Welcome to our eighth annual Top Hospitalists issue! The physicians profiled on the following pages were nominated by their colleagues and chosen by ACP Hospitalist's editorial board for their accomplishments in areas of hospitalist practice such as patient care, quality improvement, and medical education. Read on to learn about their achievements and innovations, and make a note to nominate any top docs you know next summer. Note: ACP Hospitalist's Top Hospitalists feature is not part of the ACP National Awards Program.
Nasim Afsar-manesh, MD, FACP
Medical school: University of California, Davis
Residency: University of California, Los Angeles (UCLA) Medical Center
Title: Chief quality officer in the department of medicine at UCLA Health
Trying to help more than 1 patient at a time
Nasim Afsar-manesh, MD, FACP, discovered her passion for quality improvement only a few months into her first job as a hospitalist. Although she loved caring for individual patients, she also saw the potential to make a much broader impact by improving underlying systems and processes of care.
“After my first 6 months in the hospital, I realized that we didn't always deliver care in a reliable way,” said Dr. Afsar-manesh. “If we got busy on service, for example, we might forget to ensure that everyone got DVT [deep venous thrombosis] prophylaxis or that we removed Foley catheters.”
The realization prompted her to enroll in a 4-month advanced training program focused on quality improvement at Intermountain Healthcare in Salt Lake City, after which she was asked to direct quality and safety for UCLA's department of neurosurgery and for the health system as the associate chief medical officer. She has since taken on progressively more responsibility, spearheading quality initiatives in hospital medicine and across the department of medicine.
One of her proudest accomplishments is creating a comprehensive quality improvement program encompassing 11 divisions in the department of medicine. After building a list of nationally endorsed quality measures and internal priorities, Dr. Afsar-manesh created multidisciplinary teams to formulate best practices, establish goals, and set a course for improvement.
Over the past year, the program has produced more than 53 initiatives in the areas of population health (including chronic disease management and preventive care), readmission prevention, and mortality reduction.
“All of our divisions have their respective priorities, as well as unique resources and cultures,” she said. “What was exciting for me was figuring out how to engage these diverse groups of dedicated, thoughtful providers and staff and, despite everything else they have to do, ask them to rethink how they deliver care and what could be improved.”
Clinicians have to be able to visualize how quality improvement might affect their day-to-day practice in order to buy into making changes, she said. It's important to start by explaining why a particular initiative is important and what you are trying to achieve.
“We are data-driven,” said Dr. Afsar-manesh. “For a lot of people, it's very motivating to see the data and realize they are actually improving.”
The program has produced tangible results, including a bundle of evidence-based practices for prevention of hospital-acquired infections that has led to reductions in utilization of central lines, Foley catheters, and telemetry and an increase in DVT prophylaxis.
Overseeing the department's quality programs and fulfilling clinical responsibilities, while also pursuing an MBA, adds up to much more than a full-time job, but Dr. Afsar-manesh is well suited to the challenge.
“I think it's part of my DNA to want to improve things,” she said. “When I feel like I can impact the patients in front of me, as well as the many patients who will follow after them, it's truly incredible.”
Kunal Bhagat, MD, FACP
Medical school: University of Kansas School of Medicine, Kansas City, Kan.
Residency: Christiana Care Health System, Newark, Del.
Title: Practice group leader for IPC Healthcare at Christiana Hospital in Newark, Del.
Identifying when less is more
As leader of a year-long Lean Six Sigma Green Belt project aimed at reducing inappropriate physical therapy consults, Kunal Bhagat, MD, FACP, made a useful discovery: If a consult is listed on the general admission order set, there's a good chance a physician will order it.
Order sets are designed to streamline the admission process and avoid oversights, but they can also encourage unnecessary consults and tests, which in turn can create significant waste, said Dr. Bhagat. The Green Belt project is a case in point: When physical therapy (PT) was removed from the general order set, consults fell from 36% to 27%, and the addition of 3 other measures decreased it to 7%.
“The ease of ordering was leading to unnecessary consults,” he said. “Physicians can still make the order, but it has to be a separate process as opposed to checking a box on the order set.”
A key part of reducing unnecessary care is encouraging people to become more aware and thoughtful about why they are actually ordering a consultation or test, he said. A survey of physicians and nurses performed as part of the Green Belt project revealed that PT consults are often ordered reflexively in certain clinical scenarios but could be avoided with simple observation and nursing assessments.
For example, instead of immediately ordering PT for a patient who has been lying in bed for several days, a physician could ask a nurse to walk the patient around before deciding if a consult is needed, he said. Similarly, clinicians should check an elderly patient's mobility before ordering a consult solely based on age and consider whether mobility might improve without intervention.
“Our project is making people think more about whether the medical condition that led to the patient being weak is actually going to improve, eliminating the need for PT,” he said. “Now those issues are getting discussed during rounding.”
Dr. Bhagat is known for his ability to build bridges between clinicians and hospital administration and to incorporate hospital goals—such as early discharge and patient satisfaction—into daily practice.
“Through his tireless work, he has helped meld the strengths of 2 large hospitalist groups—IPC and Christiana Care Health System's own in-house hospitalist group—into 1 highly functioning and cohesive unit,” said Adam Singer, MD, ACP Member, CEO of IPC Healthcare. “So impressive are Dr. Bhagat's contributions that he was chosen as one of IPC's Clinicians of the Year for 2014, which is the highest honor bestowed upon anyone at our company.”
Dr. Bhagat attributes his success partly to spending several years in the outpatient world before becoming a hospitalist. Having worked on both sides, he sees opportunities for cost savings that others may miss.
“Being an outpatient physician gave me insight into the things that do not need to be addressed in the inpatient setting,” he said. “A lot of times hospitalists think they're helping a patient by dealing with issues in the hospital, but an echocardiogram, for example, does not always have to be done in the hospital.”
Suparna Dutta, MD, MPH
Medical school: University of Buffalo, N.Y.
Residency: Yale University-Griffin Hospital, Derby, Conn.
Title: Medical director of the attending directed service and medical floor 7N atrium, Rush University Medical Center, Chicago
Adding communication tools and new types of clinicians to the team
When Suparna Dutta, MD, MPH, joined the hospitalist program at Rush University Medical Center, the group's patient communication scores were low, around the 20th percentile nationally. Dr. Dutta immediately saw through to the heart of the problem: Physicians didn't know what they were doing wrong or how to fix it.
“We've put a big emphasis on shifting culture and incorporating best practices into our regimen,” said Dr. Dutta. By educating physicians about best practices from the literature and giving them tools and feedback to help them improve, Dr. Dutta helped push the group's Hospital Consumer Assessment of Healthcare Providers and Systems scores into the 80th to 90th percentile.
For example, she standardized the use of hospitalist cards and whiteboards that make it easier for patients to identify the physician in charge of their care and understand the role of the hospitalist. Physicians also check in with patients later in the day to follow up on test results or procedures and coordinate with nurses and consultants to ensure everyone is delivering a consistent message.
Providing immediate, direct feedback is a critical piece of the puzzle, she said.
“We had medical students ask patients about their stay and whether their physicians had used the hospitalist cards and whiteboards,” she said. “The results were reported back to the hospitalists and residents and allowed the physicians access to more immediate and specific feedback.”
Dr. Dutta also instituted another culture change at the hospital: adding nurse practitioners and physician assistants to the care team in place of residents on a nonteaching service. Although there was some resistance to the concept of a nonteaching service at first, hospitalists now embrace the change as a way of reducing workload for all medical teams and allowing individual physicians to spend more time with each patient.
“It was a big shift for hospitalists to get used to working on a team without residents, but advanced practice providers have gradually become a necessary part of the service,” said Dr. Dutta. “We have been able to reduce our hospitalists' daily patient load from 18 to 19 to 13 to 14 patients, on average.”
The initiatives add to Dr. Dutta's impressive track record on quality improvement. In another project, she restructured morning rounds to facilitate early discharge, resulting in an increase in discharge orders before 11 a.m. from 15% to 36% in the first year.
The success of the system hinges on preparation the day before, she said. During afternoon rounds, physicians identify patients ready to go home the next day and enter conditional discharge orders, which alert nurses and others on the care team to make the necessary preparations for the next morning.
“The next day, instead of seeing the newest admissions first, physicians see patients who are likely to go home that day while residents check in with new patients,” she said. “The goal is to have attendings see the potential discharges and put in final discharge orders quickly so they can improve throughput and move on to new admissions.”
Dr. Dutta is also helping educate students about quality improvement. An elective that she initiated was so popular that she was asked to design an entire quality and safety curriculum for the medical school. As part of that, she's created an online repository for students to submit project ideas and connect with physicians or teams working in those areas.
“I'm trying to make this very hands-on,” said Dr. Dutta. “I want students to see what's really happening behind the scenes at the hospital and help them get involved.”
Hamid Feiz, MD, ACP Member
Medical school: Universidad Iberoamerican (UNIBE) School of Medicine, Santo Domingo, Dominican Republic
Residency: University of Florida Gainesville-Shands Medical Center
Title: Program director of the internal medicine residency program and chief of the division of hospital medicine, Aventura Hospital and Medical Center, Aventura, Fla.; Associate clinical dean, Nova Southeastern University School of Medicine, Fort Lauderdale, Fla.
Transforming a struggling program into a top performer
Aventura Hospital's hospitalist group was struggling with nearly 30% staff turnover and low morale when Hamid Feiz, MD, ACP Member, took over as the medical director in 2012. As if getting the program back on track wasn't challenging enough, he was also charged with launching and accrediting the Hospital Corporation of America's first graduate medical education program, an internal medicine residency at Aventura.
“We were facing a lot of challenges at that time,” said Dr. Feiz, who previously served as associate program director for the internal medicine for the residency program at Cleveland Clinic. “But the first thing I needed to do was make sure we had a functional and high quality hospitalist program that was ready to raise the bar further.”
He started by meeting with existing staff to set a new strategic course with clear vision, expectations and quality targets. Some hospitalists—struggling to handle a daily patient load of 25 to 30—were ready to resign, but most agreed to stay and give Dr. Feiz a chance to make changes.
Over the next 12 to 18 months, Dr. Feiz stabilized the staff and recruited several new hospitalists. At the same time, the group made leaps forward in quality, improving length of stay, decreasing cost per case, and improving performance on key metrics such as time from ED arrival to admission and early discharge.
“Hospitalists needed predictability in their everyday work and clear expectations in order to improve quality and efficiency of patient care,” said Dr. Feiz. “Initially, I worked alongside them on days and nights to help me get to know the challenges they were facing.”
Dr. Feiz added 4 nurse practitioners and physician assistants to the hospitalist team to improve workflow and relieve some of the pressure on physicians. They now play a crucial role in streamlining the admission and discharge process, helping with ED throughput, and providing cross-coverage on night shifts.
After Dr. Feiz's success with Aventura's hospitalist program, Hospital Corporation of America's division leadership asked him to assist with another hospitalist program that had similar challenges. The program saw significant improvements in group stability and outcomes at 12 months.
At the same time, Dr. Feiz got the residency program at Aventura up and running. Taking on the role of program director, he managed the application process for Accreditation Council for Graduate Medical Education approval, helped structure the curriculum, and recruited faculty. The program enrolled its first class of 12 residents last year and added 10 more this year.
“Dr. Feiz is held in high regard by all the residents for his mentorship and teaching skills,” said Kristoff Naberezny, MD, ACP Member, a colleague at Aventura. “Over the past year, he has given over 20 didactic lectures to our residents and has mentored various quality improvement and research projects.”
For Dr. Feiz, growing the residency program and mentoring young physicians are among the most gratifying parts of his job. He takes great pride in the fact that several residents have already been recognized at national meetings for outstanding poster or oral presentations despite competing against residents in much more established programs.
“Getting a residency program accredited and being able to help make it successful has been extremely rewarding,” he said. “The next step for me is to keep raising the bar on quality of care, patient safety and satisfaction, and scholarly activity at our teaching institution.”
Josiah Halm, MD, MS, FACP
Medical school: University of Ghana Medical School, Accra, Ghana
Residency: Cook County Hospital, Chicago
Title: Section chief of hospital medicine at the University of Texas MD Anderson Cancer Center in Houston
Carving a niche in the medical management of hospitalized cancer patients
It used to be that most cancer patients who presented to MD Anderson Cancer Center's ED with medical problems ended up spending several days in the hospital. But Josiah Halm, MD, MS, FACP, had a hunch that better coordination between hospitalists and ED physicians might result in shorter stays for patients who did not require intensive management.
To test the idea, the hospital launched an observation unit pilot program aimed at speeding the discharge process for patients whose medical complications required follow-up care but not necessarily a prolonged hospital stay. Under the program, hospitalists would designate certain patients as observation status so they could get immediate attention.
“We take care of the acute post-ED visit and discharge patients in a timely fashion,” said Dr. Halm, who became the unit's first director following the success of the pilot. “Patients can return home earlier, and it frees up beds and decreases costs for the hospital.”
He is also working on establishing a discharge clinic to keep some of those patients from being readmitted within 30 days. The idea grew out of a research study in which Dr. Halm and his colleagues discovered that many hospitalized patients with advanced disease or multiple comorbidities are readmitted at a median of 10 days after discharge.
The researchers concluded that better coordination among primary care physicians, oncologists, and other specialists to manage comorbidities might decrease the readmission rate. They also observed that patients discharged to hospice were less likely to be readmitted, suggesting a role for hospitalists in aiding that transition.
Both initiatives demonstrate Dr. Halm's ability to build consensus and collaborate across departments to improve quality and efficiency, said Carmen Escalante, MD, chair of the MD Anderson's department of internal medicine.
“Dr. Halm has superb interpersonal skills and is greatly admired by his colleagues for his fair and reasonable approach in addressing issues,” said Dr. Escalante. “He always exhibits calmness when faced with difficult and critical situations. This characteristic is noteworthy in a busy, fast-paced, and frequently stressful environment of inpatient care.”
Those qualities have also helped build trust between oncologists and hospitalists at the cancer center. Since Dr. Halm's arrival, hospitalists have taken on increasingly greater responsibility for the medical management of cancer patients, expanding from gastrointestinal medical oncology patients to almost all solid tumor patients admitted for medical problems.
“We can manage cancer patients' comorbidities and get them well enough to resume treatment in a timely fashion or help with transitioning to hospice,” said Dr. Halm. “We as hospitalists have come to understand the unique issues that these patients face related to chemotherapy or radiation and how they affect overall care.”
To help meet the growing demand for hospitalists specializing in oncology, Dr. Halm and the division of internal medicine recently partnered with Houston-based Baylor College of Medicine to launch MD Anderson's first internal medicine residency program, designed to train future internists in treating the medical complications of cancer and related treatments. Plans are also in the works for an oncology hospitalist fellowship program.
“We want to be known as the premier place for the hospitalized cancer patient,” said Dr. Halm, “advancing clinical care, quality improvement, patient safety, research, and education.”
Joan Krikava, MD, FACP
Medical school: University of Minnesota, Minneapolis
Residency: Abbott Northwestern Hospital, Minneapolis
Title: Chair of the hospitalist department, New Ulm Medical Center, New Ulm, Minn.
Blazing a trail in rural hospital medicine
Back in the early 2000s, it was difficult to drum up much support for starting a hospitalist service in the rural community of New Ulm, Minn. Primary care physicians were used to caring for all of their patients' needs and resisted the idea of handing over the reins at hospital admission.
But Joan Krikava, MD, FACP, pushed forward, guided by a gut feeling that a hospital medicine program and dedicated ED staff would help the 25-bed New Ulm Medical Center, which serves a community of about 13,500, attract new talent down the road.
“It was becoming a real recruitment disadvantage to expect physicians to run from clinic to emergency room to hospital,” said Dr. Krikava, who previously spent 24 years with Physicians Group of New Ulm, both as an office-based internist and as medical director of clinic and hospital services. “It became clear that if we didn't change something, we were going to have a really hard time keeping our clinic staffed as some of our physicians got closer to retirement.”
It took some time to get funding and convince physicians to buy into the plan, but in 2007 New Ulm launched its first hospitalist service, with 6 physicians led by Dr. Krikava. In addition to 24/7 general inpatient care, the group provided consultations to surgery, obstetrics, and psychiatry.
There are some advantages to working in a small center, Dr. Krikava observed, such as familiarity between hospital and outpatient physicians, which facilitates handoffs and coordination of care between the hospital and adjoining ambulatory clinic, where most of the town's primary care physicians see patients. Primary care physicians can easily check on their hospitalized patients and communicate with attending hospitalists.
“We get a lot of nuanced information from primary care physicians that can help improve the patient's stay,” she noted. “And many of the hospitalists are people who have lived in the community for a long time, so many patients already know them.”
Still, rural medicine presents some unique challenges, said Dr. Krikava. Hospitalists must be able to make quick decisions about triaging patients to the appropriate level of care—which could be 100 miles away in Minneapolis-St. Paul or Rochester.
“As a 25-bed hospital, we don't have everything a bigger hospital has, and it takes a great deal of organization to stabilize patients who are unstable and oversee getting them transferred,” she said. “You don't want to send away the patients that you're capable of caring for, but you also don't want to keep someone who needs a higher level of care.”
She stepped away from her administrative role as medical director 2 years ago to work full time on patient care, which is still her favorite part of the job.
Dr. Krikava connects with her patients in a special way, according to Lori Wightman, RN, former president of New Ulm Medical Center: “She uses her own life experiences to help understand patients and help them find the strength to get through difficult situations.”
Phuoc Le, MD
Medical school: Stanford University School of Medicine, Stanford, Calif.
Residency: Harvard Medical School (Brigham and Women's Hospital, Massachusetts General Hospital)
Title: Assistant professor of medicine and pediatrics, University of California, San Francisco; Assistant professor of public health, University of California, Berkeley
Former refugee becomes a force for global health
Phuoc Le, MD,'s path from a rural village in Vietnam to the halls of Harvard and Stanford is a classic example of how the American dream is supposed to play out. He was born just after the end of the Vietnam War, and one of his earliest memories is fleeing the country with his mother on a small fishing boat en route to Hong Kong and eventual political asylum in the United States.
“We lived in housing projects in Wichita, Kan., and then went to live near relatives in Sacramento,” said Dr. Le. “I went to a gang-ridden high school where achievement was not the norm, but my siblings and I got through it because we were grateful for the chance just to go to school.”
Dr. Le went on to attend some of the most revered schools in the country, including completing a combined medicine, pediatrics, and global health equity residency at Harvard Medical School in Boston, where he worked under Partners in Health cofounder Paul Farmer, MD. The 5-year residency program, which included stints in Haiti, Rwanda, and other poor countries, cemented his passion for global health.
“I wanted to do more than see patients at the ends of their lives when diseases have become irreversible,” said Dr. Le, who also holds a master's degree in public health and is fluent in Vietnamese, Chinese, and Spanish. “Working with Paul, I saw firsthand how global health is practiced and how the root causes of diseases—such as access to running water and electricity—are addressed.”
His experiences set the stage for becoming a full-time hospitalist, with an emphasis on global health, said Dr. Le. His work with Partners in Health taught him about the value of working in teams to improve systems, skills that are readily transferable to hospital medicine.
At the University of California, San Francisco (UCSF), Dr. Le helped to initiate a Global Health Core within the hospital medicine division. The group has grown from 5 to 12 faculty members and also launched the nation's first Hospital Medicine-Global Health Fellowship, establishing UCSF as a leader in the emerging field.
“When Phuoc joined UCSF, we had a few hospitalists interested in global health and had set up small initiatives in Africa, Asia, and China,” said Bradley Sharpe, MD, UCSF's associate chief of hospital medicine. “Phuoc's arrival changed everything, and we now have become a magnet for hospitalists with this interest.”
Dr. Le and his team make regular trips to a hospital in Hinche, Haiti, where they have maintained a close partnership since the 2010 earthquake. They also visit rural hospitals in India, Liberia, and Nepal several times a year, where they have global health fellows working with partner organizations to strengthen health systems.
One of Dr. Le's most successful recent initiatives is the UCSF Global Health Boot Camp, a 4-day CME course that teaches strategies for working in the developing world to physicians, nurses, pharmacists, and others. The first course in 2014 attracted so much interest that some applicants had to be turned away. Dr. Le also established the Health, Equity, Action, and Leadership, or HEAL, initiative, a 2-year fellowship for physicians, nurses, and pharmacists that involves working in underserved domestic, as well as international, communities.
“Every fellow spends half of their time in the Navajo Nation in New Mexico or Arizona, where there is a staggeringly high prevalence of diabetes, hypertension, liver disease, and other problems,” said Dr. Le. “Many of the root causes of disease we see in developing countries are also happening here.”
Felipe Orellana, MD
Medical school: University of Missouri-Kansas City
Residency: University of Missouri-Kansas City
Title: Practice group leader for IPC Healthcare and chief medical officer at Barnes Jewish-St. Peters Hospital, St. Louis
Ambitious CPOE rollout leads to better care, fewer errors
While treating diabetic patients, Felipe Orellana, MD, noticed a disturbing trend: Many type 1 diabetics were not getting the basal insulin they needed, putting them at risk for hyperglycemia or diabetic ketoacidosis. Fortunately, as lead physician of a systemwide computerized physician order entry (CPOE) rollout, he was in a position to do something about the problem.
“We found that many diabetics were being misidentified as type 2 and having their medications withheld before procedures,” said Dr. Orellana. “We worked with admitting physicians and nurses to screen these patients based on their past medical history and medications to make sure they were not misdiagnosed.”
An evidence-based order set in the CPOE is now helping prevent complications in diabetic patients treated at Barnes Jewish-St. Peters, a 110-bed community hospital that is part of the 12-hospital nonprofit BJC Healthcare system. It is one of 150 new CPOE order sets, which are continuously updated to reflect emerging evidence on best practices and medications for a wide range of diagnoses.
Dr. Orellana's experience developing these order sets drove home the crucial role of standardizing best practices to prevent medication and clerical errors that can lead to poor patient outcomes, he said. The CPOE project was ambitious but proved both reassuring and educational.
“We pulled together groups of physicians from different specialties and hospitals who had never collaborated in the past to come up with standardized practices,” said Dr. Orellana. “Physicians got a chance to see how their peers were doing things and who was getting good results. We found we could learn from one another and improve overall care.”
Dr. Orellana also mounted an effective campaign to educate physicians about the new system and encourage them to use it. As a result of his efforts, 80% of physicians have integrated the system into their everyday practice, making Barnes Jewish-St. Peters the top hospital in the BJC Healthcare system for CPOE compliance.
As chief medical officer, Dr. Orellana is also a key player in helping the hospital reach quality targets. For example, he helped to establish multidisciplinary teams of physicians, nurses, administrators, and pharmacists, among others, to track progress on common issues, such as preventing central-line bloodstream infections, Clostridium difficile, and catheter-associated urinary tract infections and providing deep venous thrombosis prophylaxis.
The effort has been successful on several fronts, including a 25% improvement in falls and injuries per 1,000 patient-days.
Central to Dr. Orellana's success as a leader is his emphasis on teamwork and his ability to encourage and motivate others, said Adam Singer, MD, ACP Member, CEO of IPC Healthcare.
“He not only mentors his staff and colleagues, but has made it a priority to encourage individual initiative,” said Dr. Singer. “For example, he rounds with nurses who are studying to obtain their Master's to become an NP and helps them with their education.”
For Dr. Orellana, the opportunity to help improve overall quality and delivery of care is a major source of job satisfaction. “Our job extends beyond direct patient care,” he said. “We can make a big impact through our experience and what we notice. I always keep my eyes open for ways to improve care and make things safer.”
Ankur Segon, MD, FACP
Medical school: University College of Medical Sciences, New Delhi, India
Residency: St. Francis Hospital, Evanston, Ill.
Title: Associate professor of general internal medicine, Medical College of Wisconsin, Milwaukee
Designing education that reflects real-world practice
Attendance at the Medical College of Wisconsin's sub-internship capstone course was hovering at around 40% when Ankur Segon, MD, FACP, took over as director in 2011. To boost interest in the half-day sessions, he came up with a novel strategy: Let the students decide on the content.
“We started having students vote on the topics they wanted to learn about,” said Dr. Segon, who directs the month-long course for fourth-year medical students. “My feeling was that these students are really focused on becoming interns the following year, and they would want to learn about the things that would help them most with that major transition.”
Now, instead of dissecting clinical case studies, students are exposed to topics such as anticoagulation and antibiotic prescribing, cross-coverage scenarios, or approaches to common diagnoses. Student response has been overwhelmingly positive, driving attendance up to almost 80%.
It's one way that Dr. Segon has expanded the medical student curriculum to include more practice-oriented topics, such as discharge planning and coordination with nurses and other clinicians. He's also sparked interest in hospital medicine by introducing a popular elective rotation and taking the lead in creating an academic fellowship program that will enroll its first class in July 2016.
His efforts have earned him stellar teaching evaluations as well as recognition by his institution, which awarded him its faculty vitality award in 2014.
At the same time, Dr. Segon has been actively involved in several quality improvement projects. In one, he designed a randomized controlled trial in which hospitalists in an intervention group received next-day feedback on how well they communicated with patients and how they scored in relationship to their peers.
“We found that satisfaction scores were 5% higher in the intervention group,” said Dr. Segon. “If you get an e-mail in the morning saying your patient satisfaction scores are around 40% while the rest of the section's is around 80%, it's a motivation to go back and think about the previous day and how you might do things differently.”
The project is now being expanded to the entire hospital medicine section and revised to include patient comments as well as numerical scores.
Another project aimed at reducing average length of stay (LOS) for community-acquired pneumonia. Hospitalists receive regular reports on their individual LOS averages compared with section benchmarks, along with a list of recommended best practices. Although the data haven't yet been analyzed, the idea is to help physicians improve by giving them useful data and practical tools.
“The key thing that's important in any project is taking into account what the front-line person, whether it's a learner or a hospitalist, really needs to know,” said Dr. Segon. “People are motivated to do well, and change should be built around giving them the right tools to help them get their work done in the best possible way.”
Simonne Stahl, MD
Medical school: Université Claude Bernard, Lyon, France
Residency: St. Michael's Medical Center, Newark, N.J.
Title: Hospitalist, Onslow Memorial Hospital, Jacksonville, N.C.
Volunteering at free clinic helps lower readmissions of poor, uninsured
After putting in 12-hour-plus days for 7 days straight, most hospitalists look forward to relaxing a bit during their week off. But Simonne Stahl, MD, chooses to spend at least part of that time at a nearby clinic caring for patients who might otherwise have no access to follow-up care after leaving the hospital.
“The patients I see at the clinic might be the same ones I saw in the hospital last week with uncontrolled diabetes or hypertension,” said Dr. Stahl, who volunteers at least 1 day every other week at the Caring Community Clinic, a free primary care service for low-income and uninsured patients supported by Onslow Memorial Hospital. “Without the clinic, not only would these patients return to the hospital, but their life expectancies would probably be very poor.”
Providing funding for the clinic also makes business sense for Onslow Memorial as a way of preventing 30-day readmissions due to lack of follow-up care among patients lacking access to primary care services. Dr. Stahl suspects that the clinic also helps avert initial ED visits by offering preventive care to patients who could not otherwise afford it.
“I've seen the worst disease of my career at this clinic,” said Dr. Stahl, who spent 15 years working as an ED physician before becoming a hospitalist. “One young woman with uncontrolled diabetes became a bilateral amputee due to a bone infection. Several women who never had access to preventive screening have come in with large masses in their breasts.”
Because North Carolina did not expand Medicaid under the Affordable Care Act, low-income adults in the state, many of whom work, often cannot afford to seek regular primary care, said Dr. Stahl. As a result, they end up in the hospital when they have serious or end-stage diseases requiring expensive—but often unsuccessful—treatments.
While those cases can be frustrating for physicians, Dr. Stahl takes great satisfaction in being able to help some patients and connect with them beyond their hospital stay. A young man diagnosed with heart failure is a case in point.
“We recently treated a 35-year-old man who came in with very high blood pressure and heart failure, gave him medications, and referred him to a cardiologist at our hospital who waived his fee,” said Dr. Stahl. “He went on to be treated for heart failure at a tertiary center, and the other day his girlfriend told me that he was playing basketball and had his life back.”
Dr. Stahl, who is board-certified in both emergency and internal medicine, spent much of her career working in busy trauma centers. She enjoyed the intensity of the work but said that hospital medicine is a much better fit.
“As soon as I started rounding on patients, I knew this was my niche,” she said. “Intellectually it's so much more rewarding to treat patients admitted to the hospital rather than just triage them in the ED. Hospitalists and primary care physicians working together can make a big difference in patients' lives.”