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

In 1975, the Johns Hopkins Medical house staff was reorganized into four Firms. Each Firm provides inpatient and outpatient care to a group of patients. Two of the goals of the reorganization were to improve accessibility and continuity of care. This study, based on a before and after research design utilizing routinely collected data, sought to determine whether these goals had been attained. Accessibility was assessed by observing changes in waiting time for appointments, broken appointments, and number of patients seen before their scheduled appointments. The results showed that mean waiting time for a Medical Clinic appointment fell from 15 days to 1 day (p < 0.01); broken appointments for new patients fell from 54% to 34% (p < 0.01); no significant changes occurred in broken appointments for old clinic patients (34% vs 32%); and patients seen before their scheduled appointments increased from 30% to 38% (p < 0.001). Continuity was assessed by observing changes in use of emergency and walk-in clinic services, the proportion of Medical Clinic patients lost to follow-up care, the proportion of hospital readmissions returning to the same nursing unit, and the proportion of patients discharged from the hospital who returned to the Medical Clinic. The results showed that use of emergency and walk-in clinic services fell slightly, from 24% of all visits before to 22% of all visits after the Firm System (p < 0.001); no change occurred in the proportion of patients lost to Medical Clinic follow-up (21% before and after the Firm System); the proportion of hospital readmissions returning to the same nursing unit increased from 35% to 73% (p < 0.005); and the proportion of patients discharged from the hospital who returned to the Medical Clinic increased from 21% to 35% (p < 0.001). These data suggest that implementing the Firm System led to improvement in several selected aspects of accessibility and continuity of care but that further improvements could be made.