Every academic medical center faces drivers for change, including new Residency Review Committee requirements, the desire to provide more cost-efficient care, and the only-brief opportunity for the hospital experience to be beneficial to both patients and their physicians. In late 1996, the Department of Internal Medicine at Mayo Clinic identified the need to systematically analyze its inpatient practice and decide whether the current models of care were clinically and operationally viable. Our responsibility was to assess the present situation and plan for the future.
When the Department of Medicine decided to focus strategically on the inpatient practice, we had too many physicians spending too little time devoted to hospitalized patients. On average our physicians spent fewer than six weeks per year in the hospital. This staffing pattern was inconsistent with departmental expectations and was thought to be significantly below the level necessary to meet the needs of today's patients. There was no external force mandating that Mayo outpatient physicians give up their hospital cases to another group of Mayo inpatient physicians and no reason to downsize, as the practice was robust.
Although each academic medical center must face its own challenges and problem solve in unique ways, many issues are ubiquitous.1 New program requirements for residency education in internal medicine provided further reasons to make departmental changes. The new requirements stated that residents must:
- spend at least 33% of their time in ambulatory sites (an increase from 25%);
- spend at least half a day each week over the 36 months of training managing a panel of general internal medicine patients in continuity (up from half a day every other week);
- spend 50% of their inpatient experience on general internal medicine services; and
- receive instruction in managed care, including the development and use of critical pathways and cost-efficient use of medical resources.
We developed a set of hypotheses that challenged whether new inpatient models with greater physician commitment could impact quality of care; patient, resident, and staff satisfaction; and financial performance.
- Inpatient training for residents can be enhanced by physicians who have greater interest and experience in the hospital practice.
- A change in the physician staffing model will improve the delivery of care; improve the quality of care; and have a positive impact on the consultants.
- The costs of inpatient care activities are market-competitive and generate a positive net operating income that meets the financial goals of the department and institution.
- A patient's perception of the quality of care is significantly affected by the degree of coordination among consultants, care team, and patient.
- There is a positive relationship between the amount of time spent in the inpatient setting and the rewards of a collaborative practice of medicine.
Below, we describe the approach our department took to restructuring its inpatient practice.
THE RESTRUCTURING PROCESS
Overall, the inpatient practice was thought to be viable but tenuous given the expectation of continued market pressures on it. Analysis showed improvement opportunities centered around five themes: patient service, quality and performance, education and research, staff satisfaction, and referring physician satisfaction. The external pressures were carefully considered because market responsiveness is critical to the future success of any practice. Physicians needed to more aggressively manage the entire hospitalization course of each patient, especially the first 24 hours, and to eliminate structural idle time.
The best-practice design was cultivated from site visits, literature reviews, and additional interviews. Detailed analyses were completed of core processes and systems (from admission to discharge), financial performance, and staffing structures. Andersen Consulting provided an analysis of external forces that would affect future inpatient practice organization, including competition, consumer desires, government and regulatory entities, and payer practices.
Focus groups indicated that care delivery needed to be more service driven and committed to meeting not only the needs but also the expectations of hospitalized patients and their family members. Patients and family members expected that communication with physicians in charge of their care would be predictable and timely. Patients expressed the need to be treated as partners in care, not as conditions to be treated. Indeed, more “mindful” care is now an integral part of evidence-based teaching in our medical school and residency program.2
We found an opportunity to reduce clinical and operational variation (and thus resource consumption) by implementing disease-management protocols on all services and more closely supervising residents. Physicians expressed the need for more timely data regarding patterns of practice and resource use to enable them to make positive changes.
The excellent learning experience for students, residents, and fellows needed to be protected. Residents desired optimum exposure to specialists, generalists, and great teachers. Although concerns were expressed regarding the need for autonomy in the learning experience, residents also desired more consistent mentorship and guidance. A more focused hospital experience for all learners would include teachers dedicated to the hospital experience. Those teachers would also establish career paths based on the opportunities for education and clinical research by solving the problems facing them on a daily basis.
Department of Medicine physicians wanted a more controlled, predictable workday and more time to pursue their individual medical and research quests. Nurses believed that their skills were underused and desired more substantive roles as members of the patient's care team. Ancillary service staff such as social workers believed that they could have a more meaningful impact with more consistent and predictable interactions with attending physicians.
We developed a set of design elements to serve as a checklist for inpatient model redesign. These important elements include the use of a smaller cadre of physicians assigned to the inpatient practice for both primary and subspecialty care, an eight-week minimum commitment to the inpatient practice, and an expectation of sameday consultations provided by our internal medicine consultative services.
During the development and early implementation phases, several concerns have been apparent. There remains a generalist-versus-specialist debate, although this centers on issues that were present before the reorganization. Some division chairs have expressed concern about their ability to recruit and retain staff if hospital service options are decreased. Last, the continuity of care for outpatients has been a source of concern to physicians providing primary care and to hematologists with chemotherapy patients.
Two significant lessons were learned. First, communication within the department is critical and must occur through traditional as well as nontraditional means. Second, we found it necessary to continue to address generalist-versus-specialist issues. We need to continually reiterate the philosophy that specialists and generalists need to work together as a team to achieve the best outcomes for patients hospitalized on internal medicine services.
The project we have described and the process we have undertaken should not be unique to Mayo Clinic. Hospitalists have been shown to improve the efficiency of inpatient care, including interventions at teaching hospitals.3,4 At academic centers, they have the resources and numbers of patients to produce and evaluate practice guidelines and to assess utilization practices.5 As teachers, they can supervise housestaff closely and be involved with teaching bedside procedures. The hypotheses we developed and the goals we set may help others find their own way toward better amd more cost-efficient care that preserves and enhances the learning environment. Our Department of Medicine saw a need for change in its inpatient practice and responded with new models for primary care, subspecialty care, and hospital consultative services that have applicability for all teaching programs.
1. Goldman L. The academic health care system. Preserving the missions as the paradigm shifts. JAMA. 1995;273:1549–52.
2. Epstein RM. Mindful practice. JAMA. 1999; 282:833–9.
3. Wachter RM, Katz P, Showstack J, Bindman AB, Goldman L. Reorganizing an academic medical service: impact on cost, quality, pajtient satisfaction, and education. JAMA. 1998;279:1560–5.
4. Diamond HS, Goldberg E, Janosky JE. The effect of full-time faculty hospitalists on the efficiency of care at a community teaching hospital. Ann Intern Med. 1998;129:197–203.
5. Michota F Jr, Lewis T, Cash J. The hospitalist: will inpatient specialists improve care? Cleve Clin J Med. 1998;65:297–300.