Community-based, Hospital-Affiliated Medical Group Becomes a Successful Accountable Care Organization.

Leadership of a multispecialty group practice within a health system recognized in 2015 that population health management requires quality performance improvement and organizational culture change. While blueprints for building successful Accountable Care Organizations (ACOs) exist in the literature, few describe the journey to achieving both shared savings and high quality outcomes achieved by a medical group within an academic health system. Clinician education and engagement, prioritizing prevention and achieving benchmarks, developing supportive roles, more precise documentation of accurate diagnostic coding, and risk stratification constituted the approach. When first participating as an ACO, the medical group built programs and teams to improve quality, while CMS simultaneously changed quality measurements from pay-for-reporting to pay-for-performance. Quality scores initially dipped, though scores have since risen to 98.44% in 2020. Between 2015 and 2017, financial results were more than $10 million below the threshold, while in performance years 2018 to 2020, Northeast Medical Group achieved $24 million in aggregate in shared savings.

Prevention is better: the case of the underutilized failure mode effect analysis in patient safety.

Prospective hazard analysis methodologies, like failure modes and effects analysis (FMEA), have been tried and tested in the engineering industry and are more recently gaining momentum in healthcare. Considering FMEA's evidence based successes, this commentary makes the case that healthcare is underutilizing the methodology by relying on retrospective hazard analysis. Healthcare leaders should determine where prospective hazard analysis principles could be better built into care delivery planning and processes that will enhance patient safety.

Creating a Patient-Centered Health Care Delivery System: A Systematic Review of Health Care Quality From the Patient Perspective.

Patient experience is one of key domains of value-based purchasing that can serve as a measure of quality and be used to improve the delivery of health services. The aims of this study are to explore patient perceptions of quality of health care and to understand how perceptions may differ by settings and condition. A systematic review of multiple databases was conducted for studies targeting patient perceptions of quality of care. Two reviewers screened and extracted data independently. Data synthesis was performed following a meta-narrative approach. A total of 36 studies were included that identified 10 quality dimensions perceived by patients: communication, access, shared decision making, provider knowledge and skills, physical environment, patient education, electronic medical record, pain control, discharge process, and preventive services. These dimensions can be used in planning and evaluating health care delivery. Future research should evaluate the effect of interventions targeting patient experience on patient outcomes.

Reflective Practice: A Tool for Readmission Reduction.

Factors intrinsic to local practice, but not captured by the medical record, contribute to readmissions. Frontline providers familiar with their practice systems can identify these. The objective was to decrease 30-day hospital readmissions. The intervention involved retrospective review by hospitalists of their own patients' readmissions, using reflective practice guided by a chart review tool. Subjects were patients discharged by hospitalists and readmitted to a tertiary care academic medical center. Hospitalists reviewed 193 readmissions of 170 patients. Factors contributing to readmission were grouped under patient characteristics, operational factors, and care transition. After reflection, physicians scheduled earlier follow-up appointments while nurse practitioners and physician assistants improved discharge instructions. Readmissions decreased during the review period, and the decrease sustained for one year after the review period. Hospitalists reflected on and identified local practice factors that contributed to their own patients' 30-day readmissions. Reflective practice may be an effective strategy to decrease hospital readmissions.

Clinical decision support improves quality of telephone triage documentation--an analysis of triage documentation before and after computerized clinical decision support.

BACKGROUND: Clinical decision support (CDS) has been shown to be effective in improving medical safety and quality but there is little information on how telephone triage benefits from CDS. The aim of our study was to compare triage documentation quality associated with the use of a clinical decision support tool, ExpertRN©. METHODS: We examined 50 triage documents before and after a CDS tool was used in nursing triage. To control for the effects of CDS training we had an additional control group of triage documents created by nurses who were trained in the CDS tool, but who did not use it in selected notes. The CDS intervention cohort of triage notes was compared to both the pre-CDS notes and the CDS trained (but not using CDS) cohort. Cohorts were compared using the documentation standards of the American Academy of Ambulatory Care Nursing (AAACN). We also compared triage note content (documentation of associated positive and negative features relating to the symptoms, self-care instructions, and warning signs to watch for), and documentation defects pertinent to triage safety. RESULTS: Three of five AAACN documentation standards were significantly improved with CDS. There was a mean of 36.7 symptom features documented in triage notes for the CDS group but only 10.7 symptom features in the pre-CDS cohort (p < 0.0001) and 10.2 for the cohort that was CDS-trained but not using CDS (p < 0.0001). The difference between the mean of 10.2 symptom features documented in the pre-CDS and the mean of 10.7 symptom features documented in the CDS-trained but not using was not statistically significant (p = 0.68). CONCLUSIONS: CDS significantly improves triage note documentation quality. CDS-aided triage notes had significantly more information about symptoms, warning signs and self-care. The changes in triage documentation appeared to be the result of the CDS alone and not due to any CDS training that came with the CDS intervention. Although this study shows that CDS can improve documentation, further study is needed to determine if it results in improved care.

Physician satisfaction and burnout at different career stages.

OBJECTIVE: To explore the work lives, professional satisfaction, and burnout of US physicians by career stage and differences across sexes, specialties, and practice setting. PARTICIPANTS AND METHODS: We conducted a cross-sectional study that involved a large sample of US physicians from all specialty disciplines in June 2011. The survey included the Maslach Burnout Inventory and items that explored professional life and career satisfaction. Physicians who had been in practice 10 years or less, 11 to 20 years, and 21 years or more were considered to be in early, middle, and late career, respectively. RESULTS: Early career physicians had the lowest satisfaction with overall career choice (being a physician), the highest frequency of work-home conflicts, and the highest rates of depersonalization (all P<.001). Physicians in middle career worked more hours, took more overnight calls, had the lowest satisfaction with their specialty choice and their work-life balance, and had the highest rates of emotional exhaustion and burnout (all P<.001). Middle career physicians were most likely to plan to leave the practice of medicine for reasons other than retirement in the next 24 months (4.8%, 12.5%, and 5.2% for early, middle, and late career, respectively). The challenges of middle career were observed in both men and women and across specialties and practice types. CONCLUSION: Burnout, satisfaction, and other professional challenges for physicians vary by career stage. Middle career appears to be a particularly challenging time for physicians. Efforts to promote career satisfaction, reduce burnout, and facilitate retention need to be expanded beyond early career interventions and may need to be tailored by career stage.

Mentoring programs for physicians in academic medicine: a systematic review.

PURPOSE: Mentoring is vital to professional development in the field of medicine, influencing career choice and faculty retention; thus, the authors reviewed mentoring programs for physicians and aimed to identify key components that contribute to these programs' success. METHOD: The authors searched the MEDLINE, EMBASE, and Scopus databases for articles from January 2000 through May 2011 that described mentoring programs for practicing physicians. The authors reviewed 16 articles, describing 18 programs, extracting program objectives, components, and outcomes. They synthesized findings to determine key elements of successful programs. RESULTS: All of the programs described in the articles focused on academic physicians. The authors identified seven mentoring models: dyad, peer, facilitated peer, speed, functional, group, and distance. The dyad model was most common. The authors identified seven potential components of a formal mentoring program: mentor preparation, planning committees, mentor-mentee contracts, mentor-mentee pairing, mentoring activities, formal curricula, and program funding. Of these, the formation of mentor-mentee pairs received the most attention in published reports. Mentees favored choosing their own mentors; mentors and mentees alike valued protected time. One barrier to program development was limited resources. Written agreements were important to set limits and encourage accountability to the mentoring relationship. Program evaluation was primarily subjective, using locally developed surveys. No programs reported long-term results. CONCLUSIONS: The authors identified key program elements that could contribute to successful physician mentoring. Future research might further clarify the use of these elements and employ standardized evaluation methods to determine the long-term effects of mentoring.

Protective eyewear selection for interventional fluoroscopy.

Three protective eyewear models were evaluated to determine effectiveness in reducing radiation dose to a fluoroscopist's eyes. The performance of the protective eyewear was measured using radiation dosimeters in a fluoroscopy suite. An Eyewear Protection Factor was determined for each model in each of three exposure orientations. The protection was strongly influenced by the location of the radiation source. When the source was in front of the fluoroscopist, the lead equivalence was important. When the source was to the side of the fluoroscopist, the cross section of the side shield had a significant influence on protection. Protective eyewear selection needs to include consideration of job task and head orientation to the radiation source as well as the possibility that face shape and eyewear fit may also impact the radiation dose to the eye.

A clinical deterioration prediction tool for internal medicine patients.

Many early warning models for hospitalized patients use variables measured on admission to the hospital ward; few have been rigorously derived and validated. The objective was to create and validate a clinical deterioration prediction tool using routinely collected clinical and nursing measurements. Multivariate regression analysis was used to determine clinical variables statistically associated with clinical deterioration; subsequently, the model tool was retrospectively validated using a different cohort of medical inpatients. The Braden Scale (P = .01; odds ratio [OR] = 0.91; confidence interval [CI] = 0.84-0.98), respiratory rate (P < .01; OR = 1.08; CI = 1.04-1.13), oxygen saturation (P < .01; OR = 0.97; CI = 0.96-0.99), and shock index (P < .01; OR = 2.37; CI = 1.14-3.98) were predictive of clinical deterioration 2-12 hours in the future. When applied to the validation cohort, the tool demonstrated fair concordance with actual outcomes. This tool created using routinely collected clinical measurements can serve as a very early warning system for hospitalized medical patients.

Nutrition in the hospitalized patient.

Almost 50% of patients are malnourished on admission; many others develop malnutrition during admission. Malnutrition contributes to hospital morbidity, mortality, costs, and readmissions. The Joint Commission requires malnutrition risk screening on admission. If screening identifies malnutrition risk, a nutrition assessment is required to create a nutrition care plan. The plan should be initiated early in the hospital course, as even patients with normal nutrition become malnourished quickly when acutely ill. While the Harris-Benedict equation is the most commonly used method to estimate calories, its accuracy may not be optimal in all patients. Calculating the caloric needs of acutely ill obese patients is particularly problematic. In general, a patient's caloric intake should be slightly less than calculated needs to avoid the metabolic risks of overfeeding. However, most patients do not receive their goal calories or receive parenteral nutrition due to erroneous practices of awaiting return of bowel sounds or holding feeding for gastric residual volumes. Patients with inadequate intake over time may develop potentially fatal refeeding syndrome. The hospitalist must be able to recognize the risk factors for malnutrition, patients at risk of refeeding syndrome, and the optimal route for nutrition support. Finally, education of patients and their caregivers about nutrition support must begin before discharge, and include coordination of care with outpatient facilities. As with all other aspects of discharge, it is the hospitalist's role to assure smooth transition of the nutrition care plan to an outpatient setting.

The positive impact of a facilitated peer mentoring program on academic skills of women faculty.

BACKGROUND: In academic medicine, women physicians lag behind their male counterparts in advancement and promotion to leadership positions. Lack of mentoring, among other factors, has been reported to contribute to this disparity. Peer mentoring has been reported as a successful alternative to the dyadic mentoring model for women interested in improving their academic productivity. We describe a facilitated peer mentoring program in our institution's department of medicine. METHODS: Nineteen women enrolled in the program were divided into 5 groups. Each group had an assigned facilitator. Members of the respective groups met together with their facilitators at regular intervals during the 12 months of the project. A pre- and post-program evaluation consisting of a 25-item self-assessment of academic skills, self-efficacy, and academic career satisfaction was administered to each participant. RESULTS: At the end of 12 months, a total of 9 manuscripts were submitted to peer-reviewed journals, 6 of which are in press or have been published, and another 2 of which have been invited to be revised and resubmitted. At the end of the program, participants reported an increase in their satisfaction with academic achievement (mean score increase, 2.32 to 3.63; P = 0.0001), improvement in skills necessary to effectively search the medical literature (mean score increase, 3.32 to 4.05; P = 0.0009), an improvement in their ability to write a comprehensive review article (mean score increase, 2.89 to 3.63; P = 0.0017), and an improvement in their ability to critically evaluate the medical literature (mean score increased from 3.11 to 3.89; P = 0.0008). CONCLUSIONS: This facilitated peer mentoring program demonstrated a positive impact on the academic skills and manuscript writing for junior women faculty. This 1-year program required minimal institutional resources, and suggests a need for further study of this and other mentoring programs for women faculty.

Should you search the Internet for information about your acute symptom?

OBJECTIVE: To determine if symptom-related Web sites give sufficient information for users to seek urgent care when warranted. MATERIALS AND METHODS: We reviewed 120 Web sites (15 sites for each of eight acute symptoms). Symptom-related sites were identified with Google, Yahoo!®, and Bing™ searches and focused on potentially hazardous symptoms such as chest pain, shortness of breath, abdominal pain, and syncope. We reviewed each symptom-related site for the presence of critical symptom indicators (key symptom characteristics and associated factors) that triage the user to urgent care. RESULTS: Of the 120 sites reviewed, 41 (33%) contained no critical symptom indicators. No site contained a complete set of critical symptom indicators. Overall, out of the 1,020 total critical symptoms searched for in the sites, we only found 329 (32%). When present, critical symptom indicators were found on the top half of the first page of the site in only 34%. Specific recommendations for further care were absent in 42% of the cases where critical symptom indicators were identified. CONCLUSIONS: Symptom-related sites ranked highly by major search engines lack much of the information needed to make a decision about whether a symptom needs urgent attention. When present, this information is usually not located where users can rapidly access it and often lacks prescriptive guidance for users to seek care. Until more sites contain at least minimal triage advice, relying on an Internet search to help determine the urgency of a symptom could be risky.

Is an occupational examination superior to an occupational health history alone for preplacement screening in health care settings?

OBJECTIVES: To determine whether preplacement recommendations following an occupationally focused medical history is different from those following an occupational consultation. METHODS: This was a retrospective cohort study of 172 applicants to our institution. RESULTS: Following provider review of occupational history survey alone, none of the applicants had restrictions recommended. In comparison, only 163 applicants (94.7%) were recommended to be hired without restrictions following provider review of the same patient's occupational history and examination (P = 0.0078). CONCLUSION: A well-designed questionnaire is useful for screening applicants for preplacement examinations and assures sufficient detail to allow for a large proportion of individuals to proceed to employment without an occupational examination. However, in this study, a small but statistically significant portion (5%) of applicants required occupational examinations for appropriate work recommendations.

Do timely outpatient follow-up visits decrease hospital readmission rates?

It is widely believed that timely follow-up decreases hospital readmissions; however, the literature evaluating time to follow-up is limited. The authors conducted a retrospective analysis of patients discharged from a tertiary care academic medical center and evaluated the relationship between outpatient follow-up appointments made and 30-day unplanned readmissions. Of 1044 patients discharged home, 518 (49.6%) patients had scheduled follow-up ≤14 days after discharge, 52 (4.9%) patients were scheduled ≥15 days after discharge, and 474 (45.4%) had no scheduled follow-up. There was no statistical difference in 30-day readmissions between patients with follow-up within 14 days and those with follow-up 15 days or longer from discharge (P = .36) or between patients with follow-up within 14 days and those without scheduled follow-up (P = .75). The timing of postdischarge follow-up did not affect readmissions. Further research is needed to determine such factors and to prospectively study time to outpatient follow-up after discharge and the decrease in readmission rates.

Using a framework for spread of best practices to implement successful venous thromboembolism prophylaxis throughout a large hospital system.

Best practices take time to spread passively, at times contributing to suboptimal results in health care. Managed diffusion, often referred to as "spread," may hasten broad-scale implementation of best practices. At our institution, appropriate use of venous thromboembolism (VTE) prophylaxis had been markedly improved in select areas by 2 independent quality improvement teams. We wanted to accelerate the adaptation of those locally learned best practices across our entire institution and did so by following an explicit framework for spread. We report our experience using this framework, noting both how the framework helped anticipate needs and what challenges we encountered that were not anticipated based on the spread plan. Using our framework, we were able to spread the changes across more than 79 distinct hospital services, improving use of appropriate VTE prophylaxis to more than 95%. Use of an explicit, well-constructed spread plan allows for an orderly management of diffusion of best practices.

The value of telephone triage for patients with appendicitis.

Although it has been assumed that telephone triage can directly benefit patients by facilitating early diagnosis and treatment, this potential benefit has not been well documented. Using appendicitis cases ascertained from claims data, we compared telephone triage recommendations with what the callers originally intended to do. Over a two-year period, there were 20,230 calls to a telephone triage centre in the US where insurance information was available. Of these, 12,709 calls (63%) had insurance claims made within seven days of the call. Among these calls, 46 had a diagnosis of appendicitis. In 72% of calls concerning appendicitis, the telephone triage recommendation was for a more rapid evaluation than the caller originally intended (P < 0.0001). In 91% of the appendicitis cases, triage nurses directed callers to care within 8 h, but without triage advice, only 39% of callers stated they would have sought care within 8 h (P < 0.0001). Telephone triage significantly reduced the delay in care for appendicitis in comparison with what the caller would have done. This suggests that telephone triage potentially reduces the morbidity associated with appendicitis.

The power of collaboration: integrating a preventive medicine-public health curriculum into a pediatric residency.

This is one of six short papers that describe additional innovations to help integrate public health into medical education; these were featured in the "Patients and Populations: Public Health in Medical Education" conference. They represent relatively new endeavors or curricular components that had not been explored in prior publications. Although evaluation data are lacking, it was considered to be of value to medical educators to share a brief description of the collaboration between the Division of Preventive, Occupational, and Aerospace Medicine and the Department of Pediatrics at Mayo Clinic to integrate a preventive medicine-public health curriculum into the pediatric residency.