Change You Should Believe In

The Hospitalist. 2010 July;2010(07):

July 1, 2010 | The Hospitalist

What’s really needed, Dr. Vidyarthi says, is a hospital’s commitment to more effective transitions and its hospitalists’ leadership in driving a comprehensive, multidisciplinary, team- and evidence-based QI process. The new process should be a QI-based solution to a hospital’s care-transitions issues. “Before you can standardize your process, you need to understand it,” she says. “This is a complex problem, and it needs a multifaceted solution. But this lies squarely within the hospitalist arena. We’re part of everything that happens in the hospital.

We created an intervention that automatically triggers an e-mail with the finalized test results to the responsible providers. The intervention creates a loop of communication between the inpatient attending and the PCP. What we hope to show in our research over the next year or two is whether the intervention actually increases awareness of test results by providers.

—Anuj Dalal, MD, Brigham and Women’s Hospital, Boston

Hospital administrators are looking to HM to solve transition and readmission problems now, says Tina Budnitz, MPH, BOOST Project Director (Better Outcomes for Older Adults through Safe Transitions). She expects the scrutiny from the C-suite, legislators, and watchdog groups to increase as the spotlight continues to shine on the healthcare system.

“Any hospitalist can act as a leader in their institution,” Budnitz says. “Be a change agent, pull a group together, and start asking questions: Do we have safe care-transitions practices and processes in place? Just by asking the right question, you can be a catalyst for the system.”

Budnitz also emphasizes the importance of teamwork in the hospital setting. “How can I help my teammates? What am I communicating to the nurses on rounds?” she says. “Can you initiate dialogue with your outpatient medical groups: ‘These faxes we’re sending you—is that information getting to you in ways and times that are helpful? And, by the way, when your patient is admitted, this information would really help me.’ ”

Dr. Vidyarthi (right) routinely speaks about solutions to transitions. She says hospitals and HM groups need systems that allow people—or forces them—to do the “right thing.”

Innovative Strategies

One of the most important initiatives responding to concerns about care transitions is Project BOOST (www.hos pitalmedicine.org/BOOST), a comprehensive toolkit for improving a hospital’s transitions of care. The project aims to build a national consensus for best practices in transitions; collaborate with representatives from the Agency for Healthcare Research and Quality (AHRQ), the Centers for Medicare and Medicaid Services (CMS), and the Joint Commission; and develop a national resource library, Budnitz says.

“Project BOOST not only puts forth best practices for admitting patients, planning for discharge, and then doing the discharge, it also helps show facilities how to change their systems, with resources and tools for analyzing and re-engineering the system,” she says. “Sites get one-to-one assistance from a mentor.”

Six hospitals signed on to the pilot program in 2008; 24 more joined last year. In January, SHM announced a collaborative with the University of Michigan and Blue Cross Blue Shield of Michigan for 15 Michigan hospitals to receive training and mentorship starting in May. And last month, SHM and the California HealthCare Foundation announced a Project BOOST initiative for 20 of the health system’s hospitals (see “California Dreamin’”, p. 6). Other free resources offered on the BOOST Web portal include clinical, data collection, and project management tools. SHM also has a DVD that explains how to use the “teachback” method to improve communication with patients.

Re-Engineered Discharges

The basic components of the PROJECT RED checklist:

Educate the patient about his or her diagnosis throughout the hospital stay.
Schedule appointments for clinician follow-up and post-discharge testing.
Discuss with the patient any tests or studies that have been completed in the hospital and discuss who will be responsible for following up the results.
Organize post-discharge services.
Confirm the medication plan.
Reconcile the discharge plan with national guidelines and critical pathways.
Review the appropriate steps for what to do if a problem arises.
Expedite transmission of the discharge resume (summary) to the physicians (and other services, i.e., visiting nurses) accepting responsibility for the patient’s care after discharge.
Assess the degree of understanding by asking them to explain in their own words the details of the plan.
Give the patient a written discharge plan at the time of discharge.
Provide telephone reinforcement of the discharge plan and problem-solving two to three days after discharge.

For more detailed information, visit the-hospitalist.org for the complete checklist.

Source: Jack BW, Chetty VK, Anthony D. The Re-Engineered Discharge: A RCT of a comprehensive hospital discharge program. Ann Int Med. 2009;150:178-187.