My colleague, Ben Taylor, and I have an editorial in the new issue of the Archives of Internal Medicine – Do Hospitalists Improve Quality? (full text only to subscribers)

This editorial addresses several important issues: the definition of quality, the value of performance measures, the difference between quality and safety, alternative analyses, alternative explanations, and finally, what questions should we ask in 2009 about hospitalists and quality.

Readers can imagine our comments on quality and performance measures. We stress the role of hospitalists in developing protocols to improve safety, e.g., no wrong limb surgery, limited catheter related urinary tract infections, limited line infections, no meds to the wrong patient.

Much of our opinion stresses the difference amongst hospitals in how hospitalist groups integrate into hospital culture. We opine that likely the best situations include full integration of hospitalists into various important hospital committees. We know that at too many hospitals, the hospitalists are just hired to function as super-residents.

We finish our editorial with these 3 paragraphs:

We suggest studying hospitalist groups and their structure. Hospitalists can bring their greatest value when they become integrated into the hospital culture. Given the confusing term quality, we recommend focusing on safety issues rather than core disease measures as indicators of hospitalist contributions. Hospitalists have the best opportunity to observe process variations that increase the risk of a serious adverse outcome—or sentinel event. The salient question thus should focus on what do hospitalists do with these observations, or at a higher level, what can they do about dangerous processes. Thus, we should understand the preparedness and ability of hospitalists to assume roles and contribute to safety efforts as well as hospital support and commitment to addressing these important efforts. All physicians who have experienced these lapses in care understand that preventing error recurrence has more meaning and likely more impact than documenting smoking cessation counseling on discharge.

While difficult to perform, studies examining truer measures of hospitalist influence will come when we understand their influence on these safety issues. We should not take a database-driven approach but rather a hospital-by-hospital study that documents safety and hospitalist group structure. Rather than “single-site” studies, we need comparisons of multiple sites, studying their structures and impact on safety. Such studies would allow us to understand “best practices” for hospitalist group organization, exploring questions such as the following: What are the likely differences between the good situations and the undesirable situations? Do these differences reflect on the hospital administration or on the hospitalists themselves? Are there hospital characteristics that predict better hospitalist programs, which in turn, may be able to provide safer medical care?

As a young field, hospital medicine has strengths and weaknesses. Future investigations should focus on defining the strengths and minimizing the weaknesses. We believe that hospitalists can help decrease hospital errors and improve safety if they are totally integrated with hospital processes and supported as champions for these important efforts. Lumping hospitalists without a consideration of organizational differences could hide the promise of excellent hospitalist groups. The major contribution of hospital medicine should involve system improvement along with excellent bedside care. We must understand the contributors as well as the detractors to excellence for the hospitalist movement to achieve its full potential.

I hope that hospitalist bloggers will comment on the editorial and our proposal. We will continue to have hospitalist programs in this country for many reasons. We now should focus on the best structures so that overall patient care benefits from the insights of those how spend all their professional time working in the hospital.

The Wall Street Journal Health Blog weighs in – Do Hospitalists Improve the Quality of Care? and quotes us.

Related posts:

1. Hospital safety and root cause analysis
2. An interview about hospitalists
3. Thoughts on the Academic Hospitalist Academy
4. Some hospitalist jobs are better than others
5. The quality portfolio

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