Next Step in Sustainability: Re-Thinking How Hospitalists Organize Their Work

Do we really need another commentary on the shortcomings of the 7-on/7-off work schedule?  My colleague John Nelson has written and spoken about this extensively, most recently in his January 2016 column in The Hospitalist.  And while I’ve been planning to write this post for a while, Bob Wachter got the jump on me by famously declaring at his HM16 closing presentation in March that “I think one thing we got wrong was a 7-days-on/7-days-off schedule.”  Nevertheless, I can’t resist weighing in.

When I first started working with hospitalist groups more than a dozen years ago, hospitalists routinely told me that the 7-on/7-off schedule was one of the main reasons they chose to go into this specialty.  But too often when I visit groups today there are at least a few more experienced doctors who say they are thinking of leaving the field if they can’t find an alternative to the systole-diastole lifestyle this schedule creates.  More and more groups are beginning to explore how they can continue to offer 7-on/7-off schedules to members who seek it, while creating different schedule options for others.

In my view, this type of flexibility is an important key to long-term sustainability.  Almost none of us in our 50’s and 60’s wants to organize our work in the same ways we did in our 30’s or 40’s, and we don’t desire to balance work and other aspects of our life in the same ways.  The groups that become most successful at creating jobs people will want to do for a career will be those who figure out how to offer different ways of working to people at different points in their lives.

That being said, hospitalists who do choose 7-on/7-off should acknowledge the costs of cramming all their work into relatively few, very long days of work annually – not just the costs to themselves and their families in terms of fatigue, stress, and resentment of work, but also the costs to patients and to other members of the care team related to the potential for increased errors and decreased quality of interpersonal interactions.  The same thing is true of the nursing profession that has almost universally embraced 12-hour shifts in the inpatient setting.

I also hear a lot about “staffing to demand,” which for most groups means having someone on back-up call to come in if things get uncomfortably busy.  That’s a reasonable strategy, but not the only one.  How about creating a schedule in which each hospitalist agrees to work more days each year, resulting in staffing that on most days is more than is really needed to get the work done.  On days when workload is normal or low, most of the hospitalists would finish work and leave early. But on days when workload is high, there are already enough providers available to get the work done – without having to call someone else in.  In this model hospitalists would trade more days off for a generally lower workload each day and no requirement to be on jeopardy call.

In addition to seeking alternative scheduling models that spread a full time hospitalist’s work out in different ways, groups should think about offering part time work to those who want it.  I also know of some groups that have created opportunities for funded QI/PI project time as a way to decompress a hospitalist’s hectic work life and offer greater work variety.  For example, Dr. Therese Franco at Virginia Mason in Seattle told me her organization has a formal process for hospitalists to submit an application for QI projects they are interested in undertaking.  Applications are reviewed by hospital leaders and if selected, the doctor is provided with protected time for the project.  This is built into the hospitalist group’s budget so it doesn’t leave them short-handed.

Re-thinking how we organize work also involves being on the lookout for opportunities to adjust work flows to minimize low-value work and re-work.  For example, most groups of more than about a dozen providers have moved to having a dedicated admitter during the daytime because it makes rounding easier for the other providers.  Most of them will acknowledge this model’s negative impacts on continuity (and potentially on patient satisfaction and ED flow).  But few consider the inefficiencies created for the hospitalists themselves.

Think about it: even though I’m here today seeing patients, someone else is going to admit a patient that I will see tomorrow, spending an hour or so getting to know that patient and developing a plan of care.  Tomorrow morning I will have to come in and do much of that work all over again – much more work than I would have had to do if I had admitted the patient myself the previous day.  So the overall work being done by the group is increased because much of the work of getting to know the patient and understanding the plan of care is being done twice.

Another example of low-value work is the inefficient process many groups undertake to meet each morning to divide up overnight admissions.  It should be possible to create a set of rules by which the night doctor can assign each admission to a specific doctor who will assume care the next morning.  Not only can this reduce morning inefficiencies, but it can also yield benefits in patient satisfaction (the nocturnist gets to “manage up” the doc who will be taking over the next day) and care team communication (the correct attending’s name is in the chart from the beginning).

I don’t have all the answers, but creative and motivated hospital medicine groups across the country are diligently working to find better ways to schedule and allocate their work with the goal of improving not just efficiency but work-life balance, overall job satisfaction, and ultimately career sustainability.  If your group is doing something innovative in this regard, I’d love to hear from you.