Knowledge has been limited by the rate of discovery in the past, but is now limited by the

rate of implementation. Patient “flow” (the rate

at which each needed service is provided)

through hospital and health care systems falls

squarely in this realm, offering implementation challenges and, at the same time, many

research opportunities. 

Principles of Flow Systems

For years, we in health care acted as though

“we were different” so the laws of supply and

demand and the principles of flow systems

didn’t really apply since “each patient is unique”

and the “industry is different.” We are now discovering otherwise. For example, just like the

telephone systems that Dr. Erlang studied

more than 100 years ago, we know that any

system that fully utilizes our services will create

a waiting time for that service. Thinking of

ourselves as a big system—one that has

patients (not widgets) needing to get in, receive

care, and move through one step to another—

has been a journey too slow in starting. 

VA estimates more than three billion dollars

per year in resources have been spent buying

care from non-VA organizations, much of it

because “we’re full.” VA patients are more

reliant on Medicare for hospitalization than on

the VA system. And, VA has at least 120,000

more days of inpatient stay than comparable

private sector benchmarks. Recognition that

we are falling short in these areas is driving us

to improve our systems. 

How can we become the best in patient flow?

The answer demands leadership, execution,

teamwork, measurement, and the capacity to

change. We must reduce delays experienced b

patients throughout the VA system. Consider,

for example, the frequent experience of

patients seeking colon cancer screening. The

patient waits for an appointment in primary

care, waits for lab results, waits for additional

tests, waits for colonoscopy, waits for surgery

(if necessary), and waits for the results.

Together, these waiting times in VA facilities

can result in a nearly one-year delay in the

diagnosis of colon cancer. 

Just as fast food pulled itself out of a slow,

multi-step past through systems engineering,

so too can VA eliminate unneeded delays. VA

must balance demand for a service with the

supply of the service. Eliminate backlogs.

Decrease queues. Develop contingency plans.

Manage demand and increase supply.

Synchronize the flow of work. Predict and

anticipate needs through effective communica

tion. Optimize space, equipment, and staff,

and, finally, manage constraints to flow within

and between departments. The VA system

includes a number of flow systems and we

must realize that care can only go as fast as th

slowest part of that system. Failure to leverage

these principles can result in the entire emergency room, or operating room, coming to a

halt because (unknowingly) everyone is waitin

for something as simple as a transporter to

move patients. Hospital discharge processes

can slow to a crawl because the doctor is on

the phone making appointments, something

others could do. Outpatient appointment

delays result in patients not receiving timely

follow-up from hospital care. This delay can

FORUM

The Challenges of Inpatient Flow in VA

By Mike Davies, M.D., FACP, University of South Dakota and VA Black Hills Health Care System

Contents

Director’s Letter 2

Response to Commentary 3

Research Highlights 4

Dialogue: The Role of

Hospitalists in VHA 7

July 2007 VA Health Services Research & Development Service

A publication of the VA Office of Research 

& Development, Health Services Research 

& Development Service, Center for

Information Dissemination and Education

Resources, in conjunction with AcademyHealth

translating research 

into quality health care

for veterans

continued on page 
2 ■ Forum/July 2007

Director’s Letter

It has been a very busy spring for

HSR&D. We have enhanced our data

security procedures and training, and

will continue to monitor and make

improvements so that we can ensure we

are doing everything possible to protect

sensitive and private information of all

the veterans we have the privilege to

serve. In August, the Scientific Merit

Review Board will review the 112 proposals

received in the June submission cycle. 

This summer we also are investigating

the feasibility of developing several new

initiatives. One possible initiative would

develop an HSR&D component to the

Office of Research and Development’s

(ORD’s) VA Genomics Medicine Program.

For example, HSR&D might focus on

studying the organization and delivery of

genomics medicine, and/or HSR&D

investigators could evaluate the impact

of genomics on health outcomes. 

Another initiative might involve the partnering of researchers and informatics

experts to enhance the application of

natural language processing to best facilitate the translation of clinicians’ written

notes in patient records. This information could greatly expand our ability to

study and improve the quality of VA

health care, as well as patient safety and

outcomes.

Additionally, we are working in collaboration with colleagues in ORD to explore

the viability of an OIF/OEF twin registry.

Similar to the Vietnam Twin Registry, an

OIF/OEF twin registry would allow us to

compare the effects of wartime service

by studying pairs of twins, in which one

twin was deployed to conflicts in Iraq

and/or Afghanistan, and the other was

not. All three of these possible initiatives

would, of course, depend on the Fiscal

Year 2008 budget, and we are hopeful. 

Seth A. Eisen, M.D., M.Sc.

Director, HSR&D

cause a readmission. These are just a few

examples.

Effectively applying these principles to flow

systems is not something that can be done

with a traditional management approach. It

requires true system redesign! This “workplace of the future” requires that the people

who do the work (not someone from the

outside) redesign and continually improve

their own work. These work teams must

consist of the indispensable staff each

provider interacts with on a day-to-day basis

in order to carry out our mission. Teams are

the engines that run the flow machine in

health care as well as industry. These teams

must regard each other as peers. They must

know their aim, collect data to inform the

day-to-day work, and make appropriate and

effective change to continually improve outcomes. This teamwork may be a culture

change (system redesign) that will not happen entirely within the confines of the

offices of leaders, but through the leadership of every work unit in our system. 

These systems changes represent a significant opportunity for research. Hundreds, if

not thousands, of questions exist; questions

that are at the heart of creating the effective,

efficient, and satisfying system we all desire.

Questions Pose Challenges

Many of these research questions center on

variation. Variation in “natural” and “artificially” generated arrival rates can dangerously overfill hospitals, cause diversion, and

overstress staff. What drives the variation?

How can a hospital measure, predict, and

respond to this? How do we determine,

arrive at, and maintain the “sweet spot” for

workload on any service? Are hospitalists

the best way to deliver inpatient care? How

should rounds be conducted? Should

rounds be done twice daily? At what level

should care occur on the weekend? Should

every admission be reviewed by a senior

clinician? What attitudes and behaviors are

common in the highest performing teams?

What aspects of nurse-physician communication are essential to perfect flow? How do

departments communicate with each other

and respond to these critical changes in

demand? What types of information should

connect departments together? And impor

tantly, does delay for care result in patient

morbidity and mortality?

In addition, research shows nurse staffing

levels and skills are related to LOS, morbid

ity, and mortality. What policies, practices,

and levels of staffing drive safe care?

Scheduling in the operating room, eliminating no-shows for elective procedures,

and the presence of fast tracks in the emer

gency department add to the opportunity

for systems improvements. What is the

best way to achieve a fully activated and

functioning workplace of the future? 

Success in this research involves not only

moving front line “improvement” efforts

further along the continuum of using tradi

tional research tools to analyze their data,

but also moving researchers toward an

interest in these practical, day-to-day problems

Research opportunities in the area of hospita

flow are abundant and must be addressed.

Developing and applying techniques to

manage the VA inpatient hospital system

better will benefit veterans in ways that othe

systems are not in a position to discover.

This is a great opportunity for research

knowledge and skill to be applied to improv

the daily work we’re involved in to provide

high quality hospital care for veterans. ■

“Research opportunities in the area

of hospital flow are abundant and

must be addressed. Developing

and applying techniques to manag

the VA inpatient hospital system

better will benefit veterans in way

that other systems are not in a

position to discover.”
Forum/July 2007 ■ 

Response to Commentary

Improving Inpatient Flow and Efficiency in the

VA Health Care System: Research Opportunities

By Stephan D. Fihn, M.D., M.P.H., Director, HSR&D Center of Excellence, VA Puget Sound

Two decades ago, the VA health care system was a loosely aggregated group of hospitals with only rudimentary facilities for

outpatient care. Since then, VHA has

transformed into a highly integrated system with a 40 percent reduction in hospital beds and a massive expansion of ambulatory care. Although twice as much is

spent on outpatient services, the outlay for

acute hospital care in VHA is about $6 billion annually. In his provocative commentary, Dr. Davies cogently argues that hospital resources are being deployed inefficiently to the detriment of the entire system, patients included. He highlights the

paradox that in order to embark upon the

painstaking, incremental process of

improvement, we must completely overhaul the organization and culture of medicine. As Dr. Davies notes, this will require

a framework of genuine teamwork that

supplants the present environment in

which communication is fragmented and

medical care is relatively uncoordinated,

even within the narrow confines of the

hospital. 

Need to Focus Research on Inpatient

Settings

Many hospitals have aggressively undertaken

efforts to enhance efficiency through use

of care maps and pathways, process

improvement, and other techniques.

Available data indicate that in specific settings, such as joint replacement surgery or

cardiac surgery, these efforts can reduce

lengths of stay and cost without compromising outcomes, but most studies are

seriously flawed by use of historical controls and insufficient follow-up.1 Hospitals

have also embraced physicians whose primary site of practice is the inpatient ward,

of whom there are now more than 15,000,

with the expectation that this type of dedicated workforce would improve patient flow

and efficiency. Research to date indicates

that gains, though statistically significant,

are relatively modest.2

Despite these changes in process and structure, questions abound about the most effective strategies for improving both efficiency

and quality. Dr. Davies enumerates a litany

of potential research topics. Hospital managers are now faced with the stark realization

that their institutions are inefficient and

need reengineering, but have no blueprints. 

In our zeal to develop innovative programs

for managing chronic illness in the expanded

ambulatory setting, perhaps health services

researchers, including those of us in VA, have

neglected this important area of research.

Although studies evaluating geriatric

assessment units and programs to prevent

falls or decubitus ulcers in elderly hospitalized patients have been conducted by VA

investigators, relatively few studies have

squarely addressed strategies to improve 

the flow and efficiency of inpatient care.

Nationally, the average length of stay is 4.8

days, and even a casual observer recognizes

that patients spend much of this time out of

their rooms. More than half of all hospital

admissions involve at least one procedure

and patients often migrate through several

hospital units during a single stay. Each of

these transitions represents an opportunity

for miscommunication, inefficiency, and

error. It would seem a propitious time to

focus some of our research energy on the

inpatient setting. 

Improved Information Resources

Needed

To effectively tackle such questions will

require robust new data sources characteriz

ing the dynamic inpatient environment and

encompassing not only what resources are

used but also the sequence and timing with

which they are applied. In addition, there

must be a roster of all professionals workin

in this environment, how they are deployed

and how they interact with one another.

These data must, in turn, be linked to infor

mation about the clinical characteristics of

patients and their outcomes. This unified

data system would enable us to assess varia

tions in how, when, where, and by whom

patients are treated. 

Constructing these information resources 

and evaluating strategies to improve inpatien

care will necessitate partnerships between

researchers and managers. One commendable example has been the creation of the

Inpatient Evaluation Center (IPEC) by Dr.

Peter Almenoff and Dr. Marta Render at 

the Cincinnati VA, who have aggregated

data from ViSTA systems across VHA (see

related article on page 6). This has enabled

them to start examining patterns of patient

flow within the hospital, e.g., medical ward t

OR to ICU. They find that certain patterns

appear to be markers for higher mortality. 

A more comprehensive data system would

permit a more informative analysis. 

In addition to developing new data sources

investigators must adopt more sophisticate

approaches to assessing care. Hospitalizations are often viewed as episodes of care

rather than only a segment in the overall

process, which includes care received in

other locations, e.g., outpatient clinics or

procedure suites. Adapting conceptual mod

els, research designs, and analytic procedures to consider hospital admissions as

continued on page 
VHA has undergone a remarkable transformation over the past decade and is now

widely recognized as a national leader in

chronic disease management. This transformation has also been associated with

marked declines in inpatient utilization.

Between 1996 and 2004, average daily

inpatient census fell by 44 percent system

wide and average length of stay (LOS) by

40 percent.1 Nonetheless, LOS remains

roughly two days higher in VHA than the

private sector. Given that VHA spends nearly

a third of its budget on inpatient care, this

difference has significant cost implications.

Findings from Analysis of Utilization

Patterns 

In an effort to examine utilization patterns,

VHA has implemented a number of complementary activities. The Inpatient

Evaluation Center (IPEC) has identified

marked differences in ICU admission practices for low severity patients and variations

in ICU LOS.2 In a related initiative, investigators at CRIISP are collaborating with

IPEC to develop normative comparisons for

patients admitted to medical and surgical

services and to identify factors that may

underlie differences in LOS. This effort has

involved the development of risk-adjustment models using Patient Treatment File

data and facility-level laboratory data.

Preliminary work in medical and surgical

patients admitted to 20 VA facilities in

VISNs 10, 15, and 23 during FY 2005 has

revealed several interesting findings. First,

the proportion of acute medicine patients

admitted to observation beds ranged from

Research Highlights

Improving Inpatient Utilization in VHA

By Gary E. Rosenthal, M.D., Center for Research in the Implementation of Innovative

Strategies in Practice (CRIISP), Iowa City VA Medical Center, and Barbara Manning, VHA

Office of the Assistant Deputy Under Secretary for Health for Policy and Planning

0 percent to 40 percent (median, 6 percent)

at these facilities, while the proportion of

patients with a LOS of less than 24 hours

ranged from 5 percent to 32 percent (median, 12 percent). These data indicate substantial variation in facilities’ strategies for initially assessing patients and pose challenges

with regard to eliminating selection bias in

comparing hospital LOS.

Second, using the VA Bedsection File, differences were found in the proportion of

patients managed by one treating specialty,

but housed on a different specialty unit—

raising questions about the optimal way to

aggregate and report data. Third, the analysis found variations in LOS, with differences in observed and predicted LOS for

medical patients ranging from –0.7 to 1.3

days across facilities. Not surprisingly, the

overall difference in observed and predicted

LOS was 1.8 days for patients discharged to

skilled care facilities. However, differences

varied from –0.3 to 4.5 days across facilities,

suggesting marked variation in the effectiveness of social services and/or availability of

skilled care beds.

Milliman Data Analysis

A final effort to examine utilization has

been conducted by Milliman, Inc. for the

VHA Office of the Assistant Deputy Under

Secretary for Health for Policy and

Planning. This effort has involved the application to VA administrative data of proprietary diagnosis-specific LOS models that

were developed using CMS Medpar files.

For each diagnosis, Milliman has used

Medicare claims data to identify a best prac4 ■ Forum/July 2007

tice benchmark. The Milliman method the

determines the total number of hospital

days, in excess of the benchmark, which ar

reported as “potentially avoidable days.”

These analyses for FY 2006 found that VA

hospitals had a higher percentage of poten

tially avoidable days than the average private sector hospital for both medical (37

percent vs. 27 percent) and surgical patient

(45 percent vs. 25 percent). For medical

patients, differences ranged from 39 percent to 57 percent across individual VISNs.

In addition to national and VISN summaries, Milliman provides profiles of individual VA facilities relative to private sector

Medicare hospitals in the same market.

While the Milliman data is subject to a

number of potential methodological limitations, the data do provide snapshots of utilization patterns that may yield clues for

more in-depth studies to discern the under

lying sources of variation.

As VHA looks to monitor and improve the

quality and efficiency of inpatient care,

there will likely be an increasing emphasis

on normative data. This emphasis holds

tremendous opportunities for VA HSR&D

investigators to develop new metrics for

examining inpatient efficiency. These new

metrics need, first, to improve upon the sig

nal to noise ratio of current methods and,

second, to serve as tools for identifying bes

practices within VA facilities that may be

transferable to other settings. ■

References

1 Health Care Analysis and Information

Group. Acute Inpatient Care in VHA–2005

Report. Washington, DC. 2006. Office of

the ADUSH for Policy and Planning,

Veterans Health Administration. 

2 Render ML, Kim HM, Deddens J, et al.

Variation in Outcomes in Veterans Affairs

Intensive Care Units with a Computerized

Severity Measure. Critical Care Medicine

2005; 33:930-9.
Forum/July 2007 ■ 

Hospital-acquired infections are common,

costly, and potentially life threatening.

Preventing hospital-acquired—also called

nosocomial infection—is an important

patient safety issue. The Centers for

Disease Control and Prevention (CDC) estimates that hospital-acquired infections

affect about 2 million patients hospitalized

in acute care settings annually in the

United States and cost over $3.5 billion per

year. Academic researchers estimate that at

least 20 percent of all nosocomial infections can be prevented; over half of

catheter-related infections are preventable.

Given the high use of medical devices, the

VA provides an appropriate setting to investigate methods for preventing hospitalacquired infection and for translating these

research findings into everyday practice. 

Catheter-Related UTI

The most common hospital-acquired infection is urinary tract infection (UTI), which

accounts for about 40 percent of all nosocomial infections. Urinary catheters are associated with the vast majority of nosocomial

UTI. Almost 25 percent of patients will

have a urinary catheter at some point during their hospital stay. Several studies have

found that for about one-third of the days

that a patient is catheterized, the catheter is

unjustified and unnecessary. In a multicenter study, we found that about one-fourth of

house staff and more than one-third of

attending physicians were unaware that

their own patients were catheterized. We

believe that our findings explain, at least in

part, why patients are catheterized for

unjustified reasons: physicians are often

Enhancing Patient Safety by Preventing HospitalAcquired Infection

By Sanjay Saint, M.D., M.P.H., VA Ann Arbor Healthcare System, HSR&D Center for

Practice Management & Outcomes Research and the University of Michigan Medical School

unaware that the catheter is in place and

therefore do not write an order to have the

catheter removed.

Few interventions have been found to

decrease the incidence of catheter-related

UTI. The best strategy to prevent nosocomial UTI is to avoid catheterization itself. In

those patients who truly require catheterization, the use of proper insertion and maintenance techniques is paramount. In fact,

the most important infection control advance

in urinary catheter-related infection prevention was the introduction five decades ago

of the closed catheter drainage system.

Proper aseptic technique, including aseptic

insertion and maintenance of the catheter

and drainage bag, remain essential in preventing catheter-related UTI. We have evaluated a novel urinary catheter “reminder”

system in both a VA and non-VA hospital

and found that this simple intervention significantly decreases urinary catheter use.

One of our studies utilized the VA’s computerized order entry system to remind VA

physicians to remove the catheter after three

days. Alternatives to indwelling catheters

should also be considered when appropriate.

Central Venous Catheter-Related

Infection Prevention

Intravascular catheters are the most common cause of nosocomial bacteremia, with

catheter-related bloodstream infection (CRBSI) affecting over 200,000 patients per

year in the United States. CR-BSI is associated with an increased risk of death, and

each episode of CR-BSI has an attributable

cost of at least $10,000.

Several evidence-based methods exist for

preventing this common inpatient complication. Two of the most important practices

are the use of maximum sterile barriers

during catheter insertion (to avoid inadvertent contamination of the central line) and

the use of chlorhexidine gluconate at the

insertion site (rather than povidone-iodine)

Additionally, avoiding both unnecessarily

prolonged central venous catheterization

and catheterization of the femoral vein are

important methods of reducing infection

rates. Assiduously adhering to proper hand

hygiene and general infection control principles still remain crucial practices for preventing CR-BSI. A recent quasi-experimental collaborative study of Michigan hospital

reported dramatic reductions in CR-BSI

rates using a bundled approach of practices

similar to the ones listed above.1

Translating Research Into Practice

The VA Ann Arbor Healthcare System’s

Center of Excellence is leading an HSR&D

funded project (“Translating Infection

Prevention Evidence to Enhance Patient

Safety”) that aims to better understand the

adoption of infection prevention practices

by individual VA and non-VA hospitals and

the factors that potentially promote or

inhibit effective implementation of these

practices. Our ultimate objective is to develop

strategies to optimize the successful implementation of key practices in the field of

patient safety and nosocomial infection pre

vention. We look forward to sharing these

findings with you in the future. ■

Reference

1 Pronovost P, et al. An Intervention to

Decrease Catheter-Related Bloodstream

Infections in the ICU. New England Journa

of Medicine 2006; 355(26):2725-32.
Research Highlights

Creating a National Program for Transformative

Practice

By Marta L. Render, M.D., VA Inpatient Evaluation Center, Cincinnati VAMC and University

of Cincinnati, Division of Pulmonary Critical Care, and Peter Almenoff, M.D., VISN 15,

University of Kansas, Division of Pulmonary Critical Care and VACO 

6 ■ Forum/July 2007

National priorities for U.S. health care

include reduction of injury to patients,

implementation of practices that improve

important outcomes, and more efficient use

of the health care workforce and other

resources. In 2005, VA launched the

Inpatient Evaluation Center (IPEC) with the

goals of: a) measuring and reporting risk

adjusted mortality and LOS for patients in

acute care, b) developing internal and external

benchmarks, and c) implementing evidencebased practices (EBP) based on those 

metrics using the following operational

principles. 

Use information systems to measure. Use

people to create change. The VA IPEC

extracts data elements related to outcomes

and processes for all acute care patients

from each hospital in the VA on a quarterly

basis. For outcomes, the IPEC calculates a

predicted mortality and length of stay for

each patient using validated methods.1

Patients are assigned to diagnostic groups

and source of admission (emergency

department/outpatient clinic, ward, other

hospital, nursing home, or operating room),

comorbid diseases are determined, and

abnormal vital signs are measured by examining the worst of 11 laboratory variables

from the first 24 hours surrounding ICU

admission. The predicted mortality risk and

length of stay permits determination of

standardized mortality ratio and observed

minus expected length of stay calculated for

each ICU, resulting in measurement of two

dimensions of care. Process measures

include mean glucose, and hospital

acquired infection rates. 

Attention is a limited resource. Provide

feedback that suggests change in practices.

The most valuable resource in the VA is the

time and attention of leadership at multiple

levels. The VA IPEC designed its reporting

approach so that leadership at the VISN

and medical center level as well as clinicians leading intensive care units may

access their reports on the IPEC Intranet

website (http://vaww1.va.gov/IPEC/). The

website reports provide graphic depiction of

results and identify potential opportunities

for changes in practice. Each reporting

cycle concludes with a VISN-wide conference call with IPEC that discusses opportunities for change, likely new metrics, and

annual goals. These calls also offer the

opportunity for clinicians to ask questions

and describe relevant operation issues. 

Create competition. Transparency is an

important tool to improve patient safety.

The performance of each intensive care

unit in a VISN is compared to the mean

and highest (or lowest) performance for the

metric in the VA nationally, and stratified

by type of ICU. Performance results are visible to all the clinicians and hospital leaders

in that VISN. Grouping results by type and

level of ICU creates a sense of fairness. The

argument that the data is wrong, patients

are sicker, or it’s a sampling error is easier

to defuse when the sample is 100 percent

of admissions, cases are risk adjusted, and

the reference population is other similar VA

hospitals. Since no one likes to be last, the

open comparison is intended to stimulate

practice change. 

Share learning. VA hospitals vary from

tightly affiliated medical centers with highpowered research universities to rural facili

ties. In each, talented clinicians develop

strategies to advance evidence-based practice. This effort and expertise is captured

and shared on the IPEC website in EBP

toolboxes that highlight tools to streamline

implementation of these practices (reduction in catheter-related blood stream infection and ventilator associated pneumonia,

glycemic control, and improved hospital

flow). IPEC promotes change in specific

practices by offering web-based conference

calls to initiate change, by conducting follow-up calls, and by providing mentoring. 

Report method limitations. The measured

outcomes in the IPEC—mortality and

LOS—create what essentially is a mathematical model of ICU care, a model which

cannot include every possible important

element in survival or LOS. Recent challenges have been to develop strategies to

identify when and if ICU performance falls

beyond the normal range. Workgroups

such as a clinicians’ advisory group formed

from ICU directors and nurses in the field,

an oversight board representing national

leadership, and a methodology workgroup

provide grounding in interpretation and

potential limitations of results. 

In summary, the IPEC is a unique program

within VA, providing continuous monitoring of outcomes and processes in acute car

via extraction, analysis, and reporting of

data. IPEC’s activities are critical to implementation of national quality improvement

projects as well as identification of unique

medical center vulnerability that can be

addressed with specific projects. ■

Reference 

1 Render ML, Kim HM, Welsh DE, et al.

Automated Intensive Care Unit Risk

Adjustment: Results from a National

Veterans Affairs Study. Critical Care

Medicine 2003; 31(6):1638-46.
Forum/July 2007 ■ 

The term “hospitalist” was coined in 1996

and refers to a physician who spends all or

the majority of his/her clinical, administrative, educational, or research activities in

the care of hospitalized patients.1 The

growth of hospitalist models of care has

been dramatic in the private sector with

over 15,000 hospitalists in practice and projections of over 30,000 hospitalists by

2010. Only recently has this growth been

appreciated in VHA. Based on a recent survey, 76 of 118 VAMCs (64 percent) employ

an estimated 300 hospitalists who care for

67 percent of the general medical patients

in those VAMCs with hospitalists. 

In VHA and elsewhere, no two hospitalist

programs are alike; programs are formed

and evolve to meet the needs of the facility.

These needs include, but are not limited to,

direct patient care, teaching and trainee

supervision, quality, efficiency, job satisfaction, committee membership, non-medicine

consultation services, urgent care, and other

inpatient, general medicine-related duties. 

Hospitalists Lead to Improvements

As hospitalist models of care grew in the

1990s, there was concern that the “handoff” from primary care providers to hospitalists would erode the primary care relationship, result in discontinuity, and lead to

poorer satisfaction and quality. Studies in

non-VA settings have shown no evidence

that this has happened and in fact show a

consistent improvement in efficiency (e.g.,

10-15 percent reduction in LOS and costs),

improved or stable quality, and no adverse

effect on patient satisfaction. In teaching

settings, hospitalists have been shown to

improve resident and student satisfaction

with inpatient teaching. 

The application of these non-VA studies

and experiences to VA is an important

question. Through the Office of Patient

Care Services, a Hospitalist Field Advisory

Committee (FAC) has been formed to

address these and other issues and to identify potential benefits and pitfalls with this

model of care in VHA. The FAC has developed a “VHA Hospitalist Handbook” to

address the role of hospitalists in patient

care, teaching, and quality improvement. 

The concern about hand-offs and communication with primary care is important, yet

prior research and experience suggest that

hospitalists can improve the hand-off process.

In VHA, the traditional model of care has

been to have separate outpatient and inpatient physicians. With a fully integrated

electronic medical record, the discontinuity

effect of hospitalists should be minimized.

To date, no studies have evaluated the

impact of hospitalists in VHA on efficiency

(e.g., LOS, costs) or quality. However, with

many studies showing an improvement

associated with hospitalists and none showing a harmful effect, it may be reasonable

to extrapolate these findings to VHA. 

The Role of Hospitalists in VHA

By Peter J. Kaboli, M.D., M.S., The Center for Research in the Implementation of Innovative

Strategies in Practice (CRIISP), Iowa City VA Medical Center

Hospitalists in VHA

While current inpatient physician staffing

models in VHA are quite variable, our survey shows 95 percent of VHA hospitalists

are VHA employed, with very few contract

hospitalists. Hospitalist programs have on

average 3.95 full time equivalents (FTEs)

and 13 percent provide 24-hour inpatient

coverage. In academic-affiliated VAMCs,

hospitalists cover both resident “teaching”

and staff only “non-teaching” inpatient services. When asked how reductions in residency work hours impacted hospitalist services, 42 percent of VAMCs were more like

ly to start or expand a hospitalist program,

33 percent were more likely to use nonteaching services, and 35 percent were more

likely to use mid-level providers.

One of the primary challenges of inpatient

medical services is optimizing efficiency

while simultaneously improving quality. An

important role for hospitalists to improve

efficiency in VHA is working with the Flow

Improvement Inpatient Initiative (FIX). As

quality measures are being expanded for

medical inpatients, hospitalists can play an

important role in defining, documenting,

and measuring inpatient quality. For both

efficiency and quality measures, hospitalists

should work closely with emergency depart

ments, intensive care units, and non-medicine specialties in VHA. Future research in

VHA should evaluate the impact of the orga

nization of inpatient care, including hospitalists, on inpatient clinical practice guideline use and other VHA quality measures. 

Another important challenge in the adoption of hospitalist models of care relates to

work load, duty hours, and comparable pay.

Currently, hospitalists are included with

general internists in the most recent physician pay bill. However, hospitalist work

hours in some VAMCs are more similar to

emergency medicine specialists. Current

Dialogue

Alan S. Perry, M.H.A., FACHE, Director, VA

Central California Health Care System asked

our author to discuss the VA experience and

research with the hospitalist model of care,

including the “hand-off” from primary care

provider to hospitalist, patient satisfaction with

hospitalists, their performance on clinical practice guidelines and other VHA measures, and

their impact on residency and teaching programs.

continued on page 
FORUM 

Geraldine McGlynn, Editor-in-Chief

Margaret Trinity, Editor

Editorial Board

Peter Almenoff, M.D., Director, VA Network #15,

Kansas City, MO

Martin P. Charns, D.B.A., Director, VA HSR&D

Center of Excellence, Boston, MA

Seth A. Eisen, M.D., M.Sc., Director, HSR&D

Joseph Francis, M.D., M.P.H., Deputy Chief

Research and Development Officer, Associate

Director, HSR&D QUERI, Central Office

Rodney A. Hayward, M.D., Director, VA HSR&D

Center of Excellence, Ann Arbor, MI

Shirley Meehan, M.B.A., Ph.D., Deputy Director,

VA HSR&D, Central Office

Michael J. Miller, M.D., Ph.D., Chief Medical

Officer, VA Network #1, Bedford, MA

Eugene Z. Oddone, M.D., M.H.Sc., Director, 

VA HSR&D Center of Excellence, Durham, NC

Alan S. Perry, M.H.A., FACHE, Director,

VA Central California Health Care System

Fihn continued from page 3 Kaboli continued from page 7

simply one component of a patient’s care

will lead to performance measures that are

more practical and clinically relevant than

those in current use. 

In summary, we should heed Dr. Davies’

challenge and join forces to better understand and improve the manner in which we

provide care to patients in the hospital. ■

References

1 Kim S, Losina E, Solomon DH, et al.

Effectiveness of Clinical Pathways for Total

Knee and Total Hip Arthroplasty: Literature

Review. Journal of Arthroplasty 2003; 18:69-74.

2 Everett G, Uddin N, Rudloff B.

Comparison of Hospital Costs and Length

of Stay for Community Internists,

Hospitalists, and Academicians. Journal of

General Internal Medicine 2007; 22:662-7. 

private sector pay is, in general, higher than

general internists in the same market. This

has significant implications for the recruitment and retention of hospitalists in VHA. 

In summary, hospitalist programs have

expanded rapidly in VHA to mirror private

sector growth. In VAMCs with hospitalists,

hospitalists should be viewed as champions

of inpatient quality, efficiency, and teaching.

In facilities without hospitalists, a needs

assessment should be undertaken to determine how to take advantage of the unique

role hospitalists play in VHA. ■

For questions, please contact the author at

peter.kaboli@va.gov

Reference

1 Wachter RM, Goldman L. The Emerging

Role of "Hospitalists" in the American

Health Care System. New England Journal of

Medicine 1996; 335:514-7.