The Creating Incentives and Continuity Leading to Efficiency staffing model: a quality improvement initiative in hospital medicine.

OBJECTIVE To determine the effect of a hospitalist-developed, continuity-centered hospitalist staffing model on patient outcomes and resource use. METHODS The Creating Incentives and Continuity Leading to Efficiency (CICLE) staffing model was conceived by a group of hospitalists who sought to improve continuity of inpatient care. Using a retrospective, observational, pre-post study design, we compared patient-level data for all discharges from our hospitalist service from 6 months after implementation of the CICLE staffing model (September 1, 2009, through February 28, 2010; n=1585) with data from those same months in the prior year (September 1, 2008, through February 28, 2009; n=1808). We used the number of unique hospitalists who documented an encounter during the admission as a measure of continuity of care. Length of stay and hospital charges per admission constituted the measures of resource use. RESULTS The odds of having a single hospitalist for the entire hospitalization nearly doubled under the CICLE model (odds ratio, 1.87; 95% confidence interval, 1.60-2.2; P<.001). Mean length of stay decreased 7.5% (from 2.92 before to 2.70 days after initiation of the model; P<.001). Mean hospital charge per admission decreased 8.5% (from $7224.33 before to $6607.79 after initiation of the model; P<.001). Thirty-day readmission rates were not substantially affected by the CICLE model (15.0% before to 17.3% after initiation of the model; P=.08). CONCLUSION Improved continuity of care among hospitalists was associated with reductions in length of stay and lower health care costs. These benefits were realized without substantially affecting readmission rates. The staffing model can be achieved by reorganizing existing hospitalists and may not require the hiring of additional personnel. The CICLE staffing model is a viable option for hospitalist groups that are aiming to diminish resource use and improve quality of care.

[1]  Jeffrey L. Schnipper,et al.  Association of Communication Between Hospital-based Physicians and Primary Care Providers with Patient Outcomes , 2008, Journal of General Internal Medicine.

[2]  Thomas G Rundall,et al.  The Impact of Hospitalists on the Cost and Quality of Inpatient Care in the United States: A Research Synthesis , 2005, Medical care research and review : MCRR.

[3]  S. Kripalani,et al.  Promoting effective transitions of care at hospital discharge: a review of key issues for hospitalists. , 2007, Journal of hospital medicine.

[4]  P Mills,et al.  The SQUIRE (Standards for QUality Improvement Reporting Excellence) guidelines for quality improvement reporting: explanation and elaboration , 2008, Quality & Safety in Health Care.

[5]  L. Andrews,et al.  An alternative strategy for studying adverse events in medical care , 1997, The Lancet.

[6]  T. Brennan,et al.  The nature of adverse events in hospitalized patients. Results of the Harvard Medical Practice Study II. , 1991, The New England journal of medicine.

[7]  N. Uddin,et al.  Comparison of hospital costs and length of stay associated with general internists and hospitalist physicians at a community hospital. , 2004, The American journal of managed care.

[8]  V. Arora,et al.  Care transitions for hospitalized patients. , 2008, The Medical clinics of North America.

[9]  A. Auerbach,et al.  Outcomes of care by hospitalists, general internists, and family physicians. , 2007, The New England journal of medicine.

[10]  Mark V. Williams,et al.  Transitions of Care Consensus Policy Statement American College of Physicians-Society of General Internal Medicine-Society of Hospital Medicine-American Geriatrics Society-American College of Emergency Physicians-Society of Academic Emergency Medicine , 2009, Journal of General Internal Medicine.

[11]  Genna R. Cohen,et al.  Hospitalists and care transitions: the divorce of inpatient and outpatient care. , 2008, Health affairs.

[12]  M. C. Peterson.  A systematic review of outcomes and quality measures in adult patients cared for by hospitalists vs nonhospitalists. , 2009, Mayo Clinic proceedings.

[13]  Rajendu Srivastava,et al.  Impact of a Hospitalist System on Length of Stay and Cost for Children With Common Conditions , 2007, Pediatrics.

[14]  C. Croux,et al.  Robust Regression in Stata , 2008 .

[15]  P. J. Huber.  The behavior of maximum likelihood estimates under nonstandard conditions , 1967 .

[16]  H. L. Le Roy,et al.  Proceedings of the Fifth Berkeley Symposium on Mathematical Statistics and Probability; Vol. IV , 1969 .

[17]  B. Dowd,et al.  The Effects of Scheduled Intern Rotation on the Cost and Quality of Teaching Hospital Care , 1994, Evaluation & the health professions.

[18]  E. Rich,et al.  Post-call transfer of resident responsibility , 1990, Journal of General Internal Medicine.

[19]  K. Shojania,et al.  National Patient Safety Goals. , 2006, Bulletin of the American College of Surgeons.

[20]  Mark V. Williams,et al.  Transitions of Care Consensus policy statement: American College of Physicians, Society of General Internal Medicine, Society of Hospital Medicine, American Geriatrics Society, American College Of Emergency Physicians, and Society for Academic Emergency Medicine. , 2009, Journal of hospital medicine.

[21]  D. Baker,et al.  Deficits in communication and information transfer between hospital-based and primary care physicians: implications for patient safety and continuity of care. , 2007, JAMA.

[22]  D. Baker,et al.  Results of the Medications At Transitions and Clinical Handoffs (MATCH) Study: An Analysis of Medication Reconciliation Errors and Risk Factors at Hospital Admission , 2010, Journal of General Internal Medicine.

[23]  Michael D Cohen,et al.  The published literature on handoffs in hospitals: deficiencies identified in an extensive review , 2010, Quality and Safety in Health Care.

[24]  Sunil Kripalani,et al.  Hospitalist handoffs: a systematic review and task force recommendations. , 2009, Journal of hospital medicine.

[25]  R. Wachter.  The state of hospital medicine in 2008. , 2008, The Medical clinics of North America.

[26]  Intern Call Structure and Patient Satisfaction , 1997 .

[27]  Kenneth Epstein,et al.  The impact of fragmentation of hospitalist care on length of stay. , 2010, Journal of hospital medicine.

[28]  C. Vincent.  Understanding and responding to adverse events. , 2003, The New England journal of medicine.

[29]  A. Wall,et al.  Book ReviewTo Err is Human: building a safer health system Kohn L T Corrigan J M Donaldson M S Washington DC USA: Institute of Medicine/National Academy Press ISBN 0 309 06837 1 $34.95 , 2000 .

[30]  H. White.  A Heteroskedasticity-Consistent Covariance Matrix Estimator and a Direct Test for Heteroskedasticity , 1980 .

[31]  L. Halasyamani,et al.  Transition of care for hospitalized elderly patients--development of a discharge checklist for hospitalists. , 2006, Journal of hospital medicine.