Outline 1. Background/Context 2. Objective and Hypotheses 3. Who to - - PowerPoint PPT Presentation
Hospitalist Workload and Its Impact on Quality of Care and Patient Safety Henry Michtalik, MD, MPH An Intensive Intro to Clinical Research July 22, 2011 Outline 1. Background/Context 2. Objective and Hypotheses 3. Who to study? 4. What to
Henry Michtalik, MD, MPH An Intensive Intro to Clinical Research July 22, 2011
Physician workload is an integral part of many
public policy.
Patient safety is an integral part of quality healthcare
These two areas of healthcare research are often explored
Historically, nursing-patient ratios and resident-physician
http://nathanbond.wordpress.com/2008/12/28/the-elephant-in-the-room/
Ratios and staffing plans have been studied and established for
Hospitalists now account for nearly 40%, and in some regions
Hospitalists provide a unique venue to study the effect of
Johns Hopkins Clinical Research Network
to innovative therapies and outcomes research in their own local
array of research projects relevant to their communities.”
To study Hospitalists from the seven hospitals within the Johns Hopkins
Clinical Research Network to assess the typical patient:physician ratio and examine and describe its variability.
structure.
To adjust this ratio for the significant patient, physician, and hospital level
factors which affect the number of patients that a single attending physician may be responsible for and assess its impact on quality of care measures, including readmissions, healthcare acquired conditions and mortality.
and safety measures, even after adjustment for patient, physician, and hospital level factors.
Ultimately, we seek to identify factors in attending physician workload
which can be improved upon to make inpatient care a safer, more efficient, and higher quality care experience.
Table 1: Summary of Factors Affecting Patient:Physician Ratio
Level Variable Name Type Patient Average Age (Years) Continuous Race Categorical Gender Dichotomous Typical Insurance Status Categorical Average Acuity of Care Categorical Frequency of Readmissions Continuous Physician Age (Years) Continuous Race Categorical Gender Dichotomous Average Workday (Hrs) Continuous Assistance by Midlevels or Housestaff (%) Continuous Clinical Experience (Years) Continuous Annual Salary ($) Continuous Bonus ($) Continuous Physician Group Size Continuous Non-Direct Patient Care Responsibilities (%) Continuous Hospital Practice Area Categorical Practice Location Categorical Magnet Status Dichotomous System to Deal With Increased Patient Volumes Categorical
Table 2A: Selected Joint Commission Quality of Care Measures Applicable to Hospitalists
Category Descriptiona Acute MI AMI-2 Aspirin prescribed at discharge AMI-3 ACEI for LVSD AMI-4 Adult smoking cessation advice/counseling AMI-5 Beta blocker prescribed at discharge AMI-9 Inpatient mortality Heart Failure HF-1 Discharge instructions HF-2 LVF assessment HF-3 ACEI for LVSD HF-4 Adult smoking cessation advice/counseling Community Acquired Pneumonia CAP-1 Oxygenation assessment CAP-2 Pneumococcal screening and/or vaccination CAP-3 Blood cultures CAP-4a Adult smoking cessation advice/counseling CAP-5 Antibiotic timing a: Labels correspond to Joint Commission core measure
Table 2B: Selected Maryland Health Services Cost Review Commission Quality of Care Measures Applicable to Hospitalists
Category Descriptionb Neurologic 1 Stroke & Intracranial Hemorrhage 2 Extreme CNS Complications 36 Acute Mental Health Changes 47 Encephalopathy Pulmonary 3, 4 Acute Pulmonary Edema and Respiratory Failure 5 Pneumonia & Other Lung Infections 6 Aspiration Pneumonia 7 Pulmonary Embolism 8 Other Pulmonary Complications 49 Iatrogenic Pneumothorax Cardiac 9 Shock 10 Congestive Heart Failure 11 Acute Myocardial Infarction 12 Cardiac Arrhythmias & Conduction Disturbances 13 Other Cardiac Complications 14 Ventricular Fibrillation/Cardiac Arrest Gastrointestinal 17, 18 Major Gastrointestinal Complications 19 Major Liver Complications 20 Other Gastrointestinal Complications Infectious 21 Clostridium Difficile Colitis 22 Urinary Tract Infection 33 Cellulitis 34 Moderate Infectious 35 Septicemia & Severe Infections 54 Infections due to Central Venous Catheters Genitourinary 23 GU Complications Except UTI 24, 25 Renal Failure Other 15 Peripheral Vascular Complications Except Venous Thrombosis 16 Venous Thrombosis 26 Diabetic Ketoacidosis & Coma 28 In-Hospital Trauma and Fractures 48 Other Complications of Medical Care 50 Mechanical Complication of Device, Implant & Graft 53 Infection, Inflammation & Clotting Complications of Peripheral Vascular Catheters & Infusions b: Numbers correspond to MHSCRC Potentially Preventable Complication (PPC) indexing number
Predictors Outcomes
patient:physician ratio per weekday shift based on administrative billing data in each of the sites.
variability in the ratio over time (weekly) within and between sites.
(within sites) and ANOVA (between sites), we will calculate the adjusted patient:physician ratio adjusted for patient, physician, and hospital factors.
patient:physician ratio.
using two main outcome measures. One outcome will be percent compliance with JC core measures; the second will be absolute number
between the adjusted patient:physician ratio and our quality of care measure using Analysis of Variance for JC compliance and poisson regression for HPHAC events.
between the adjusted ratio and percent 30 day readmission and in- hospital mortality
Improve our knowledge in the relationship between attending
physician workload and quality of care.
Define the association and identify important patient-, physician-,
and hospital-level factors that affect physician workload.
Control for differences seen between patient populations,
physicians, and hospitals, allowing for standardization of workload.
Lead to a greater focus on patient:physician ratios, distribution of
responsibilities, and staffing plans, similar to those implemented and required for nursing.
Hopefully translate into safer and higher quality care. Necessary, especially in the setting of increased patient access, a
greater focus on patient safety and hospital acquired conditions, and rising healthcare costs.
It affects you, your family, and your institution.
Daniel Brotman, MD, FACP; Director, Hospitalist Program, Johns
Hopkins Hospital
Daniel E. Ford, MD, MPH; Professor of Medicine, Vice Dean for
Clinical Research
Peter Pronovost, MD, PhD; Professor of Medicine, Medical
Director for the Center for Innovation in Quality Patient Care
The Rockin’ Small Group Number 8
The Instructors of this Course!
Physicians reported that their patient load often (≥4/5)
day (21.5%)
Summary
reported an unsafe workload at least monthly.
workload has often caused incomplete patient discussions, unnecessary tests and procedures, admission/discharge delays, and excessive cross-coverage.
adversely affecting patient safety and quality of care and should be further explored.
Limitations
encounters, suggesting misinterpretation
hours, suggesting misinterpretation
parameters
202 Respondents 291 Respondents 890 Invitations to Participate 506 Respondents
5 Eliminated because did not complete any of the safety questions
501 Respondents
At Least Monthly Less Than Monthly Frequency of Unsafe Census
Associated WITH frequent UNsafe
clinical work
NOT Associated with frequent UNsafe
Associated WITH frequent safe