How Hospitalists in Training Are Improving Quality of Patient Care in Dutch Hospitals

Introduction The hospitalist is a well-known professional in American hospital care, providing good clinical care with better continuity of care, less fragmentation, and at a lower cost.1 They are an indispensable link in hospital care. In analogy to this profession, a training program for hospitalist doctors was introduced in the Netherlands in 2012, through The Association of Hospitalists (Vereniging voor ZiekenhuisGeneeskunde [VvZG]), which was established in 2012. With the agreement of all medical scientific associations, the specialty of hospitalist doctors was officially recognized by the College of Medical Specialties (College Geneeskundig Specialisten) in 2014. Since then, about 70 hospitalist doctors have been trained, based in 9 hospitals throughout the Netherlands. The hospitalist training program has a duration of 3 years after medical school. It includes intensive training in several clinical specialties: internal medicine, surgery, geriatrics, anesthesia, neurology, and a so-called transmural, primary care internship. During these years, there has been special attention for multimorbidity. The training program also includes 2 intensive, multiple-day courses in clinical governance and quality improvement (QI). The first course is about clinical governance and includes accountability for patient care, clinical audit, implementing evidence-based practice, the patient experience, patient safety, risk management, and root cause analysis of serious incidents. The second course is about QI and is focused on the step-by-step completion of a QI project, following a model used in the United Kingdom, the so-called A-TEAM methodology.2,3 Hospitalists are required to complete a QI project by the end of their training. Both the 5-day clinical governance and QI courses are now taught by experienced hospitalists; the courses were developed and are supported by materials supplied by Healthcare Quality Quest, a UK provider of these training courses.2 Over the past 12 years, hospitalist trainees have taken on a wide range of subjects for QI and made substantial contributions to improving patient care in the hospitals in which they work. This article will give an overall impression on the scope of the QI projects carried out by hospitalist trainees. Method The approach to QI used by the hospitalists is generic and based on a model that consists of the following stages:2,3 (A) agreeing on what to improve, (T) testing commitment to the project by the involved stakeholders, (E) establishing a baseline of current practice, (A) analyzing current practice to identify problems and their causes, and acting to improve practice through various interventions, and (M) measuring again to see if the change interventions have been successful. There are large differences in tools and techniques used in all different stages. For example, for agreement on the subject, the techniques such as the nominal group technique (ranking ideas), the Delphi technique (prioritizing), quality impact analysis (what matters), and multivoting are used. For testing commitment, the force field analysis is the most popular to use, but stakeholder analysis and also Delphi technique are used in this stage. At the stage of establishing the baseline, different techniques used depended on the subject of the QI project. Process mapping is frequently used for analyzing how things work at the start of the project. But also run charts, surveys, and clinical audits are used a lot. At this stage, literature searches for appraising evidence about the subject and benchmarking are used. Also, basic measurements or counts can be used (eg, how many patients at department x have thrombosis prophylaxis as described in the Padua guidelines). In the analytic phase where the hospitalists really dive into “the why?” behind the problem, they use pattern analysis, fishbone analysis, and the “5 times why-tool.” After these analytic stages, there will be phases of formulating one or more interventions to implement in trying to improve quality on the concerning subject, implementing itself, and afterward measuring the difference. The database of the QI projects carried out by hospitalist trainees was accessed to learn about the subjects covered and the extent to which they influence clinical practice in the hospitals where the hospitalists work. The database is maintained by the Association of Hospitalists. All projects were performed according to the A-TEAM methodology as described above. The subjects of the QI projects were grouped into themes including medication safety, anticoagulation, allergies, pain management, frail elderly patients, the perioperative process, patient flow, overall clinical care, communication and information transfer, and others. In order to provide more insight into the methodology, 3 projects of different themes are highlighted. The projects were chosen that the authors have full access to. A conscious choice was made to pick 3 projects of the earlier years (2017, 2019, and 2020) to find out if the improvements have been maintained, failed, or even have been extended. In order to give an actual status update the authors contacted Dutch hospitalists and asked about the sustainability of their project. It was not possible to track this down for every project because sometimes the hospitalists leave their training hospital when they complete their training to take full-time employment as a hospitalist in other clinics or sometimes overseas. Results A total of 75 QI projects were completed by the hospitalist trainees over 12 years. The subjects of the projects by theme are in Table 1. Two of the QI projects have been published.4,5 Three of the older projects are highlighted in the following sections. Table 1. - Quality Improvement Projects Carried Out by Dutch Hospitalists in Training. Polypharmacy and medication safety • Medication verification in the cardiology department • Improving medication safety at discharge from the hospital for elderly people • Improving medication safety in the ear nose throat (ENT) department • Medication safety in the transfer department (Dutch department managing transferal of patients to rehabilitation, nursing home, or their own homes with home nursing care) • Prevention of avoidable damage caused by diuretic drugs in chemotherapy for testicular cancer • Improving medication safety on admission for surgical patients • Improving scanning of both the patient and the medication when administering medication • Avoiding the use of sedatives and long-acting opiates until the night after surgery in patients who have received intrathecal morphine • Improving the timeliness of switching from intravenous to oral antibiotics in the infectious diseases department • Reducing polypharmacy in the elderly Anticoagulation • Increasing patient safety by increasing knowledge in the use of anticoagulation • Process improvement for dosing vitamin K antagonists • Improving venous thromboembolism prophylaxis in the internal medicine and geriatric departments • Improving attention to anticoagulation by means of a pocket card • Improving reporting of anticoagulation use in the preoperative screening application2 • The use of perioperative platelet aggregation inhibitors and NSAIDs in elective hip or knee replacement Allergies • Development and implementation of a new allergy and side effect registration method • Improving the care for patients with suspected penicillin allergy Pain management • Improving pain management for back problems • Improving pain management in stroke care unit patients • Postoperative assessment of pain measurement in orthopedic patients • Implementation of work process agreement “paracetamol 1 hour preoperatively” • Improving postoperative pain control in general surgery, vascular surgery, and trauma surgery • Improving postoperative pain relief in a surgical department of an academic hospital Frail elderly • Correct application of nursing interventions to prevent delirium • Improving delirium prevention in vulnerable elderly people • Drawing up and implementing a hospital-wide fall protocol • Improving care for the vulnerable cardiothoracic surgery patients through the implementation of a frailty score • Drawing up and implementing the Comprehensive Geriatric Assessment form • Early detection and prevention of delirium implementing working agreements for shortening the length of stay of geriatric patients in the emergency department The perioperative process • Implementation of an Early Warning Score system in the surgical department • Implementing the “Enhanced Recovery After Surgery” protocol in the surgical department • POOP: Post-Operative Constipation Prevention project • Improving the process for perioperative diabetes care in patients with diabetes mellitus admitted to the surgical department. • Perioperative glucose control in patients with diabetes mellitus – hospital wide • Analysis of registration of the Early Warning Score in the cardiothoracic surgery department • Improving routine use of bladder catheters during elective placement of total knee prosthesis Patient flow • Implement the national transmural care path for acute lung attacks with admission of COPD patients • Reducing the length of stay of lung patients in the Acute Service • Improving patient flow at the gastroenterology department through the implementation of best practices for doctors’ rounds • Improving transfers of patients between the Center for Unplanned Admissions and the Medium Care Unit • Improving discharge procedures • Improving patient rounds • The doctors round card: an initiative to promote patient participation during clinical admission to the gastroenterology department • Application of discharge criteria for heart failure patients in the cardiology department • Interhospital ICU transport • Optimizing transfer of care from the ICU adults to the Intensive Nursing Care Unit • ICU discharge: improving patient safety through handoff improvement and increased awareness Overall improvement of clinical care • Complication registration and discussion in the neurology department • Improving intravenous needle care in the pulmonary medicine department • Reducing sedentary behavior of patients admitted for pulmonary medicine • Optimizing care for the sleepless patient in the hospital • Is bandaging necessary to prevent intravenous access from dislocating • Improving timely indication of palliative care and starting a “two-track policy” for patients with hematological malignancies • From improvisation to implementation of the Modified Early Warning Score hospital wide in times of crisis Communication/information transfer • Inform patients faster and better about diagnosis and purpose of admission • Communication with patients and first contacts in the geriatric department • Improve the timeliness and content of discharge letters in the cardiology department • Improve the timeliness of discharge letters and current medication overview on discharge from the neurology department to another health care institution • Communication regarding discharge from the cardiology department • Improving the transfer of information between doctor and patient regarding treatment limitations in the cardiology department • Improve the timeliness of medical discharge letters and up-to-date medication overviews on discharge from the surgical department • Optimize communication between the transfer agency and the nursing department • Organizing postdischarge communication for cardiology patients • Improving the provision of patient information about working on recovery during admission for postoperative colorectal patients • Improve the timeliness of the medical discharge to the general practitioner on discharge • Improving the transfer of care for terminally ill patients • Pleasant, effective, and safe communication between doctors and nurses for good quality care in the short-stay department • Learning from patients: “the art of informing” • Implementing the proactive palliative heart failure care plan Other subjects • A quality improvement project regarding resuscitation policy, hospital wide. • Tissue donation3 • Clinical improvement project “care process for living kidney donation.” • No more “hocus pocus” for hospitalists in training in an academic hospital: about the skill of point-of-care ultrasound • Evaluation of and vision on the positioning of the hospitalist in Dutch health care Abbreviation: COPD, chronic obstructive pulmonary disease; ICU, intensive care unit; NSAID, non steroidal anti inflammatory drugs. Short Summary of QI Project 1: Improving Medication Safety at Discharge From the Hospital for Elderly People Agree on the Subject and Test Commitment A brainstorm and in second phase a nominal group process were used. The goal was to improve medication safety at discharge for people 70 years of age and older from the internal medicine department. Establish the Baseline The hospitalist in training started with a literature research to find out a “best practice.” After that, there was a preliminary measurement in the form of a clinical audit and a process chart was also made. With a focus group, a root cause analysis was made. In addition, a local general practitioner (GP) was peer reviewed to ask what they missed in the transfer of care and information after hospital admission. Also, a patient satisfaction survey was done. Analyze Current Practices and Implement Improvement Results The clinical audit (n = 72) showed that medication safety at discharge did comply with best practices in less than 50% of cases. One of the most important things of the root cause analysis was that there was a local protocol for the nurses for discharge, but not for the doctors. The peer review with a local GP said that discharge letters often are later than the national agreement prescribes (<24 hours after discharge). If medication is changed or stopped during admission most of the time the reasons why are not explained in the letter. Nor is it clear to the GP whether they should follow up on anything. The patient satisfaction survey had a response rate of 20% (n = 55). About 30.7% of patients think communication during admission was insufficient. And 43.9% of patients think communication at discharge was insufficient. Improvement Plan A short, easy-to-use protocol was made for the doctors, which formulated a couple of steps to take at discharge. The key elements of that protocol are: There has to be a discharge conversation between the doctor and the patient. This discharge conversation needs to be noted in the patient's file. If medication is changed or stopped, there has to be an explanation in the discharge letter. Discharge letters need to be sent <24 hours after discharge. Measure Again After the implementation of the protocol, a clinical audit was repeated. It showed that compliance with best practices is now reached in 80% of cases. There also was an analysis of the different steps in the protocol to see how to improve even more in the future. Actual State of the Project (Done in 2017) The project is further developed and implemented hospital wide. With nowadays support from the pharmacy assistants. Short Summary of QI Project 2: Improving Venous Thromboembolism Prophylaxis in the Internal Medicine and Geriatric Departments Agree on the Subject and Test Commitment A brainstorm was used to agree on the subject. The goal was to improve adequate use of thromboembolism prophylaxis to prevent avoidable damage to patients at the internal medicine and geriatrics department. Establish the Baseline The hospitalist in training started with a literature research to find out the “best practice.” After that, there was a preliminary measurement in the form of a clinical audit. A survey to all doctors (in training) at these 2 departments was used to make a root cause analysis. Analyze Current Practices and Implement Improvement Results A literature research was done. It shows that the Dutch national guideline was up to date with the most recent literature. From there on, the hospitalist in training used the Dutch national guideline as best practice. The core of this protocol is the Padua Prediction Score. A clinical audit showed a difference between policy regarding thromboembolic prophylaxis upon admission and policy during admission. At the internal medicine department, thromboembolic prophylaxis upon admission did comply with best practice in 88% of cases. However, evaluation during admission complied with best practice in only 37% of cases. At the geriatrics department, thromboembolic prophylaxis upon admission did comply with best practice in 77% of cases. However, evaluation during admission complied with best practices in 85% of cases. The survey to all doctors in training showed us that no one really knew the national guidelines. It also showed us that at the internal medicine department, the Padua Prediction Score was used upon admission, but there was no structural attention to evaluate this in the daily rounds. At the geriatric department, nobody even heard of the Padua Prediction Score, but there was structural attention to thromboembolic prophylaxis in the daily rounds. Improvement Plan A short local protocol was made, derived from the national guideline. Training about this theme and the protocol was provided to all doctors in training. Measure Again After the implementation of the protocol, a clinical audit was repeated. It showed that both departments improved. At the internal medicine department, thromboembolic prophylaxis upon admission had risen to 93% compliance with best practice. At the geriatrics department, compliance was 96%. Evaluation during admission reached a markable 100% in the geriatrics department. However, at the internal medicine department, compliance was 44%. Actual State of the Project (Done in 2020) The anticoagulant committee evaluates this subject on a structural basis, hospital wide. Short Summary of QI Project 3: Implementation of Work Process Agreement “Paracetamol 1 Hour Preoperatively” Agree on the Subject and Test Commitment In 2017, a local work agreement was changed about the use of paracetamol perioperatively. At first, paracetamol was given intravenously at induction of anesthesia. They changed to oral paracetamol 1 hour before, with the calculated significant cost savings. The hospitalist in training noticed during her internship that this working agreement was not always followed. With the medical specialists of the department anesthesiology and surgery and executives, she agreed to investigate this. Establish the Baseline The hospitalist in training did a preliminary measurement through a clinical audit. Analyze Current Practice and Implement Improvement Results The clinical audit showed that only 41% of patients were treated with oral paracetamol, as the new work agreements intended. With a focus group of nurses and doctors from the involved departments, a root cause analysis was made. The 5 times why the method was also used to further specify the causes of the problem. In the same group, improvement measures were explored through the Commercial Aviation Safety Team model. This is helpful to prioritize the measures and decide what to focus on. Improvement Plan The hospitalist worked in a short-cycled improvement method. In this method, small changes and evaluation alternate. A protocol was written for the surgical admission department. Different ways of communication were used: newsletters, shift handovers, and email. The key element was to decide who was for the Measure Again In the short-cycled improvement method, frequently again after different small steps of In this different for the were as different ways of communication about the With every the of compliance In the in of paracetamol was given 1 hour the as the working agreement intended. 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