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Journal of Patient SafetyIssue: Volume 5(1), March 2009, pp 3-8Copyright: © 2009 Lippincott Williams & Wilkins, Inc.Publication Type: [Original Articles]DOI: 10.1097/PTS.0b013e31819751f2ISSN: 1549-8417Accession: 01209203-200903000-00002Keywords: hospitalists, patient safety, adverse eventsHide Cover [Original Articles]< Previous Article Table of Contents Next Article >Hospitalists as Emerging Leaders in Patient Safety: Lessons Learned and Future DirectionsFlanders, Scott A. MD*†; Kaufman, Samuel R. MA†‡; Saint, Sanjay MD, MPH§*†‡; Parekh, Vikas I. MD*†Author InformationFrom the *Hospitalist Program, University of Michigan Division of General Medicine, †Division of General Medicine, University of Michigan Department of Internal Medicine, ‡VA/UM Patient Safety Enhancement Program, and §Center for Practice Management and Outcomes Research, Ann Arbor VA Health Services Research & Development Center of Excellence, Ann Arbor, Michigan.Received April 28, 2008, and in revised form October 27, 2008.Accepted for publication October 28, 2008.Reprints: Scott A. Flanders, MD, Department of Internal Medicine, Taubman Center, 1500 E. Medical Center Drive, Rm 3119F, Ann Arbor, MI 48109-0376 (e-mail: flanders@umich.edu).Support: Funded by a grant from Blue Cross Blue Shield of Michigan Foundation.AbstractObjective: To examine the results of a multi-institution, hospitalist-centered consortium designed to disseminate knowledge of best practices relevant to patient safety and to facilitate institutional innovation around such practices.Methods: The Hospitalists as Emerging Leaders in Patient Safety (HELPS) consortium consisted of a hospitalist lead and a patient safety representative from each of 9 health care systems in southeastern Michigan. The consortium's aim was to provide rapid dissemination of best practices in patient safety through regular group meetings and to facilitate implementation and analysis of hospitalist-led patient safety initiatives. Key safety targets included prevention of device-related infections, creating a culture of safety, care transitions, medication safety, fall prevention, perioperative care, intensive care unit safety, and end-of-life care. Participating institutions were free to implement any of the best practices and had access to the expertise of the HELPS coordinating site. Surveys were used to assess knowledge dissemination among participants.Results: Participating institutions described their patient safety initiative and identified several key barriers and facilitators encountered during implementation. Common themes emerged among both barriers and facilitators. In postmeeting surveys to measure dissemination, consortium participants answered a mean of 84.2% (SD = 19.2) of the questions correctly.Conclusions: The HELPS consortium successfully disseminated knowledge regarding best practices and identified common barriers and facilitators faced by hospitalists and institutions attempting to improve safety. The next step is to transform the consortium into a robust quality collaborative that leverages key facilitators and prospectively addresses barriers to implementing high-impact interventions in a multihospital setting.One of the most important changes in the organization, financing, and delivery of hospital care in the past decade has been the rapid emergence of hospitalists, physicians, usually general internists, whose clinical focus is on the hospitalized patient, as providers of inpatient care. Varied forces have driven the hospitalist movement. First, as patient illnesses have become more severe and complex, physicians have found it difficult to balance inpatient and outpatient care and have tended to focus on 1 of the 2.1-3 Second, studies suggesting improved clinical efficiency with hospitalists have made hospital medicine programs appealing to hospital administrators.4,5 Third, in teaching hospitals, the demand for hospitalists has grown markedly in response to the need for increased oversight of trainees and the mandate to reduce residency work hours. Finally, the increasingly common practice of "comanagement" of medically complex surgical patients, driven by both surgeons and hospitals, has pushed the demand for hospitalists even higher.6 Overall, it is estimated that there are currently 15,000 practicing hospitalists nationally, and projections suggest that this number may exceed 30,000 by 2010, which is equal to the number of cardiologists currently practicing in the United States.7Back to TopMost hospitalists and hospital medicine programs participate in, and in many cases coordinate, quality improvement and patient safety activities in their respective hospitals. In addition, use of a hospitalist model results in the consolidation of care for large numbers of hospitalized patients into the hands of just a few physicians. Targeting just a few key hospitalists at each institution would thus potentially affect the care of many patients. With this premise in mind, 2 years ago, we created the Hospitalists as Emerging Leaders in Patient Safety (HELPS) consortium with funding from the Blue Cross Blue Shield of Michigan Foundation. The HELPS consortium consisted of a hospitalist lead and a patient safety or quality improvement representative from each of 9 health care systems across southeastern Michigan, representing a diverse group of hospitals that include teaching and nonteaching, urban and rural, government and private, as well as academic and community settings. The aim of the consortium was to provide rapid dissemination of best practices in patient safety and to facilitate the implementation and analysis of hospitalist-led patient safety initiatives. A fuller description, together with a discussion of theoretical underpinnings, has been presented previously.8 Here we report on what we accomplished, what lessons we learned, and what next steps we propose.METHODSThe program was carried out over 2 years and was structured around 8 target areas, each addressed in its own meeting. The first meeting consisted of a quality improvement methodological primer, and the next 7 were devoted to different substantive patient safety-related topics. The program concluded with a final, half-day session drawing out what was learned and next steps. In Table 1, we show the target areas and the project associated with it.Table 1Over 2 years, we disseminated and discussed best practices related to key inpatient safety areas such as prevention of device-related infections, creating a culture of safety, care transitions, medication safety (anticoagulant use in hospitalized patients), fall prevention, perioperative care, intensive care unit safety, and end-of-life care. Participating institutions were free to implement any of the best practices, and key project participants at the HELPS coordinating site (University of Michigan) were available to facilitate project implementation and analysis of its impact. We also conducted regular web-based surveys after the discussions to assess the knowledge gained by participants and to determine prevalent practices at the various participating institutions.Back to TopIn hearing presentations describing best practices and both successful and unsuccessful implementation attempts in diverse clinical settings, consortium participants better understood the key facilitators that made projects possible as well as barriers that likely would have to be overcome. Importantly, all the representatives of hospitalist programs and hospital-based patient safety and quality improvement departments in hospitals throughout southeastern Michigan became well acquainted and comfortable with sharing data in order to improve inpatient safety.RESULTSBack to TopParticipating hospitals were a diverse group of institutions including large urban academic medical centers, but also rural, nonteaching, and community hospitals, as shown in Table 2. Hospitals also had a wide range of information technology capabilities and diverse experience with patient safety and quality improvement initiatives. The hospitalist programs at participating hospitals managed large volumes of patients, and all had been involved in past quality improvement initiatives. Representative projects by participating hospitals and the outcomes addressed are provided in Table 3.Table 2Table 3Barriers and FacilitatorsEach institution, when presenting a description of their patient safety initiative, was asked to identify the key barriers and facilitators they identified in the course of implementing their project. We then categorized the facilitators and barriers to determine the frequency with which they occurred (Tables 4 and 5). Common themes emerged among both barriers and facilitators. Most institutions reported that their solutions to safety problems created more work, or required hospital staff to change longstanding practices, both of which were substantial barriers to overcome. These issues were addressed successfully when improvement teams were able to get institutional buy-in for the new process and create and highlight "synergies" between their goals (improving safety) and other institutional priorities (reducing costs). Similarly, several hospitals reported problems when no individual or group "owned" the new process and when they tried to adopt an easier to implement, "one size fits all" approach to patients. These were addressed with multidisciplinary teams, clear lines of authority, creating formal quality improvement processes that allow for rapid cycle redesign, and the feedback of data demonstrating that an approach, although labor intensive, was leading to safer care.Table 4Table 5Back to TopAfter hearing presentations from hospitals working through these barriers and facilitators, several consortium participants brought successful strategies back to their institutions in an attempt to facilitate work in a targeted safety area. A formal analysis of the extent to which this was happening was not performed, but examples of this cross-institution fertilization are provided in Table 6.Table 6Knowledge DisseminationOne of the purposes of this consortium was to disseminate knowledge regarding best practices in a way that would be readily understandable and applicable to the diverse institutions involved. We also wanted to determine participants' attitudes to the practices shared at the meetings and whether they would be inclined to put into practice what they learned. Presentations were deliberately oriented to the nuts and bolts of implementation and evaluation.We created a series of web-based surveys, administered in the days after the meetings, to assess whether the information delivered was actually retained, as well as to learn about participant attitudes and behavior regarding the practices discussed. Because we found that many participants would not respond to the survey unless reminded to do so, we implemented a reminder and tracked completion. When the reminder was implemented, the response rate was approximately 100%. Questions concerned either knowledge or attitudes and behaviors related to the patient safety intervention discussed. Examples of the different question types are reproduced in Table 7.Table 7Back to TopThe knowledge-related questions all had right and wrong answers. We used the answers for 29 knowledge-related questions to generalize about whether the participants learned what they were taught. Specifically, using the percentage correct for each knowledge-related question, we computed the median and mean percentages correct across all of the questions. The resulting median was 87.5, and the mean was 84.2 (SD = 19.2).DISCUSSIONThere is a great need to improve the quality and safety of care delivered in hospitals across the U.S. Efforts at improvement, however, must be compatible with changes in the organization and delivery of care that began a decade ago and continue to accelerate. The most notable of these changes has been the emergence of hospitalists. The HELPS consortium successfully brought together hospitalist leaders and institutional quality improvement and patient safety leaders from 9 health care systems in southeastern Michigan around the common goals of sharing best practices in the implementation of quality and safety initiatives. Over the course of periodic formal sessions and longitudinal informal collaboration, we successfully engaged participants in both the sharing of project experiences as well as a discussion of facilitators and barriers to change. At the outset, we hoped to leverage the opportunity created by the hospitalist movement to potentially impact a large number of patients through the actions of a few providers.Our primary goal was the dissemination of knowledge and best practices among members. Consortium members met 9 times over the 2 years. Six participating health systems presented a quality improvement or safety intervention that they implemented at their institution. We also exposed members to 2 national experts in the area of patient safety, and at the end of the 2-year period invited all members to review their projects and to bring together our collective experiences in order to create a list of common facilitators and barriers to successful process change. In addition, we assessed for knowledge improvement after each formal session and saw measurable changes in knowledge, which is often a prerequisite step for implementing change. Specifically, we used the answers for 29 knowledge-related questions to generalize about whether the participants learned what they were taught. Although we conducted no pre-meeting questionnaire and thus cannot distinguish between background information that participants brought with them and information they acquired from the presentation, many questions probed for quite specific details from the presentations, details that would typically not be known even by someone with substantial background information on the general topic. For this reason, we believe that high scores do indicate that new knowledge was indeed acquired from the presentation.A secondary goal was to encourage each member institution to implement a project at their site and to assist the institution in these endeavors including the process of implementation and rigorous measurement of their outcomes. Although we were hopeful that members might implement a project based on ideas gained from the consortium, we fully expected most to tackle problems previously identified as important to their local stake holders, and indeed this was the case. We used the consortium as a forum for discussion as well as a way to provide feedback and improvement ideas to members who shared their projects. In fact, we describe several examples (Table 6) where 1 hospital learned from another and attempted to use a strategy they had discovered as a member of the consortium. We also encouraged participants to use the resources of the HELPS consortium including support from the VA/UM Patient Safety Enhancement Program (http://www.med.umich.edu/psep). Participants used these resources in order to better implement and analyze their projects. Not all institutions, however, took advantage of these resources. In part, we felt this was because many programs did not realize the need for up-front input in facilitating implementation, or preferred a more rapid implementation that affected a larger cohort which may not have been possible had the focus been on data analysis and a rigorous evaluation of the project's impact (which may have required control groups or analysis of temporal trends). Despite these challenges, in the end, we were able to combine the collective experiences of our members and discover that this diverse group of providers and organizations shared many common barriers and facilitators (Tables 4 and 5) to implementing change.A review of the common barriers and facilitators that we derived from the HELPS experience is consistent with prior reports on the challenges of quality improvement, barriers to physician behavior change, and translating research into practice.9,10 Cabana et al 9 have previously described a useful framework for understanding the reasons that physicians fail to follow clinical practice guidelines. Their model divides barriers to changing physician practice into 3 broad categories: knowledge barriers such as lack of familiarity or awareness, attitude barriers such as lack of motivation, lack of agreement with guidelines, and finally behavioral barriers such as lack of time, resources, or organizational constraints. Using this model as a foundation, we designed our consortium in a manner that would target all 3 of these categories.In our experience, knowledge-based barriers proved the easiest to overcome, our structure of a consortium of interested hospitalists and quality improvement and patient safety leaders coming together to share their knowledge and practical experience facilitated the process. In addition, we partnered community physicians, academic physicians, content experts, and institutional leaders to create a panel of participants with a wide range of both content and practical knowledge. Our assessments of participants showed that they improved their knowledge after each session.Attitudinal barriers are often cited as significant problems in the implementation of change. Our consortium hoped to overcome these barriers via several routes. First, we chose to target a small group of providers, hospitalists, who care for a large number of hospitalized patients, thereby allowing each individual who changed behavior to have a large impact on patients. In addition, hospitalists are within a specialty focused on quality and safety, their baseline attitudes are more likely to be focused toward making changes in practice. We also hoped that by sharing the collective experiences of many different institutions that our participants could see that successful changes could be made and barriers overcome. We also joined hospitalists with institutional representatives in an effort to empower hospitalists in the facilitation of change. Reviewing the collective experience of our participants, many of our assumptions were confirmed. The most often cited facilitator, having engaged "champions" or process owners, was common across our sites. In addition, the ability to measure and feedback outcomes was another key facilitator to overcome attitudinal barriers. Other reports, however, have not consistently shown outcome feedback to be critical. Shojania and Grimshaw 10suggest feedback has only limited impact on change. We suspect that feedback was more important in our consortium because of the unique nature of hospitalist physicians who see their charge as improving processes and outcomes and may thus be more likely to respond to feedback. Another observation was that creating competition among providers or groups of providers via measurement of outcomes facilitated change, suggesting that the manner in which performance data is presented to providers is key to its ability to impact change.Finally, behavioral barriers have often been thought to be the most daunting to overcome, yet the most important to consider. To implement best practices, ultimately the behaviors of physicians, or of health systems, must be altered. Barriers met in an attempt to achieve this goal may be financial, such as reimbursement issues, or structural, such as existing poor processes or time constraints. In our experience, the common barriers in this area were new process avoidance due to time or financial constraints, inertia due to difficulty in changing existing processes and a lack of clear lines of responsibility that allowed providers to "disengage" from the issue. We felt that hospitalists aligned with institutional leaders may have a better chance of overcoming these issues because many hospitalists are hired with the specific mission of improving operations and are financially supported by hospitals to pursue these changes. Importantly, among our top facilitators of change was the presence of a multidisciplinary team with leadership backing. We also noted that projects that leveraged synergies by fixing more than 1 problem (thereby potentially overcoming some time or financial barriers to participation) were thought to be more successful than others.There are, however, limitations to the conclusions drawn from the HELPS consortium. Our consortium was designed to disseminate knowledge and share experiences in quality improvement and patient safety. Beyond objective measurements of knowledge, our outcome assessments are primarily qualitative. In addition, each member hospital chose a project that was aligned with their local needs and interests, and we did not ask institutions to try to implement each other's projects and experience. Thus, we can only speculate on whether these interventions can be translated across institutions. Nevertheless, the discovery of many shared facilitators and barriers among this group of organizations suggests that there is potential for cross-institution spread of intervention. Other collaboratives have shown that by carefully choosing interventions and using a consortium model, they can rapidly and effectively implement best practices across varied institutions.11,12Back to TopAn additional limitation is our inability to measure rigorously the outcomes of individual projects at most participating institutions. Although we provided resources for analysis and encouraged study designs that would facilitate rigorous evaluations of outcomes, few availed themselves of this assistance. We suspect this is in part because a rigorous analysis of an initiative was not required by the consortium or hospitals supporting the initiative and because methodological rigor is not easily accomplished. Indeed, a common theme in this area was a pressure to rapidly implement projects and not take the time to design the projects in a way that would allow meaningful comparison and statistical analysis. This theme in quality improvement has also been noted in the literature, and our experience validates prior observations.13,14 Finally, although many hospitals did implement safety projects, it is too early to tell if these improvements were long-lasting and sustainable. Follow-up data will be required to evaluate this important issue fully.CONCLUSIONSWe have shown through the creation of the HELPS consortium that a collaborative centered on hospitalists can be developed and is sustainable over time. The model of sharing experiences resulted in improvements in the knowledge of participants and likely improved both attitudinal and behavior barriers to implementing change. In addition, we identified several common barriers and facilitators for successful hospitalist-led quality improvement initiatives among a diverse group of health systems suggesting that there are commonalities that can be exploited in attempts to disseminate evidence-based interventions.Back to TopThe next step is to transform our hospitalist consortium into a quality collaborative as has been done in other specialties.11,12 The goal of such a collaborative would be to identify high-impact interventions that have strong evidence (eg, venous thromboembolism prophylaxis in high-risk populations, preventing hospital-acquired urinary tract infection by timely removal of urinary catheters) and then use the collaborative structure to measure and share performance data, work on systems-based implementation, and use rapid cycle change to improve outcomes simultaneously at all participating sites. To succeed, the collaborative would require standardized multiinstitution data collection to measure performance and systematically assess the clinical impact of process improvements. In addition, although hospitalists would be critical participants and potential champions, any intervention that cuts across large patient populations would require participation of other physician groups, nursing, and key hospital staff. The collaborative would build off the experiences of HELPS by better understanding common barriers to hospital-based patient safety improvement and the solutions that are known to overcome such barriers. Although the requirements of a formal hospitalist quality collaborative may seem daunting, we remain convinced that by harnessing the collective wisdom of hospitalist groups and hospital leaders, we can be successful in this endeavor.REFERENCES1. Flanders SA, Wachter RM. Hospitalists: the new model of inpatient medical care in the United States. Eur J Intern Med. 2003;14:65-70. [Context Link]2. Saint S, Konrad TR, Golin CE, et al. Characteristics of general internists who practice only outpatient medicine: Results from the physician worklife study. Seminars in Medical Practice. 2002;5:5-11. [Context Link]3. Saint S, Christakis DA, Baldwin LM, et al. Is hospitalism new? An analysis of medicare data from Washington State in 1994. Eff Clin Pract. 2000;3:35-39. [Context Link]4. Parekh V, Saint S, Furney S, et al. What effect does inpatient physician specialty and experience have on clinical outcomes and resource utilization on a general medical service? J Gen Intern Med. 2004;19:395-401.[Context Link]5. Wachter RM, Goldman L. The hospitalist movement 5 years later. JAMA. 2002;287:487-494. [Context Link]6. Huddleston JM, Long KH, Naessens JM, et al. Medical and surgical comanagement after elective hip and knee arthroplasty: a randomized, controlled trial. Ann Intern Med. 2004;141:28-38. [Context Link]7. Kralovec PD, Miller JA, Wellikson L, et al. The status of hospital medicine groups in the United States. J Hosp Med. 2006;1:75-80. [Context Link]8. Flanders SA, Kaufman SR, Saint S. Hospitalists as emerging leaders in patient safety: targeting a few to affect many. J Patient Saf. 2005;1:78-82. [Context Link]9. Cabana MD, Rand CS, Powe NR, et al. Why don't physicians follow clinical practice guidelines? A framework for improvement. JAMA. 1999;282:1458-1465. [Context Link]10. Shojania KG, Grimshaw JM. Evidence-based quality improvement: the state of the science. Health Aff (Millwood). 2005;24:138-150. [Context Link]11. Pronovost P, Needham D, Berenholtz S, et al. An intervention to decrease catheter-related bloodstream infections in the ICU. N Engl J Med. 2006;355:2725-2732. [Context Link]12. Moscucci M, Share D, Kline-Rogers E, et al. The Blue Cross Blue Shield of Michigan Cardiovascular Consortium (BMC2) collaborative quality improvement initiative in percutaneous coronary interventions. J Interv Cardiol 2002;15:381-386. [Context Link]13. Winters BD, Pham J, Pronovost PJ. Rapid response teams-walk, don't run. JAMA. 2006;296:1645-1647.[Context Link]14. Auerbach AD, Landefeld CS, Shojania KG. The tension between needing to improve care and knowing how to do it. N Engl J Med. 2007;357:608-613. [Context Link]Key Words: hospitalists; patient safety; adverse eventsIMAGE GALLERY HYPERLINK "http://ovidsp.tx.ovid.com.library.capella.edu/sp-3.16.0b/ovidweb.cgi?&S=HHLMFPPCIADDJBAGNCKKLGMCEEBNAA00&Full+Text=L%7cS.sh.22.23%7c0%7c01209203-200903000-00002&image_gallery_select=selectall&resultset=S.sh.22%7c1" Select All  Table 1 Table 2 Table 3 Table 4 Table 5 Table 6 Table 7 
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