Keiki Hinami

Validation of new readmission data in the American College of Surgeons National Surgical Quality Improvement Program.

BACKGROUND Hospital readmissions are gathering increasing attention as a measure of health care quality and as a cost-saving target. The American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) recently began collecting data related to 30-day postoperative readmissions. Our objectives were to assess the accuracy of the ACS NSQIP readmission variable by comparison with the medical record, and to evaluate the readmission variable against administrative data. STUDY DESIGN Readmission data captured in ACS NSQIP at a single academic institution between January and December 2011 were compared with data abstracted from the medical record and administrative data. RESULTS Of 1,748 cases captured in ACS NSQIP, 119 (6.8%) had an all-cause readmission event identified, and ACS NSQIP had very high agreement with chart review for identifying all-cause readmission events (κ = 0.98). For 1,110 inpatient cases successfully matched with administrative data, agreement with chart review for identifying all-cause readmissions was also very high (κ = 0.97). For identifying unplanned readmission events, ACS NSQIP had good agreement with chart review (κ = 0.67). Overall, agreement with chart review on cause of readmission was higher for ACS NSQIP (κ = 0.75) than for administrative data (κ = 0.46). CONCLUSIONS The ACS NSQIP accurately captured all-cause and unplanned readmission events and had good agreement with the medical record with respect to cause of readmission. Administrative data accurately captured all-cause readmissions, but could not identify unplanned readmissions and less consistently agreed with chart review on cause. The granularity of clinically collected data offers tremendous advantages for directing future quality efforts targeting surgical readmission.

Structured interdisciplinary rounds in a medical teaching unit: improving patient safety.

BACKGROUND Effective collaboration and teamwork is essential to providing safe hospital care. The objective of this study was to assess the effect of an intervention designed to improve interdisciplinary collaboration and lower the rate of adverse events (AEs). METHODS The study was a controlled trial of an intervention, Structured Inter-Disciplinary Rounds, implemented in 1 of 2 similar medical teaching units in a tertiary care academic hospital. The intervention combined a structured format for communication with a forum for regular interdisciplinary meetings. We conducted a retrospective medical record review evaluating 370 randomly selected patients admitted to the intervention and control units (n = 185 each) in the 24 weeks after and 185 admitted to the intervention unit in the 24 weeks before the implementation of Structured Inter-Disciplinary Rounds (N = 555). Medical records were screened for AEs. Two hospitalists confirmed the presence of AEs and assessed their preventability and severity in a masked fashion. We used multivariable Poisson regression models to compare the adjusted incidence of AEs in the intervention unit to that in concurrent and historic control units. RESULTS The rate of AEs was 3.9 per 100 patient-days for the intervention unit compared with 7.2 and 7.7 per 100 patient-days, respectively, for the concurrent and historic control units (adjusted rate ratio, 0.54; P = .005; and 0.51; P = .001). The rate of preventable AEs was 0.9 per 100 patient-days for the intervention unit compared with 2.8 and 2.1 per 100 patient-days for the concurrent and historic control units (adjusted rate ratio, 0.27; P = .002; and 0.37; P = .02). The low number of AEs rated as serious or life-threatening precluded statistical analysis for differences in rates of events classified as serious or serious and preventable. CONCLUSION Structured Inter-Disciplinary Rounds significantly reduced the adjusted rate of AEs in a medical teaching unit.

Understanding communication during hospitalist service changes: A mixed methods study

BACKGROUND Little data exist to inform hospitalist communication during service changes. OBJECTIVE To characterize hospitalist handoffs during service changes. DESIGN Serial survey study. SETTING Single academic medical center. MEASUREMENTS From May to December 2007, 60 service changes among 17 hospitalists on a nonteaching service were targeted for evaluation using an anonymous 18-item survey that was completed by hospitalists within 48 hours of assuming care for patients. Survey items assessed completeness of handoff communication, certainty of patient care plans, missed information, time spent recovering information, and near misses/adverse events due to incomplete handoffs. The association between completeness of communication and handoff outcomes was examined. Narrative comments were analyzed qualitatively. RESULTS Ninety-three percent (56/60) of surveys were returned. All 17 hospitalists participated. Thirteen percent of respondents reported incomplete handoffs and 18% were uncertain of care plan on transition day. At least 1 near miss, attributable to incomplete communication was reported by 16%. Hospitalists who reported incomplete handoffs were more likely to report uncertainty about patient care plans on the transition day (71% incomplete vs. 10% complete, P < 0.01), discovery of missing information (71% incomplete vs. 24% complete, P = 0.01), near misses/adverse events (57% incomplete vs. 10% complete, P < 0.01), and more time resolving issues arising from missed information (71% incomplete vs. 22% complete, P < 0.01). Qualitative comments suggest the need for a more systematic, focused, team-based, and patient-centered handoff model. CONCLUSIONS Incomplete handoffs during service changes are associated with uncertainty and potential patient harm. Suggestions to improve the completeness of hospitalist service change communications are offered.

Worklife and Satisfaction of Hospitalists: Toward Flourishing Careers

ABSTRACTBACKGROUNDThe number of hospitalists in the US is growing rapidly, yet little is known about their worklife to inform whether hospital medicine is a viable long-term career for physicians.OBJECTIVEDetermine current satisfaction levels among hospitalists.DESIGNSurvey study.METHODSA national random stratified sample of 3,105 potential hospitalists plus 662 hospitalist employees of three multi-state hospitalist companies were administered the Hospital Medicine Physician Worklife Survey. Using 5-point Likert scales, the survey assessed demographic information, global job and specialty satisfaction, and 11 satisfaction domains: workload, compensation, care quality, organizational fairness, autonomy, personal time, organizational climate, and relationships with colleagues, staff, patients, and leader. Relationships between global satisfaction and satisfaction domains, and burnout symptoms and career longevity were explored.RESULTSThere were 816 hospitalist responses (adjusted response rate, 25.6%). Correcting for oversampling of pediatricians, 33.5% of respondents were women, and 7.4% were pediatricians. Overall, 62.6% of respondents reported high satisfaction (≥4 on a 5-point scale) with their job, and 69.0% with their specialty. Hospitalists were most satisfied with the quality of care they provided and relationships with staff and colleagues. They were least satisfied with organizational climate, autonomy, compensation, and availability of personal time. In adjusted analysis, satisfaction with organizational climate, quality of care provided, organizational fairness, personal time, relationship with leader, compensation, and relationship with patients predicted job satisfaction. Satisfaction with personal time, care quality, patient relationships, staff relationships, and compensation predicted specialty satisfaction. Job burnout symptoms were reported by 29.9% of respondents who were more likely to leave and reduce work effort.CONCLUSIONSHospitalists rate their job and specialty satisfaction highly, but burnout symptoms are common. Hospitalist programs should focus on organizational climate, organizational fairness, personal time, and compensation to improve satisfaction and minimize attrition.

A matter of priorities? Exploring the persistent gender pay gap in hospital medicine.

BACKGROUND Gender earnings disparities among physicians exist even after considering differences in specialty, part-time status, and practice type. Little is known about the role of job satisfaction priorities on earnings differences. OBJECTIVE To examine gender differences in work characteristics and job satisfaction priorities, and their relationship with gender earnings disparities among hospitalists. DESIGN Observational cross-sectional survey study. PARTICIPANTS US hospitalists in 2010. MEASUREMENTS Self-reported income, work characteristics, and priorities among job satisfaction domains. RESULTS On average, women compared to men hospitalists were younger, less likely to be leaders, worked fewer full-time equivalents, worked more nights, reported fewer daily billable encounters, more were pediatricians, worked in university settings, worked in the Western United States, and were divorced. More hospitalists of both genders prioritized optimal workload among the satisfaction domains. However, substantial pay ranked second in prevalence by men and fourth by women. Women hospitalists earned

Person‐job fit: An exploratory cross‐sectional analysis of hospitalists

14,581 less than their male peers in an analysis adjusting for these differences. CONCLUSIONS The gender earnings gap persists among hospitalists. A portion of the disparity is explained by the fewer women hospitalists compared to men who prioritize pay.

Provider expectations and experiences of comanagement

BACKGROUND Person-job fit is an organizational construct shown to impact the entry, performance, and retention of workers. Even as a growing number of physicians work under employed situations, little is known about how physicians select, develop, and perform in organizational settings. OBJECTIVE Our objective was to validate in the hospitalist physician workforce features of person-job fit observed in workers of other industries. DESIGN The design was a secondary survey data analysis from a national stratified sample of practicing US hospitalists. MEASURES The measures were person-job fit; likelihood of leaving practice or reducing workload; organizational climate; relationships with colleagues, staff, and patients; participation in suboptimal patient care activities. RESULTS Responses to the Hospital Medicine Physician Worklife Survey by 816 (sample response rate 26%) practicing hospitalists were analyzed. Job attrition and reselection improved job fit among hospitalists entering the job market. Better job fit was achieved through hospitalists engaging a variety of personal skills and abilities in their jobs. Job fit increased with time together with socialization and internalization of organizational values. Hospitalists with higher job fit felt they performed better in their jobs. CONCLUSIONS Features of person-job fit for hospitalists conformed to what have been observed in nonphysician workforces. Person-job fit may be a useful complementary survey measure related to job satisfaction but with a greater focus on function.

Patient-level exclusions from mHealth in a safety-net health system

BACKGROUND Hospitalist comanagement of complex surgical and medical specialty patients is increasingly common, but it is unclear how provider expectations and experiences under the collaborative practice model differ from those of traditional consultations. METHODS We analyzed survey data examining expectations and experiences on a medical hepatology comanagement service. Participating hospitalists, nonphysician providers (NPPs), hepatologists, and fellows completed a Baseline Survey that addressed preferences for decision-making under comanagement. Repeated Surveys, administered to each unique team of comanagers, addressed their experiences with decision-making on their rotations on the service between April and October 2008. RESULTS All 43 providers completed the Baseline Survey. Among these, 32 providers who rotated on the service completed 79% (177/223) of Repeated Surveys. The majority of respondents indicated understanding their role. More providers of every professional role indicated their preference for hospitalists to participate in every management decision and for hepatologists not to participate in every management decision. Most indicated that they both preferred and experienced the direction of management issues by a single physician leader. Almost all indicated at baseline that comanagement tends to improve patient care (hospitalists 94%, hepatologists 83%, NPPs 100%, fellows 100%), although fewer NPPs (40%) and fellows (50%) felt comanagement actually improved care following their rotations. CONCLUSIONS Preferences and experiences about provider roles are not uniform under comanagement, and conflicting preferences exist around decision-making processes. Providers generally agreed that comanaging hospitalists should participate broadly in management decisions.

Interventions to Reduce 30-Day Rehospitalization: A Systematic Review

&NA; Excitement about mobile health (mHealth) for improving care transitions is fueled by widespread adoption of smartphones across all social segments, but new disparities can emerge around nonadopters of technology‐based communications. We conducted a cross‐sectional survey of urban lowincome adults to assess inadequate reading health literacy and limited English proficiency as factors affecting access to and engagement with mHealth. Although the proportion owning smartphones were comparable to national figures, adjusted analysis showed fewer patients with inadequate reading health literacy having Internet access (odds ratio [95% confidence interval]: 0.50 [0.26‐0.95]), e‐mail (0.43 [0.24‐0.79]), and interest in using e‐mail (0.34 [0.18‐0.65]) for healthcare communications. Fewer patients with limited English proficiency were interested in using mobile apps (0.2 [0.09‐0.46]). Inpatient status was independently associated with less interest in text messaging (0.46 [0.25‐0.87]). mHealth exclusions around literacy and language proficiency threaten equity, and innovative solutions are needed to realize mHealths potential for reducing disparities.