Initiating the firm system at a community teaching hospital

The Medical Center of Central Massachusetts-Memorial, a 350-bed private community teaching hospital, initiated a firm system for multiple reasons: to improve teaching, improve physician nursing relations, improve discharge planning, and to improve quality assurance/utilization review activities. In this system, private physician groups were randomized to four geographic medical wards, each of which had a distinctive subspecialty identity: oncology, cardiology, nephrology, and diabetes. Primary care internists became the Firm Directors, and subspecialists, already identified with those geographic wards, became Associate Firm Directors. The new system has produced several exciting successes; better bedside teaching and a project to shorten the length of stay of common diagnoses are two examples. Problems remain: resident complaints about imbalanced admissions and an increased census are two issues that we must overcome.