-year students in preparation for residency.
Dr. Farnan and her team implemented the study “Handoff education and evaluation: piloting the observed simulated handoff experience (OSHE),” published in the February 2010 Journal of General Internal Medicine. She and her team are now helping the University of Michigan and other institutions implement OSHE at their hospitals.
More recently, Dr. Farnan has been investigating how digital media will affect professionalism in the digital age. Her interest was sparked after a medical student posted a music video parody on a website that included the UC and medical school logos, which brought complaints from some alumni and students.
“We made it into an educational project where we tried to assess beliefs that students had about professional responsibility regarding their behavior on the Web,” said Dr. Farnan. As a result of that research, discussion of projecting a digital image is now included as part of the first-year curriculum on professionalism. Dr. Farnan is now working on a qualitative study on patient-physician interactions via social media.
Education will always be a common thread running through her research and clinical activities, she said, but working directly with students is her passion.
“Having house staff and medical students around to reinvigorate the entire enterprise here keeps us constantly moving, constantly thinking and reevaluating,” she said. “It staves off the complacency one could get if you were just singly focused on your own career.”
Teaching residents to count costs
V. Susan George, FACP
Medical school: National University of Singapore
Residency: Saint Vincent Hospital, Worcester, Mass.
Current titles: Director of the hospitalist service, Saint Vincent Hospital; assistant professor of medicine and associate program director of the internal medicine residency program, University of Massachusetts Medical School, Worcester
How do you liven up a potentially dry resident seminar on cost-effectiveness? V. Susan George, FACP, hit upon a strategy that plays into doctors' competitive natures: Make it a contest.
Several times a year, Dr. George moderates a match between teams of residents during morning report at Saint Vincent, a 350-bed community-based teaching hospital. Knowing that residents often order laboratory and radiological tests without an idea of actual cost incurred, she asks the teams to list the tests they would order for a hypothetical patient and add up the costs. The winning team is the one that has the lowest tab, while still ordering the necessary tests to correctly diagnose and manage the patient safely.
“It teaches them that every test they order and everything they do for the patient must be justified by evidence-based medicine,” said Dr. George. “There should be no reflexive ordering of labs or radiological studies.”
The contest is one of the ways that Dr. George combines her interest in quality improvement and patient safety with her love of teaching. She also conducts monthly patient safety rounds during which she reviews the circumstances surrounding mortality, morbidity or near misses that occurred on the medical service in preceding months.
“I ask them to think about what we did wrong—was it a failure of barrier systems to prevent error, or was it a skill-based or knowledge-based error?” she said. One incident, for example, involved an intern who hesitated to consult the on-call cardiologist on an abnormal electrocardiogram. The incident led to the hospital installing an electronic EKG system that all cardiologists can access from home to confirm whether or not a test is normal.
“Residents often bring up problems with processes that we might not be aware of,” she noted. “It helps us to create a safer environment for our patients, and the residents feel like valued members of the team. I always make sure that when we go back over [the incident] the next month, I close the loop by updating them on what we did to correct the problem.”
As testament to her teaching skills, the hospital's 75 residents last year selected Dr. George for the John J. McKeever Award, recognizing her as the outstanding medical educator of the year.
“Her evaluation database is populated with enviable comments from students and residents, who perennially rank her in the top 5% of the faculty here,” said Anthony L. Esposito, FACP, chief of Saint Vincent's department of medicine and the colleague who nominated Dr. George as a top hospitalist. “Not only is her fund of knowledge and clinical acumen stellar, but she relays information and patient care expertise in a thoughtful, humble and engaging manner.”
Soon after joining Saint Vincent Hospital in 2007, Dr. George was asked to help set up a hospitalist program. Under her watch, the program has expanded from two to 10 full-time hospitalists, increased the average number of daily encounters from 20 to 60 patients, and decreased length of stay by 50%. With those results, it's not surprising that she was named 2009 Physician of the Year by the hospital's senior administration and 600-physician medical staff.
As chair of the hospital's Department of Medicine Performance Improvement Committee, Dr. George was instrumental in the hospital achieving nearly 100% compliance on all Joint Commission core measures and implementing standardized anticoagulation, pain control and stroke management programs.
Dr. George has also successfully engaged community physicians and convinced many to sign on with the hospitalist group, in part by emphasizing the importance of communication and customer service.
“I hold my group responsible for holding up our end of the communication,” she explained. When a patient is admitted, his or her primary care physician receives a fax alert along with contact information for the attending hospitalist. The attending then follows up to keep the physician informed of the patient's progress, especially at the time of discharge. The primary care physician receives the discharge summary and discharge instructions in real time.
“Once a primary care physician has an unpleasant experience, as in not being involved or informed of their patient's care, they would hesitate to use our service,” said Dr. George. “I have to keep reminding my team that we need to provide excellent customer relations and deliver outstanding patient care to stay ahead of the game.”
Discharge initiatives shorten LOS, improve transitions
Allen L. Johnson, ACP Member
Medical school: University of Wisconsin Medical School, Madison, Wis.
Residency: Virginia Mason Medical Center, Seattle
Current title: Physician director, PeaceHealth St. Joseph Medical Center, Bellingham, Wash.
Reducing the average length of stay seemed like an intractable problem when Allen L. Johnson, ACP Member, assumed leadership of St. Joseph's hospitalist program about a year ago. Then Dr. Johnson had a breakthrough: What if you could lower the overall average by focusing on the small percentage of patients at the top end of the curve?
“The bulk of our curve is people staying from one to seven days and that isn't going to change much,” said Dr. Johnson, who leads a team of 14 full-time-equivalent hospitalists at St. Joseph, a community hospital that is part of the PeaceHealth System with facilities in Alaska, Washington and Oregon. “What became evident is that there are outliers who are here for 20-30 days” who are driving up the average, he said.
Dr. Johnson approached the problem by creating a multidisciplinary discharge group that brought clinicians together with social workers, administrators, ethicists and psychiatrists. The group collaborates on how to handle logistically difficult patients, and patients whose behaviors may lead to difficulties with ongoing care and discharge plans.
One group idea was to craft standard policies for managing patients' behavioral issues that could make their conditions worse and prolong their stays. For example, the group developed a protocol on what to do when an intravenous drug user on IV antibiotics for endocarditis tries to leave the hospital or sabatoges his or her care while in the hospital.
“We've tried to set boundaries that are fair and consistent to try to change that behavior instead of having a doctor come up with different rules every day,” said Dr. Johnson.
The group also solves problems with difficult discharge scenarios. In one case, they enlisted a senior administrator to use a higher level of communication to expedite an interstate transfer to another facility.
So far, the group seems to be having an impact. St. Joseph's average LOS has dropped from 4.5 to just under 4 days since the program began.
Dr. Johnson has also introduced a standardized discharge summary to improve the transition from hospital to primary care. The template includes a checklist of 20 elements that were vetted by hospitalists and primary care physicians in a pilot project at St. Joseph's.
“I met with primary care physicians to see what they were looking for and tried to develop a template in response to what they needed at time of discharge,” said Dr. Johnson, who worked on the project with PeaceHealth hospitalists in Oregon as part of a four-month PeaceHealth leadership training program. In a post-pilot survey, 64% of primary care physicians said they preferred the new format while 100% of participating hospitalists said it improved patient care.
Dr. Johnson, who spent 10 years as an emergency physician before becoming a hospitalist, is now working with the trauma surgery department on creating a medical trauma team to stratify trauma patients based on specific criteria. The goal is to identify and redirect patients to the medical service who are at low risk for needing surgery, in order to take pressure off the trauma team.
Like many of his projects, the trauma initiative brings together different departments and specialties with a common goal of improving efficiency. Often, said Dr. Johnson, just getting people to communicate is the key to improving care.
“It all feeds into the idea of co-management” and transitions of care, said Dr. Johnson. “A lot of times in medicine, it's the simple things that need to happen, not the complicated or esoteric.”
Blood management, preop innovations bring national recognition
Ajay Kumar, FACP
Medical school: Bangalore Medical College, India
Residency: St. Vincent's Charity Hospital, Cleveland
Current titles: Assistant professor of medicine and medical director of the Internal Medicine Preoperative Assessment, Consult and Treatment (IMPACT) Center and blood management, department of hospital medicine, Quality and Patient Safety Institute, Cleveland Clinic
Several years ago, Ajay Kumar, FACP, and his colleagues on Cleveland Clinic's blood utilization committee were faced with the challenge of how to reduce blood use without sacrificing the quality of patient care. Their solution may have seemed obvious in the business world but was fairly radical for medicine: Make doctors accountable and establish reasonable parameters for blood use.
“With the support of leadership, our team came up with a policy that all blood needs to be given with authorization, with staff names attached at the time of order entry,” said Dr. Kumar, who joined the clinic as a hospitalist in 2004. By tracking and analyzing orders, raising awareness and creating a patient-centered blood management program, the Cleveland Clinic was able to reduce overall blood use by 10% in 2007-08, and has made steady progress since.
“Our case load has gone up but not our blood use,” said Dr. Kumar. A key to the project's success was assessing why doctors were ordering blood products and whether the order was justified by the patient's hemoglobin level. That analysis allowed the organization to develop a comprehensive, data-driven program that helped change the culture for the institution's 2,000 physicians, 900 residents and several hundred mid-level providers.
The project is just one of the innovations Dr. Kumar has led or participated in at Cleveland Clinic over the past five years. He also oversees the clinic's Internal Medicine Preoperative Assessment, Consult and Treatment (IMPACT) Center, where he has streamlined documentation, improved patient flow and worked to improve a clinical triaging algorithm.
The IMPACT Center, staffed by 5.5 full-time hospitalists, two nurses and administrative staff, was designed to help prevent postsurgical complications by evaluating patients undergoing noncardiac surgery to assess risks and make evidence-based recommendations to the surgical team. Nearly 17,000 patients were seen at the clinic last year, said Dr. Kumar.
Dr. Kumar oversees a systematic approach to the preoperative evaluation process based on algorithms. Patients recommended for surgery are scheduled for the IMPACT Center and, if needed according to algorithms, lab and imaging tests. The center provides a patient-centered approach to preoperative evaluation.
The system has not only lowered the risk of postsurgical complications but also reduced surgical delays and cancellations, said Dr. Kumar. The IMPACT Center's administrative staff tracks the progress of each patient and alerts physicians if any test results are missing so that problems can be resolved before the day of surgery.
Dr. Kumar has continued to improve the IMPACT Center's processes by, for example, creating task forces in specific areas such as preoperative testing and preoperative management of anemia. “I want the IMPACT Center to be known as one of the best preop centers in the country,” he said.
He also co-led a team to create and implement a secure, flexible sign-out system at Cleveland Clinic. The system, which was presented as a best practice at the 2010 Joint Commission Annual Conference on Quality and Patient Safety, provides a standardized platform to pass patients' relevant information at shift changes.
Dr. Kumar's vision is to establish an integrated patient-centered blood management program throughout Cleveland Clinic's health system (it is now in two of the eight hospitals), and put the issue on the national health care agenda. To that end, he directed a national Blood Management Summit at Cleveland Clinic in 2008, and is directing another summit in November to spread the word to other institutions.
“I like to bring people together from different areas to talk about a common objective,” said Dr. Kumar. “If you are able to convince people of the reasons for change, you can get them on board.”
Insulin program boosts glycemic control and hospital prestige
Kendall M. Rogers, FACP
Medical school: University of New Mexico (UNM) School of Medicine, Albuquerque
Residency: UNM Hospital
Current titles: Chief of hospital medicine, UNM Hospital, and associate professor, UNM School of Medicine
Three years ago, Kendall M. Rogers, FACP, went into a meeting planning to approve a new insulin order set and came out an hour later in charge of a hospital-wide glycemic control initiative. While he says he may have been a “reluctant leader” at first, Dr. Rogers built the program into one of the hospital's most successful quality improvement efforts.
“We've taken a hospital that was in the lowest quartile in terms of national standards and made it into a top-performing hospital in glycemic control,” said Dr. Rogers, who has grown the hospital medicine division from four to 17 hospitalists since becoming chief in 2007. Recently, UNM was rated in the top 10 for glycemic control among 575 hospitals, according to the 2009 RALS report, which collects and tracks hospital blood glucose data.
As with most of Dr. Rogers' projects, the success of the glycemic control program hinged on teamwork. Multi-disciplinary teams—composed of pharmacists, diabetic educators, physicians and nurses—met regularly to go over data and develop protocols while a glycemic control “SWAT team” spent one hour a week identifying patients who were out of control and investigating what went wrong.
The results are impressive: In two years, the hospital cut its severe hyperglycemia rate by 36% and the hypoglycemia rate by 55%. Dr. Rogers now serves as a mentor to 10 other hospitals through the Society of Hospital Medicine's Glycemic Control Mentored Implementation Program and he's leading an effort to enroll 100 additional hospitals.
“Everything we try to do around hospital medicine is creating a team-based approach to care,” said Dr. Rogers. Besides glycemic control, he has created multidisciplinary teams around nurse-physician communication, VTE prophylaxis, transitions of care, and creation of many clinical order sets.
The nurse-physician communication initiative brought together nurses, pharmacists, midlevels and hospitalists to develop guidelines for effective communication, such as providing nurses with cell phones and developing algorithms for how nurses should escalate calls to contact attendings. One of the most successful aspects of the project was implementing electronic physician documentation to improve communication among the entire clinical team, said Dr. Rogers.
“If you look at most hospitals, the primary communication method for doctors and nurses is through orders, but orders have no context,” he explained. “They don't tell a nurse what the physician is thinking or what they are trying to prevent through that order.”
The new system makes electronic handoff sheets accessible to physicians, nurses and case managers so that everyone uses the same record and can make appropriate changes or notes. Standardized templates for the handoff sheet and progress notes include information such as code and nutrition status, VTE prophylaxis and plans for discharge.
“If a nurse sees that a patient's discharge destination is home and she knows that the patient hasn't been out of bed for three days, she is prompted to let physicians know that home may not be a realistic destination,” Dr. Rogers said. “That's really helped us with the discharge-planning process.”
Dr. Rogers also leads a one-month elective for internal medicine residents focused on leadership, health policy, quality improvement and information technology. Now in its sixth year, the course is so popular that the university plans to extend the content to all residents. As co-chair of the Medical Education Task Force for the American College of Physician Executives, Dr. Rogers is also working to incorporate these topics into medical school and residency curriculums nationwide.
“I teach them all the things I didn't learn during my residency,” said Dr. Rogers. “Hospitalists, and all physicians, are naturally looked to as team leaders but they receive next-to-no training. We are creating a culture of leadership.”
Helping residents put QI into practice
Anjala Tess, ACP Member
Medical school: Washington University in St. Louis School of Medicine, St. Louis
Residency: Beth Israel Deaconess Medical Center, Boston
Current title: Associate director of internal medicine residency training program, Beth Israel Deaconess Medical Center
When surveys at Beth Israel Deaconess Medical Center found that patients felt shortchanged on face time with their doctors, Anjala Tess, ACP Member, and a team of residents decided to investigate with a time-motion study. Their conclusion: Residents could be much more engaged in patient care if they weren't spending so much time planning discharges.
“After a resident called out the problem, we asked a group of nurses to help us figure out how to offload some of that work from interns,” said Dr. Tess. The eventual result was a new program, spearheaded by Dr. Tess and administrator Sarah O’Neill, MBA, that has become a cornerstone of Beth Israel Deaconess' discharge process from the medical floors.
For the new discharge program, staff nurses contact a patient's primary care physician prior to discharge, make follow-up appointments, verify insurance, update medical records and ensure all clinicians get the necessary paperwork. The system not only has saved time for residents but improved accuracy because the nurses are familiar with referral networks and how to link patients with the correct physicians for follow-up.
“No one who uses the service can imagine what life was like before it existed,” said Melissa L.P. Mattison, ACP Member, a colleague who nominated Dr. Tess as a top hospitalist. “Now patients receive better care and inpatient physicians are using their valuable time to care for patients rather than make phone calls to schedule follow-up appointments.”
The new program encapsulates Dr. Tess' teaching philosophy: The best way to engage residents in quality improvement is to show them how it applies to their everyday practice.
“Residents tend to take on a passive role in terms of improving the system because they're so busy doing the clinical work and managing patients that they're not really thinking actively about the system around them,” said Dr. Tess. “We want to empower residents to speak up and participate in the change process.”
Dr. Tess helped design and now leads Beth Israel Deaconess' Stoneman Quality Improvement elective, a three-week course that teaches residents how to apply lean methods to increase efficiency and value, and allows them to participate in actual quality improvement projects at the hospital. Dr. Tess also co-leads a weeklong retreat with Dr. Julius Yang on quality improvement for residents and nurses.
“It's like a conversion experience,” said Dr. Tess of the retreat. “It fundamentally changes the way the residents think about the health care system and their role within it. At the end of the retreat and the elective we find that we get many more requests from residents to look at something differently.”
Dr. Tess also leads an elective course for residents that focuses on the business side of hospital medicine.
“I felt like residents didn't have a sense of the finances of medicine and the structure of a hospital,” she said. As a result, six years ago she put together a three-week elective that pulled together all of the business principles involved in running a successful hospitalist program.
The course is structured similarly to a business plan competition, with teams of residents competing to come up with the best proposal for either rescuing a struggling hospitalist program or building one from scratch. After doing fieldwork in community hospitals, the teams pitch their ideas to a faculty panel that chooses the winner based on the quality of the team's mission statements and financial and organizational plans.
“It's like a business case study but it really crystallizes for people why jobs are structured the way they are and why hospitals do things the way they do when they start programs,” she said. “It's all stuff that I learned on the fly.”
Clinical specialty paths attract ‘career hospitalists' to Henry Ford
Peter Y. Watson, FACP
Medical school: Wayne State University, Detroit
Residency: Henry Ford Hospital, Detroit
Current titles: Division head of the division of hospitalist medicine, Henry Ford Hospital, and assistant professor of internal medicine, Wayne State University School of Medicine
Hiring 35 hospitalists in less than five years is a major feat, but Peter Y. Watson, FACP, is gearing up for an even bigger challenge: keeping all those new recruits happy. For Dr. Watson, that means providing a path for career hospitalists to learn and grow without leaving the five-hospital Henry Ford Health System.
“I don't want to make the position about the schedule and just coming to work, but about a professionally fulfilling experience no matter how long they are with us,” said Dr. Watson, who has grown Henry Ford's hospitalist division from 14 to 49 hospitalists since becoming the group's leader almost five years ago. “We want to create a structure where they will continue to be challenged.”
To achieve those goals, Dr. Watson has expanded the division's clinical portfolio to create new opportunities for physicians while meeting the emerging needs of the hospital. For example, the division recently took over the advanced heart failure service, providing an opportunity for hospitalists to acquire skills in advanced heart failure and inpatient transplant management.
“It creates a whole new dimension in the group that provides a more interesting clinical experience for them,” he explained. Besides cardiology, hospitalists can choose to follow tracks in preoperative service, general inpatient medicine or inpatient geriatric care.
The system attracts physicians because of the opportunity to become experts in a particular area of practice, he said, and also establishes the hospitalist group as a diverse unit with a variety of skill sets and leadership opportunities.
“That has paid dividends for the hospital because we are able to support all of these services that either our Detroit campus or our regional campus hospitals require,” said Dr. Watson, who oversees the full-time hospitalist service at the main Detroit campus and three out of the other four area hospitals in the Henry Ford Health System.
Dr. Watson has also helped introduce collaborative rounds in several of the hospitals, a system of regular, structured collaborative communication among inpatient staff, including nurses, case managers, hospitalists, residents and other members of the care team. The idea is that teams that communicate and work collaboratively—as opposed to individuals working in parallel—will improve patient care and lead to better outcomes.
The collaborative model is in line with Dr. Watson's goal to foster a teaching environment where established hospitalists cultivate independent thinking skills in junior and senior residents in order to help them transition from intern to supervising resident to full-time staff member.
“Teaching critical thinking and how to manage patients independently is extremely important,” said Dr. Watson. “We've been working on how to teach that kind of understanding when we're rounding with residents.”
Dr. Watson plans to continue growing the hospitalist service according to the needs of the system. He may eventually have hospitalist services at all five Henry Ford hospitals with expanded staff at the Detroit and West Bloomfield campuses. Ultimately, he said, growth isn't just about numbers but developing a sustainable infrastructure for fulfilling the system's clinical, educational and research missions.
“We've made a remarkable transformation from a small group of highly skilled clinicians to a group that cares for patients at four different hospitals on a 24/7 basis,” he said. “That's given us even more opportunities to create an environment for staff to come here and have an identity.”