Background: Integrated inpatient-outpatient firms developed in residencies with single institutions may not be applicable to residency programs with multiple inpatient and outpatient training sites. Our objective was to develop a firm in a multisite residency program that improved education and patient care.

Description: One ward team was restructured into a firm that included two interns, three residents, and four private practice internists whose patients were admitted to the firm. Educational impact, length of stay, hospital charges, and in-hospital mortality were evaluated.

Evaluation: The firm experience increased outpatient training, fostered mentoring relationships, and increased attending availability. Mean length of stay (5.7 vs. 6.5 days, p =. 2) and mean hospital charges ($10,888 vs. $12,316, p =. 8) for firm and nonfirm patients, respectively, were not different. In-hospital mortality was lower for firm patients (9 of 348, 3%, vs. 87 of 1,565, 6%; p =. 02).

Conclusions: Firm structures with educational and patient care advantages can be instituted in multisite residencies.