Hospitalists as Safety Intervention

Tuesday, December 5, 200612:00 – 1:00 p.m. Eastern Time

Moderator: Christopher Landrigan, MD, MPH, FAAPPediatric Hospitalist / Research & Fellowship DirectorChildren’s Hospital Boston, Inpatient Pediatrics

ServiceBoston, Massachusetts

This activity was funded through an educational grant from the

Physicians’ Foundation for Health Systems Excellence.

Disclosure of Financial Relationships and Resolution of Conflicts of Interest for AAP CME Activities Grid

The AAP CME program aims to develop, maintain, and increase the competency, skills, and professional performance of pediatric healthcare professionals by providing high quality, relevant, accessible and cost-effective educational experiences. The AAP CME program provides activities to meet the participants’ identified education needs and to support their lifelong learning towards a goal of improving care for children and families (AAP CME Program Mission Statement, August 2004).

The AAP recognizes that there are a variety of financial relationships between individuals and commercial interests that require review to identify possible conflicts of interest in a CME activity. The “AAP Policy on Disclosure of Financial Relationships and Resolution of Conflicts of Interest for AAP CME Activities” is designed to ensure quality, objective, balanced, and scientifically rigorous AAP CME activities by identifying and resolving all potential conflicts of interest prior to the confirmation of service of those in a position to influence and/or control CME content. The AAP has taken steps to resolve any potential conflicts of interest.

All AAP CME activities will strictly adhere to the 2004 Updated Accreditation Council for Continuing Medical Education (ACCME) Standards for Commercial Support: Standards to Ensure the Independence of CME Activities. In accordance with these Standards, the following decisions will be made free of the control of a commercial interest: identification of CME needs, determination of educational objectives, selection and presentation of content, selection of all persons and organizations that will be in a position to control the content, selection of educational methods, and evaluation of the CME activity.

The purpose of this policy is to ensure all potential conflicts of interest are identified and mechanisms to resolve them prior to the CME activity are implemented in ways that are consistent with the public good. The AAP is committed to providing learners with commercially unbiased CME activities.

DISCLOSURESActivity Title: Safer Health Care for Kids - Webinar Hospitalists as Safety Intervention Activity Date: December 5, 2006

DISCLOSURE OF FINANCIAL RELATIONSHIPS All individuals in a position to influence and/or control the content of AAP CME activities are required to disclose to the AAP and subsequently to learners that the individual either has no relevant financial relationships or any financial relationships with the manufacturer(s) of any commercial product(s) and/or provider of commercial services discussed in CME activities.

Name Name of Commercial Interest(s)*

(*Entity producing

health care goods

or services)

Nature of Relevant Financial

Relationship(s) (If yes, please list: Research Grant,

Speaker’s Bureau, Stock/Bonds

excluding mutual funds, Consultant,

Other - identify)

CME Content Will Include

Discussion/ Reference to Commercial

Products/Services

Disclosure of Off-Label (Unapproved)/Investigational Uses of Products

AAP CME faculty are required to disclose to the AAP and to learners when they plan to discuss or

demonstrate pharmaceuticals and/or medical devices that are not approved

Jack M. Percelay, MD, MPH, FAAP

No No No No

Erin R. Stucky, MD, FAAP

No No No No

DISCLOSURESSAFER HEALTH CARE FOR KIDS - PROJECT ADVISORY COMMITTEE AND STAFF DISCLOSURE OF FINANCIAL RELATIONSHIPS All individuals in a position to influence and/or control the content of AAP CME activities are required to disclose to the AAP and subsequently to learners that the individual either has no relevant financial relationships or any financial relationships with the manufacturer(s) of any commercial product(s) and/or provider of commercial services discussed in CME activities.

Name Name of Commercial Interest(s)*

(*Entity producing health care goods

or services)

Nature of Relevant Financial Relationship(s)

(If yes, please list: Research Grant, Speaker’s

Bureau, Stock/Bonds excluding mutual funds,

Consultant, Other - identify)

CME Content Will Include Discussion/

Reference to Commercial Products/Services

Disclosure of Off-Label (Unapproved)/Investigational Uses

of Products AAP CME faculty are required to

disclose to the AAP and to learners when they plan to discuss or

demonstrate pharmaceuticals and/or medical devices that are not approved

Karen Frush, MD, FAAP (PAC Member)

No No No No

Uma Kotagal, MD, MBBS, MSc, FAAP (PAC Member)

No No No No

Christopher Landrigan, MD, MPH, FAAP (PAC Member)

No No No No

Marlene R. Miller, MD, MSc, FAAP (PAC Chair)

No No No No

Paul Sharek, MD, MPH. FAAP (PAC Member)

No No No No

Erin Stucky, MD, FAAP (PAC Member)

No No Not sure No

Nancy Nelson (AAP Staff) No No No No

Melissa Singleton, MEd (Project Manager – AAP Consultant)

No No No No

Junelle Speller (AAP Staff) No No No No

Linda Walsh, MAB (AAP Staff)

No No No No

DISCLOSURESAAP COMMITTEE ON CONTINUING MEDICAL EDUCATION (COCME) DISCLOSURE OF FINANCIAL RELATIONSHIPS All individuals in a position to influence and/or control the content of AAP CME activities are required to disclose to the AAP and subsequently to learners that the individual either has no relevant financial relationships or any financial relationships with the manufacturer(s) of any commercial product(s) and/or provider of commercial services discussed in CME activities.

Name Name of Commercial Interest(s)*

(*Entity producing health care goods

or services)

Nature of Relevant Financial Relationship(s)

(If yes, please list: Research Grant, Speaker’s

Bureau, Stock/Bonds excluding mutual funds,

Consultant, Other - identify)

CME Content Will Include Discussion/

Reference to Commercial Products/Services

Disclosure of Off-Label (Unapproved)/Investigational Uses

of Products AAP CME faculty are required to

disclose to the AAP and to learners when they plan to discuss or

demonstrate pharmaceuticals and/or medical devices that are not approved

Ellen Buerk, MD, FAAP

No No No No

Meg Fisher, MD, FAAP

No No No No

Robert A. Wiebe, MD, FAAP

No No Not sure No

Jack Dolcourt, MD, FAAP

No No No No

Thomas W. Pendergrass, MD, FAAP

No No No No

Beverly P. Wood, MD, FAAP No No No No

CME CREDIT

The American Academy of Pediatrics (AAP) is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

 The AAP designates this educational activity for a

maximum of 1.0 AMA PRA Category 1 Credit™. Physicians should only claim credit commensurate with the extent of their participation in the activity.

 This activity is acceptable for up to 1.0 AAP credit.

This credit can be applied toward the AAP CME/CPD Award available to Fellows and Candidate Fellows of the American Academy of Pediatrics.

OTHER CREDIT

This webinar is approved by the National Association of Pediatric Nurse Practitioners (NAPNAP) for 1.2 NAPNAP contact hours of which 0.0 contain pharmacology (Rx) content. The AAP is designated as Agency #17. Upon completion of the program, each participant desiring NAPNAP contact hours should send a completed certificate of attendance, along with the required recording fee ($10 for NAPNAP members, $15 for nonmembers), to the NAPNAP National Office at 20 Brace Road, Suite 200, Cherry Hill, NJ 08034-2633.

 The American Academy of Physician Assistants

accepts AMA PRA Category 1 Credit(s)TM from organizations accredited by the ACCME .

Jack M. Percelay, MD, MPH, FAAPPediatric HospitalistHunterdon Medical CenterFlemington, New Jersey

Erin R. Stucky, MD, FAAPPediatric HospitalistChildren’s Specialists of San DiegoRady Children’s HospitalSan Diego, California

Hospitalists as Safety Intervention

Jack Percelay MD, MPH, FAAPErin Stucky MD, FAAP

AAP Safer Health Care for Kids Webinar

December 5, 2006

Disclosures

• Dr Erin Stucky does in fact have a time twizzler just like Hermione Granger and that is how she is able to accomplish so much in so little time

• Dr Jack Percelay is significantly taller than Erin Stucky

What we will cover today

Participants shall be able to:• a. List key resources and personnel to

establish a pediatric patient safety program in a community hospital.

• b. Name key hospital committees and (medical staff) department relationships through which the hospitalist can effect patient safety changes.

• c. Identify specific patient safety targets for pediatric hospitalists in community and children's hospitals.

Wachter NEJM OriginalDefinition of Hospitalist

• “Hospitalists are physicians who spend more than 25% of their time based in a hospital setting, where they serve as Physicians-of-record after accepting “hand-offs” of hospitalized patients from primary care physicians, returning those patients to the care of the primary care physicians at the time of hospital discharge.”

Society of Hospital Medicine

Current Definition of Hospitalist• “Physicians whose primary professional focus

is the general medical care of hospitalized patients. Their activities include patient care, teaching, research, and leadership related to hospital care.”

Key Features of Definition

• Hospital is exclusive work environment

• Commitment to systems improvement• Communication, communication,

communication • Implicit risk of the handoff• Multiple roles besides purely clinical

care

SHM ProjectionsNumber of Hospitalists

AAP Section on Hospital Medicine – October 1998 75 members– October, 2006 670 members

AAP Guiding Principles for Pediatric Hospitalist

Programs 1 Voluntary referrals.

2 Designed for Local Needs3 BC/BE pediatric equivalent training4 Include appropriate follow-up5 Timely and complete communication6 Data collection

Pediatrics, April 2005

Community HospitalistsMany of these points will also apply to the

Children’s Hospitalist

Multiple Hospitalist RolesMultiple Opportunities

• Pediatric ward – teaching residents• Nursery • NICU and PICU• Emergency Department• Hospital services – radiology,

sedation • Clinical partners – nursing,

respiratory therapy, pharmacy

Ingredients for a Successful Hospitalist/Hospitalist

Program • Clinical acumen and communication

skills • Broad systems interest• Lead by example• Shared quality and outcome goals,

not just revenue• Job description, compensation,

career advancement linked to performance improvement

Hospital RelationshipsInstitutional Leadership

• In community hospital, hospitalist is often the physician leader for pediatrics

• Department chair may be office based

• Unlikely to have pediatric ER• Neonatology often present, rarely

involved with ward

Hospital RelationshipsKey Contacts for Pediatric

Advocacy • VP of Medical Affairs• Patient Safety Officer• Department of Pediatrics Chair• Pharmacy, Radiology and Laboratory• Nurse Manager, VP of Nursing• Risk Manager• JCAHO• PI/QI

Hospital RelationshipsKey Physician Contacts

• Department Chair• Office based PCPs, • Sub-specialists, adult and pediatric• Surgeons--general, pediatric &

subspecialty • Anesthesiologists• Radiologists• ER• Pathologist/Clinical Lab Director• Outside tertiary care referral subspecialists

Hospital RelationshipsKey Committee Involvement • Patient Safety• Pharmacy and Therapeutics• Performance Improvement/QI• JCAHO• Credentials• Forms/Medical Records• Education• Multi-disciplinary Pediatric Committee

– Create one if it doesn’t already exist

Initial Safety Efforts Leading by Example

• Culture of safety• Teamwork• Do the little things right--if you

don’t, no one will•ALWAYS wash hands,• always write mg/kg

• Monitor and evaluate your own performance– Ask for feedback, debrief

Other Safety Projects for the Community

Hospitalist • Clinical Practice Guidelines• Transitions of Care and Hand-offs• Medication safety and weight based

dosing• Infection control• Rapid Response Team • Other knock-offs of successful projects

already implemented in children’s hospitals

Tips for Success Vigilance on Advocacy

Issues• Put pediatrics on the dashboard

– Infrastructure is geared towards adult population

• Get buy-in from pediatricians• Get buy-in from adults

– Use example “if it were your child (use name)”

Tips for Success Beware of Potential

Pitfalls• Change is never easy• Be cautious about how high to set the

bar– Depends on local culture and

politics– First task is to get buy-in for your

hospitalist program– Identify and respect potential

obstacles

Suggestions

• Start small, improve your practice first• Create alliances with non-physicians• Create physician alliances

– Specialty and surgical co-management*• Let others advocate for your expanded role• Change systems to change behaviors/

outcomes

*Pediatrics March 2003, pp. 707-709

Opportunities for the Community Pediatric

Hospitalist• Potential to directly impact care • Potential for a significant leadership

role in your hospital– May extend to adult safety areas

• Regional and national pediatric hospitalist and/or pediatric patient safety activities

Children’s Hospitalists

Perceptions – real or not?

• Less individual responsibility to lead?• Focus on the greater good for all

children• Infrastructure in place • Sophisticated endeavors: RRT, safety

rounds• Administrators chart the safety course?

Key Resources and Personnel: the Hospital• All noted with Community Hospitalists

apply• Liaisons with units intimate

– Respecting expertise– Transfers of care; RRT; medication

reconciliation

• Partnership with PCPs– CSHCN, access for outpatient f/u studies

• Key hospital administrators may be Hospitalists

Key Resources and personnel – The look

withinWhat qualities should you expect when

hiring a Children’s Hospitalist?• Role on the pediatric ward

– Culture; IHI efforts; teach safety at bedside

• Role in the Hospital – Chair committees; seek projects;

formal safety education

Key Resources and personnel – The look

withinRole with the Hospital • Local leader /representative

– Discuss best practices, NACHRI, NICHQ interpretation

• JCAHO implementation• The “go to” division for safety

challenges • The “go to” division for patient safety

research

Hospital Committees and Department

Relationships• All noted with Community Hospitalists apply• QI and Medical Staff Executive Committee

memberships a must• Department of Surgery and Trauma

Committees• Key M&M Committees: Critical care,

Transport, Emergency Department, Pediatrics

• Chair of the University Department of Pediatrics

Specific Safety Targets • Surgical and specialty co-management• Medication reconciliation• RRT• IHI bundles; 100L lives campaign• Trauma and Emergency Preparedness• Transport systems• Sedation• Teaching oversight, curriculum

development• Fatigue and stress education

Tips for success

• All noted with Community Hospitalists apply

• Awareness of site-specific issues• Learn your system and stakeholders• Insert safety as part of your division’s

mission• Legitimize hospitalists’ efforts in

patient safety by leading systems improvement efforts

Hospital Medicine Web Resources

– AAP Section on Hospital Medicine and LISTSERV•NAlexander@aap.org

– Ambulatory Pediatric Association Special Interest Group in Hospital Medicine•www.Ambpeds.org

– Society of Hospital Medicine•www.hospitalmedicine.org

Patient Safety Resources – AAP Practice Management – Safety.

http://practice.aap.org/topicBrowse.aspx?nodeID=1000.1013.1020

– AAP Things that work. http://www.aap.org/visit/thingsthatworkcall.htm

– Child Health Corporation of America CHCA http://www.chca.com/company_profile/pi/index.html

– Agency for Healthcare Research and Quality AHRQ www.ahrq.org.

– National Insitute for Child Health Quality. http://www.nichq.org/nichq 100 Lives campaign.

Patient Safety Resources – Institute for HealthCare Improvement

http://www.ihi.org/ihi Leadership Guide to Patient Safety – Free download.

– Principles of Patient Safety in Pediatrics Pediatrics Vol. 107 No. 6 June 2001, pp. 1473-1475 American Academy of Pediatrics National Initiative for Children's Health Care Quality Project Advisory Committee

– AAP Safer Heath Care for Kids Webinars– AAP Safety email list