Patient Satisfaction

You Have Lowered Length of Stay. Congratulations. You’re Fired.

For several decades, providers working within hospitals have had incentives to reduce stay durations and keep patient flow tip-top. DRG-based and capitated payments expedited that shift. Accompanying the change, physicians became more aware of the potential repercussions of sicker and quicker discharges. They began to monitor their care and as best as possible, use what measures they could ascertain as a proxy for quality (readmissions and hospital acquired conditions). Providers balanced the harms of a continued stay over the benefits of added days, not to mention the need for cost savings. However, the narrow focus on the hospital stay, the first three to seven days of illness, distracted us from the out weeks after discharge. With the acceleration of inpatient episodes, we cast patients to post-acute settings unprepared for the hardship they would face. By the latter, I mean, frailty risk, more reliance on others for help, and a greater need…

Wrongful Life

There have been recent discussions in the lay media about a growing trend of litigation cases focused not on the “right to live”, but rather on the “right to die”. These cases have involved patients who received aggressive treatment, despite having documentation of their wishes not to receive such aggressive treatment. Although unsettling, it is not surprising that this issue has arisen, given the national conversations about the exorbitant cost of care at the end of life in the U.S., and the frequency with which patients do not receive end of life care that is concordant with their wishes. These conversations have spurned providers and patients to discuss and document their wishes, via advanced care directives and/or POLST orders (Physicians Orders for Life Sustaining Treatment). There is now even a national day devoted to advanced care decision making (National Healthcare Decisions Day). While these documents are increasingly available for hospitalists…

It’s Time for a Buzz Cut

I sometimes joke that hospitalists are the medicine version of the mullet haircut – you know, all business in "the front" (i.e. the patient care area) and all party in "the back" (i.e. the work room). In "the back", the usual scenario is to complain and moan about our frequent flyers, our drug seekers, our many unsaveable patients, the incredible situations ("He put a nail where??), with good-natured but somewhat bitter truculence about sharing duties with housestaff and general whining about hospital leadership. Generally, as long as these semi-inappropriate conversations and remarks were kept "backstage", and our demeanor was professional "onstage", I felt it was harmless. You know, gallows humor. A coping mechanism. And often entertaining. But there was always a part of me that wondered if these "backstage" conversations were having a more corrosive impact on communication with our patients. Does it normalize a negative judgement about patients if…

Is Patient-Centered Care Bad for Resident Education? #JHMChat Explores #meded & #ptexp

The term “patient-centered” has become a healthcare buzzword and was certainly popularized by the creation of the patient-centered medical home in ambulatory care. In the inpatient world, patient-centered rounds symbolizes this effort to improve patient experience and is the subject of a new study in this month’s Journal of Hospital Medicine, which we'll discuss on next Monday's #JHMChat at 9 p.m. EST on Twitter. In a randomized trial, Brad Monash and UCSF colleagues explored the impact of patient-centered rounds on patient experience. Patient-centered rounds was a bundle of 5 evidence-based practices: 1) pre-rounds huddle; 2) bedside rounds; 3) nurse integration; 4) real-time order entry; and 5) whiteboard updates. The control group continued with routine practice of attending rounds. The study was impressive for several reasons, but one in particular caught my attention – an army of 30 pre-med students volunteered to be observers (and also get shadowing experience?) to monitor…

The Nursing Home Get Out of Jail Card (“We Don’t Want Our Patient Back”). It’s Now Adios.

The Centers for Medicare & Medicaid Services (CMS) has not updated its rules ("conditions for participation") for nursing homes in twenty-five years. Late last year they finally did. Many of the changes will have an impact on the daily lives of NH residents but are far removed from hospital medicine.  Think a resident's ability to pick their own roommate and have all hours visitors.  However, there are a few changes that intersect with HM, and a notable one will affect how you respond to a frequently encountered roadblock long-term care facilities sometimes throw our way. First, though, some of the changes CMS finalized.  With SHM members now moving into the post-acute and LTC realm, several have real relevance (I only cite a sliver of them): (more…)
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