Guiding Principles for Pediatric Hospital Medicine Programs

The American Academy of Pediatrics formally recognized pediatric hospital medicine as a discrete area of practice in 1999 when it approved the formation of the Provisional Section on Hospital Care. This entity subsequently became the focal point for general pediatricians with a primary interest in inpatient pediatric medicine and led to the approval of the American Academy of Pediatrics Section on Hospital Medicine. Wachter and Goldman initially coined the term “hospitalist” in 1996,¹ and it is now an easily recognized designation, describing a physician whose primary professional focus is the general medical care of hospitalized patients and whose activities include patient care, teaching, research, and leadership related to hospital medicine.² The last policy statement³ reflected the initiation and introduction of pediatric hospitalists and their expected growth in the form of groups and programs. This statement speaks to the expanded roles and responsibilities of a more defined group of pediatricians and their integrated role among a community of pediatricians within and without the hospital setting. As before, the Section on Hospital Medicine strongly supports a policy of voluntary referrals to pediatric hospital medicine programs and suggests that primary care physicians retain the option to admit and manage their own patients.

Pediatric hospital medicine programs vary considerably in size, scope of practice, and structure. A wide array of programs now exists, ranging from those based in small community hospitals to those found within large academic centers. The range of services provided by a pediatric hospitalist group is dependent on the needs of the institution and the ability of the group to provide these services, which may include the following:

• General inpatient pediatric care

• Perioperative surgical and medical subspecialty care⁴ 

• Delivery room services

• Newborn nursery care

• NICU and PICU coverage

• Pediatric emergency department evaluation

• Consultation or short-stay observation unit services

• Sedation services

• Palliative care

• Coordinated, family-centered interdisciplinary admission and discharge planning that includes the essential role of the primary care physician

Pediatric hospital medicine programs may incorporate teaching, mentoring, and other academic responsibilities, especially if programs are affiliated with academic centers. At the community hospital level, programs may be supported by a larger tertiary care center or may be completely independent. Programs may be privately run, supported by hospital-based physician foundations, or funded by other for-profit organizations. Regardless of the many variations in size or scope of these practices, all programs should strive to provide continuity of care with the medical home of primary care physicians, pediatric medical subspecialists, and pediatric surgical specialists for each child.⁵ 

Transitioning patients safely back into the community at the time of discharge is a primary concern of every hospitalist. Admission and discharge planning should emphasize the importance of the medical home, communication with the primary care physician (and vice versa), pediatric medical subspecialists or pediatric surgical specialists, or other service providers involved in the patient’s care.⁶ The inpatient team should coordinate an interdisciplinary plan of care that includes the patient, family, the primary care provider, and social and other services when necessary. All communication should be timely and complete, including hand-off communication within and between hospitals. Hospitalists should work with their primary care referral centers to establish the preferred means of communication and guidelines for frequency of communication beyond admission and discharge.

Developing and maintaining a successful pediatric hospital medicine program requires an understanding of the underlying pediatric vision of the greater institution. It is essential to develop a mission for the program that includes its purpose and scope of services and establishes the basis for organizational support and a long-term viable financial model. This includes understanding the initial goals for the development of the program, the high-priority issues of the program, and its potentials for success and failure. Hospital medicine leaders need to understand the hospital environment in which they work and then define their own program within that environment. This is particularly true in community and non–children’s hospitals, where program leaders must be strong advocates for children throughout the hospital. Pediatric hospital medicine leaders should develop a strategic plan for the program that includes stability, expansion of services, and integration into the overall hospital organization and management. In the process of doing this, individual members and program leaders should have a full understanding of the institution’s organizational structure and the chain of command. Care needs to be taken to ensure the scope of the program is matched by the abilities of the hospital medicine service, in terms of both clinical skills and manpower. It is important to have well-described agreements for the role of the hospital medicine service that are open to modification with changes in staffing, experience, or other events that affect the scope of practice.

Physicians serving as pediatric hospitalists should be board certified or board eligible in pediatrics. Ongoing professional practice evaluation should require demonstration of adequate patient volumes, procedural competency, and participation in quality improvement projects. Physicians should participate in continuing medical education and lifelong learning activities with a focus on inpatient pediatrics, systems of care, safety issues, and other topics directly relevant to pediatric hospital medicine.

Pediatric hospital medicine program leadership should identify the skill sets needed for employment and define the roles of its members. These skill sets might include the following:

• Expertise in the care of pediatric inpatients from neonates to adolescents

• Skill in the coordination of medically complex patients

• Understanding of the management of pain, sedation, and palliative care in children

• Ability to provide team leadership and mentoring

• Experience in academic teaching and research

• Participation and leadership in local, state, and national organizations

• Involvement and leadership in hospital committees and initiatives

• Skill in communication practices, both internal and external

• Experience in child health care advocacy and welfare

A full set of knowledge and skills is described in the Pediatric Hospital Medicine Core Competencies.⁷ 

Leadership should advocate for a stable, defined workforce that promotes healthy work hours, avoids health care worker fatigue,⁸ enhances overall career satisfaction, and supports financial viability of the program, including appropriate physician compensation. Program and individual performance target goals and objectives should be consistently and periodically reviewed and monitored for success. Each program, in keeping with its own scope of practice and cognizant of national performance indicators, should set its own practice performance indicators, describe them in a concise and easily understandable format, and review them on a regular basis. Key parameters should focus on both the goals of the pediatric hospital medicine program as part of a larger organization and the goals of its individual members. For example, group program goals could include financial and revenue parameters, recognized safety and clinical quality indicators,⁹ and advocacy and leadership roles in the larger organization. Within the group itself, members may have a personal performance review that focuses on individual goals, such as community advocacy, contributions to departmental improvements, academic achievements, research projects, participation in local or national organizations, or other indicators of professional development and excellence.

Pediatric hospitalists are unequivocal champions for the hospitalized child. Their focus is on the safety of children, and pediatric hospitalists advocate for services and programs that support the best possible outcomes for children. This is especially true for pediatric programs that exist within a larger, diverse hospital environment in which pediatric patients often represent a small portion of the inpatient population. To do this, pediatric hospitalists should fully participate in hospital committees, policy groups, task forces, and program development initiatives that support these goals. Committees particularly important for pediatric representation include pharmacy and therapeutics, credentials, emergency and transport services, patient safety, quality performance and improvement, and medical executive committees, among others. Pediatric hospitalists are well positioned to take leadership roles in quality improvement, safety, performance improvement, risk management, disaster preparedness, rapid response teams, and medical informatics systems. In addition, hospitalists are ideally suited to develop effective transitions of care, promote patient- and family-centered rounds, coordinate care for medically complex patients, develop efficient and effective methods of communication with primary care and subspecialty physicians, and strengthen the medical home. Hospitalists should play key roles in ensuring compliance with standards of The Joint Commission, National Patient Safety Goals, and other regulatory targets. They should develop evidence-based guidelines for the pediatric service. When pediatric services intersect with other hospital services, benchmarks, outcomes data, and goals should be developed to improve health care outcomes for pediatric inpatients.

Pediatric hospitalists often serve as leaders in patient care: they interface with pediatric medical subspecialists and pediatric surgical specialists, primary care physicians, nurses, and others in the hospital environment to help provide patients with a consistent message of quality and safety that enables effective medical decision-making.

The hospital setting may serve to magnify health and safety issues in the local environment. Pediatric hospitalists have the opportunity to be advocates in the community by recognizing patterns of illness and injury not easily evident to individual ambulatory physicians and alerting the local medical community to these concerns. It is essential to conclude that the standards set forth in this statement are directed not only at pediatric hospitalists: it is the responsibility of all pediatric physician leaders within hospitals to champion the best and safest medical care for their patients.

Hospitalists are not the only providers who work in the hospital setting. Other providers are focused on the care and well-being of their hospitalized patients. Those providers should be equally invested in the care process and can similarly integrate themselves into the hospital environment through interdisciplinary work, care coordination, quality improvement, and leadership activities to produce the best outcomes.

The following basic principles are recommended for pediatric hospital medicine programs:

1. Each Program Is Unique. Each pediatric hospital medicine program should be designed to meet the unique needs of the patients, families, and physicians in the community it serves. This may include the option for private pediatricians and other qualified primary (or subspecialty) care physicians to retain the option to admit and manage their own patients. Regardless of who admits the pediatric patient, attending physicians should strive to meet the unique needs of each patient, maintain continuity with the patient’s medical home, and place special emphasis on transitions of care.¹⁰ 

2. Understand the Institution. Pediatric hospitalists and their leadership should be fully versed in the organizational structure of the institution and seek leadership roles and active participation in the clinical, administrative, and information technology committees of the institution. They should seek strategies for involvement in the hospital systems that ensure quality of care and safety for pediatric patients.

3. Leadership and Expertise. Pediatric hospital medicine group members should seek opportunities to develop expertise in areas such as leadership, quality, safety, performance improvement, risk management, disaster relief, rapid response, and other hospital and community health initiatives. These expanded qualifications diversify and strengthen the hospitalist group, provide additional areas of interest, and promote long-term career satisfaction for individual physicians.

4. Patient- and Family-Centered Care. Pediatric hospitalists should promote patient- and family-centered care that includes an opportunity for the patient and family to participate in decision-making about treatment plans and effective discharge planning.¹¹ This should be a part of integrated multidisciplinary care planning that includes other hospital services and the primary care physician.

5. Coordination of the Care Team. Pediatric hospitalists should serve as leaders in the coordination of care of the hospitalized patient, champion the medical home, and develop effective admission and discharge planning. They are available to provide the patient and his or her family with a consistent message and optimally communicate with primary care physicians, pediatric medical subspecialists and pediatric surgical specialists, medically complex care teams, nurses, respiratory care therapists, pain management teams, and others. The pediatric hospitalist, as leader of the inpatient team, coordinates interdisciplinary care and promotes an environment for optimal medical decision-making. Primary care physicians are strongly encouraged to participate in the interdisciplinary care of patients and ensure the patients’ successful transition back to their medical home.

6. Outcomes and Data. Pediatric hospital medicine programs should be supported by data collection and outcome-based assessments to monitor their performance and drive quality improvement for hospitalized children.

7. Advocacy. Pediatric hospitalists are in a position to be strong and active champions of pediatric safety and promote the finest pediatric hospital services. They should vigorously advocate for programs that improve the quality and safety of care provided to all children throughout the hospital setting and beyond.

8. Added Value. Pediatric hospital medicine and pediatric department leaders should promote recognition of value added by hospitalists to hospital programs¹² and support compensation equity for pediatric hospitalists. Examples of the added value by hospitalists include their support and understanding of hospital systems, their availability for hospital committee participation, their ability to recognize potential areas of quality improvement in patient care, the care of unassigned patients, and the timely management of children with acute changes in medical status.

The purpose of this statement has been to address the particular roles and responsibilities of pediatric hospitalists, but it is implicit in all the aforementioned recommendations that the overarching goal is always to provide the best possible care for children and protect the safety of children in the hospital setting. This is the responsibility of all physicians who care for children and all leaders in pediatrics and hospital medicine.

Laura J. Mirkinson, MD, FAAP,^† Past Section Executive Committee Chairperson

Jennifer A. Daru, MD, FAAP, Chairperson

Erin R. Stucky Fisher, MD, FAAP

Matthew D. Garber, MD, FAAP

Paul D. Hain, MD, FAAP

A. Steve Narang, MD, FAAP

Ricardo A. Quinonez, MD, FAAP

Daniel A. Rauch, MD, FAAP, Immediate Past Chairperson

Elena Aragona, MD – Section on Medical Students, Residents, and Fellowship Trainees

S. Niccole Alexander, MPP

^†Deceased