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Success Story: Keeping Teamlets Together in Resident Clinics

Learn how the Natividad Family Medicine Residency Program's approach kept teamlets of residents and their assigned medical assistants working together

About the Organization

Natividad is a public safety-net hospital located in Salinas, CA, which has provided health care to the residents of Monterey County for over 132 years. Natividad makes health care accessible to all patients regardless of their ability to pay. The hospital operates with a medical team of more than 380 physicians and has several specialty clinics and outpatient primary care clinics operated by the Monterey County Health Department. It is also a teaching hospital affiliated with the University of California, San Francisco. Recognized nationally and internationally as a model program, Natividad's Family Medicine Residency Program provides postgraduate training for physicians specializing in family medicine.

What Was the Problem?

The family medicine residency clinic has 8 teams, each with 4 residents (at least 1 from each year of residency), 2 medical assistants (MAs), and 1 faculty member. When in clinic, residents were paired with their team MAs to form a teamlet only 50% of the time due to scheduling issues. This disrupted the team and made learning to work together more difficult for both residents and MAs. In general, when teamlets are consistent, teamlet members have a better understanding of what they can expect from each other as well as each person's work habits. Natividad has observed that this improves efficiency and increases work satisfaction.

The clinic director and manager discovered that last minute vacation requests and schedule changes were destabilizing teams and teamlets. In addition, this had a ripple effect on other aspects of the practice–the director and manager observed excessive patient visit cancellations and rescheduled visits to other teams. The clinic management and residency coordinator decided to make teamlet stability a goal.

Developing the Intervention

To improve teamlet stability, the clinic first reduced variability in resident scheduling. To this end, the residency program revised its rotation templates to schedule a balanced number of residents in clinic each day. This is called “level loading.”

To reduce last minute schedule changes and vacation requests, the program also created a new scheduling policy. Per policy, the clinic schedule is now set in advance for the entire academic year. Vacations are pre-set into each rotation. Changes to this pre-set schedule must be requested and approved 90 days in advance. All changes need approval by the program scheduler because only this individual has the perspective to see how the clinic may be affected.

Some residents were also selectively requesting their clinic days as vacation days. To avoid this, the policy now states that vacations must be taken in 1-week blocks. The policy uses jeopardy residents to cover in clinic when a resident is unable to attend for a particular session. With clinic days having an equal priority as inpatient days, clinic residents are no longer used as jeopardy residents and pulled away to cover hospital services.


“It has been rewarding to see residents and MAs develop deeper working relationships. By third year we see residents feeling close enough to their MAs to bring little gifts and treats for them. They communicate in respectful, natural, effective ways evidencing safe, trusted teamwork.”

—Christina Zaro, MD

The group estimates that implementing a revised rotation template and vacation scheduling policy has eliminated 70% to 80% of schedule changes. It is rare that residents are pulled from clinic to cover other services since a jeopardy resident can fill that role if needed. Teamlets are now stable, with residents and at least 1 of their 2 team MAs working together 80% to 90% of the time. If residents need to move due to space or precepting ratio balance, one of their team MAs moves with them. The Family Medicine Residency Program administers a “Joy in Clinic” survey semi-annually for residents and faculty. The most recent survey averaged 7.5, or “happy in clinic” on a 10-point scale, where scores of 7-8 are defined as happy and scores of 9–10 are defined as very happy. This survey result is in part due to resident scheduling with resultant stable teams and improved continuity.

“Our semi-annual Joy in Clinic survey asks residents ‘What makes clinic enjoyable?’ Recent common responses include ‘relationships with patients and staff’, ‘the MAs’, ‘continuity’, ‘working with my MAs’, ‘interactions with MAs.’ They also list continuity and relationships with patients which we believe are also outcomes of more stable schedules and team-based care.”

—Walter W. Mills, MD
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