Assessment Description
Respond to the following:
- Explain why collaboration is important in managing a patient.
- What is your responsibility as an AGACNP in the outpatient setting?
- How does it differ from an inpatient setting?
- Discuss a situation in which you have successfully collaborated or delegated to ensure the patient’s plan of care goes as planned.
- The patient needs may be emotional, spiritual, or physical in nature. Include discussion of how the Christian worldview perspective can be applied to meet these patient needs.
Support your summary and recommendations plan with a minimum of two APRN approved scholarly resources.
You must answer all parts of this discussion question to receive full credit.
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CHAPTER 7
Principles of Evidence-Based Medicine
and Quality of Evidence
Daniel I. Steinberg, MD
INTRODUCTION
A BRIEF HISTORY
The March 1, 1981 issue of the Canadian Medical Association Journal included a
landmark article titled “How to read clinical journals: I. Why to read them and how to start
reading them critically.” Written by David Sackett, MD (1934–2015) of McMaster
University, it introduced a series of articles that highlighted the importance of critical
appraisal of the literature. Starting in 1993, a set of articles in the Journal of the American
Medical Association titled “Users’ guides to the medical literature” reprised and expanded
on the earlier series. These works, and other efforts by their authors, made critical
appraisal of the literature accessible to the masses and laid the groundwork for evidence-
based medicine (EBM).
Gordon Guyatt, MD, coined the term “evidence-based medicine” in the early 1990s,
while he served as the internal medicine residency program director at McMaster
University. Dr. Guyatt and colleagues had incorporated critical appraisal of the literature
into the residency program curriculum, and Dr. Guyatt wanted a term to describe and
advertise their efforts.
EBM caught on quickly over subsequent years as practicing physicians and training
programs embraced and taught its methods, with dissemination greatly fueled by the rise
of the Internet.
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ROLE OF CLINICAL JUDGMENT AND PATIENT PREFERENCES IN EBM
An early criticism of EBM, which some still harbor, was that it did not properly
acknowledge the importance of clinical judgment or patient preferences. In an updated
framework for evidence-based practice by R. Brian Haynes, P.J. Devereaux, and Gordon
Guyatt in 2002, evidence-based decisions are based on four cardinal elements: (1) the
research evidence, (2) the patient’s clinical state and circumstances, (3) the patient’s
preferences, and (4) the clinician’s judgment and expertise.
PRACTICE POINT
Clinical judgment and expertise are essential to the practice of EBM. These skills
facilitate optimal decision making by allowing the clinician to properly weigh the
research evidence in the context of the patient’s individual clinical circumstances and
preferences. Decisions should never be based on the evidence alone.
Practicing EBM may appear to be a straightforward affair with its methodical
approaches to clinical question construction and to searching and critically appraising the
literature. However, hospitalists should not confuse process with content, and they will
often find that EBM tends to highlight clinical uncertainty and gaps in the medical
literature. High-quality evidence does not exist to guide all clinical decisions, and
extrapolation from lower quality evid
1578185 – McGraw-Hill Professional ©
CHAPTER 21
Principles and Models of Quality
Improvement: Plan-Do-Study-Act
Emmanuel S. King, MD, FHM
Jennifer S. Myers, MD, FHM
INTRODUCTION
Achieving better health outcomes for patients and populations requires a focus on
continuous quality improvement (QI). While physicians pride themselves on being subject
matter experts in their focused area of medical practice, such knowledge alone is
insufficient to produce fundamental changes in the delivery of health care. Physicians
who practice in complex hospital and health care systems must acquire another kind of
knowledge in order to develop and execute change.
W. Edwards Deming, an American statistician and professor who is widely credited
with improvement in manufacturing in the United States and Japan, has described this
knowledge as a “system of profound knowledge” (Figure 21-1). This knowledge is
composed of the following items: appreciation for a system, understanding variation,
building knowledge, and the human side of change. These concepts are just beginning to
be taught to health care professionals and are essential for anyone who wishes to
improve the health care delivery system.
1578185 – McGraw-Hill Professional ©
Figure 21-1 Deming’s System of Profound Knowledge. (Reproduced, with permission, from
Langley GJ, et al. The Improvement Guide: A Practical Approach to Enhancing
Organization Performance, 2nd ed. San Francisco, CA: Jossey-Bass; 2009.)
All hospitalists have witnessed changes that did not result in fundamental
improvements within their hospital systems: the computerized order set that was
successfully implemented but never revised based on prescribers’ feedback, the paper
checklist for medication reconciliation that never gets filled out, or the new rounding
system that worked for the first few weeks but then failed to become a standard part of
practice due to physician variation or lack of commitment. These are all examples of first-
order changes—changes that ultimately returned the system to the normal level of
performance. In quality improvement work, individuals must strive for second-order
changes, which are changes that truly alter the system and result in a higher level of
system performance. Such changes impact how work is done, produce visible, positive
differences in results relative to historical norms, and have a lasting impact. Although the
model for improvement described below may seem simple, it is actually quite demanding
when used properly; and the process is essential to both learning and ultimately changing
complex systems.
PLAN-DO-STUDY-ACT AS A TOOL FOR QUALITY IMPROVEMENT
The Plan-Do-Study-Act (PDSA) model is a commonly used method in quality
improvement. Shewart and Deming described the model many years ago when they
studied quality in other industries. This mod
1578185 – McGraw-Hill Professional ©
ospitalists assume patients understand their presence at the bedside. More effort in
explaining the role of the hospitalist as the internal medicine physician or family medicine
physician who is responsible for patient care while the patient is in the hospital is
essential. Once patients understand that the hospitalist is the physician assuming
responsibility for everything from admission to discharge, including making patient
rounds and ordering all needed tests and procedures it helps them understand why the
hospitalist is caring for them. An important component of the dialog is that the patient
understands that their primary care provider (PCP) is informed of their progress and
resumes care for the patient postdischarge.
With the Centers for Medicare and Medicaid Services moving from a fee-for-service to
a fee-for-value payor, the hospitalist takes on an important role in coordination of care
with a focus on population health. Today there is a deeper understanding of the
importance of managing population health to drive the health of the community that a
health system serves. Central to this movement is the need for robust measurement
systems that enable us to concentrate on the outcomes of a population instead of
individual silos within the delivery system. Hospitalists are in unique position to deliver on
the Institute of Medicine’s “Triple Aim,” targeting better health for the population, better
quality and patient experience of care while lowering the cost of care. With more than 50%
of all health care spending generated from the acute care admission through the 90-day
postacute period, the hospitalists team is ideally suited to manage care from the
emergency department (ED) to postacute care.
The highest performing hospitalist groups can bring value to the populations they
serve through predictable outcomes. Hospitals would benefit from bringing hospitalists
into the discussion about population health and overall performance improvement in
acute and postacute care management. Many hospital Accountable Care Organizations
(ACOs) have not focused on a postacute care strategy, where much of the variability and
costs occur in the 90-day period following discharge nor have they recognized the role
hospitalists can play in tackling this issue. Improving performance across the acute
episode of care is best achieved with a comprehensive hospitalist infrastructure that
incorporates physician development, leadership support and incorporation of evidence-
based data to measure performance and drive continuous quality improvement. High-
performing hospitalist teams that hardwire these elements into their practice will drive
performance improvements and grow their practice.
This chapter explores the specific components essential to building, growing, and
managing a thriving hospitalist practice with staying power in light of the new fee-for-
1578185 – McGraw-Hill Professional ©
CHAPTER 26
Negotiation and Conflict Resolution
Leslie A. Flores, MHA
INTRODUCTION
Hospitalists face the potential for conflict every day. They work in highly complex
organizations and in order to be successful they must interact effectively with a wide
variety of individuals in what is often a challenging, emotionally charged environment.
Hospitalists must learn to navigate not only the formal organizational bureaucracy of
rules, systems, and processes, but also the informal political hierarchy that influences
power and decision making. Often, they must do so with little or no formal training in
conflict management at an early stage in their medical careers. In addition, they may
encounter conflicts between what others would like them to accomplish and their own
workload demands and professional expectations.
Hospital Medicine is also a young, evolving specialty that has enjoyed unprecedented
growth by serving the needs of multiple competing stakeholders. Although the specialty is
maturing, it is still populated by a high proportion of recent residency graduates and early-
career clinicians who may not have a complete understanding of the specialty or even
have career advancement on their radar screen. The potential exists for the service
obligations—both clinical and in the area of institutional performance improvement—of
hospitalists to overwhelm opportunities for professional development, and this may
promote career dissatisfaction, turnover, and symptoms of burnout. Leaders of hospitalist
services may find themselves isolated as they advocate for the professional development
and job satisfaction of group members while meeting the service expectations of their
employers or supervisors. The professional medical society for hospitalists, the Society of
1578185 – McGraw-Hill Professional ©
Hospital Medicine, is rapidly developing flexible support resources for hospitalists relating
to business and clinical practice, engagement and career satisfaction, core competencies,
and role expectations. Until these standards become widely disseminated and health care
services become better designed and hence less prone to error, hospitalists will continue to
work in a hospital environment where they will increasingly be expected to perform as
change agents at a time when change may not be welcomed by their hospitalist
colleagues or others at their institutions.
For the purposes of this chapter, it will be important to distinguish between
disagreements and conflicts. Disagreements happen regularly in human interactions, and
occur whenever two or more individuals have differing opinions about something. A
disagreement need not devolve into a conflict, and many do not. Conflicts arise when a
party perceives that another party has negatively affected or will negatively affect
agendas that the first p
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