I’ve been writing this darn blog post for four days. Every time I sit down to work on it the phone rings, someone knocks on the door, or I hear that little “ding” that means I have a new email or text. Sometimes it’s my own brain interrupting me, telling me I forgot something or that something else on my list is more urgent. Occasionally it’s just asking me what’s in the fridge. I’m no expert in the field of interruption science, but even I know these interruptions are killing my productivity.
When I talk with hospitalists around the country about factors that negatively impact their productivity and professional satisfaction, interruptions – especially low-value ones – are usually high on the list. This won’t be news to anyone, I’m sure, but strategies for reducing or more effectively dealing with interruptions are hard to come by.
Studies suggest that workers are interrupted a dozen or more times per hour, at the cost of billions of dollars annually in lost productivity and errors1. There’s also research showing that when workers are interrupted it takes an average of 25 minutes to return to their original task2. For hospitalists, these types of interruptions pose clear risks to patient safety and quality as well as to productivity and hospitalist job satisfaction.
John Nelson wrote a 2008 column in The Hospitalist suggesting that utilizing rounding assistants for each hospitalist and moving to unit-based assignment could aid interruption management. The idea of rounding assistants hasn’t gained much traction, but geographic assignment has become commonplace. And though it reduces the frequency of pages and calls, they often are replaced by increased in-person interruptions. Win Whitcomb wrote a great article that offered some very practical suggestions for managing interruptions including identifying and protecting “high-stakes moments” and establishing practices decrease interruptions such as unit-based assignments and multidisciplinary rounds. Here are some additional thoughts.
Offer to work with nursing colleagues on a process improvement initiative around interruptions. Problems associated with the need to interrupt hospitalists are frustrating to nurses too, and nurses can be open to working on this issue if approached in the right way. That means treating them as colleagues and acknowledging interruptions as a collective problem that everyone owns a piece of, rather than a blame game. Such projects are already underway at a couple of places I know of, where physicians and nurses are developing tactics to decrease low-value interruptions and improve overall communication.
Differentiate between urgent and non-urgent communication. Years ago paper medical records often contained a brightly-colored sheet (call it the “purple sheet”) where nurses could note routine communications that could wait until the doctor was reviewing the chart. With the advent of EHRs the purple sheet went away and often wasn’t replaced with an alternative, so now many nurses have no option besides paging for everything. Consider developing a replacement mechanism for non-urgent communication, and reserving paging or calling for issues that require an urgent response. If you go down this path, though, there should be clear rules around what constitutes non-urgent vs. urgent items. And hospitalists will need to be sure to regularly check the non-urgent communication channels and not just ignore them.
Pre-empt interruptions whenever feasible. Are there ways you can get out in front of some potential interruptions? Hospitalists working at night often complain about the volume of floor calls, but what if the night hospitalist routinely made rounds to each patient care unit at a fairly predictable time? You could train the nurses to hold a lot of non-urgent communication, if they know you’ll be dropping by to check in with them later. Another idea for pre-empting interruptions would be to implement an admission order set with generous prn orders (appropriate to the patient’s condition, of course) so that you don’t need to be called for things like laxatives, sleeping pills, or comfort care items.
Own your own piece of the interruption puzzle. Some interruptions are self-created, like my obsession with what’s in the fridge. Do you have work habits that undermine your own focus? Those of us who are social animals may unwittingly choose to work in locations that almost guarantee someone will stop by to ask a question or chat. Sometimes we try to do too many things at once and keep interrupting ourselves. Or we might not be as responsive to pages as we should be, resulting in added calls and pages. Think twice before calling or paging someone else: is the reason you want to contact her worth the interruption to her productivity? By respecting the time and attention of others perhaps we can teach them to respect our time as well.
Accept that interruptions are unavoidable, and sometimes even offer value. You’ll never get rid of all interruptions, so developing coping mechanisms to remain effective in an interruption-rich environment is important. Turn off your phone or pager briefly when you are involved in a high-stakes activity – a delicate patient/family conference or complicated medication reconciliation. Before responding to an interruption, find a good stopping point and jot down notes about items still on your mind. Work to change your mindset so that you can think of at least some interruptions as opportunities to help increase the effectiveness of others on your team and bolster your relationships with them. Finally, look for value in your interruptions. Did you learn something that changes an aspect of your work or that allows you to be more efficient? Did the interruption offer a needed break from a mentally or emotionally exhausting task? Sometimes there’s no silver lining to an interruption, but I think we’d all see the silver linings more often if we just look for them.
This is a vital topic. I worked in one hospital where the program director promoted interruptions because she wanted to, “…have good communication with the nurses.” But there were over eighty phone calls per twelve hour shift and at least that many face-to-face interruptions. It was impossible to work. Typical phone calls were things like:
“Have you put a diet order in the computer for this admission yet?”
“Have you put a code status in the computer for this admission yet?”
“Did you order antibiotics on this patient?”
This went on all day. But, if you replied, “If you are wondering what is in the computer, please check the computer before interrupting me. If this does not answer your question, then please call me immediately,” you were considered a disruptive physician.
They even had one coding nurse who would interrupt the physicians constantly with, “Are there any additional codes you would like to capture on this admission?” But if the doctor’s response was, “I am not sure. Did I miss something?” The answer was, “Oh, I can’t answer that. We are prohibited by law from making suggestions.” So then the physician would stop what he/she was doing and start reviewing the chart while being pleasantly stared at by this coder. “What did I fail to include in the billing? Morbid obesity? An electrolyte abnormality?” This experience was like playing a round of Jeopardy except that it a was maddeningly frustrating interruption that required nothing more than a sticky note on the front of the chart. This program had the highest turnover I have ever seen (as well as the highest pay) but the administration blamed it on a series of disgruntled physicians and geography. There was no insight.
I was practicing in the seventh degree of Hell.
I worked as a locums in another program for a couple of months. On the first day I had two phone calls. I chuckled to myself as I flew through my work and thought, “The staff does not know how to reach me yet!!” By day three there had been only five phone calls. So at this point I became concerned and began asking ward clerks and staff whether or not they knew how to reach me. They all did, they all had my contact information. Had I died? Was this Heaven? What was the difference? So I started asking about policies. Nurses were surprised by my questions and often responded with, “But don’t interruptions contribute to errors and reduce productivity?” Say, WHAT?!?! Then I started asking around further, “What is happening here and why?” The entire system had evolved into one where every effort was made to avoid unnecessary interruptions of physicians, pharmacists, and nurses.
I then tried to understand how such a system had evolved, because this system was no accident. I found that every hospitalist site program director, as well as the overall program director had advanced degrees in hospital management. They knew what they were doing. This program was the direct result of Intelligent Design! They worked directly with every level of the hospital to develop a cohesive and well-run system and boy, oh boy, did it show.
I had died, this was heaven.
Wow Creed. That’s amazing.