Prioritizing Patient Safety Efforts in Office Practice Settings.

Objectives: Outpatient care settings face unique risks of adverse events and medico-legal liability, often worsened by inconsistent processes and fragmented care. Health systems are increasingly providing integrated care that includes outpatient care, but models of how to systematically target medico-legal risk in office practices are largely absent. Innovative and scalable efforts are needed to guide large health systems in their approach to outpatient safety.

Building a Medicaid Ambulatory Complex Care Program Within an Urban Medical Home.

Five percent of Medicaid patients account for 50% of total costs. Preventable costs are often incurred by patients with complex medical, behavioral, and social needs who disproportionately utilize acute care services. Evidence for design, implementation, and evaluation of complex care programs in the urban Medicaid population is lacking.

Strategic Review Process for an Accountable Care Organization and Emerging Accountable Care Best Practices.

Accountable Care Organizations (ACOs), like other care entities, must be strategic about which initiatives they support in the quest for higher value. This article reviews the current strategic planning process for the Johns Hopkins Medicine Alliance for Patients (JMAP), a Medicare Shared Savings Program Track 1 ACO. It reviews the 3 focus areas for the 2017 strategic review process - (1) optimizing care coordination for complex, at-risk patients, (2) post-acute care, and (3) specialty care integration - reviewing cost savings and quality improvement opportunities, associated best practices from the literature, and opportunities to leverage and advance existing ACO and health system efforts in each area.

Establishing an Ambulatory Medicine Quality and Safety Oversight Structure: Leveraging the Fractal Model.

Problem: Academic health systems face challenges in the governance and oversight of quality and safety efforts across their organizations. Ambulatory practices, which are growing in number, size, and complexity, face particular challenges in these areas.

Approach: In February 2014, leaders at Johns Hopkins Medicine (JHM) implemented a governance, oversight, and accountability structure for quality and safety efforts across JHM ambulatory practices.

The intersection between clinical excellence and role modeling in medicine.

Background: Role modeling is an integral component of medical education. The literature suggests that being a clinically excellent academic physician and serving as a role model for trainees are integrally related.

Purpose: To explore the relationship between being considered clinically excellent and being considered an effective role model.

Patient safety perceptions of primary care providers after implementation of an electronic medical record system.

Background: Increasing the use of electronic medical records (EMR) has been suggested as an important strategy for improving healthcare safety.

Objective: To sequentially measure, evaluate, and respond to safety culture and practice safety concerns following EMR implementation.

Design: Safety culture was assessed using a validated tool (Safety Attitudes Questionnaire; SAQ), immediately following EMR implementation (T1) and at 1.

The effect of computerized provider order entry on medical students' ability to write orders.

Background: Computerized provider order entry (CPOE) is being implemented at increasing numbers of U.S. hospitals, yet the effects of CPOE on medical student education are largely unstudied.

Advantages and challenges of working as a clinician in an academic department of medicine: academic clinicians' perspectives.

Background: The provision of high-quality clinical care is critical to the mission of academic and nonacademic clinical settings and is of foremost importance to academic and nonacademic physicians. Concern has been increasingly raised that the rewards systems at most academic institutions may discourage those with a passion for clinical care over research or teaching from staying in academia. In addition to the advantages afforded by academic institutions, academic physicians may perceive important challenges, disincentives, and limitations to providing excellent clinical care.

Creating an academy of clinical excellence at Johns Hopkins Bayview Medical Center: a 3-year experience.

Academic health centers (AHCs) are committed to the tripartite missions of research, education, and patient care. Promotion decisions at many AHCs focus predominantly on research accomplishments, and some members of the community remain concerned about how to reward clinicians who excel in, and spend a majority of their time, caring for patients. Many clinically excellent physicians contribute substantively to all aspects of the mission by collaborating with researchers (either through intellectual discourse or enrolling participants in trials), by serving as role models for trainees with respect to ideal caring and practice, and by attracting patients to the institution.

Implications of academic medicine's failure to recognize clinical excellence.

Objective: To better understand the implications of inadequately recognizing clinical excellence in academia by exploring the perspectives of clinically excellent faculty within prominent American departments of medicine.

Design: Qualitative study.

Setting: 8 academic institutions.

Documentation of code status and discussion of goals of care in gravely ill hospitalized patients.

Background: Timely discussions about goals of care in critically ill patients have been shown to be important.

Methods: We conducted a retrospective chart review over 2 years (2003-2004) of patients admitted to our medical service who were classified as "expected to die." Charts were evaluated for do-not-resuscitate (DNR) documentation and discussions of goals of care.

Pilot study comparing patients' valuation of health-care services with Medicare's relative value units.

Background And Aims: Physician reimbursement for services and thus income are largely determined by the Medicare Resource-Based Relative Value Scale. Patients' assessment of the value of physician services has never been considered in the calculation. This study sought to compare patients' valuation of health-care services to Medicare's relative value unit (RVU) assessments and to discover patients' perceptions about the relative differences in incomes across physician specialties.

Active bed management by hospitalists and emergency department throughput.

Background: When emergency departments are overcrowded, ambulances are diverted. Interventions focused primarily on emergency departments have had limited success.

Objective: To discover whether an active bed management, quality improvement initiative could reduce ambulance diversion hours and emergency department throughput times.

Clinical excellence in academia: perspectives from masterful academic clinicians.

Objective: To better understand and characterize clinical excellence in academia by exploring the perspectives of clinically excellent faculty in the top American departments of medicine.

Participants And Methods: Between March 1 and May 31, 2007, 2 investigators conducted in-depth semistructured interviews with 24 clinically excellent Department of Medicine physicians at 8 academic institutions. Interview transcripts were independently analyzed by 2 investigators and compared for agreement.

An innovative approach to supporting hospitalist physicians towards academic success.

Background: Academic hospitalist physicians face significant challenges that may threaten their chances for successful and timely promotions, such as heavy clinical workloads, limited training in research, and relatively few experienced mentors in their field. The appreciable growth of hospital medicine groups in recent years, as has occurred at our institution, compounds the predicament by diluting the limited resources that are available to support these physicians.

Methods: A needs assessment was followed by the development of specific objectives for the division and for individual members of the division related to academic success.

The good news about CPOE and medical student ordering ability.

When the quality of orders written by medical students was compared for those who trained at hospitals using computerized provider order entry (CPOE) to those who trained using handwritten orders, no significant differences were found.

Do fears of malpractice litigation influence teaching behaviors?

Background: Medical malpractice is prominently positioned in the consciousness of American physicians, and the perceived threat of malpractice litigation may push physicians to practice defensively and alter their teaching behaviors.

Purpose: The purposes of this study were to characterize the attitudes of academic medical faculty toward malpractice litigation and to identify teaching behaviors associated with fear of malpractice litigation.

Methods: We surveyed 270 full-time clinically active physicians in the Department of Medicine at a large academic medical center.

Health care utilization and the proportion of primary care physicians.

Background: The impact of primary care physicians on health care utilization remains controversial. Some have hypothesized that primary care physicians decrease health care utilization through enhanced coordination of care and a preventive care focus.

Methods: Using data from the Area Resource File (a Health Resources and Services Administration US county-level database) for the years 1990, 1995, and 1999, we performed a retrospective cross-sectional analysis with generalized estimating equations to determine if measures of health care utilization (inpatient admissions, outpatient visits, emergency department visits, and surgeries) were associated with the proportion of primary care physicians to total physicians within metropolitan statistical areas.

Discharging patients earlier in the day: a concept worth evaluating.

Patient discharges from the hospital often occur late in the day and are frequently clustered after 4 PM. When inpatients leave earlier in the day, quality is improved because new admissions awaiting beds are able to leave the emergency department sooner and emergency department waiting room backlog is reduced. Nursing staff, whose work patterns traditionally result in high activity of discharge and admission between 5 PM and 8 PM, benefit by spreading out their work across a longer part of the day.

Facing the malpractice crisis: academic physicians' willingness to accept quick fix solutions.

Background: We sought to determine the willingness of academic physicians to accept strategies to contain institutional malpractice costs.

Methods: We surveyed all 270 Department of Medicine physicians at a large academic center. Respondents were asked about their knowledge regarding malpractice premiums, willingness to reduce patient-care activities and accept decreases in compensation.

Morbidity and mortality conference, grand rounds, and the ACGME's core competencies.

Morbidity and Mortality (M&M) Conferences are an Accreditation Council for Graduate Medical Education (ACGME) mandated educational series that occur regularly at all institutions that have residency training programs. The potential for learning from medical errors, complications, and unanticipated outcomes is immense--provided that the focus is on education, as opposed to culpability. The education innovation described in this manuscript is the manner in which we have used the ACGME Outcome Project's 6 core competencies as the structure upon which the cases discussed at our M&M conference are framed.

Interdisciplinary medical, nursing, and administrator education in practice: the Johns Hopkins experience.

Reforming graduate medical, nursing and health administrators' education to include the core competencies of interdisciplinary teamwork and quality improvement (QI) techniques is a key strategy to improve quality in hospital settings. Practicing clinicians are best positioned in these settings to understand systems issues and craft potential solutions. The authors describe how, in ten months during 2004 and 2005 the school of medicine, the school of nursing, and an administrative residency program, all at Johns Hopkins University, implemented and evaluated the Achieving Competency Today II Program (ACT II), a structured and interdisciplinary approach to learning QI that was piloted at various sites around the United States.