Background: Evidence is equivocal that unit-based interventions improve quality on inpatient medical services, but most studies have reported their effect in isolation. These interventions may be better conceptualized as complementary components of a redesigned clinical microsystem. A clinical microsystem is defined as the small group of people who work together in a defined setting on a regular basis to provide care. Effective clinical microsystems have clinical aims, linked processes, a shared information environment, and measure performance outcomes.
Methods: We sought to characterize use of unit-based interventions on medical services, as well as the number and combination of interventions implemented. We conducted a cross-sectional survey of hospital medicine group leaders and Internal Medicine (IM) residency program directors. The survey asked about the use, implementation, and intensity of various unit-based interventions, including localization of physicians to specific units, nurse-physician co-leadership, interdisciplinary rounds (IDR), and access to quality performance data.
Results: Sixty-two hospital medicine group leaders (response rate=20.7%) and 94 IM program directors (response rate=22.6%) responded. No single intervention was used by the vast majority of sites, and the extent and intensity of use varied. As shown in Tables 1 and 2, less than a third of respondents indicated that physicians typically cared for patients on only 1-2 units, a third or less had unit co-leadership on a majority of hospital units, less than half had daily IDR, and approximately half had access to unit level performance data. A majority of groups and programs had fully implemented 0 to 1 intervention and few (≤5%) had implemented 4. No pattern of interventions was predominant.
Conclusions: Hospital medicine group leaders and IM program directors reported variation in use of unit-based interventions to improve quality of care for medical inpatients. While our results may be explained by adaptation of interventions for site specific goals and context, we believe it is more likely that deliberate efforts to redesign the clinical microsystems in which medical patients receive care have not yet occurred. We suggest implementation and evaluation of complementary interventions anchored in a clinical microsystem framework to determine their effectiveness at improving care.
