Geographical assignment of hospitalists in an urban teaching hospital: feasibility and impact on efficiency and provider satisfaction

<p><b>Objective</b>: To evaluate whether implementation of a geographic model of assigning hospitalists is feasible and sustainable in a large hospitalist program and assess its impact on provider satisfaction, perceived efficiency and patient outcomes.</p> <p><b>Methods</b>: Pre (3 months) – post (12 months) intervention study conducted from June 2014 through September 2015 at a tertiary care medical center with a large hospitalist program caring for patients scattered in 4 buildings and 16 floors. Hospitalists were assigned to a particular nursing unit (geographic assignment) with a goal of having over 80% of their assigned patients located on their assigned unit. Satisfaction and perceived efficiency were assessed through a survey administered before and after the intervention.</p> <p><b>Results</b>: Geographic assignment percentage increased from an average of 60% in the pre-intervention period to 93% post-intervention. The number of hospitalists covering a 32 bed unit decreased from 8–10 pre to 2–3 post-intervention. A majority of physicians (87%) thought that geography had a positive impact on the overall quality of care. Respondents reported that they felt that geography increased time spent with patient/caregivers to discuss plan of care (p < 0.001); improved communication with nurses (p = 0.0009); and increased sense of teamwork with nurses/case managers (p < 0.001). Mean length of stay (4.54 vs 4.62 days), 30-day readmission rates (16.0% vs 16.6%) and patient satisfaction (79.9 vs 77.3) did not change significantly between the pre- and post-implementation period. The discharge before noon rate improved slightly (47.5% – 54.1%).</p> <p><b>Conclusions</b>: Implementation of a unit-based model in a large hospitalist program is feasible and sustainable with appropriate planning and support. The geographical model of care increased provider satisfaction and perceived efficiency; it also facilitated the implementation of other key interventions such as interdisciplinary rounds.</p

Physician communication coaching effects on patient experience

<div><p>Background</p><p>Excellent communication is a necessary component of high-quality health care. We aimed to determine whether a training module could improve patients’ perceptions of physician communication behaviors, as measured by change over time in domains of patient experience scores related to physician communication.</p><p>Study design</p><p>We designed a comprehensive physician-training module focused on improving specific “etiquette-based” physician communication skills through standardized simulations and physician coaching with structured feedback. We employed a quasi-experimental pre-post design, with an intervention group consisting of internal medicine hospitalists and residents and a control group consisting of surgeons. The outcome was percent “always” scores for questions related to patients’ perceptions of physician communication using the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey and a Non-HCAHPS Physician-Specific Patient Experience Survey (NHPPES) administered to patients cared for by hospitalists.</p><p>Results</p><p>A total of 128 physicians participated in the simulation. Responses from 5020 patients were analyzed using HCAHPS survey data and 1990 patients using NHPPES survey data. The intercept shift, or the degree of change from pre-intervention percent “always” responses, for the HCAHPS questions of doctors “treating patients with courtesy” “explaining things in a way patients could understand,” and “overall teamwork” showed no significant differences between surgical control and hospitalist intervention patients. Adjusted NHPPES percent excellent survey results increased significantly post-intervention for the questions of specified individual doctors “keeping patient informed” (adjusted intercept shift 9.9% P = 0.019), “overall teamwork” (adjusted intercept shift 11%, P = 0.037), and “using words the patient could understand” (adjusted intercept shift 14.8%, p = 0.001).</p><p>Conclusion</p><p>A simulation based physician communication coaching method focused on specific “etiquette-based” communication behaviors through a deliberate practice framework was not associated with significantly improved HCAHPS physician communication patient experience scores. Further research could reveal ways that this model affects patients’ perceptions of physician communication relating to specific physicians or behaviors.</p></div

HCAHPS intercept shift by provider group over time period.

<p>HCAHPS intercept shift by provider group over time period.</p

Non-HCAHPS physician specific patient experience survey (NHPPES) intercept shift by time period.

<p>Non-HCAHPS physician specific patient experience survey (NHPPES) intercept shift by time period.</p

HCAHPS trends in “Percent Always” and NHPPES trends in “Percent Excellent”

<p>HCAHPS trends in “Percent Always” and NHPPES trends in “Percent Excellent”</p

HCAHPS patient characteristics by provider group over time period.

<p>HCAHPS patient characteristics by provider group over time period.</p

NHPPES patient characteristics by time period.

<p>NHPPES patient characteristics by time period.</p

Biotherapeutics with minor differences in sequence can be distinguished by the IVCIA assay.

<p>Several sequence variants of FP1 varying by one (mutant-1 and mutant-2) or two (mutant-3) amino acids, as well as FP1 lacking the Fc domain (FP1 (no Fc)) were tested in the in the IVCIA assay using 50 healthy human donors over 5–8 days. FP1 is a biotherapeutic fusion protein of an enzyme fused to the Fc domain of a monoclonal antibody. The percentage of donors with either A) a positive T-cell proliferative response ([3H]-thymidine uptake) or B) an increase in the number (No.) of IL-2 secreting cells (Elispot), or C) both positive T-cell proliferative responses and an increase in the number of IL-2 secreting cells are shown. A response was considered positive if the SI≥2.0 (<i>p</i><0.05) above the background response.</p

Stages of biotherapeutic development where the IVCIA assay can be used for risk assessment related to attributes.

<p><i>In silico</i> or algorithm based assessments rank order and identify lead candidates based on the least sequence based risk. <i>In vitro</i> assessments identify non-sequence attributes and any immune mediated target based risk at preclinical stage prior to first in human (FIH). Pharmacogenomic assessments for HLA can be introduced in long-term clinical studies (Phase 1b/2) to evaluate associations of HLA with clinical immunogenicity. Immunogenicity assessments measured in serum as ADA span the breadth of clinical trials and disease indications (FIH to Launch/post launch). <i>In vitro</i> assays also provide attribute related risk assessment of manufactured lots, lot-to-lot comparability, and risk post packaging due to attributes related to storage, shipping, handling, and device-related leachates.</p

High numbers of aggregates of a wide array of antibodies can be detected by the IVCIA assay.

<p>10 mAbs (with known or predicted rates of clinical immunogenicity) were aggregated by stirring stress and then evaluated in the IVCIA assay in a population of 50 heathy human donors. The percentage of donors that responded to the original mAb (<i>solid bars</i>) and the aggregated mAb (<i>striped bars</i>) by A) positive T-cell proliferative responses ([³H]-thymidine uptake) or B) an increase in the number (No.) of IL-2 secreting cells (Elispot) over the course of the entire study (5–8 days) are displayed. The percentage of donors that showed C) either a positive T-cell proliferation response or an increase in the concentration of IL-2 secreted (multiplex cytokine analysis) or D) a positive T-cell proliferation response and an increase in the number of IL-2 secreting cells are depicted. The y-axes of graphs in Figs <a href="http://www.plosone.org/article/info:doi/10.1371/journal.pone.0159328#pone.0159328.g001" target="_blank">1</a> and <a href="http://www.plosone.org/article/info:doi/10.1371/journal.pone.0159328#pone.0159328.g004" target="_blank">4</a> are on different scales. Not all donors were tested for IL-2 concentration for some samples (<i>grey circles</i>). A response was considered positive if the SI ≥ 2.0 (<i>p</i><0.05) for proliferation or number of IL-2 secreting cells, or the SI ≥ 1.9 for IL-2 concentration (above the background response). Borderline responses were also included in some cases (SI≥1.9, <i>p</i><0.05), and are shown with one asterisk. mAbs are in the same order as <a href="http://www.plosone.org/article/info:doi/10.1371/journal.pone.0159328#pone.0159328.g001" target="_blank">Fig 1</a>. The scale bars at the top of each graph show the highest incidence of immunogenicity reported for each mAb in <a href="http://www.plosone.org/article/info:doi/10.1371/journal.pone.0159328#pone.0159328.t001" target="_blank">Table 1</a>. All rates are associated with diverse disease indications and assay testing platforms with variable sensitivity. <i>Black circles</i> show the responses in duplicate experiments in different sets of 50 donors.</p