title: Navigating tensions: integrating palliative care consultation services into an academic medical center setting.
abstract: BACKGROUND
  Despite rapid proliferation of hospital-based palliative care consultation services (PCCSs) across the country, there is little description of the dynamic processes that the PCCS and the non-PCCS hospital cultures experience during the institutionalization of a successful PCCS.
  
  
  OBJECTIVE
  To describe the institutionalization of a new PCCS in a quaternary care academic medical center (AMC) and highlight two themes, cost and quality, that pervaded the dynamics involved from the inception to the successful integration of the service.
  
  
  METHODS
  Ethnography using longitudinal field observations, in-depth interviews, and the collection of artifacts. The study was performed in a 750-bed quaternary care AMC in the northeastern region of the U.S. Participants were a purposefully selected sample (n=79) of 1) senior-level institutional administrators, including clinical leaders in nursing, medicine, and social work, 2) clinicians who used the PCCS, either commonly or rarely, and 3) members of the PCCS core and extended teams.
  
  
  RESULTS
  Key infrastructure components that contributed to the successful integration of the PCCS included top level interprofessional administrative buy-in to the quality and cost arguments for PCCS, PCCS leadership selection, robust data collection strategies emphasizing quality outcome data, the adoption of the "physician referral only" rule, and incremental and sustainable growth. The PCCS service grew an average of 23% per year from 2003 to 2009.
  
  
  CONCLUSIONS
  An in-depth understanding of the dynamic interaction of the infrastructures and processes of a successful institutionalization, in their unique complexity, may help other PCCSs identify and negotiate attributes of their own circumstances that will increase their chances for successful and sustainable implementation.
authors.affiliation: School of Nursing, University of Rochester, Rochester, New York 14642, USA. sally_norton@urmc.rochester.edu
authors.forename: Sally A
authors.initials: SA
authors.lastname: Norton
authors.forename: Bethel Ann
authors.initials: BA
authors.lastname: Powers
authors.forename: Madeline H
authors.initials: MH
authors.lastname: Schmitt
authors.forename: Maureen
authors.initials: M
authors.lastname: Metzger
authors.forename: Eileen
authors.initials: E
authors.lastname: Fairbanks
authors.forename: Jane
authors.initials: J
authors.lastname: Deluca
authors.forename: Timothy E
authors.initials: TE
authors.lastname: Quill
mesh_terms: D000046:Academic Medical Centers / Q000191:economics / Q000458:organization & administration* / Q000592:standards; D017048:Health Care Costs; D006801:Humans; D008505:Medical Staff, Hospital; D009722:Nurse Practitioners; D010166:Palliative Care / Q000191:economics / Q000458:organization & administration* / Q000592:standards; D010348:Patient Care Team; D010820:Physicians; D012017:Referral and Consultation / Q000191:economics / Q000458:organization & administration* / Q000592:standards