Showing papers by "Kevin J. O'Leary published in 2017"

Hospital-based clinicians’ use of technology for patient care-related communication: A national survey

Abstract: Objective To characterize current use of communication technologies, including standard text messaging and secure mobile messaging applications, for patient care-related (PCR) communication. Methods We used a Society of Hospital Medicine database to conduct a national cross-sectional survey of hospital-based clinicians. Results We analyzed data from 620 survey respondents (adjusted response rate, 11.0%). Pagers were provided by hospitals to 495 (79.8%) of these clinicians, and 304 (49%) of the 620 reported they received PCR messages most commonly by pager. Use of standard text messaging for PCR communication was common, with 300 (52.9%) of 567 clinicians reporting receipt of standard text messages once or more per day. Overall, 21.5% (122/567) of respondents received standard text messages that included individually identifiable information, 41.3% (234/567) received messages that included some identifiable information (eg, patient initials), and 21.0% (119/567) received messages for urgent clinical issues at least once per day. About one-fourth of respondents (26.6%, 146/549) reported their organization had implemented a secure messaging application that some clinicians were using, whereas few (7.3%, 40/549) reported their organization had implemented an application that most clinicians were using. Discussion Pagers remain the technology most commonly used by hospital-based clinicians, but a majority also use standard text messaging for PCR communication, and relatively few hospitals have fully implemented secure mobile messaging applications. Conclusion The wide range of technologies used suggests an evolution of methods to support communication among healthcare professionals.

Differences in Routine Laboratory Ordering Between a Teaching Service and a Hospitalist Service at a Single Academic Medical Center.

Abstract: OBJECTIVES Studies have shown that the overutilization of laboratory tests ("labs") for hospitalized patients is common and can cause adverse health outcomes. Our objective was to compare the ordering tendencies for routine complete blood counts (CBC) and chemistry panels by internal medicine residents and hospitalists. METHODS This observational study included a survey of medicine residents and hospitalists and a retrospective analysis of labs ordering data. The retrospective data analysis comprised patients admitted to either the teaching service or nonteaching hospitalist service at a single hospital during 2014. The survey asked residents and hospitalists about their practices and preferences on labs ordering. The frequency and timing of one-time and daily CBC and basic chemistry panel ordering for teaching service and hospitalist patients were obtained from our data warehouse. The average number of CBCs per patient per day and chemistry panels per patient per day was calculated for both services and multivariate regression was performed to control for patient characteristics. RESULTS Forty-four of 120 (37%) residents and 41 of 53 (77%) hospitalists responded to the survey. Forty-four (100%) residents reported ordering a daily CBC and chemistry panel rather than one-time labs at patient admission compared with 22 (54%) hospitalists (P < 0.001). For CBCs, teaching service patients averaged 1.72/day and hospitalist service patients averaged 1.43/day (P < 0.001). For basic chemistry panels, teaching service patients averaged 1.96/day and hospitalist service patients averaged 1.78/day (P < 0.001). Results were similar in multivariate regression models adjusting for patient characteristics. CONCLUSIONS Residents' self-reported and actual use of CBCs and chemistry panels is significantly higher than that of hospitalists in the same hospital. Our results reveal an opportunity for greater supervision and improved instruction of cost-conscious ordering practices.

Evaluation of a novel mentor program to improve surgical care for US hospitals.

Abstract: Objective To evaluate a novel mentor program for 27 US surgeons, charged with improving quality at their respective hospitals, having been paired 1:1 with 27 surgeon mentors through a state-wide quality improvement (QI) initiative. Design Mixed-methods utilizing quantitative surveys and in-depth semi-structured interviews. Setting The Illinois Surgical Quality Improvement Collaborative (ISQIC) utilized a novel Mentor Program to guide surgeons new to QI. Participants All mentor-mentee pairs received the survey (n = 27). Purposive sampling identified a subset of mentors (n = 8) and mentees (n = 4) for in-depth semi-structured interviews. Intervention Surgeons with expertise in QI mentored surgeons new to QI. Main outcome measures (i) Quantitative: self-reported satisfaction with the mentor program; (ii) Qualitative: key themes suggesting actions and strategies to facilitate mentorship in QI. Results Mentees expressed satisfaction with the mentor program (n = 24, 88.9%) and agreed that mentorship is vital to ISQIC (n = 24, 88.9%). Analysis of interview data revealed four key themes: (i) nuances of data management, (ii) culture of quality and safety, (iii) mentor-mentee relationship and (iv) logistics. Strategies from these key themes include: utilize raw data for in-depth QI understanding, facilitate presentations to build QI support, identify opportunities for in-person meetings and establish scheduled conference calls. The mentor's role required sharing experiences and acting as a resource. The mentee's role required actively bringing questions and identifying barriers. Conclusions Mentorship plays a vital role in advancing surgeon knowledge and engagement with QI in ISQIC. Key themes in mentorship reflect strategies to best facilitate mentorship, which may serve as a guide to other collaboratives.

Impact of a Video-Based Interactive Workshop on Unprofessional Behaviors Among Internal Medicine Residents

Abstract: Background Unprofessional behaviors undermine the hospital learning environment and the quality of patient care. Objective To assess the impact of an interactive workshop on the perceptions of and self-reported participation in unprofessional behaviors. Methods We conducted a pre-post survey study at 3 internal medicine residency programs. For the workshop we identified unprofessional behaviors related to on-call etiquette: “blocking” an admission, disparaging a colleague, and misrepresenting a test as urgent. Formal debriefing tools were utilized to guide the discussion. We fielded an internally developed 20-item survey on perception and participation in unprofessional behaviors prior to the workshop. An online “booster” quiz was delivered at 4 months postworkshop, and the 20-item survey was repeated at 9 months postworkshop. Results were compared to a previously published control from the same institutions, which showed that perceptions of unprofessional behavior did not change and participa...

Inpatient notes: Sensemaking - Fostering a shared understanding in clinical teams

Abstract: A growing literature focuses on teams and teamwork in health care, noting the importance of relationships, communication, and coordination; however, it is surprisingly mixed in terms of the associa...

Reducing Routine Labs-Teaching Residents Restraint.

Abstract: Inappropriate resource utilization is a pervasive problem in healthcare, and it has received increasing emphasis over the last few years as financial strain on the healthcare system has grown. This waste has led to new models of care—bundled care payments, accountable care organizations, and merit-based payment systems. Professional organizations have also emphasized the provision of high-value care and avoiding unnecessary diagnostic testing and treatment. In April 2012, the American Board of Internal Medicine (ABIM) launched the Choosing Wisely initiative to assist professional societies in putting forth recommendations on clinical circumstances in which particular tests and procedures should be avoided. Until recently, teaching cost-effective care was not widely considered an important part of internal medicine residency programs. In a 2010 study surveying residents about resource utilization feedback, only 37% of internal medicine residents reported receiving any feedback on resource utilization and 20% reported receiving regular feedback.1 These findings are especially significant in the broader context of national healthcare spending, as there is evidence that physicians who train in high-spending localities tend to have high-spending patterns later in their careers.2 Another study showed similar findings when looking at region of training relative to success at recognizing high-value care on ABIM test questions.3 The Accreditation Council for Graduate Medical Education has developed the Clinical Learning Environment Review program to help address this need. This program provides feedback to teaching hospitals about their success at teaching residents and fellows to provide high-value medical care. Given the current zeitgeist of emphasizing cost-effective, high-value care, appropriate utilization of routine labs is one area that stands out as an especially low-hanging fruit. The Society of Hospital Medicine, as part of the Choosing Wisely campaign, recommended minimizing routine lab draws in hospitalized patients with clinical and laboratory stability.4 Certainly, avoiding unnecessary routine lab draws is ideal because it saves patients the pain of superfluous phlebotomy, allows phlebotomy resources to be directed to blood draws with actual clinical utility, and saves money. There is also good evidence that hospital-acquired anemia, an effect of overuse of routine blood draws, has an adverse impact on morbidity and mortality in postmyocardial infarction patients5,6 and more generally in hospitalized patients.7 Several studies have examined lab utilization on teaching services. Not surprisingly, the vast majority of test utilization is attributable to the interns (45%) and residents (26%), rather than attendings.8 Another study showed that internal medicine residents at one center had a much stronger self-reported predilection for ordering daily recurring routine labs rather than one-time labs for the following morning when admitting patients and when picking up patients, as compared with hospitalist attendings.9 This self-reported tendency translated into ordering more complete blood counts and basic chemistry panels per patient per day. A qualitative study looking at why internal medicine and general surgery residents ordered unnecessary labs yielded a number of responses, including ingrained habit, lack of price transparency, clinical uncertainty, belief that the attending expected it, and absence of a culture emphasizing resource utilization.10 In this issue of the Journal of Hospital Medicine, Kurtzman and colleagues report on a mixed-methods study looking at internal medicine resident engagement at their center with an electronic medical record–associated dashboard providing feedback on lab utilization.11 Over a 6-month period, the residents randomized into the dashboard group received weekly e-mails while on service with a brief synopsis of their lab utilization relative to their peers and also a link to a dashboard with a time-series display of their relative lab ordering. While the majority of residents (74%) opened the e-mail, only a minority (21%) actually accessed the dashboard. Also, there was not a statistically significant relationship between dashboard use and lab ordering, though there was a trend to decreased lab ordering associated with opening the dashboard. The residents who participated in a focus group expressed both positive and negative opinions on the dashboard. This is one example of social comparison feedback, which aims to improve performance by providing information to physicians on their performance relative to their peers. It has been shown to be effective in other areas of clinical medicine like limiting antibiotic overutilization in patients with upper respiratory infections.12 One study examining social comparison feedback and objective feedback found that social comparison feedback improved performance for a simulated work task more for high performers but less for low performers than standard objective feedback.13 The utility of this type of feedback has not been extensively studied in healthcare. *Address for correspondence and reprint requests: Michael I. Ellenbogen, MD, Hospitalist Program, Division of General Internal Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland; Telephone: 443-287-4362; Fax: 410502-0923; E-mail: mellenb6@jhmi.edu

Collaboration, Interruptions and Changeover Times: Model and Empirical Study of Hospitalist Processing Times

Abstract: Collaboration is important in services, but may lead to interruptions. Professionals exercise discretion on whether to preempt individual tasks to switch to collaborative tasks. Task switching can introduce setup times, often mental and unobservable, when resuming the preempted task and thus can increase workload.We analyze and quantify how collaboration, through interruptions and setup times, affects workload. We introduce an episodal workflow model that captures the interruption dynamics — each switch and the episode of work it preempts — present in settings where collaboration and multitasking is paramount. We then deploy the model in a field study of hospital medicine physicians — “hospitalists.” A hospitalist’s patient-care routine includes visiting patients and consulting with other caregivers to guide patient diagnosis and treatment.A rigorous empirical analysis is presented using a dataset assembled from direct observation of physician activity and pager-log data. We estimate that a hospitalist incurs a total setup time of 5min per patient per day, which represents a significant 20% of the workload: caring for 14 patients per day, a hospitalist spends more than one hour each day on setups. Switches causally lead to longer documentation time in general but the magnitude of the effect depends on the trigger: when the switch is triggered by the hospitalist the setup time is smaller.