From the 2023 HVPA National Conference
Michelle Knees DO (University of Colorado Anschutz Medical Campus), Andrew Berry MD (Rocky Mountain Regional VA Medical Center; University of Colorado Anschutz Medical Campus), Mel Anderson MD
Although many institutions have hospitalist metric tracking systems, the purposes of these reports are variable. Review of the relevant literature reveals a trend toward using metrics to identify physician outliers in readmissions or other performance-based metrics, to help guide physician performance feedback, and to inform institutional-level understanding of hospitalist divisions. However, most hospitalists receive minimal patient-specific feedback from their time on service and only discover specific readmissions or out-of-hospital deaths if they have a self-initiated patient tracking system. This leads to difficulty identifying personal knowledge or practice deficits, as well as difficulty in identifying systems-level problems. Additionally, hospitalists report concerns about attribution of patient metrics to only the discharging physician and feel that certain metrics, such as length-of-stay or some readmissions, are outside of their control. The effect of personalized, patient-specific reports on hospitalist performance patterns and burnout remains unknown.
This project sought to create a safe and confidential report at the Rocky Mountain Regional VA Medical Center which would empower hospitalists to understand metrics which are tracked at a hospital level while also allowing them to access individual patient data which has more clinically significant meaning. A novel “Hospitalist Reflection Report,” in which hospitalists were provided monthly confidential feedback about their time on service, including CMI, OMELOS, and discharges per week, was created in November 2021.
Hospitalists were also given group averages for these metrics to better inform comparisons over time. Most importantly, however, they were given patient names and identifiers for their 30-day readmissions and out-of-hospital patient deaths. In addition to patient information, hospitalists were encouraged to chart review any unexpected outcomes and were given prompts to guide them through how to think about readmissions and deaths in a way which promotes self-reflection, identification of possible practice-changing habits, and identification of possible systems-level problems. Additionally, hospitalists had the chance to discuss their findings in a monthly group session which focused on promoting wins as well as a discussion of errors to normalize mistakes while still advocating for continual improvement.
Hospitalist attitudes about metric tracking were analyzed via survey pre-and post-project implementation from October 2021 to February 2022. Pre-implementation, 33% of respondents worried that the metrics might be used punitively but few hospitalists felt that the reports would worsen their burnout. Most hospitalists also thought that these reports would improve their patient care and wanted a safe venue in which to discuss their reports. Post-report survey results showed a positive trend in hospitalist-perceived importance of CMI, OMELOS, and throughput, as well as readmissions and deaths. Hospitalists also had decreased concerns about the impact of metrics. This project was successful enough that it is now being scaled to several other national VA hospitalist groups.