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Hospital medicine: getting to the next level

January 2008

The recent study by Lindenauer et al published in the Dec. 20, 2007, NEJM and the accompanying editorial by Dr. Laurence F. McMahon are both very enlightening.

They also set the stage for a robust debate and discourse within the hospitalist community, academia, policy-makers and hospital administrators. Let me start by saying that I am no expert when it comes to dissecting medical studies, and this blog should in no way be construed as a scientific and statistical review of the study.

Having said that, Lindenauer’s study is certainly the most comprehensive retrospective cohort study to date covering close to 77,000 patients over two and half years comparing outcomes of care among hospitalists, general internists and family practioners. The gist of the study is that hospitalist care resulted in only modest gains in length of stay (0.4 days) and cost of care ($268 on average), without any difference in mortality or in 14-day readmission rates.

The title of Dr. McMahon’s related editorial is “The Hospitalist Movement–Time to Move On.” I concur with what he says is now a reality, and I quote him here: “The emergence of hospitalist care as an integral part of the clinical delivery system is a fact. The question is not how much better or worse hospitalists are in caring for inpatients, nor is it how much they ‘save’ the health care system. The real issue is, how do we construct a health care delivery system with hospitalists among its core providers?”

For hospitalists, I see the question going forward as being: How do we make ourselves even better? Like any business or service, our success lies in achieving two goals: First, we need to meet the expectations of our clients/customers, whether those are patients (our most important customers) or primary care providers, specialists, hospital administrators or insurance companies.

Second, we need to demonstrate to our clients that we are constantly improving. This is where I would like to introduce to Dr. W. Edwards Demmings, an MIT professor who, more then half a century ago, shook corporate thinking when it came to quality.

He devised a 14-step plan for business success, which Japanese industrialists took very much to heart. The gist of those 14 principles is that we have to improve constantly and forever.

Dr. Demmings’ revolutionary model now encompasses quality-improvement concepts such as Lean Thinking, Six Sigma and Kaizen. How do we incorporate these concepts into clinical practice and our daily jobs?

How do we marry these concepts to external benchmarks such as those used in the NCQA’s Quality Compass product, which reports quality data submitted by different health plans? And is it possible to develop a mathematical/statistical model to show the impact that hospitalists have on patient throughput in hospitals utilizing queuing theory, an approach that can help us balance demand and capacity?

The path ahead is filled with opportunities and challenges. As hospitalists, we need to look outside our hospital corridors and learn quickly about how best to manage clinical and operational processes, cut out waste, and standardize practices based upon best available evidence. At the same time, we need to embed safety at every step and learn how to best work around those problems–like short staffing–that routinely slow down our workflow and hamper our ability to deliver optimal care.

I solicit your thoughts on how to elevate hospital medicine to the next level. I look forward to your ideas about small changes that we can make in our daily work lives that will make a difference not only to our patients but also to the field of hospital medicine.