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

By  |  May 19, 2016 | 

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.

 

8 Comments

  1. David Gates May 20, 2016 at 10:57 am - Reply

    Your comments are timely, particularly as we are understanding the contribution of physician burnout.

    Perhaps 12 hours on/12 hours off, 7 on/7 off maximizes calendar time off, but it does not really serve patients, hospitalists, or hospitals well.

    We should be rethinking the 8 hour work day, in my opinion.

  2. Terri May 20, 2016 at 11:57 am - Reply

    I am an app provider with close to 20+ yrs of experience as a hospitalist. I have worked almost every inconceivable schedule, including both days and nights. I would advicate for the following: One week in a 3 week set off for a total of 84 hrs with 6 hrs built in for pto/holidays if the beancounters are counting hrs. But really, who gets out at 701am if you signout correctly and not on the fly. Builds in coverage for an unanticipated absence if someone is ill or other mishap. It also gives you more flexibility to work perhaps 3 shifts one week, 4 the next with a week off. With mid-levels, admin thinks its ok many times to flip our day and night shifts around like its nothing. At least this a more humane transition to nights. 30/hrs per week in most places make you eligible for full time benefits. You can always wt the night shifts if someone is reluctant to take a pay cut. Also gives you more eligible providers within the group to pick up extra shifts when census is high or anticipate a heavy d/c day at the last minute. But most providers gladly will take a decreased compensation package for this schedule. I love this schedule!!!!

  3. Bindu May 20, 2016 at 4:57 pm - Reply

    Hi
    I am exploring schedule options other than 7 on-7 off.

    Would love to chat with you about other models

    • Leslie Flores
      Leslie Flores May 26, 2016 at 2:20 pm - Reply

      Bindu, I’d be happy to chat. Please feel free to contact me directly at [email protected]. – Leslie

  4. Mark Thoelke May 20, 2016 at 5:37 pm - Reply

    Interesting discussion. Doing this for 16 years now with a couple hundred docs’ feedback to go on by now. I don’t see any good alternative to 7on 7off. People dont want to sit around on jeopardy call. People dont want to spend more days in the hospital. Assuming the workload is reasonable, the continuity afforded by 7on is hard to argue.
    We have had our night crew assign the night admits for some time to get the day docs able to pick up lists and start working. We are also trying to make the work day easier by taking clerical duties off the docs plates. We try to get half of the docs out a bit earlier every day.
    My guess is that after much discussion, most groups will end up sticking with 7on-7off. Writing this on day 5 of 7.

  5. Basava May 24, 2016 at 10:11 pm - Reply

    HI
    7On/7 off was the reason I got into hospital medicine and still like it as it provides continuity of care when LOS 3.1= 3.6 days. better collaboration with consultants who work also like Hospitalist with week on consultant for specialty. and if working in a teaching hospital – more continuous supervision with residents ( 1 week ) .

    I do see burn out by day 5 when all 5 days have been busy. with kids and getting older we flexed into 5/5 model for some over lapping with 7/7 and found it more easy for those jeopardy calls- influx of volume or sick calls when 6th day is option. there is no perfect model as every one wants few days , less work more money- frustration with fluctuation in census.
    B

  6. Edmund Cheung May 27, 2016 at 5:59 pm - Reply

    What Goes around Comes Around!

    I am Physician in Charge of a Large Hospitalist Group (35 docs) and we are part of an even larger organization (510 Hospitalist). 15 Years ago we had the 7on/off schedule but then moved to a 15 day -3 group rotation of 5 days / 5 days / 5 days rounding. So each “group” of 10 hospitalist round for 5 days and then in between they do 2 to 4 shifts of overnights or other admitting shifts. We also used to round and admit at the same time. However, we then switched to separate admitting and rounding about 10 years ago.

    Now because we are large enough and want to provide flexability for all our hospitalist, we are reviving options of 7/7 rounding and combining Rounding and Admitting for some. What we eventually will probably end up with is a hybrid model that hopefully will work (or at least better) for everyone. Backup coverage however, still maybe a sore point.

    Again What Goes Around Comes Around.
    Probably no perfect model that satisfies everyone. But flexability is the key. Thanks

  7. Tanya February 26, 2018 at 9:02 am - Reply

    Hello,
    I have been doing this for the last 10 yrs now.
    Our Hospital is very excited about daily Huddle.
    As a result all Physicians have a Geographic Model of being distributed.
    After being the admitter, Day 1 rounding involves picking up a brand new list of 18 pts on 1 particular floor.
    Day 2- if patients are transferred to another unit, I lose that patient and get a new one from overnight admissions – on my floor.
    This leads to loss of continuity as I am not able to follow any of my admissions that I did as Day call and lose out on following transfers to other floors as well.
    Is there any way you can suggest that we can maintain continuity of care from Day call onwards and be able to continue Huddle?
    Thanks

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About the Author:

Leslie Flores
Leslie Flores is a founding partner at Nelson Flores Hospital Medicine Consultants, a consulting practice that has specialized in helping clients enhance the effectiveness and value of hospital medicine programs as well as those in other hospital-focused practice specialties since 2004. Ms. Flores began her career as a hospital executive, after receiving a BS degree in biological sciences at the University of California at Irvine and a Master’s in healthcare administration from the University of Minnesota. In addition to her leadership experience in hospital operations, business development, managed care and physician relations, she has provided consulting, training and leadership coaching services for hospitals, physician groups, and other healthcare organizations. Ms. Flores is an active speaker and writer on hospitalist practice management topics and serves on SHM’s Practice Analysis and Annual Meeting Committees. She serves as an informal advisor to SHM on practice management-related issues and helps to coordinate SHM’s bi-annual State of Hospital Medicine Survey.

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