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CHAPTER 26 Negotiation and Conflict Resolution

Leslie A. Flores, MHA

INTRODUCTION Hospitalists face the potential for conflict every day. They work in highly complex organizations and in order to be successful they must interact effectively with a wide variety of individuals in what is often a challenging, emotionally charged environment. Hospitalists must learn to navigate not only the formal organizational bureaucracy of rules, systems, and processes, but also the informal political hierarchy that influences power and decision making. Often, they must do so with little or no formal training in conflict management at an early stage in their medical careers. In addition, they may encounter conflicts between what others would like them to accomplish and their own workload demands and professional expectations.

Hospital Medicine is also a young, evolving specialty that has enjoyed unprecedented growth by serving the needs of multiple competing stakeholders. Although the specialty is maturing, it is still populated by a high proportion of recent residency graduates and early- career clinicians who may not have a complete understanding of the specialty or even have career advancement on their radar screen. The potential exists for the service obligations—both clinical and in the area of institutional performance improvement—of hospitalists to overwhelm opportunities for professional development, and this may promote career dissatisfaction, turnover, and symptoms of burnout. Leaders of hospitalist services may find themselves isolated as they advocate for the professional development and job satisfaction of group members while meeting the service expectations of their employers or supervisors. The professional medical society for hospitalists, the Society of

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Hospital Medicine, is rapidly developing flexible support resources for hospitalists relating to business and clinical practice, engagement and career satisfaction, core competencies, and role expectations. Until these standards become widely disseminated and health care services become better designed and hence less prone to error, hospitalists will continue to work in a hospital environment where they will increasingly be expected to perform as change agents at a time when change may not be welcomed by their hospitalist colleagues or others at their institutions.

For the purposes of this chapter, it will be important to distinguish between disagreements and conflicts. Disagreements happen regularly in human interactions, and occur whenever two or more individuals have differing opinions about something. A disagreement need not devolve into a conflict, and many do not. Conflicts arise when a party perceives that another party has negatively affected or will negatively affect agendas that the first party cares about. Conflicts are defined as processes that occur when tensions develop, that is, the emotions associated with a disagreement become so elevated that they impede the ability of the parties to interact with each other effectively.

Almost all conflict is a result of unmet expectations. For hospitalists, this commonly arises when there is a lack of understanding or a difference in expectations about their role. Hospitalists may assume that primary care physicians have explained to patients that someone else will be seeing them in the hospital. Patients and families, however, may not understand why their primary care physician is not present in the hospital and directing their care. Emergency Medicine physicians may expect the hospitalist to respond promptly to take a complicated social admission off their hands whereas hospitalists may feel that it is the role of the emergency room physicians to discharge patients who do not require admission. Emergency Medicine physicians and staff may expect for patients be triaged to hospital floors (to reduce emergency department length of stay) before critical information is available, or may expect hospitalists to care for patients in the emergency department when no beds are available. Meanwhile, floor nurses may expect hospitalists to be immediately available to address nonurgent requests. There may be differences of opinion among specialists and generalists regarding diagnosis, workup, and treatment or the role of the hospitalists in comanagement of specialty patients. All physicians expect to be treated professionally, to have some autonomy over clinical decision making, and to have a reasonable work-life balance. Hospital administrators and employers, however, may demand that hospitalists to perform nonphysician tasks or solve problems for other physician groups without taking into account the perspectives of the hospitalists or staffing needs for time-consuming tasks. When such expectations go unmet, people get frustrated or angry. They often respond in ways that then heighten frustration or anger on the part of others. Emotions on both sides become elevated, and the stage is set for a conflict.

PRACTICE POINT

Almost all conflict is a result of unmet expectations. For hospitalists this commonly arises when there is a lack of understanding or a difference in expectations about their role.

The most common reasons that expectations go unmet include:

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Lack of Clarity About What is Expected, or About How the Expectation Will Be Met. It is easy to assume that because one’s expectations are clearly understood by oneself, they are clear to others as well. Hospitalists may assume a patient understands the proposed treatment plan, but the patient or family member may fail to understand the implications for likely discharge plans. Even when expectations are carefully explained, the other party may hear or interpret them differently than the speaker intends. The other party may also react more to the emotional aspect of the discussion or who is doing the talking rather than to the content. Lack of Agreement About What is Expected Or How to Achieve It. The high degree of complexity in error prone health care systems, stress and pressure, and the need for rapid change are important sources of potential conflict. Sometimes each party’s expectations are clearly understood by the other party, but they simply disagree with each other about the desired outcome, the method of achieving it, or both. This can occur if the parties have competing needs or interests. For example, although resident work hour restrictions are clearly delineated in the academic setting, stress and pressure develop for hospitalists when the increased service obligations resulting from such restrictions conflict with their expectation for professional advancement. All parties may agree on the importance of improving patient flow from the Emergency Department to the inpatient floor, but may disagree about the specific methods to be employed by Emergency Medicine physicians, hospitalists, and others to achieve this goal. Changing hospital processes to promote improved quality or greater efficiency often demand changes to hospitalist work flow that are stressful for the hospitalists.

In addition, age, gender, and cultural differences may play a role in the development and management of conflict. A generational gap may result in differences in work expectations, a paternalistic view of who is actually in charge, or resistance to changing to new work requirements. Men and women may have different expectations of their work, and often have different ways of responding to stress, emotion, and conflict. In the United States, men often tend to use a competing or forcing style when faced with conflict, whereas women often tend to use compromising, accommodating, and avoiding.

A key aspect of cultural differences is the degree to which a person tends to identify most strongly with the group of which he or she is a part (a “collectivist culture”) as opposed to identifying with the self (an “individualistic culture”). Individualistic cultures, which are the dominant cultures found in North America and Western Europe, value autonomy, creativity, and personal initiative. Much of the rest of the world is composed of collectivist cultures, which instead value conformity and harmony. A meta-analysis of studies on culture and conflict resolution styles found that people in individualistic cultures tend to choose forcing as a conflict style more often and people who come from collectivistic cultures tend to choose withdrawing, compromising, or problem-solving styles instead.

THE POTENTIAL BENEFITS OF CONFLICT Conflicts are inevitable in human interactions. The increasingly complex and collaborative nature of the work that hospitalists do as team-based care models have emerged increases the risk that interpersonal conflicts may arise. The increasing cost pressures and competition for scarce resources that exist in an era of national health care reform have

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increased stress and opportunities for conflict for all health care professionals. These conflicts can be destructive if not effectively managed. But a healthy approach to conflict management acknowledges that not all conflict is entirely negative. There are potential benefits that may be derived from conflicts under certain circumstances. DeChurch and Marks (2001) reported that the ways in which groups handle conflict help to determine whether or not benefits were realized, noting that “the relationship between task conflict and group performance was positive when conflict was actively managed and negative when it was passively managed.” This suggests that Hospital Medicine physicians will be well served to develop effective conflict management skills that can help them increase the likelihood that the conflicts they will inevitably face may yield positive results. In order to do so, it will be important for hospitalists to think strategically about how one may extract the maximum benefit from conflicts that do occur. Some of the potential benefits of appropriately managed conflict include:

Catalyst for Change. Conflicts can force needed change by surfacing problems that otherwise might not be recognized, and by elevating latent issues to a level that demands attention. This can be especially valuable in tradition-bound, change- resistant organizations. Improved Outcomes. Similarly, conflicts can ultimately yield improved outcomes when they facilitate learning in the search for better solutions and bring to the forefront useful information and emotions that lie below the surface. Balance. Healthy conflict helps to ensure that balance is maintained among competing needs and perspectives. Increased Accountability. Because conflicts involve strong emotions, healthy conflict resolution usually involves careful articulation of what the parties have agreed to do to resolve it, and a significant degree of accountability to ensure that the agreements are followed through. Improved Relationships. When people skillfully manage a conflict in healthy, respectful ways, it can actually serve to strengthen their relationship going forward. They end up understanding each other better, and building greater trust because they have demonstrated that they can overcome differences.

KEY PRINCIPLES IN CONFLICT MANAGEMENT

This chapter offers five key principles that represent a good start for those who wish to build better conflict management skills (Table 26-1). However, more detailed treatments of all of these principles and others are contained in the references at the end of this chapter.

TABLE 26-1 Five Key Principles of Effective Conflict Management

1. Commit to confronting 2. Attend to the conditions 3. Identify one’s personal contribution 4. Consider what is underlying others’ behavior 5. Clarify

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1. Commit to Confronting. Most people tend to shy away from conflict. It is tempting to believe that the problem will go away by itself if left alone; that others will soften their positions, forget about the issue, or change their minds, if given enough time. But when pressed, most people will acknowledge this is simply a convenient excuse for avoiding a confrontation that they fear could become uncomfortable or out-and- out unpleasant. Another important reason that people avoid conflict is their fear that openly confronting the situation will make things worse, rather than better. They may worry about handling the confrontation badly and unintentionally causing the situation to deteriorate, or they may fear that the conflict is intractable and that no matter how carefully and skillfully the situation is handled, the outcome will be negative.

In fact, conflicts cannot be resolved if they are not confronted. They may be glossed over or pushed into the background, but not truly resolved. And such conflicts are likely to surface again, often in unanticipated and damaging ways. Thus, a willingness to acknowledge the existence of a conflict and to step up and confront it is a precondition to effectively managing the conflict.

PRACTICE POINT

A willingness to acknowledge the existence of a conflict and to step up and confront it is a precondition to effectively managing the conflict. This requires an open and honest discussion of the issue, usually face to face, with the goal of understanding the root causes (the unmet expectations) that led to the conflict and addressing them.

In this context, the term “confrontation” is not intended to mean an angry, emotional exchange of verbal attacks. Instead, “confrontation” refers here to an open and honest discussion of the issue, usually face to face, with the goal of understanding the root causes (the unmet expectations) that led to the conflict and addressing them. The remaining principles in this secion are intended to assist the confronter, once the decision to confront has been made, to carefully plan the confrontation (when time permits), and to handle it successfully.

2. Attend to the Conditions. Patterson et al (2002) note that there are two components to every successful crucial conversation: the actual content of the conversation, and the conditions under which the conversation occurs. Most people, when planning to confront or actually engage in a confrontation (a “crucial conversation”), think primarily about the content of the conversation: “What is this conflict about? What steps will resolve it? What points do I need to be sure to make? What will I say to get my points across? What will the other person say?”

People skilled in conflict management realize that the conditions matter just as much as—in fact, maybe more than—the content does. What types of conditions matter? The physical conditions matter a great deal. Is the conversation taking place in a private place instead of in public? Are the people involved in the conversation sitting or standing so they can engage each other at eye level, or is one person sitting with the other standing over

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him? Is there a desk or other impediment between the participants? Is the room too large or too small, too hot or too cold to be comfortable?

Psychological conditions matter even more. The hospitalist who wishes to be skilled at conflict management must learn to pay attention to what the other person or people involved in the conflict are experiencing emotionally. Are they feeling attacked or are they feeling safe? Do they feel that the hospitalist respects them and has their best interests at heart, or do they feel that their interests will be ignored or belittled? Do they sense that the hospitalist is going to push her agenda or opinion and ignore theirs, or do they believe the hospitalist is willing to listen and take their point of view into consideration? Do they feel that the hospitalist’s opinion matters, or that dialogue should occur at a “higher level” with senior physician leaders to the exclusion of hospitalists?

Before the actual content—what the conflict is about and how it should be resolved— can be effectively addressed, the skilled conflict manager must take steps to set up conditions that allow all parties to feel comfortable, safe, and heard. The necessary steps to creating these positive conditions involve ensuring mutual respect among the parties, and identifying or creating a mutual purpose. In other words, do others believe the hospitalist sees them as individuals worthy of the respect and consideration due to every human being, and do they believe that the hospitalist is mindful of their interests as well as his own in seeking an acceptable resolution?

PRACTICE POINT

Before the actual content—what the conflict is about and how it should be resolved— can be effectively addressed, the skilled conflict manager must take steps to set up conditions that allow all parties to feel comfortable, safe, and heard. The necessary steps to creating these positive conditions involve ensuring mutual respect among the parties and identifying or creating a mutual purpose.

3. Identify One’s Personal Contribution. Conflicts occur when emotions get in the way of resolving disagreements. This is true not only of others with whom a hospitalist may come in conflict, but of the hospitalist himself. Another important competency for skilled conflict managers is the ability to step back from their own emotions and assess their personal contribution to the situation; in other words, what impact are their own biases, assumptions, emotions, and actions having on the conflict itself, and on their approach to managing it? Do they truly intend to seek mutually acceptable solutions or do they just want to win?

For example, the person seeking to manage a conflict must pay attention not only to what others are experiencing emotionally but also to what he is experiencing emotionally himself. He needs to ask, “Am I feeling safe or am I under attack? Do I believe the others involved in this conflict will listen to me and take my interests into consideration, or not?” However, simply identifying one’s own emotional state is not adequate. Effective conflict managers should also have the self-awareness to understand how their emotions will tend to influence their behavior in the confrontation. These tendencies are described as a person’s “style under stress.”

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The Style Under Stress Inventory3 in Table 26-2 is based on the concept of conversational safety, and will assist individuals in assessing their own personal style under stress. In completing the questions, one should answer “T” for true or “F” for false, based on one’s most common tendencies when in conflict situations in the work setting. People feel safe in a crucial conversation if they believe that they will be listened to respectfully and if they do not feel attacked or ignored. They feel that the other parties have their interests at heart, or at least that others’ interests and their own are not diametrically opposed without room for finding common ground. The inventory is designed to help people understand how they tend to behave when they do not feel safe in a crucial conversation.

TABLE 26-2 Style Under Stress Test

1. Rather than tell people exactly what I think, sometimes I rely on jokes, sarcasm, or snide remarks to let them know I’m frustrated.

T F

2. When I have got something tough to bring up, sometimes I offer weak or insincere compliments to soften the blow.

T F

3. Sometimes when people bring up a touchy or awkward issue I try to change the subject.

T F

4. When it comes to dealing with awkward or stressful subjects, sometimes I hold back rather than give my full and candid opinion.

T F

5. At times I avoid situations that might bring me into contact with people I’m having problems with.

T F

6. I have put off returning phone calls or e-mails because I simply did not want to deal with the person who sent them.

T F

7. In order to get my point across, I sometimes exaggerate my side of the argument.

T F

8. If I seem to be losing control of a conversation, I might cut people off or change the subject in order to bring it back to where I think it should be.

T F

9. When others make points that seem stupid to me, I sometimes let them know it without holding back at all.

T F

10. When I’m stunned by a comment, sometimes I say things that others might take as forceful or attacking, comments such as “give me a break!” or “that’s ridiculous!”

T F

11. Sometimes when things get heated I move from arguing against others’ points to saying things that might hurt them personally.

T F

12. If I get into a heated discussion, I’ve been known to be tough on the other person. In fact, they might feel a bit insulted or hurt.

T F

Excerpted with permission from Patterson K, Grenny J, McMillan R, et al. Crucial Conversations: Tools for Talking When Stakes are High. New York, NY: McGraw-Hill; 2002.

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Individuals responding “true” for several of the first six questions are said to be going to silence when under the stress of a challenging conflict situation. This means they will tend to try to downplay or sugarcoat an issue, or even avoid it outright by changing the subject or disengaging when they do not feel safe. In such cases, they may believe that they have raised an issue and articulated their concerns, but others may be left confused or unaware of how strongly the person feels about the issue because of his silence tendencies. On the other hand, answering “true” to some or all of questions 7 through 12 means the person tends to go to violence when feeling unsafe in a conversation. These people will often try to force their opinion on others by controlling the conversation and either prevent others from speaking or belittle their contributions when they do.

Both silence and violence can be extremely damaging, when the goal of the conversation is to confront disagreements and work toward mutually acceptable solutions. When people understand their own silence or violence tendencies, they can begin to pay attention to how they are responding during conflict situations. They can look for evidence that they are not feeling safe and then step back to assess the impact their silence or violence is having on the conversation and adjust their interactions accordingly. As awareness of these tendencies grows over time, people can begin to anticipate situations in which safety may be at risk and to proactively develop plans to manage their own tendencies to go to silence or violence.

When thinking about one’s personal contribution to a conflict situation, one should also be cognizant of individual assumptions and biases about others involved in the conflict, and especially one’s beliefs about others’ intentions. For example, it is usually helpful to consider the problem of intent versus impact. When analyzing a conflict, one should consider asking, “Is it the impact (ie, the outcome) of the other person’s behavior that is bothering me so much, or is it what I believe about the person’s intentions?”

This distinction is important because humans tend to overemphasize dispositional factors such as personality type or motives, and to discount situational factors such as external stressors, when interpreting the behavior of others; this phenomenon is known by psychologists as the fundamental attribution error or correspondence bias. Because of this bias, the emotions a person experiences about a disagreement, and thus the level of conflict that ensues, may be heightened as a result of presumed negative intentions on the part of others (“that surgeon is just lazy”) and discounting the circumstantial factors that may be influencing others’ behavior (“that surgeon is under real pressure to produce good outcomes, and does not have the training or experience to manage these complex medication regimens”).

The fundamental attribution error may be exacerbated by a related tendency known as the actor-observer bias in which one tends to attribute others’ behavior to their dispositions but to attribute one’s own behavior to the circumstances (“that family member lost her temper because she’s a demanding jerk, but I only lost my temper because she pushed me over the edge”). Self-awareness is critical for effective conflict management, especially awareness of one’s own assumptions and biases.

PRACTICE POINT

Self-awareness is critical for effective conflict management, especially awareness of one’s own assumptions and biases.

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4. Consider What is Underlying Others’ Behavior. One of the keys to effective conflict management is the ability to analyze why others respond the way they do in conflict situations (taking into account both dispositional factors and situational factors), and to modify one’s interactions accordingly. The concept of conversational safety applies to the other parties involved in a conflict situation, as well as to oneself. Skilled conflict managers become adept at not only reading and adjusting their own behaviors, but also at looking for signs that others are not feeling safe. Hospitalists may become more accepting of the anger expressed by patients’ families, the critical comments from other medical staff members, or the sugar-coated change of subject by the hospital executive when they realize that these behaviors often result from others’ fear(s) that they will be treated with disrespect, attacked, or ignored. If they can then work to address those underlying fears (part of paying attention to conditions) before launching into the content of the conversation, they will be more successful.

PRACTICE POINT

One of the keys to effective conflict management is the ability to analyze why others respond the way they do in conflict situations (taking into account both dispositional factors and situational factors), and to modify interactions accordingly. When someone acts in ways that contribute to a heightened level of conflict, it is worth considering whether that person has underlying human needs that are going unmet and that are contributing to his or her challenging behavior.

Another way of thinking about this issue is to anticipate that the more significant the conflict, the greater the chance that people will respond to it emotionally rather than logically. While it is not a clinically accurate model, it may be useful to think of peoples’ brains as having a logical core, surrounded by a layer of emotion (Figure 26-1). Every interaction a person has, no matter how logical it is, passes through this emotional filter on its way in or out.

Figure 26-1 Logic and emotion diagram.

For most people and under normal circumstances, the layer of emotion surrounding the logical core is relatively thin and the information from the interaction passes through it

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in both directions, informed by the emotion but not substantially altered by it. In a conflict situation, however, the emotional layer surrounding the logical core inflates like a balloon. In this situation, the expanded emotional layer takes over and prevents logical conversation and data from passing through. The person is responding from her or his emotion, rather than from logic. A hospitalist may be attempting to have a very logical conversation with a family member, assuming that she is addressing the family member’s logical core. But the hospitalist’s logical words cannot get through the family member’s inflated emotional layer. The hospitalist is talking logic, and the family members are responding from emotion; so no wonder they are unable to relate to each other. In such situations, it is necessary to let some air out of the balloon—to give the emotional layer a chance to deflate—before it will be possible to re-engage the logical core in problem solving or conflict resolution. Sometimes this requires stepping away from the conversation for a while and coming back to it later.

In addition to the overwhelming influence of emotion on how others respond to conflict situations, Heifetz and Linsky (2002) have argued that there are powerful and universal human needs that influence behavior, sometimes in dysfunctional or disruptive ways:

Every human being needs some degree of power and control, affirmation and importance, as well as intimacy and delight…. We all have hungers, which are expressions of our normal human needs. But sometimes those hungers disrupt our capacity to act wisely or purposefully. Perhaps one of our needs is too great and renders us vulnerable. Perhaps the setting in which we operate exaggerates our normal level of need, amplifying our desires and overwhelming our usual self-controls. Or, our hungers might be unchecked simply because our human needs are not being met in our personal lives.

When someone acts in ways that contribute to a heightened level of conflict, it is worth considering whether that person has underlying human needs that are going unmet, and that are contributing to his or her challenging behavior.

5. Clarify. When confronting another person about a conflict situation, effective communication skills are essential. It is important to clarify what one is attempting to convey; it is also important to clarify the other person’s point of view. Important communication skills include

Setting the stage. Keeping in mind the principles of mutual respect and mutual purpose, it may be valuable to start out by communicating one’s own positive intentions to the other person(s) in a way that builds toward these goals. Managing expectations. Hospitalists should clearly communicate what their own expectations were in the situation that gave rise to the conflict, and seek to understand what the other person’s expectations were. This will create a foundation for further dialogue about the differences between what each party expected and what actually occurred. Active listening. Active listening skills involve not just hearing what the other person says, but also

actively engaging the other person with eye contact and body language;

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working to enable the other person to feel comfortable sharing potentially difficult information; listening “between the lines” for what is not being said, as well as what is being said; acknowledging the reality and legitimacy of the other person’s emotions; paraphrasing and reframing to ensure understanding of the other person’s perspective; asking questions and probing to understand root causes; staying focused on the other person, rather than one’s own planned response.

Joint problem solving. Engaging all parties to the conflict in joint problem solving will help to clarify what needs to happen to resolve the conflict, and what the alternatives are for moving forward out of conflict. It will also help build mutual support of and commitment to the agreed-upon approach. Articulating next steps. Establishing a clear path of next steps and assigning responsibilities are vital components of a clear and effective communication process. It is worth talking both about the expected outcome, and about the method or process by which the outcome will be achieved: it is not uncommon for new conflicts to arise inadvertently when two parties believe they understand what will happen, only to clash over how it will be accomplished.

PRACTICE POINT

When confronting another person in a conflict situation, effective communication skills are essential. It is important to focus on ensuring clarity, both in what one is attempting to convey, and in understanding the other person’s point of view. Important communication skills include setting the stage, managing expectations, active listening, joint problem solving, and articulating next steps.

STRATEGIES FOR EFFECTIVE CONFLICT MANAGEMENT: CONFLICT RESOLUTION AND NEGOTIATION

1. The Talking Stick. Stephen Covey (1989) highlighted the importance of empathetic communication in describing the principle, “Seek first to understand, then to be understood.” Covey (2004) further described the use among Native American cultures of the Talking Stick as a tool to help people resolve differences by creating greater mutual understanding and respect.5 The Talking Stick is passed from one person to another, and only the person who is holding the Talking Stick is allowed to present her or his perspective. This ensures that only one person talks at a time, and increases the ability of others to listen because they are not permitted to argue or make their own points until the person holding the Talking Stick has finished.

The most powerful aspect of the Talking Stick, however, is that the person holding it does not relinquish it until she is satisfied that she has been fully understood by the others. It is the responsibility of the listeners to listen carefully and with empathy, and to

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ensure that the speaker feels understood—not necessarily agreed with—just understood. Once the speaker is satisfied that others understand him, she passes the Talking Stick on and assumes the responsibility to listen and make the next speaker feel understood. Covey describes the value of the Talking Stick as follows:

This way, all of the parties involved take responsibility for one hundred percent of the communication, both speaking and listening. Once each of the parties feels understood, an amazing thing usually happens. Negative energy dissipates, contention evaporates, mutual respect grows, and people become creative. New ideas emerge. Third alternatives appear.

One does not need to use a physical Talking Stick to gain these benefits. It is possible to establish a framework for interacting in which the parties agree that they will alternate the responsibilities of talking and listening until both feel fully understood. This process can be very effective in facilitating the resolution of conflicts between hospitalists and other specialists regarding scope and service issues. Some parties may be able to do this independently, while others may benefit from facilitation by a third party mediator.

2. Unhappy Patients and Families: Take the HEAT. Some of the most challenging conflicts that hospitalists must manage are those that involve the unmet expectations of patients and families. Keeping in mind the role of emotion in conflict, Byham (1993) recommends the following approach for those who are responsible for addressing the needs of unhappy patients and families, as summarized by the acronym “Take the HEAT”:

Hear them out. Active listening without interrupting, disagreeing, or defending is the crucial first step. Angry patients and family members need to be able to express their emotions in order to let some of the air out of the emotional balloon. Empathize. As with Covey’s Talking Stick example, patients and families need to feel understood. It is not necessary to agree with them, but it is important to acknowledge their feelings and to attempt to understand the issue from their perspective. Apologize. Byham points out that even if one does not wish to admit fault, it is important to apologize for the situation, and for the fact that the patient’s expectations were not met. Take responsibility for action. Once the emotional balloon has been deflated, it is often possible to re-engage the patient or family member on a logical basis. A good way to make this transition is to take some concrete action, either to resolve the problem on the spot or to demonstrate a desire to improve the situation.

3. Principles of Effective Negotiation. Hospitalists frequently find themselves in potential conflict situations in which negotiation is an effective strategy for addressing the issue. These may include formal negotiations such as the development of professional service agreements, employment contracts, or incentive compensation metrics, or they may be less formal interactions such as working with specialists to define admitting responsibilities or co-management services. Strong negotiation skills are also valuable for hospitalists working on

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medical staff committees or quality improvement projects when the diverse interests of many parties must be reconciled.

In traditional negotiations, each party stakes out a formal position and then proceeds to bargain from that position, using various tactics to “win” points that bring the final compromise outcome closer to this position. By contrast, the Principled Negotiation model developed by Fisher and Ury (1981) focuses on understanding all the parties’ underlying interests and on identifying objective, fair options that can satisfy everyone. The four tenets of Principled Negotiation are as follows:

Separate the people from the problem. This principle addresses the role of emotions and relationships in influencing one’s perceptions about the negotiation. The authors suggest that negotiators seek to identify when relationships (either as friends or adversaries) may be getting in the way of seeking the best outcome, and that negotiators address these emotional aspects directly and openly with the goal of moving beyond them into objective and collaborative problem solving. Focus on interests, not positions. It is crucial to look beyond the formal stance a person has taken and attempt to understand his underlying interests, the “root causes” of his position. By understanding all parties’ basic interests (both one’s own and the other person’s), one increases the chances of identifying new perspectives or solutions that will meet both parties’ interests. Invent options for mutual gain. The authors argue that once emotional and relationship issues have been separated from the substantive problem, and all parties’ underlying interests are understood, the role of the parties is to invent better options. The steps in this process are: separating the identification of options from the act of judging them, looking for many options rather than a single answer, focusing on options that result in mutual gains, and then coming up with ways to make the decisions easy. Insist on using objective criteria. Finally, Fisher and Ury acknowledge that despite one’s best efforts, negotiators will sometimes face situations in which interests are truly in intractable conflict and mutually acceptable options may not be available. In these cases, effective negotiators will insist that decisions be made using objective, usually externally validated, criteria.

In addition to the tenets of Principled Negotiation outlined above, it is important to recognize that when the issues are complex, even the best and most carefully documented negotiation will probably fail to anticipate every nuance that may arise going forward. For example, when hospitalists negotiate and memorialize a “service agreement” with a group of specialists to define who will admit which types of patients, invariably a patient will present who does not fit neatly into any of the categories specified in the service agreement. If the potential for this to occur is not acknowledged and planned for up front, additional conflicts may arise despite the parties’ careful efforts. The most valuable asset in such situations is a strong underlying relationship of mutual trust and respect that will enable the parties to resolve these issues on a case-by-case basis. The bottom line is that even the best negotiation skills and most clearly drafted documents cannot substitute for strong relationships.

CONCLUSION

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Conflict is inevitable in human interactions, and the potential for serious conflict will grow as the complexity of interactions increases. The extremely challenging milieus in which hospitalists practice are rife with misunderstandings, disagreements, and unmet expectations, placing hospitalists at risk for conflict on a daily basis. Therefore, the ability to understand and effectively manage conflict should be a core competency for all hospitalists. The first step in building effective conflict management skills is to understand the causes and potential benefits of conflict. Next, hospitalists should learn and apply key principles of conflict management; and finally, hospitalists need to develop competence and confidence in implementing useful strategies for managing different types of conflict.

SUGGESTED READINGS Covey SR. The 7 Habits of Highly Effective People. New York, NY: Simon and Schuster;

1989:235-260. DeChurch LA, Marks MA. Maximizing the benefits of task conflict: the role of conflict

management. Int J Conflict Manag. 2001;12:4-22. Gilbert DT, Malone PS. The correspondence bias. Psychol Bull. 1995;117:21-38. Holt JL, DeVore CJ. Culture, gender, organizational role, and styles of conflict resolution: a

meta-analysis. Int J Intercult Relat. 2005;29:165-196. Jones EE, Nisbett RE. The Actor and the Observer: Divergent Perceptions of the Causes of

Behavior. New York, NY: General Learning Press; 1971. Patterson K, Grenny J, McMillan R, et al. Crucial Conversations: Tools for Talking when

Stakes are High. New York, NY: McGraw Hill; 2002. Ross L. The intuitive psychologist and his shortcomings: distortions in the attribution

process. In: Berkowitz L, ed. Advances in Experimental Social Psychology. vol. 10. Orlando, FL: Academic Press; 1977:173-240.

Thomas KW, Thomas GF, Shaubhut N. Conflict styles of men and women at six organization levels. Int J Conflict Manage. 2008;19:148-166.

Triandis HC. Individualism and Collectivism. Boulder, CO: Westview Press; 1995.

REFERENCES 1. Patterson K, G

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ospitalists assume patients understand their presence at the bedside. More effort in explaining the role of the hospitalist as the internal medicine physician or family medicine physician who is responsible for patient care while the patient is in the hospital is essential. Once patients understand that the hospitalist is the physician assuming responsibility for everything from admission to discharge, including making patient rounds and ordering all needed tests and procedures it helps them understand why the hospitalist is caring for them. An important component of the dialog is that the patient understands that their primary care provider (PCP) is informed of their progress and resumes care for the patient postdischarge.

With the Centers for Medicare and Medicaid Services moving from a fee-for-service to a fee-for-value payor, the hospitalist takes on an important role in coordination of care with a focus on population health. Today there is a deeper understanding of the importance of managing population health to drive the health of the community that a health system serves. Central to this movement is the need for robust measurement systems that enable us to concentrate on the outcomes of a population instead of individual silos within the delivery system. Hospitalists are in unique position to deliver on the Institute of Medicine’s “Triple Aim,” targeting better health for the population, better quality and patient experience of care while lowering the cost of care. With more than 50% of all health care spending generated from the acute care admission through the 90-day postacute period, the hospitalists team is ideally suited to manage care from the emergency department (ED) to postacute care.

The highest performing hospitalist groups can bring value to the populations they serve through predictable outcomes. Hospitals would benefit from bringing hospitalists into the discussion about population health and overall performance improvement in acute and postacute care management. Many hospital Accountable Care Organizations (ACOs) have not focused on a postacute care strategy, where much of the variability and costs occur in the 90-day period following discharge nor have they recognized the role hospitalists can play in tackling this issue. Improving performance across the acute episode of care is best achieved with a comprehensive hospitalist infrastructure that incorporates physician development, leadership support and incorporation of evidence- based data to measure performance and drive continuous quality improvement. High- performing hospitalist teams that hardwire these elements into their practice will drive performance improvements and grow their practice.

This chapter explores the specific components essential to building, growing, and managing a thriving hospitalist practice with staying power in light of the new fee-for- value environment.

STRATEGIC PLANNING It is important to have a strategic plan for the practice around growth and the types of hospitals and programs best aligned with agreed upon goals and objectives. For example, strategic planning may require not aligning with all groups requesting support of the hospitalist team. If a group does not fit your strategic profile or geography, it may be best to decline the opportunity to manage a program. Depending on the goals of the practice, certain approaches may not promote patient satisfaction or continuity of care goals. For

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example, when a hospital simply wants your team to cover admissions during the “off hours” that residents are not covering patients and then transfer patients back to residents or surgeons during “peak hours”. These practices work against the goals of improving the patient experience of care and can erode coordination of care. Obstacles of geographic distance requiring a day of travel of the core management team present an additional burden that may make it best to pass up the opportunity to service a hospital if key management team members cannot be present on a regular basis. Each hospitalist group should critically evaluate whether the growth in a new hospital makes sense based on the values and goals of the hospitalist practice, in addition to the hospital seeking hospitalist services.

STRATEGIC PLANNING PROCESS Before starting a hospitalist practice, determine factors that predict the success or failure. Identify the business and financial motivators required to build, expand, and manage a hospitalist service. These factors should incorporate the needs of the hospital and community the practice it serves.

PRACTICE POINT The hospitalist practice must start with a strategic planning process.

What are the goals of the practice? What are the needs of the hospital? How feasible is it to recruit to the location? What outcomes and metrics are expected by the hospital? Can the practice commit to the hospital’s performance expectations?

In order to build a hospitalist practice, hospital leaders should:

Define the scope of services. Articulate the vision, mission, values, and key value drivers (KVDs) of the practice. Establish the employment model and compensation strategy to drive performance. Determine the size and cost of the program.

After a program is up and running, successful practices may be faced with unprecedented growth. Hospital leaders will need to:

Set expectations and priorities for growth. Define key stakeholders. Plan for growth. Assess the evolving needs of the service, such as using advance practitioner providers (NPs and PAs). Determine the skills in a hospitalist practice and the need for additional provider training.

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Determine whether the requested skill set of providers by hospital administration coincides with the ability to recruit to the program. Reassess the compensation model as the needs of the service change. For example, hospitalists with the skills to provide ICU procedures will cost more per shift than general medical hospitalists.

From the building stage forward, there is a constant need for outstanding management to ensure a hospitalist practice thrives by using the steps provided in the following tables: (Tables 23-1, 23-2, and 23-3)

TABLE 23-1 Building a Hospitalist Program: Key Factors to Consider

Characteristics Examples Recruiting • Is the location conducive to recruiting hospitalists?

Do they need to recruit a leader? Compensation plan • What is the market rate? Number of encounters/physician • What is the number of patients at 7 AM census?

• What total number of patient encounters will physicians manage per day?

• What is the acuity of patients in the mix? Schedule • Is a traditional block schedule feasible?

• Do you offer additional vacation days? Management support • What local support is required?

• What regional support is required? Tools to support communications, charge capture, scheduling, metrics

• How will hospitalists record charges? • Is there a convenient method to communicate to

PCPs? • How will you demonstrate improvement in

performance? • How will the group demonstrate quality?

Clinical processes development • What best practices does the group adopt? • How do the processes impact care?

TABLE 23-2 Growing a Hospitalist Program: Core Values and Goals

Characteristics Examples Quality • Measure length of stay

• Measure readmissions rate • Measure CMS core measures • Measure time of discharge • Measure case mix index

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Satisfaction • Measure patient satisfaction • Measure nursing satisfaction • Measure PCP satisfaction • Measure specialist satisfaction • Measure administrative staff satisfaction

Efficiency • Determine how to improve admission and discharge efficiency

Innovation • What tools can be developed to support the team’s core values?

Teamwork • Determine how the team interacts with monthly and quarterly meetings.

• How do you organize in teams? • What is the role of advance practice providers?

Leadership • Is there a leadership development training path? • Is there a medical director or chief hospitalist on the site? • Are there regional leaders for clinical and business

operations? Financial • Does the group charge a fee for services?

• What are the overhead costs to manage the practice? • Is there a clear return on investment for the hospital to retain

services of the group? Integrity • What guidance does the team provide to the physicians in

the group? • How do we manage the impact of actions, values, methods,

measures, principles, expectations, and outcomes of the team?

• What criteria are used to assess integrity of candidates? Research • Is the group involved in research?

• Is there support for data collection and analysis? • What funding is available to the group to support research?

PCP satisfaction • How does the group measure PCP satisfaction? • Does the group reach out to the PCPs? • How does the group track referrals from PCPs?

Nursing satisfaction • How does the group measure nursing satisfaction? • Does the group interface with nursing? • How does the group track nursing impact on outcomes?

Specialist satisfaction • How does the group measure specialist satisfaction? • Does the group reach out to the specialist? • How does the group track referrals from specialists?

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TABLE 23-3 Managing a Hospitalist Program: Key Strategies for Effective Management

Characteristics Examples Recruiting • How does the group identify new hires?

• Does the group use a recruiting agency? Overhead • What percentage of revenue is allocated to support

programs (overhead)? • Do costs incorporate utilization of advance practice

professionals, nurses, support staff, and locum tenens? Training • What allocation of resources does the group have for CME

training? • How are new group members trained? • How are leaders mentored?

Growth • Does the group want to expand? • Is the group capable of taking on additional patients at the

primary site? Service lines • Does the group focus on acute care contracts with

traditional hospitalists? • Does the group provide intensivists services? • Are there other service lines to consider: surgicalists,

laborists, academic hospitalists, post-acute care/transitional care?

Improvement strategies • Where is the group’s focus on quality? Efficiency? Satisfaction?

Define the right leadership and structure. Create an ownership mentality. Setting up the right processes. Tracking and reporting actionable data. Provider education focused on leadership excellence and performance management. Promoting outreach to the physician community and facilitating transitions of care.

BUILDING A HOSPITALIST PRACTICE Building a hospitalist practice starts with defining the prospective hospital partner’s needs for a hospitalist program. In many community hospitals, a hospitalist program is created to care for the unassigned patient population. But even the definition of an unassigned patient is subject to much interpretation. For example, at many hospitals in the Puget Sound region of Washington State, an unassigned patient is any patient showing up in the emergency department and requiring admission who does not have a primary care doctor that admits patients at the hospital. In contrast, in Orlando, Florida, an unassigned patient is only defined as a patient who has no primary care doctor. In Orlando, if a patient has a

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primary care provider but that doctor does not have admitting privileges, it is standard practice to call the primary care provider to identify who will care for the patient in the hospital.

PRACTICE POINT The needs assessment, from the perspective of the hospital might include:

PCP and/or surgical dissatisfaction Admission and management of unassigned patients Admission and management of overflow patients due to American College of Graduate Medical Education (ACGME) work hour restrictions High inpatient census and long average length of stay (ALOS) Low reported performance measures External regulation (rapid response teams, code teams, etc)

In addition to covering the unassigned patient population, many hospitalist services cover those primary care providers who do not want the responsibility of admitting their own patients. There are two main forms of coverage relationships: coverage arrangements for 24 hours per day, 7 days per week; and coverage which is more like a house staff model in which the hospitalist admits the patients but then turns the care back over to the PCP the next day. These latter models continue to decline in numbers because of difficulty with recruitment of high-quality providers motivated to build a meaningful career with a resident-type model.

Hospitalist programs may also be created to manage medical specialty and surgical patients, usually after establishment of the initial hospitalist program.

It is essential to determine which patients the hospitalist group will manage, the scope of services, and whether additional training for some of the program members will be required. According to the Medical Group Management Association and Society of Hospital Medicine 2014 State of Hospital Medicine Report (n = 4867) (see Figure 23-1).

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Figure 23-1 Specialty composition of survey respondents. (Source: 2014 State of Hospital Medicine Report. Reprinted with permission from the Society of Hospital Medicine.)

Eighty-three percent of practicing hospitalists are trained in internal medicine, 10% in family medicine, 7% in pediatrics, and 1% in med/peds. Data from the American Medical Group Association (n = 3700) report hospitalist training to represent 89% internal medicine, 6% family medicine, 5% pediatrics (did not ask about med/peds). When looking at the combined MGMA (community hospitals) and AMGA (academic hospitals) data, the distribution represents training spanning 80% internal medicine, 8.5% family medicine, 10% peds and 1% med/peds. The general trend represents and increased in hospitalists with family medicine training.

In most community hospitals today, hospitalists manage ICU patients. While there are just over 10,000 intensivist physicians in the United States, there is an increasing demand for critical care services to serve the aging population and extended life expectancy. Although the number of critical care physicians in training has been growing, it will be difficult to meet the patient demand with the rapidly aging population. Research indicates the increased demand creates a shortfall of intensivists equal to 35% by 2020, requiring hospitalists to step in to fill some of the demand. In general, the larger the hospital the less ICU medicine a hospitalist performs. Many hospitals have mandatory ICU consults after a set number of days or hours in the ICU or they provide specific guidelines on managing ventilated patients. The most popular model may be a hybrid arrangement in which access to a critical care physician occurs during the day and for emergencies but in-house at night. In such cases the hospitalist commonly does the work around admissions and daily visits with a consult and a follow-up visit by the pulmonary critical care physicians.

With the labor shortage being even more severe for critical care, hybrid models, along with the advent of telemedicine, are likely to take on even more ICU coverage responsibilities in the future. In general, leapfrog compliance guidelines drive a dedicated intensivist model, typically mandated in regional and tertiary hospitals.

“Code coverage” also defines the scope of the hospitalist practice. Many hospitals provide a separate code team, made up of the emergency medicine physician or in-house

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intensivist plus respiratory therapy, nurses, technicians, and pharmacists. Increasingly, hospitalists are being asked to partake in responding to the code process and arranging patient transfers to the ICU. In general, emergency physicians have more training and chances to keep their skills sharp around the procedures of a code, including intubation, starting central lines, and transvenous pacing. Typically, while an emergency medicine physician may respond first, a hospitalist with advanced cardiac life support training assumes leadership of the code.

Whether the hospitalist scheduled for the night shift is actually in the hospital or at home on call for emergencies also defines the scope of practice. Hospital-employed and hospital-contracted models tend to have in-house coverage while physicians who are part of a private fee-for-service group without a hospital contract tend to be available as an on- call physician available from home. Variables that impact the decision beyond economics include the volume of cross-coverage patients, the number of admissions per night, coexisting resident coverage, and the response time of the physician, if on call from home.

DEFINING THE TYPE OF EMPLOYMENT MODEL

There are several common employment models for hospitalist practices: employed by a private practice, by a hospital, by a multispecialty group, by a health plan/HMO, or a multisite or national practice. Among the multisite or national practice subgroups there are staffing solutions that specialize in emergency medicine, anesthesia, and a host of other physician specialists. Some of these multisite specialty practices will hire hospitalists who work as independent contractors alongside the specialist. Among the national hospitalist groups there is a wide spectrum of employment arrangements ranging from those offering ownership and partnership to those that operate solely with independent contractors.

DEFINING THE VISION, MISSION, VALUES, AND KEY VALUE DRIVERS OF YOUR PRACTICE

It is critically important to define the vision, mission and values of the practice from its inception. The leaders and hospitalists should take this task seriously. Schedule time to discuss and debate what is important to the group and leadership. The process of constructing your program’s mission and vision statement should not be taken lightly. This process can take weeks to develop. Start by establishing dedicated time and secure an environment that is conducive to having uninterrupted, frank discussions. Enlist the input of all team members.

A mission statement explains the overall purpose of the hospitalist practice. The mission statement articulates what the organization does right now, in the most general sense. In this way, the mission also sets parameters for what the organization, through omission, does not do. Example of a mission statement: “The Hospitalist Group of Hilltop builds healthy relationships between St. John’s Hospital and primary care providers in the community through public education and direct assistance services.”

By comparison, the vision statement articulates the future of the organization and the community that it serves. The vision statement, when compared with the current reality of the organization or the community, implies the work still needs to be accomplished. In this way, it lends credibility and motivation to the mission statement. Example of a vision statement: “The Hospitalist Group envisions a group practice that drives improvements in patient outcomes including evidence that reflects our value to hospitals in our community.”

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On a yearly basis the practice should define key value drivers that articulate the focus of the organization and those areas that require organizational focus in order for the business to grow. Key value drivers (KVDs) should be set by the leaders with input from the entire team. KVDs must be easy to remember, measurable, and achievable. The behaviors that support the key values should also be clearly defined. In doing so, those in the practice will have a clear understanding of expectations even prior to joining the practice. These behaviors should be reinforced through the compensation and promotion practices of the group to make the practice values meaningful and alive on a daily basis. Typically teams evaluate progress on KVDs monthly or quarterly.

ESTABLISHING METRICS AND SETTING NEW GOALS FOR PERFORMANCE AND OUTCOMES

Standard outcome metrics including average length of stay, core measures, case mix index, cost per case, and discharge efficiency are expected by hospital administration from the hospitalist group. It is essential to meet with the hospital and obtain agreement on which initiatives the hospitalist team will focus. Establish a data collection and reporting mechanism and the frequency of assessments. Practice metrics that are becoming increasingly important to hospitals include the Healthcare Cost and Utilization Project (called “H-CUP”). HCUP is a set of health care databases, software tools, and products developed through a Federal-State-Industry partnership and sponsored by the Agency for Healthcare Research and Quality. Using the HCUP databases collates data collection from State organizations, hospital associations, private data organizations, and the Federal government creating a national data benchmark.

HCUP databases include the largest collection of longitudinal hospital care data in the United States, with all-payer, encounter-level information going back to 1988. These databases enable evaluation of cost and quality of health services, medical practice patterns, access to health care, and outcomes of treatments at the national, State, and local levels.

In addition to the standard outcome measures and HCUP data, it is useful to track and report other practice related trends, including PCP referral volume and referral patterns, patient satisfaction, physician recruiting efficiency, physician retention and 30-day same diagnosis readmission rates (Figure 23-2).

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Figure 23-2 A dashboard of standard outcome metrics organized by volume of patients, quality, utilization, satisfaction trend, and market data indicators including evaluating performance to HCUP data.

MARKETING YOUR HOSPITALIST SERVICES

The best marketing generates word-of-mouth public relations based on how satisfied your patients are as well as the nursing and other hospital staff. An effective campaign requires all hospitalists on the team to be fully engaged with the practice’s vision, mission and values.

In addition to the passive marketing that comes from word-of-mouth marketing, it is important to develop a marketing plan. A typical marketing plan for a practice includes initiatives that drive patient satisfaction to generating awareness in the community through PCP outreach. Create a budget that supports the plan.

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PRACTICE POINT Your marketing plan should include segments that target the following areas:

Identify your target markets: Decide which target markets you want to canvas. You can either target referrals in specific geographic areas or by targeting outreach to specialists. Develop a public relations plan: Launch a new program with press releases, open house events, or broadcast the addition to new physicians through flyers or direct mail campaigns. Create a promotion/awareness plan: You can develop practice-branded written articles on a variety of topics that convey answers to patients’ questions using topics such as What is a Hospitalist? or Improving Patient’s Health Literacy. Use these in a mailing to your community or have the hospital place your articles in their newsletter. Develop a social media campaign to highlight the culture of your practice to support recruiting and growth efforts. Develop patient satisfaction tools: Create large, oversized business cards with photos of physicians, hospitalist brochures with photos of engaged, friendly physicians; consider web-based information to share with patients. Create recruiting advertisements for physicians: Provide your recruiters with materials about the opportunity or special information about the location and hospital. Place them in hospitalist journals as print advertisements and classified ads. Conduct market research: Conduct market research in your local area to be sure you know what the local market is paying for hospitalists and places they practice and who might be interested in joining your practice in the area. Profile your team: Utilize a website and direct mail with photography of your team or host an open house or educational event. Develop a social media strategy: Share the culture of your team to encourage prospective referrals for service and for recruiting.

DESIGNING THE MODEL

It is essential to determine the size of the practice needed. The volume of patients who will be seen on a daily, nightly, and monthly basis determines the size of the practice. Next, assess the number of physicians required to meet the needs of the practice based on that estimated patient volume. The number of physicians depends on what is considered an acceptable workload of patients to manage per day, per night, and per month. To determine the number of patients, define the average number of admissions per day. If the emergency department uses a tracking tool, review the data to project the number of unassigned patients based on historical data. In many hospitals, these data are not accessible prior to initiating a program. Historically, the ward clerks simply entered the admitting physician’s name in the hospital information system without mention of the fact that the patient did not have a primary care physician. It is essential to have a way to track the types of patients by referral type (eg, by PCP, unassigned, or consultations) when the hospitalist program begins operation.

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In addition to determining the volume of unassigned patients, estimate the number of PCPs interested in turning over care. The only risk of double counting is if no hospitalist program existed before a new program starting up. Typically, in that scenario, the primary care provider was also likely cover unassigned patients.

After determining the number of admissions per year, divide the admissions by 365 days per year to obtain a rough estimate of the number of physicians required. Then take the average length of stay for the patients and add 1 extra for the day of discharge. Take this number and multiply it by the number of admissions per day to determine the 7:00 AM census. For example, if there are five admissions per day with an average 4-day length of stay, the 7:00 AM census would be calculated as 5 × (4 ALOS + 1) = 25 patients at 7:00 AM. With the 7:00 AM census determined, calculate the number of the physicians per morning required for the hospitalist program.

There is much debate over the most appropriate census for the physician who begins rounding at 7:00 AM. In general, based on a typical mix of a few ICU patients and the balance of the load being medical patients, a hospitalist can manage 15 patients safely and efficiently. This number varies considerably due to the different agendas, acuity of patients, concomitant responsibilities such as rapid response teams, code teams, teaching, and goals of practices. To achieve the objectives of early discharge, multiple visits a day and a considerable amount of committee involvement, hospitalists can maintain a census in the range of 14 to 15 patients. If the goal is productivity, and in some cases the use of advanced practitioner providers (APPs), the volume per hospitalist may be as high as 20 patients per day. Some practices define the census as the number of encounters per day, which include new admissions as well as discharges.

In a pure productivity-driven private practice model, the night shifts are often covered from home (eg, only coming back to the hospital for emergencies). This typically also means that the day-shift doctors might share night call, even after working all day. In many practices today, the night shift is covered by a separate physician, a nocturnist, due to the volume of admissions at night and the volume of cross-cover work needed.

In general, the billing revenue of a nocturnist hospitalist is lower than a day-shift hospitalist.

A highly prevalent hospital-employed and national group practice model includes a schedule in which the hospitalist physician is on duty for 12 hours, 7 days a week and the following week the physicians is off for 7 days. There are also hybrid arrangements in which the physician works about the same total number of hours per month but with shorter periods of time on duty. In such a model, a 7:00 AM census of 25 to 30 patients would likely have six full-time physicians. In contrast, a private group model may take every fourth night of call from home, which could be managed with four full-time physicians on the team. The marketplace supply and demand for physicians and goals of various clients (eg, a hospital, HMO, or payor) often dictates the type of model required.

DETERMINING THE COST AND DIRECT COST OF THE HOSPITALIST PROGRAM

Calculating the cost of a hospitalist program includes direct labor costs: salaries of the providers, benefits cost, malpractice coverage, and billing costs. The volume of patient visits, the payer mix, and the distribution of CPT codes reported determine the direct patient care revenues of the practice. The medical director who typically has responsibility for driving hospital outcomes determines any additional revenues. According to a survey conducted by the Society of Hospital Medicine in 2014, 89.3% of hospitalist programs

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required a subsidy or fee to help with the payer mix of the unassigned patients, night call coverage in-house, and for those organizations that focus on driving performance through service offerings. The ranges of fees hospitals pay range from $0 per year to $250,000 per physician annually. Fees are typically based on scope of work and payer mix.

SETTING THE COMPENSATION MODEL

In conjunction with determining the cost of the program, a compensation model must be established. In the past decade, two significant challenges drove hospitalist compensation: an imbalance of supply and demand, coupled with the rapid rise of salaries that began escalating in 2001. This phenomenon has created a significant compression in salaries. Often the least experienced physician’s compensation is closely aligned with the most experienced physicians in the practice. This compensation compression creates a dichotomy in the reward system on physician skill and experience levels creating challenging team dynamics. There are two primary models: a productivity model or a salary model. Many salary models also include a component of compensation focused on productivity and quality metrics as well as outcomes.

Recruiting a team of physicians and hiring a leader is a critical core competency for every hospitalist practice as discussed in Chapter 25. Acquiring effective recruiting techniques is an area of investment that should not be minimized or overlooked in the development of a strong hospitalist practice.

GROWING A HOSPITALIST PRACTICE SETTING PRIORITIES FOR GROWTH

Once the practice launches, priorities must be established for the growth of the hospitalist program. If the unassigned patients are already covered in the practice, the next step could be a myriad of other opportunities, including contracting with PCP practices. It is essential to understand the scope of growth and prepare in advance of the patients’ arrival. Many practices have failed or imploded by taking on more growth than they could handle. If there is a desire to handle 15 more patients per day with a 7 days on/7 days off model, it might be as simple as figuring out the need to hire two more physicians. However, if the program is already quite busy and adding three to four new admissions per day is in the growth plan, adding an admitting shift may be called for as well.

PRACTICE POINT Use these common areas of practice management and determine whether you are prepared to grow. Reflect about your hospitalist practice:

What are your priorities? What are your goals and core values? What effort can you invest to grow?

What are the expectations of external interests?

Performance measures.

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Satisfaction of outside primary care physician groups. The Joint Commission requirements. ACGME. Public performance reporting, obtaining ≥ 90% core measure scores.

What is your work environment saying about the practice?

Patient safety, quality, satisfaction. Efficiency of care. Career satisfaction that integrates core values. Service excellence and patient safety. Continuous quality improvement and innovation. Professional growth, leadership, and scholarship.

What are the expectations of hospital management?

Caring for unassigned/uncompensated patients. Reducing ALOS for top 10 DRGs by hospitalist discharge volume. 24/7 service demands. Reducing practice variation of hospitalists. Hospitalist training on palliative care, end-of-life, and other medical specialties. Development of a comanagement consulting service or a preoperative testing center. Improvement of patient ED to floor times. Care of admitted patients in the ED. Managing the chest pain unit or rapid admission team. Improvement of chart documentation for core measures (such as smoking cessation counseling). Improvement of billing for services provided. Leadership of rapid response teams for ill inpatients. Development of a transitional care program to address continuity of care in postacute facilities or providing care in the patient’s home.

Does the practice have these evaluations and measurements in place? Report card for hospitalists. Primary care physician survey. Multiyear strategic planning, quarterly reports. Hospitalist career satisfaction survey. Hospitalist annual retreat with management to establish goals. Develop a 3-year plan for a hospitalist service that mirrors the hospital’s multiyear plan. Create a meaningful, motivating, and achievable blueprint for clinical enterprise.

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Proactively support mission of patient care, quality improvement, and patient-centered care.

DEFINING KEY STAKEHOLDERS

The key stakeholders in the practice need to be clearly defined. Certainly, the doctors and advanced practice team members in the practice are key stakeholders, but in many practices the hospital administration is also a key stakeholder. Identifying priorities is much like a game of chess. For example, if you choose to help solve another primary care group’s needs before helping the orthopedic group with comanagement needs there may be repercussions. You should expect that the hospital administrator want to weigh in on how this decision impacts the hospital and its development plans.

INCORPORATING ADVANCED PRACTITIONER PROVIDERS

Another key decision for program growth is how to incorporate advanced practice providers in the practice. While this topic is covered in the literature, there are plenty of mixed opinions on the use of advanced practice providers in the inpatient setting. We have found two main areas of optimal benefit in our practices.

The first benefit for incorporating nurse practitioners (NPs) and physician assistants (PAs) is in very small programs of four full-time physicians with a daily census that can have dramatic swings around the average. The cost of an NP or PA provider is about one- half the labor cost of a physician, and this can be a cost-effective way to leverage the existing physician coverage.

There is also a benefit from the use of advanced practice providers (APPs) in very large programs, particularly in the management of surgical patients for their comorbid conditions. Many practices have incorporated APPs due to the physician shortage and a failure to recruit and retain high-quality physicians. One unique challenge is that many APP’s value comes from their experience. An APP practicing in the acute care setting for 10 years is much more likely to be able to function as a hospitalist than a new graduate APP. For hospitalist physicians, there is clearly value and competency in new a physician starting to work directly upon completing their training. It is crucial to understand both the state and hospital-specific by-laws associated with the use of NPs and PAs. Without such understanding, the proposed program plan could be rejected by the hospital. For example, if the rules state that the NPs’ work must be signed off and reviewed by a hospitalist it does not create the same workforce multiplier as a site where on the right patients, the NP can operate relatively independently.

TYPES OF PHYSICIANS IN THE PRACTICE

Another area of importance in growing a hospitalist practice involves the types of physicians utilized. It is becoming more common to have family medicine-trained hospitalists practicing alongside internal medicine hospitalists in the same practice. Much has been debated on this topic and today nearly 10% of hospitalists nationwide are family medicine trained. Factors that go into the determination to hire them include their comfort level with ICU patients and their experience managing the higher-level acuity patients. Another challenge is their ability to navigate the local politics associated with an internal medicine outpatient practice referring its inpatient practice to a family medicine physician.

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We have found that the experience of the provider trumps all board certification. There are plenty of internal medicine physicians unqualified to practice as hospitalists as well.

THE PROS AND CONS OF CAPS ON SERVICES

During the hospitalist practice growth phase, the group must be able to handle all of the new patients it agreed to accept or have a Plan B. Plan B might include a floodgate that closes in the form of a cap. This has been achieved at some hospitals to maintain safe and effective volumes. Two types of caps exist including those requiring a backup system. The backup system can be the existing hospitalists at a very high labor cost to a hospital or the new group of primary care physicians who have asked for coverage; this group may need to agree to provide occasional coverage at the hospital. The latter group of physicians tends to be a short-term patch; they can quickly lose their skills and credentialing in the inpatient setting. Ideally, if the hospitalist group has agreed to accept a new group of patients, they need to have the capacity 24 hours per day, 7 days per week. A “sick call” rotation to cover anticipated maternity and paternity leaves as well as unexpected absences may have the benefit of allowing hospitalists to focus on career development, especially quality improvement initiatives when they are not seeing patients, and not overwhelming them with service obligations.

MANAGING THE HOSPITALIST PRACTICE SELECTING THE RIGHT LEADERSHIP AND STRUCTURE

There is a shortage of high-quality physician leaders in the United States. To properly manage the practice, it is critical to appoint the most capable physician leader and establish an effective practice structure. The hospitalist leaders’ roles are complex; they not only serve the hospitalists’ team but also play significant roles within the hospital. In these roles, hospitalist directors are the most connected to how things work on a daily basis. Strong hospitalist physician leaders must lead by example. They must have effective organizational skills, be great communicators, and seek win-win situations for the hospitalist team, medical staff, and hospital. Hospitalist leaders also need to be aware of the professional goals of their members and delegate some responsibilities so that each member can also flourish and find a professional niche within the organization. Hospitalist directors may become isolated in their role, so it is important to ensure that they have advocates or mentors who can promote their agendas as well as provide counseling related to hospital politics. See Chapter 6: Leadership.

Many hospitalist programs include a version of shift work. This type of schedule combined with the Generation Y culture in medical school today, centered on work hours and patient volume restrictions, have led to a unique challenge in hospital medicine. Many physicians seek direct employment models. They place a very high level of value for time off. This can make it challenging to engage them in what matters to make a practice successful. Ensuring the right fit begins with the initial interview when performance expectations are clearly articulated.

CREATING AN OWNERSHIP MENTALITY

Like any small business, an ownership mentality is essential to the success of the hospitalist practice. It is ideal to introduce the importance of the ownership mentality expected during the hiring process. Those applicants who give solid examples of times in

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their career where they got involved, highlight scenarios when they did things because they thought no one else could do it better, and are passionate about those experiences is telling of their potential. These are typically indicators that the physician is the type of hospitalist who can make the practice excel. Defining the behaviors that support the values of the practice and then evaluating and rewarding those behaviors goes a long way to reinforcing what is important. For example, if participating in hospitalist committees is important and it can be rewarded as part of how the productivity dollars are allotted. Leading a hospital committee or playing a leadership role within the medical staff could be rewarded to an even greater extent.

SETTING UP THE RIGHT PROCESSES

Part of managing the practice is ensuring that the right processes are in place. Processes should be established for physician scheduling and daily case management meetings. Hospitalist processes should be highly sophisticated to drive improvements in utilization, documentation, discharge planning, and prospective quality metric monitoring. All of these processes require a tremendous amount of time, energy, and in many cases, technology and infrastructure to drive clinical and financial performance for the hospital and hospitalist practice.

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CHAPTER 21 Principles and Models of Quality

Improvement: Plan-Do-Study-Act

Emmanuel S. King, MD, FHM

Jennifer S. Myers, MD, FHM

INTRODUCTION Achieving better health outcomes for patients and populations requires a focus on continuous quality improvement (QI). While physicians pride themselves on being subject matter experts in their focused area of medical practice, such knowledge alone is insufficient to produce fundamental changes in the delivery of health care. Physicians who practice in complex hospital and health care systems must acquire another kind of knowledge in order to develop and execute change.

W. Edwards Deming, an American statistician and professor who is widely credited with improvement in manufacturing in the United States and Japan, has described this knowledge as a “system of profound knowledge” (Figure 21-1). This knowledge is composed of the following items: appreciation for a system, understanding variation, building knowledge, and the human side of change. These concepts are just beginning to be taught to health care professionals and are essential for anyone who wishes to improve the health care delivery system.

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Figure 21-1 Deming’s System of Profound Knowledge. (Reproduced, with permission, from Langley GJ, et al. The Improvement Guide: A Practical Approach to Enhancing Organization Performance, 2nd ed. San Francisco, CA: Jossey-Bass; 2009.)

All hospitalists have witnessed changes that did not result in fundamental improvements within their hospital systems: the computerized order set that was successfully implemented but never revised based on prescribers’ feedback, the paper checklist for medication reconciliation that never gets filled out, or the new rounding system that worked for the first few weeks but then failed to become a standard part of practice due to physician variation or lack of commitment. These are all examples of first- order changes—changes that ultimately returned the system to the normal level of performance. In quality improvement work, individuals must strive for second-order changes, which are changes that truly alter the system and result in a higher level of system performance. Such changes impact how work is done, produce visible, positive differences in results relative to historical norms, and have a lasting impact. Although the model for improvement described below may seem simple, it is actually quite demanding when used properly; and the process is essential to both learning and ultimately changing complex systems.

PLAN-DO-STUDY-ACT AS A TOOL FOR QUALITY IMPROVEMENT

The Plan-Do-Study-Act (PDSA) model is a commonly used method in quality improvement. Shewart and Deming described the model many years ago when they studied quality in other industries. This model first appeared in health care when Berwick described how the tools could be applied using an iterative approach to change. Using a “test-and-learn approach” in which a hypothesis is tested, retested, and refined, the PDSA cycle allows for controlled change experiments on a small scale before expansion to a larger system. The four repetitive steps of PDSA—plan, do, study, and act—are carried out until fundamental improvement, which can be exponentially larger than the original hypothesis, takes place (Figure 21-2).

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Figure 21-2 The Plan-Do-Study-Act Cycle. (Reproduced, with permission, from Langley GJ, et al. The Improvement Guide: A Practical Approach to Enhancing Organization Performance, 2nd ed. San Francisco, CA: Jossey-Bass; 2009.)

PRACTICE POINT

Use a “test-and-learn approach” to solve quality problems. The PDSA—plan, do, study, and act—framework is one popular model to organize your approach to quality improvement work.

PLAN

During the Plan phase, the team generates broad questions, hypotheses, and a data collection plan. It is critically important during this period to define expectations and assign tasks and accountability to every team member. In the planning phase of the PDSA cycle, it is prudent to invest significant time and develop a well-framed question by reviewing related research and local projects and defining meaningful process and outcome measurements. Broad questions at the outset of a PDSA cycle can include “What are we trying to accomplish?” and “What changes can we make that will result in an

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improvement?” The ideal data collection tool answers the question: “How will we know that a change is an improvement?” It is also helpful for the team to generate predictions of the answers to questions early on. This aids in framing the plan more completely, to uncover underlying assumptions or biases before any testing, and to enhance learning in the Study phase by providing a baseline point of comparison.

Teams new to QI frequently will struggle with the question, “How do we measure improvement?” Defining discrete process measures is a good starting point when using PDSA. Process measures are used to assess whether the cycle is being carried out as planned. This is in contrast to outcome measures, which are used to track success or failure and focus on the specific outcome that the team is trying to achieve.

DO

The Do phase in PDSA is a period of active implementation. It involves feedback on the new process from end users and rigorous data collection. An overarching goal of this phase is to capture and document not only compliance with the new process, but also deviations, defects, or barriers in the process. There are always aspects of quality improvement projects that do not go as planned, and flexibility and open-mindedness are critical to maximize learning from improvement. The quality of the Do phase is intimately related to the quality of the Plan phase. A pitfall for many novice QI teams is to give in to the temptation to jump straight to implementing change without spending a significant amount of time planning. A poorly conceptualized improvement plan, an absence of a sound data collection model, or unclear accountabilities can have adverse effects on the implementation or “do” phase of a new initiative.

STUDY

Analysis of available process and outcome metrics and a qualitative appraisal of the process are the key activities in the Study phase. Time should be set aside to perform a critical review of the data collected and compare it to historical data (when available) and baseline predictions. Close attention should be paid to possible defects in any element of the process, including the data collection plan. If such issues are uncovered, the team may need to revise the initial data collection tools and overall plan. Thoughtful review of all trials, even those that were clearly unsuccessful based on metrics, is a critical and valuable process for the team. In fact, the “failures” in a PDSA cycle can yield unanticipated and improved directions. As the Study phase progresses, time should be spent considering if a follow-up PDSA cycle is planned and exactly what elements to include in that cycle.

ACT

The final component in a PDSA cycle is Act. The team should convene for a feedback and action planning session. Frontline workers in the system that is being changed should be included for honest input. A team approach rather than a “top-down” approach facilitates an open review of successes and failures. An action plan that encompasses lessons learned in the first three steps should then be put into motion. During this stage decisions are made about repeating certain test cycles after improvements are made or “spinning off” new test cycles based on the original one.

RAPID CYCLE, CONTINUOUS, AND SEQUENTIAL PDSA

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In its most basic form, the PDSA model described above can be applied to change a single process. However, teams in health care often confront problems that require multiple changes, in parallel or succession, in order for improvement to happen. Caution is advised when initiating several PDSA cycles simultaneously, especially if there are significantly different data collection plans or if the team is inexperienced in QI methods. An alternative is a sequential PDSA model in which one PDSA cycle feeds into the next. This approach, in which teams continually change and refine their processes based on data evaluation and feedback, is called “continuous quality improvement.” Experienced QI teams strive to utilize this approach. Rapid cycle PDSA is a continuous QI process that lends itself well to projects that are focused on relatively small-scale changes. It is typically used by seasoned QI teams who are familiar with the PDSA model and who wish to implement rapid change.

AN EXAMPLE OF PDSA IN ACTION To illustrate the PDSA model for improvement, a real QI project is presented here from start to finish. A hospitalist group sought to implement a new discharge planning toolkit aimed at improving transitions in care through risk assessment at the time of hospital admission. A QI team was formed with representatives from health care professionals involved in the discharge planning process. While their ultimate goal was to reduce unplanned readmissions, their first team goal involved creating a new process to coordinate and request risk-specific interventions from other teams (eg, nurse educators, pharmacists, a nurse for postdischarge follow-up phone calls) for patients deemed “high risk for hospital re-admission or transition in care problems” by a screening tool. In preparation for the project, the QI team also performed a stakeholder analysis, which is a tool that QI teams can use to identify all of the individuals and groups with a “stake” in the process being discussed.

CYCLE 1

PLAN

The initial PDSA cycle involved piloting a readmission risk screening tool. A weekly meeting was convened that included representative users of the tool and assigned specific responsibilities and tasks with due dates to each team member. At baseline, the biggest barriers to overcome were the perception that the new tool was extra work, introducing a paper-based tool in a largely electronic health care environment, and lack of a tight infrastructure tying the requests to existing risk-specific interventions. Based on these concerns, the team reduced the number of interventions on the initial tool. A data collection plan was started and included both quantitative process metrics (eg, compliance rates with the tool, frequency of risk factors identified on the tool) and qualitative data from the users of the tool.

DO

The new tool was piloted for 2 weeks, during which time data was collected and feedback was solicited from the frontline team.

STUDY

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After 2 weeks, the data showed that overall compliance with the tool was moderately high, but that two risk factors, health literacy and depression, had unexpectedly low percentages. On further inquiry, members of the team admitted that when they performed the risk screen, they paused on those two questions and frequently left them blank, concerned that it might take too much time during the admission process and frustrate new users of the tool.

ACT

The team decided to make another edit to the tool before the second PDSA cycle. The health literacy and depression screening questions were removed based on feedback, with a plan to reintroduce them when the tool was more embedded in the hospital admission workflow.

CYCLE 2 PLAN

The second PDSA cycle focused on follow-up data collection with the health literacy and depression screening questions removed from the tool, to test the theory that this would improve compliance. The data collection plan was to track overall compliance with the tool for a 2-week period. In order to isolate any improvement as a result of this one small change, no other changes were made during this time.

DO

The new version of the tool was implemented.

STUDY

Compliance rates significantly increased from moderately high to very high, and the risk factor screening data remained unchanged. Qualitative feedback from frontline users was that the risk screening process was more streamlined and acceptable.

ACT

A brief but successful cycle 2 ended with a plan to add an intervention checklist to the tool in the next phase.

CYCLE 3

PLAN

The goal of cycle 3 was to associate risk-specific interventions (education, follow-up phone calls, and social work interventions) with a patient’s individual risk factor profile. To meet this goal, the team implemented a new version of the tool that included the risk- specific intervention requests and tracked request type and volume. A 2-week cycle was planned with continued weekly meetings during this time.

DO

The team implemented a tool that allowed for interventions to be requested at the time of risk factor screening.

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STUDY

After 2 weeks, the data showed stable high compliance with the form, stable risk factor data, but very low utilization of intervention requests. At feedback meetings, frontline users stated that at the time of admission, they were not ready to place a request for an intervention. They felt that intervention requests should be discussed in a multidisciplinary team on a follow-up hospital day when more information was available.

ACT

Discharge planners on the team suggested that the intervention request process be integrated into daily discharge planning rounds, during which the entire patient care team (physician, nurse practitioner, registered nurse, discharge planners, patient service representative, and social worker) discussed each patient on the service. A nurse practitioner and patient service representative drafted paper forms that could be used to communicate requests for each of the interventions to the appropriate personnel and to document completion of the task. The next phase would trial this new process.

CYCLE 4 PLAN

Cycle 4 was focused on implementing and studying the new discharge rounds process to request risk-specific interventions. The frequency of intervention requests in each category was added to the existing process metrics. Since this was a more substantial change than before and involved more than just one team of frontline users, a 4-week cycle duration was chosen.

DO

Clinicians continued to screen patients using the risk screening tool, intervention request forms were kept on hand during discharge rounds, and the patient service representative and discharge planners prompted the teams to request interventions based on patient risk factors. The requests were forwarded to the appropriate personnel (registered nurse, pharmacist, nurse educator), who then documented completion of the intervention on the form.

STUDY

Compliance rates and risk factor data remained steady, but there was a significant increase in intervention requests in all categories. However, documentation of completion of the intervention was low. It was determined that the documentation requirements were unfamiliar to the intervention teams, which was an oversight.

ACT

For the next cycle further improvements in documentation of intervention completion and a reintroduction of the health literacy and depression screening questions was planned.

LESSONS LEARNED

This example illustrates several important points for successful use of the PDSA model. First, the engagement and involvement of the end users of new QI tools and processes is

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critical to the success of any improvement project. These users are experts in the process who often know what should be tested next, and perfect champions when changes are disseminated on a larger scale. While it may be impossible to address or fix every problem that they identify, hearing their input, implementing changes based on their suggestions, and giving praise for their involvement and patience is an important skill for leaders of QI. Second, flexibility and creative thinking, skills that are used frequently in clinical care, are also essential in QI. In the case study, several barriers were identified such as: concerns about paper forms, perception that certain risk factors would halt the risk screening process, and lack of infrastructure around the systematic documentation of interventions. As these barriers became apparent, the team remained flexible and changed a part of the new process without compromising the integrity and team goals of the project.

PRACTICE POINT Critical to the success of any quality improvement project:

Performing a stakeholder analysis to help identify all individuals and teams that have a “stake” in the quality problem that is being addressed.

Engagement and involvement of the “end” users of new QI tools and processes. Small tests of change that include data collection followed by data analysis and decisions on how to proceed.

ALTERNATIVE MODELS OF QUALITY IMPROVEMENT

In addition to the PDSA model described above, there are other frameworks that have been used to design and execute quality improvement projects. Adopting one specific framework (as opposed to adopting several) allows an organization to learn a common language and approach to improvement. Six Sigma and Lean are two common frameworks that will be briefly described.

Six Sigma was developed by Motorola in the mid-1980s and is focused on reducing variations in a process. Six Sigma is a popular performance improvement methodology which uses a five-phase approach to problem solving, called DMAIC (Define, Measure, Analyze, Improve, and Control). This framework guides users to define their QI goals, measure the current process, analyze root causes of the quality problem, improve the process on the basis of the previous steps, and finally control the process to ensure that variances are corrected before they result in defects and the new process becomes standard work.

Lean manufacturing (or just “Lean”) was adapted from the Toyota Production Systems and is focused on continuously reducing waste in operations and enhancing the value proposition to customers. The Lean approach is based on a few key principles: defining the problem from the customer perspective, identifying the activities required to provide the customer with a product or service, producing the products or services only when needed by customers, and pursuing perfection in the process.

CONCLUSION

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Plan-Do-Study-Act has remained a fundamental tool for continuous quality improvement. Once comfortable applying this iterative app

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CHAPTER 7 Principles of Evidence-Based Medicine

and Quality of Evidence

Daniel I. Steinberg, MD

INTRODUCTION A BRIEF HISTORY

The March 1, 1981 issue of the Canadian Medical Association Journal included a landmark article titled “How to read clinical journals: I. Why to read them and how to start reading them critically.” Written by David Sackett, MD (1934–2015) of McMaster University, it introduced a series of articles that highlighted the importance of critical appraisal of the literature. Starting in 1993, a set of articles in the Journal of the American Medical Association titled “Users’ guides to the medical literature” reprised and expanded on the earlier series. These works, and other efforts by their authors, made critical appraisal of the literature accessible to the masses and laid the groundwork for evidence- based medicine (EBM).

Gordon Guyatt, MD, coined the term “evidence-based medicine” in the early 1990s, while he served as the internal medicine residency program director at McMaster University. Dr. Guyatt and colleagues had incorporated critical appraisal of the literature into the residency program curriculum, and Dr. Guyatt wanted a term to describe and advertise their efforts.

EBM caught on quickly over subsequent years as practicing physicians and training programs embraced and taught its methods, with dissemination greatly fueled by the rise of the Internet.

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ROLE OF CLINICAL JUDGMENT AND PATIENT PREFERENCES IN EBM

An early criticism of EBM, which some still harbor, was that it did not properly acknowledge the importance of clinical judgment or patient preferences. In an updated framework for evidence-based practice by R. Brian Haynes, P.J. Devereaux, and Gordon Guyatt in 2002, evidence-based decisions are based on four cardinal elements: (1) the research evidence, (2) the patient’s clinical state and circumstances, (3) the patient’s preferences, and (4) the clinician’s judgment and expertise.

PRACTICE POINT

Clinical judgment and expertise are essential to the practice of EBM. These skills facilitate optimal decision making by allowing the clinician to properly weigh the research evidence in the context of the patient’s individual clinical circumstances and preferences. Decisions should never be based on the evidence alone.

Practicing EBM may appear to be a straightforward affair with its methodical approaches to clinical question construction and to searching and critically appraising the literature. However, hospitalists should not confuse process with content, and they will often find that EBM tends to highlight clinical uncertainty and gaps in the medical literature. High-quality evidence does not exist to guide all clinical decisions, and extrapolation from lower quality evidence is often necessary. Bayesian diagnostic decision making often relies on clinical judgment to formulate pretest probabilities or to deal with the uncertainty that accompanies inconclusive post-test probabilities. Learning to deal with uncertainty is a core competency of EBM, which draws heavily on clinical judgment and experience.

STAYING UP TO DATE WITH THE LITERATURE PUSH INFORMATION RESOURCES

Few clinicians have the time to consistently read medical journals, identify relevant new research and critically appraise new studies to determine if they should be incorporated into one’s practice. “Push” information resources are resources that send content out to their users on a regular basis. “Pull” information resources are databases that clinicians search in order to answer a clinical question. Pull resources are discussed later in this chapter. Table 7-1 lists selected high-quality push and pull information resources.

TABLE 7-1 High-Quality Push and Pull Resources

Push Resources Pull Resources Resources that automatically send new, high-quality evidence to users via e-mail or RSS feed aggregator

Databases that are searched as needed to answer clinical questions

ACP JournalWise ACP Journal Club http://journalwise.acponline.org http://annals.org/journalclub.aspx

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BMJ Clinical Evidence BMJ Clinical Evidence http://clinicalevidence.bmj.com http://clinicalevidence.bmj.com DynaMed Cochrane Collaboration https://www.dynamed.com http://www.cochrane.org Evidence Updates DynaMed https://plus.mcmaster.ca/evidenceupdates https://www.dynamed.com NEJM Journal Watch NEJM Journal Watch http://www.jwatch.org http://www.jwatch.org PubMed (using an My NCBI account and search strategies created by the user, see text) http://www.ncbi.nlm.nih.gov/pubmed

Practice Guidelines from professional societies, eg, AHRQ National Guideline Clearing House http://www.guideline.gov

  PubMed   http://www.ncbi.nlm.nih.gov/pubmed

Trip Database https://www.tripdatabase.com

McMaster PLUS (Premium Literature Service) continuously searches over 120 medical journals and selects evidence for critical appraisal. Articles that pass the critical appraisal process and are also rated as clinically relevant and newsworthy by their team of reviewers are then transferred to the PLUS database. The PLUS database contributes content to evidence-based summary resources such as EvidenceUpdates, ACP JournalWise, DynaMed, and ClinicalEvidence. These resources all offer e-mail alerts to users. ACP Journal Club and NEJM Journal Watch critically appraise and produce synopses of high-quality evidence accompanied by expert commentary. PubMed, through its free account service “My NCBI,” allows users to receive the results of literature search strategies they either design or select (via the “Clinical Queries” feature) by e-mail on a regular basis.

PRACTICE POINT

Hospitalists should strongly consider using an e-mail-based alerting service or RSS (Rich Site Summary) feed aggregator from a high-quality evidence-based summary push resource to effectively stay up to date on the literature. Hospitalists can pair a virtual file cabinet with these resources to form an effective information management system that will make evidence readily available at the point of care.

KEEPING INFORMATION AT HAND: THE VIRTUAL FILE CABINET

Although the traditional way of storing articles for later reference is to use a physical file cabinet, this approach has a number of disadvantages. File cabinets are not mobile, they

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cannot be quickly searched or updated, and determining how to best file something for easy retrieval can be confusing. A clinician might ask himself/herself in frustration: “Did I file that great article on pulmonary manifestations of HIV under ‘HIV,’ or ‘infectious disease,’ or ‘pulmonary’?” They do not offer a way to electronically add content to them or electronically share content with others, making them incompatible with modern communication methods such as e-mail.

The virtual file cabinet (VFC) is an Internet cloud-based electronic document storage system that synchronizes across multiple electronic devices (eg, smartphone, tablet, laptop computer). A VFC is an effective way for hospitalists to electronically file articles they receive from a push information resource as described above for easy retrieval at the point of care. Box, Dropbox, Evernote, and Google Drive are some examples of the commercial products that currently exist that can be used as a virtual file cabinet. Products such as these also offer easy options for electronically sharing content with others.

THE EBM PROCESS: ASKING AND ANSWERING CLINICAL QUESTIONS Practicing EBM often involves asking and answering questions that arise during the care of patients. There are four steps in this process: (1) asking a focused clinical question, (2) searching the literature for the best available evidence, (3) critically appraising the literature, and (4) applying the literature to an individual patient. This chapter explores the basic principles of EBM as they relate to these four steps.

STEP 1: ASKING A FOCUSED CLINICAL QUESTION

Clinical questions fall into two general groups: background or foreground questions. Background questions ask about general knowledge, pathophysiology, epidemiology, and broad aspects of diagnosis and treatment. “What are the treatments for epilepsy?” is an example of a background question. Junior learners often ask background questions, and answers can often be found in textbooks. Foreground questions are more focused, address specific clinical situations, and facilitate the delivery of the most up-to-date, evidence-based care. Experienced clinicians ask foreground questions, with answers residing more in the medical literature. Hospitalists should always aim to construct focused foreground questions. These are further discussed below.

Most hospitalists would recognize the question, “Should patients with heart disease receive regular vaccinations?” as one that is overly broad. Not all heart diseases are the same, nor are all vaccinations, and the specific benefits patients might reap from vaccination are not specified by the question. Clinical questions need to be focused in order to be answerable. In addition to clinical questions about therapy, clinicians can ask focused clinical questions about diagnostic tests, about the harm an intervention might cause, about prognosis, or about differential diagnosis.

Clinical questions should be constructed using the “P-I-C-O” format. “P” stands for “population” and describes the patient the question is about in proper detail. “I” stands for “intervention” and refers to the therapy or diagnostic test in question. “C” stands for “comparison” and describes either an alternative treatment or standard of care (for questions about therapy) or the gold standard test (for questions about diagnostic tests). “O” stands for “outcome,” which should be clinically important and patient-centered. Surrogate markers of clinically important outcomes are acceptable.

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An example of a well-built clinical question about therapy is: “In patients admitted to the hospital with non-ST elevation myocardial infarction (P), what is the effect of influenza vaccination at discharge (I) as compared to no vaccination (C) on recurrent acute coronary syndrome or mortality (O)?”

An example of a properly designed clinical question about a diagnostic test is: “In patients presenting to the emergency department with suspected infection (P), how accurate is a history of shaking chills (I), as compared a gold standard of blood cultures (C) in diagnosing bacteremia (O)?”

When clinical questions do not perfectly fit into the P-I-C-O format, clinicians should follow as many of the above principles as possible.

PRACTICE POINT

Clinical questions must be focused to be answerable. Hospitalists should use the widely accepted “Population–Intervention–Comparison–Outcome” (P-I-C-O) format to construct focused clinical questions.

STEP 2: SEARCHING THE LITERATURE

Pull information resources

With a properly constructed clinical question in hand, the hospitalist can now search the literature to find the answer. The first step is to select an information resource that is appropriate for the clinical question and the amount of time available. Databases that are searched in an on-demand way in order to answer a clinical question are called pull resources.

In many cases, and especially when time is limited, one should first consult a high- quality summary pull resource. Summary resources that are frequently updated assess the quality of the evidence presented and are user-friendly and preferable. Examples include BMJ Clinical Evidence, ACP Journal Club, DynaMed, the Cochrane Collaboration, NEJM Journal Watch, UpToDate, and practice guidelines from professional societies. All are highly useful. Each has its strengths and weaknesses. UpToDate is fast to use, comprehensive, and provides expert guidance in an easy to digest, narrative format, but it is not as rigorously constructed as the others. ACP Journal Club provides excellent summaries of highly selected literature deemed valid and relevant to clinical practice, but as a result its database is not comprehensive. DynaMed is rigorously constructed and presents a lot of primary data from clinical trials, often in an outline format. The Cochrane Collaboration produces high-quality systematic reviews of the evidence. Practice guidelines are excellent resources that offer clear recommendations, but their quality can vary, update intervals can be long, and users must pay close attention to the level of evidence and strength of recommendations in published practice guidelines.

If one has more time, or if a deeper dive is needed after consulting a summary resource, the primary literature can be searched via PubMed (preferably using “Clinical Queries” option for clinical questions) or Trip Database (preferably using “PICO search” option for clinical questions). For certain questions, a content-specific resource can be best. JAMAEvidence catalogs evidence on the accuracy of history and physical exam

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findings. The Cochrane Collaboration focuses on systematic reviews. No single resource is perfect and clinicians should adopt a “toolbox” approach by becoming familiar with a few resources.

PRACTICE POINT

Pull resources are databases that are searched in an on-demand way to answer a clinical question. Pull resources have different and often complementary roles. None are perfect, and hospitalists should adopt a “toolbox” approach in which they become familiar with a few resources. The type of question and the amount of time available to answer the question should help determine which resource the hospitalist consults.

THE HIERARCHY OF EVIDENCE

Hospitalists should know which types of clinical trials will best answer different types of clinical questions, and which study designs will provide the most powerful results. The randomized controlled trial (RCT) is the gold standard for determining the effect of a therapeutic intervention.

Determining the accuracy of a diagnostic test requires a prospective design in which the test is studied in the same clinical setting it will be used, and is compared against an acceptable gold standard. The effect of a diagnostic test on clinical outcomes can be determined by a randomized controlled trial, in which the test in question is treated as the intervention and another diagnostic approach (preferably a gold standard if available) is considered the comparison.

A systematic review is a summary of the evidence on a topic in which the literature search and selection of evidence has been performed in a rigorous, transparent, and reproducible way. The most valuable systematic reviews will also include a meta-analysis. In a meta-analysis, the results of multiple similar types of studies (RCTs, observational studies, or studies of diagnostic tests) are statistically combined to offer more powerful results. What a meta-analysis gains in power, it can sometimes lose in applicability and focus if too much clinical heterogeneity exists among the patients included from individual studies. With that caveat, a high-quality systematic review that includes a meta- analysis is considered to be the highest level of evidence. Table 7-2 describes the hierarchy of evidence for different types of clinical questions.

TABLE 7-2 Hierarchy of Evidence for Different Types of Clinical Questions

Type of Clinical Question Best Types of Articles (Listed in Decreasing Level of Evidence)

Therapy or harm 1. Systematic review/meta-analysis of randomized controlled trials

2. Randomized controlled trial 3. Cohort study 4. Case-control study 5. Case series

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6. Case reports 7. Expert opinion

Accuracy of a diagnostic test

1. Systematic review/meta-analysis 2. Prospective comparison against gold standard conducted

in setting diagnostic test will be used in practice Prognosis 1. Systematic review/meta-analysis

2. Prospective cohort study of a representative, homologous patient group with appropriate follow-up and objective outcomes.

3. Retrospective case-controlled study Differential diagnosis of a condition

1. Systematic review/meta-analysis 2. Prospective evaluation of a representative sample that

includes definitive diagnostic evaluation, performed in a setting similar to actual practice

STEP 3: CRITICALLY APPRAISING THE LITERATURE

Although summary resources that appraise the medical literature have risen in quality and are an essential resource for clinicians, they will not always provide the answer to a clinical question. In addition, hospitalists may participate in discussions around particular studies, attend “journal club” conferences, or teach junior learners about evidence-based medicine. Hospitalists must have solid critical appraisal skills. The Users’ Guides to the Medical Literature (McGraw-Hill, 2014) is the benchmark textbook for learning how to practice EBM. It proposes an effective method for critical appraisal that has been widely adopted. The principles and approach it endorses are discussed further in this chapter.

In appraising any type of study, three broad questions must be answered:

1. Are the results valid? 2. What are the results? 3. How can I apply the results to patient care?

The critical appraisal process asks these three questions of each type of study, including those about therapy, diagnosis, harm, prognosis, and systematic reviews. Each of the three major questions is answered through a subset of critical appraisal questions that are specific to each study type. The critical appraisal questions help determine if a study used proper methods to prevent bias, if the results are large enough to be meaningful, and whether the results can be applied to a particular patient or population.

PRACTICE POINT

Critical appraisal focuses on answering three broad questions: Are the results valid? What are the results? How can I apply the results to patient care? The Users’ Guides to the Medical Literature offers a methodical approach to answering these questions for studies about therapy, diagnosis, harm, and prognosis, and for systematic reviews.

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In recent years, a new type of evidence, the results of quality improvement studies, has risen in prominence. As hospitalists often are involved in quality improvement efforts, they should have a working knowledge of how to critically appraise this type of evidence. The Users’ Guides to the Medical Literature offers further instruction in this area.

This chapter will illustrate the critical appraisal process through analysis of an article about therapy, as randomized controlled trials and prospective cohort studies are among the most common types of evidence encountered in practice. Table 7-3 outlines the critical appraisal questions, which are discussed in detail below. Clinicians should refer to the Users’ Guides to the Medical Literature for a complete list of critical appraisal questions for different types of research studies.

TABLE 7-3 Critical Appraisal Questions for an Article About Therapy

Main Question Supplemental Questions 1. Is the study valid? a. Were patients randomized?

b. Was group allocation concealed? c. Were patients in the study groups similar with respect

to prognostic variables? d. To what extent was the study blinded? e. Was follow-up complete? f.  Were patients analyzed in the groups to which they

were first assigned (ie, intention to treat)? g. Was the trial stopped early?

2. What are the results? a. How large was the treatment effect? (What were the RRR and the ARR?)

b. How precise were the results? (What were the confidence intervals?)

3. How can I apply the results to patient care?

a. Were the study patients similar to my patients? b. Were all clinically important outcomes considered? c. Are the likely treatment benefits worth the potential

harm and costs? (eg, what is the number needed to treat? What is the number needed to harm?)

Adapted from Guyatt G, et al., eds. Users’ Guides to the Medical Literature: A Manual for Evidence- Based Clinical Practice, 3rd ed. New York, NY: McGraw-Hill Education; 2014.

CRITICAL APPRAISAL OF AN ARTICLE ABOUT THERAPY

To critically appraise an article about therapy, the clinician should answer the following set of questions.

Are the results valid

Were patients randomized? Randomization will best ensure that the intervention and control groups are equal at the start of the trial, except for the intervention being tested. In observational studies, investigators must take special steps to ensure experimental and comparison cohorts are evenly matched. Randomization does much of this automatically.

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Was group allocation concealed? When allocation concealment is present, those enrolling patients into the study during randomization are blinded to what group (ie, intervention or control) the patients are being assigned. Without allocation concealment, for example, a patient being enrolled but who is viewed as likely having a bad outcome might be steered into the comparison group, potentially improving the results in the intervention group. Were patients in the study groups similar with respect to known prognostic variables? This is necessary to isolate the effect of the intervention and minimize confounders. Proper randomization will ensure this. In the absence of randomization, clinicians should look to see that the intervention and comparison groups were carefully matched so as to be equal for all possible confounders. This is often difficult to do, which is why randomization is preferred. To what extent was the study blinded? The term “double-blind” does not describe all parties that should be blinded in an RCT. For maximum validity, multiple groups should be blinded, including those selecting patients for randomization (ie, allocation concealment), the patients, those administering the intervention, the data collectors/analysts, and the outcome assessors. When patients or those administering the intervention cannot be blinded (as in trials of certain surgeries or procedures), allocation concealment, as well as blinding of data analysts and outcome assessors, is essential. Was the follow-up complete? Studies should track the outcomes of all participants. Patients may be lost to follow-up if they suffer a negative outcome or find the intervention too difficult to comply with. Both of these reasons would be highly relevant to the results of a study. Were patients analyzed in the groups to which they were first assigned (ie, intention to treat)? The principle of “intention to treat” highlights that in a clinical trial, the offering of an intervention to participants is being tested as much as the other effects of the intervention. If for instance participants do not like the taste of a pill or find a study protocol too hard to comply with and drop out of a trial or asked to be switched to the other arm as a result, these consequences must be recorded as part of the results of the study. Outcomes must be attributed to the group to which participants were initially assigned. A trial that follows the intention to treat principle will give the best estimate of what will happen if a therapy is offered to a population. In a “per protocol analysis,” the study results represent only what happened to those who actually accept the intervention and complete the trial. This type of analysis can inform what effect a therapy would have if taken properly by a highly compliant patient. Was the trial stopped early? Follow-up must be an appropriate length for the outcome measured. For example, 3 days might be an appropriate follow-up period for an intervention to reduce acute pain, but it would likely be too short for an intervention designed to reduce LDL cholesterol or to improve functional status. Randomized controlled trials that are stopped early because of benefit may overestimate the effect of an intervention. A large benefit observed early in a trial may be due chance, and may be greater that what would be observed if the trial were allowed to run to completion.

What are the results

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How large was the treatment effect (ie, what were the relative risk reduction and absolute risk reduction?)? Clinicians should consider results of a study using the absolute risk reduction (ARR), where the ARR% = event rate in comparison group – event rate in experimental group. The relative risk reduction (RRR) is calculated as RRR% = event rate in comparison group – event rate in experimental group/event rate in comparison group. The RRR allows one to determine the effect of a therapy on an individual patient according to their baseline risk.

Consider the study by Sharma et al., published in the American Journal of Gastroenterology in 2013, that randomized 120 hospitalized patients with cirrhosis and overt hepatic encephalopathy to rifaximin versus placebo. In-hospital death occurred in 24% of the rifaximin group and in 49% of the placebo group. Here the ARR is 25% (49% – 24%) and the RRR is 51% (49% – 24%/49%).

Clinicians can use the RRR to estimate the effect a therapy will have on individual patients they treat that may be more or less sick than the average patient in a study. For example, if a patient is estimated to have a baseline risk of dying of 60%, rifaximin will reduce this patient’s risk of dying to 30.6% (60% × 0.51). In this case the ARR will be 60%-30.6% = 29.4% which is higher than what the rifaximin group as a whole experienced in the trial. In a similar way, lower baseline risk will result in lower absolute risk reduction.

PRACTICE POINT

A randomized controlled trial describes the average effect of an intervention across the group of patients studied. The effect an intervention will have on any individual patient can be determined by combining that patient’s baseline risk with the relative risk reduction (RRR) reported in the trial. Clinicians can estimate their patient’s baseline risk by comparing them to the clinical characteristics and comorbidities of patients in a trial, and by using their clinical judgment and expertise.

HOW PRECISE WAS THE ESTIMATE OF THE TREATMENT EFFECT? (WHAT WERE THE CONFIDENCE INTERVALS?)

Confidence intervals provide more information than P-values alone, giving an estimate of the range of possible results. Some high-quality evidence-based summary resources, such as ACP Journal Club, emphasize confidence intervals and the helpful picture they paint of the results.

In the study of rifaximin described above, the RRR = 51% (95% CI, 20-71). In “plain English,” this 95% confidence interval tells us that rifaximin most likely reduces in-hospital death by 51% (the “point estimate”) but it may reduce in death by as little as 20%, or by as much as 71%. There is a 95% chance that the true effect is between 20% and 71%, a 2.5% chance the true effect is below 20%, and a 2.5% chance it is above 71%.

In order to determine whether a trial has found two therapies to be equivalent, clinicians should examine the upper and lower limits of the 95% confidence interval. If either would be clinically significant if true, the two therapies studied cannot be called equivalent, and further research is needed. A 2014 study by Regimbeau et al. published in the Journal of the American Medical Association found that in patients undergoing cholecystectomy for acute calculous cholecystitis, postoperative antibiotics reduced

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infection by an absolute risk reduction of 1.9% (95% CI, –9.0-5.1, P < 0.05). The confidence interval indicates that antibiotics most likely reduce infection by 1.9%, but may reduce infection by as much as 5.1% (in which case most clinicians would prescribe them), or may increase infection by as much as 9% (in which case most clinicians would not prescribe them). In this study, the true effect of antibiotics on postoperative infection could not be determined as they could be either beneficial or harmful, and further study is needed. A common misinterpretation of these results, which could occur if the confidence intervals are not noted, would be: “the P-value is greater than 0.05 so there is no difference between antibiotics and placebo and the two are equivalent.”

Two factors affect the width of a confidence interval: the number of patients and the frequency of the outcome in a study. In our example of the Regimbeau trial, further studies that enroll larger numbers of patients or measure more postoperative infections could result in a narrower confidence interval as well as a different point estimate.

PRACTICE POINT

Confidence intervals are preferable to P-values when considering the results of a clinical trial, as they give more information about the range of possible results, including the best and worst case scenarios.

How can I apply the results to patient care

Were the study patients similar to my patients? The more a patient meets the inclusion criteria, and the less they meet the exclusion criteria, the more confidently the results of a study can be applied to them. Clinicians should consider the setting of a study as well as whether those who administered the intervention had specialized expertise that is not available locally. Were all clinically important outcomes considered? The “grandmother test” can help determine if an outcome is clinically relevant. Outcomes that would be valued by the average person (eg, someone’s grandmother) are clinically important; outcomes that would not be valued are not clinically relevant and should not be measured by clinical trials. For example, outcomes such as a reduction in pain, an increase in survival, or a reduction hospital admission are likely to be meaningful to patients, while biochemical, laboratory, or purely hemodynamic outcomes are not. An exception is when nonclinical outcomes are established surrogate markers for clinically important outcomes. Composite outcomes of clinical endpoints are valid, but if possible studies should make clear how much each individual endpoint is driving the composite result.

PRACTICE POINT

Hospitalists should value studies that measure clinically important endpoints (or surrogate markers of these) over those that measure physiologic or biochemical endpoints.

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ARE THE LIKELY TREATMENT BENEFITS WORTH THE POTENTIAL HARM AND COSTS? (WHAT IS THE NUMBER NEEDED TO TREAT? WHAT IS THE NUMBER NEEDED TO HARM?)

The number needed to treat (NNT) describes how many patients must be treated with an intervention to produce one positive outcome or prevent one negative outcome. The NNT allows clinicians to compare the effects of different therapies, and is calculated as NNT = 100/ARR%. In the study by Sharma et al. discussed above, in-hospital death occurred in 24% of the rifaximin group and in 49% of the placebo group. Here the ARR is 25% (49% – 24%) and the NNT is 4 (100/25). In other words, we need to give four patients rifaximin to prevent one patient from dying in the hospital.

In order to best inform risk/benefit discussions about a therapy, studies should measure important adverse effects. The number needed to harm (NNH) describes how many patients must be treated for one to experience a particular adverse effect. These two numbers can be compared for an intervention and a particular adverse effect to determine the net benefit or harm. In addition to the likelihood of adverse events and their morbidity, the level of concern a patient has about particular side effects must be considered. Many studies do not assess cost, and those that do often determine cost-effectiveness at the population level, which is less relevant to the individual patient. The extent to which a therapy is covered by insurance is highly relevant to patients and should always be considered.

STEP 4: APPLYING THE LITERATURE TO AN INDIVIDUAL PATIENT

For the findings of a study to be useful in clinical care, the critical appraisal process must yield a satisfactory answer to each of the three broad questions discussed above: a study must be valid, it must report important results, and it must be applicable to the patient at hand. If any of these three elements is missing, the study findings may not be appropriate for implementation into practice.

When a study has used valid methods, has reported highly important results, and has enrolled patients clearly similar to the patient in question, the hospitalist can confidently apply its findings. But conducting clinical studies is often difficult work, and few studies are perfect in every way. Clinicians need to learn which validity or applicability issues represent fatal flaws, and which ones still allow the results of a study to be considered. This is a skill that comes with experience.

The hospitalist must remember that best evidence-based decisions incorporate not only the evidence, but also the individual clinical circumstances and preferences of patients. In most cases, patient values and preferences are more important than the other factors.

CONCLUSION This chapter has focused on skills such as the construction of focused clinical questions and how to search and critically appraise the literature. These skills are necessary but not sufficient for the practice of EBM. The hospitalist’s knowledge of the patient is at the heart of evidence-based practice. The right clinical questions cannot be asked unless the hospitalist first has a clear understanding of the patient’s clinical issues, and the literature cannot be applied to a patient without knowledge of their values and preferences. Communication skills, history and physical examination skills, illness scripts, problem re

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