Visiting professorship in hospital medicine: An innovative twist for a growing specialty.

INTRODUCTION: As an emerging and rapidly growing specialty, academic hospitalists face unique challenges in career advancement. Key mentoring needs, especially developing reputation and relationships outside of their institution are often challenging. METHODS: We describe the structure of a novel Visiting Professorship in Hospital Medicine Program. It utilizes reciprocal exchanges of hospitalist faculty at the rank of late assistant to early associate professor. The program is designed explicitly to facilitate spread of innovation between institutions through a presentation by the visiting professor and exposure to an innovation at the host hospital medicine group. It provides a platform to advance the career success of both early- and midcareer hospitalist faculty through 1-on-1 coaching sessions between the visiting professor and early-career faculty at the host institution and commitment by visiting professors to engage in mentoring after the visit. RESULTS: Five academic hospitalist groups participated. Seven visiting professors met with 29 early-career faculty. Experience following faculty exchange visits demonstrates program effectiveness, as perceived by both early-career faculty and the visiting professors, in advancing the goals of mentorship and career advancement. One-year follow-up suggests that 62% of early-career faculty will engage in subsequent interactions with the visiting professor, and half report spread of innovation between academic hospital medicine groups. CONCLUSIONS: The Visiting Professorship in Hospital Medicine offers a low-cost framework to promote collaboration between academic hospital medicine groups and facilitate interinstitutional hospitalist mentoring. It is reported to be effective for the goal of professional development for midcareer hospitalists. Journal of Hospital Medicine 2016;11:714-718. © 2016 Society of Hospital Medicine.

Patients, Nurses, and Physicians Working Together to Develop a Discharge Entrustable Professional Activity Assessment Tool.

PROBLEM: The Accreditation Council for Graduate Medical Education milestones were written by physicians and thus may not reflect all the behaviors necessary for physicians to optimize their performance as a key member of an interprofessional team. APPROACH: From April to May 2013, the authors, Educational Research Outcomes Collaborative leaders, assembled interprofessional team discussion groups, including patients or family members, nurses, physician trainees, physician educators, and other staff (optional), at 11 internal medicine (IM) programs. Led by the site's principal investigator, the groups generated a list of physician behaviors related to the entrustable professional activity (EPA) of a safe and effective discharge of a patient from the hospital, and prioritized those behaviors. OUTCOMES: A total of 182 behaviors were listed, with lists consisting of between 10 and 29 behaviors. Overall, the site principal investigators described all participants as emerging from the activity with a new understanding of the complexity of training physicians for the discharge EPA. The authors batched behaviors into six components of a safe and effective discharge: medication reconciliation, discharge summary, patient/caregiver communication, team communication, active collaboration, and anticipation of posthospital needs. Specific, high-priority behavior examples for each component were identified, and an assessment tool for direct observation was developed for the discharge EPA. NEXT STEPS: The authors are currently evaluating trainee and educator perceptions of the assessment tool after implementation in 15 IM programs. Additional next steps include developing tools for other EPAs, as well as a broader evaluation of patient outcomes in the era of milestone-based assessment.

Impact of a clinical pharmacist stress ulcer prophylaxis management program on inappropriate use in hospitalized patients.

PURPOSE: Appropriate utilization of stress ulcer prophylaxis should be limited to high-risk, intensive care unit (ICU) patients. However, inappropriate stress ulcer prophylaxis use among all hospitalized patients remains a concern. The purpose of this study was to evaluate the clinical and economic impact of a novel pharmacist-managed stress ulcer prophylaxis program in ICU and general ward patients. METHODS: This retrospective, pre- and poststudy design was conducted in adult ICU and general ward patients at a large academic medical center between January 1, 2011 and January 31, 2012 to compare the rates of inappropriate stress ulcer prophylaxis before and after the implementation of a pharmacist-led stress ulcer prophylaxis management program. RESULTS: A total of 1134 unique patients consisting of 16,415 patient days were evaluated. The relative reduction in the rate of inappropriate stress ulcer prophylaxis days after program implementation in ICU and general ward patients was 58.3% and 83.5%, respectively (P < .001). The rates of ICU patients inappropriately continued on stress ulcer prophylaxis upon hospital discharge in the pre- and postimplementation groups were 29.9% and 3.6%, respectively (P < .001), whereas general ward patients significantly decreased from 36.2% to 5.4% in the pre- and postimplementation groups, respectively (P < .001). Total inpatient costs associated with all stress ulcer prophylaxis administered was $20,052.70 in the pre- and $3280.49 in the postimplementation group (P < .001), resulting in an estimated cost savings of > $200,000 annually. No differences in clinical outcomes were observed. CONCLUSIONS: The implementation of a pharmacist-managed stress ulcer prophylaxis program was associated with a decrease in inappropriate acid suppression rates during hospitalization and upon discharge, as well as significant cost savings.

Using a mentoring approach to implement an inpatient glycemic control program in United States hospitals.

BACKGROUND: establishing an inpatient glycemic control program is challenging, requires years of work, significant education and coordination of medical, nursing, dietary, and pharmacy staff, and support from administration and Performance Improvement departments. We undertook a 2 year quality improvement project assisting 10 medical centers (academic and community) across the US to implement inpatient glycemic control programs. METHODS: the project was comprised of 3 interventions. (1) One day site visit with a faculty team (MD and CDE) to meet with key personnel, identify deficiencies and barriers to change, set site specific goals and develop strategies and timelines for performance improvement. (2) Three webinar follow-up sessions. (3) Web site for educational resources. Updates, challenges, and accomplishments for each site were reviewed at the time of each webinar and progress measured at the completion of the project with an evaluation questionnaire. RESULTS: as a result of our intervention, institutions revised and simplified formularies and insulin order sets (with CHO counting options); implemented glucometrics and CDE monitoring of inpatient glucoses (assisting providers with orders); added new protocols for DKA and perinatal treatment; and implemented nursing, physician and patient education initiatives. Changes were institution specific, fitting the local needs and cultures. As to the extent to which Institution׳s goals were satisfied: 2 reported "completely", 4 "mostly," 3 "partially," and 1 "marginally". Institutions continue to move toward fulfilling their goals. CONCLUSIONS: an individualized, structured, performance improvement approach with expert faculty mentors can help facilitate change in an institution dedicated to implementing an inpatient glycemic control program.

The Power of Collaboration: Experiences From the Educational Innovations Project and Implications for the Next Accreditation System.

BACKGROUND: The Internal Medicine Educational Innovations Project (EIP) is a 10-year pilot project for innovating in accreditation, which involves annual reporting of information and less-restrictive requirements for a group of high-performing programs. The EIP program directors' experiences offer insight into the benefits and challenges of innovative approaches to accreditation as the Accreditation Council for Graduate Medical Education transitions to the Next Accreditation System. OBJECTIVE: We assessed participating program directors' perceptions of the EIP at the midpoint of the project's 10-year life span. METHODS: We conducted telephone interviews with 15 of 18 current EIP programs (83% response rate) using a 19-item, open-ended, structured survey. Emerging themes were identified with content analysis. RESULTS: Respondents identified a number of the benefits from the EIP, most prominent among them, collaboration between programs (87%, 13 of 15) and culture change around quality improvement (47%, 7 of 15). The greatest benefit for residents was training in quality improvement methods (53%, 8 of 15), enhancing those residents' ability to become change agents in their future careers. Although the requirement for annual data reporting was identified by 60% (9 of 15) of program directors as the biggest challenge, respondents also considered it an important element for achieving progress on innovations. Program directors unanimously reported their ability to sustain innovation projects beyond the 10-year participation in EIP. CONCLUSIONS: The work of EIP was not viewed as "more work," but as "different work," which created a new mindset of continuous quality improvement in residency training. Lessons learned offer insight into the value of collaboration and opportunities to use accreditation to foster innovation.

The Quality and Safety Educators Academy: fulfilling an unmet need for faculty development.

Educating physician trainees in the principles of quality improvement (QI) and patient safety (PS) is a national imperative. Few faculty are trained in these disciplines, and few teaching institutions have the resources and infrastructure to develop faculty as instructors of these skills. The authors designed a 3-day, in-person academy to provide medical educators with the knowledge and tools to integrate QI and PS concepts into their training programs. The curriculum provided instruction in quality and safety, curriculum development and assessment, change management, and professional development while fostering peer networking, mentorship, and professional development. This article describes the characteristics, experiences, and needs of a cross-sectional group of faculty interested in acquiring skills to help them succeed as quality and safety educators. It also describes the guiding principles, curriculum blueprint, program evaluation, and lessons learned from this experience which could be applied to future faculty development programs in quality and safety education.

Playing with curricular milestones in the educational sandbox: Q-sort results from an internal medicine educational collaborative.

PURPOSE: In competency-based medical education, the focus of assessment is on learner demonstration of predefined outcomes or competencies. One strategy being used in internal medicine (IM) is applying curricular milestones to assessment and reporting milestones to competence determination. The authors report a practical method for identifying sets of curricular milestones for assessment of a landmark, or a point where a resident can be entrusted with increased responsibility. METHOD: Thirteen IM residency programs joined in an educational collaborative to apply curricular milestones to training. The authors developed a game using Q-sort methodology to identify high-priority milestones for the landmark "Ready for indirect supervision in essential ambulatory care" (EsAMB). During May to December 2010, the programs'ambulatory faculty participated in the Q-sort game to prioritize 22 milestones for EsAMB. The authors analyzed the data to identify the top 8 milestones. RESULTS: In total, 149 faculty units (1-4 faculty each) participated. There was strong agreement on the top eight milestones; six had more than 92% agreement across programs, and five had 75% agreement across all faculty units. During the Q-sort game, faculty engaged in dynamic discussion about milestones and expressed interest in applying the game to other milestones and educational settings. CONCLUSIONS: The Q-sort game enabled diverse programs to prioritize curricular milestones with interprogram and interparticipant consistency. A Q-sort exercise is an engaging and playful way to address milestones in medical education and may provide a practical first step toward using milestones in the real-world educational setting.

The other nursing shortage: a regional collaboration to address the shortage of nursing faculty.

A regional collaborative of one major hospital system and nine schools of nursing has addressed the critical shortage of nursing faculty in Northeast Ohio. This model of institutional collaboration is preparing expert nurse clinicians from the hospital nursing staff to assume clinical faculty roles in regional schools of nursing while maintaining their primary role as clinical staff. The model included the development of a recruitment campaign, a uniform application process, an online database, faculty orientation programs, and continuing faculty development opportunities. Currently, more than 240 clinical nursing staff have applied for the program. Two faculty orientation sessions were attended by more than 100 prospective faculty. Additionally, the first continuing faculty development workshop was attended by more than 170 current and prospective nursing faculty. Now in its third year of implementation, the project is expanding its scope to include a broader base of regional partners and to address the issue of sustainability.

Perioperative care of the geriatric patient with diabetes or hyperglycemia.

The incidence of diabetes in the geriatric population is increasing and the resulting co-morbidities have led to corresponding increases in hospital admissions and surgeries. The weight of the evidence and national guidelines should dissuade us from allowing uncontrolled hyperglycemia in the geriatric perioperative population, but the glycemic target should be modified upwards based on the individual patient characteristics, and in environments that do not have an established track record of reaching more aggressive targets safely. Insulin is the most effective and flexible regimen to achieve inpatient glycemic control, whether by infusion or by subcutaneous basal bolus regimens. Strategies for safe and effective dosing and adjustment of insulin regimens, and methods to avoid hypoglycemia in the perioperative period are outlined. Finally, discharge planning should take into consideration a patient's HbA1c, preoperative glycemic control, inpatient glycemic regimen and control, financial and physical limitations, social support, co-morbid medical conditions, episodes of hypoglycemia, and overall prognosis to create an individualized safe and effective medication regimen for optimal glycemic control at home.