Translating evidence into practice: pursuing perfection in pneumococcal vaccination in a rural community.

There are many challenges to effectively and efficiently translating evidence into practice. Potential strategies include (1) training more evidence-based practitioners in the art and science of evidence-based medicine, (2) enhancing the quality and availability of systematic reviews, and (3) more effectively linking evidence-based practitioners and evidence users through comprehensive behavioral change initiatives. Herein we explore the third strategy and highlight the key elements of success for a program using behavioral change strategies. We present a clinical model based on clear understanding of the "problem," a systematic approach to diagnosis, selection of scientifically sound treatment options, and effective evaluation with appropriate modification of the treatment plan. A successful program begins with effective team leadership, the expression of a clinically compelling case for change, and commitment to the pursuit of perfection in the delivery of key evidence-based interventions. The team must then diagnose behavioral barriers to change, using a systematic approach based on a published rigorous differential diagnosis framework. This diagnostic step provides the foundation for selection of effective dissemination and implementation strategies (treatments) proven to improve processes of care and clinical outcomes. Finally the team must evaluate progress toward perfection, reviewing interim data and adjusting the treatment regimen to newly diagnosed barriers. We then present a specific project (improving pneumococcal immunization rates in our rural community) and interim results to demonstrate the use of the framework in the real world.

Can practice guidelines safely reduce hospital length of stay? Results from a multicenter interventional study.

BACKGROUND: Although practice guidelines about appropriate lengths of stay have been widely promulgated, their effects on patient outcomes are not clear. Our objective was to study the effects of length of stay practice guidelines on patient outcomes. PATIENTS AND METHODS: We performed a prospective, nonrandomized, interventional trial in six geographically distributed hospitals, among consecutively hospitalized "low-risk" patients with total hip replacement, hip fracture, or knee replacement. Case managers provided physicians with patient risk information based on guideline recommendations. We measured length of stay, compliance with recommended guideline length of stay, health status, hospital readmission rates, return to emergency department, return to work and recreation, and patient satisfaction. RESULTS: A total of 560 patients were included in the study. For patients with knee replacement, there was a statistically significant increase in practice guideline compliance (27% baseline versus 53% intervention, P <0.0001) and reduction in length of stay (5.2 days versus 4.6 days, P <0.001) when compared with the baseline period. For hip replacement patients, there similarly was an increase in practice guideline compliance (66% baseline versus 82% intervention, P = 0.01) and reduction in length of stay (5.1 days versus 4.8 days, P = 0.03). Significant reductions in length of stay were not observed for patients recovering after hip fracture despite a significant increase in guideline compliance. There were few statistically significant changes in patient outcomes related to reductions in lengths of stay, including health status, hospital readmission rates, return to emergency department, return to work and recreation, and patient satisfaction. For patients undergoing hip replacement, very short lengths of stay (shorter than the guideline recommendation) were associated with an increased rate of discharging patients to nursing homes and rehabilitation facilities (21% versus 7%, P = 0.01), and hip fracture patients with very short lengths of stay required more visits to the doctor after discharge (56% versus 25%, P = 0.04). CONCLUSION: Reductions in lengths of stay were most often associated with no significant change in patient outcomes. However, very short lengths of stay were associated with increased intensity of care following discharge for patients undergoing hip surgery, indicating possible cost shifting (the cost incurred by transferring patients to rehabilitation facilities may have been greater than had the patients remained in the acute care hospital for an additional 1 or 2 days and been sent directly home). These results emphasize the importance of monitoring the effects of cost containment and other systematic efforts to change patient care at the local level.

How to use practice guidelines in the intensive care unit: Diagnosis and management of unstable angina.

OBJECTIVE: Practice guidelines are often based on expert opinion, and are sometimes based on research evidence, but are usually a mix of both. The goal of this article is to aid in the evaluation of the validity of practice guidelines. DATA SYNTHESIS: The Agency for Health Care Policy and Research Practice Guideline on Management of Unstable Angina and other relevant primary and synthetic research. METHODS: Critical appraisal of guidelines requires understanding how guideline developers identified, appraised, and summarized the evidence, and how they chose the values reflected in their recommendations. To determine whether guidelines are applicable in our practice, we look for clear and concise recommendations about specific populations, describing common options linked to clinically important outcomes. Guidelines must be considered in light of local skills, culture, and resources, and need to be individualized to different patients and settings. CONCLUSIONS: As better evidence and new clinical insights emerge, guidelines require updating. The ultimate value of a guideline is determined by evaluating its effect on process of care, resource utilization, and most importantly, patient outcomes.

The clinical benefit of in-hospital observation in 'low-risk' pneumonia patients after conversion from parenteral to oral antimicrobial therapy.

OBJECTIVE: To assess the benefit of in-hospital observation in "low-risk" patients with community-acquired pneumonia. DESIGN: Retrospective review of data from a prospective study. SETTING: Teaching community hospital. PATIENTS: We studied 717 consecutive, adult patients admitted to the hospital for pneumonia. MEASUREMENTS AND RESULTS: One hundred forty-five patients were classified at low-risk for complications using previously studied criteria; 144 (99%) charts were available for review. Two patients had "obvious reasons for continued hospitalization" on the day of antibiotic conversion and were excluded. One hundred two patients were observed, and 40 were not observed in-hospital after switch to oral antibiotics. No patient from either group required medical intervention within 24 h after hospital discharge. Five "observed" patients (5%, 95% confidence interval [CI], 2 to 11%) returned to the emergency department, three (3%; 95% CI, 0 to 9%) with respiratory complaints. Two (2%; 95% CI, 0 to 7%) "observed" patients were admitted to the hospital with recurrent pneumonia. One (3%; 95% CI, 0 to 13%) "not observed" patient returned to the emergency department with a nonrespiratory complaint and was not admitted. No patient from either group died within 30-day clinical follow-up. The length of stay for the "observed" and "not observed" groups was 98+/-33 h and 83+/-49 h, respectively. The difference in length of stay was 15 h (95% CI, 3 to 27). CONCLUSIONS: In-hospital observation for low-risk patients admitted with community-acquired pneumonia after switch from parenteral to oral antibiotics is of limited benefit, and elimination of this practice could potentially reduce length of stay by almost 1 day per patient. This could translate into a cost savings of $57,200 for the 22-month study period. These results require prospective validation in a larger study.

The relation between systematic reviews and practice guidelines.

Clinical practice guidelines have been developed to improve the process and outcomes of health care and to optimize resource utilization. By addressing such issues as prevention, diagnosis, and treatment, they can aid in health care decision making at many levels. Several other decision aids are cast in the guideline lexicon, regardless of their focus, formulation, or format; this can foster misunderstanding of the term "guideline." Whether created or adapted locally or nationally, most guidelines are an amalgam of clinical experience, expert opinion, and research evidence. Approaches to practice guideline development vary widely. Given the resources required to identify all relevant primary studies, many guidelines rely on systematic reviews that were either previously published or created de novo by guideline developers. Systematic reviews can aid in guideline development because they involve searching for, selecting, critically appraising, and summarizing the results of primary research. The more rigorous the review methods used and the higher the quality of the primary research that is synthesized, the more evidence-based the practice guideline is likely to be. Summaries of relevant research incorporated into guideline documents can help to keep practitioners up to date with the literature. Systematic reviews have also been published on the dissemination and implementation strategies most likely to change clinician behavior and improve patient outcomes. These can be useful in more effectively translating research evidence into practice.

Peripherally inserted central catheters in general medicine.

OBJECTIVE: To report the success rate and complications associated with peripherally inserted central venous catheters (PICCs) and to compare costs between PICCs and centrally inserted central catheters. MATERIAL AND METHODS: We undertook a cohort study of the first 1,000 patients referred to the PICC service of a large tertiary-care, university-affiliated, community hospital. The data were analyzed for insertion success rate, insertion mode, complication rate, successful completion, insertion costs, and applicability of PICCs in "high-risk" groups (transplant, human immunodeficiency virus-infected, intensive-care unit, and pediatric populations). RESULTS: Of 1,000 consecutive PICC attempts, 963 (96.3%) were successful. Cutdown procedures were necessary in 141 insertions (14.6%). Complications of PICC placement occurred in 170 cases (17.7%). Among the major complications were a need for multiple attempts at insertion in 92 cases, malpositioning in 56, mechanical phlebitis in 37, clotting in 37, and bleeding in 5. The rate for completion of therapy was 68.9%. Frequent reasons for early termination were dislodgment (in 85 cases) and infection (in 72-37 confirmed and 35 potential cases). The rate of confirmed infection was 11 per 10,000 catheter days. The costs of PICC insertion were less than those associated with centrally inserted central catheters. CONCLUSIONS: PICCs can satisfy long-term vascular needs and are safe in many patient populations. The infection rate did not depend on insertion mode, lumen number, or patient's immune status. Use of total parenteral nutrition was the most important risk factor in all patient subsets. Cost and safety considerations strongly favor PICCs as alternatives to other vascular access devices.

An evidence-based medicine approach to the diagnosis and management of musculoskeletal complaints.

Evidence-based medicine is an approach to clinical practice and teaching that emphasizes decision-making based on rigorous analysis of clinical research tailored to the individual characteristics of a specific patient. As such, it can be considered the scientifically grounded art of medicine. Through evidence-based guidelines, pathways, and algorithms, the care of populations of patients may also be facilitated by informing individual practitioners of optimal decision-making in specific situations or providing the foundation for comprehensive "disease management" programs. These programs coordinate care for patients with chronic conditions, such as rheumatoid arthritis and osteoarthritis, across time and multiple disciplines. We present an approach to the development of decision-making aids, including guidelines and algorithms, which should be helpful in the care of individual patients and populations for whom physicians and other healthcare practitioners are responsible.

Prospective evaluation of a clinical guideline recommending hospital length of stay in upper gastrointestinal tract hemorrhage.

CONTEXT: Upper gastrointestinal tract hemorrhage (UGIH) is a common and potentially life-threatening disorder. Resource utilization can vary without adverse effect on patient outcome. Clinical practice guidelines are a potential solution to reduce variation in practice while improving patient outcomes. OBJECTIVE: To validate prospectively the safety, acceptability, and impact of a clinical practice guideline defining the medically appropriate length of stay (LOS) for patients hospitalized with UGIH. DESIGN: Prospective, controlled time-series study with an alternate-month design. Outcome surveyors and patients were blinded to study group allocation. GUIDELINE: A retrospectively validated scoring system using 4 independent variables: hemodynamics, time from bleeding, comorbidity, and esophagogastroduodenoscopy (EGD) findings to predict risk of adverse events. The quantitative risk for the low-risk subset was 0.6% (95% confidence interval [CI], 0.0%-2.0%) for subsequent complications and 0% (95% CI, 0.0%-0.9%) for life-threatening complications from this retrospective evaluation. SETTING: A 1000-bed, not-for-profit, university-affiliated teaching hospital. PATIENTS: Consecutive adult patients hospitalized for acute UGIH. INTERVENTION: Concurrent feedback of guideline recommendation (same-day hospital discharge) to physicians caring for patients at low risk for complication. No risk information was provided during control months. RESULTS: Seventy percent (209/299) of UGIH patients achieved low-risk status according to the guideline and were therefore potentially suitable for early discharge from the hospital. Providing real-time quantitative risk information (intervention group only) was associated with an increase in guideline compliance from 30% to 70% (P<.001) and a decrease in mean (SD) LOS from 4.6 (3.5) days to 2.9 (1.3) days (mean reduction of 1.7 days per patient; P<.001). No differences in complications, patient health status, or patient satisfaction were found when measured 1 month after discharge. An independent variable predicting decreased hospital LOS for low-risk UGIH patients was early EGD. CONCLUSIONS: Implementation of the clinical practice guideline safely reduced hospital LOS for selected low-risk patients with acute UGIH. Further prospective validation in other settings is warranted.

Systematic reviews, economic evaluations, and practice guidelines: can research synthesis help us care for the critically ill?

Blending the art and science of medicine in the ICU setting is a growing challenge, given modern technological advances, spiraling healthcare costs, and the need to carefully consider evidence from the biomedical literature in our practice. Rather than keeping up to date with all primary research relevant to critical care, intensivists are increasingly seeking synthetic research to help with their day-to-day decision-making. Synthetic research includes systematic reviews, practice guidelines, and economic evaluations. These publications can address questions of prevention, diagnosis, treatment, rehabilitation, and/or palliation, thereby helping intensivists to integrate the results of sound research at the bedside.

Upper gastrointestinal hemorrhage clinical--guideline determining the optimal hospital length of stay.

PURPOSE: Physicians lack objective outcome data to define the medically appropriate length of stay (LOS) for patients hospitalized with acute upper gastrointestinal hemorrhage (UGIH), resulting in wide variations in resource utilization and quality of care. A clinical practice guideline with the ability to assign relative risk for adverse events is proposed. METHODS: A comprehensive scoring system was derived from the literature by using four variables; hemodynamics, time from bleeding, comorbidity, and esophagoduodenoscopy findings. The discriminatory ability, potential safety, and impact on resource utilization of the clinical practice guideline was measured in a retrospective, observational study. RESULTS: Seventy percent of UGIH patients (349 of 500) achieved low-risk status according to the guideline, and, were therefore potentially suitable for early discharge from the hospital. If low-risk patients were discharged based upon the guideline, mean (+/- SD) hospital LOS would have been decreased from 4.8 +/- 2.4 days to 2.7 +/- 1.4 days; mean reduction was 2.1 bed-days per patient (95% CI 1.8 to 2.3, P <0.001). LOS would have increased in 4% of cases. Adopting the guideline's recommendation of early discharge would have resulted in a 0.6% (95% CI 0.07 to 2.1) complication rate, with no worsening of quality of care, as judged by implicit review. CONCLUSIONS: The proposed clinical practice guideline may safely reduce hospital LOS for selected low-risk patients with acute UGIH. Moreover, it also may reduce premature discharge of high-risk patients prone to life-threatening events.

Evaluation of a pneumonia practice guideline in an interventional trial.

There are few available data to define the medically necessary duration of stay for patients hospitalized with pneumonia. Therefore, we investigated the safety and effectiveness of a practice guideline that provided information about switching patients from parenteral to oral antimicrobials and early hospital discharge. The study was a prospective controlled study with an alternate month design. The practice guideline was studied in 146 "low-risk" pneumonia patients hospitalized during a 22-month period. Medical care consistent with the practice guideline occurred in 64% and 76% of patients during control and intervention periods, respectively (p=0.15). There were no differences in patient outcomes in the control and intervention groups when measured 1 mo after hospital discharge, including hospital readmission rates, health-related quality of life, and patient satisfaction. Explicit and implicit review revealed that 98.6% (95% confidence interval [CI]: 95.1%, 99.8%) of low-risk patients would not have benefited from continued hospitalization after the fourth hospital day. The 30-d survival rate of the low-risk pneumonia patients was 99.3% (95% CI: 96.2%, 100%) and patient outcomes appeared to be favorable compared with previously published values. We conclude that duration of hospital stay was frequently consistent with the practice guideline in both study groups, and patient outcomes remained unchanged. The guideline will require additional testing before it can be recommended for use.

Total knee replacement. A guideline to reduce postoperative length of stay.

In a retrospective study in an academic, acute-care community hospital, we studied the possible safety and effectiveness of a practice guideline recommending early discharge from the hospital for patients having uncomplicated total knee replacement. Of 206 patients receiving knee replacements, 162 (79%) were classified by the guideline as being at low risk for complications between the 4th and 7th postoperative days. Use of the guideline could have reduced the postoperative length of stay from 7.3 +/- 2.6 days to 4 days for the 112 patients (54%) who became low risk on the 4th postoperative day. Explicit and implicit review of the quality of care determined that 157 patients (96.9%; 95% confidence interval, (92.9%, 99.0%) could have been safely transferred from the acute-care hospital to an appropriate setting when they became classified at low risk between the 4th and 7th postoperative days. Clinical practice guidelines can possibly be used to reduce the postoperative length of acute-care hospital stay for patients having knee replacements. This guideline requires further study in a controlled clinical trial before it can be recommended for use.

Applied health services research: responding to the changing health care environment.

Health care in America is changing rapidly. The forces that are reforming our health care system are both numerous and compelling. Americans are requesting access to more affordable health care. At the same time, many Americans want to build upon what is considered the best and most technologically advanced health care system in the world. Especially during economically troubled times, innovative and well-formulated solutions to respond to these fundamental challenges are needed to improve the quality and accessibility of health care. It is essential that policy markers base their health care decisions on sound medical research that specifically examines which aspects of medical care improve patient outcomes.

Measuring and improving physician compliance with clinical practice guidelines. A controlled interventional trial.

OBJECTIVE: To determine factors that may lead physicians not to comply with clinical practice guidelines. DESIGN: Retrospective analysis of patients whose physicians were not compliant with discharge recommendations from a prospective, controlled interventional trial of a guideline to reduce hospital length of stay for patients admitted for chest pain. SETTING: A large community teaching hospital. PARTICIPANTS: Patients admitted with chest pain who were not discharged according to a practice guideline. RESULTS: 79 (34%) of 230 patients with chest pain classified as being at low risk by concurrent or retrospective review were not discharged by day 3 (the guideline recommendation). Of these 79 patients, 33 (42%) were misclassified at concurrent review (10 were falsely classified as being at high risk and 23 were falsely classified as being at low risk). Of 46 correctly classified patients, 11 (14%) were classified as having noncompliant physicians because of health care system inefficiencies. The status of 7 (9%) patients was changed to high risk between initial classification and potential discharge. For 15 patients (19%), no obvious reason for delayed discharge was found, but they had a higher severity of illness than did low-risk patients discharged according to the guideline as measured by mean time-insensitive predictive instrument scores (41.3% +/- [SD] 14.1% compared with 31.5% +/- 14.3%; P = 0.017). In 13 patients (16%), physicians refused to follow the guideline recommendations. CONCLUSIONS: In measuring and attempting to improve physician compliance with a length-of-stay guideline, physician refusal accounts for a small percentage (16%) of noncompliance. Implementation issues, health care system inefficiency, and severity of illness were the predominant reasons why physicians did not comply with guidelines. Our study further supports the principle that clinical practice guidelines should complement rather than be a substitute for physician judgment.

Reducing lengths of stay in the coronary care unit with a practice guideline for patients with congestive heart failure. Insights from a controlled clinical trial.

Although more than 1,000 medical practice guidelines have been developed, there have been few evaluations of their use in clinical practice or information to judge whether practice guidelines can be used to reduce health care costs. For this reason, the authors conducted a prospective controlled clinical trial with an alternating-month design at a large teaching community hospital to study the use of a practice guideline to promote early transfer of patients admitted to a hospital with congestive heart failure (CHF) from the coronary care unit (CCU) and intermediate care unit to unmonitored beds. The practice guideline was supported by locally derived risk information and recommended consideration of early "step-down" transfer of low-risk patients with CHF 24 hours after hospital admission. Physicians caring for patients identified as "low risk" received concurrent personalized written and verbal reminders concerning the guideline recommendation. Study subjects were patients admitted to a hospital CCU and intermediate care unit between November 1, 1991 and April 30, 1993 with a diagnosis of CHF or pulmonary edema. Ninety patients with CHF were identified as low risk according to the guideline during the study period. Feedback of the practice guideline recommendation was not associated with a significant increase in physician adoption of the guideline or shorter lengths of stay in the CCU or intermediate care unit. Physicians may have compensated for statistically insignificant reductions in monitored lengths of stay by increasing the length of stay in unmonitored beds (1.80 +/- 2.32 to 4.02 +/- 4.09 days, P = .002) and the total length of stay (4.73 +/- 2.43 to 6.71 +/- 5.44 days, P = .03). Quality of patient care, patient outcomes, and patient satisfaction were not affected by the guideline. Our study results suggest that implementation of a locally derived practice guideline for patients with CHF did not result in adoption of the guideline by physicians. The complexity of implementing the guideline, changes in physician practice before the study, and the failure of the guideline to address the continuum of patient care across monitored and unmonitored beds may have accounted for rejection of the guideline. Our experience demonstrates that practice guidelines, whenever possible, should be evaluated in prospective trials before they should be disseminated for widespread use.

Hip replacement and hip hemiarthroplasty surgery: potential opportunities to shorten lengths of hospital stay.

The potential safety and effectiveness of a practice guideline recommending a 5-day postoperative stay in the acute care hospital for hip surgery patients without clinical findings predictive of a complicated hospital course was studied retrospectively in 230 patients hospitalized for total hip replacement, total hip replacement with osteotomy, or hip hemiarthroplasty. Seventy percent of total hip replacement and hip hemiarthroplasty patients were classified as being at "low risk" for complications by the guideline (161 patients, or 73% of patients who remained hospitalized). Use of the guideline could have reduced the hospital length of stay from 8.4 days (standard deviation 3.3) to 5.9 days for these selected low-risk patients. Moreover, physicians' implicit review determined that 0% of patients (95% confidence interval, 0% to 2.3%) had a complication that would have benefited from continued stay in an acute care hospital after the fifth postoperative day. Our practice guideline may have the potential to safely reduce acute care hospital length of stay for patients recovering after total hip replacement and hip hemiarthroplasty. The guideline will require further study in a prospective clinical trial before it can be recommended for widespread use.

Identification of low-risk hospitalized patients with pneumonia. Implications for early conversion to oral antimicrobial therapy.

PURPOSE: Few available data exist to define either the medically necessary duration of parenteral antimicrobial therapy or length of stay for hospitalized patients with pneumonia. Therefore, we investigated the potential safety and effectiveness of a practice guideline recommending early conversion of low-risk patients with pneumonia from parenteral to oral antimicrobial therapy and early hospital discharge. PATIENTS AND METHODS: The practice guideline was studied retrospectively in 503 hospitalized patients with pneumonia at a teaching community hospital. RESULTS: Thirty-three percent of patients with pneumonia were classified as at low risk for complications and potentially suitable for early conversion to oral antimicrobial therapy according to the guideline. Were the guideline to have been used to guide patient discharge decisions, 619 additional bed-days would have been made available to accommodate incoming patients. A consensus among physician reviewers led to the judgment that quality of care would not have worsened for 98.2 percent of low-risk patients had they been switched to oral antimicrobial therapy on the third hospital day, nor would quality of care have been worsened for 93.4 percent of low-risk patients had they been discharged on the fourth hospital day. CONCLUSION: The practice guideline that we studied has the potential to safely reduce the duration of parenteral antimicrobial therapy and length of hospital stay for selected low-risk patients with pneumonia. The guideline should be studied in a prospective clinical trial.

Practice guidelines and reminders to reduce duration of hospital stay for patients with chest pain. An interventional trial.

OBJECTIVE: The acceptability, safety, and efficacy of practice guidelines have rarely been evaluated. Moreover, despite the recent development of guidelines and decision aids for patients admitted to coronary care and intermediate care units, few have been tested in clinical practice. DESIGN: A prospective, controlled clinical trial with an alternate-month design. SETTING: A large teaching community hospital. PATIENTS: Patients admitted to coronary care and intermediate care units with chest pain who were considered at low risk for complications according to a practice guideline (n = 375). INTERVENTION: Physicians caring for patients with chest pain who were at low risk for complications received concurrent, personalized written and verbal reminders regarding a guideline that recommended a 2-day hospital stay. RESULTS: Use of the practice guideline recommendation with concurrent reminders was associated with a 50% to 69% increase in guideline compliance (P < 0.001) and a decrease in length of stay from 3.54 +/- 4.1 to 2.63 +/- 3.0 days (0.91-day reduction, 95% CI, 0.18 to 1.63; P = 0.02) for all patients with chest pain considered at low risk for complications. The intervention was associated with a total (direct and indirect) cost reduction of $1397 per patient (CI, $176 to $2618; P = 0.03). No significant difference was found in the hospital complication rate between patients admitted to the hospital during control and intervention periods, and no significant difference was noted in complications, patient health status, or patient satisfaction when measured 1 month after hospital discharge. CONCLUSION: These results suggest that implementation of this practice guideline through concurrent reminders reduced hospital costs for patients with chest pain considered at low risk for complications. Further study of the guideline is warranted.

Introduction of total quality management (TQM) into an internal medicine residency.

In spite of significant enthusiasm for the principles and methods of total quality management (TQM) in health care organizations, there have been only a few creative programs applying TQM to medical education. In addition, teaching programs are under significant pressure to teach and practice cost-effective medicine and to produce more sophisticated general internists. In July 1992, the governance and operation of the internal medicine training program at Cedars-Sinai Medical Center was restructured to integrate a TQM program with a health services research section and a resource management department. This restructured program transfers significant programmatic responsibility and power to houseofficers. Within the playing field defined through a housestaff values statement and requirements of the Accreditation Council for Graduate Medical Education and the American Board of Internal Medicine, the housestaff have brought about substantial change. The first housestaff survey after the new program was operational for six months revealed that 68% of the 77 respondents felt the housestaff had greater programmatic influence, 68% felt that the rate of program change was "better," and 63% felt the overall training program had improved, while 3% felt it had worsened after the restructuring. Fifty-six percent of the housestaff felt the new program should be continued unchanged, and 29% felt it should be continued with changes. Housestaff teams have approached educational issues, quality-of-care problems, and resource management challenges through formal scientific problem-solving techniques. This article discusses the lessons learned in the first six months and the program improvements that will be attempted in the future.(ABSTRACT TRUNCATED AT 250 WORDS)