6 Ways to Reduce Liability Risks as a Hospitalist

Hospitalists face unique liability risk due to their multifaceted role. The most common area of risk is communication around patient handoffs, which is compounded by the fact that there is often confusion about the hospitalist’s role. Even the most experienced, highest quality physicians face risk of litigation. Fortunately, there are key areas hospitalists can focus to not only deliver better patient experience, but also avoid lawsuits.

1.    Communication. Communication. Communication. 

Communication is far and away the most critically important way to reduce risk and improve patient experience. Ensure you always take the time to communicate effectively, clearly, and thoroughly with the patient, the patient’s family, your physician colleagues, and nursing staff.

2.    Spend more time with the patient on admission/early in the hospitalization.

We are all busy as providers, but the smallest extra steps can go a long way. I recommend spending extra time with hospitalized patients as they are admitted and early on in their stay to build trust with the patient and their family. Once a facility knows they are in good hands, they are much more relaxed and ongoing exchanges become more relaxed and take less time.

3.    Treat all staff with professionalism and courtesy.

Being kind to your colleagues and everyone you interface with pays dividends in all aspects of your practice. When you take time to do small things like say hello, smile, and treat everyone you interact with respectfully, you garner respect yourself. Nurses, physicians, and patients themselves are less likely to report anything negative if you are consistently professional and cordial.  Arrogance and/or disregard for the concerns of colleagues or families is one of the fastest ways to find yourself named in a malpractice lawsuit or a complaint to the state medical board.  

4.    If you are asked to see a patient due to a change in clinical status, do it.

If anyone asks you to see a patient due to a real or perceived change in their clinical status, it is important that you do so. If that patient has a bad outcome and it is documented that you were asked to visit the patient, that is very difficult to explain/defend. When in doubt, make time to see the patient.

5.    Never hurry.

Even if you feel too busy for questions or if you feel rushed, never let a patient or their family see that. Be upfront with patients about your availability. For example, if you are on call and know you may be interrupted, take time to let the patient know that at the beginning of the visit so they are not surprised when you are called away. Taking time to sit down in a patient’s room is a good way to establish that your undivided attention is on the patient and that you are not in a rush to see your next patient.

6.    Own your mistakes.

First, ensure you know your facility and your physician group’s policies on reporting mistakes or omissions. They are not all created equal and dealing with each situation is unique. If you make a mistake or document something incorrectly, take time to place an addendum in the patient’s medical record. It is critical that you NEVER lie and NEVER change anything in a medical record.

Incorporating these best practices into your practice will have benefits far beyond reducing risk. They will also improve patient experience, your efficiency, and the quality of care you provide. In the event that you do face a complaint or litigation, the worst thing you can do is ignore it. Educate yourself on the resources you have available to you if you do face a suit or complaint, such as colleagues and legal representation.

9 Important Issues Hospitalists Should Discuss with ED Counterparts

Hospitalists and emergency medicine physicians interface at a crucial point in the patient care continuum: where patients in need of further treatment are discharged for outpatient treatment or admitted to the hospital. Both groups share the same prerogative: provide high quality patient care and achieve positive outcomes. However, there are times when the two groups are at odds, especially when there is a gray area regarding the best care setting for a given patient.

Hospitalists and ED physicians have different, and sometimes conflicting, priorities. ED physicians are driven by throughput: moving patients through the ED quickly and efficiently. Hospitalists are driven by efficiently managing inpatient length of stay. The key to reducing tension between the two groups is to bring them together to discuss how they can better serve one another.  

In my experience as a hospitalist, I have found that there are a few key issues that are crucial to discuss with my ED counterparts. The list below is a good reference for common issues to address at an interdisciplinary meeting.

Inpatient Patient Sources

The ED is not a hospitalist’s only source of patients. We also manage consults from other services, direct admissions from primary care physicians, ICU transfers, and admissions from free standing emergency departments. Simply discussing the patient load and being open about the fact that the ED is not the only source of patients can help reframe your conversation. A hospitalist and ED physician should always take time understand the volume of patients the other practice is handling to better understand one another’s perspective and make informed requests and decisions together.

Labs and Imaging before Admission Calls   

When possible, it is extremely helpful for hospitalists when the ED completes labs and imaging before admission rather than admitting a patient with pending results. Sometimes, the results change whether the patient can be admitted to the floor vs. the ICU. A good starting point is to determine a protocol for labs and imaging and establish common exceptions so that everyone shares the same expectation of how labs and imaging will be handled.

Protocol for Borderline-for-Admission Patients

When it is not clear whether a patient needs to be admitted, it is helpful for an ED physician to ask their hospitalist counterpart their opinion before making a decision. Guidelines evolve and patients that we would have been admitted just five years ago can often be treated safely as an outpatient (e.g. in the case of a stable pulmonary embolism). It is helpful to discuss these types of cases and establish an interdisciplinary algorithm on how to handle each case.

Documentation of Conversations with Consultants

To avoid confusion over whether an ED physician spoke with a consultant, it is important that ED physicians always document whether they talked to a consultant directly or whether they are awaiting a call back from a consultant. If this is not mutually understood, confusion and delay of patient care is common, especially if the patient is admitted overnight and there is a handoff to a daytime hospitalist. A good remedy for this is to establish a protocol on how to handle overnight admissions handoffs and documentation of conversations with consultants. Thorough communication and documentation are critical. 

Batching Admissions

Sometimes, calling in multiple admissions at once is impossible to avoid. However, it can be very difficult for a hospitalist practice to handle 3, 4, 5, or even more admissions at once. In my experience, there are certain ED physicians who have a reputation for calling with a bundle of admissions at the end of their shift. Often, this is simply because that physician does not fully grasp the effect it has on their hospitalist counterpart. The best solution is to openly communicate and establish mutually beneficial strategies to avoid bundling admissions.  

Treatment Updates

There are often changes in things like recommended antibiotics for certain infections or new drugs like novel oral anticoagulants (NOACs).  When these changes occur it often changes the recommendations related to treatment and which labs to order or not order. I recommend establishing regular interdisciplinary meetings where updates like these can be shared. And, when in doubt, I recommend that providers speak to one another about their choice to ensure there is no confusion and that the patient receives the best treatment possible.

Stating Patient Name and Room Number

As hospitalists, we understand that the ED is always working to make patients better in the fastest way possible. However, it is crucial to slow down to communicate details to avoid errors. I recommend establishing a simple checklist for the order of information shared on a phone call between a hospitalist and ED physician. In my experience, it is very helpful for the ED doctor to slowly and clearly spell the patient’s name and state their room number before sharing any diagnosis or medical information.

Being Upfront about Challenges

Hospitalists understand that we will not always know precisely what is going on with the patient at the time they present. As hospitalists, we have the luxury of figuring it out over days instead of hours. I recommend establishing a safe, trusting culture of communication between the two practices, where ED physicians feel comfortable stating that they are not sure what is wrong with the patient, that it is a social admission and there is no safe place for the patient to go outside of the hospital, or that they forgot to order something important. When a hospitalist is not informed, it puts us in a difficult position, especially if we cannot see the patient immediately. 

Protocol for Primary Psychiatric Diagnosis.

Most hospitalists and acute care hospitals are not equipped to take care of primary psychiatric patients safely. If this is the case at your facility, it is important to make your ED colleagues aware that often once a primary psychiatric patient is admitted, transfer is much harder from the inpatient side vs. from the ED. Establishing a set protocol for handling psychiatric patients will alleviate difficult situations for both practices.  

Overall, the best place to start is to ask your ED colleagues how you can make their life easier, and brainstorm collaborative, mutually beneficial solutions. Simply being aware of our counterpart’s perspective and establishing interdisciplinary protocols to reference goes a long way to improve transitions of care from the ED.

Rethinking Hospitalist Peer Review: How to Make it Productive and Positive, Not Punitive

Consistent and constructive peer review in hospitalist groups is not common. In fact, most groups only trigger peer review when a sentinel event arises. In my experience leading hundreds of hospitalists, I consistently find defensive behavior or—at the very least—avoidance of the peer review process. Clinicians view peer review as a punishment and unwelcome spotlight on shortcomings. It does not have to be that way. Peer review, when done right, has the power to improve patient care, boost service quality, and decrease the frequency of sentinel events.

Instead of viewing peer review as an inconvenience, what if we make it part of a culture of continuous improvement? Rather than considering it an unwanted disruption, what if we embrace it as a part of our regular education and quality improvement efforts? Shaping how a hospitalist team views peer review starts with the way the medical director and hospital leadership approach it.  

Peer review is not a personal attack, instead it is educational and beneficial to patients. Additionally, it is confidential and not discoverable legally, protecting the physicians under review. Hospitalist leaders have an opportunity to make peer review a regular part of the culture of the program by designing a system to support it and communicating the value that program will present to the patient, provider, program, and hospital.

By putting a structure in place to support peer review and focusing on its collective value, the culture surrounding peer review in a hospitalist group can shift from subjective and confrontational to educational and collaborative, ultimately increasing patient safety and overall quality of care.  Below are four key ways I suggest hospitalist leaders shift their team’s take on peer review:

1.    Design a regular peer review process of all providers.

A regular peer review process is central to changing the culture of a hospitalist team’s peer review process. An anonymous survey that allows team members and leaders alike to give their colleagues anonymous constructive feedback is a great first step. This survey should center on your unique priorities, which may include efficiency, communication with colleagues and patients, documentation, engagement in meetings, quality measures, or other specific improvement initiatives.

2.    Establish and support your peer review committee.

In addition to more general surveys on team member performance, it is also important to establish a formal group to perform peer review. Common hurdles associated with this include: fear of ramifications for criticizing friends and increased workload in an already busy practice. These hurdles can be overcome by focusing the team on the collective educational benefit and improved patient outcomes. Furthermore, clearly defining committee member rolls and providing committee training on peer review best practices ensures a consistent, timely, and objective process.

3.    Do not wait for sentinel events, schedule regular review meetings.

Rather than conducting peer review as-needed, build it into your ongoing quality improvement efforts. For example, set up a quarterly meeting to review findings from the anonymous colleague survey and monthly meetings to discuss randomly selected charts or cases as a group. A consistent schedule ensures no provider feels singled out and all providers benefit and learn from the discussion. 

4.    Establish guidelines/resources for physicians who receive a peer review letter.

As part of these regular review meetings, also educate team members on what to expect and best practices for response in order to make the process as valuable as possible. Simply communicating the value of the findings of the review can be enough to encourage a provider not to ignore a peer review letter and to respond positively rather than angrily or defensively. Additionally, make the timeline expectations clear to providers (i.e. when is a response expected, and when they can expect a response from the peer review committee). It is also helpful to provide the physician a resource to proofread their response and manage the process, so they are not surprised by a letter or a negative conclusion when it comes time for hospital reappointment.

By making regular anonymous feedback and peer review part of the culture of your hospitalist program, you soften the impact of one-off peer review letters associated with sentinel events. Over time, hospitalists will consider peer review of their work an indispensable part of their continuing education efforts and the continuous improvement of patient care.

3 Reasons to Combine your Low Volume Hospital’s Emergency and Inpatient Service

The idea that a hospitalist program is cost prohibitive for smaller community hospitals (less than 12,000 annual emergency department visits) is a dated myth. Reaping the benefits of a robust hospitalist program and emergency department without the cost of two full programs is possible. It simply requires innovation. Hybrid emergency department and inpatient care management is that innovative solution.

Emergency medicine and hospital medicine can be integrated by combining the two services into a single patient care service. In this model, inpatient care is provided as an extension of traditional emergency department services by providers who are skilled in both emergency and inpatient care. A single physician (or physician and advanced practice provider team) cares for the same patient throughout their hospital visit.

This model is a good fit for smaller hospitals because it allows for the most efficient use of provider coverage. The staffing model will vary based on your volume trends. When designing your staffing model for a hybrid program you must consider:

·      Arrival and average daily census patterns

·      Physician shift length (12 or 24)

·      How to cover volume surges

·      After midnight admission processes

In our experience, the program works best when there is a backup call schedule arranged for volume surges and physicians work 24 hour shifts, handling rounding in the morning before ED volumes peak for the day and writing H&Ps during rounding time for patients admitted after midnight. 

The hybrid model is a cost-effective and efficient alternative to running separate programs or managing rotating call with community physicians. Below are the top 3 reasons to adopt a hybrid model at your small community hospital, rural hospital, or critical access hospital.

1.     Cost effectiveness.

The price tag associated with running emergency and inpatient programs is typically cost prohibitive for smaller community hospitals. The patient volume in most smaller community hospitals doesn’t financially support two separate programs. The hybrid approach offers a lower cost solution than two programs while also improving admit/ transfer ratios.

2.     Improved care continuity.

In the hybrid ED and hospitalist management model, one physician cares for a single patient as they transition from emergency care to inpatient care. This eliminates the risks often associated with transitions of care, including: communication breakdowns, unnecessary readmissions, poor patient experience, and more. The hybrid model allows you to implement standardized clinical pathways and order sets that transition seamlessly from the ED to inpatient care so the patient has a positive, consistent experience.

3.     Added inpatient care delivery stability and consistency.  

Traditional ED and hospitalist programs can have difficultly aligning performance and patient experience. Additionally, the two common alternatives to two separate programs—rounding by community physicians and reliance on locum tenens providers—make it difficult to ensure consistent, reliable care. A community physician’s primary commitment is to his/her outpatient clinic patients, so rounding often happens outside of clinic office hours. This results in delays to inpatient codes, patient status changes, order clarification and/or changes, and consultations, which increases length of stay. By implementing a dedicated provider or provider team that is committed to both ED and inpatient care, unassigned admissions are reduced because all patients are admitted by the same service line.

A hybrid emergency and hospitalist program is a great alternative to two, high-cost separate programs, relying on community physicians to accommodate rounding in their already-busy schedules, or calling in locum tenens physicians who are not invested in the community to provide inpatient care. The hybrid program adds more continuity to your patient’s experience, shortens length of stay, increases efficiency of the admissions process, and improves admit/transfer ratios, ultimately improving hospital performance overall.