Challenges in an X + Y ambulatory model.

BACKGROUND: Internal medicine training requires significant exposure to ambulatory practice. Ensuring continuity of patient care is challenging, especially with intermittent ambulatory resident assignments. A popular scheduling model is an X + Y block system where residents rotate for X weeks on inpatient rotations followed by Y weeks on ambulatory clinics. Although benefits exist with the X + Y model, it has drawbacks, particularly for continuity of care: residents struggle to obtain follow-up test results and return patient calls promptly. To provide patients with seamless continuity the programme assigned two Managing Clinic Continuity Care Residents (MCCCRs) to cover all tasks. The MCCCRs were soon overwhelmed by the number of tasks and became dissatisfied with the workflow, however, resulting in a low task-completion rate.

METHOD: In our 4 + 1 model residents are divided into five cohorts, we created mini-practice groups (MPGs) consisting of one resident from each cohort. Each week the resident in the clinic is assigned to act as the Practice Clinic Continuity of Care Resident (PCCCR) for the MPG. This individual is responsible for addressing the patient tasks of the other four residents in the MPG. For optimal performance, the previous two MCCCRs are now assigned for oversight only each week. We tracked task-completion rates weekly and surveyed residents for satisfaction.

RESULTS: Following the redistribution of responsibilities, the task-completion rates improved from 75 to 97%. The MCCCR satisfaction rate for the workflow increased from zero to 63%, and the on-time note completion rates increased from 21 to 67%.

CONCLUSION: Modification of the X + Y model using the MPG structure ensured the timely completion of patient-related tasks, and improved the overall experience for both patients and providers. Modification of the X + Y model using the MPG structure ensured the timely completion of patient-related tasks, and improved the overall experience for both patients and providers.