Reorganization of a medical house staff (firm system): its effect on accessibility and continuity of care

An organizational innovation: the Yale Primary Care Residency Program's experience with a firm system

BACKGROUND

Integrated inpatient-outpatient firms developed in residencies with single institutions may not be applicable to residency programs with multiple inpatient and outpatient training sites. Our objective was to develop a firm in a multisite residency program that improved education and patient care.

DESCRIPTION

One ward team was restructured into a firm that included two interns, three residents, and four private practice internists whose patients were admitted to the firm. Educational impact, length of stay, hospital charges, and in-hospital mortality were evaluated.

EVALUATION

The firm experience increased outpatient training, fostered mentoring relationships, and increased attending availability. Mean length of stay (5.7 vs. 6.5 days, p = .2) and mean hospital charges ($10,888 vs. $12,316, p = .8) for firm and nonfirm patients, respectively, were not different. In-hospital mortality was lower for firm patients (9 of 348, 3%, vs. 87 of 1,565, 6%; p = .02).

CONCLUSIONS

Firm structures with educational and patient care advantages can be instituted in multisite residencies.

Hospital-based group practice: does it change clinic patterns of care?

Initiation of a hospital-based faculty group practice to replace part of a general medical clinic was evaluated in a quasi-experimental design. Practice setting (where patients received their primary care) was the independent variable. The group practice, unlike the traditional clinic, emphasized primary care by providing 24-hour, seven day/week access by telephone; continuity between inpatient and ambulatory care (all patients admitted as private patients of group practice attending physicians) and coordination of care. Resource use, including visits to the primary care site, the emergency room and specialty clinics, and tests ordered at each site were tracked for one year by chart review. Multivariate analysis showed that, contrary to expectations, group practice patients had no fewer emergency room or specialty clinic visits, although they did make more visits to the practice. With respect to tests, practice patients had almost two more tests ordered in the primary care site than clinic patients, although there was no concomitant reduction in tests ordered at other sites. The authors conclude that ambulatory care resource use is an insufficient measure of the effect of a change in practice setting.