5 ways to improve hospital medicine

Hospital medicine has rapidly become one of the largest specialties in the United States. As the number of practicing hospital medicine doctors soars above the 30,000 mark and health care reform takes hold, the specialty finds itself at the forefront of American medicine. And for good reason. It is a young, dynamic, varied and flexible specialty that can be practiced in a number of different settings. Hospital medicine doctors are no longer just the “stand-in” for the patient’s primary care physician. Hospitals all over the country are increasingly looking to hospitalists to drive quality improvement forward. Having been in practice for over five years, I feel that the best and most committed hospital medicine doctors (that I myself have used as role models) have been the ones who enjoy patient care above all else, and then find a particular niche that they become expert in.

I have had the opportunity to work in a number of different hospitals up and down the East Coast, ranging from large urban medical centers, to more rural community hospitals. The challenges faced in many of these places are almost identical. I would like to identify 5 areas to focus that will take our specialty to the next level:

1. Rounding models. Currently, most hospitalists typically have patients scattered around the hospital on different floors. Their patients will be seen at completely random times. One may be seen at 7:30am and another at 3pm — often with no rhyme or reason behind the times. The solution to this problem is to institute good old-fashioned ward rounds, ideally multidisciplinary rounding, within the patient’s room. This should be accomplished on all the patients by mid/late morning, with a definitive plan in place that is clear and succinct. Such a system works best when all patients are kept on one floor, in a geographical rounding model. This has a whole host of additional benefits — including vastly improving efficiency and reducing the volume of pages.

2. Program organization. Unfortunately most hospitalists work in a system of “hospital medicine chaos.” I use the term endearingly, because it’s not the fault of any doctor or even hospital. It’s the fact that our specialty is still new and largely disorganized. Hospitalists need to be able to focus on each patient, and not be multitasking to an unsafe degree. As well as more organized rounding models, programs can do this with other techniques such as utilizing a dedicated “admitter” in the emergency room and making sure that any additional call coverage is manageable. This will enable a better focus on metrics such as early discharges, reducing length of stay, and higher patient satisfaction.

3. Transitions of care. Two particular problems are admission medication reconciliation and the discharge process. The former has been a problem in every hospital I’ve worked in. It often seems impossible to get a complete and accurate medication list. There are a number of reasons why this eludes us, including the patient themselves not knowing what they are taking, and the admitting doctor having several different lists available to them! We need to get a “no ifs, ands, or buts medication list.” Studies are increasingly proving the value of pharmacists stationed in the emergency room to hand hospitalists this list when patients are admitted. Think this is expensive? Consider the reduced medication errors and improved patient safety.

The discharge process is another big area for improvement. By its nature a risky process and fraught with potential problems, we need to make every hospital discharge as thorough and seamless as possible. The role of the hospitalist is invaluable in making this happen.

4. Focusing on the patient. The drive to enhance patient satisfaction and improve the health care experience is really not rocket science. We need to listen to patients and take on board their concerns. The most common complaints I hear from my patients are usually quite straightforward, and I’m sure similar to what other doctors hear up and down the country — among them are a good night’s sleep and better hospital food! Not far behind is patients simply wanting more time with their doctors and nurses. We need to get back to the fundamentals of good medicine in a comfortable, healing environment.

5. Integrating health care IT with frontline hospital medicine. Meaningful use implementation has meant that hospitalists are having to work more than ever with information technology. This will only increase with time. Unfortunately, most of the current IT solutions are slow, inefficient, and cumbersome. They take time away from our patients. Hospital doctors should insist on IT that is optimized to our unique workflow. Rapid order entry (ideally using mobile technology) and efficient EMRs are the way of the future.

Ahead lie enormous opportunities for process improvement and making a real difference in our patients’ lives. We must remain fully engaged and more importantly lead in these hospital processes. The old attitude of many administrators that “hospitalists don’t make any money for the hospital” is rapidly turning into “hospitalists are crucial for our organization’s success.” The first few years have been a bit of a rocky road, and most programs around the country are still disorganized and can’t achieve the metrics that are needed to take things to the next level. Once we organize the specialty better, there’s no limit to high hospital care can soar.

This is a tremendously rewarding career. There are very few specialties left where you are the “captain of the ship,” guiding patients through their illness, forming strong relationships with both them and their families. Being a good old-fashioned doc with solid clinical and reasoning skills that are applied on a daily basis. Hospital medicine is one of them, and I feel blessed to be practicing it.

Suneel Dhand is an internal medicine physician and author of Thomas Jefferson: Lessons from a Secret Buddha and High Percentage Wellness Steps: Natural, Proven, Everyday Steps to Improve Your Health & Well-being.  He blogs at his self-titled site, Suneel Dhand.

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  • guest

    Just out of curiosity, what do you consider to be the optimal patient load, that is, the highest number of patients a doctor can see in a typical day and still provide high-quality care? And how many hospitals are ensuring that their hospitalists’ caseloads do not exceed this limit?

  • guest

    Um. Quite frankly, as a patient, if I have a bad experience with a hospital or with a doctor, I think it is entirely within my right to make a change. When I do so, I am not “shopping,” I am attempting to responsibly advocate for myself to obtain adequate care in a broken system. The fact that my records cannot easily be transmitted between systems is hardly a reason for me to be compelled to stay in a situation where I am not getting good care.

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