Ben-Menachem T, Estrada C, Young M J, Peethambaram P, Krol G, Scher E J, Lesch M
Department of Internal Medicine, Henry Ford Health System, Detroit, MI 48202, USA.
Am J Med. 1996 Feb;100(2):224-9. doi: 10.1016/s0002-9343(97)89463-6.
Internal medicine training programs must adapt to health care systems faced with balancing the competitive priorities of patient-care responsibilities and educational needs.
To evaluated the effects of a major organizational change on the inpatient service of an internal medicine residency program in a vertically integrated health system.
We changed the structure of our program from a system in which the hospitalized patients' primary physicians were responsible for daily inpatient management, while teaching was assigned to a defined teaching rounder, to a method in which the rounding attending was responsible for both teaching and patient care. Measurements before and after the change in the rounding system included: the McGill University clinical tutor evaluations, time-motion observations of house staff, patient satisfaction surveys, average length of stay data, and physician focus groups to assess physician satisfaction.
The rounding attendings consistently received excellent to superior ratings by the house staff both before and after the implemented change. Compared to time-motion observations performed before the change, observations recorded after the change suggested that a greater percent of house staff time was spent on educational activities. The responses of patient satisfaction surveys indicated that the perception of quality of care remained high after the system change. Lastly, the average length of stay for patients on the general internal medicine and subspecialty services was reduced from 7.6 days before the change to 6.6 days after the change, a difference of 0.92 day (95% confidence interval 1.3 to 0.6, P < 0.001).
Through organizational restructuring, it is possible to improve the quality of patient care and improving the efficiency of patient-care management.
内科培训项目必须适应医疗保健系统，该系统面临着平衡患者护理责任和教育需求这两个相互竞争的优先事项。
评估一项重大组织变革对垂直整合医疗系统中内科住院医师培训项目的住院服务的影响。
我们将项目结构从一种模式转变为另一种模式，原模式中住院患者的主治医生负责日常住院管理，而教学工作分配给特定的教学巡诊医生；新模式中巡诊主治医生同时负责教学和患者护理。巡诊系统变革前后的测量指标包括：麦吉尔大学临床导师评估、住院医师的时间动作观察、患者满意度调查、平均住院时间数据，以及评估医生满意度的医生焦点小组。
在实施变革前后，巡诊主治医生始终获得住院医师的优秀至上等评分。与变革前进行的时间动作观察相比，变革后记录的观察结果表明，住院医师花在教育活动上的时间比例更高。患者满意度调查的回复表明，系统变革后对护理质量的感知仍然很高。最后，普通内科和亚专科服务患者的平均住院时间从变革前的7.6天降至变革后的6.6天，相差0.92天（95%置信区间1.3至0.6，P<0.001）。
通过组织架构重组，有可能提高患者护理质量并提高患者护理管理效率。
