Professional Development

Prioritizing General Internal Medicine in a Large Academic Medical Centre: The “ED-GIM Redesign” Experience

Dante Morra, MD, Howard B. Abrams, MD

About the Authors

Dante Morra is the clinical teaching unit director at the Toronto General Hospital for the University Health Network in Toronto. Howard Abrams is the division head, General Internal Medicine, for the University Health Network and Mount Sinai Hospital in Toronto.

The Canadian health care system is experiencing huge external pressures as it changes its focus from the delivery of catastrophic care to chronic disease management. General internal medicine (GIM) is the key player in this transformation and will develop into the core specialty of most hospitals. The subspecialty programs that many institutions pride themselves on depend on a functional and well-organized GIM presence to provide comprehensive care to patients with multisystem illness. Internists must work with hospitals, the Ministry of Health, and the public to create positive change for the system, even though this process is difficult. 

GIM at the University Health Network (UHN) in Toronto has rapidly emerged as a key focus of senior management over the past year through the Emergency Department – General Internal Medicine (ED-GIM) Redesign project. This commentary explores the process of reprioritization and reflects lessons learned in this rapidly changing environment.

Initiating a New Perspective: GIM Is the Core Business of Hospitals

The UHN is one of the largest academic health science centres in Canada, with an operating budget of over $850 million dollars.1 The hospital has a bold vision statement of global impact and, for the past decade, has focused on the high-profile programs of transplantation, cancer, cardiac disease, neuroscience, and musculoskeletal health. Each of these programs has large operating budgets and well-developed research platforms, with extensive financial support from well-funded foundations. Although GIM cares for the largest volume of in-patients, contributes the most hours to medical education, and is one of the most successful research divisions, it remained largely unnoticed within the larger program grouping of community and population health (along with family medicine, mental health, women’s health, and emergency medicine).2

In the new Ontario health landscape, Local Health Integration Networks (LHINs) were created to facilitate a regional model of health care delivery, governance, and funding. The LHIN structure created accountability agreements to set benchmarks for delivery of service from the hospitals. Common case mix groupings (CMGs) were established in the accountability agreements, of which a large number fell into GIM diagnostic categories. The accountability agreements, in conjunction with a focus on emergency room wait times, created a strong external pressure on the hospital. As environments undergo rapid change and shifting accountabilities, there is a tendency for physicians and departments with a lower profile to hide and to protect existing positions. We took a different approach and engaged the hospital leadership in an attempt to communicate the strategic importance of GIM. We chose to change our message from discussions revolving around patient care and the needs of our population to the importance of GIM in maintaining the organization’s profile, and meeting its vision of global impact. After careful analysis provided in part by the GIM Division, the hospital leadership embarked on a project to transform the role of GIM in the ED.

Living the ED-GIM Tool Kit: Walking the Tightrope

The UHN in partnership with North York General Hospital engaged the Ontario Ministry of Health and Long-Term Care (MOHLTC) in creating a project to deliver operational improvement through the ED-GIM patient care axis. The goal was to create a “tool kit” of interventions that could be used by other hospitals. As this project was accepted, GIM was vaulted from isolation to a primary focus of the hospital with a large project management office to support this change. Senior management attended town hall meetings, the chief executive officer toured the wards, and the hospital news section had features on GIM. Consultants were brought in and, through a dizzying series of meetings, the organization began to create interventions that could be piloted and tested. After years of low visibility in the hospital’s strategic planning process, it was refreshing to see the enhancement of GIM now become a priority of senior management and the hospital board.

As physician leaders, we were aware that the project team’s short-term focus on the tool kit would not create a solution. We felt it was important to use this window of opportunity to establish a longer-term transformation focus. As clinical leaders, we knew this would translate into walking a tightrope of present and future trade-offs. It further creates a tension of managing risk of failure through the speed of change. There is a constant negotiation process that takes place while navigating this narrow path; one must remain positive, engaged, and helpful in creating interventions but provide constant cautions as to why short-term interventions might not work in the current environment. The attention is a real opportunity for change, but it is risky because we know the problems are difficult to solve. How does one provide the truth that is necessary for real change but by its very nature might scare off the attention being provided? This became an awkward courting process in which we attempted to create small operational wins while introducing the hospital and the project teams to the real deep-seated, systemic problems.

Where We Stand Today: Lessons Learned

The tool kit was delivered to the MOHLTC in February 2007. There were 30 documented interventions implemented in a whirlwind 8-month period. The teams created to develop these interventions were composed of project managers, an interprofessional group of clinicians, performance measurement team members, and several high-level administrators. The interventions ranged from new models of care delivery to sophisticated electronic bed-tracking applications. The interventions were measured through general hospital metrics (e.g., length of stay) and other more focused operational metrics (e.g., time to clean bed from discharge). Some of the interventions required minimal resources (e.g., preprinted admission order sets in the ED), and others were complicated and were resource intensive (e.g., best practice implementation of health care staffing – corrected for acuity and workload). The GIM environment has certainly improved, but we are far from the real transformation GIM requires. The emergency room is still full of GIM patients, and GIM still has the organization’s attention. Although the organization is committed to a multiyear transformation, some project teams are beginning to move away. There is a concern that GIM could drift back to its previous position as an underrepresented service in a large specialized hospital.

Some key lessons learned from the ED-GIM process involve brand recognition, teamwork, and risk tolerance.

Brand Recognition: GIM as the Core Business of Hospitals

GIM has an identity problem, especially at our “quaternary care” organization. A disease, an organ, or a technology associated with a subspecialty is relatively easy to create an identity around, but GIM cannot be defined in simple terms. GIM operates and delivers care in a complex environment. We are dealing with the new realities of future health care delivery. Although we provide the largest volume of in-patient care and support every other subspecialty program, we had a great deal of difficulty explaining what we do and how important GIM is for the organization. In fact, prioritizing GIM depends on senior management understanding what we have to offer. Hence, we have to understand what the institution needs and work together to solve common problems.

Teamwork

As physicians, we often approach problems from a truth knower perspective, believing we are experts on everything that takes place in our units. This can limit our ability to learn from highly sophisticated project managers and corporate strategic thinkers. It is important to keep an open mind and consider different approaches to common problems.

Risk Tolerance

Physicians need to take on risk in making changes to the health care system, recognizing that these initiatives could fail. We have to acknowledge that the best decisions may come from a team approach rather than individual enterprise.

Conclusion

It is imperative that GIM take an active role in shaping the process of health care delivery to meet future needs. Internists, armed with their complex problem-solving skills and multisystem approach to care, are uniquely suited to help enable systematic change. GIM leaders must make an effort to understand what issues and challenges their organization or regional units face in the short to medium term, and to communicate the important role our specialty has. Internists must convince their administrators that, as large stakeholders and skilled problem solvers, we have the ability to bring about successful change. By telling health care planners who we are, what we do, and what we are capable of, we can develop a mutually beneficial partnership to improve the delivery of care in hospitals everywhere.

Acknowledgements

We would like to acknowledge Michael Baker, Catherine Zahn, and Bob Bell for their tremendous leadership in helping to transform GIM at the UHN, as well as Kumanan Wilson for the suggestion to write up our experience and share the ED-GIM project with our colleagues.

References

1.           UHN Facts. Retrieved April 16, 2007, from http://www.uhn.ca/About_UHN/corporate_info/index.asp.

2.           UHN Program Structure. Retrieved April 16, 2007, from http://www.uhn.ca/About_UHN/programs/index.asp.

Article Citation: Moora D, Abrams H. Prioritizing general internal medicine in a a large academic medical centre:The :ED-GIM redesign" experience. Can J Gen Intern Med 2007;2(3):21-22