The development and pilot of a novel mobile application to assess clinician perception of workload and work environment

BACKGROUND

Traditional measures of workload such as wRVUs may not be adequate to understand the impact of workload on key outcomes.

OBJECTIVE

The objective of this study was to develop a mobile application to assess, in near real time, clinicians' perception of workload and work environment.

DESIGNS, SETTINGS AND PARTICIPANTS

We developed the GrittyWork™ application (GW App) using the Chokshi and Mann process model for user-centered digital development. Study occured at a single academic medical center with hospitalist clinicians.

MAIN OUTCOME MEASURES AND MEASURES

Measures included the System Usability Scale (SUS), use measures from GW App, electronic health record (EHR) event log data and note counts, and qualitative interviews.

RESULTS

From October 28, 2022 to November 3, 2022, six hospitalist clinicians provided feedback on the early prototype of the GW App, and from February 28, 2023 to June 8, 2023, 30 hospitalist clinicians participated in the pilot while on clinical service. All 30 clinicians (100%) participated in the pilot submitting data for a total of 122 shifts. Participants reported working 10 ± 1 h per day (mean ± SD) and were responsible for an average of 11 ± 3 patients per day. The postpilot evaluation of the GW App showed a SUS score of 86 ± 11 and a participant preference toward mobile application-based surveys (73% of participants). Regarding workload measures, EHR event log data and notes data correlated with physician-reported workloads. Applying user-centered design techniques, we successfully developed a mobile application with high usability. These data can be paired with EHR event log data and outcomes to provide insights into the impact of workloads and work environments on outcomes.

Impact of billing reforms on academic hospitalist physician and advanced practice provider collaboration: A qualitative study

BACKGROUND

Medicare previously announced plans for new billing reforms for inpatient visits that are shared by physicians and advanced practice providers (APPs) whereby the clinician spending the most time on the patient visit would bill for the visit.

OBJECTIVE

To understand how inpatient hospital medicine teams utilize APPs in patient care and how the proposed billing policies might impact future APP utilization.

DESIGN, SETTING AND PARTICIPANTS

We conducted focus groups with hospitalist physicians, APPs, and other leaders from 21 academic hospitals across the United States. Utilizing rapid qualitative methods, focus groups were analyzed using a mixed inductive and deductive method at the semantic level with templated summaries and matrix analysis. Thirty-three individuals (physicians [n = 21], APPs [n = 10], practice manager [n = 1], and patient representative [n = 1]) participated in six focus groups.

RESULTS

Four themes emerged from the analysis of the focus groups, including: (1) staffing models with APPs are rapidly evolving, (2) these changes were felt to be driven by staffing shortages, financial models, and governance with minimal consideration to teamwork and relationships, (3) time-based billing was perceived to value tasks over cognitive workload, and (4) that the proposed billing changes may create unintended consequences impacting collaboration and professional satisfaction.

CONCLUSIONS

Physician and APP collaborative care models are increasingly evolving to independent visits often driven by workloads, financial drivers, and local regulations such as medical staff rules and hospital bylaws. Understanding which staffing models produce optimal patient, clinician, and organizational outcomes should inform billing policies rather than the reverse.

Communicating Patient Discharge Readiness: An Implementation Evaluation in an Inpatient Hospital Medicine Setting

BACKGROUND

The progression of patients through a hospital from admission to discharge can be slowed by delays in patient discharge, increasing pressure on health care staff. We designed and piloted the Discharge Today tool, with the goal of improving the efficiency of patient discharge; however, adoption remained low.

PURPOSE

To close this implementation gap, we deployed and evaluated a 4-part implementation strategy bundle.

METHODS

We measured the success of implementation by evaluating validated implementation outcomes using both quantitative and qualitative methods, grounded in Normalization Process Theory.

RESULTS

The implementation strategies used were effective for increasing use of the Discharge Today tool by hospital medicine physicians and advanced practice providers during both the active and passive implementation periods.

CONCLUSIONS

While the implementation strategies used were effective, qualitative findings indicate that limitations in the functionality of the tool, alongside inconsistent use of the tool across clinical staff, continued to inhibit adoption.

Hospitalist Shared Leadership for Safety, Health, and Well-Being at Work: United States, 2022‒2023

We assessed how hospitalists frame workplace safety, health, and well-being (SHW); their perception of hospital supports for SHW; and whether and how they are sharing leadership responsibility for each other's SHW. Our findings highlight the important role of local support for hospitalist SHW and reveal the systemic, hospital-wide problems that may impede their SHW. We believe that positioning hospitalists as leaders for SHW will result in systems-wide changes in practices to support the SHW of all care team members. (Am J Public Health. 2024;114(S2):S162-S166. https://doi.org/10.2105/AJPH.2024.307573).

Achieving diagnostic excellence through prevention and teamwork (ADEPT) study protocol: A multicenter, prospective quality and safety program to improve diagnostic processes in medical inpatients

BACKGROUND

Few hospitals have built surveillance for diagnostic errors into usual care or used comparative quantitative and qualitative data to understand their diagnostic processes and implement interventions designed to reduce these errors.

OBJECTIVES

To build surveillance for diagnostic errors into usual care, benchmark diagnostic performance across sites, pilot test interventions, and evaluate the program's impact on diagnostic error rates.

METHODS AND ANALYSIS

Achieving diagnostic excellence through prevention and teamwork (ADEPT) is a multicenter, real-world quality and safety program utilizing interrupted time-series techniques to evaluate outcomes. Study subjects will be a randomly sampled population of medical patients hospitalized at 16 US hospitals who died, were transferred to intensive care, or had a rapid response during the hospitalization. Surveillance for diagnostic errors will occur on 10 events per month per site using a previously established two-person adjudication process. Concurrent reviews of patients who had a qualifying event in the previous week will allow for surveys of clinicians to better understand contributors to diagnostic error, or conversely, examples of diagnostic excellence, which cannot be gleaned from medical record review alone. With guidance from national experts in quality and safety, sites will report and benchmark diagnostic error rates, share lessons regarding underlying causes, and design, implement, and pilot test interventions using both Safety I and Safety II approaches aimed at patients, providers, and health systems. Safety II approaches will focus on cases where diagnostic error did not occur, applying theories of how people and systems are able to succeed under varying conditions. The primary outcome will be the number of diagnostic errors per patient, using segmented multivariable regression to evaluate change in y-intercept and change in slope after initiation of the program.

ETHICS AND DISSEMINATION

The study has been approved by the University of California, San Francisco Institutional Review Board (IRB), which is serving as the single IRB. Intervention toolkits and study findings will be disseminated through partners including Vizient, The Joint Commission, and Press-Ganey, and through national meetings, scientific journals, and publications aimed at the general public.

Impact of Clinical Demands on the Educational Mission in Hospital Medicine at 17 Academic Medical Centers : A Qualitative Analysis

BACKGROUND

Clinical growth is outpacing the growth of traditional educational opportunities at academic medical centers (AMCs).

OBJECTIVE

To understand the impact of clinical growth on the educational mission for academic hospitalists.

DESIGN

Qualitative study using semistructured interviews that were analyzed using a mixed inductive and deductive method at the semantic level.

SETTING

Large AMCs across the United States that experienced clinical growth in the past 5 years.

PARTICIPANTS

Division heads, section heads, and other hospital medicine (HM) leaders who oversaw and guided academic and clinical efforts of HM programs.

MEASUREMENTS

Themes and subthemes.

RESULTS

From September 2021 to January 2022, HM leaders from 17 AMCs participated in the interviews, and 3 key themes emerged. First, AMCs' disproportionate clinical growth highlighted the tension between clinical and educational missions. This included a mismatch in supply and demand for traditional teaching time, competing priorities, and clinical growth being seen as both an opportunity and a threat. Second, amid the shifting landscape of high clinical demands and evolving educational opportunities, hospitalists still strongly prefer traditional teaching. To address this mismatch, HM groups have had to alter recruitment strategies and create innovative solutions to help build academic careers. Third, participants noted a need to reimagine the role and identity of an academic hospitalist, emphasizing tailored career pathways and educational roles spanning well beyond traditional house staff teaching teams.

LIMITATION

The study focused on large AMCs.

CONCLUSION

Although HM groups have implemented many creative strategies to address clinical growth and keep education front and center, challenges remain, particularly heavy clinical workloads and a continued dilution of traditional teaching opportunities.

PRIMARY FUNDING SOURCE

Society of Hospital Medicine Student Scholar Grant.

Exploring the Impact of COVID-19 on Women Hospitalists: A Mixed-Gender Qualitative Analysis

BACKGROUND

Women physicians have faced persistent challenges, including gender bias, salary inequities, a disproportionate share of caregiving and domestic responsibilities, and limited representation in leadership. Data indicate the COVID-19 pandemic further highlighted and exacerbated these inequities.

OBJECTIVE

To understand the pandemic's impact on women physicians and to brainstorm solutions to better support women physicians.

DESIGN

Mixed-gender semi-structured focus groups.

PARTICIPANTS

Hospitalists in the Hospital Medicine Reengineering Network (HOMERuN).

APPROACH

Six semi-structured virtual focus groups were held with 22 individuals from 13 institutions comprised primarily of academic hospitalist physicians. Rapid qualitative methods including templated summaries and matrix analysis were applied to identify major themes and subthemes.

KEY RESULTS

Four key themes emerged: (1) the pandemic exacerbated perceived gender inequities, (2) women's academic productivity and career development were negatively impacted, (3) women held disproportionate roles as caregivers and household managers, and (4) institutional pandemic responses were often misaligned with workforce needs, especially those of women hospitalists. Multiple interventions were proposed including: creating targeted workforce solutions and benefits to address the disproportionate caregiving burden placed on women, addressing hospitalist scheduling and leave practices, ensuring promotion pathways value clinical and COVID-19 contributions, creating transparency around salary and non-clinical time allocation, and ensuring women are better represented in leadership roles.

CONCLUSIONS

Hospitalists perceived and experienced that women physicians faced negative impacts from the pandemic in multiple domains including leadership opportunities and scholarship, while also shouldering larger caregiving duties than men. There are many opportunities to improve workplace conditions for women; however, current institutional efforts were perceived as misaligned to actual needs. Thus, policy and programmatic changes, such as those proposed by this cohort of hospitalists, are needed to advance equity in the workplace.

Salient Measures of Hospitalist Workload

Importance

The ideal hospitalist workload and optimal way to measure it are not well understood.

Objective

To obtain expert consensus on the salient measures of hospitalist workload.

Design, Setting, and Participants

This qualitative study used a 3-round Delphi technique between April 5 and July 13, 2022, involving national experts within and external to the field. Experts included hospitalist clinicians, leaders, and administrators, as well as researchers with expertise in human factors engineering and cognitive load theory.

Main Outcomes and Measures

Three rounds of surveys were conducted, during which participants provided input on the salient measures of hospitalist workload across various domains. In the first round, free-text data collected from the surveys were analyzed using a directed qualitative content approach. In the second and third rounds, participants rated each measure's relevance on a Likert scale, and consensus was evaluated using the IQR. Percentage agreement was also calculated.

Results

Seventeen individuals from 14 organizations, encompassing clinicians, leaders, administrators, and researchers, participated in 3 rounds of surveys. In round 1, participants provided 135 unique qualitative comments across 10 domains, with 192 unique measures identified. Of the 192 measures presented in the second round, 6 (3%) were considered highly relevant, and 25 (13%) were considered moderately relevant. In round 3, 161 measures not meeting consensus were evaluated, with 25 (16%) considered highly relevant and 95 (59%) considered moderately relevant. Examples of measures considered highly relevant included a patient complexity score and outcome measures such as savings from hospital days avoided and clinician turnover.

Conclusions and Relevance

In this qualitative study measuring hospitalist workload, multiple measures, including those quantifying work demands and the association of those demands with outcomes, were considered relevant for measuring and understanding workloads. The findings suggest that relying on traditional measures, such as productivity-related measures and financial measures, may offer an incomplete understanding of workloads and their association with key outcomes. By embracing a broader range of measures, organizations may be able to better capture the complexity and nuances of hospitalist work demands and their outcomes on clinicians, patients, and organizations.

Prevalence and Causes of Diagnostic Errors in Hospitalized Patients Under Investigation for COVID-19

BACKGROUND

The COVID-19 pandemic required clinicians to care for a disease with evolving characteristics while also adhering to care changes (e.g., physical distancing practices) that might lead to diagnostic errors (DEs).

OBJECTIVE

To determine the frequency of DEs and their causes among patients hospitalized under investigation (PUI) for COVID-19.

DESIGN

Retrospective cohort.

SETTING

Eight medical centers affiliated with the Hospital Medicine ReEngineering Network (HOMERuN).

TARGET POPULATION

Adults hospitalized under investigation (PUI) for COVID-19 infection between February and July 2020.

MEASUREMENTS

We randomly selected up to 8 cases per site per month for review, with each case reviewed by two clinicians to determine whether a DE (defined as a missed or delayed diagnosis) occurred, and whether any diagnostic process faults took place. We used bivariable statistics to compare patients with and without DE and multivariable models to determine which process faults or patient factors were associated with DEs.

RESULTS

Two hundred and fifty-seven patient charts underwent review, of which 36 (14%) had a diagnostic error. Patients with and without DE were statistically similar in terms of socioeconomic factors, comorbidities, risk factors for COVID-19, and COVID-19 test turnaround time and eventual positivity. Most common diagnostic process faults contributing to DE were problems with clinical assessment, testing choices, history taking, and physical examination (all p < 0.01). Diagnostic process faults associated with policies and procedures related to COVID-19 were not associated with DE risk. Fourteen patients (35.9% of patients with errors and 5.4% overall) suffered harm or death due to diagnostic error.

LIMITATIONS

Results are limited by available documentation and do not capture communication between providers and patients.

CONCLUSION

Among PUI patients, DEs were common and not associated with pandemic-related care changes, suggesting the importance of more general diagnostic process gaps in error propagation.

Discharge in the a.m.: A randomized controlled trial of physician rounding styles to improve hospital throughput and length of stay

BACKGROUND

To relieve hospital capacity strain, hospitals often encourage clinicians to prioritize early morning discharges which may have unintended consequences.

OBJECTIVE

We aimed to test the effects of hospitalist physicians prioritizing discharging patients first compared to usual rounding style.

DESIGN, SETTING AND PARTICIPANTS

Prospective, multi-center randomized controlled trial. Three large academic hospitals. Participants were Hospital Medicine attending-level physicians and patients the physicians cared for during the study who were at least 18 years of age, admitted to a Medicine service, and assigned by standard practice to a hospitalist team.

INTERVENTION

Physicians were randomized to: (1) prioritizing discharging patients first as care allowed or (2) usual practice.

MAIN OUTCOME AND MEASURES

Main outcome measure was discharge order time. Secondary outcomes were actual discharge time, length of stay (LOS), and order times for procedures, consults, and imaging.

RESULTS

From February 9, 2021, to July 31, 2021, 4437 patients were discharged by 59 physicians randomized to prioritize discharging patients first or round per usual practice. In primary adjusted analyses (intention-to-treat), findings showed no significant difference for discharge order time (13:03 ± 2 h:31 min vs. 13:11 ± 2 h:33 min, p = .11) or discharge time (15:22 ± 2 h:50 min vs. 15:21 ± 2 h:50 min, p = .45), for physicians randomized to prioritize discharging patients first compared to physicians using usual rounding style, respectively, and there was no significant change in LOS or on order times of other physician orders.

CONCLUSIONS

Prioritizing discharging patients first did not result in significantly earlier discharges or reduced LOS.

Building a thriving academic hospitalist workforce: A rapid qualitative analysis identifying key areas of focus in the field

BACKGROUND

The hospitalist workforce has been at the forefront of the pandemic and has been stretched in both clinical and nonclinical domains. We aimed to understand current and future workforce concerns, as well as strategies to cultivate a thriving hospital medicine workforce.

DESIGN, SETTING, AND PARTICIPANTS

We conducted qualitative, semistructured focus groups with practicing hospitalists via video conferencing (Zoom). Utilizing components from the Brainwriting Premortem Approach, attendees were split into small focus groups and listed their thoughts about workforce issues that hospitalists may encounter in the next 3 years, identifying the highest priority workforce issues for the hospital medicine community. Each small group discussed the most pressing workforce issues. These ideas were then shared across the entire group and ranked. We used rapid qualitative analysis to guide a structured exploration of themes and subthemes.

RESULTS

Five focus groups were held with 18 participants from 13 academic institutions. We identified five key areas: (1) support for workforce wellness; (2) staffing and pipeline development to maintain an adequate workforce to match clinical growth; (3) scope of work, including how hospitalist work is defined and whether the clinical skillset should be expanded; (4) commitment to the academic mission in the setting of rapid and unpredictable clinical growth; and (5) alignment between the duties of hospitalists and resources of hospitals. Hospitalists voiced numerous concerns about the future of our workforce. Several domains were identified as high-priority areas of focus to address current and future challenges.

Characteristics of adult hospital medicine fellowships in the United States: A cross-sectional survey study

BACKGROUND

Hospitalists who seek academic careers are interested in developing skills in research, education, and quality improvement (QI). Since these are not major foci of residency programs, hospitalists may pursue a hospital medicine fellowship to acquire these skill sets.

OBJECTIVE

We sought to characterize the current state of hospital medicine fellowships in the United States, including demographics, clinical requirements, curricular focus, financial structure, and scholarly outputs. DESIGNS, SETTINGS, AND PARTICIPANTS: This was a cross-sectional study of 32 hospital medicine fellowship programs across the United States in 2020-2021. An electronic survey was emailed to program leaders.

RESULTS

Out of 32 eligible programs contacted, 19 (59.4%) programs responded, representing 22 fellowship tracks. Most (63.2%) programs have been in existence for 5 years or less. Fourteen (63.6%) of the tracks had multiple focus areas, while 8 (36.4%) had a single focus. Of the 14 fellowship tracks with multiple focus areas, 6 (42.8%) reported research, QI and medical education as curricular elements. All 14 reported research as one of the curricular elements. The majority (68.4%) of programs offered opportunities to obtain a master's degree, though the field of degree varied widely. A median of 50% (IQR 0) of fellows' time was spent in clinical activities. Considerable heterogeneity exists among adult hospital medicine fellowship programs. The majority focus on research, QI, and/or medical education. Hospital medicine fellowships offer opportunities for intesive faculty development and unique career pathways.

Inpatient clinician workload: a scoping review protocol to understand the definition, measurement and impact of non-procedural clinician workloads

INTRODUCTION

Clinicians that care for hospitalised patients face unprecedented work conditions with exposure to highly infectious disease, exceedingly high patient numbers, and unpredictable work demands, all of which have resulted in increases in stress and burnout. Preliminary studies suggest that increasing workloads negatively affect inpatient clinician well-being and may negatively affect job performance; yet high workloads may be prioritised secondary to financial drivers or from workforce shortages. Despite this, the correlation between workload and these negative outcomes has not been fully quantified. Additionally, there are no clear measures for inpatient clinician workload and no standards to define ideal workloads. Using the protocol described here, we will perform a scoping review of the literature to generate a comprehensive understanding of how clinician workload of medical patients is currently defined, measured in clinical settings and its impact on the workforce, patients and institutional outcomes.

METHODS AND ANALYSIS

We will follow the methodology outlined by Joanna Briggs Institute and Arksey and O'Malley to conduct a comprehensive search of major electronic databases including Ovid Medline (PubMed), Embase (Embase.com), PsycINFO, ProQuest Dissertations and Google Scholar. All relevant published peer-reviewed and dissertaion grey literature will be included. Data will be extracted using a standardised form to capture key article information. Results will be presented in a descriptive narrative format.

ETHICS AND DISSEMINATION

This review does not require ethics approval though all included studies will be screened to ensure appropriate approval. The synthesis of this literature will provide a better understanding of the current state of work for inpatient clinicians, associated outcomes, and will identify gaps in the literature. These findings will be used in conjunction with an expert Delphi panel to identify measures of inpatient clinician workload to then guide the development of a novel workforce mobile application to actively track clinician work. We aim to lay the groundwork for future workforce studies to understand the optimal workloads that drive key outcomes for clinicians, patients and institutions.

Adaptability on Shifting Ground: a Rapid Qualitative Assessment of Multi-institutional Inpatient Surge Planning and Workforce Deployment During the COVID-19 Pandemic

BACKGROUND

During the initial wave of COVID-19 hospitalizations, care delivery and workforce adaptations were rapidly implemented. In response to subsequent surges of patients, institutions have deployed, modified, and/or discontinued their workforce plans.

OBJECTIVE

Using rapid qualitative methods, we sought to explore hospitalists' experiences with workforce deployment, types of clinicians deployed, and challenges encountered with subsequent iterations of surge planning during the COVID-19 pandemic across a collaborative of hospital medicine groups.

APPROACH

Using rapid qualitative methods, focus groups were conducted in partnership with the Hospital Medicine Reengineering Network (HOMERuN). We interviewed physicians, advanced practice providers (APP), and physician researchers about (1) ongoing adaptations to the workforce as a result of the COVID-19 pandemic, (2) current struggles with workforce planning, and (3) evolution of workforce planning.

KEY RESULTS

We conducted five focus groups with 33 individuals from 24 institutions, representing 52% of HOMERuN sites. A variety of adaptations was described by participants, some common across institutions and others specific to the institution's location and context. Adaptations implemented shifted from the first waves of COVID patients to subsequent waves. Three global themes also emerged: (1) adaptability and comfort with dynamic change, (2) the importance of the unique hospitalist skillset for effective surge planning and redeployment, and (3) the lack of universal solutions.

CONCLUSIONS

Hospital workforce adaptations to the COVID pandemic continued to evolve. While few approaches were universally effective in managing surges of patients, and successful adaptations were highly context dependent, the ability to navigate a complex system, adaptability, and comfort in a chaotic, dynamic environment were themes considered most critical to successful surge management. However, resource constraints and sustained high workload levels raised issues of burnout.

Men and Women Pursue Nonlinear Career Paths, but Impacts Differ: a Cross-Sectional Study of Academic Hospitalists

BACKGROUND

Nonlinear career paths are increasingly common. Women in academia pursuing nonlinear career paths experience negative impacts on career trajectory. No published studies have examined how pursuit of nonlinear career paths might perpetuate gender inequities within academic hospital medicine.

OBJECTIVE

(1) Compare the frequency of nonlinear career paths by gender among academic hospitalists; (2) assess the perceived impact of two types of nonlinear career paths-extended leave (EL) and non-traditional work arrangements (NTWA) on hospitalists' personal lives and careers.

DESIGN, SETTING, AND PARTICIPANTS

Cross-sectional descriptive survey study of adult hospitalist physicians in three academic centers within the USA.

INTERVENTION

Electronic survey including closed- and open-ended items assessing respondent utilization of and experiences with nonlinear career paths.

MAIN OUTCOMES AND MEASURES

(1) Associations between EL and demographic variables as well as gender differences in leave length and NTWA strategies using Fisher's exact test; 2) grounded theory qualitative analysis of open-text responses.

KEY RESULTS

Compared with men, women reported taking EL more often (p = 0.035) and for longer periods (p = 0.002). Men and women reported taking NTWA at similar rates. Women reported negative impacts of EL within domains of personal life, career, well-being, and work-life integration whereas men only reported negative impacts to career. Men and women described positive impacts of NTWA across all domains.

CONCLUSIONS

Women academic hospitalists reported taking EL more often than men and experienced disproportionately more adverse impacts to personal lives and careers. Surprisingly, men reported taking NTWA to address burnout and childbirth at similar rates to women. Our findings lay the groundwork for additional exploration of cultural and policy interventions, particularly improved paid leave policies.

Concepts and metrics of clinician attention: a scoping review protocol

INTRODUCTION

There is growing emphasis on the importance of both the cognitive and behavioural phenomenon of attention for clinicians engaged in patient care. Aspects of attention such as cognitive load, distraction and task switching have been studied in various settings with different methodologies. Using the protocol described here, we aim to systematically review the medical literature in order to map the concept of attention and to synthesise diverse concepts and methods under the broader category of research focused on 'attention'.

METHODS AND ANALYSIS

Following the methodology described by the Joanna Briggs Institute and Arksey and O'Malley, our scoping review conducts an iterative search of Cumulative Index of Nursing and Allied Health Literature (CINAHL), Medline (PubMed) and EMBASE (Ovid). An initial limited search based on key concepts and terminology will generate relevant articles which in turn will be mined for additional keywords and index terms to guide a formal literature search. Our multidisciplinary team will extract data into a matrix, including a small random sample of the same studies (to ensure concordance), and present the results in a descriptive narrative format.

ETHICS AND DISSEMINATION

As a secondary analysis, our study does not require ethics approval, and we will ensure that included studies have appropriate approval. We anticipate results will identify diverse ways of conceptualising clinician attention and will provide a foundation for developing additional metrics and study methods to optimise attention in the clinical environment. We will disseminate results through journals and conferences and coordinate with colleagues doing work in adjacent fields.

The Impact of Hospital Capacity Strain: a Qualitative Analysis of Experience and Solutions at 13 Academic Medical Centers

BACKGROUND

Hospital capacity strain impacts quality of care and hospital throughput and may also impact the well being of clinical staff and teams as well as their ability to do their job. Institutions have implemented a wide array of tactics to help manage hospital capacity strain with variable success.

OBJECTIVE

Through qualitative interviews, our study explored interventions used to address hospital capacity strain and the perceived impact of these interventions, as well as how hospital capacity strain impacts patients, the workforce, and other institutional priorities.

DESIGN, SETTING, AND PARTICIPANTS

Qualitative study utilizing semi-structured interviews at 13 large urban academic medical centers across the USA from June 21, 2019, to August 22, 2019 (pre-COVID-19). Interviews were recorded, professionally transcribed verbatim, coded, and then analyzed using a mixed inductive and deductive method at the semantic level.

MAIN OUTCOME MEASURES

Themes and subthemes of semi-structured interviews were identified.

RESULTS

Twenty-nine hospitalist leaders and hospital leaders were interviewed. Across the 13 sites, a multitude of provider, care team, and institutional tactics were implemented with perceived variable success. While there was some agreement between hospitalist leaders and hospital leaders, there was also some disagreement about the perceived successes of the various tactics deployed. We found three main themes: (1) hospital capacity strain is complex and difficult to predict, (2) the interventions that were perceived to have worked the best when facing strain were to ensure appropriate resources; however, less costly solutions were often deployed and this may lead to unanticipated negative consequences, and (3) hospital capacity strain and the tactics deployed may negatively impact the workforce and can lead to conflict.

CONCLUSIONS

While institutions have employed many different tactics to manage hospital capacity strain and see this as a priority, tactics seen as having the highest yield are often not the first employed.

Hospitalists' perspectives on challenging patient encounters and physician well-being: A qualitative study

OBJECTIVE

Challenging patient encounters contribute to physician burnout, though little is known about how these impact hospitalists specifically. This study explores how hospitalists characterize challenging patient encounters and their impact on hospitalist well-being to inform organizational efforts.

METHODS

We conducted a qualitative, descriptive study with 15 physician hospitalist faculty at two locations, a tertiary academic and safety-net hospital, utilizing a conceptual framework based on the Stanford Wellness Framework for physician resilience around challenging patient encounters.

RESULTS

Two themes emerged: feelings of helplessness and time-consuming encounters. Helplessness was associated with systems issues, misaligned patient/provider goals, and violence. Time-consuming encounters were due to systems issues, misaligned goals requiring prolonged conversations, and patient factors. These factors were found to negatively impact hospitalist well-being. Resilience strategies included developing and teaching empathy and seeking expert/colleague opinion through debriefing, peer-to-peer interactions, and external resources.

CONCLUSIONS

Organizational strategies to support hospitalists in the context of challenging patient encounters require a multifaceted approach: improved system processes, fostering a local culture of empathy-building, and supporting peer-to-peer relationships and debriefing mechanisms.

PRACTICE IMPLICATIONS

Enhanced communication around system process improvements and culture of wellness, in addition to communication skills and mindfulness, could improve hospitalist well-being.

The impact of surge adaptations on hospitalist care teams during the COVID-19 pandemic utilizing a rapid qualitative analysis approach

Background

Hospital systems have rapidly adapted to manage the influx of patients with COVID-19 and hospitalists, specialists in inpatient care, have been at the forefront of this response, rapidly adapting to serve the ever-changing needs of the community and hospital system. Institutional leaders, including clinical care team members and administrators, deployed many different strategies (i.e. adaptations) to manage the influx of patients. While many different strategies were utilized in hospitals across the United States, it is unclear how frontline care teams experienced these strategies and multifaceted changes. As these surge adaptations likely directly impact clinical care teams, we aimed to understand the perceptions and impact of these clinical care and staffing adaptations on hospitalists and care team members in order to optimize future surge plans.

Methods

Qualitative, semi-structured interviews and focus groups with hospitalist physicians, advanced practice providers (APPs), and hospital nursing and care management staff at a quaternary academic medical center. Interviews focused on the impact of COVID-19 surge practices on the following areas: (1) the experience of clinical care teams with the adaptations used to manage the surge (2) the perception and experience with the communication strategies utilized (3) the personal experience with the adaptations (i.e. how they impacted the individual) and (4) if participants had recommendations on strategies for future surges. We utilized rapid qualitative analysis methods to explore themes and subthemes.

Results

We conducted five focus groups and 21 interviews. Three themes emerged from the work including (1) dynamic clinical experience with a lot of uncertainty, (2) the importance of visible leadership with a focus on sense-making, and (3) the significant emotional toll on care team members. Subthemes included sufficient workforce, role delineation and training, information sharing, the unique dichotomy between the need for flexibility and the need for structure, the importance of communication, and the emotional toll not only on the provider but their families. Several recommendations came from this work.

Conclusions

COVID-19 surge practices have had direct impact on hospitalists and care team members. Several tactics were identified to help mitigate the many negative effects of COVID-19 on frontline hospitalist providers and care teams.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13690-022-00804-7.

Utilization of a National Writing Challenge to Promote Scholarly Work: A Pilot Study

Background

Hospitalists value mentorship and scholarly work, yet often struggle to find time and mentors amid busy clinical workloads.

Objective

To help catalyze writing for hospitalists nationally, we created a Writing Challenge, where we asked hospitalists to commit to the goal of writing 400 words a day, four days a week, for four weeks.

Methods

Prospective, programmatic evaluation with daily logs followed by a survey at the completion of the project. The four-week Writing Challenge occurred between June 7 and July 5, 2021. Email invitations to participate in the challenge were disseminated to peer networks, and the challenge was promoted using social media. Participants agreed to attempt to write 400 words per day, four days per week, for four weeks.

Results

Seventy-four individuals from 28 institutions registered for the Writing Challenge, with 36 (49%) participating in the challenge by logging their writing. Participants wrote an average of 4,372 +/- 4,324 words during the challenge. Sixty-eight percent of the participants reported that their amount of writing increased during the challenge and 50% of the participants stated they planned to publish their work, though many participants (46%) reported struggling to write each day.

Conclusions

The Writing Challenge is one way to generate increased writing and may result in increased scholarly output for academic hospitalists.

The Effectiveness of a Multidisciplinary Electronic Discharge Readiness Tool: Prospective, Single-Center, Pre-Post Study

Background

In the face of hospital capacity strain, hospitals have developed multifaceted plans to try to improve patient flow. Many of these initiatives have focused on the timing of discharges and on lowering lengths of stay, and they have met with variable success. We deployed a novel tool in the electronic health record to enhance discharge communication.

Objective

The aim of this study is to evaluate the effectiveness of a discharge communication tool.

Methods

This was a prospective, single-center, pre-post study. Hospitalist physicians and advanced practice providers (APPs) used the Discharge Today Tool to update patient discharge readiness every morning and at any time the patient status changed throughout the day. Primary outcomes were tool use, time of day the clinician entered the discharge order, time of day the patient left the hospital, and hospital length of stay. We used linear mixed modeling and generalized linear mixed modeling, with team and discharging provider included in all the models to account for patients cared for by the same team and the same provider.

Results

During the pilot implementation period from March 5, 2019, to July 31, 2019, a total of 4707 patients were discharged (compared with 4558 patients discharged during the preimplementation period). A total of 352 clinical staff had used the tool, and 84.85% (3994/4707) of the patients during the pilot period had a discharge status assigned at least once. In a survey, most respondents reported that the tool was helpful (32/34, 94% of clinical staff) and either saved time or did not add additional time to their workflow (21/24, 88% of providers, and 34/34, 100% of clinical staff). Although improvements were not observed in either unadjusted or adjusted analyses, after including starting morning census per team as an effect modifier, there was a reduction in the time of day the discharge order was entered into the electronic health record by the discharging physician and in the time of day the patient left the hospital (decrease of 2.9 minutes per additional patient, P=.07, and 3 minutes per additional patient, P=.07, respectively). As an effect modifier, for teams that included an APP, there was a significant reduction in the time of day the patient left the hospital beyond the reduction seen for teams without an APP (decrease of 19.1 minutes per patient, P=.04). Finally, in the adjusted analysis, hospital length of stay decreased by an average of 3.7% (P=.06).

Conclusions

The Discharge Today tool allows for real time documentation and sharing of discharge status. Our results suggest an overall positive response by care team members and that the tool may be useful for improving discharge time and length of stay if a team is staffed with an APP or in higher-census situations.

Predictors of a Top-Box Patient Experience: A Retrospective Observational Study of HCAHPS Data at a Safety Net Institution

Hospitals commonly seek to improve patient experience as measured by the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey, yet there are limited data to guide improvement efforts. The HCAHPS survey was developed for interhospital comparisons, whereas its use in intrahospital comparisons has not been validated. We sought to better understand the validity of utilizing intrahospital score comparisons and to identify the factors that may predict top-box HCAHPS scores. We performed a retrospective observational cohort study at an academic urban safety-net hospital examining 4898 HCAHPS surveys completed by hospitalized patients. We found that while most Patient-Mix Adjustment factors for which HCAHPS scores are adjusted were associated with top-box scores on intrahospital comparisons, few additional variables were associated with top-box scores. Further, HCAHPS questions pertaining to nurse and doctor communication were highly correlated with overall hospital rating, suggesting that communication-related factors may influence a patient’s hospital experience more strongly than do administrative factors.

COVID-19's impact on faculty and staff at a School of Medicine in the US: what is the blueprint for the future?

Background

The Coronavirus Disease 2019 (COVID-19) caused unprecedented challenges within medical centers, revealing inequities embedded in the medical community and exposing fragile social support systems. While faculty and staff faced extraordinary demands in workplace duties, personal responsibilities also increased. The goal of this study was to understand the impact of the COVID-19 pandemic on personal and professional activities of faculty and staff in order to illuminate current challenges and explore solutions.

Methods

Qualitative, semi-structured group interviews involved faculty and staff at four affiliate sites within the Department of Medicine at the University of Colorado, School of Medicine. Focus groups addressed the impact of COVID-19 on (1) Changes to roles and responsibilities at work and at home, (2) Resources utilized to manage these changes and, (3) Potential strategies for how the Department could assist faculty and staff. Thematic analysis was conducted using an inductive method at the semantic level to form themes and subthemes.

Results

Qualitative analysis of focus group transcripts revealed themes of: (1) Challenges and disparities experienced during the pandemic, (2) Disproportionate impact on women personally and professionally, (3) Institutional factors that contributed to wellness and burnout, and (4) Solutions and strategies to support faculty and staff. Within each of these themes were multiple subthemes including increased professional and personal demands, concern for personal safety, a sense of internal guilt, financial uncertainty, missed professional opportunities, and a negative impact on mentoring. Solutions were offered and included an emphasis on addressing preexisting inequities, the importance of community, and workplace flexibility.

Conclusions

The COVID-19 pandemic created burdens for already challenged faculty and staff in both their personal and professional lives. Swift action and advocacy by academic institutions is needed to support the lives and careers of our colleagues now and in the future.

Development and Implementation of a Multidisciplinary Electronic Discharge Readiness Tool: User-Centered Design Approach

BACKGROUND

Typical solutions for improving discharge planning often rely on one-way communication mechanisms, static data entry into the electronic health record (EHR), or in-person meetings. Lack of timely and effective communication can adversely affect patients and their care teams.

OBJECTIVE

Applying robust user-centered design strategies, we aimed to design an innovative EHR-based discharge readiness communication tool (the Discharge Today tool) to enable care teams to communicate any barriers to discharge, the status of patient discharge readiness, and patient discharge needs in real time across hospital settings.

METHODS

We employed multiple user-centered design strategies, including exploration of the current state for documenting discharge readiness and directing discharge planning, iterative low-fidelity prototypes, multidisciplinary stakeholder meetings, a brainwriting premortem exercise, and preproduction user testing. We iteratively collected feedback from users via meetings and surveys.

RESULTS

We conducted 28 meetings with 20 different stakeholder groups. From these stakeholder meetings, we developed 14 low-fidelity prototypes prior to deploying the Discharge Today tool for our pilot study. During the pilot study, stakeholders requested 46 modifications, of which 25 (54%) were successfully executed. We found that most providers who responded to the survey reported that the tool either saved time or did not change the amount of time required to complete their discharge workflow (21/24, 88%). Responses to open-ended questions offered both positive feedback and opportunities for improvement in the domains of efficiency, integration into workflow, avoidance of redundancies, expedited communication, and patient-centeredness.

CONCLUSIONS

Survey data suggest that this electronic discharge readiness tool has been successfully adopted by providers and clinical staff. Frequent stakeholder engagement and iterative user-centered design were critical to the successful implementation of this tool.

Advancing Diversity, Equity, and Inclusion in Hospital Medicine

BACKGROUND

In nearly all areas of academic medicine, disparities still exist for women and underrepresented minorities (URMs).

OBJECTIVES

Develop a strategic plan for advancing diversity, equity, and inclusion (DEI); implement and evaluate the plan, specifically focusing on compensation, recruitment, and policies.

DESIGN, SETTING, PARTICIPANTS

Programmatic evaluation conducted in the division of hospital medicine (DHM) at a major academic medical center involving DHM faculty and staff.

MEASUREMENTS

(1) Development and implementation of strategic plan, including policies, processes, and practices related to key components of DEI program; (2) assessment of specific DEI outcomes, including plan implementation, pre-post salary data disparities based on academic rank, and pre-post disparities for protected time for similar roles.

RESULTS

Using information gathered from a focus group with DHM faculty, an iterative strategic plan for DEI was developed and deployed, with key components of focus being institutional structures, our people, our environments, and our core mission areas. A director of DEI was established to help oversee these efforts. Using a two-phase approach, salary disparities by rank were eliminated. Internally funded protected time was standardized for leadership roles. A data dashboard has been developed to track high-level successes and areas for future focus.

CONCLUSION

Using a systematic evidence-based approach with key stakeholder involvement, a division-wide DEI strategy was developed and implemented. While this work is ongoing, short-term wins are possible, in particular around salary equity and development of policies and structures to promote DEI.

Perspectives on Patient Experience: A National Survey of Hospitalists

Despite efforts to improve patient experience (PX), little is known about the perspective of hospitalists regarding PX initiatives and priorities. A survey was distributed to hospitalist groups across the country assessing involvement in PX initiatives and their perceived effectiveness, what PX means to providers, and facilitators/barriers in improving PX. Ninety-nine percent of respondents had encountered some improvement activity around PX. The most prevalent were communication training, group Hospital Consumer Assessment of Healthcare Providers and Systems data, and interdisciplinary bedside rounding. Respondents rated most initiatives a 5 to 6 out of 10 for their effectiveness, with the perception of effectiveness increasing with respondents' assessment of patient experience priority. Learning about others' experiences in improving PX and learning about potential collaborations for quality improvement or research in these areas were areas of interest for future work. Qualitative work highlighted potential barriers in improving PX such as workload and staffing constraints, uncontrollable environmental factors, and unrealistic patient expectations. Improving PX is a priority, and there are many initiatives in place with perceived variable success and perceived barriers in improving PX.

Characterization of Anonymous Physician Perspectives on COVID-19 Using Social Media Data

Physicians' beliefs and attitudes about COVID-19 are important to ascertain because of their central role in providing care to patients during the pandemic. Identifying topics and sentiments discussed by physicians and other healthcare workers can lead to identification of gaps relating to theCOVID-19 pandemic response within the healthcare system. To better understand physicians' perspectives on the COVID-19 response, we extracted Twitter data from a specific user group that allows physicians to stay anonymous while expressing their perspectives about the COVID-19 pandemic. All tweets were in English. We measured most frequent bigrams and trigrams, compared sentiment analysis methods, and compared our findings to a larger Twitter dataset containing general COVID-19 related discourse. We found significant differences between the two datasets for specific topical phrases. No statistically significant difference was found in sentiments between the two datasets, and both trended slightly more positive than negative. Upon comparison to manual sentiment analysis, it was determined that these sentiment analysis methods should be improved to accurately capture sentiments of anonymous physician data. Anonymous physician social media data is a unique source of information that provides important insights into COVID-19 perspectives.

Harnessing the Power of Hospitalists in Operational Disaster Planning: COVID-19

Hospitalists are well poised to serve in key leadership roles and in frontline care in particular when facing a pandemic such as the SARS-CoV-2 (COVID-19) infection. Much of the disaster planning in hospitals around the country addresses overcrowded emergency departments and decompressing these locations; however, in the case of COVID-19, intensive care units, emergency departments, and medical wards ran the risk of being overwhelmed by a large influx of patients needing high-level medical care. In a matter of days, our Division of Hospital Medicine, in partnership with our hospital, health system, and academic institution, was able to modify and deploy existing disaster plans to quickly care for an influx of medically complex patients. We describe a scaled approach to managing hospitalist clinical operations during the COVID-19 pandemic.

What Do Patients Want? A Qualitative Analysis of Patient, Provider, and Administrative Perceptions and Expectations About Patients' Hospital Stays

Patient experience is increasingly recognized as a measure of health care quality and patient-centered care and is currently measured through the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS). The HCAHPS survey may miss key factors important to patients, and in particular, to underserved patient populations. We performed a qualitative study utilizing semi-structured interviews with 45 hospitalized English- and Spanish-speaking patients and 6 focus groups with physicians, nurses, and administrators at a large, urban safety-net hospital. Four main themes were important to patients: (1) the hospital environment including cleanliness and how hospital policies and procedures impact patients’ perceived autonomy, (2) whole-person care, (3) communication with and between care teams and utilizing words that patients can understand, and (4) responsiveness and attentiveness to needs. We found that several key themes that were important to patients are not fully addressed in the HCAHPS survey and there is a disconnect between what patients and care teams believe patients want and what hospital policies drive in the care environment.

Patient Perception of Plain-Language Medical Notes Generated Using Artificial Intelligence Software: Pilot Mixed-Methods Study

Background

Clinicians’ time with patients has become increasingly limited due to regulatory burden, documentation and billing, administrative responsibilities, and market forces. These factors limit clinicians’ time to deliver thorough explanations to patients. OpenNotes began as a research initiative exploring the ability of sharing medical notes with patients to help patients understand their health care. Providing patients access to their medical notes has been shown to have many benefits, including improved patient satisfaction and clinical outcomes. OpenNotes has since evolved into a national movement that helps clinicians share notes with patients. However, a significant barrier to the widespread adoption of OpenNotes has been clinicians’ concerns that OpenNotes may cost additional time to correct patient confusion over medical language. Recent advances in artificial intelligence (AI) technology may help resolve this concern by converting medical notes to plain language with minimal time required of clinicians.

Objective

This pilot study assesses patient comprehension and perceived benefits, concerns, and insights regarding an AI-simplified note through comprehension questions and guided interview.

Methods

Synthea, a synthetic patient generator, was used to generate a standardized medical-language patient note which was then simplified using AI software. A multiple-choice comprehension assessment questionnaire was drafted with physician input. Study participants were recruited from inpatients at the University of Colorado Hospital. Participants were randomly assigned to be tested for their comprehension of the standardized medical-language version or AI-generated plain-language version of the patient note. Following this, participants reviewed the opposite version of the note and participated in a guided interview. A Student t test was performed to assess for differences in comprehension assessment scores between plain-language and medical-language note groups. Multivariate modeling was performed to assess the impact of demographic variables on comprehension. Interview responses were thematically analyzed.

Results

Twenty patients agreed to participate. The mean number of comprehension assessment questions answered correctly was found to be higher in the plain-language group compared with the medical-language group; however, the Student t test was found to be underpowered to determine if this was significant. Age, ethnicity, and health literacy were found to have a significant impact on comprehension scores by multivariate modeling. Thematic analysis of guided interviews highlighted patients’ perceived benefits, concerns, and suggestions regarding such notes. Major themes of benefits were that simplified plain-language notes may (1) be more useable than unsimplified medical-language notes, (2) improve the patient-clinician relationship, and (3) empower patients through an enhanced understanding of their health care.

Conclusions

AI software may translate medical notes into plain-language notes that are perceived as beneficial by patients. Limitations included sample size, inpatient-only setting, and possible confounding factors. Larger studies are needed to assess comprehension. Insight from patient responses to guided interviews can guide the future study and development of this technology.

Developing a Patient- and Family-Centered Research Agenda for Hospital Medicine: The Improving Hospital Outcomes through Patient Engagement (i-HOPE) Study

BACKGROUND

Patient, caregiver, and other stakeholder priorities have not been robustly incorporated into directing hospital-based research and improvement efforts.

OBJECTIVE

To systematically engage stakeholders to identify important questions of adult hospitalized patients and to create a prioritized research agenda for improving the care of adult hospitalized patients.

DESIGN

A collaborative approach to stakeholder engagement and research question prioritization.

SETTING & PARTICIPANTS

Researchers and patients from eight academic and community medical centers partnered with 39 patient, caregiver, professional, research, and medical organizations.

METHODS

We applied established standards for formulating research questions and stakeholder engagement. This included: a multi-pronged, inclusive patient and stakeholder engagement strategy; surveys of patients and stakeholder organizations to identify important questions; content analysis of submitted questions; and a 2-day in-person meeting with stakeholder organization representatives and patient partners to prioritize and rank submitted questions.

RESULTS

A total of 499 respondents including patients, caregivers, healthcare providers, and researchers from 39 organizations submitted 782 research questions. These questions were categorized into 70 distinct topics-52 that were health system related and 18 disease specific. From these categories, we identified 36 common questions; the final 11 questions were identified, prioritized and ranked during an in-person priority-setting meeting. Questions considered highest priority related to ensuring shared treatment and goals of care decision making and improving hospital discharge handoff to other care facilities and providers.

CONCLUSION

We identified 11 prioritized research questions that should galvanize funders, researchers, and patient advocates to address and improve the care of hospitalized adult patients.

SPEAKers at the National Society of Hospital Medicine Meeting: A Follow-UP Study of Gender Equity for Conference Speakers from 2015 to 2019. The SPEAK UP Study

Women continue to be underrepresented as speakers at national conferences, and research has shown similar trends in hospital medicine. The Society of Hospital Medicine (SHM) Annual Meeting has historically had an open call peer review process for workshop speakers and, in 2019, expanded the process for didactic speakers. We aimed to assess the overall conference trends for women speakers and whether the systematic processes in recruitment procedures (ie, open call) resulted in improved representation of women speakers. We also sought to understand how the proportion of women speakers might affect overall scores of the conference. From 2015 to 2019, the overall representation of women speakers increased, as did evaluation scores during the same time period. When selection processes included the open call peer review process, there were higher proportions of women speakers. An open call process with peer review for speakers may be a systematic process that national meetings could replicate to reduce gender inequities.

Opioid Utilization and Perception of Pain Control in Hospitalized Patients: A Cross-Sectional Study of 11 Sites in 8 Countries

BACKGROUND

Hospitalized patients are frequently treated with opioids for pain control, and receipt of opioids at hospital discharge may increase the risk of future chronic opioid use.

OBJECTIVE

To compare inpatient analgesic prescribing patterns and patients' perception of pain control in the United States and non-US hospitals.

DESIGN

Cross-sectional observational study.

SETTING

Four hospitals in the US and seven in seven other countries.

PARTICIPANTS

Medical inpatients reporting pain.

MEASUREMENTS

Opioid analgesics dispensed during the first 24-36 hours of hospitalization and at discharge; assessments and beliefs about pain.

RESULTS

We acquired completed surveys for 981 patients, 503 of 719 patients in the US and 478 of 590 patients in other countries. After adjusting for confounding factors, we found that more US patients were given opioids during their hospitalization compared with patients in other countries, regardless of whether they did or did not report taking opioids prior to admission (92% vs 70% and 71% vs 41%, respectively; P < .05), and similar trends were seen for opioids prescribed at discharge. Patient satisfaction, beliefs, and expectations about pain control differed between patients in the US and other sites.

LIMITATIONS

Limited number of sites and patients/country.

CONCLUSIONS

In the hospitals we sampled, our data suggest that physicians in the US may prescribe opioids more frequently during patients' hospitalizations and at discharge than their colleagues in other countries, and patients have different beliefs and expectations about pain control. Efforts to curb the opioid epidemic likely need to include addressing inpatient analgesic prescribing practices and patients' expectations regarding pain control.

State of Research in Adult Hospital Medicine: Results of a National Survey

BACKGROUND

Little is known about the state of research in academic hospital medicine (HM) despite the substantial growth of this specialty.

METHODS

We used the Society of Hospital Medicine (SHM) membership database to identify research programs and their leadership. In addition, the members of the SHM Research Committee identified individuals who lead research programs in HM. A convenience sample of programs and individuals was thus created. A survey instrument containing questions regarding institutional information, research activities, training opportunities, and funding sources was pilot tested and refined for electronic dissemination. Data were summarized using descriptive statistics.

RESULTS

A total of 100 eligible programs and corresponding individuals were identified. Among these programs, 28 completed the survey in its entirety (response rate 28%). Among the 1,586 faculty members represented in the 28 programs, 192 (12%) were identified as engaging in or having obtained extramural funding for research, and 656 (41%) were identified as engaging in quality improvement efforts. Most programs (61%) indicated that they received $500,000 or less in research funding, whereas 29% indicated that they received >$1 million in funding. Major sources of grant support included the Agency for Healthcare Research and Quality, National Institutes of Health, and the Veterans Health Administration. Only five programs indicated that they currently have a research fellowship program in HM. These programs cited lack of funding as a major barrier to establishing fellowships. Almost half of respondents (48%) indicated that their faculty published between 11-50 peer-reviewed manuscripts each year.

CONCLUSION

This survey provides the first national summary of research activities in HM. Future waves of the survey can help determine whether the research footprint of the field is growing.

You Can't Have It All: The Experience of Academic Hospitalists During Pregnancy, Parental Leave, and Return to Work

BACKGROUND

The United States lags behind most other countries regarding the support for working mothers and parental leave. Data are limited to describe the experience of female hospital medicine physicians during pregnancy, parental leave, and their return to work in academic hospital medicine.

METHODS

We conducted a qualitative descriptive study including interviews with 10 female academic hospitalists chosen from institutions across the country that are represented in Society of Hospital Medicine (SHM) Committees. Interview guides were based on the following domains: experience in pregnancy, parental leave, and return to work. Interviews were recorded, transcribed verbatim, and analyzed using a general inductive approach to theme analysis using the ATLAS.ti software (Scientific Software Development GmbH, Berlin, Germany).

PRIMARY OUTCOME

Women in hospital medicine experience the following six common challenges in their experience as new parents, each of which has the potential to impact their career trajectory, wellness, and are associated with areas for institutional improvement: (1) access to paid parental leave, (2) physical challenges, (3) breastfeeding, (4) career opportunities, (5) colleague responses, and (6) empathy in patient care.

Barriers to Early Hospital Discharge: A Cross-Sectional Study at Five Academic Hospitals

BACKGROUND

Understanding the issues delaying hospital discharges may inform efforts to improve hospital throughput.

OBJECTIVE

This study was conducted to identify and determine the frequency of barriers contributing to delays in placing discharge orders.

DESIGN

This was a prospective, cross-sectional study. Physicians were surveyed at approximately 8:00 AM, 12:00 PM, and 3:00 PM and were asked to identify patients that were "definite" or "possible" discharges and to describe the specific barriers to writing discharge orders.

SETTING

This study was conducted at five hospitals in the United States.

PARTICIPANTS

The study participants were attending and housestaff physicians on general medicine services.

PRIMARY OUTCOMES AND MEASURES

Specific barriers to writing discharge orders were the primary outcomes; the secondary outcomes included discharge order time for high versus low team census, teaching versus nonteaching services, and rounding style.

RESULTS

Among 1,584 patient evaluations, the most common delays for patients identified as "definite" discharges (n = 949) were related to caring for other patients on the team or waiting to staff patients with attendings. The most common barriers for patients identified as "possible" discharges (n = 1,237) were awaiting patient improvement and for ancillary services to complete care. Discharge orders were written a median of 43-58 minutes earlier for patients on teams with a smaller versus larger census, on nonteaching versus teaching services, and when rounding on patients likely to be discharged first (all P < .003).

CONCLUSIONS

Discharge orders for patients ready for discharge are most commonly delayed because physicians are caring for other patients. Discharges of patients awaiting care completion are most commonly delayed because of imbalances between availability and demand for ancillary services. Team census, rounding style, and teaching teams affect discharge times.