Background. Many academically affiliated hospitals are moving from an inpatient, subspecialty orientation in their patient care and educational programs toward a greater emphasis on ambulatory and primary care. Few studies have focused on the organizational, staffing, and management issues involved in implementing these changes. Method. The authors carried out a qualitative evaluation of the process of change in an academic Department of Veterans Affairs hospital during implementation of a major ambulatory primary care program. They interviewed four top managers individually and 59 top and middle managers, house officers, and patients in focus groups in the spring of 1992, nine months after implementation of the key components of the program. Four raters independently evaluated written transcripts of focus-group sessions and identified themes. Results. The main problems identified were difficulty with administrative integration between inpatient and outpatient services; need for training, retraining, and orientation; tensions due to changes in roles and organizational culture; and inefficiency due to the need for frequent negotiations in daily work life. These four problems reflected tensions associated with new demands imposed by matrix management, changing job descriptions, policies and procedures, and changing patterns of communication and record keeping. Conclusion. During the process of implementation of a primary care focus throughout a medical center, extra demands upon staff are inevitable and should be anticipated and planned for. Twelve key factors for successful organizational chanpe are discussed.
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