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.

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.

Practical Applications of Rapid Qualitative Analysis for Operations, Quality Improvement, and Research in Dynamically Changing Hospital Environments.

BACKGROUND: Health care systems are in a constant state of change. As such, methods to quickly acquire and analyze data are essential to effectively evaluate current processes and improvement projects. Rapid qualitative analysis offers an expeditious approach to evaluate complex, dynamic, and time-sensitive issues. METHODS: We used rapid data acquisition and qualitative methods to assess six real-world problems the hospitalist field faced during the COVID-19 pandemic. We iteratively modified and applied a six-step framework for conducting rapid qualitative analysis, including determining if rapid methods are appropriate, creating a team, selecting a data collection approach, data analysis, and synthesis and dissemination. Virtual platforms were used for focus groups and interviews; templated summaries and matrix analyses were then applied to allow for rapid qualitative analyses. RESULTS: We conducted six projects using rapid data acquisition and rapid qualitative analysis from December 4, 2020, to January 14, 2022, each of which included 23 to 33 participants. One project involved participants from a single institution; the remainder included participants from 15 to 24 institutions. These projects led to the refinement of an adapted rapid qualitative method for evaluation of hospitalist-driven operational, research, and quality improvement efforts. We describe how we used these methods and disseminated our results. We also discuss situations for which rapid qualitative methods are well-suited and strengths and weaknesses of the methods. CONCLUSION: Rapid qualitative methods paired with rapid data acquisition can be employed for prompt turnaround assessments of quality, operational, and research projects in complex health care environments. Although rapid qualitative analysis is not meant to replace more traditional qualitative methods, it may be appropriate in certain situations. Application of a framework to guide projects using a rapid qualitative approach can help provide structure to the analysis and instill confidence in the findings.

Closer to or Farther away from an Ideal Model of Care? Lessons Learned from Geographic Cohorting

Geographic “cohorting,” “co-location,” “regionalization,” or “localization” refers to the assignation of a hospitalist team to a specific inpatient unit. Its benefits may be related to the formation of a team and the additional interventions like interdisciplinary rounding that the enhanced proximity facilitates. However, cohorting is often adopted in isolation of the bundled approach within which it has proven beneficial. Cohorting may also be associated with unintended consequences such as increased interruptions and increased indirect care time. Institutions may increase patient loads in anticipation of the efficiency gained by cohorting—leading to further increases in interruptions and time away from the bedside. Fragmented attention and increases in indirect care may lead to a perception of increased workload, errors, and burnout. As hospital medicine evolves, there are lessons to be learned by studying cohorting. Institutions and inpatient units should work in synergy to shape the day-to-day work which directly affects patient and clinician outcomes—and ultimately culminates in the success or failure of the parent organization. Such synergy can manifest in workflow design and metric selection. Attention to workloads and adopting the principles of continuous quality improvement are also crucial to developing models of care that deliver excellent care.

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.

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.

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.

Bracing for the Wave: a Multi-Institutional Survey Analysis of Inpatient Workforce Adaptations in the First Phase of COVID-19.

BACKGROUND: Medical centers across the country have had to rapidly adapt clinician staffing strategies to accommodate large influxes of patients with the coronavirus disease 2019 (COVID-19). OBJECTIVE: We sought to understand the adaptations and staffing strategies that US academic medical centers employed in the inpatient setting early in the spread of COVID-19, and to assess whether those changes were sustained during the first phase of the pandemic. DESIGN: Cross-sectional survey assessing organization-level, team-level, and clinician-level inpatient workforce adaptations. PARTICIPANTS: Hospital medicine leadership at 27 academic medical centers in the USA. KEY RESULTS: Twenty-seven of 36 centers responded to the survey (75%). Widespread practices included frequent staffing reassessment, organization-level changes such as geographic cohorting and redeployment of non-hospitalists, and exempting high-risk healthcare workers from direct care of patients with COVID-19. Several practices were implemented but discontinued, such as reduction of non-essential services, indicating that they were less sustainable for large centers. CONCLUSION: These findings provide guidance for inpatient leaders seeking to identify sustainable practices for COVID-19 inpatient workforce planning.

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.

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.