As pressure mounts on hospitals to improve quality and reduce costs, they have turned to medicine's fastest growing physician specialty—hospital medicine---to improve clinical performance and operational efficiency. How this new role for hospitalists plays out varies according to the type, location and creativity of individual healthcare organizations and the resources available to them. This editorial webinar will explore the steps health care organizations should take to prepare and position their hospitalists for quality-improvement responsibilities. Our panel of experts will share their insights, experiences and proven strategies for success.

1. WEBINAR WELCOME!
How hospitalists can lead on quality
Dr. Kevin O’Leary
Chief of the Division of
Hospital Medicine
Northwestern University
Feinberg School of Medicine
Dr. Vercin Ephrem
Chief of Hospital
Medicine
LRGHealthcare
Maureen McKinney
Editorial Programs
Manager
Modern Healthcare
During today’s discussion, feel free to submit
questions at any time by using the questions box.
A follow-up e-mail will be sent to all attendees
with links to the presentation materials online.
Dr. Robert Wachter
Chief of the Division
of Hospital Medicine
UCSF Medical Center
Panelists:

2. WEBINAR HOUSEKEEPING

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

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

5. Wachter RM, Goldman L. NEJM 1996

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

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

8. Why We’re Being Pressured to Change

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

10. Do Data Support Hospitalists’’’’ ““““Value””””?
Yes (generally)
Wachter, JAMA 2002 & many others
Key organizational question: do the advantages of
focused practice and on-site presence outweigh the
disadvantages of ““““purposeful discontinuity””””
Vast majority of published studies show ~15% fall
in costs and LOS; many now show better quality

11. The Fundamental Economic
Truths of the Hospitalist Field
Non-procedural E&M hospital codes are a
tough way to make a living
90% of hospitalist groups receive support
– > $20B (40K hospitalists x $150K/MD x 90%) in
new hospital -> MD dollars since field began
This isn’t charity: there must be a ROI
– Initially, this was cost and LOS reduction
– Now increasingly quality, safety, pt experience, IT
A positive side-effect: unique hospital-MD
alignment/synergy; perhaps a model for others

12. 50-60% comes
from the hospital

13. My Decision as SHM Prez in 1999
Risk that hospitalists were being branded as
being all about efficiency, LOS
No physician wants to be “about”
getting grandma out of the
building a day earlier
To Err is Human published:
opportunity for hospital
medicine to “own” safety, quality
The “two sick patients” mantra

14. Business Case for Quality and
Safety has Grown
Percent of hospital dollars at risk based on
performance in 2000: zero
Percent at risk in 2008: zero (but stricter
accreditation requirements, public reporting)
Percent at risk in 2014: 3-4%
Percent at risk in 2017: 7-8%
Percent at risk in 2020: who knows, but more

15. Value Oversight
Committee
Quality
Improvement
(ie, Evidence-
based Practices)
Pt Experience
(ie, HCAHPS
scores, patient
complaints)
Patient Safety
(ie, Case revus,
Safety Culture,
“Never
Events”)
Cost/Waste
Reduction
Targeted
Initiatives
(ie, Nebs to
MDIs, less labs)
Lean Initiatives
(ie, Improving
discharge
process)
Numerator of the Value Equation Denominator of the Value Equation
UCSF’s Model Organizational Chart
for a “Value Improvement” Program

16. Hospitalists as System Leaders

17. The Bottom Line and a Few Predictions
Hospitalists are now the major U.S. providers of hospital
care
Studies will continue to show improved value
The Swiss-army-knife-nature of the field will make it a
perpetually exciting (and challenging) place to be
– Uniquely context dependent
Often an island of MD-hospital integration in a non-ACO
world (and doesn’t take 50 yrs to build)
The U.S. healthcare marketplace will
not tolerate failure to innovate in the
name of tradition

18. Could this be worse?

19. “We think that the anxiety, demoralization, and sense of
loss of control that afflict all too many healthcare
professionals today comes not from finding themselves
to be participants in systems of care, but rather from
finding themselves lacking the skills and knowledge to
thrive as effective, proud, and well-oriented agents of
change in those systems…. A physician equipped to help
improve healthcare will be not demoralized, but
optimistic; not helpless in the face of complexity, but
empowered; not frightened by measurement, but made
curious and more interested; not forced by culture to
wear the mask of the lonely hero, but armed with
confidence to make a better contribution to the whole.”
Berwick & Finkelstein, Acad Med 2010

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

21. LRGHealthcare
• Lakes Region General Hospital-137 Bed Rural Community Hospital
• Franklin Regional Hospital-25 Bed Critical Access Hospital
• Two Ambulatory Surgery Centers
• 100+ Provider Practices including 2 Rural Health Clinics
• 13 Hospitalists & 6 APRNs for 2 hospitals & 4 Nursing Homes
• 32,597 ED Visits/Year, 16 % ED Admits

22. Hospitalists in Community Hospital
Leading Quality
• Ideal Position, Since Hospitalist is Knowledgeable about the Entire
Patient Care Continuum
• Working with Same Team on a Daily Basis to Ensure Best Practices
Are Followed
• Easier to Implement Quality Improvements projects & Ensure that
they are Being Followed
• Ability to Involve Other Community Partners in Quality Projects

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

24. • Launched in 2010, BOOST Implementation Team included
other Health Care Related Agencies including Home Health,
Mental Health, Long Term Care
•Common Goals
•Developed Systems to Communicate & Coordinate in
Caring for Patients
•Used all the BOOST Tools such Risk Identification, Teach-
Back, etc.
Implementation of BOOST-Better Outcomes By
Optimizing Safe Transitions

25. • Patient Flow Meetings:
• Co-Chairs Hospitalist/ ER
• Bed “Czar” Concept
• “Bed Ahead” Process
• Bridge Orders to Facilitate Admission
• Hall Beds
Process Improvements in Transitioning Patients from
ED to Bed

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

27. •Daily Rounding with Hospitalist and the Entire
Multidisciplinary Team
•Medication Reconciliation with Hospitalist and Clinical
Pharmacist Day Prior to Discharged
•Weekly Meeting to Discuss “Challenging Discharges” &
Review of Readmissions for Learning by Team
•“Almost Home” to Teach Patients/Families to Care for
Themselves at Home
•As of Feb, 2015, Bedside Medication Delivery Prior to
Discharge
Process Improvements in Transitioning Patients from
Bed to Discharge

28. • Home Care, Embedded Care Coordinator, Long Term
Care Staff at Discharge Planning Meeting Helping to
Facilitate Communication About Patient
• Hospitalist contacting PCP Prior to Discharge
• Follow up Appointment with PCP within 3 to 7 Days
• Embedded Care Coordinators making follow up
phone calls to patients within 48 hours of Discharge
• Hospitalists caring for patients in the Nursing Homes
Transitioning Patients from Discharge to
Nursing Home or Home

29. The Rate for the Top 10% of US Hospitals is 16.9%-We are 16.9%
We are 221 out of 2331 Hospitals
LRGH
LRGH

30. The Top 10% of US Hospital Rate is 20.9%- We are 21.7%
We are 785 out of 3996 Hospitals & went from 18 in NH
to 8
LRGH LRGH

31. Top 10% of US Hospital Rate is 15.9%-- We are 16.6%
We have to reduce readmissions by 0.7%-top 10% of
Hospitals
LRGH
LRGH

32. LRGHealthcare

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

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

35. Recognize trends that affect both
hospitals and hospital medicine

36. ACA Impact on Hospitals
• Will expand the base of insured patients
• Decrease overall payment rates to hospitals
• Incentives and penalties
– Readmission Reduction Program
– Value Based Purchasing
– HAC Reduction Program
– Bundled payments
– Accountable Care Organizations

37. Source: New York Times

38. What does consolidation mean for
hospitalists?
• Hospitals will prefer single group per hospital
• Lays foundation for true partnership
• Potential for collaboration across sites
– Joint recruitment, credentialing
– Share best practices, innovate on larger scale
• Pressure to address population health (high
utilizers, recidivist patients)

39. Create innovative partnerships
between hospitalists and hospital

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

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

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

43. • Unit Based Co-leadership
– Nurse manager and unit medical director
– Co-leadership training
• Structured Inter-Disciplinary Rounds (SIDR)
– Designed by frontline professionals
– Uses a structured communication tool
– Nurse manager & medical director co-facilitate
– All RNs, physicians, pharmacists, social work, and
case management attend
INTERACT Intervention:
Unit Based Co-leadership and SIDR

44. INTERACT Results
• Significant improvements in collaboration & teamwork
• Significant reduction in rate of adverse events
O’Leary KJ et al. J Hosp Med. 2010. O’Leary KJ et al. Arch Intern Med. 2011.
89
46
0
10
20
30
40
50
60
70
80
90
100
Physicians rate
RNs
RNs rate
Physicians
90
76
0
10
20
30
40
50
60
70
80
90
100
Physicians rate
RNs
RNs rate
Physicians
Control Units Intervention Units
Graphs show % rating collaboration as high or very high

45. Develop Quality Improvement
Leaders

46. Professional Development
Opportunities in QI
• Internal programs
• Certificate programs
– Intermountain Healthcare ATP, IHI, NAHQ
• Masters programs
– Northwestern, Thomas Jefferson University
Hospitals should invest in professional development

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

50. WEBINAR
TODAY’S PANELISTS
How hospitalists can lead on quality
During today’s discussion, feel free to submit questions at any time by using the questions box
Dr. Kevin O’Leary
Chief of the Division of
Hospital Medicine
Northwestern University
Feinberg School of Medicine
Dr. Vercin Ephrem
Chief of Hospital
Medicine
LRGHealthcare
Maureen McKinney
Editorial Programs
Manager
Modern Healthcare
Dr. Robert Wachter
Chief of the Division
of Hospital Medicine
UCSF Medical Center

51. Expect a follow-up email within two weeks
with links to presentation materials and
information about how to offer feedback.
For more information about
upcoming webinars, please visit
ModernHealthcare.com/webinars
WEBINAR THANK YOU FOR ATTENDING
How hospitalists can lead on quality
Thanks also to our panelists:
Dr. Kevin O’Leary
Chief of the Division
of Hospital Medicine
Northwestern University
Feinberg School of Medicine
Dr. Vercin Ephrem
Chief of Hospital
Medicine
LRGHealthcare
Maureen McKinney
Editorial Programs
Manager
Modern Healthcare
Dr. Robert Wachter
Chief of the Division
of Hospital Medicine
UCSF Medical Center