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Separating Residents' Inpatient and Outpatient Responsibilities: Improving Patient Safety, Learning Environments, and
Carol K Bates1, Julius Yang, Grace Huang
1C.K. Bates is associate professor of medicine, Harvard Medical School, Division of General Medicine and Primary Care, Beth Israel Deaconess Medical Center, and associate dean for faculty affairs, Harvard Medical School, Boston, Massachusetts. J. Yang is assistant professor of medicine, Harvard Medical School, Division of General Medicine and Primary Care, Beth Israel Deaconess Medical Center, director of inpatient quality, Department of Health Care Quality, and associate director of the internal medicine residency program, Beth Israel Deaconess Medical Center, Boston, Massachusetts. G. Huang is associate professor of medicine, Harvard Medical School, Division of General Medicine and Primary Care, Beth Israel Deaconess Medical Center, Boston, Massachusetts. A.V. Tess is associate professor of medicine, Harvard Medical School, Division of General Medicine and Primary Care, Beth Israel Deaconess Medical Center, and associate director of the internal medicine residency program, Beth Israel Deaconess Medical Center, Boston, Massachusetts. E. Reynolds is associate professor of medicine, Harvard Medical School, Division of General Medicine and Primary Care, Beth Israel Deaconess Medical Center, and vice chair for education, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts. A. Vanka is instructor in medicine, Harvard Medical School, Division of General Medicine and Primary Care, Beth Israel Deaconess Medical Center, and associate director of the internal medicine residency program, Beth Israel Deaconess Medical Center, Boston, Massachusetts. L. Caines is assistant clinical professor and codirector of the medical school course on Introduction to Clinical Medicine, University of Connecticut School of Medicine, Farmington, Connecticut. C.C. Smith is associate professor of medicine, Harvard Medical School, Division of General Medicine and Primary Care, Beth Israel Deaconess Medical Center, and director of the internal medicine residency progra
Problem:
Current regulations for internal medicine residency programs require scheduling that minimizes conflict between inpatient and outpatient responsibilities. To meet these regulations, the internal medicine residency program at Beth Israel Deaconess Medical Center implemented a unique scheduling model--the Alternating Call and Elective Scheduling (ACES) model-in July 2009.
Approach:
Beginning in academic year 2009-2010, the authors restructured schedules for their 95 postgraduate year 2 and 3 internal medicine residents using the ACES model. They report pre- and postimplementation housestaff responses from end-of-year program evaluation and culture-of-safety surveys, as well as residents' pre- and postintervention schedule and patient visit data.
Outcomes:
Prior to the intervention, 13/83 (16%) residents agreed that the structure of residency training minimized conflict between inpatient and outpatient responsibilities; after the intervention, 82/84 (98%) agreed with this statement. Before the intervention, 23/83 (28%) residents felt that the schedule promoted inpatient safety, compared with 83/84 (99%) after the intervention. Agreement that the schedule promoted outpatient safety went from 28/83 (34%) preintervention to 73/84 (87%) postintervention. Before the intervention, 45/84 (54%) residents felt that the schedule promoted a continuous healing relationship with continuity patients, compared with 67/84 (80%) after the intervention. After implementation, residents' continuity visits with their own patients increased by 14%, and total annual patient visits increased by 16%.
Next Steps:
Separating residents' inpatient and outpatient responsibilities may improve patient safety, the learning environment, and resident-patient relationships. Future innovations might focus on improving patient safety and decreasing stress in the outpatient environment.
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