Welcome to our sixth annual Top Hospitalists issue. We're excited to showcase the hard work, talent and creativity of the 10 physicians profiled on the following pages. Our call for nominations last spring yielded an impressive number of responses from peers, supervisors, mentors and mentees. ACP Hospitalist's editorial board members reviewed those nominations and selected the Top Hospitalists, who have done admirable work in the areas of patient rounding, resident education, technology, workload balance, efficiency of care, and more. We hope you find their work as inspiring as we did, and we look to receiving your nominations for next year's honorees.
Note: ACP Hospitalist's Top Hospitalists feature is not part of the ACP National Awards Program.
Bedside rounding takes patient-centered care to new level
Mel L. Anderson, MD, FACP
Medical School: University of Texas Health Science Center at Houston
Residency: David Grant U.S. Air Force Medical Center, Travis Air Force Base, Calif.
Title: Chief, hospital medicine section, and associate chief, medical service, Veterans Affairs (VA) Eastern Colorado Health Care System; associate professor of medicine, University of Colorado School of Medicine, Aurora, Colo.
For all the talk about the value of patient-centered care, many hospitalists still round on patients in a conference room or hallway. Mel L. Anderson, MD, FACP, takes a different approach at VA Eastern Colorado Health Care System, where hospitalists and nurses conduct daily rounds at the patient's bedside.
“Rounding at the bedside is an opportunity to combine patient care and teaching seamlessly,” said Dr. Anderson, who spent 4 years on active duty in the U.S. Air Force after completing his residency. “We can directly connect what's being reported about the patient with reality, take advantage of the teaching opportunities that come from the physical exam and educate our patients at the same time.”
Considered a national expert on bedside rounding, Dr. Anderson conducts faculty workshops at his own and other institutions. He tries to dispel the widespread perception that rounding at the bedside is impractical in a health care environment that stresses productivity and efficiency.
“In the 1960s, most rounds were conducted at the bedside but now it's under 20%,” he said. “We try to give hospitalists an approach and let them know it can be effective and even more efficient.”
Despite the conventional wisdom that rounding may take longer at the bedside than in a conference room, the bedside method can be as or more efficient overall, said Dr. Anderson. Typically, the physician obtains all needed information in one visit at the bedside and can start talking to the team about implementing a care plan immediately.
“A hospitalist may spend 2 hours rounding in a conference room and then go to see the patient later in the day and change his or her mind about the care plan based on talking and examining the patient,” he said. “But if everyone is there at 9:00 a.m. at the bedside, we're more likely to get it right the first time.”
In an observational study published in June in JAMA Internal Medicine, Dr. Anderson and colleagues showed that bedside rounding took no longer than conference room rounding, results that are consistent with prior literature. “But we fully appreciate that faculty must develop a method for effective bedside rounding and that a key component of doing so involves deliberate practice as a faculty member,” he said.
Dr. Anderson also helped initiate a system of multidisciplinary bedside rounding at his hospital, in which the inpatient physician team, the patient's nurse, a care coordination nurse, and often a pharmacist meet together at the bedside. Since this process began, pages to medical housestaff dropped by 50% as a result of having everyone in the same room at the same time, he said.
To implement multidisciplinary bedside rounds, Dr. Anderson had to overcome a number of scheduling issues. For example, nurses originally were unable to attend rounds because they were administering medications at that time. Dr. Anderson worked with pharmacists and the computer division to change medication administration by 2 hours so that nurses could participate.
Having nurses on hand when the care plan is drawn up puts everyone on the same page immediately, he said. If the patient is slated for discharge, for example, the nurse can start preparing and educating the patient. Or if the care plan involves introducing new medication, the nurse can be ready to observe the patient's response to treatment.
“Now they are spending their time and energy in a way that has us all pulling in the same direction,” said Dr. Anderson. And nurses like being more involved in the process, he added. Since bedside co-rounding began, there have been numerous requests from nurses to shift from nights to days so that they can participate in rounds.
New physicians and housestaff are sometimes hesitant to embrace bedside rounding because they've been trained to think of it as less efficient, said Dr. Anderson. But once they see the benefits, “it's difficult to imagine doing it any other way.”
Background in private practice informs hospitalist care
Brent Box, MD
Medical School: Mercer University of Medicine, Macon, Ga.
Residency: Naval Hospital, Portsmouth, Va., and University of Alabama at Birmingham
Title: Chief hospitalist and chief medical officer, Gordon Hospital, Calhoun, Ga.
Gordon Hospital, a community hospital with 69 beds in Calhoun, Ga., may be among the smallest of the 44 hospitals in Adventist Health System (AHS), but it's also one of the most respected. That's largely due to the hospitalist program run by Brent Box, MD, who is often held up as a model of how to organize and lead a successful program.
“Dr. Box is regarded by Adventist Health System as having developed the ideal model,” said Carlene Jamerson, chief clinical officer for AHS. “He serves as a resource for chief hospitalists from other hospitals within the system.”
Dr. Box's style of rounding has contributed to his success since he was hired by AHS in 2009 to start a hospitalist service at Gordon.
Everyone involved in patient care offers input during morning rounds held at each unit's nursing station, according to Dr. Box. “We've done rounds with an interdisciplinary team every morning for the past 5 years,” he said.
Nurses update the team on the patient's progress, pharmacists discuss potential medication interactions and antibiotic stewardship, physical therapists weigh in on the functional level of the patient and case managers help develop a sound discharge plan.
Over the past year, Dr. Box introduced a readmission team into the process, which works to eliminate gaps in care by ensuring that patients are seen by their primary care physician soon after discharge and opening up communication with home health care. While it's too early for conclusive data, the hospital has already made strides toward the eventual goal of reducing readmissions by 25%.
Dr. Box also initiated a glycemic collaborative, known as “sugar rounds,” that has significantly improved care for diabetic patients. The team meets every morning at the end of interdisciplinary rounds to review its list of patients with hyper- or hypoglycemia and to make adjustments as necessary.
“It all happens by 9:45 a.m., so every patient is adjusted early in the day rather than as they are seen by a physician,” said Dr. Box. “In a few minutes, we can go through our entire list of patients and adjust insulin dosing. That's helped us bring our blood sugar rates into our goal range.”
Dr. Box makes a point of bringing younger hospitalists into the rounding process and encouraging them to participate. His goal, he said, is to train physicians who “practice as well-trained general internists” and know how to work through complex cases.
“I teach my hospitalists that they should feel free to bring in consultants, but not because they haven't thought through the problem,” he said. “A well-trained general internist can take care of the majority of problems that come through a general medical hospital.”
Dr. Box's philosophy at the bedside stems from spending 15 years in private practice before switching to hospital medicine. All hospitalists should have some training in ambulatory care so they understand the full spectrum of the disease process, he said.
“I hope our training programs will continue to emphasize the need to see patients in the outpatient arena so that hospitalists are trained in the disease process when it's not active,” he said. “Patients with heart failure, for example, often do well for months or years and then have an exacerbation. Knowing what that patient looks like when he's stable helps you to be a good hospitalist.”
Although he now spends about a quarter of his time on administrative work, caring for patients and teaching at the bedside remain his passion, said Dr. Box.
“Every patient deserves to have a captain of the ship for their care,” he said, “and that's the role that hospitalists play.”
Crossing departmental lines to solve problems, create solutions
Joan Curcio, MD, ACP Member
Medical School: Ross University School of Medicine, Commonwealth of Dominica, West Indies
Residency: Mount Sinai School of Medicine/Elmhurst Hospital Center, Elmhurst, N.Y.
Title: Director of inpatient medical service, Elmhurst Hospital Center
During rounds one morning at Elmhurst Hospital Center, a resident, social worker and nurse were sharing their frustrations that a patient had been waiting weeks for a neurosurgical brace. Fortunately, a staff hospitalist was sitting in on the discussion and later relayed the complaints to her supervisor, Joan Curcio, MD, ACP Member.
“We brought in all the people involved—orthopedics, neurosurgery, rehab, an administrator, and a representative from vending—and in one meeting we were able to achieve everything that needs to be done to get the brace,” said Dr. Curcio, who has led Elmhurst's 8 hospitalists for the past 6 years.
The case is typical of Dr. Curcio's approach to problem solving: Get all significant stakeholders in one room, identify the issues and hammer out a solution that meets everyone's needs. In the case of the brace, the group discovered that fixing a couple of logistical roadblocks—such as incorrect completion of prescriptions—sped up the ordering process significantly, potentially preventing weeks of unnecessary hospitalization.
“Dr. Curcio has aggressively approached efficiency in a variety of ways on our service,” said Joseph Masci, MD, FACP, director of medicine at Elmhurst, part of New York City's public hospital system. “She has a gift for anticipating obstacles and designing solutions quickly and effectively.”
Geographic rounding—where physicians are assigned to specific units rather than traveling throughout the hospital to see patients—laid the foundation for other innovations that have improved workflow and decreased length of stay, said Dr. Curcio, who implemented the system after becoming division chief. Before geographic assignments, hospitalist teams spent almost 2 hours rounding on patients; under the new system that time was slashed to about 20 minutes.
Having physicians physically in one place with the rest of the care team paved the way for interdisciplinary rounds, which made it easier to address problems that cross boundaries, such as the brace situation, said Dr. Curcio.
“The geographic assignments were a base change that allowed all other interventions to happen,” said Dr. Curcio. Six months after the system was implemented, average length of stay dropped by 0.9 day while average dwell time in the ED was reduced by 3.5 hours.
Another of Dr. Curcio's accomplishments was the launch of a nonteaching service for low-acuity patients. Working with the nursing staff, she created a 13-bed unit staffed by a nurse practitioner, a social worker and an attending physician. Patients were either low-acuity patients in the hospital for observation or those with complicated social issues that prevented them from leaving the hospital.
The program was especially successful in dealing with the latter group, many of whom had been in the hospital for months or even years, said Dr. Curcio. In one case, the team was able to work with administrators to send a woman to Greece, the only place where she had family and health care coverage.
Dr. Curcio has also boosted the hospital's bottom line by initiating physician cross-training with the hospital's health information management department to improve coding and billing practices. The program was launched in 2009 and by 2011 resulted in increased revenues of almost $10 million for the hospital and $70 million across Health and Hospitals Corp. (the public hospital system for New York City) through increased charge capture.
Dr. Curcio almost always agrees to requests to serve on new committees or task forces because she finds they inevitably lead to new insights that help her solve the next problem.
“I'm involved in a lot of areas outside of the department of medicine, and that's allowed me to see what's going on all over the hospital,” she said. “I have a good feel for what everyone needs, so I can get the right people together to collaborate.”
Teacher, mentor is expert in curriculum development
Daniel D. Dressler, MD, FACP
Medical School: Emory University School of Medicine, Atlanta
Residency: Emory University School of Medicine
Title: Professor of medicine, associate program director of the internal medicine residency program, and section head for education in the division of hospital medicine, Emory University School of Medicine
Recently, Daniel Dressler, MD, FACP, had a medical student arrive at his office brimming over with enthusiasm about a clinical case she hoped to present at a conference. Would he help her write it up?
“After I helped her, she went on to present it at regional and national conferences and win first place among hundreds of other poster presenters,” said Dr. Dressler, who serves as mentor to more than 75 faculty, residents and students at Emory. “It was very satisfying for both me and the student.”
When he's not teaching or mentoring, Dr. Dressler is often involved in developing curricula. He redesigned and directs the evidence-based curriculum for Emory's internal medicine residency program, has chaired the Society of Hospital Medicine's core curriculum committee, and serves as course director for the Annual Southern Hospital Medicine Conference.
He enjoys all aspects of educating younger physicians, but mentoring often results in the greatest personal satisfaction, he said. Whether it's through classroom instruction, bedside rounds or a friendly conversation, Dr. Dressler always finds time to lend an ear or offer advice.
“Sometimes even at 6 o’clock in the morning, I might grab some coffee with a junior faculty member and talk for an hour about their interests and plans,” he said. “It's great to see young faculty members find the aspects of clinical care, scholarship or teaching that they love and help them find the ways in which they can be successful in those areas.”
Since medical school, Dr. Dressler has had an interest in evidence-based medicine and how physicians make clinical decisions.
“When you see variations in clinical practice, it makes you want to dig deep into the medical literature to find literature to support the best possible practice based on the question or problem at hand,” he said. “That's why I started to study how we can use medical literature to support decision making.”
After finishing his residency training and a fellowship in hospital medicine, Dr. Dressler completed a master of science degree in clinical research. He went on to edit 2 major textbooks: “Core Competencies in Hospital Medicine” in 2006 and the recently released “Principles and Practices of Hospital Medicine.”
Much has changed in how physicians are trained since he went through medical school, he noted. For example, no one was discussing quality improvement 10 or 20 years ago, but now it's become a mandatory part of residency training.
“A lot of our learning was on the fly,” he said. “Now we have a much more robust quality improvement training that starts in medical school. Those coming out of training now are more geared toward appreciating and understanding that quality improvement is an active part of practice that we need to be thinking about on a daily basis.”
One of the training programs Dr. Dressler developed for residents is based on evidence that trainees learn better in hands-on situations where they receive immediate feedback. The MegaCode resuscitation training course allows residents to run codes on simulated patients and get active, immediate feedback from faculty.
“They get to practice in a traditionally very stressful situation knowing that it's simulated, so when they do encounter a live patient they will be more comfortable,” he said. “And as we give them feedback, if they aren't doing well enough, they can come back and get reevaluated.”
The program mirrors a general trend in medical education to scrutinize not just what but how students are being taught, said Dr. Dressler.
“We're moving towards being assessed as teachers and trainers,” he said. “We need to show that the learners have learned what we're teaching, so we're constantly assessing them on their actual skills.”
A passion for making technology work in clinical practice
Tom Dues, MD, ACP Member
Medical School: University of Louisville School of Medicine, Louisville, Ky.
Residency: University of Louisville School of Medicine
Title: Hospitalist and chief medical information officer, University of Louisville Hospital, and associate professor, University of Louisville School of Medicine
As physician champion for computerized physician order entry back in 2001, Tom Dues, MD, ACP Member, was invited to the University of Louisville Hospital's first meeting to discuss adopting electronic health records (EHRs). It turned out to be a career-altering moment for Dr. Dues, who discovered a passion for working with medical information technology (IT).
“I am struck by how simple electronic pathways designed with the physician and patient in mind can improve the outcome and safety of our patients in very real and measurable ways,” said Dr. Dues, who started as a physician champion in 2001 and became the hospital's chief medical information officer in 2011. “One intervention or screen design can help prevent adverse events for thousands of patients.”
Dr. Dues now spends half of his time on IT issues and the other half on patient care and teaching. A little over a year ago, he moved his office out of the hospital into a neighboring building housing the IT staff in order to facilitate daily meetings.
“I'm here for the clinical input, which is what the IT folks really need and want,” he said. “It's really important that the physicians who use the system most should have input on the front end of application designs. Our input won't be heard unless we're in the room when decisions are made.”
As a hospitalist and educator, Dr. Dues sees evidence every day of how technology can aid the clinical decision-making process and improve care. Even small reminders or warnings that pop up on a screen can have a huge impact.
For example, a few years ago he helped design pathways for the discharge process that included a vaccination reminder screen. Physicians were given information about the patient's immunization status and reminded to order the correct vaccines before the patient left.
“As a result of that reminder screen, our year-over-year vaccination rates increased 5-fold from one flu season to the next,” he said. “It's really impressive when you can touch so many patients with electronic design improvements.”
As the hospital's physician IT expert, Dr. Dues has become involved in many other quality improvement projects. For example, he helped develop a medication reconciliation system that provides medication information at every transition in the patient's care and at discharge.
“We tried to make it as easy as possible for nurses and physicians to make medication reconciliation part of the routine discharge pathway, and we've had a lot of success,” he said. “We track how soon medications are reconciled after admission, and the rate within 24 hours of admission has been well over 90%, rising to 100% during patients' stay.”
Dr. Dues also helped integrate a modified early warning system (MEWS) score into the EHR. The system amasses data based on a patient's vital signs and assessments and calculates an overall score alerting nurses to deteriorations in a patient's condition that require some type of immediate attention, from alerting a physician to calling a stat response team or requesting transfer to the ICU.
Most recently, Dr. Dues helped develop a venous thromboembolism (VTE) prophylaxis screen on the EHR that incorporates clinical decision support. Physicians answer a few questions about the patient's condition, and the tool combines those answers with other patient data such as age, weight, gender, creatinine clearance and allergic reactions to arrive at an overall risk score. On the basis of that score, the physician is given suggestions for medications and other recommendations to prevent VTE.
For Dr. Dues, there is great satisfaction in seeing electronic systems evolve and improve based on input from clinicians on the front lines of care.
“It used to be that electronic systems were developed based on the best way to organize data, but it's important that they be molded as much as possible to our current practice,” he said. “The best way to incorporate all the good things about electronic systems is to make them fit the way we see patients.”
Adding checklists and new responsibilities for mid-levels
Deanne Kashiwagi, MD, FACP
Medical School: Loyola University, Chicago
Residency: Indiana University Hospital, Indianapolis
Title: Consultant and practice chair, hospital internal medicine, Mayo Clinic, Rochester, Minn.
The style of daily rounds at Mayo Clinic used to be as individual as each physician, but that sometimes led to omissions, such as failing to check the patient's skin or considering whether to remove a catheter. Deanne Kashiwagi, MD, FACP, set out to change that by expanding the use of a checklist to encourage clinicians to communicate with nurses about the same issues with every patient.
“The checklist prevents things from being overlooked,” said Dr. Kashiwagi, who joined Mayo 5 years ago and in 2012 was promoted to practice chair of a division with 8 primary hospitalist services and a consult service covering 2 hospitals. “It's a visible reminder in the room that there are several components that should be addressed each day.”
In addition to checklists, Dr. Kashiwagi has worked to improve the rounding process by encouraging teamwork among physicians, nurses and mid-level practitioners and helping develop new tools to reduce potentially avoidable readmissions.
“She has been a champion for standardizing teamwork and assuring that the nurse practitioners and physician assistants in our division practice at the highest level possible,” said Kevin Whitford, MD, ACP Member, chair of the division.
For Dr. Kashiwagi, giving mid-level practitioners more responsibility is a win-win because it helps the hospital deal with a physician shortage and leads to greater career satisfaction for nurse practitioners and physician assistants.
For example, the division recently tested a practice model that allocated more patients to each attending physician while at the same time increasing the number of mid-levels on the service.
“Our mid-levels have a lot of autonomy and view themselves as the patient's primary caregiver, so they really embraced the initiative,” she said. “It's been successful enough as a pilot that we may plan to expand use of the model.”
Dr. Kashiwagi has also transformed the division's traditional morbidity and mortality conferences to focus on process rather than individual errors. For example, when a few clinicians noticed a delay in the performance of inpatient electromyography, it was discovered that physician orders were being printed in an outpatient location that was not staffed after hours or on weekends and holidays.
“The information was added to the [computerized physician order entry] screen to educate providers and allow them to adjust and plan so as not to hold up other studies or dismissal,” she said. “It was a small, easily fixed problem but as we tackled more issues, our experience grew and allowed us to undertake larger quality improvement projects together.”
As a teaching attending, Dr. Kashiwagi emphasizes the importance of focusing on the patient and asking questions. She asks residents to reflect on how they communicate with patients. Do they explain things in language that patients can understand? Do they approach patients as people and discuss (rather than dictate) the plan of care?
“It's not my style to stand at the end of the bed and tell the patient this is what we're going to do,” she said. “I prefer to have a conversation.”
She also tries to impart a lesson she learned early on from a mentor: “Just because we can doesn't mean we should,” a principle that hit home during several stints volunteering at a medical mission in Bolivia.
“Caring for patients without access to the abundance of resources I'm used to in this country gave me the opportunity to determine what was absolutely necessary to forward a patient's care and what was less critical,” she said. “I tried to bring this same decision-making process home with me.”
Helping spread best practices on workload, performance
Henry Michtalik, MD
Medical School: Albany Medical College, Albany, N.Y.
Residency: University of Miami/Jackson Memorial Hospital, Miami
Title: Assistant professor of medicine, clinical research scholar, Johns Hopkins University School of Medicine, Baltimore
Henry Michtalik, MD, likens a well-functioning hospitalist group to a winning football team. The chances of succeeding are much higher if everyone is engaged in the process, heading in the same direction and working toward a common goal.
“I take a triangular approach,” said Dr. Michtalik, whose research focuses on issues surrounding physician workload, productivity, safety and quality. “You must have situational awareness (the what), alignment of incentives (the why) and engagement (the how)” for a project to be successful, he said.
A major goal of Dr. Michtalik's research on physician workload is figuring out how to align the incentives of payers, institutions and clinicians. He recently incorporated the Johns Hopkins Clinical Research Network, a multistate database for clinicians, to measure processes and outcomes, share problems and solutions, and develop best practices on structuring workload.
“There are many workload factors that really aren't reported in the literature, so it's difficult to compare one program to another,” he said. “We hope to look at hospitalist teams and structures, learn what works and what doesn't and really improve care from the bottom up.”
Dr. Michtalik's research began with a survey of hospitalists, published in the January 2013 JAMA Internal Medicine, in which 40% of respondents said their typical inpatient census exceeded safe levels at least monthly. Respondents also noted that heavy workloads likely contributed to patient transfers, morbidity or mortality and left inadequate time to discuss treatment options with patients and families.
“There's been a lot of work done with respect to residents and work hours, but we have limited data on attending physicians,” he said. “As the health care environment changes with increasing restrictions on work hours and greater focus on reimbursement and throughput, there are a lot of workload issues that we need to address to avoid potential adverse consequences.”
For example, Dr. Michtalik is currently examining the use of physician dashboards. Using common performance measurements, such as venous thromboembolism (VTE) prophylaxis, the dashboards provide real-time feedback to physicians on their compliance with clinical guidelines and best practices.
A study of Dr. Michtalik's, which was presented at the Society of Hospital Medicine's 2013 annual meeting, found that the introduction of a dashboard boosted physician compliance with VTE prophylaxis from 84% to 90% (compared to using computerized order entry decision support only). Compliance reached almost 95% with the addition of payment incentives, which served primarily as a method of engagement rather than additional revenue.
The dashboards, which are now used routinely at Johns Hopkins and are soon to be expanded throughout the Johns Hopkins Network, suggest that feedback is a more effective motivator than monetary rewards, he said.
“Payment incentives were a way to engage providers, but they really weren't working towards that,” said Dr. Michtalik. “Being able to see how you're doing in real time and how your colleagues are doing were the key motivators. They're able to know what the expectations are right away and how they can improve.”
Fostering an open culture of communication is another key to ensuring the best care, he said. Everyone on the care team should feel free to raise safety concerns and suggest improvements without fear of blame or repercussions.
We can always say that someone drawing up the wrong concentration of potassium from the wrong vial is an individual error, but the bigger questions are why did that person have access to that higher-potency vial? Why was an individual able to confuse the two?” said Dr. Michtalik. “By addressing the system we don't just fix one instance; we answer the main question ‘why’, learn, change, protect future patients, and have a much larger impact.”
Diverse interests linked by commitment to improving care
David G. Paje, MD, FACP
Medical School: University of the Philippines College of Medicine, Manila, Philippines
Residency: Wayne State University, Detroit Medical Center, Detroit
Title: Associate division head of hospital medicine, Henry Ford Medical Group/Henry Ford Health System, Detroit
Ask David Paje, MD, FACP, what he's most passionate about in his career, and you're likely to get a range of answers—from teaching at the bedside to clinical research to strategic planning to informatics, to name a few. It may seem like there's too much on his plate, he admitted, but he's never been one to stand by when there are problems to be solved.
“When I see issues or problems and I think I can contribute in terms of knowledge or ideas, I have to act and get involved,” said Dr. Paje, who was named associate division head in 2010 when the Henry Ford hospitalist practice had just expanded rapidly from 1 to 4 hospital sites. “I can't stand not doing anything. I want to educate myself and be part of the solution.”
It's one thing to have your hand in many projects but another to be considered an expert in several of those areas, said Dr. Paje's colleague Peter Watson, MD, FACP, division head of hospital medicine at Henry Ford. Recognized as a national expert in observation medicine, Dr. Paje is also a popular teacher, an accomplished clinical researcher and an authority on clinical data management.
“Dr. Paje displays all the qualities that I believe are important in a hospitalist,” said Dr. Watson. “An excellent fund of general medical knowledge, strong leadership ability, a high level of professionalism, a dedication to patient-centered care, a high level of integrity, and a true passion for hospital medicine.”
For Dr. Paje, improving patient care is the common thread that links his many interests. The challenges, issues or problems he faces every day as an attending physician often lead to a new learning endeavor or quality improvement initiative.
For example, in his clinical work he observed that electronic health record (EHR) systems, while convenient and powerful, are not always as relevant as they could be to clinical care. To help change that, he invested time in learning basic programming and design principles, eventually becoming certified as a physician program builder by Verona, Wis.-based software maker Epic Systems.
“I'm very interested in informatics and analytics,” said Dr. Paje, who serves as an advisor for the implementation of the Epic EHR system at his hospital. But at the same time, “It's not all about having fancy gadgets and the latest computer applications. I always bring my trainees back to what this is all about— striving to find ways to improve the care we provide to our patients because we treat them like our own friends and family.”
Becoming physician champion for Henry Ford in the Michigan Blue Cross/Blue Shield Hospital Medicine Safety Consortium's initiative to improve venous thromboembolism (VTE) prevention represented another opportunity to use his analytical and data management expertise to improve care.
“Because of our group's efforts, our VTE assessment rate for medical patients was 98% in 2012,” said Dr. Paje. “More recently, we put together a systemwide policy on VTE prophylaxis for medical patients and collaborated with our IT [information technology] partners to leverage our new electronic medical record system in implementing that policy.”
Dr. Paje was also the lead physician in the development of a geographic observation unit that has consistently delivered high-quality and efficient care since 2011. Under his stewardship, the hospital dramatically improved the average length of stay (LOS) for patients under observation, with an overall unit average of 18 hours. For patients being evaluated for chest pain, the average LOS dropped from around 30 hours to about 17 hours.
“One of the most important keys to our success,” he said, “is building a multidisciplinary collaboration and keeping the team highly engaged by regularly reviewing and discussing performance measures, and by challenging ourselves to find opportunities for improvement.”
Compassion, continuity key to success
John H. Rickelman, DO
Medical School: Kirksville College of Osteopathic medicine, Kirksville, Mo.
Residency: Northeast Regional Medical Center, Kirksville
Critical Care Fellowship: University of Iowa Hospitals and Clinics, Iowa City
Title: Hospitalist, critical care specialist, Northeast Regional Medical Center, Kirksville
During his 20s, John H. Rickelman, DO, spent 9 years watching his mother struggle with breast cancer. During that difficult time, when he was also in medical training, he remembers being grateful to her oncologist for talking frankly about end-of-life care.
“I was there when her oncologist very compassionately and matter-of-factly talked to her about her options,” said Dr. Rickelman, a member of a 4-person team of hospitalists at Northeast Regional Medical Center (NERMC). “He didn't try to make it bad or good, just said, ‘Here are your options.’ He listened to what she wanted.”
The experience, along with his training in critical care medicine, underscored for him the importance of addressing end-of-life care issues with patients while they are still well enough to convey their wishes. He encourages the hospitalists he works with as well as the new trainees he teaches to start the conversation as soon as possible with critically ill patients.
“Physicians and nurses who haven't dealt much with death often see it as a failure and are hesitant to bring up do-not- resuscitate [DNR] status with patients,” he said. “I used to tell patients with a DNR order that we're going to ‘withdraw care’ and then realized how wrong I was in saying that—we never withdraw care, we just change the nature of it.”
For Dr. Rickelman, being in a small hospitalist group at a small community hospital (105 beds) has clear advantages over being part of a large academic institution.
“My partners and I know each other well and are constantly talking about what works and what doesn't,” he said. “When we hear about cutting-edge practices that we think might work we try them out—we don't have to go through 80 committees first.”
The hospital's success with eliminating central-line infections is a case in point. Dr. Rickelman implemented maximal barrier precautions as soon as he started the hospitalist program. As new partners joined the group, “it was just what we did,” he said. The hospital has not had a central-line infection in 3 years.
“Some bigger institutions are slow to implement and enforce basic practices like handwashing and checklists,” he said. “We instituted some of the body contamination practices, such as [chlorhexidine gluconate] body washes for ventilator patients and chlorhexidine wipes, long before they were standard practice.”
Dr. Rickelman has also led an initiative to reduce delirium by changing the hospital's sedation practice. Over the past year, he instituted daily “nap time” breaks between 1 p.m. and 3 p.m., and stressed minimized stimulation after 10 p.m to improve patient day/night cycles and sleep patterns. He also introduced early ambulation for ventilated patients based on studies showing that it can reduce time spent in intensive care and improve functional status.
“I intubated one patient with acute respiratory distress syndrome on Monday and had her up and walking on Tuesday. She was off the ventilator in 5 days,” said Dr. Rickelman. “That won't happen with every patient, but if you don't look and try, you won't know.”
Dr. Rickelman also led the implementation of a rapid response system that has dramatically reduced the code blue rate. He attributes the program's success to having a team that's “always around” and can deal with issues as they arise.
“Our team spans the hospital,” said Dr. Rickelman, noting that hospitalists typically work 3 out of every 4 weeks while splitting night call and weekends evenly among the group. “It's not unheard of for us to have a ventilated patient in the ICU, see them through critical care and the entire duration of their stay in the hospital. We tend to keep continuity with our patients unless we go off service,” he said.
By all accounts, Dr. Rickelman's efforts have paid off. The hospital has been recognized by Thomson Reuters as a Top 100 hospital twice since he took over the division, and has received the Everest Award for safety improvement several times.
“Dr. Rickelman has nearly single-handedly built the hospitalist program from scratch over the last eight years,” said John H. Grider, DO, ACP Member, a colleague at NERMC. “He is the best hospitalist I have ever met and the benchmark to which his colleagues and trainees aspire.”
Making hospitalists' lives more predictable and efficient
Judy Tan Shumway, DO, ACP Member
Medical School: College of Osteopathic Medicine of the Pacific, Western University of Health Sciences, Pomona, Calif.
Residency: Johns Hopkins University Internal Medicine Program at Sinai Hospital of Baltimore
Title: Practice group leader and regional medical director, San Antonio, Texas Region, IPC The Hospitalist Company
Hospitalists' days are inherently unpredictable, but good program leaders find ways to infuse order into the chaos. For ACP Member Judy Tan Shumway, DO, that means communicating with co-workers proactively to make schedules that ensure success for the group but are detailed enough to attend to the individual needs of her providers.
“When you don't know what's ahead of you, it can be very anxiety-provoking,” said Dr. Shumway, who leads IPC's practice group at HCA Methodist Stone Oak Hospital in San Antonio. “It used to be that our schedule was so flexible and unpredictable, you could wait out tough days until the less busy days came. But now, we are predictably busy every day we work. You have to schedule adequate time off. That's the only way to ensure time for rest and recovery.”
Dr. Shumway takes a mathematical approach to scheduling that allows for full coverage on weekends and holidays while still giving everyone adequate time off. Hospitalists work 8 consecutive days followed by 2 nights and 4 days off. She also introduced unit-based rounding, which has made physicians' whereabouts more predictable and reduced interruptions from pages.
A strong believer in work-life balance, Dr. Shumway encourages her team members to be open about their priorities. This communication is facilitated by weekly meetings and group texting which allows ample opportunity for teambuilding. Keeping the dialogue open allows adjustment in their schedules when possible.
Examples of these accommodations include shifting one hospitalist to night coverage so she could be on hand for her daughter's after-school activities, adjusting the call hours for another clinician to make sure she could attend her son's sports practices, and scheduling afternoons off for another colleague to make his tee-times.
“The schedule is like a big puzzle. Each of us have other priorities and commitments. Our pieces are made of different shapes and sizes that come together to complete that puzzle,” said Dr. Shumway. “Things work best when you have a core team that isn't just revolving through the practice. It helps with retention if you can accommodate everyone's needs.”
The benefits of unit-based rounding trickle down from hospitalists to everyone they work with in the course of a day, said Dr. Shumway. In the past, a hospitalist would admit a patient and follow her throughout her stay. But this sometimes resulted in several hospitalists present in the ICU all at once, following different patients, while other units were left without any physician presence for several hours.
“Nurses never really knew when a hospitalist would come to their unit,” said Dr. Shumway. “Now, as soon as the hospitalist hits the unit, nurses know who will be rounding on all the patients. Less anxiety translates into less need for interruptions. In fact, nursing can help us prioritize patients, i.e., who can be discharged, who needs to be seen earlier, or who is going to be off the unit for a test or procedure.”
Under the new system, consultants also find it easier to determine who is covering their patients. Surgeons can be reassured that there is always a hospitalist available on the surgery unit to follow their patients postoperatively, so that they can shift their focus to the operating rooms.
For hospitalists, working on one unit facilitates developing team relationships with staff members and gives them more time for discussions with families and patients.
“Unit-based rounding is positive on a lot of fronts because now you have a foundation on which to organize other initiatives, like physician-nurse or multidisciplinary rounding. Once a hospital can predict a hospitalist's schedule, it becomes easier to work together to achieve a mutually beneficial goal,” said Dr. Shumway.
As a leader, Dr. Shumway embraces open communication. She tends to address difficult issues head on at the local level and doesn't hesitate to call people out when something goes wrong. Her role as the Regional Medical Director of IPC in San Antonio has opened the door for her to engage the leadership from each hospital as well as the leaders in large regional and national healthcare organizations. She also serves on the Hospital Quality and Patient Safety committee and Interdisciplinary Teamwork subcommittee for the Society of Hospital Medicine.
When the hospital implemented electronic health records, for example, Dr. Shumway worked closely with the hospital CEO and insisted that physicians use electronic progress notes to facilitate handoffs. Every day, she reviewed the entire census and checked for omissions, which were addressed openly during weekly staff meetings, enabling her to keep the hospital leadership informed in real time.
“To hold people accountable you first need to make sure everyone understands why we do what we do. Once they understand they usually follow suit,” she said. “People will do things as long as they make sense. As a leader, I give them the rationale as opposed to just handing them a list of tasks that need to be done.”