We also aimed to understand the perceptions of study participants about the impact of the HM service on quality of care. Survey participants not only expressed reasonable satisfaction with various aspects of hospitalists’ performance, but also described a positive impact on care quality after the implementation of their new services. This was also reflected in the interviews:
- "The clinical knowledge of the new hospitalists is far better. Some are internal medicine trained, so they bring better knowledge and skills. I feel comfortable that they can take patients and manage them. I wasn’t always comfortable with doing that in the past." (Emergency Physician, Site C)
- "Hospitalists are really familiar with acute care and how it works. They’ve become more familiar with the discharge planning system and thus know more about the resources available. And even something as simple as knowing which forms to use." (Dietician, Site A)
It must be noted that these observations should ideally be corroborated through a robust before-after analysis of various quality measures. While such an analysis was beyond the scope of our current project, we have previously demonstrated that across our network (including the 3 sites included in our evaluation) hospitalist care is associated with lower mortality and readmission rates.4 Our findings appear to confirm previous suggestions that hospitalists’ dedicated focus on inpatient care may allow them to develop enhanced skills in the management of common conditions in the acute care setting17 which can be perceived to be of value to other hospital-based care providers.
The issue of frequent handover among hospitalists was the most commonly identified challenge by both survey respondents and interviewees:
- "They’re very reluctant to discharge patients if it’s their first day with the patient. Even if the previous hospitalist said they were ready for discharge, the new doc wants to run all of their own tests before they feel comfortable. Maybe it’s a trust issue between hospitalists when they hand patients over. It’s also being personally liable for patients if you discharge them." (Patient Care Coordinator, Site A)
- "Communication is an issue. There’s lots of turnover in hospitalists. Relationships were closer with GPs because we had so much more interaction with particular individuals." (Hospitalist Physician Leader, Site A)
It must be noted that we conducted our evaluation in a relatively short time span (within 2 years) after the 3 services were implemented. Developing trust among a large number of hospitalists newly recruited to these programs can take time and may be a factor that can explain the reluctance of some to discharge patients after handoffs. However, concerns about discontinuity of care inherent in the hospitalist model are not new.18,19 Better continuity has been associated with higher probability of patient discharges20 and improved outcomes.21 To address this challenge, the hospitalist community has focused on defining the core competencies associated with high quality handovers,22 and deliberate efforts to improve the quality of handoffs through quality improvement methodologies.23 Our study participants similarly identified these measures as potential solutions. Despite this, addressing hospitalist continuity of care remains a pressing challenge for the broader hospitalist community.24
Our evaluation has a number of methodological limitations. First, the survey response rate was only 14%, which raises questions about nonresponse bias and the representativeness of the findings to the larger population of interest. While the distribution of respondents was largely similar to the overall sampled population, a number of factors may have impacted our response rate. For example, we were only able to distribute our survey to health care providers’ institutional email addresses. Moreover, while we provided incentives for participation and sent out a number of reminders, we solely relied on one communication modality (ie, electronic communication) and did not utilize other methods (such as posters, reminder at meetings, in-person invitations). Second, while the survey included a number of open-ended questions, many of these responses were at times brief and difficult to interpret and were not included in the analysis. Third, all data collected were self-reported. For example, we could not corroborate comments about participation in interdisciplinary rounds by objective measures such as attendance records or direct observation. Self-report data is subjective in nature and is vulnerable to a range of biases, such as social desirability bias.25 Finally, patient satisfaction and experience with hospitalist care were not assessed by patients themselves. Ideally, standardized cross-site indicators should validate our patient-related results.