Hospitalist Shared Leadership for Safety, Health, and Well-Being at Work: United States, 2022‒2023.

We assessed how hospitalists frame workplace safety, health, and well-being (SHW); their perception of hospital supports for SHW; and whether and how they are sharing leadership responsibility for each other's SHW. Our findings highlight the important role of local support for hospitalist SHW and reveal the systemic, hospital-wide problems that may impede their SHW. We believe that positioning hospitalists as leaders for SHW will result in systems-wide changes in practices to support the SHW of all care team members. (Am J Public Health. 2024;114(S2):S162-S166. https://doi.org/10.2105/AJPH.2024.307573).

Exploring the Impact of COVID-19 on Women Hospitalists: A Mixed-Gender Qualitative Analysis.

BACKGROUND: Women physicians have faced persistent challenges, including gender bias, salary inequities, a disproportionate share of caregiving and domestic responsibilities, and limited representation in leadership. Data indicate the COVID-19 pandemic further highlighted and exacerbated these inequities. OBJECTIVE: To understand the pandemic's impact on women physicians and to brainstorm solutions to better support women physicians. DESIGN: Mixed-gender semi-structured focus groups. PARTICIPANTS: Hospitalists in the Hospital Medicine Reengineering Network (HOMERuN). APPROACH: Six semi-structured virtual focus groups were held with 22 individuals from 13 institutions comprised primarily of academic hospitalist physicians. Rapid qualitative methods including templated summaries and matrix analysis were applied to identify major themes and subthemes. KEY RESULTS: Four key themes emerged: (1) the pandemic exacerbated perceived gender inequities, (2) women's academic productivity and career development were negatively impacted, (3) women held disproportionate roles as caregivers and household managers, and (4) institutional pandemic responses were often misaligned with workforce needs, especially those of women hospitalists. Multiple interventions were proposed including: creating targeted workforce solutions and benefits to address the disproportionate caregiving burden placed on women, addressing hospitalist scheduling and leave practices, ensuring promotion pathways value clinical and COVID-19 contributions, creating transparency around salary and non-clinical time allocation, and ensuring women are better represented in leadership roles. CONCLUSIONS: Hospitalists perceived and experienced that women physicians faced negative impacts from the pandemic in multiple domains including leadership opportunities and scholarship, while also shouldering larger caregiving duties than men. There are many opportunities to improve workplace conditions for women; however, current institutional efforts were perceived as misaligned to actual needs. Thus, policy and programmatic changes, such as those proposed by this cohort of hospitalists, are needed to advance equity in the workplace.

Prevalence and Causes of Diagnostic Errors in Hospitalized Patients Under Investigation for COVID-19.

BACKGROUND: The COVID-19 pandemic required clinicians to care for a disease with evolving characteristics while also adhering to care changes (e.g., physical distancing practices) that might lead to diagnostic errors (DEs). OBJECTIVE: To determine the frequency of DEs and their causes among patients hospitalized under investigation (PUI) for COVID-19. DESIGN: Retrospective cohort. SETTING: Eight medical centers affiliated with the Hospital Medicine ReEngineering Network (HOMERuN). TARGET POPULATION: Adults hospitalized under investigation (PUI) for COVID-19 infection between February and July 2020. MEASUREMENTS: We randomly selected up to 8 cases per site per month for review, with each case reviewed by two clinicians to determine whether a DE (defined as a missed or delayed diagnosis) occurred, and whether any diagnostic process faults took place. We used bivariable statistics to compare patients with and without DE and multivariable models to determine which process faults or patient factors were associated with DEs. RESULTS: Two hundred and fifty-seven patient charts underwent review, of which 36 (14%) had a diagnostic error. Patients with and without DE were statistically similar in terms of socioeconomic factors, comorbidities, risk factors for COVID-19, and COVID-19 test turnaround time and eventual positivity. Most common diagnostic process faults contributing to DE were problems with clinical assessment, testing choices, history taking, and physical examination (all p < 0.01). Diagnostic process faults associated with policies and procedures related to COVID-19 were not associated with DE risk. Fourteen patients (35.9% of patients with errors and 5.4% overall) suffered harm or death due to diagnostic error. LIMITATIONS: Results are limited by available documentation and do not capture communication between providers and patients. CONCLUSION: Among PUI patients, DEs were common and not associated with pandemic-related care changes, suggesting the importance of more general diagnostic process gaps in error propagation.

Adaptability on Shifting Ground: a Rapid Qualitative Assessment of Multi-institutional Inpatient Surge Planning and Workforce Deployment During the COVID-19 Pandemic.

BACKGROUND: During the initial wave of COVID-19 hospitalizations, care delivery and workforce adaptations were rapidly implemented. In response to subsequent surges of patients, institutions have deployed, modified, and/or discontinued their workforce plans. OBJECTIVE: Using rapid qualitative methods, we sought to explore hospitalists' experiences with workforce deployment, types of clinicians deployed, and challenges encountered with subsequent iterations of surge planning during the COVID-19 pandemic across a collaborative of hospital medicine groups. APPROACH: Using rapid qualitative methods, focus groups were conducted in partnership with the Hospital Medicine Reengineering Network (HOMERuN). We interviewed physicians, advanced practice providers (APP), and physician researchers about (1) ongoing adaptations to the workforce as a result of the COVID-19 pandemic, (2) current struggles with workforce planning, and (3) evolution of workforce planning. KEY RESULTS: We conducted five focus groups with 33 individuals from 24 institutions, representing 52% of HOMERuN sites. A variety of adaptations was described by participants, some common across institutions and others specific to the institution's location and context. Adaptations implemented shifted from the first waves of COVID patients to subsequent waves. Three global themes also emerged: (1) adaptability and comfort with dynamic change, (2) the importance of the unique hospitalist skillset for effective surge planning and redeployment, and (3) the lack of universal solutions. CONCLUSIONS: Hospital workforce adaptations to the COVID pandemic continued to evolve. While few approaches were universally effective in managing surges of patients, and successful adaptations were highly context dependent, the ability to navigate a complex system, adaptability, and comfort in a chaotic, dynamic environment were themes considered most critical to successful surge management. However, resource constraints and sustained high workload levels raised issues of burnout.

Effect of an attending nurse on timeliness of discharge, patient satisfaction, and readmission.

AIMS: To improve the timeliness and quality of discharge for patients by creating the role of the attending nurse. BACKGROUND: Discharge time affects hospital throughput and patient satisfaction. Bedside nurses and hospitalists have competing priorities that can hinder performing timely, high-quality discharges. METHODS: This retrospective analysis evaluated the effect of an attending nurse paired with a hospital medicine physician on discharge time and quality. A total of 8329 patient discharges were eligible for the study, and propensity score matching yielded 2715 matched pairs. RESULTS: In the post-intervention matched cohort, the percentage of patients discharged before 2 PM increased from 34.4% to 45.9% (p < .01), and the median discharge time moved 48 min earlier. In the unmatched cohort, patient satisfaction with the discharge process improved on several questions. While length of stay was not affected, the 30-day readmission rate did increase from 8.9% to 10.7% (p = .02). CONCLUSION: With the new attending nurse role, we positively impacted throughput by shifting discharge times earlier in the day while improving patient satisfaction. Length of stay stayed the same but the 30-day readmission rate increased. IMPLICATIONS FOR NURSING MANAGEMENT: Our multidisciplinary approach to the problem of late discharge times led to the creation of a new role. This role made ownership of discharge tasks clear and reduced competing priorities, freeing up nurses and hospitalists to perform other care-related responsibilities without holding up discharges.

Bracing for the Wave: a Multi-Institutional Survey Analysis of Inpatient Workforce Adaptations in the First Phase of COVID-19.

BACKGROUND: Medical centers across the country have had to rapidly adapt clinician staffing strategies to accommodate large influxes of patients with the coronavirus disease 2019 (COVID-19). OBJECTIVE: We sought to understand the adaptations and staffing strategies that US academic medical centers employed in the inpatient setting early in the spread of COVID-19, and to assess whether those changes were sustained during the first phase of the pandemic. DESIGN: Cross-sectional survey assessing organization-level, team-level, and clinician-level inpatient workforce adaptations. PARTICIPANTS: Hospital medicine leadership at 27 academic medical centers in the USA. KEY RESULTS: Twenty-seven of 36 centers responded to the survey (75%). Widespread practices included frequent staffing reassessment, organization-level changes such as geographic cohorting and redeployment of non-hospitalists, and exempting high-risk healthcare workers from direct care of patients with COVID-19. Several practices were implemented but discontinued, such as reduction of non-essential services, indicating that they were less sustainable for large centers. CONCLUSION: These findings provide guidance for inpatient leaders seeking to identify sustainable practices for COVID-19 inpatient workforce planning.

Use of Unit-Based Interventions to Improve the Quality of Care for Hospitalized Medical Patients: A National Survey.

BACKGROUND: Recent publications have drawn attention to interventions to redesign aspects of care delivery for hospitalized medical patients, including localization of physicians to specific units, nurse-physician co-leadership, interdisciplinary rounds (IDR), and access to quality performance data. Use of these interventions across hospitals has not been previously described. METHODS: A cross-sectional survey of internal medicine (IM) residency program directors and hospital medicine group (HMG) leaders in the United States was conducted to characterize use of unit-based interventions on inpatient medical services. The survey served as a pilot study to assess the use of localization of physicians to specific units, nurse-physician co-leadership, IDR, and access to quality performance data. RESULTS: Ninety-four IM program directors (response rate, 23.3%) and 62 HMG leaders (response rate, 20.7%) responded. No single intervention was used by the vast majority of sites, and the extent and intensity of use varied. About a quarter of respondents indicated that physicians typically cared for patients on only one to two units, a third or fewer had unit co-leadership on at least half of hospital units, fewer than half had daily IDR, and approximately half had access to unit-level performance data. Most IM programs and hospitalist groups had implemented 0 to 1 interventions to a high degree of fidelity, and few (≤ 5%) had implemented all 4. CONCLUSION: IM program directors and HMG leaders reported variation in use of unit-based interventions to improve quality of care for medical inpatients. Future research should evaluate the association of the degree and intensity of using unit-based interventions on patient outcomes.

Contextual Factors Influencing the Implementation of a Multifaceted Intervention to Improve Teamwork and Quality for Hospitalized Patients: A Multisite Qualitative Comparative Case Study.

BACKGROUND: Many hospitals have begun to implement models that combine interventions to redesign care for medical patients. These models include localization of physicians to specific units, nurse-physician co-leadership, and interprofessional rounds. Understanding contextual factors, the circumstances surrounding an implementation effort that influence its success, is essential to provide guidance to leaders implementing similar models of care. METHODS: A multisite qualitative comparative case study was conducted with four hospitals in the REdesigning SystEms to Improve Teamwork and Quality for Hospitalized Patients (RESET) study. Researchers conducted observations and semistructured interviews with 40 health care professionals and four implementation mentors. Researchers used inductive qualitative content analysis, reviewed fidelity of implementation trends, and performed cross-case analysis to identify contextual factors and their influence on implementation. RESULTS: Four contextual factors were associated with implementation success: (1) senior hospital leader involvement and organizational support; (2) alignment of RESET with organizational, hospital, and professional group priorities; (3) site leaders' engagement in RESET and relationship with one another; and (4) perceptions of need and intervention benefits among professionals. Implementation was optimal when senior leadership was stable and tangibly involved; organizational, hospital, and group goals were aligned; site leaders were committed and collaborated well; and nurses and physicians perceived a need for and benefits from the interventions. CONCLUSION: Four interrelated contextual factors are associated with the implementation of combined interventions to redesign care for hospitalized medical patients. Hospital leaders should consider these findings prior to implementing similar interventions and be prepared to address challenges related to these factors during implementation.

Impact of billing reforms on academic hospitalist physician and advanced practice provider collaboration: A qualitative study.

BACKGROUND: Medicare previously announced plans for new billing reforms for inpatient visits that are shared by physicians and advanced practice providers (APPs) whereby the clinician spending the most time on the patient visit would bill for the visit. OBJECTIVE: To understand how inpatient hospital medicine teams utilize APPs in patient care and how the proposed billing policies might impact future APP utilization. DESIGN, SETTING AND PARTICIPANTS: We conducted focus groups with hospitalist physicians, APPs, and other leaders from 21 academic hospitals across the United States. Utilizing rapid qualitative methods, focus groups were analyzed using a mixed inductive and deductive method at the semantic level with templated summaries and matrix analysis. Thirty-three individuals (physicians [n = 21], APPs [n = 10], practice manager [n = 1], and patient representative [n = 1]) participated in six focus groups. RESULTS: Four themes emerged from the analysis of the focus groups, including: (1) staffing models with APPs are rapidly evolving, (2) these changes were felt to be driven by staffing shortages, financial models, and governance with minimal consideration to teamwork and relationships, (3) time-based billing was perceived to value tasks over cognitive workload, and (4) that the proposed billing changes may create unintended consequences impacting collaboration and professional satisfaction. CONCLUSIONS: Physician and APP collaborative care models are increasingly evolving to independent visits often driven by workloads, financial drivers, and local regulations such as medical staff rules and hospital bylaws. Understanding which staffing models produce optimal patient, clinician, and organizational outcomes should inform billing policies rather than the reverse.

Identifying and Measuring Administrative Harms Experienced by Hospitalists and Administrative Leaders.

Importance: Administrative harm (AH), defined as the adverse consequences of administrative decisions within health care that impact work structure, processes, and programs, is pervasive in medicine, yet poorly understood and described. Objective: To explore common AHs experienced by hospitalist clinicians and administrative leaders, understand the challenges that exist in identifying and measuring AH, and identify potential approaches to mitigate AH. Design, Setting, and Participants: A qualitative study using a mixed-methods approach with a 12-question survey and semistructured virtual focus groups was held on June 13 and August 11, 2023. Rapid qualitative methods including templated summaries and matrix analysis were applied. The participants included 2 consortiums comprising hospitalist clinicians, researchers, administrative leaders, and members of a patient and family advisory council. Main Outcomes and Measures: Quantitative data from the survey on specific aspects of experiences related to AH were collected. Focus groups were conducted using a semistructured focus group guide. Themes and subthemes were identified. Results: Forty-one individuals from 32 different organizations participated in the focus groups, with 32 participants (78%) responding to a brief survey. Survey participants included physicians (91%), administrative professionals (6%), an advanced practice clinician (3%), and those in leadership roles (44%), with participants able to select more than one role. Only 6% of participants were familiar with the term administrative harm to a great extent, 100% felt that collaboration between administrators and clinicians is crucial for reducing AH, and 81% had personally participated in a decision that led to AH to some degree. Three main themes were identified: (1) AH is pervasive and comes from all levels of leadership, and the phenomenon was felt to be widespread and arose from multiple sources within health care systems; (2) organizations lack mechanisms for identification, measurement, and feedback, and these challenges stem from a lack of psychological safety, workplace cultures, and ambiguity in who owns a decision; and (3) organizational pressures were recognized as contributors to AHs. Many ideas were proposed as solutions. Conclusions and Relevance: The findings of this study suggest that AH is widespread with wide-reaching impact, yet organizations do not have mechanisms to identify or address it.

Building a thriving academic hospitalist workforce: A rapid qualitative analysis identifying key areas of focus in the field.

BACKGROUND: The hospitalist workforce has been at the forefront of the pandemic and has been stretched in both clinical and nonclinical domains. We aimed to understand current and future workforce concerns, as well as strategies to cultivate a thriving hospital medicine workforce. DESIGN, SETTING, AND PARTICIPANTS: We conducted qualitative, semistructured focus groups with practicing hospitalists via video conferencing (Zoom). Utilizing components from the Brainwriting Premortem Approach, attendees were split into small focus groups and listed their thoughts about workforce issues that hospitalists may encounter in the next 3 years, identifying the highest priority workforce issues for the hospital medicine community. Each small group discussed the most pressing workforce issues. These ideas were then shared across the entire group and ranked. We used rapid qualitative analysis to guide a structured exploration of themes and subthemes. RESULTS: Five focus groups were held with 18 participants from 13 academic institutions. We identified five key areas: (1) support for workforce wellness; (2) staffing and pipeline development to maintain an adequate workforce to match clinical growth; (3) scope of work, including how hospitalist work is defined and whether the clinical skillset should be expanded; (4) commitment to the academic mission in the setting of rapid and unpredictable clinical growth; and (5) alignment between the duties of hospitalists and resources of hospitals. Hospitalists voiced numerous concerns about the future of our workforce. Several domains were identified as high-priority areas of focus to address current and future challenges.

Practical Applications of Rapid Qualitative Analysis for Operations, Quality Improvement, and Research in Dynamically Changing Hospital Environments.

BACKGROUND: Health care systems are in a constant state of change. As such, methods to quickly acquire and analyze data are essential to effectively evaluate current processes and improvement projects. Rapid qualitative analysis offers an expeditious approach to evaluate complex, dynamic, and time-sensitive issues. METHODS: We used rapid data acquisition and qualitative methods to assess six real-world problems the hospitalist field faced during the COVID-19 pandemic. We iteratively modified and applied a six-step framework for conducting rapid qualitative analysis, including determining if rapid methods are appropriate, creating a team, selecting a data collection approach, data analysis, and synthesis and dissemination. Virtual platforms were used for focus groups and interviews; templated summaries and matrix analyses were then applied to allow for rapid qualitative analyses. RESULTS: We conducted six projects using rapid data acquisition and rapid qualitative analysis from December 4, 2020, to January 14, 2022, each of which included 23 to 33 participants. One project involved participants from a single institution; the remainder included participants from 15 to 24 institutions. These projects led to the refinement of an adapted rapid qualitative method for evaluation of hospitalist-driven operational, research, and quality improvement efforts. We describe how we used these methods and disseminated our results. We also discuss situations for which rapid qualitative methods are well-suited and strengths and weaknesses of the methods. CONCLUSION: Rapid qualitative methods paired with rapid data acquisition can be employed for prompt turnaround assessments of quality, operational, and research projects in complex health care environments. Although rapid qualitative analysis is not meant to replace more traditional qualitative methods, it may be appropriate in certain situations. Application of a framework to guide projects using a rapid qualitative approach can help provide structure to the analysis and instill confidence in the findings.

Prevalence of grade II and III obesity among patients hospitalized with cardiovascular diagnoses in 2002 v. 2009.

BACKGROUND: The prevalence of obesity has increased markedly over the past four decades; however, some reports suggest a recent plateau. There is little information available regarding recent changes in obesity prevalence among patients hospitalized with cardiovascular disease. OBJECTIVE: To define obesity trends among patients hospitalized with cardiovascular disease between 2002 and 2009 at an academic medical center. METHODS: This is a retrospective database analysis of patients admitted with cardiovascular diagnoses in 2002 versus 2009. Using ICD-9 codes, the study population was generated. Body mass index (BMI) was calculated by dividing weight in kilograms by height in meters squared (Quetelet index). Patients were assigned to 1 of 5 BMI categories: normal weight (BMI < 19-24.99), overweight (BMI 25-29.99), Grades I obesity (BMI 30-34.99), Grade II obesity (BMI 35-39.99), and Grade III obesity (BMI > 40). Patient demographics are compared with Student's T-tests for continuous data and chi2 tests for categorical data. Logistic regression models were developed in the overall cohort to ascertain differences in obesity grades I, II & III between the two time points with age, gender, race and primary ICD-9 code included as covariates. The logistic regression models were then repeated for each primary ICD-9 code. RESULTS: Patients admitted with cardiovascular diagnoses in 2002 (n = 1271) and 2009 (n = 1576) were stratified by BMI categories. Over this period of nine years, obesity prevalence increased significantly from 28.5% to 38.4% of patients. In particular, Grades II and III obesity increased markedly from 2002 to 2009 (7.6% versus 9.9%, and 2.7% versus 7.5%; unadjusted p = 0.04, p < 0.001 and adjusted p = 0.09 and p < 0.0001 respectively). Individuals with Grade III obesity had a higher incidence of arrhythmias, coronary heart disease, and valvular heart disease. CONCLUSIONS: Grade II and III obesity has markedly increased among patients admitted to our hospital with major cardiovascular diagnoses in the period 2002 to 2009. With respect to hospitalized patients, the obesity epidemic is still on a steeply rising trajectory, especially for the extremely obese categories.

Classifying and Disclosing Medical Errors.

Medical errors are an unfortunate but common occurrence in health care. It is important to understand what medical errors are and what types of harm can occur to patients. Along with recognition of the error, disclosure is an equally important part of the process. Clinicians should provide open and honest discussion about the events that occurred to patients along with feedback to institutions on ways to prevent such errors in the future.

Learning from Missed Opportunities Through Reflective Practice.

Identification of diagnostic errors is difficult but is not alone sufficient for performance improvement. Instead, cases must be reflected on to identify ways to improve decision-making in the future. There are many tools and modalities to retrospectively reflect on action to study medical decisions and outcomes and improve future performance. Reflection in action-in which diagnostic decisions are considered in real-time-may also improve medical decision-making especially through strategies such as structured reflection. Ongoing regular feedback can normalize the discussion about improving decision-making, enable reflective practice, and improve decision making.

Relational aspects of regulating clinical work: examining electronic and in-person compliance mechanisms.

BACKGROUND: Clinical documentation quality is an important way to facilitate clinical communication, improve patient safety metrics and optimise hospital coding and public reporting. However, the monitoring of clinicians by external individuals (ie, those outside the profession or emanating from outside clinical teams) raises difficult questions relating to the autonomy of clinicians and an organisation's control over clinical work. Typically, documentation improvement initiatives have relied solely on electronic monitoring systems to vet clinician documentation. In such systems, quality personnel monitor clinical documentation and, on encountering potentially problematic content, use an electronic querying system to ask the clinicians to voluntarily clarify or modify the text if appropriate. Importantly, clinicians retain their professional autonomy and can choose to disagree with documentation requests. The current study empirically examines a clinical documentation improvement program which takes a different approach. This programme uses two modes of querying clinicians: (1) conventional electronic documentation clarification queries and (2) in-person verbal documentation clarification requests. METHODS: We conducted regression analyses using archival documentation query data (n=19 650) from an American teaching hospital to compare the efficacy of conventional electronic documentation clarification queries and in-person verbal documentation clarification requests. Our dependent variable is the length of time between the documentation clarification request and the resolution of the query (ie, the time until a clinician responds). FINDINGS: Our analyses demonstrate that in-person verbal documentation clarification requests are associated with a 30-hour reduction in the time it takes for a query to be resolved relative to electronic-only queries. PRACTICAL IMPLICATIONS: The results suggest that while electronic regulatory systems might afford hospitals with opportunities to scale quality initiatives in a cost-effective manner, organisational efforts to influence clinical work may yet benefit from the human touch of in-person regulator-clinician interaction. Furthermore, the replacement of in-person compliance interactions with digital compliance requests can potentially produce negative compliance outcomes.

Implementation of a triage nurse role and the effect on hospitalist workload.

OBJECTIVES: Hospital medicine groups vary staffing models to match available workforce with expected patient volumes and acuity. Larger groups often assign a single hospitalist to triage pager duty which can be burdensome due to frequent interruptions and multitasking. We introduced a new role, the Triage nurse, to hold the triage pager and distribute patients. We sought to determine the effect of this Triage Nurse on the perceived workload of hospitalists and frequency of pages. METHODS: We partnered with our patient throughput department to implement the Triage Nurse role who took the responsibility of tracking and distributing admissions among three admitting physicians along with coordinating report. We used the National Aeronautics and Space Administration-Task Load Index (NASA-TLX) to measure perceived workload and accessed pager logs of admitters for 3 months before and after implementation. RESULTS: Overall, 50 of an expected 67 NASA-TLX surveys (74.6%) were returned in the pre-intervention period and 64 of 92 (69.6%) were returned in the post-intervention period. We found a statistically significant reduction in the domains of physical demand, temporal demand, effort and frustration from pre- to post-intervention periods (p < 0.01). There was also a significant decrease in the performance domain (p = 0.01) with a lower number indicative of better perceived performance. There was a significant reduction in the mean number of pages received by admitting hospitalists over their 9-h shifts (81.3 + 17.3 vs 52.4 + 7.3; p < 0.01). CONCLUSION: The implementation of the Triage Nurse role was associated with a significant decrease in the perceived workload of admitting hospitalists. Our findings are important because workload and interruptions can contribute to errors and burnout. Future studies should test interventions to improve hospitalist workload and evaluate their effect on patient outcomes and physician wellness.