Hospitalists as Safety Intervention Tuesday, December 5, 2006 12:00 – 1:00 p.m. Eastern Time

1. Hospitalists as Safety InterventionTuesday, December 5, 200612:00 – 1:00 p.m. Eastern Time

2. Moderator: Christopher Landrigan, MD, MPH, FAAP Pediatric Hospitalist / Research & Fellowship Director Children’s Hospital Boston, Inpatient Pediatrics Service Boston, Massachusetts

3. This activity was funded through an educational grant from the Physicians’ Foundation for Health Systems Excellence.

4. Disclosure of Financial Relationships and Resolution of Conflicts of Interest for AAP CME Activities Grid The AAP CME program aims to develop, maintain, and increase the competency, skills, and professional performance of pediatric healthcare professionals by providing high quality, relevant, accessible and cost-effective educational experiences. The AAP CME program provides activities to meet the participants’ identified education needs and to support their lifelong learning towards a goal of improving care for children and families (AAP CME Program Mission Statement, August 2004). The AAP recognizes that there are a variety of financial relationships between individuals and commercial interests that require review to identify possible conflicts of interest in a CME activity. The “AAP Policy on Disclosure of Financial Relationships and Resolution of Conflicts of Interest for AAP CME Activities” is designed to ensure quality, objective, balanced, and scientifically rigorous AAP CME activities by identifying and resolving all potential conflicts of interest prior to the confirmation of service of those in a position to influence and/or control CME content. The AAP has taken steps to resolve any potential conflicts of interest. All AAP CME activities will strictly adhere to the 2004 Updated Accreditation Council for Continuing Medical Education (ACCME) Standards for Commercial Support: Standards to Ensure the Independence of CME Activities. In accordance with these Standards, the following decisions will be made free of the control of a commercial interest: identification of CME needs, determination of educational objectives, selection and presentation of content, selection of all persons and organizations that will be in a position to control the content, selection of educational methods, and evaluation of the CME activity. The purpose of this policy is to ensure all potential conflicts of interest are identified and mechanisms to resolve them prior to the CME activity are implemented in ways that are consistent with the public good. The AAP is committed to providing learners with commercially unbiased CME activities.

5. DISCLOSURES

6. DISCLOSURES

7. DISCLOSURES

8. CME CREDIT The American Academy of Pediatrics (AAP) is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. The AAP designates this educational activity for a maximum of 1.0 AMA PRA Category 1 Credit™. Physicians should only claim credit commensurate with the extent of their participation in the activity. This activity is acceptable for up to 1.0 AAP credit. This credit can be applied toward the AAP CME/CPD Award available to Fellows and Candidate Fellows of the American Academy of Pediatrics.

9. OTHER CREDIT This webinar is approved by the National Association of Pediatric Nurse Practitioners (NAPNAP) for 1.2 NAPNAP contact hours of which 0.0 contain pharmacology (Rx) content. The AAP is designated as Agency #17. Upon completion of the program, each participant desiring NAPNAP contact hours should send a completed certificate of attendance, along with the required recording fee ($10 for NAPNAP members, $15 for nonmembers), to the NAPNAP National Office at 20 Brace Road, Suite 200, Cherry Hill, NJ 08034-2633. The American Academy of Physician Assistants accepts AMA PRA Category 1 Credit(s)TM from organizations accredited by the ACCME .

10. Jack M. Percelay, MD, MPH, FAAP Pediatric Hospitalist Hunterdon Medical Center Flemington, New Jersey

11. Erin R. Stucky, MD, FAAP Pediatric Hospitalist Children’s Specialists of San Diego Rady Children’s Hospital San Diego, California

12. Hospitalists as Safety Intervention Jack Percelay MD, MPH, FAAP Erin Stucky MD, FAAP AAP Safer Health Care for Kids Webinar December 5, 2006

13. Disclosures • Dr Erin Stucky does in fact have a time twizzler just like Hermione Granger and that is how she is able to accomplish so much in so little time • Dr Jack Percelay is significantly taller than Erin Stucky

14. What we will cover today Participants shall be able to: • a. List key resources and personnel to establish a pediatric patient safety program in a community hospital. • b. Name key hospital committees and (medical staff) department relationships through which the hospitalist can effect patient safety changes. • c. Identify specific patient safety targets for pediatric hospitalists in community and children's hospitals.

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

16. Society of Hospital MedicineCurrent Definition of Hospitalist • “Physicians whose primary professional focus is the general medical care of hospitalized patients. Their activities include patient care, teaching, research, and leadership related to hospital care.”

17. Key Features of Definition • Hospital is exclusive work environment • Commitment to systems improvement • Communication, communication, communication • Implicit risk of the handoff • Multiple roles besides purely clinical care

18. SHM ProjectionsNumber of Hospitalists AAP Section on Hospital Medicine • October 1998 75 members • October, 2006 670 members

19. AAP Guiding Principles for Pediatric Hospitalist Programs 1 Voluntary referrals. 2 Designed for Local Needs 3 BC/BE pediatric equivalent training 4 Include appropriate follow-up 5 Timely and complete communication 6 Data collection Pediatrics, April 2005

20. Community Hospitalists Many of these points will also apply to the Children’s Hospitalist

21. Multiple Hospitalist RolesMultiple Opportunities • Pediatric ward – teaching residents • Nursery • NICU and PICU • Emergency Department • Hospital services – radiology, sedation • Clinical partners – nursing, respiratory therapy, pharmacy

22. Ingredients for a Successful Hospitalist/Hospitalist Program • Clinical acumen and communication skills • Broad systems interest • Lead by example • Shared quality and outcome goals, not just revenue • Job description, compensation, career advancement linked to performance improvement

23. Hospital RelationshipsInstitutional Leadership • In community hospital, hospitalist is often the physician leader for pediatrics • Department chair may be office based • Unlikely to have pediatric ER • Neonatology often present, rarely involved with ward

24. Hospital RelationshipsKey Contacts for Pediatric Advocacy • VP of Medical Affairs • Patient Safety Officer • Department of Pediatrics Chair • Pharmacy, Radiology and Laboratory • Nurse Manager, VP of Nursing • Risk Manager • JCAHO • PI/QI

25. Hospital RelationshipsKey Physician Contacts • Department Chair • Office based PCPs, • Sub-specialists, adult and pediatric • Surgeons--general, pediatric & subspecialty • Anesthesiologists • Radiologists • ER • Pathologist/Clinical Lab Director • Outside tertiary care referral subspecialists

26. Hospital RelationshipsKey Committee Involvement • Patient Safety • Pharmacy and Therapeutics • Performance Improvement/QI • JCAHO • Credentials • Forms/Medical Records • Education • Multi-disciplinary Pediatric Committee • Create one if it doesn’t already exist

27. Initial Safety Efforts Leading by Example • Culture of safety • Teamwork • Do the little things right--if you don’t, no one will • ALWAYS wash hands, • always write mg/kg • Monitor and evaluate your own performance • Ask for feedback, debrief

28. Other Safety Projects for the Community Hospitalist • Clinical Practice Guidelines • Transitions of Care and Hand-offs • Medication safety and weight based dosing • Infection control • Rapid Response Team • Other knock-offs of successful projects already implemented in children’s hospitals

29. Tips for Success Vigilance on Advocacy Issues • Put pediatrics on the dashboard • Infrastructure is geared towards adult population • Get buy-in from pediatricians • Get buy-in from adults • Use example “if it were your child (use name)”

30. Tips for Success Beware of Potential Pitfalls • Change is never easy • Be cautious about how high to set the bar • Depends on local culture and politics • First task is to get buy-in for your hospitalist program • Identify and respect potential obstacles

31. Suggestions • Start small, improve your practice first • Create alliances with non-physicians • Create physician alliances • Specialty and surgical co-management* • Let others advocate for your expanded role • Change systems to change behaviors/ outcomes *Pediatrics March 2003, pp. 707-709

32. Opportunities for the Community Pediatric Hospitalist • Potential to directly impact care • Potential for a significant leadership role in your hospital • May extend to adult safety areas • Regional and national pediatric hospitalist and/or pediatric patient safety activities

33. Children’s Hospitalists

34. Perceptions – real or not? • Less individual responsibility to lead? • Focus on the greater good for all children • Infrastructure in place • Sophisticated endeavors: RRT, safety rounds • Administrators chart the safety course?

35. Key Resources and Personnel: the Hospital • All noted with Community Hospitalists apply • Liaisons with units intimate • Respecting expertise • Transfers of care; RRT; medication reconciliation • Partnership with PCPs • CSHCN, access for outpatient f/u studies • Key hospital administrators may be Hospitalists

36. Key Resources and personnel – The look within What qualities should you expect when hiring a Children’s Hospitalist? • Role on the pediatric ward • Culture; IHI efforts; teach safety at bedside • Role in the Hospital • Chair committees; seek projects; formal safety education

37. Key Resources and personnel – The look within Role with the Hospital • Local leader /representative • Discuss best practices, NACHRI, NICHQ interpretation • JCAHO implementation • The “go to” division for safety challenges • The “go to” division for patient safety research

38. Hospital Committees and Department Relationships • All noted with Community Hospitalists apply • QI and Medical Staff Executive Committee memberships a must • Department of Surgery and Trauma Committees • Key M&M Committees: Critical care, Transport, Emergency Department, Pediatrics • Chair of the University Department of Pediatrics

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

40. Tips for success • All noted with Community Hospitalists apply • Awareness of site-specific issues • Learn your system and stakeholders • Insert safety as part of your division’s mission • Legitimize hospitalists’ efforts in patient safety by leading systems improvement efforts

41. Hospital Medicine Web Resources • AAP Section on Hospital Medicine and LISTSERV • NAlexander@aap.org • Ambulatory Pediatric Association Special Interest Group in Hospital Medicine • www.Ambpeds.org • Society of Hospital Medicine • www.hospitalmedicine.org

42. Patient Safety Resources • AAP Practice Management – Safety. http://practice.aap.org/topicBrowse.aspx?nodeID=1000.1013.1020 • AAP Things that work.http://www.aap.org/visit/thingsthatworkcall.htm • Child Health Corporation of America CHCA http://www.chca.com/company_profile/pi/index.html • Agency for Healthcare Research and Quality AHRQ www.ahrq.org. • National Insitute for Child Health Quality. http://www.nichq.org/nichq 100 Lives campaign.

43. Patient Safety Resources • Institute for HealthCare Improvement http://www.ihi.org/ihi Leadership Guide to Patient Safety – Free download. • Principles of Patient Safety in Pediatrics Pediatrics Vol. 107 No. 6 June 2001, pp. 1473-1475 American Academy of Pediatrics National Initiative for Children's Health Care Quality Project Advisory Committee • AAP Safer Heath Care for Kids Webinars • AAP Safety email list