- Michelle Marks
1. As the Chair of Pediatric Hospital Medicine at Cleveland Clinic Children’s, what do you think about pediatric hospital medicine becoming a subspecialty? How has the field changed in the past 10 years?
Having worked and led in the field of PHM since 1996, I am very excited about the growth and development of PHM over the years. I think the development of PHM into a subspecialty was inevitable based on the unique skill set of Pediatric Hospitalists. I’m proud to have been on the forefront of subspecialty, and Cleveland Clinic Children’s has one of the longest running fellowship programs having just graduated our 8th fellow in 2021. Also, the fellowship program received ABP certification in 2020! Although each PHM program has its nuisances, over the last 10 years, I’ve seen the programs coalesce around the PHM core competencies and fellowship training.
2. You were a co-author of “A Proposed Dashboard for Pediatric Hospital Medicine Groups” in Hospital Pediatrics. What is a dashboard, and what is its purpose?
Technically, a dashboard is type of graphical user interface which often provides at-a glance views of key performance indicators relevant to a particular objective or business process. It can be used internally to mark progress or externally to benchmark amongst colleagues/programs. I have found them very useful in advocating for need resources within our program, when you have national data regarding what is going on outside your doors its very useful! Working on a common dashboard also helps leaders begin to talk a common language when collect data and advocating for their programs. Over the time, I have seen dashboards and visual management have become more mainstream and more useful, now they are used every day in clinical as well as business areas throughout most systems.
3. You were interviewed for The Hospitalist’s article “Maternity management” in 2011. What can leaders do to help pediatric hospitalists take their full maternity leave? Do you think maternity leave has improved since 2011? How do you see it changing in the future?
At the time of the interview, it was amazing to me how many institutions did not fund and/or support taking a full maternity leave which I would argue is 12 weeks. While things have improved, I do think there is still pressure for young mothers to return to work quickly for service coverage reasons but also academic productivity reasons. Personally, I feel it is unacceptable for individuals to be required to “make up” clinical time they missed while they are on leave. New mothers should not be penalized for having a family. As leaders, we can support wellness for mother and baby by fully supporting and normalizing maternity leave as a necessary part of or the post-partum experience and hold other leaders accountable for their actions in this area. As the much need discussion regarding gender equity and diversity in PHM practice and leadership evolves, I expect there will be improvements in this area for all.
4. At Hospital Medicine 2007 in Dallas Texas, you had an abstract titled “Pediatric Observation vs. Admission Designation: Optimizing Performance Through Rapid‐Cycle Improvement.” Since then, how is your hospital doing in selecting the correct status, observation vs. admission? Do you have any quick tips for choosing the correct one?
Choosing the correct status is an ongoing challenge for any group and requires constant monitoring as the criteria for observation vs. admission status changes almost yearly. Over time, more and more diagnoses and care has shifted to Observation/lower level of service. When we started this project, it was our top reason for denial of payment by insurers. Our group does pretty well in this area, as we have a staff within our group who focuses on utilization review and regularly review denials and other data to find opportunities to improve. The best tip I have is to become familiar with Interqual or other commercial software your hospital and insurance companies use to determine status then develop easy “cheat sheets” for staff within your group to choose the correct status. We did this for our top 5 diagnoses and once staff providers get the gist of these 5, its pretty easy to apply the concepts more broadly.
5. After reading “Improving Documentation of Inpatient Problem Lists in Electronic Health Record: A Quality Improvement Project” in Journal of Patient Safety (2018), I realize that I could do a better job updating my patients’ problem lists. What advice do you have for pediatric hospitalists trying to improve them?
The problem list is important for 2 reasons; one it is a snapshot of the overall patient, anyone reviewing the medical record can quickly look at the problem list and get a general idea of patient complexity and issues that need to be addressed on admission or in a clinical setting. Second, the problem list is used to calculate DRG (diagnostic related groups) and case mix index which determines complexity of patient; this in turn is used to determine hospital technical reimbursement and can be used to benchmark like institutions. The problem with problem lists is they are not maintained well and become a dumping ground of diagnoses--they must be maintained! The best advice I have is to add problem list maintenance to your workflow like writing a note and billing on every patient every day. I personally log into a patient record and begin by reviewing/updating the problem list, then note writing/signing, then billing. Reviewing and updating the problem list needs to become a habit like any other … the EMR can help with this by building in prompts to review and update the problem list.
6. In “Pediatric Hospital Discharges to Home Health and Post acute Facility Care: A National Study” (JAMA Pediatrics 2016), you found that home health care and facility-based post acute care are infrequently used after discharge for hospitalized children. Why do you think this is, and which patients would benefit from these services?
I think these services are used infrequently and unevenly across the country based on availability in certain states and regions but also due to lack of knowledge by providers of what is available to patients in specific states and regions. The availability issue is compounded by the variability between states on how Medicaid specifically and Children’s Health Care is funded, there are no consistent requirements or standards across the states. For example in some states, home nursing and post-acute care facilities are non-existent and in states with these resources, the availability has been worsened by the pandemic, especially home nursing. The knowledge issue should start to be addressed by training programs. Now that transitions of care are part of the core curriculum for residency and fellowships, trainees should be knowledgeable about resources for post-acute area in the area of their training and should ask or be aware of the resources available in the area where they practice after training is complete.. The patients who would benefit most from these services are patients and families who have had a significant change in function from previous baseline, patients with new technology such as trach and vents, and patients with complex diagnoses.
7. Jack Percelay often ends his list-serve commentary with the phrase “that’s just my 2 pennies.” What are your two cents?
My 2 cents: My journey through PHM has taken me many places and through many different roles. I started out as the weirdo who liked inpatient medicine and enjoyed the complexity of the unknown … “you want to be a “resident forever” who does that???” The other outpatient pediatricians were HAPPY to let me cover all the inpatient time I wanted! PHM at CC started out as a small 4-person group and developed into a 25 staff, 10NPs, 2 fellows department, and we diversified and took on all the other tasks required in a hospital that no else wanted to do … we developed to a SUBSPECIALTY! Personally, I went from staff, to center head, to department chair and now medical director of Cleveland Clinic Children’s Hospital for Rehabilitation. I did not feel READY for the all opportunities when they presented themselves to me; however, I took them on and what a ride! My advice to you is take the opportunities as they come because you never know where they will take you!
Having worked and led in the field of PHM since 1996, I am very excited about the growth and development of PHM over the years. I think the development of PHM into a subspecialty was inevitable based on the unique skill set of Pediatric Hospitalists. I’m proud to have been on the forefront of subspecialty, and Cleveland Clinic Children’s has one of the longest running fellowship programs having just graduated our 8th fellow in 2021. Also, the fellowship program received ABP certification in 2020! Although each PHM program has its nuisances, over the last 10 years, I’ve seen the programs coalesce around the PHM core competencies and fellowship training.
2. You were a co-author of “A Proposed Dashboard for Pediatric Hospital Medicine Groups” in Hospital Pediatrics. What is a dashboard, and what is its purpose?
Technically, a dashboard is type of graphical user interface which often provides at-a glance views of key performance indicators relevant to a particular objective or business process. It can be used internally to mark progress or externally to benchmark amongst colleagues/programs. I have found them very useful in advocating for need resources within our program, when you have national data regarding what is going on outside your doors its very useful! Working on a common dashboard also helps leaders begin to talk a common language when collect data and advocating for their programs. Over the time, I have seen dashboards and visual management have become more mainstream and more useful, now they are used every day in clinical as well as business areas throughout most systems.
3. You were interviewed for The Hospitalist’s article “Maternity management” in 2011. What can leaders do to help pediatric hospitalists take their full maternity leave? Do you think maternity leave has improved since 2011? How do you see it changing in the future?
At the time of the interview, it was amazing to me how many institutions did not fund and/or support taking a full maternity leave which I would argue is 12 weeks. While things have improved, I do think there is still pressure for young mothers to return to work quickly for service coverage reasons but also academic productivity reasons. Personally, I feel it is unacceptable for individuals to be required to “make up” clinical time they missed while they are on leave. New mothers should not be penalized for having a family. As leaders, we can support wellness for mother and baby by fully supporting and normalizing maternity leave as a necessary part of or the post-partum experience and hold other leaders accountable for their actions in this area. As the much need discussion regarding gender equity and diversity in PHM practice and leadership evolves, I expect there will be improvements in this area for all.
4. At Hospital Medicine 2007 in Dallas Texas, you had an abstract titled “Pediatric Observation vs. Admission Designation: Optimizing Performance Through Rapid‐Cycle Improvement.” Since then, how is your hospital doing in selecting the correct status, observation vs. admission? Do you have any quick tips for choosing the correct one?
Choosing the correct status is an ongoing challenge for any group and requires constant monitoring as the criteria for observation vs. admission status changes almost yearly. Over time, more and more diagnoses and care has shifted to Observation/lower level of service. When we started this project, it was our top reason for denial of payment by insurers. Our group does pretty well in this area, as we have a staff within our group who focuses on utilization review and regularly review denials and other data to find opportunities to improve. The best tip I have is to become familiar with Interqual or other commercial software your hospital and insurance companies use to determine status then develop easy “cheat sheets” for staff within your group to choose the correct status. We did this for our top 5 diagnoses and once staff providers get the gist of these 5, its pretty easy to apply the concepts more broadly.
5. After reading “Improving Documentation of Inpatient Problem Lists in Electronic Health Record: A Quality Improvement Project” in Journal of Patient Safety (2018), I realize that I could do a better job updating my patients’ problem lists. What advice do you have for pediatric hospitalists trying to improve them?
The problem list is important for 2 reasons; one it is a snapshot of the overall patient, anyone reviewing the medical record can quickly look at the problem list and get a general idea of patient complexity and issues that need to be addressed on admission or in a clinical setting. Second, the problem list is used to calculate DRG (diagnostic related groups) and case mix index which determines complexity of patient; this in turn is used to determine hospital technical reimbursement and can be used to benchmark like institutions. The problem with problem lists is they are not maintained well and become a dumping ground of diagnoses--they must be maintained! The best advice I have is to add problem list maintenance to your workflow like writing a note and billing on every patient every day. I personally log into a patient record and begin by reviewing/updating the problem list, then note writing/signing, then billing. Reviewing and updating the problem list needs to become a habit like any other … the EMR can help with this by building in prompts to review and update the problem list.
6. In “Pediatric Hospital Discharges to Home Health and Post acute Facility Care: A National Study” (JAMA Pediatrics 2016), you found that home health care and facility-based post acute care are infrequently used after discharge for hospitalized children. Why do you think this is, and which patients would benefit from these services?
I think these services are used infrequently and unevenly across the country based on availability in certain states and regions but also due to lack of knowledge by providers of what is available to patients in specific states and regions. The availability issue is compounded by the variability between states on how Medicaid specifically and Children’s Health Care is funded, there are no consistent requirements or standards across the states. For example in some states, home nursing and post-acute care facilities are non-existent and in states with these resources, the availability has been worsened by the pandemic, especially home nursing. The knowledge issue should start to be addressed by training programs. Now that transitions of care are part of the core curriculum for residency and fellowships, trainees should be knowledgeable about resources for post-acute area in the area of their training and should ask or be aware of the resources available in the area where they practice after training is complete.. The patients who would benefit most from these services are patients and families who have had a significant change in function from previous baseline, patients with new technology such as trach and vents, and patients with complex diagnoses.
7. Jack Percelay often ends his list-serve commentary with the phrase “that’s just my 2 pennies.” What are your two cents?
My 2 cents: My journey through PHM has taken me many places and through many different roles. I started out as the weirdo who liked inpatient medicine and enjoyed the complexity of the unknown … “you want to be a “resident forever” who does that???” The other outpatient pediatricians were HAPPY to let me cover all the inpatient time I wanted! PHM at CC started out as a small 4-person group and developed into a 25 staff, 10NPs, 2 fellows department, and we diversified and took on all the other tasks required in a hospital that no else wanted to do … we developed to a SUBSPECIALTY! Personally, I went from staff, to center head, to department chair and now medical director of Cleveland Clinic Children’s Hospital for Rehabilitation. I did not feel READY for the all opportunities when they presented themselves to me; however, I took them on and what a ride! My advice to you is take the opportunities as they come because you never know where they will take you!