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This survey study aimed to provide a contemporary appraisal of advanced practice provider (APP) practice and to summarize perceptions of the benefits and challenges of integrating APPs into adult academic hospital medicine (HM) groups. We surveyed leaders of academic HM groups. We received responses from 43 of 86 groups (50%) surveyed. Thirty-four (79%) reported that they employed APPs. In most groups (85%), APPs were reported to perform daily tasks of patient care, including rounding and documentation. Less than half of the groups reported that APPs had completed HM-specific postgraduate training. The reported benefits of APPs included improved perceived quality of care and greater volume of patients that could be seen. Reported challenges included training requirements and support for new hires. Further investigation is needed to determine which APP team structures deliver the highest quality care. There may be a role for expanding standardized competency-based postgraduate training for APPs planning to practice HM.

Transitional care (TC) has received widespread attention from researchers, health system leaders, clinicians, and policy makers as they attempt to improve health outcomes and reduce preventable hospital readmissions, yet little is known about the critical elements of effective TC and how they relate to patients' and caregivers' needs and experiences. To address this gap, the Patient-Centered Outcomes Research Institute (PCORI) funded a national study, Achieving patient-centered Care and optimized Health In care transitions by Evaluating the Value of Evidence (Project ACHIEVE). A primary aim of the study is the identification of TC components that yield desired patient and caregiver outcomes. Project ACHIEVE established a multistakeholder workgroup to recommend essential TC components for vulnerable Medicare beneficiaries. Guided by a review of published evidence, the workgroup identified and defined a preliminary set of components and then analyzed how well the set aligned with real-world patients' and caregivers' experiences. Through this process, the workgroup identified eight TC components: patient engagement, caregiver engagement, complexity and medication management, patient education, caregiver education, patients' and caregivers' well-being, care continuity, and accountability. Although the degree of attention given to each component will vary based on the specific needs of patients and caregivers, workgroup members agree that health systems need to address all components to ensure optimal TC for all Medicare beneficiaries.

Problem Inefficient implementation of evidence‐based care garners increasing attention as a source of suboptimal value of clinical care, and integration of quality improvement methodology into clinical practice represents a potential solution. Academic medical centers (AMCs) often have expertise in implementation science, yet it is not leveraged effectively to solve operational inefficiencies or to rapidly implement evidence‐based practices (EBPs). Approach To leverage in‐house research expertise, the University of Kentucky (UK) College of Medicine and Center for Health Services Research (CHSR) launched a pilot awards program—Value of Innovation to Implementation Program (VI2P)—across its health system and six health professional colleges. Criteria for awards included a transdisciplinary research team and addressing health disparity issues faced by Kentucky. Outcome measures included EBP adoption and implementation and future funding. Outcomes The VI2P produced 26 transdisciplinary teams that submitted letters of intent. Ten teams were invited to submit full proposal, and four projects were selected for award, spanning the entire continuum of health‐impact research. Three nonawarded projects were implemented and prompted system redesign for an “implementation research living laboratory.” A Workgroup for ImplementatioN Science (WINS) was established to forge transdisciplinary teams to pursue federal grant funding yielding proposals totaling $17.17 million submitted, $4.38 million awarded, and $5.97 million under review. Junior faculty were encouraged to pursue implementation science as a research focus. Next Steps UK WINS will continue serve as the hub for dissemination and implementation researchers at UK. On the basis of the enthusiasm expressed by multiple groups and many inquiries about the future training opportunities at UK, we plan to develop a tailored dissemination and implementation (D&I) training program to build research and practice capacity at UK.

Internal medicine (IM) residents and hospitalist physicians commonly perform thoracenteses. National data show that thoracenteses are also frequently referred to other services such as interventional radiology (IR), increasing healthcare costs. Simulation-based mastery learning (SBML) is an effective method to boost physicians' procedural skills and self-confidence. This study aimed to (1) assess the effect of SBML on IM residents' simulated thoracentesis skills and (2) compare thoracentesis referral patterns, self-confidence, and reasons for referral between traditionally trained residents (non-SBML-trained), SBML-trained residents, and hospitalist physicians. A random sample of 112 IM residents at an academic medical center completed thoracentesis SBML from December 2012 to May 2015. We surveyed physicians caring for hospitalized patients with thoracenteses during the same time period and compared referral patterns, self-confidence, and reasons for referral. SBML-trained resident thoracentesis skills improved from a median of 57.6% (interquartile range [IQR] 43.3-76.9) at pretest to 96.2% (IQR 96.2-100.0) at post-test (P < 0.001). Surveys demonstrated that traditionally trained residents were more likely to refer to IR and cited lower confidence as reasons. SBML-trained residents were more likely to perform bedside thoracenteses. Hospitalist physicians were most likely to refer to pulmonary medicine and cited lack of time to perform the procedure as the main reason. SBML-trained residents were most confident about their thoracentesis skills, despite hospitalist physicians having more experience. This study identifies confidence and time as reasons physicians refer thoracenteses rather than perform them at the bedside. Thoracentesis SBML boosts skills and promotes bedside procedures that are safe and less expensive than referrals. Journal of Hospital Medicine 2016;11:792-795. © 2016 Society of Hospital Medicine.

BACKGROUND Previous data suggest that direct pharmacist interaction with patients through medication reconciliation, discharge counseling, and postdischarge phone calls decreases the number of adverse drug events (ADEs) and plays an overall positive role in transitional care. Previous studies have evaluated pharmacist involvement in improving transitional care, but these studies did not include multiple postdischarge follow-up phone calls. OBJECTIVES The objectives of this study were to assess the impact of pharmacist involvement in transitions of care as measured by decreased medication errors (MEs) and ADEs, patients' knowledge related to communication about their medications as measured by improvement in the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) scores, and 30-day all-cause inpatient readmissions and emergency department (ED) visits. METHODS This was a prospective, randomized, single-period longitudinal study that occurred from November 2012 through June 2013 at an urban, tertiary, academic medical center. Patients admitted to 2 designated internal medicine units on high-risk medications or with greater than 3 prescription medications upon discharge were included for randomization. The control group received the usual hospital standard of care. The study group received face-to-face medication reconciliation, a patient-specific pharmaceutical care plan, discharge counseling, and postdischarge phone calls on days 3, 14, and 30 to provide education and assess study endpoints. RESULTS A total of 278 patients were included in the final analysis, with 141 in the control group and 137 in the study group. Fifty-five patients (39%) in the control arm experienced an inpatient readmission or ED visit within 30-days postdischarge compared to 34 patients (24.8%) in the study arm (P = 0.01). Eighteen patients (12.8%) in the control group experienced an ADEs or MEs compared to 11 patients (8%) in the study group (P > 0.05). The HCAHPS scores during the study period showed a 9% improvement for the assessed questionnaire domain (P > 0.05). CONCLUSIONS This study demonstrated that pharmacist involvement in hospital discharge transitions of care had a positive impact on decreasing composite inpatient readmissions and ED visits. Statistically significant difference in medication-related events and HCAHPS scores were not observed. Patients with moderately complex medication regimens benefited from a continuity of care involving a pharmacy team during transitions in care. Journal of Hospital Medicine 2016;11:39–44. © 2015 Society of Hospital Medicine

BACKGROUND The recent intense attention to hospital readmissions and their implications for quality, safety, and reimbursement necessitates understanding specific subsets of readmitted patients. Frequently admitted patients, defined as patients who are admitted 5 or more times within 1 year, may have some distinguishing characteristics that require novel solutions. METHODS A comprehensive administrative database (University HealthSystem Consortium's Clinical Data Base/Resource Manager™) was analyzed to identify demographic, social, and clinical characteristics of frequently admitted patients in 101 US academic medical centers. RESULTS We studied 28,291 frequently admitted patients with 180,185 admissions over a 1-year period (2011–2012). These patients comprise 1.6% of all patients, but account for 8% of all admissions and 7% of direct costs. Their admissions are driven by multiple chronic conditions; compared to other hospitalized patients, they have significantly more comorbidities (an average of 7.1 vs 2.5), and 84% of their admissions are to medical services. A minority, but significantly more than other patients, have comorbidities of psychosis or substance abuse. Moreover, although they are slightly more likely than other patients to be on Medicaid or to be uninsured (27.6% vs 21.6%), nearly three-quarters have private or Medicare coverage. CONCLUSIONS Patients who are frequently admitted to US academic medical centers are likely to have multiple complex chronic conditions and may have behavioral comorbidities that mediate their health behaviors, resulting in acute episodes requiring hospitalization. This information can be used to identify solutions for preventing repeat hospitalization for this small group of patients who consume a highly disproportionate share of healthcare resources. Journal of Hospital Medicine 2015;10:563–568. © 2015 The Authors Journal of Hospital Medicine published by Wiley Periodicals, Inc. on behalf of Society of Hospital Medicine

BACKGROUND Patient-physician continuity is difficult to achieve in hospital settings because of the need to provide care continuously. The impact of hospital physician discontinuity on patient safety is unknown. OBJECTIVE To determine the association between hospital physician continuity and the incidence of adverse events (AEs). DESIGN Retrospective observational study using multivariable models to adjust for patient characteristics. PARTICIPANTS Patients admitted to a nonteaching hospitalist service in a large academic hospital between March 1, 2009 and December 31, 2011. MAIN MEASURE(S) Two measures of continuity were used. The Number of Physicians Index (NPI) was the total number of unique hospitalists caring for a patient. The Usual Provider of Care (UPC) Index was the proportion of encounters with the most frequently encountered hospitalist. Outcome measures were AEs detected by automated queries of information systems and confirmed by 2 physician researchers. KEY RESULTS Our analysis included data from 474 hospitalizations. In unadjusted models, each 1-unit increase in the NPI (ie, less continuity) was significantly associated with the incidence of 1 or more AEs (odds ratio = 1.75; P

BACKGROUND Obesity-related comorbidities frequently contribute to acute illness. Obesity interventions during hospitalization are not often utilized but may be effective. OBJECTIVE To examine whether inpatient weight loss intervention with postdischarge follow-up results in weight loss at 6 months when compared to control. DESIGN Prospective, randomized controlled trial. SETTING Academic medical center in Chicago, Illinois. PATIENTS Obese adult inpatients. INTERVENTION Intervention subjects viewed a weight education video, underwent personalized counseling, and set specific weight loss, dietary, and fitness goals prior to discharge. All participants were followed by phone over the subsequent 6 months. The trial was unblinded to participants, physicians, and investigators. MEASUREMENTS Primary outcome was weight change between groups at 6 months. Weight change from baseline and waist-to-hip ratios (WHR) were also assessed. RESULTS For 176 participants in the intention-to-treat analysis, mean baseline weight for the intervention group was 107.7 kg (standard deviation [SD] = 16.7) and 105.1 kg (SD = 17.4) for controls. Mean weight loss at 6 months was 1.08 kg (SD = 4.33) for intervention subjects and 1.35 kg (SD = 3.65) among controls. There was no significant difference in weight loss between groups at 6 months (P = 0.26). As-treated analysis yielded similar results. There were no differences in WHRs between the intervention and control at 6 months (0.04 vs 0.04, P = 0.59). CONCLUSIONS We found no difference in weight loss between the intervention and control groups at 6 months. Journal of Hospital Medicine 2014;9:515–520. © 2014 Society of Hospital Medicine

BACKGROUND Simple interventions such as facecards can improve patients' knowledge of names and roles of hospital physicians, but the effect on other aspects of the patient-physician relationship is not clear. OBJECTIVE To pilot an intervention to improve familiarity with physicians and assess its potential to improve patients' satisfaction, trust, and agreement with physicians. DESIGN Cluster randomized controlled trial assessing the impact of physician facecards. Physician facecards included pictures of physicians and descriptions of their roles. We performed structured interviews of randomly selected patients to assess outcomes. SETTING One of 2 similar hospitalist units and 1 of 2 teaching-service units in a large teaching hospital were randomly selected to implement the intervention. MEASUREMENTS Satisfaction with physician communication and overall hospital care was assessed using the Hospital Consumer Assessment of Healthcare Providers and Systems. Trust and agreement were each assessed through instruments used in prior research. RESULTS Overall, 138 patients completed interviews, with no differences in age, sex, or race between those receiving facecards and those not. More patients who received facecards correctly identified ≥1 hospital physician (89.1% vs 51.1%; P

BACKGROUND Rehospitalization is a prominent target for healthcare quality improvement and performance-based reimbursement. The generalizability of existing evidence on best practices is unknown. OBJECTIVE To determine the effect of Project BOOST (Better Outcomes for Older adults through Safe Transitions) on rehospitalization rates and length of stay. DESIGN Semicontrolled pre–post study. SETTING/PARTICIPANTS Volunteer sample of 11 hospitals varying in geography, size, and academic affiliation. INTERVENTION Hospitals implemented Project BOOST-recommended tools supported by an external quality improvement physician mentor. METHODS Pre–post changes in readmission rates and length of stay within BOOST units, and between BOOST units and site-designated control units. RESULTS The average rate of 30-day rehospitalization in BOOST units was 14.7% prior to implementation and 12.7% 12 months later (P = 0.010), reflecting an absolute reduction of 2% and a relative reduction of 13.6%. Rehospitalization rates for matched control units were 14.0% in the preintervention period and 14.1% in the postintervention period (P = 0.831). The mean absolute reduction in readmission rates in BOOST units compared to control units was 2.0% (P = 0.054 for signed rank test comparing differences in readmission rate reduction in BOOST units compared to site-matched control units). CONCLUSIONS Participation in Project BOOST appeared to be associated with a decrease in readmission rates. Journal of Hospital Medicine 2013;8:421–427. © 2013 Society of Hospital Medicine

Chronic disabling occupational musculoskeletal pain disorder (CDOMPD) patients often have high levels of somatization, a phenomenon in which somatic symptoms are medically unexplainable. Examination of 1,458 CDOMPD patients, who completed the patient health questionnaire (PHQ) somatization module from 2003 to 2010 and underwent functional restoration treatment, were divided into low, moderate, and high somatization at pretreatment. Somatization was highly responsive to treatment, and those with high somatization reported the highest depressive symptoms, disability, and pain intensity, and the lowest health-related quality of life at pre- and post-treatment. Somatization levels significantly predicted 1-year socioeconomic outcomes of work return, work retention, and healthcare utilization. High somatization may act as a “red flag” for clinicians, indicating patients may be at risk for poor treatment outcomes.

Diabet. Med. 29, 212–219 (2012) Abstract Aims In cohort studies, Type 2 diabetes mellitus has been associated with decreased forced 1 s expiratory volume and forced vital capacity. We examined if forced vital capacity, forced 1 s expiratory volume and diffusion lung capacity correlate with diabetes mellitus across different races in a clinical setting. Methods We examined the medical records of 19 882 adults 18–97 years of age in our centre from 1 January 2000 to 1 May 2009. After excluding patients with diseases causing abnormal lung function, 4164 subjects were available for analysis. We used multiple linear regressions to examine cross-sectional differences in forced vital capacity, forced 1 s expiratory volume and carbon monoxide diffusing capacity between patients with and without diabetes mellitus, after adjustment for age, age2, sex, race, height, height2, smoking, BMI and heart failure. Results Patients with diabetes (n = 560) were older (62 ± 12 vs. 55 ± 16 years), more likely to be men (56 vs. 43%), overweight (BMI 31.7 ± 8.5 vs. 27.3 ± 6.7 kg/m2), have heart failure (33 vs. 14%) and less likely to be Caucasians (65 vs. 76%) and never smokers (66 vs. 72%) compared with patients without diabetes (n = 3604). The mean unadjusted values in patients with diabetes vs. those without were: forced vital capacity 2.78 ± 0.91 vs. 3.19 ± 1.03 l; forced 1 s expiratory volume 2.17 ± 0.74 vs. 2.49 ± 0.0.83 l; and carbon monoxide diffusing capacity 16.67 ± 5.53 vs. 19.18 ± 6.72 ml−1 min−1 mmHg, all P

Background: The Pain Anxiety Symptoms Scale (PASS) was developed to measure fear and anxiety responses to pain. Many studies have found associations between PASS scores and self-report measures of pain, anxiety, and disability as well as among inhibited movement patterns and activity avoidance behaviors (eg, kinesophobia). This study aimed to identify clinically meaningful cut-off points to identify high or low levels of pain anxiety and to determine if the PASS provides additional useful information in a functional restoration (FR) treatment program for chronic disabling occupational musculoskeletal disorder (CDOMD) patients. Methods: A consecutive cohort of 551 patients with CDOMD, who entered and completed a FR program, was administered a battery of psychosocial assessments, including the PASS, at admission and discharge. Socioeconomic outcomes were collected 1 year after discharge. After identifying clinical ranges for mild, moderate, and severe pain anxiety, the three groups were compared on self-report measures of psychosocial distress, clinical diagnoses of psychosocial disorders, and 1-year socioeconomic outcomes. Results: Correlations between the PASS and all measures of pain, anxiety, and disability were statistically significant. However, only the Pain Disability Questionnaire showed a large correlation coefficient (r > 0.5). Patients with the highest PASS scores were more likely to be diagnosed with a number of Axis I (depression, opioid dependence) or Axis II (Borderline Personality) psychiatric disorders. They were more likely to display treatment-seeking behavior at 1 year after discharge. However, the PASS failed to differentiate between any other 1-year outcomes. Conclusions: The PASS is elevated when other measures of psychosocial distress are also elevated. However, the PASS fails to discriminate between different indices of depression and anxiety and it is not highly related to 1-year outcomes in a CDOMD cohort. If time and resources are limited, a different measure of psychosocial distress that does relate to socioeconomic outcomes might be a better option in a CDOMD evaluation process. Language: en

BACKGROUND: Collaborative and toolkit approaches have gained traction for improving quality in health care. OBJECTIVE: To determine if a quality improvement virtual collaborative intervention would perform better than a toolkit-only approach at preventing central line–associated bloodstream infections (CLABSIs) and ventilator-associated pneumonias (VAPs). DESIGN AND SETTING: Cluster randomized trial with the Intensive Care Units (ICUs) of 60 hospitals assigned to the Toolkit (n=29) or Virtual Collaborative (n=31) group from January 2006 through September 2007. MEASUREMENT: CLABSI and VAP rates. Follow-up survey on improvement interventions, toolkit utilization, and strategies for implementing improvement. RESULTS: A total of 83% of the Collaborative ICUs implemented all CLABSI interventions compared to 64% of those in the Toolkit group (P = 0.13), implemented daily catheter reviews more often (P = 0.04), and began this intervention sooner (P < 0.01). Eighty-six percent of the Collaborative group implemented the VAP bundle compared to 64% of the Toolkit group (P = 0.06). The CLABSI rate was 2.42 infections per 1000 catheter days at baseline and 2.73 at 18 months (P = 0.59). The VAP rate was 3.97 per 1000 ventilator days at baseline and 4.61 at 18 months (P = 0.50). Neither group improved outcomes over time; there was no differential performance between the 2 groups for either CLABSI rates (P = 0.71) or VAP rates (P = 0.80). CONCLUSION: The intensive collaborative approach outpaced the simpler toolkit approach in changing processes of care, but neither approach improved outcomes. Incorporating quality improvement methods, such as ICU checklists, into routine care processes is complex, highly context-dependent, and may take longer than 18 months to achieve. © Society of Hospital Medicine Journal of Hospital Medicine 2011

Preventable hospital readmission represents an increasingly prominent target in policy discussions aimed at reducing morbidity and cost in the U.S. health care system. Approximately one-fifth (19.6 percent) of Medicare fee-for-service beneficiaries will experience hospital readmission within 30 days of discharge (Jencks, Williams, and Coleman 2009). Up to three-quarters of these unplanned readmissions are potentially avoidable and are associated with an annual cost of U.S.$12 billion (MedPAC 2007). In response to these cost and quality implications, in July 2009 the Centers for Medicare and Medicaid Services (CMS) began reporting 30-day risk-standardized readmission rates as a measure of hospital quality (Keenan et al. 2008). This was likely a first step toward readmission rates becoming a standard indicator of inpatient and post-discharge quality of care and a metric for performance-based reimbursement (Epstein 2009). Reflecting a belief that hospital readmission is a function not only of patient morbidity but also of hospitals' management of safe transitions between the inpatient and the post-acute care setting, the Agency for Healthcare Research and Quality (AHRQ) and the National Quality Forum (NQF) have focused on the relationship between hospital readmission and patient safety (AHRQ 2009a, b; NQF 2009;). Worse performance on AHRQ's Patient Safety Indicators (PSIs) has been associated with higher readmission rates (Friedman et al. 2009). Modeled in part on Project RED (Re-Engineered Discharge) at Boston University Medical Center (Jack et al. 2009), NQF has designated evidence-based improvement in “discharge systems” as a requisite hospital practice in order to be considered “safe.” If the frequency of readmission reflects inadequate patient safety processes in the hospital, then hospitals with worse safety culture would be expected to exhibit higher levels of hospital readmission. To evaluate this supposition, we examined the relationship of a measure of hospital patient safety culture—hospital patient safety climate—and hospital readmission. We used data from a survey measuring safety climate in a national sample of hospitals and CMS risk-standardized measures of 30-day hospital readmission.

BACKGROUND: Hospitalists care for an increasing percentage of hospitalized patients, yet evaluations of patient perceptions of hospitalists' communication skills are lacking. OBJECTIVE: Assess hospitalist communication skills using the Communication Assessment Tool (CAT). METHODS: A cross-sectional study of patients, age 18 or older, admitted to the hospital medicine service at an urban, academic medical center with 873 beds. Thirty-five hospitalists assigned to both direct care and teaching service were assessed. MEASUREMENTS: Hospitalist communication was measured with the CAT. The 14-item survey, written at a fourth grade level, measures responses along a 5-point scale (“poor” to “excellent”). Scores are reported as a percentage of “excellent” responses. RESULTS: We analyzed 700 patient surveys (20 for each of 35 hospitalists). The proportion of excellent ratings for each hospitalist ranged from 38.5% to 73.5%, with an average of 59.1% excellent (SD=9.5). Highest ratings on individual CAT items were for treating the patient with respect, letting the patient talk without interruptions, and talking in terms the patient can understand. Lowest ratings were for involving the patient in decisions as much as he or she wanted, encouraging the patient to ask questions, and greeting the patient in a way that made him or her feel comfortable. Overall scale reliability was high (Cronbach's alpha = 0.97). CONCLUSIONS: The CAT can be used to gauge patient perceptions of hospitalist communication skills. Many hospitalists may benefit from targeted training to improve communication skills, particularly in the areas of encouraging questions and involving patients in decision making. Journal of Hospital Medicine 2010. © 2010 Society of Hospital Medicine.

Medication errors and adverse events caused by them are common during and after a hospitalization. The impact of these events on patient welfare and the financial burden, both to the patient and the healthcare system, are significant. In 2005, The Joint Commission put forth medication reconciliation as National Patient Safety Goal (NPSG) No. 8 in an effort to minimize adverse events caused during these types of care transitions. However, the meaningful and systematic implementation of medication reconciliation, as expressed through NPSG No. 8, proved to be extraordinarily difficult for healthcare institutions around the country. Given the importance of accurate and complete medication reconciliation for patient safety occurring across the continuum of care, the Society of Hospital Medicine convened a stakeholder conference in 2009 to begin to identify and address: (1) barriers to implementation; (2) opportunities to identify best practices surrounding medication reconciliation; (3) the role of partnerships among traditional healthcare sites and nonclinical and other community-based organizations; and (4) metrics for measuring the processes involved in medication reconciliation and their impact on preventing harm to patients. The focus of the conference was oriented toward medication reconciliation for a hospitalized patient population; however, many of the themes and concepts derived would also apply to other care settings. This paper highlights the key domains needing to be addressed and suggests first steps toward doing so. An overarching principle derived at the conference is that medication reconciliation should not be viewed as an accreditation function. It must, first and foremost, be recognized as an important element of patient safety. From this principle, the participants identified ten key areas requiring further attention in order to move medication reconciliation toward this focus. 1 There is need for a uniformly acceptable and accepted definition of what constitutes a medication and what processes are encompassed by reconciliation. Clarifying these terms is critical to ensuring more uniform impact of medication reconciliation. 2 The varying roles of the multidisciplinary participants in the reconciliation process must be clearly defined. These role definitions should include those of the patient and family/caregiver and must occur locally, taking into account the need for flexibility in design given the varying structures and resources at healthcare sites. 3 Measures of the reconciliation processes must be clinically meaningful (i.e., of defined benefit to the patient) and derived through consultation with stakeholder groups. Those measures to be reported for national benchmarking and accreditation should be limited in number and clinically meaningful. 4 While a comprehensive reconciliation system is needed across the continuum of care, a phased approach to implementation, allowing it to start slowly and be tailored to local organizational structures and work flows, will increase the chances of successful organizational uptake. 5 Developing mechanisms for prospectively and proactively identifying patients at risk for medication-related adverse events and failed reconciliation is needed. Such an alert system would help maintain vigilance toward these patient safety issues and help focus additional resources on high risk patients. 6 Given the diversity in medication reconciliation practices, research aimed at identifying effective processes is important and should be funded with national resources. Funding should include varying sites of care (e.g., urban and rural, academic and nonacademic, etc.). 7 Strategies for medication reconciliation-both successes and key lessons learned from unsuccessful efforts-should be widely disseminated. 8 A personal health record that is integrated and easily transferable between sites of care is needed to facilitate successful medication reconciliation. 9 Partnerships between healthcare organizations and community-based organizations create opportunities to reinforce medication safety principles outside the traditional clinician-patient relationship. Leveraging the influence of these organizations and other social networking platforms may augment population-based understanding of their importance and role in medication safety. 10 Aligning healthcare payment structures with medication safety goals is critical to ensure allocation of adequate resources to design and implement effective medication reconciliation processes. Medication reconciliation is complex and made more complicated by the disjointed nature of the American healthcare system. Addressing these ten points with an overarching goal of focusing on patient safety rather than accreditation should result in improvements in medication reconciliation and the health of patients.

BACKGROUND: Time studies, first developed in the late 19th century, are now being used to evaluate and improve worker efficiency in the hospital setting. This is the first review of hospital time study literature of which we are aware. PURPOSE: We performed a systematic review of the literature to better understand the available time study literature describing the activities of hospital physicians. DATA SOURCES: We searched MEDLINE, EMBASE, EMBASE Classic, PsycINFO, Cochrane Library, CINAHL, and Web of Science. We also manually reviewed the reference lists of retrieved articles and consulted experts in the field to identify additional articles for review. STUDY SELECTION: We selected studies that used time-motion or work-sampling performed via direct observation, included physicians, medical residents, or interns in their study population, and were performed on an inpatient hospital ward. DATA EXTRACTION: We abstracted data on subject population, study site, collection tools, and percentage of time spent on key categories of activity. DATA SYNTHESIS: Our search produced 11 time-motion and 2 work-sampling studies that met our criteria. These studies focused primarily on academic hospitals (92%) and the activities of physicians in training (69%). Other results varied widely. A lack of methodological standardization and dissimilar activity categorizations inhibited our efforts to summarize detailed findings across studies. However, we consistently found that activities indirectly related to a patient's care took more of hospital physicians' time than direct interaction with hospitalized patients. CONCLUSIONS: Time studies, when properly performed, have a great deal to offer in helping us understand and reengineer hospital care. Journal of Hospital Medicine 2010;5:353–359. © 2010 Society of Hospital Medicine.

BACKGROUND: The status of implementation of medication reconciliation across hospitals is variable to date; the degree to which hospitalists are involved is not known. METHODS: To better describe the current state of medication reconciliation implementation, we conducted a survey of attendees of the 2006 Society of Hospital Medicine national meeting. RESULTS: We identified a lack of uniformity across hospitals with respect to the degree of process implementation. Hospitalists were involved in design and implementation in a majority of cases, and felt that medication reconciliation would likely have a positive impact on patient safety. Tertiary care academic centers were more likely to use physicians to perform medication reconciliation, whereas community hospitals were more likely to involve nurses as well. Pharmacist participation in the medication reconciliation process was found to be quite low. Process and outcome measures were used infrequently. Patients' lack of medication knowledge and absence of preadmission medication information were cited most frequently as barriers to implementation of medication reconciliation. CONCLUSIONS: Implementation of medication reconciliation is complex and challenging. Medication information is often incomplete, and elements of the medication reconciliation process result in increased time demands on providers. Current implementation efforts often have physicians and nurses “share” responsibility for compliance, and pharmacists are underutilized in medication reconciliation processes. Hospitalists have thus far played a substantial role in process design and implementation, and should continue to lead the way in advancing efforts to successfully implement medication reconciliation. © 2008 Society of Hospital Medicine. Journal of Hospital Medicine 2008;3(6):465–472. © 2008 Societyof Hospital Medicine.

BACKGROUND: Ventilator-associated pneumonia (VAP) is widely recognized as a serious and common complication associated with high morbidity and high costs. Given the complexity of caring for heterogeneous populations in the intensive care unit (ICU), however, there is still uncertainty regarding how to diagnose and manage VAP. OBJECTIVE: We recently conducted a national collaborative aimed at reducing health care–associated infections in ICUs of hospitals operated by the Hospital Corporation of America (HCA). As part of this collaborative, we developed algorithms for diagnosing and treating VAP in mechanically ventilated patients. In the current article, we (1) review the current evidence for diagnosing VAP, (2) describe our approach for developing these algorithms, and (3) illustrate the utility of the diagnostic algorithms using clinical teaching cases. DESIGN: This was a descriptive study, using data from a national collaborative focused on reducing VAP and catheter-related bloodstream infections. SETTING: The setting of the study was 110 ICUs at 61 HCA hospitals. INTERVENTION: None. MEASUREMENTS AND RESULTS: We assembled an interdisciplinary team that included infectious disease specialists, intensivists, hospitalists, statisticians, critical care nurses, and pharmacists. After reviewing published studies and the Centers for Disease Control and Prevention VAP guidelines, the team iteratively discussed the evidence, achieved consensus, and ultimately developed these practical algorithms. The diagnostic algorithms address infant, pediatric, immunocompromised, and adult ICU patients. CONCLUSIONS: We present practical algorithms for diagnosing and managing VAP in mechanically ventilated patients. These algorithms may provide evidence-based real-time guidance to clinicians seeking a standardized approach to diagnosing and managing this challenging problem. Journal of Hospital Medicine 2008;3:409–422. © 2008 Society of Hospital Medicine.

Non–housestaff medicine services are growing rapidly in academic medical centers (AMCs), partly driven by efforts to comply with resident duty hour restrictions. Hospitalists have emerged as a solution to providing these services given their commitment to delivering efficient and high-quality care and the field's rapid growth. However, limited evidence is available on designing these services, including the similarities and differences of existing ones. We describe non–housestaff medicine services at 5 AMCs in order to share our experiences and outline important considerations in service development. We discuss common challenges in building and sustaining these models along with local institutional factors that affect decision making. Keys to success include ensuring an equitable system for scheduling and staffing, fostering opportunities for scholarly activities and academic promotion (defining the “academic hospitalist”), and providing compensation that supports recruitment and retention of hospitalists. With further work hour restrictions expected in the future and increased requests for surgical comanagement, the relationship between AMCs and hospitalists will continue to evolve. To succeed in developing hospitalist faculty who follow long careers in hospital medicine, academic leadership must carefully plan for and evaluate the methods of providing these clinical services while expanding on our academic mission. Journal of Hospital Medicine 2008;3:247–255. © 2008 Society of Hospital Medicine.

Issues related to measuring outcomes of care in geriatric evaluation and management (GEM) units were identified by the outcomes working group of the GEM evaluation conference. GEM units have as a major goal the improvement or maintenance of both physical and psychosocial function. Suggested outcome measures for physical health included survival, restricted activity days, general health perceptions, comprehensive physical function, and miscellaneous specific types of functioning. In the area of psycho-social function, the working group suggested measuring cognitive function, affect/life satisfaction, social function, and satisfaction with care. The patient's caregiver (eg, spouse or child) is often an important target of GEM care, and the group suggested measuring caregiver burden, life satisfaction, and assessment of patient behavior problems. While the primary goal of GEM units is to improve health status, their effects on the utilization and cost of health care are important to decisions about wide-spread implementation and funding. The group therefore suggested a comprehensive assessment of these outcomes. Among the large array of recommended outcomes, the most important were thought to be mortality, function, and cost.

The American Society of Health-System Pharmacists (ASHP) and the Society for Hospital Medicine (SHM) believe that the rapidly emerging hospitalist model of inpatient care offers new and significant opportunities to optimize patient care through collaboration among hospitalists, hospital pharmacists