Avoiding common scheduling and staffing mistakes
From the September ACP Observer, copyright © 2006 by the American College of Physicians.
By Deborah Gesensway
WASHINGTON—The seven days on/seven days off shift has rapidly become the work schedule of choice for hospitalist groups that have grown large enough to provide 24/7 coverage.
But according to one of the founders of the hospitalist movement, that particular shift model may paradoxically lead to physician frustration, overwork and burnout—and potentially compromise quality of care.
As hospitalist groups grow to include between six and 10 physicians or more, the overwhelming trend has been away from call-based schedules to shifts—and slotting them into shifts of seven on/seven off seems to be an obvious management tool. Plus, it has proved to be a successful recruiting tool for doctors just out of residency who see that schedule as a vast improvement over what they had in training.
But the model has its downsides particularly when shifts are rigid, said John R. Nelson, FACP, director of the hospitalist practice at Overlake Hospital in Bellevue, Wash. Dr. Nelson spoke at a full-day precourse on “Best Practices in Managing a Hospital Medicine Program” at this year’s annual Society of Hospital Medicine (SHM) meeting.
“It seems good at first," he said of the seven days on/seven days off schedule. "But it’s bad over time, and the costs are too high.”
During the session he discussed concerns about that system—and offered strategies to address hospitalists' scheduling and staffing challenges.
What does—and doesn't—work
The crux of the problem with a seven days on/seven off schedule, Dr. Nelson said, is that means the hospitalist is working only 182,5 days (or shifts) annually. That means they must compress a typical hospitalist workload into 182.5 worked days (shifts) when it might be more reasonable to spread that work over 210 or 220 days annually. Hospitalists who follow a seven on/seven off schedule often say they’re working unreasonably hard, while their productivity, measured in annual work RVUs or similar metrics, is only average or below average. But they have created this problem for themselves by trying to handle a average annual workload, and compressing it into a small number of days.
He also underscored the emotional and psychological costs of what he called the "systole/diastole" lifestyle that comes with a seven on/seven off shift. When he was working that shift schedule, he said he resented having no personal life during the 7 consecutive days of work—and when he was off, he resented that he soon would have no personal life.
Moreover, he said, he doesn’t believe a seven on/seven off schedule allows hospitalists to offer the best quality of care because it may lead to some unnecessary breaks in continuity.
Other scheduling options may prove better, he said, including the following:
Reduce the daily workload. In other words, titrate your work out over more days, so that the typical worked day is less busy than it would be on a 7 on/7 off schedule. This can make “it reasonable to work more than seven consecutive days if necessary,” he said.
Don't set exact starting and stopping times for shifts. A flexible scheduling system lets the group accommodate the natural fluctuations in patient volume and workload and offer a greater continuity of care to patients, he said. The doctors should be able to start and stop working based on that day’s patient volume so that some days will be shorter and others longer. That may mean that the number of hours a doctor will need to work may vary in an unpredictable way, but it encourages the doctors to adapt the pace of their work, the length and duration of any breaks they might take (e.g., lunch) based on the day’s patient volume and their personal needs. It also allows physicians to set their schedules around personal needs. “Sometimes I work five to six days; sometimes 10-14 days,” he said. “Variation is healthy.”
Take advantage of flexible physicians. There is a pool of physicians who, for a number of reasons—from childcare needs to spousal schedules—want to moonlight or work part-time or unusual shifts, including weekends or nights. Hiring part-timers can smooth out the peaks, he said, particularly in the busy winter months.
More scheduling pitfalls
Dr. Nelson said he also doesn't approve of two other common practices that groups have used to cope with heavy patient loads: caps and "jeopardy."
Setting patient volume caps for individual physicians is a good idea, he said, because research has shown that doctors who are too busy increasingly make mistakes.
But setting caps for the practice as a whole is "economically hazardous," he claimed: It limits the amount of money the group can make—and makes hospitalists look unprofessional. No other group of physicians working in the hospital, he pointed out, cap the number of patients they see on any given day. And if the whole hospitalist group reaches the cap and closes to new referrals, who is it that takes the new referrals until the hospitalists reopen? Having a cap for the practice encourages other doctors to view the hospitalists as residents, which can lead to unhappiness for the hospitalsits.
"Basically, all the doctors working that day need to be willing to work longer and not quit at the end of a eight, 10- or 12-hour “shift,” said Dr. Nelson. "That is what most doctors do. And when there is less than an average amount of work, the doctors should be free to go home early."
Jeopardy, meanwhile, is a scheduling system where one physician who is off is assigned to be on standby, carrying a beeper and ready to be called in if the practice gets too busy.
Although some practices have had success with such systems, Dr. Nelson said he has found they tend not to work. That's because few physicians want to “bother” their colleague and call her in to help, in part because they hope their colleagues won’t call them in when they’re next on “jeopardy.” Jeopardy systems work best, he said, when the decision to call in a standby doctor is made not by physicians but by a nurse or administrator following a set protocol.
Other staffing mistakes can sink a new hospitalist practice, he said, particularly underestimating how busy a hospitalist practice will be. Referral volume usually grows much faster than projected, making this “the most common reason for new hospitalist practices to fail,” Dr. Nelson said.
As a result, he advised groups to “slightly overstaff” rather than understaff. This not only helps the group better handle peaks and valleys but also “gives you room for growth.” With extra staff, a practice can add additional services that many hospitals are requesting, such as surgical co-management or rapid response team participation.
Also complicating staffing calculations is the fact that a new practice is likely to have high physician turnover.
“The chance is that one of four hospitalists will leave within a year, so you should start thinking about recruiting No. 5 right away,” Dr. Nelson advised. Don't forget that hospital medicine is still a common choice for young physicians waiting to start a fellowship or for a spouse to finish training.
Another big mistake, he said, is to set staffing according to projected daily census. That number can vary depending on the mix of work to be done and on the number of admissions, discharges and ICU cases. In addition, Dr. Nelson said, the increased workload required to shorten lengths of stay will necessitate a lower daily census.
Finally, established practices fall into the common pitfall of “staffing based on the schedule instead of the other way around,” he said. Schedules, he said, need to be rethought as practices grow and change.
Deborah Gesensway is a freelance health care writer in Toronto.
The information included herein should never be used as a substitute for clinical judgment and does not represent an official position of ACP.
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