New York General Hospital (NYGH) is a large, urban, academic medical

center with a 120-year history of serving its community. The majority of its

patients are insured by government programs; 20 percent of the population

in its service area is uninsured. It has consistently attracted superior faculty

drawn by the community-focused mission and the excellence of its academic

programs. Despite the adverse payer mix, NYGH has been one of the few

health systems in the metropolitan area that has been financially successful.

The medical center has invested significantly in information technology for

clinical and business systems, added 400,000 square feet of new clinical space

including a children's hospital, and refurbished aging infrastructure.

The success of NYGH has been driven by inpatient efficiency and volume.

The CEO has said that when he arrived "patients used to stay for the

season." Now, case-mix adjusted length of stay is the lowest in the region due

to implementation of a hospitalist program, markedly improved turnaround

time for diagnostic testing, and an organizational commitment to making the

medical center a seven-day operation by enhancing inpatient and outpatient

weekend services.

The medical staffacademics and voluntary physiciansinitially cooperated

with the administration to achieve better inpatient throughput, but

many saw these efforts as a threat to their autonomy and to established teaching

programs. The 24 chairs met regularly with the administration, but few

still practiced regularly and most were not intimately familiar with operational

issues outside their departments. Also, the residents felt increasingly alienated

from the departments and organization. In the middle of the academic year, a cross-departmental group of residents presented the administration with a

petition signed by 60 percent of the residents asking the leadership to recognize

a house staff union. Dr. Pack had become medical director three months before the house

staff presented their organizing petition. He was a long-time member of the

academic faculty, and had worked on the quality program and throughput in

the Department of Medicine. Dr. Pack was appointed as a second institutional

medical directorthe incumbent medical director oversaw a traditional medical

director portfolio, including quality, regulatory, risk, physician discipline,

chairs, and medical staff officers. The charge for Dr. Pack was to focus on improving

the operation and integration of services and alignment of employed

and voluntary physicians with the medical center. Dr. Pack was asked to lead

the institution's response to the house staff's organizing efforts.

4. How would you improve communication between physicians and the

hospital administration?