Published in the July 2014 issue of Today’s Hospitalist
WHEN THE CDC and the Institute for Healthcare Improvement wanted to recruit hospitalists for an antibiotic stewardship quality improvement (QI) project a few years ago, organizers ran into a major barrier: Many hospitalists were suffering from QI fatigue.
“Another #$#% QI project!?!” was a common reaction, according to Arjun Srinivasan, MD, associate director for the CDC’s Healthcare Associated Infection Prevention Programs, who was trying to get the stewardship program off the ground.
Hospitalists are being bombarded with QI requests from everyone including their hospital’s C-suite, the CMS, the Joint Commission, researchers, their own group leaders and even gung-ho colleagues. Many hospitalists are finding the prospect of trying to improve every aspect of health care quality, safety, satisfaction and costs “often on their own time and with no additional compensation or support “to be exhausting.
Quality improvement projects can be long and difficult to sustain. Take a look at “Problems that can sabotage quality improvement” here.
True, there have been upsides to hospitalists’ embrace of QI. The specialty has, after all, cemented its reputation as the group that sets the quality and safety agendas in many hospitals, and QI efforts have benefited individual hospitalists both professionally and personally.
But that success sometimes has been too much of a good thing, particularly when the actual labor for all that QI falls on the shoulders of only a few physicians in a group.
According to the 2013 Today’s Hospitalist Compensation and Career Survey, 41% of full-time hospitalists reported spending no time on committee work or quality initiatives. Those who believe that quality improvement is an essential component of hospital medicine are now asking: How can they engage more rank-and-file, nonacademic hospitalists in quality improvement? And how can they keep the few hospitalists who take on an ever-growing number of QI projects from burning out?
“Project du jour”
When it comes to quality improvement in hospital medicine, Kevin J. O’Leary, MD, chief of hospital medicine and associate chair for quality for the medicine department at the Northwestern University Feinberg School of Medicine in Chicago, is an undisputed leader in the field.
But Dr. O’Leary says he “totally gets” where QI overload comes from. “It does feel that there is a QI project du jour,” he says. “You wonder who is deciding what we are working on and is anybody coordinating that.”
As his group’s point person on quality, Dr. O’Leary is contacted about once a week with a “new project or a derivation of a prior project. We have had five falls-prevention projects in the last 14 years,” plus a slew of projects addressing teamwork.
Dr. O’Leary’s task is to find hospitalists willing to accept the invitations that cross his desk, but to not “choose the same people over and over again.” While those chosen few certainly “acquire knowledge and expertise,” he points out, they tend to burn out. Spreading the wealth is “something we don’t do very well.”
Across Chicago at the Cook County Health & Hospitals System, chief quality officer and hospitalist Krishna Das, MD, also struggles with how to expand hospitalist engagement in a seemingly endless number of projects while keeping the few hospitalists who are passionate about QI from going overboard.
Just recently, Dr. Das put the brakes on one hospitalist who proposed a readmissions project. Given the other projects already underway “including initiatives on heart failure, immunizations and alcohol withdrawal “Dr. Das thought it was going to be too much at one time.
“Charging ahead on your own just doesn’t work because inpatient work fundamentally is interdisciplinary,” Dr. Das points out. That means that any effort to improve the quality of care has to involve nurses, pharmacists, social workers or other hospital staff “all of whom are also likely overloaded. She doesn’t want to set someone up for failure and potentially lose that person for a future project.
Needed: group leadership
Some QI overload, Dr. Das says, is clearly related to personality. “There are some people who really want to make a difference but who can’t say ‘no,’ ” she points out. The solution, as she sees it, is good group leadership with skills in managing physicians, encouraging some to start participating while reining in others.
Titilola Britto, MD, chief medical officer and the medical director of the EmCare Inpatient Services hospitalist group at Cartersville Medical Center in northern Georgia, has learned through the years to slow down new hires who are keen on QI.
“For fresh graduates, the big adjustment is the workload,” says Dr. Britto. “It takes them three years to adjust to the workload before they can start thinking about quality again.”
When she first came to Cartersville a few years ago as medical director, Dr. Britto says she was given a fair amount of administrative time. That meant she could manage a number of quality improvement projects, from diabetes and stroke care to patient satisfaction, on top of patient care and other administrative responsibilities.
But more recently, particularly now that five of the group’s 12 hospitalists have been on staff for less than a year, work is much busier. Everyone has had to pick up extra clinical shifts. “Last summer, I didn’t have all the part-timers I needed, we were introducing electronic medical records, and someone was always recertifying us for diabetes or stroke or something,” Dr. Britto recalls. “I felt like running away.”
She admits to “working more hours than I should and spending less time with my family.” But she feels justified by how much the group’s HCAHPS satisfaction scores have improved over the three years she’s worked on a project to raise them.
Incentives and barriers
In the past, a small portion of the hospitalists’ salaries came from a quality-based bonus. “It had a psychological effect,” Dr. Britto points out. “People do whatever it takes to get that last dollar.” Having worked in groups that paid a quality bonus and those that didn’t, “there is often more hospitalist engagement when bonuses are tied to quality metrics. People feel like they are being rewarded for their engagements.”
But “unless you are very driven,” she adds, “it’s hard for people who have a life outside medicine and are working seven-on/seven-off to do quality projects. At the end of the day, it is about them doing it on their own time.”
It is also important, she notes, to train residents and practicing hospitalists on how to plan, initiate and conduct improvement projects and measure results. “Being familiar with effective methodologies,” she says, “will help get more people involved.”
Many experts agree that the seven-on/seven-off schedule can be an enormous problem to getting more hospitalists engaged in QI projects.
According to the CDC’s Dr. Srinivasan, that schedule was a key barrier in trying to find hospitalist takers for his antibiotic stewardship program.
Jordan Messler, MD, medical director of the 16-physician hospitalist group at Morton Plant Hospital in Clearwater, Fla., explains why. “When we recruit people to a hospitalist group by saying, ‘And now you get seven days off!,’ it’s hard to bring folks back in on their days off.”
Dr. Messler says that he is trying to change group culture so that some QI work is part of every hospitalist’s job description. And he is trying practical ways to boost physician involvement, including having people join projects as a team. “At least when you are off,” he notes, “your partner is around to go to the meetings.”
In Minneapolis, the hospitalists at Allina Health’s Abbott Northwestern Hospital face another major QI barrier, even for interested physicians: Their compensation is based entirely on productivity.
Hospitalists at a recent group retreat pointed out that their job satisfaction would improve if more people could do quality projects, rather than continuing to lean on a few people who volunteer for everything. But under the current compensation model, every minute spent away from clinical care means less pay, and few physicians are interested.
“It’s not really accessible to anyone except those professional volunteers,” explains hospitalist William P. Dickey, MD, Abbott Northwestern’s medical director of patient safety and quality. For the last 10 years, he and a few colleagues have done nearly all the group’s QI work. “What I would like to see is that your job as a hospitalist is patient care plus something else that the group has asked you to do.”
The hospitalist group is meeting later this summer, Dr. Dickey adds, to work on redesigning the compensation plan. In the new mix, as much as 10% of physician compensation may be pegged to “their participation in hospital performance initiatives.”
Hospitalists point to another hurdle that increasingly crops up: the consolidation going on among hospitals and health systems, which has made QI work much tougher.
As Florida’s Dr. Messler points out, doing quality improvement in years past meant changing one order set ” usually on paper “at one hospital. While that was hard, it was doable.
“Now we are part of an 11-hospital system,” he says. “If you want to make a change in the EMR, 11 hospitals have to approve it” “making it nearly impossible to get anything approved. “The EMR is one of our biggest barriers to QI projects.”
Chicago’s Dr. Das points to another potential problem: scheduling meetings, taking minutes, interacting with the IT department and keeping everyone in the loop. The administrative chores involved in quality projects can burn out any hospitalist volunteer.
“It’s extremely annoying to have to write up minutes when you have patients to see,” says Dr. Das. Her solution is to assign an administrative assistant to each QI project to take care of those details.
Where to find support
Lakshmi Halasyamani, MD, the chief medical officer of Cogent Healthcare, a national hospitalist and intensivist company, notes that hospitalists in community hospitals can often find administrative staff willing to help with QI work “in other hospital departments. Think about marketing, where people may have skills putting together focus groups, or environmental services, where a staff member may have unique insights on issues and challenges.
Dr. Halasyamani also says that financial incentives for quality improvement are “probably necessary but insufficient to get us where we want to get.” For one, hospitals have to back up incentives with giving doctors the skills and support they need.
“If you incentivize me to do something that I don’t know how to do, I still can’t do it,” she points out. “Next year, you create more of a financial incentive, and I still can’t do it.”
And support is only part of the equation, Dr. Halasyamani adds. “Financial incentives will get some people to perform,” she says. “But you don’t just want people to perform. You want them to embrace what they are doing because it gives them more autonomy or personal fulfillment or allows them to contribute to a greater good.”
Avoiding QI overload
According to the CDC’s Dr. Srinivasan, the best way to overcome QI fatigue is “to find ways to make the QI project ‘value-added’ to doctors’ work flow.” For his antibiotic stewardship program, for example, “the idea of reassessing therapy at 48 hours seemed to resonate with hospitalists because it helped address their need to ensure good patient handoffs.” When groups can use a QI project to make their work more efficient, he says, “it ends up being a win all the way around.”
To work on QI without burning out, says Gregory A. Maynard, MD, a hospitalist at the University of California, San Diego, and chief medical officer for the Society of Hospital Medicine’s Center for Healthcare Improvement and Innovation, you should be working on “something that you really care about, something that maybe keeps you awake at night, that you have a fire in your belly about.” One essential job of a hospitalist group leader, he adds, is to know what fuels each hospitalist and then match the right hospitalists with the right projects.
The flip side of QI fatigue is QI invigoration, which Dr. Messler says keeps him going even when he has taken on too much. “I am guilty of saying ‘yes’ to too many things.” As a result, he’s gotten used to seeing projects he’s worked on for a while fizzle out.
“But that’s the nature of it,” Dr. Messler points out. “There are a lot of competing priorities.” He’s seen, for instance, both a diabetes committee and a readmissions project fold.
“But now a nurse manager and I are working hard on teamwork and communication as part of a multidisciplinary rounds project,” he says. “I have a project that is in its infancy, but we have had success, and it is hugely rewarding. When something fails, you have to learn not to be frustrated.”
Deborah Gesensway is a freelance writer who covers U.S. health care from Toronto.
How to avoid QI fatigue
- Learn to say “no.”
Because hospital medicine touches so many aspects of inpatient care, many projects that hospitals select “may overlap with hospital medicine a tiny bit. The hospital may invite us to participate, especially if we complained before that we weren’t involved,” explains Kevin J. O’Leary, MD, chief of hospital medicine and associate chair for quality for the medicine department at Chicago’s Northwestern University Feinberg School of Medicine. “But if it doesn’t overlap much with what we do, it’s OK to politely say, ‘Not at this time. We are thrilled that you are working on it, but maybe involve us at a later stage.’ ”
- Start small.
Pick projects that are doable in a short amount of time, and don’t be put off by not having a lot of data to guide you. “If you start out saying, ‘I can’t improve anything until you give me data,’ you’ll never begin,” says Lakshmi Halasyamani, MD, the chief medical officer of Cogent Healthcare. “But saying, ‘I am going to improve with what I have,’ which may just be a few patient complaints, then you can start.” In a small hospital, for example, you might be able to test a QI innovation on 10 patients, learning from that pilot group. “It’s not a statistically valid sample for a research project, but it is going to give you enough information to better understand what to focus on,” she points out. “If 10 out of 10 people tell you that a specific current process isn’t working, it’s unlikely the next 10 are going to tell you it’s great.”
- Pay attention to internal politics.
A project won’t succeed if it doesn’t have the hospital’s backing and buy-in from many departments. “You have to understand the way the institution works to get things done more efficiently,” says Gregory A. Maynard, MD, a hospitalist at the University of California, San Diego (UCSD). If you need hospital support, whether it’s time, money or even backing, it’s best to “align what you want to do with what the administration wants to do.”
- Don’t be a cowboy.
This is what Dr. Maynard refers to as “doing quality improvement without a license” “and he admits to being guilty of this earlier in his career. “I would see a need, start working on something and pull a team together, but I wasn’t going through the official committee structure or touching base with the CMO,” Dr. Maynard says. “I didn’t stop to make sure that this was the right project for the right time.”
- Find support.
Instead of dedicated time or money, this could be administrative support. Look outside your own department, particularly for administrative staff who can manage projects. “Putting together the group, deciding when to meet, sending out invites, taking minutes, interacting with IT and nursing “these are things doctors are not naturally trained to do,” says Krishna Das, MD, a hospitalist and chief quality officer at Chicago’s Cook County Health & Hospitals System. “It’s much easier to say to physicians, ‘Come to a one-hour meeting.’ ”
- Don’t take failure personally.
“The administration is just as burned out by the barrage of publicly reported measures, value-based purchasing and regulatory requirements as front-line clinicians, if not more so,” says UCSD’s Dr. Maynard. “You try to pick projects that they will support, but sometimes it’s just plain not the right time.” That doesn’t mean that you give up, he adds, but instead do what you can. “I’ve worked on many projects where it wasn’t the right time,” he says. “And then something comes up, and it’s suddenly the right time. You have the solutions ready, and it’s a totally different world.”