A process for reducing workload and enhancing residents' education at an academic medical center.

Academic medical centers are under increasing pressure to find alternatives to residents for the provision of patient care and to expand and improve the educational opportunities for residents. To address these concerns, the authors performed a study of the medical wards at Harborview Medical Center, a county-owned medical center managed by the University of Washington School of Medicine. Admitting diagnoses, provider names, and billings were obtained from professional practice plan billing records. Based on the distribution of admitting diagnoses, a subset of patients was identified that could be removed from routine care by residents and could instead be cared for by non-physician providers (i.e., physician assistants and nurse practitioners) using clinical pathways. The cohort was large enough to reduce the number of patients per resident to within national accreditation guidelines, and to provide faculty with more time available for teaching. The authors summarize the approach used to identify the new model for care delivery indicated above and the plans made to implement that model and to analyze its impact on the quality of patient care, hospital costs, residents' education, and the process of implementing change. The authors conclude that solutions to the problems of workload and education that they confronted will vary by department and hospital setting. Yet a systematic approach to discovering solutions, such as they present, can be adapted to any setting.