What makes someone a Top Hospitalist? The doctors recognized in ACP Hospitalist's first annual Top Hospitalists issue prove that there's no single answer to that question. Our honorees include teachers, quality improvement gurus, researchers and bloggers. They've focused on improving geriatric care, growing hospital admissions, facilitating transitions of care and raising staff satisfaction, among many other things.
Our requests for nominations—sent out last spring and summer—asked for hospitalists who are making notable contributions to the field, whether through cost savings, improved work flow, patient safety, leadership, mentorship or quality improvement. In response, hospitalists were nominated by supervisors and administrators, peers in their own programs, colleagues from across the country, even some primary care physicians.
ACP Hospitalist's editorial board members sifted through the nominations and narrowed the field down to 10 Top Hospitalists, who are profiled on the following pages. The judges worked to select a group of physicians who are not only highly successful, but also diverse in their interests and backgrounds, and whose work has not already been heavily publicized.
Because the board members were impressed by the many achievements of all of our nominees, we've also included an Honor Roll to recognize those physicians who were nominated but not selected. For them, and for everyone else, there will be another opportunity again next year, when we go looking for the 2009 Top Hospitalists.
(ACP Hospitalist's Top Hospitalist issue is not part of the ACP National Awards Program).
A passion for patients and the systems that serve them
Douglas J. Apple, ACP Member
Medical school: Saba University, Dutch West Indies, Caribbean
Residency: Michigan State University
Current position: Hospitalist, Spectrum Health, Grand Rapids, Mich.
It's no wonder that Douglas J. Apple, ACP Member, is considered a rising star at Spectrum Health's Butterworth Hospital in Grand Rapids. His innovative approaches to rounding and bedded observation management have led to lower costs, increased efficiency and happier patients—all in a few short months. Dr. Apple, who joined Spectrum's 23-physician hospitalist group after completing his residency in 2003, perceived that patients under observation were being treated as inpatients, largely because there was no system in place to flag their status and no dedicated unit. So, they tended to be scattered throughout the hospital according to space.
“We divided the unit into both inpatient and bedded observation status patients to meet the needs of the system,” said Dr. Apple, a partner in Michigan Medical PC, a multispecialty group that contracts with Spectrum. Helping staff identify these patients reduced delays and increased the number of discharges within the 48-hour window that Medicare typically covers for observation status.
At the same time, Dr. Apple initiated a “geographic rounding” pilot program, where each hospitalist was assigned to round on one unit for seven days at a time instead of visiting patients throughout the hospital every shift. The model not only made rounds more efficient but also strengthened physicians' relationships with nurses, case managers and social workers.
“This changed the culture of the RNs,” said Dr. Apple. “They felt empowered about their unit being recognized for a pilot like this, and they were proactive to work with the physicians to make it work.”
Having the same physician on duty all week also led to more face-to-face conversations with other staff about patient issues as they arose, Dr. Apple said. As a result, patients received better, more individualized care.
Since the geographic rounding and observation unit pilots began in June, patient satisfaction scores as measured by the health care consulting firm Press Ganey soared from the 6th to the 87th percentile in July and 99th percentile in August. At the same time, the average length of stay in the unit dropped by 1.6 days to an average of 2.8 days.
The project encapsulated what Dr. Apple finds satisfying about hospital medicine—the combination of patient care, administrative challenges and ongoing education. He has also been very involved in the hospital's residency program, where he is a “role model,” according to colleague Carole L. Montgomery, ACP Member, who nominated him as a Top Hospitalist.
“Residents consistently hold him up as the ‘ideal physician’ based not only on his fund of medical knowledge but also on his compassionate care of patients and their families,” she said. As for the future, Dr. Apple aspires to help effect change in the wider community by helping forge better relationships between community doctors and hospitals.
It's his passion for all aspects of hospital medicine—from patient care to system efficiencies—that makes Dr. Apple stand out, said Dr. Montgomery.
“He has a natural ability to help people understand different viewpoints and remain focused on the ultimate goal of providing more efficient cost-effective care for our patients,” she said. “Doug has the complete package.”
Fully staffed unit creates quality and business opportunities
Walter R. Bohnenblust, Jr., MD
Medical school: Temple University, Philadelphia
Residency: The Reading Hospital, Reading, Pa.
Current position: Director, Hospitalist Services, The Reading Hospital
Since Reading Hospital opened its hospitalist unit in 2002, Walter R. Bohnenblust, Jr., MD, has grown the staff from four to 27, positioning the hospital as a regional leader.
He was in the right position to do so, having begun his career at Reading in 1979 as an intern and staying on ever since. He split his time evenly between hospital care and an outpatient practice. The hospital's transition to hiring hospitalists was rocky, Dr. Bohnenblust recalled, so he took over the recruitment process. “We had a lot of physicians leave practicing inpatient medicine in a very short period of time,” Dr. Bohnenblust said. “It probably took us a good year and a half to two years to recruit and staff according to our volume.”
Now that the program is fully staffed, Dr. Bohnenblust is able to implement quality measures that ensure patient care in the hospital and smooth handoffs back to the community physicians. Community physicians have signed contracts with The Reading Hospital that ask each doctor to take phone calls directly from the hospitalists instead of diverting questions to office staff. In turn, hospitalists convey discharges directly back to the approximately 100 community physicians.
Hospitalists created stroke, cardiovascular and palliative care programs at the facility. Dr. Bohnenblust and the head of neurology collaborated on the hospital's certification process with The Joint Commission—the only certified program in their market. Dr. Bohnenblust worked with neurologists to create the cohorted Stroke Unit. The service put a “brain attack” protocol in place for the emergency room with rapid triage and assessment for tPA administration. This includes rapid diagnostics, physician evaluation and a formal inclusion/exclusion protocol that becomes a permanent part of the medical record. ED physicians and hospitalists run the protocol with the neurologist as consultant.
“That dramatically increased our market share of EMS patients brought to our stroke center,” he said. Likewise, Dr. Bohnenblust partnered with The Reading Hospital's cardiology department on a heart failure unit to handle its approximately 1,000 heart failure admissions and discharges a year. Palliative care is coordinated through one hospitalist who is board certified in palliative care and internal medicine and who works with other hospitalists trained in pain control and medical ethics.
Each of these programs is possible because The Reading Hospital has a fully-staffed unit, Dr. Bohnenblust said. “One of the things in the future would be for different physicians in the group to take over one program and therefore not only do patient care but also get some experience in setting up, running and doing programs. The larger we get, the more we see we're becoming the change and quality improvement people of the hospital. That's the true value of the hospitalist program: not just seeing patients but improving processes and procedures to improve the care throughout.”
With these successes in place, Dr. Bohnenblust sees a role for more of his hospitalists to create cohorted units for chronic obstructive pulmonary disease and pneumonia. He's recruiting five more hospitalists toward that goal.
“Eight years ago people worried that patients aren't going to accept the generic doctor of the day,” Dr. Bohnenblust said. “They have seen that patients do accept our service because we've done very well and put the patient first and do patientcentered care.”
A leader who looks on the bright side of hospital medicine
David P. Chen, ACP Member
Medical school: Loma Linda University, Loma Linda, Calif.
Residency: Kettering Medical Center, Kettering, Ohio
Current position: Medical director, MultiCare Inpatient Specialists, MultiCare Health System, Tacoma, Wash.
The three Top Hospitalist nominations submitted for David P. Chen, ACP Member, testify to the fact that there are a lot of happy hospitalists at MultiCare Health System in Tacoma, Wash. As medical director of the hospitalist program, Dr. Chen sees maintaining physician satisfaction as a critical part of his job. “I'm very much in tune to the frustrations the team may be experiencing. I try to address each problem. You can't ignore them and say, ‘That's just part of the job,’” he explained. His continuing involvement in direct patient care also helps him to appreciate the needs of his hospitalists. “I think it's extremely important that hospitalist directors also do clinical care because I'm out there on the front lines, experiencing the same thing that they do,” he said.
And when the hospital medicine program has a problem, he tackles it, working collaboratively with administration and other specialties to resolve the issue. “Dr. Chen has been an incredible advocate for our hospital-employed group in many areas, including scheduling, salary and self-determination,” wrote Mary O’Rourke, MD, in her nominating essay.
Advocating for the hospitalist group has also meant setting firm boundaries as to what kinds of patients the hospitalists should admit. “There's a push from specialists, as well as a lot of times the hospital, that we should be all things to all people,” Dr. Chen said. “That's not the way to sustain a program.” After assessing what works for his docs, he sits down with specialists to work out a division of responsibility that makes everyone comfortable.
Dr. Chen also encourages his hospitalists to cooperate and form relationships with other specialties by joining hospital committees. “The biggest thing is to get the docs to recognize we play a big part in the hospital,” he said. “We're the ones who are here all the time and it's important that we have input.” Not surprisingly, he takes a sunny approach to making that happen, as well. “I encourage them positively, rather than saying, ‘You have to go to this committee.’ I try to show them how they will benefit our program and the hospital in general.”
Dr. Chen brings an optimistic attitude to overall relations with his hospitalists, too, taking time in a busy hospital to make sure that his physicians know their work is appreciated and important. “A lot of times people hear when they're not doing a good job, but they don't really hear when they are doing a good job. I try to give positive feedback when it's due.”
He attributes his program's low turnover (3% over six years) and high morale to that positive approach. “There's always two ways to present something to somebody and I try to always put a positive spin on it rather than a negative one.”
Creativity as key to success
Joseph Li, ACP Member
Medical school: University of Oklahoma College of Medicine, Oklahoma City, Okla.
Residency: New England Deaconess Hospital, Boston
Current position: Director of Hospital Medicine, Beth Israel Deaconess Medical Center, Boston
As the first hospitalist at one of the most respected teaching hospitals in the nation, Joseph Li, ACP Member, was a trailblazer from the start of his career.
That trail has only gotten brighter in the ensuing decade, as Dr. Li constantly strives to implement innovative procedures that improve the hospitalist program at Beth Israel Deaconess Medical Center (BIDMC), where he is now director of hospital medicine and associate chief of the division of general medicine and primary care.
“Dr. Li has an unusual creative spark,” wrote Russell S. Phillips, MD, chief of the division of general medicine and primary care at BIDMC, who nominated Dr. Li as a Top Hospitalist. “No program could have been more fortunate in its choice of a pioneer.”
Indeed, creativity was needed, as Dr. Li had few models to turn to for guidance when he began his hospitalist career in 1998. Seeking colleagues, he became a charter member of the National Association of Inpatient Physicians that year (the precursor to the Society of Hospital Medicine), and co-founded the Boston Area Hospitalist Group in 1999 (now the SHM Boston Chapter), groups in which he remains active. From the get-go, Dr. Li recognized the need for a strong link between hospitalists and primary care doctors.
“I knew that when a patient came in, it was important to communicate with the primary care doctor to get the past medical history, the medications and so forth,” said Dr. Li. “At the same time, it was important to provide timely information to the primary care doctors at discharge about the patient's stay.”
Dr. Li wanted to find a way to swap this information without imposing a burden on either party involved. His solution was to work with colleague David Feinbloom, ACP Member, and the hospital's information technology department to create an application that gathered all of a patient's data from different sources—the doctor's discharge diagnoses, the nurse's follow-up plan, the pharmacy's medication notes—and combine them into a single letter. It was implemented in 2000.
“The letter basically tells the primary care doctor that his or her patient was admitted to and discharged from our hospital on such and such dates, what happened during the stay, and what happened at discharge,” Dr. Li said. “When I click a button, one copy drops into our electronic medical system, another gets faxed straight to the PCP's office, and a third is faxed to our administrative assistant, who sends it to the PCP so there is built-in redundancy in case the PCP doesn't receive the faxed copy.”
Another of Dr. Li's creative ideas was the “virtual pager.” As the hospitalist program began to grow and more doctors were hired, Dr. Li realized PCPs needed an easy way to reach a hospitalist if questions arose or a patient required hospital admission. “Once we started expanding, it was no longer efficient for that primary care doctor to try to figure out which hospitalist was on duty. We could post a schedule online, but that seemed inconvenient, and schedules can change,” Dr. Li said.
So Dr. Li designated a single pager number—”9-HOSP”—for PCPs to call whenever they have a question. Each hospitalist (there are now 33) takes a turn being responsible for that pager number for a week, such that all “9-HOSP” pages are automatically routed to his or her personal pager during that time.
“This way, if you are the primary care doctor, you don't have to remember anything but the pager number,” Dr. Li said. “You just page us, and we'll figure out what to do from there. We also created one single email address which distributed the PCP to all hospitalists.”
A third innovation of Dr. Li's is the medical procedure service— something only a handful of hospitals in the nation have. Started in 2002, the service ensures that every bedside medical procedure performed by medical students or housestaff is supervised by a hospitalist.
“When I was a student and then an intern, my supervisor for these procedures was either an intern or a senior resident. That was awkward because the person might have done the procedure only one more time than I had,” Dr. Li said. “It was like the blind leading the blind.”
The medical procedure service improves the teaching and patient experience, and is also more cost-effective. Since mistakes were more common under the old system, more procedure kits were wasted.
With the success of these innovations firmly established, Dr. Li has turned his eye toward his latest project: establishing a hospitalist pre-admission clinic. This will ensure patients have a proper medical work-up by a hospitalist and anesthesiologist before elective surgery, which should reduce the chances of a bad outcome.
“Bad things will still happen after surgery occasionally,” Dr. Li said. “But we want to know we are doing everything we can to keep those times to a minimum.”
Hospitalist-geriatrician aims to improve care for elderly
Melissa L. Mattison, ACP Member
Medical school: Tufts University
Residency/Fellowship: Beth Israel Deaconess Medical Center/ Harvard Division on Aging
Current position: Hospitalist, geriatrician, Beth Israel Deaconess Medical Center, Boston
Melissa L. Mattison, ACP Member, has seen it happen many times: a 90-year-old man with a hip fracture and a 30-year-old woman with broken ribs from a car crash are admitted and prescribed similar doses of pain medication. Both patients get relief from their pain but the elderly man becomes confused from the side effects of the medication and takes longer to recover from his accident.
“The problem is that older patients can get confused if they get too much morphine or narcotics and what may be an appropriate dose in a younger patient may be just a little too much in an older one,” said Dr. Mattison, a hospitalist and geriatrician at Beth Israel Deaconess Hospital in Boston since 2004. Hospitalists are good at taking care of inpatients, she said, but most are not formally trained to deal with the unique needs of the elderly.
Dr. Mattison, one of only two geriatricians in her 30-physician hospitalist group, is doing her part to change that. Last spring, she became co-director of Beth Israel's new Acute Geriatric Unit, mostly staffed by hospitalists, and she developed and implemented the curriculum for the hospital's Advancement of Geriatric Education (AGE) Scholarship program to disseminate geriatric medicine best practices throughout the hospital.
The scholarship program, supported by a four-year grant from the Donald W. Reynolds Foundation, allows eight hospitalists a year to spend 12 months learning about geriatric care. The curriculum includes preventing decline of function, recognizing confusion and delirium, and becoming familiar with common side effects of medication in the elderly.
“Studies show that most doctors and nurses do a poor job of recognizing patients who are delirious,” said Dr. Mattison. “Frequently, older patients don't call attention to it but just lie there quietly, and no one questions them. But if someone asks the questions, they might learn that the patient really is having trouble.”
Ideally, there would be enough geriatricians to care for the growing population of seniors, said Dr. Mattison, but that's unlikely to happen considering that nearly one in five U.S. residents will be over age 65 by 2030 and the number of people age 85 or over is expected to triple between now and 2050, according to the latest projections by the U.S. Census Bureau. In the meantime, the scholarship program and other efforts aim to provide more geriatrics training to general internists.
“A lot of what we do in our scholarship is teaching physicians to think about the unique situation of their older patients,” she said. “How does the body change with age? What physiological changes occur naturally and which are the symptoms of disease? How does aging affect metabolism of medications?”
Despite her busy schedule—she also teaches medical students and is the mother of three young children—Dr. Mattison said she couldn't imagine doing more satisfying work than helping ensure that elderly patients receive outstanding clinical care. “There is no way that our medical system can formally train enough geriatricians to take care of all of these elderly patients,” she said. “But as a geriatrician and educator I can help teach others how to care for them.”
Hospitalist trains “champions” at other institutions
Gregory A. Maynard, ACP Member
Medical school: University of Illinois, Chicago
Residency: Good Samaritan Regional Medical Center / Phoenix VAMC in Phoenix
Current position: Division chief, University of California, San Diego
Gregory A. Maynard, ACP Member, said the first quality improvement project he conducted was the toughest. In 2005, he teamed with hospitalists, pulmonologists and pharmacists to assemble a venous thromboembolism (VTE) protocol that was simple enough to use that caregivers could get through it very quickly, but thorough enough to apply to every patient. (See “Success story” for more details.)
It took three years to see satisfactory results.
But as he's launched subsequent quality projects, they get easier and easier. He's now not only creating new ones, but training others to create and implement their own projects. The first lesson he learned was to keep protocols simple. “The mistake people make is they make a three-to-four page order set for VTE prophylaxis and then nobody will use it because it's too cumbersome,” Dr. Maynard said. “The protocol needs to be brought down to one page and then the order set needs to be made even smaller.”
He mandated a best-practice protocol for VTE prophylaxis on a piece of paper that is about six inches long that goes in every caregiver's order sets for admissions and transfers. The VTE module complements order set modules for decubitus ulcer prevention, diet or allergies. The order sets are integrated into patient care, “rather than a standalone order set that's off somewhere in cyberspace that people won't use because it's not integrated into the flow of their work.”
The principles of quality improvement don't change when applied to other fields, he said, so he has worked on standards for common hospitalist situations such as transitions of care, as well as clinical areas such as correct insulin use in glycemic control, community-acquired pneumonia, delirium, alcohol withdrawal and falls prevention.
He's since extended the principles by building online toolkits that hospitalists can apply to quality improvement initiatives in their own facilities, including toolkits for inpatient diabetes care and venous thromboembolism prevention. These toolkits, along with others for stroke, exist for transitions of care, and others are available through the Society of Hospital Medicine's online resource rooms.
“Those quality improvement steps are the same quality improvement steps that you use for just about anything,” he said. Dr. Maynard shares the lessons he learned from struggling with his first quality initiative by showing others how to build programs at their facilities much more quickly. He mentors “champions” who then lead quality improvement projects, instead of relying on him to actually lead the project himself. The champion is essential, he added.
“If you're going to make this work locally or try to mentor others, you have to focus on building up the skills in those people and not just leading it yourself,” he said.
After a year of Dr. Maynard's mentoring, Kendall M. Rogers, ACP Member, who nominated him as a top hospitalist, created a method for computerized physician order entry that doesn't require a proprietary electronic health record and uses the same capabilities in pdf forms.
“The best part about that kind of a program,” said Dr. Rogers, chief of hospital medicine at the University of New Mexico, “is that you actually watch these people grow so quickly as leaders and get so expert so quickly that it doesn't take very long before they are teaching you as least as much as you are teaching them.”
Restoring the joy of medicine
Neil Shapiro, ACP Member
Medical school: New York University (NYU) School of Medicine, New York
Residency: NYU Medical Center
Current position: Associate program director, NYU Internal Medicine Residency Program and assistant chief of the medical service, Department of Veterans Affairs, New York Harbor Healthcare System, New York campus.
Early in his career, Neil Shapiro, ACP Member, had such a bad experience with being overworked at a job that he considered quitting medicine altogether.
Later, after he'd decided to stick things out, the experience made him want to remind his colleagues of all the reasons to love their profession, so they would never have to go through a similar crisis of faith.
“He loves medicine and wants those around him to feel the same,” said nominating colleague Judith Brenner, ACP Member, an associate program director at NYU. “He engages those around him with his patience and quiet determination.”
His desire to stir up passion about medicine led Dr. Shapiro to begin a large undertaking two years ago: Clinical Correlations, a collaborative medical blog that Dr. Brenner said has become so well-known among those in the NYU internal medicine community, they simply call it “The Blog.”
“I started [the blog] because there has been so much negativity and focus on work hours and performance measures and paperwork, that it seemed people were losing sight of the excitement of internal medicine,” Dr. Shapiro said. “I wanted to get people talking about medicine again.”
Faculty, residents and students all contribute to The Blog, which features clinical cases, a “mystery quiz” of a puzzling image, a weekly round-up of news from the journals, summaries of Grand Rounds lectures, and commentary about medical specialty meetings, among other things.
It was originally designed for residents, but is now read by NYU faculty and medical students as well. Updated daily, it is meant to be “a morsel,” he said, not a comprehensive medical resource. It's also an ever-evolving project, he added, with future additions to include a section about cutting-edge trends in medicine, and stories by faculty and students about their funniest clinical moments.
“I always had this idea to write a book called ‘You're Killing Me: Tales of Survival from Bellevue Hospital,’ where everyone would just write his or her very best story. So this would sort of fulfill that,” Dr. Shapiro said.
Another upcoming step is to get the whole blog peerreviewed, he added.
“What I want is for an editor to take a first pass at all the posts and decide if they are worth posting or should go back to the author immediately. And then once it passes through that editor, it will go to a specialist in that field for review and they will send comments back to the author,” Dr. Shapiro said. “It will be an open process.”
Peer review should give some of the content more credibility and heft, he said, since “as a faculty member, you wouldn't necessarily or automatically want to read something by a medical student, as bad as that sounds.”
This instinct for inclusiveness—wanting both medical students and faculty to write for and read the blog—is one of the attributes that makes Dr. Shapiro stand out as a hospitalist, Dr. Brenner said.
“Within the VA system, he was identified early as someone who easily brings many people together to form a team,” she said. “The blog has given physicians a forum for asking and answering questions, and for sharing that information with the world.”
To that end, Dr. Shapiro hopes the blog will one day catch on to a broader community beyond NYU, as well.
“One of my hopes is that we will become a resource used by physicians, housestaff and students far beyond our campus,” Dr. Shapiro said.
Communicating with other docs to get things done
Tapan K. Thakur, FACP
Medical school: Patna Medical College, Bihar, India
Residency: St. Mary's Hospital, Rochester, N.Y.
Current position: Medical director, Midsouth Hospitalists, DeSoto, Miss.
It's not a typical hospitalist who has his own 800 number. As medical director of the hospitalist team at Baptist Memorial Hospital, Tapan K. Thakur, FACP, doesn't actually answer the phone on his hotline. But he was responsible for developing it. “We were trying to increase the referral base to our hospital and one of the problems doctors in the area were complaining about was how difficult it is to get a patient admitted,” Dr. Thakur said. So to alleviate the problem, the hospitalist group opened an admission hotline, 1-877-4ADMITT, manned 24/7 by nursing staff.
“Any primary care or emergency room doctor can call and give the patient's demographics and problem list, so that the nurses can triage those patients, find out the accurate level of admission and appropriate hospital, depending on their insurance and medical needs,” said Dr. Thakur.
The nurse who answers the phone then finds a bed and an on-call physician for the patient who is coming in and can even relay the bed number back to the primary care doc. The process not only expedites admissions, but is also convenient and cost effective, according to Dr. Thakur. “For example, a patient being admitted directly from a primary care office with pneumonia will not have to go to the emergency room and wait for hours to be evaluated.”
The hotline is also particularly useful for patients in need of specialty care, because the expert operators can help a phoning physician figure out which hospital in the area has a neurosurgeon or orthopedist available, for example.
“Patients love it, referring physicians love it, and the emergency room loves it. We are getting more and more calls through that hotline and we are seeing increasing volume,” said Dr. Thakur.
He has also worked to improve communication within the hospital, by updating the MedSurg committee, which had been less-than-successfully working on quality improvement. “It was not one of the more attended meetings. The committees were mostly headed by physicians. We used to decide about things and rarely did they trickle to the bottom,” said Dr. Thakur.
Now, nursing leaders from every floor are included in discussions of how to reduce nosocomial complications, from line sepsis to hip fractures. “Every meeting a new idea has come up and every floor is competing with other floors to come up with innovative ideas to reduce their complications,” he said. For example, nurses in the hospital are currently fired up about infection risks of unneeded Foley catheters and will call a physician's attention anytime they see one that should be removed.
Dr. Thakur also continues to work on facilitating communication among physicians, especially between the in- and outpatient worlds. In response to concerns from primary care physicians, a new discharge document was developed that clearly states the critical information and gets to the docs within 24 to 48 hours. There's also a soon-to-be-launched newsletter for the Memphis chapter of the Society of Hospital Medicine, which will include essays and evidence analyses from internists and specialists.
Such efforts inspired Dr. Thakur's colleagues to communicate their effusive praise for this Top Hospitalist. “Continuity is maintained and information [exchange] between him and primary care physicians is extraordinary. None of this existed before Dr. Thakur came and implemented such a program across two states!” wrote family physician Joseph S. Hunter, MD, one of Dr. Thakur's four nominators.
Team up to make quality improvement part of the job
Timothy C. Thunder, ACP Member
Medical school: University of Nevada, Reno, Nev.
Residency: Providence Portland Medical Center, Portland, Ore.
Current position: Medical director of hospitalist service, Providence Portland Medical Center
When hospitalists at Providence Portland Medical Center (PPMC) undertake quality improvement, they get more than a pat on the back. As medical director, Timothy C. Thunder, ACP Member, set up a system under which each hospitalist chooses a quality improvement project and a portion of his or her salary is then based on the results.
“It allows people to find the place that works best for them in quality improvement. Some people are project people who want to find a problem and identify ways to solve it. But some people just don't work that way and they would much rather work in an established committee structure,” said Dr. Thunder.
In addition to the individual efforts, which have included initiatives like nurse-led pneumonia vaccinations, the hospitalists also undertake annual group quality projects. Hospitalist-led initiatives were at least partially responsible for the hospital being fully in compliance with guidelines for heart failure and myocardial infarction for the last several years, Dr. Thunder said.
Quality improvement is not the only goal that the PPMC docs tackle as a team. “One of the things that I think has made our group very successful is the team approach to health care—the team being both other physicians, but also the other multidisciplinary staff involved.”
That sense of equality and all being part of the same team extends to Dr. Thunder and his co-medical director. “We try to make sure that everybody is treated equally as far as scheduling and time in any position,” Dr. Thunder said. Under the hospitalist program's rotational system, they and the rest of their physicians take turns covering all the hospitalist positions, whether it's triage or doling out overnight admissions.
“Even though it would be easier for us to say we're just going to work day shift because we have all these meetings to go to, we make sure that we all rotate through every position, so that we can communicate more effectively about what needs to change,” he said.
Changes were made to both discharge summaries and signouts under Dr. Thunder's leadership. Primary care physicians now receive standardized, streamlined discharge summaries, and hospitalists who are coming on shift can call into a voicemail system as early as the night before to learn about the patients they will be taking on. To ensure patient safety, the system's also set up so that signing-in hospitalists can always get in touch with their signing-off colleagues in case questions arise.
Dr. Thunder hopes to continue this innovation and teamwork when he takes over as president of the hospital's medical staff in February. That should be no problem, according to Douglas Koekkoek, MD, who nominated Dr. Thunder as a top hospitalist. “His level of energy and dedication … frequently awe his team, who are no slouches themselves!” wrote Dr. Koekkoek, who is chief medical officer for hospitalist programs in the Oregon region of Providence Health and Services.
Round-the-clock efficiency in a busy hospital
Ali Usmani, MD
Medical school: Dow Medical College, Karachi, Pakistan
Residency: Cleveland Clinic, Cleveland, Ohio
Current position: Clinical assistant professor and associate staff in hospital medicine department, Case Western Reserve University
For hospitalist Ali Usmani, MD, efforts to improve efficiency at the Cleveland Clinic don't end when the sun goes down. In addition to his teaching and clinical responsibilities, Dr. Usmani coordinates the hospital's moonlighting and new nocturnist services. That has meant scheduling five doctors per shift from the moonlighting pool (mostly composed of fellows and residents) and nocturnist staff (now nine docs).
Given the hospitalist workforce shortage, that could be a challenge, but Dr. Usmani has taken it in stride since the hiring of the nocturnist force this summer. “Our aim was to make it sustainable and something they would enjoy doing. We didn't want to anyone to drop out after three months.”
How does he accomplish that? “We basically let them make their own schedules. Because of the moonlighters, we have flexibility. If a nocturnist cannot do the shift, a moonlighter will do it, but the nocturnist will owe the department the hours for the next month,” explained Dr. Usmani.
So far, the program has worked well, and he has more potential applicants than he needs. His nocturnists are so happy, they want to recommend their friends for any jobs that come available, Dr. Usmani said.
Hospitalists are also happy about other innovations Dr. Usmani has worked on, including the development of geographically localized units. His hospital now has four dedicated areas for the patients of non-teaching hospitalists. “We used a process to optimize communication regarding pending discharges so that patients get to the right place over 80% of the time.” Now, on average, a hospitalist working in one of the four units has 80% of his or her patients in the same spot. “The physicians like it much better. They are walking much less and able to finish up seeing the patients much faster. The nurses like it because they can address you directly and don't have to put in a page and wait for you to call back,” said Dr. Usmani.
He also helps colleagues achieve greater efficiency by heading up the operational rounding, an effort to remove roadblocks to discharge. “For example, if they ordered an echocardiogram and it wasn't done and it's now two days later and that's holding up the patient, they will notify me.”
Dr. Usmani then gets a nurse to handle the phone calls or running around required to get the patient pushed up on the schedule. “They say, ‘This is holding up our discharge, so please do it today or move it up the list.’ We basically facilitate the discharges,” he explained.
As if that weren't enough to do, Dr. Usmani is also heavily involved in clinical research, particularly focusing on perioperative care. Right now, he's working on meta-analyses of disease management after heart failure hospitalizations. “For example, if a nurse would visit them at home once after discharge, would that decrease re-hospitalization or mortality? Or frequent telephone contact? Or follow-up in the outpatient clinic?”
Not that the answers even to those many questions will satisfy this Top Hospitalist. “I don't exactly what the future holds, but I want to be more clinically proficient and do more research and publish more,” he said.