How Hospitalists Can Lead on Quality

1. 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:

2. WEBINAR HOUSEKEEPING

3. WEBINAR NOW SPEAKING How hospitalists can lead on quality Please use the questions box on your webinar dashboard to submit questions to our moderator Maureen McKinney Editorial Programs Manager Modern Healthcare

4. WEBINAR NOW SPEAKING How hospitalists can lead on quality Please use the questions box on your webinar dashboard to submit questions to our moderator Dr. Robert Wachter Chief of the Division of Hospital Medicine UCSF Medical Center

5. Wachter RM, Goldman L. NEJM 1996

6. An SAT Question Is to The… As Is to …

7. Hospitalist Growth, 1996-present Society of Hospital Medicine 29% of US hospitals 61% of US hospitals Fastest Growing MD Specialty in US History

8. Why We’re Being Pressured to Change

9. “The Challenge That Will Dominate Your Career…”

10. 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

11. 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

12. 50-60% comes from the hospital

13. 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

14. 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

15. 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

16. Hospitalists as System Leaders

17. 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

18. Could this be worse?

19. “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

20. WEBINAR NOW SPEAKING How hospitalists can lead on quality Please use the questions box on your webinar dashboard to submit questions to our moderator Dr. Vercin Ephrem Chief of Hospital Medicine LRGHealthcare

21. 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

22. 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

23. Challenges to Hospitalists in Community Hospital Leading Quality • Financial Support • Staff Support • Few Resources

24. • 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

25. • 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

26. Transitioning Patients from ED to Bed Admit Decision to Floor

27. •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

28. • 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

29. 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

30. 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

31. 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 LRGH LRGH

32. LRGHealthcare

33. WEBINAR NOW SPEAKING How hospitalists can lead on quality Please use the questions box on your webinar dashboard to submit questions to our moderator Dr. Kevin O’Leary Chief of the Division of Hospital Medicine Northwestern University Feinberg School of Medicine

34. How Hospitalists can Lead Quality Kevin O’Leary MD, MS Northwestern Medicine

35. Recognize trends that affect both hospitals and hospital medicine

36. 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

37. Source: New York Times

38. 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)

39. Create innovative partnerships between hospitalists and hospital

40. Collaboration Between Nurses & Physicians on Medical Services 70 42 0 10 20 30 40 50 60 70 80 90 100 Hospitalists rate RNs RNs rate Hospitalists Graphs show % rating collaboration as high or very high 72 35 0 10 20 30 40 50 60 70 80 90 100 Housestaff rate RNs RNs rate Housestaff Teaching Service Hospitalist Service O'Leary KJ et al. Qual Saf Healthcare. 2010.

41. FEINBERG 15W EMERGENCY FEINBERG 16W FEINBERG 14W FEINBERG 13W FEINBERG 16E FEINBERG 14E FEINBERG 13E FEINBERG 10E FEINBERG WEST FEINBERG EAST FEINBERG 15E

42. EMERGENCY FEINBERG 16E FEINBERG 15E FEINBERG 14E FEINBERG 13E FEINBERG 10E FEINBERG WEST FEINBERG EAST FEINBERG 16W FEINBERG 15W FEINBERG 14W FEINBERG 13W

43. • 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

44. 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. 89 46 0 10 20 30 40 50 60 70 80 90 100 Physicians rate RNs RNs rate Physicians 90 76 0 10 20 30 40 50 60 70 80 90 100 Physicians rate RNs RNs rate Physicians Control Units Intervention Units Graphs show % rating collaboration as high or very high

45. Develop Quality Improvement Leaders

46. 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

47. Hospitalists and Hospital QI: You complete me You had me at hello!

48. WEBINAR TODAY’S PANELISTS How hospitalists can lead on quality 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 Hospital Medicine Northwestern University Feinberg School of Medicine Dr. Vercin Ephrem Chief of Hospital Medicine LRGHealthcare Maureen McKinney Editorial Programs Manager Modern Healthcare Dr. Robert Wachter Chief of the Division of Hospital Medicine UCSF Medical Center

49. 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 ATTENDING How hospitalists can lead on quality Thanks 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 Dr. Robert Wachter Chief of the Division of Hospital Medicine UCSF Medical Center