A Scheduling Toolkit for Medical Professionals
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What needs to be in place before you start? |
With principles for the development of safe schedules as guides, the design of actual work schedules should be developed locally with broad involvement of all affected staff, including house staff of all levels, attending physicians, and nurses in the units where they work. A commitment to fully explore, refine, and test attempted schedules is essential. Typically, the first few steps in a systemic change are mis-steps, and without the commitment and participation of all parties, most changes will fail. |
| Persistence is required until one gets the schedule right. If a change is well-planned, involves all parties, and is actively managed post-implementation such that concerns can be addressed and refinements made on the job, however, it is likely to directly improve care. At the very least, well-designed and well-managed intervention attempts provide useful lessons regarding how to take the next steps towards improvement. |
| Nursing and Other Staff Considerations |
Regular feedback from nursing staff is crucial in assessing a house staff schedule change both prior to and throughout implementation. It is important to include nurse managers and staff nurses in discussions of schedule changes before it is implemented, for advice on how a new house staff schedule affects nurses and interacts with existing nursing rotations. Disseminating understanding of the new schedule through this mechanism is also important. If nurses are not aware of how a new schedule works, it is unlikely they will know who is responsible for patient care, which may generate problems. Nursing staff also have extensive first hand experience observing house staff, and can be an invaluable source of feedback on the success of an intervention. At the time of an intervention, nursing staff may be asked to report problems that occur in patient care (both before and after a scheduling intervention is implemented); some formal surveillance safety tools incorporate staff reporting as an element of comprehensive collection of medical errors data. Nurses can also be formally or informally surveyed about the overall success and particular issues with resident groups working on various schedules. This can provide data valuable not only of use to an initial study unit, but of value in assuring smoother implementation of the schedule on additional units in the future. Nurses’ participation in house staff sign-outs of patient care is also important. Ideally, verbal sign-outs should involve nurses as well as physicians to ensure that all providers have the same awareness of key patient care issues, and can each provide input into evolving care plans. Consideration of the impact of a schedule change on other clinical staff such as pharmacists, technicians, physical therapists and others should ideally occur in a similar manner, to ensure a full understanding of the effects of an intervention, and appropriate communication and care coordination. |
| Transition Timeline |
It is unrealistic and potentially unsafe to change house staff schedules en masse. A gradual phasing in of a new schedule is essential. Prior to the implementation of any scheduling intervention, a timeline for each phase of the transition should be created. Throughout the course of a scheduling intervention, this timeline should be monitored carefully and adjusted as necessary. Transitions to new schedules will inevitably take time and each phase should involve gradual, aggressively monitored change. One way to initiate schedule changes with the least impact may be to implement new schedules only for the most junior staff (i.e., interns). As the error rates for interns may exceed those of more senior providers, interns are |
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| a key group to target for intervention. By keeping schedules the same for all other staff, disruptions to existing systems of care and the shock of the change may be mitigated. Moreover, the presence of senior housestaff and others working a traditional schedule for a time-delimited period may provide a continuity “bridge” until interns accommodate to the new schedule and develop improved signout and teamwork skills. Another way to commence change may be to introduce a new schedule only to a limited number of units; intensive care units and other high-risk settings may be high priority areas for safety interventions in many hospitals. Successful interventions may gradually be introduced into all units until all house staff are rotating on safe work schedules. Monitoring both of housestaff experience and objective outcomes is important in implementing schedule changes. |
| Shift Flexibility |
In designing new schedules for house staff it is essential that “shift work” mentality be avoided as much as possible. It is unrealistic to assume that physicians can “clock in” and “clock out” as shift-workers in a factory setting would. Schedules must be designed with flexibility in mind. It should be assumed that house staff will routinely need to stay longer than their scheduled departure times. House staff should therefore be scheduled to work for a couple of hours LESS than the maximum allowed by federal, state, or local regulations. This will allow house staff to remain on duty when required without the added pressure of work hour regulations being broken. Scheduling providers to work hour limitations should also ease the transition to a new schedule as no physician would ever feel comfortable leaving in the middle of a patient crisis due to schedule changes. |