Separating Residents' Inpatient and Outpatient Responsibilities: Improving Patient Safety, Learning Environments, and Relationships With Continuity Patients.

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.