Quality Improvement (QI)

How I Realized QI Could Be a Dirty Word

With the recent election, there has been a new recognition of the various “bubbles” we all seem to be living in. It reminds me of the parable I like to often mention, popularized by the late great writer David Foster Wallace: Two fish were swimming along when an older fish swam by, nodded his head at them and said, “Mornin’ boys, how’s the water?” The two young fish nod back and swim for a bit, then one turns to the other and says, “What the hell is water?” Recently, I read a paper that helped me realize I had been swimming in a different lake from most of the “real world” in medicine. I trained and then spent the first 4 years of my post-residency career at UCSF, where quality improvement (QI) was well established and celebrated. Sure, I suppose there were some eye rolls from a few surgeons, or…

The Medicaid Overhaul And How Hospitals And Its Providers Could Be Hardest Hit

Given the signs Paul Ryan, Speaker of the House, has flashed during his tenure, expect phase one of the health care financing overhaul to be heavily focused on Medicaid. The incoming administration aligns with this change (#6), as does the president-elect's choice of Tom Price for HHS Secretary.    This turn will have an impact on hospitals and something you should pay attention to.  You will see lots of press over the coming months, and you will hear the term Medicaid block grants.  You should have an opinion, especially if you work in a rural, safety net, urban, or academic medical center.  I would imagine that holds true for many of you. (more…)

Count Me – and My Intuition – In

In modern medicine, we’re surrounded by EMR systems, lab tests and increasingly complex medical equipment. But I sometimes stop and wonder: Where does my intuition fit into the equation? Case in point: The other day, I had one of those days that happens in hospital medicine where nothing goes right. A patient admitted right at change of shift, with a diabetic foot ulcer as a chief complaint, was found to have an 8.0-gram hemoglobin drop from her baseline. Further questioning by the night admitting MD revealed that the patient had been having melena for several days. GI was consulted, but the lab was considered to be spurious. A stat repeat CBC and type and crossmatch was ordered. The EMR system was down, though this was not apparent at first. Because of this, it was not immediately evident that the lab could not see the order entered into the EMR system.…

Wow! A Two-fer

First I hear the American Board of Pediatrics ordains hospital medicine as a bonafide subspecialty. Then, for the adults among us, CMS issues a hospitalist specialty code.  No joke.  A specialty code--go live on April 3, 2017. This has been a laborious task and years in the making. Have a lookie: If you are scratching your head and wondering about the fuss, let me tell you the insights we will draw from the new knowledge and why it will advance our specialty.  For years, hospitalists got lumped with "generalists" when CMS, researchers, or insurance companies ventured to look at physician utilization patterns and service to the healthcare system. What was our individual and collective cost or contribution to a case?  Who understood.  Any interested party trying to untangle what a doc was producing during a hospital stay had only billing patterns, i.e., the percentage of inpatient codes one charged, to determine if…

Pressure Drop

A famous joke in hospital medicine is Mitch Wilson’s oft quoted statement: “When you have seen one hospitalist group you have seen one hospitalist group.” It is true that there is much variety in comparing one practice to another. Maybe that’s why our specialty has such vigor; we are constantly trying to learn from each other and decipher and decode the problems in hospital medicine. But there is definitely one commonality in hospital medicine: pressure. We are pressured to take more patients and own more aspects of the in-hospital and post-hospital space. We are pressured to find providers, and that’s not easy to do in an environment where your neighbor might be offering more money or fewer hours to that treasured provider. This pressure on adequate and stable staffing is worsened by the shrinking reimbursements on the hospital side. A model where there is fierce competition for providers and shrinking…
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