Q: As director of quality, you strive to improve transitions of care around the time of discharge. What strategies have you implemented to improve that transition?
A: A hospitalist cannot do it alone. Discharge involves case managers and nurses and physical therapists and pharmacists. Our goal has been to create consensus and an urgency for change. … If you can show people their data and show how that is at odds with the vision of the care they are providing, that’s a really powerful force for change.
Q: What can other hospitalists do to improve transitions of care?
A: Form this group and take a good hard look at your data. Use that group to take small baby steps toward change, whether that’s always talking to primary-care physicians or having every patient who leaves have a follow-up appointment in two weeks, or calling every patient after discharge. I think people know what should be in their toolkit for a really safe transition. The problem is fighting the system and creating a group coalition that wants to do that with you.
Q: Have you noticed quantifiable improvements since you took over that role?
A: We put in place a program with residents to make it easier for them to do discharge summaries. They’re templated, they draw from the EMR, they’re concise, and they have what PCPs want. Nurses use them to provide targeted patient education and make sure patients understand their discharge instructions. That probably is my biggest tangible win. The biggest win overall is the culture change.
Q: How has the culture changed?
A: Faculty come up to you and say, “I had a readmission this month. I’m sorry. I really couldn’t prevent it. There’s nothing I could do.” Residents say, “I’ve been so good about communicating with PCPs this month. I can’t wait to see the audit data because I think my team has done really well.” We’re all thinking about what it takes to do a good discharge.
Q: What is the biggest advantage of UCSF’s comanagement service model?
A: The complexity of heart failure and oncology patients is incredible. That complexity means you need a subspecialist like a cardiologist or an oncologist, plus a hospitalist, because there are so many medicine issues along with cardiology or oncology issues. There are infections. There is renal failure. It takes a medicine head as well as a subspecialty head to take care of these patients.
Q: Do you believe that model will become popular for other programs?
A: I do, particularly on the surgical side. A lot of quality gains can be made by having a hospitalist partner with surgeons. The hospitalist can see a large number of patients and make sure everything has been thought about. When are they starting anticoagulation? When do those antibiotics need to come on or off? Those are quality measures that hospitalists are really good at, and I think that will make a fine partnership with surgical subspecialties.
Q: You strive to integrate QI initiatives into house staff education. Why is that important?
A: At an academic institution, you don’t provide care except going through the house staff. It’s important to make sure they understand this isn’t just one more box to be checked off or another thing their attending is asking of them. This is as fundamental as picking the right antibiotic to treat pneumonia or communicating with a PCP about a complicated discharge. That isn’t intuitively obvious. It became more apparent to me as I realized quality of care comes from clinical decisions as well as all of the extra effort we put into things like discharge and communication.