Jason Stein
Internist and Hospitalist
Emory University Hospital
“What I like about hospital medicine is there’s a whole lot of opportunity to put a little structure and framework around that chaos.” (1:31)
My name is Jason Stein. I’m an internist and a hospitalist and I’ve been in practice for six years. I work at Emory University Hospital and I’m a member of the Society of Hospital Medicine. About two-thirds of my time I spend taking care of patients in the hospital. So as a hospitalist all of my care is with acutely ill patients in the hospital. So, my office is the nursing unit. My co-workers are nurses and other physicians and physical therapists, pharmacists, dieticians, social workers, and occupational therapists.
In terms of patient care it’s very personal. You’re really interacting with patients when they’re at their sickest, and it’s a vulnerable time but it’s also a deeply personal time, and folks, I think, who migrate to hospital medicine are folks who are comfortable with other people and those vulnerable conditions. Hey, that describes any physician or any health care professional. But there’s an excitement to working in an acute care setting.
It’s chaotic, and what I like about hospital medicine is there’s a whole lot of opportunity to put a little structure and framework around that chaos. Things are so tough right now in terms of streamlining care; that’s why not every one of my colleagues, but a significant plurality of them, are coming to hospital medicine. They recognize during residency that they are working in a system that makes them mad when they drive home at night, and they want to come to work and get where they can do something to improve the care that’s delivered there.
“They’re the group that will naturally help navigate the tension that happens in the waters between continuity and change.” (1:03)
The hospitalists are natural leaders on their nursing unit; they’re the clinician leaders. When things are going bad on a nursing unit, they’re looked on to help in a rescue situation — the most extreme example is a patient who is arresting. We are privileged enough to occupy this tacit position of being called boss. Nobody calls us boss, but that’s the way that the dynamic feels on the nursing unit. They tend to develop, if they don’t already have it, a skill set in communication. They’ll also be the folks who come up with ideas for change and veto the bad ones and try to work on refining the good ones, in age-old ways of Plan, Do, Study, Act.
They’re also the group that will naturally help navigate the tension that happens in the waters between continuity and change. And so much of quality improvement is change and managing change, and refining it over time. It’s going to take somebody with a little bit of credibility in terms of clinical care delivery, but also in terms of quality improvement, or leadership skill set to help navigate that tension.
“In most settings you’ve got a volunteer physician leader who has some sort of quality improvement skill set trying to make the best of the situation.” (1:43)
The barriers are not where you might think; they really fall into two categories. One barrier is just the simply the skill set ― how to lead and manage change. What’s the art and science behind health care quality improvement from concepts like standardization with protocols to strategies to find out outliers for good care and remedy those in real time? What’s the skill set that allows you to develop a performance tracking system and how do you manage the data and collect it and look at it and analyze it? These are all skill sets that are not part of traditional residency training in any specialty, medicine and all the surgical subspecialties. They are, now, part of the ACGME [Accreditation Council for Graduate Medical Education] core curriculum requirements ― systems-based care and problem practice-based learning are the fifth and sixth core curricular elements for anybody going through residency and fellowship training. But having had many conversations with residency program directors and fellowship program directors, those are core competencies actually that are elusive — nobody really knows how to teach those.
That’s a problem, the skill set. The Society of Hospital Medicine actually is doing phenomenal work in terms of trying to create that body of knowledge and method of teaching it. The other barrier is the relative under-resourcing of the work that needs to be done. What I mean by that is that in most settings you’ve got a volunteer physician leader who has some sort of quality improvement skill set trying to make the best of the situation, without any dedicated time or support staff to make it happen ― almost invariably without the IT information technology elements that are so, so helpful to doing this well from the actual performance improvement to performance tracking.
“It’s at the level of the patient and provider that better care is delivered.” (0:49)
If there was a physician leader on every nursing unit who had a quality improvement skill set and also a little bit of time and resources to make things go, we could really move into hyperspace in terms of what we can do on the ground. Hey, it’s at the level of the patient and provider that better care is delivered. It doesn’t really happen anywhere else. The rest of the environment, from the federal and regulatory climate to the governance and the mission statement of the medical center and the board, to the executive suite and the chairs and the chiefs of departments and divisions — all those ingredients have to be in place and there has to be alignment from the top on down, but at the end of the day, there has to be the skill set and the resourcing of that physician leader in that clinical area to make things happen.
“By 2010, I would wager that in most hospitals, whether or not there’s an awareness of IHI, there will be a skill set in many of the clinicians there.” (0:56)
If we were able to write the history of health care quality improvement, in America anyway, the first ten years of the 21st century will show that the role for the conduct of quality improvement finally was able to shift closer to the front line and involved the physicians and nurses who deliver the care. I think we’re just now kind of getting there. And this is just based on conversations with clinician leaders who are in the trenches. By 2010, I would wager that in most hospitals, whether or not there’s an awareness of IHI, there will be a skill set in many of the clinicians there. If they know enough to thank IHI and the two decades of prework that went into this and all the intelligence and experience that grew up around the organizations that take part in the IHI network, they would say “thanks,” but my sense is it won’t matter by that point.
07/16/2008
