Harvard Work Hours Health and Safety Group

A Scheduling Toolkit for Medical Professionals

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Resident Education
A common concern among house staff regarding schedule changes is the impact that modified schedules will have on resident training.  Measures must be put in place to examine this outcome as well as patient safety and resident satisfaction.  General resident education may be assessed via questionnaire as in the example below.  Implementing assessment tools such as this will help to ensure that a scheduling intervention is not interfering with residents’ learning.  Another more objective way to assess the impact of a schedule change on resident education is to quantify residents’ participation in key educational and experiential activities, such as the number and types of procedures performed by residents; the number of hours spent in didactic training sessions; and the number of hours spend reading and studying.  Implementation of schedules that reduce work hours often limit the time available to participate in formal teaching sessions.  To address this problem, some programs have begun to record core lectures digitally, providing house staff the opportunity to view them even if they cannot be present in person at the time a lecture is delivered.
Sign Outs

In implementing scheduling changes, and in seeking to reduce house staff work hours, it is essential that a strategy for care hand-offs be in place to minimize the risk of error due to care discontinuity. Research has demonstrated that when handled improperly, work hours reduction can lead to an increased risk of hand-off errors. In one study, the risk of a medication error being made on a patient with whom one was unfamiliar was greatly increased, though this risk was essentially eliminated in a second study following the introduction of a structured, computer-based sign-out form (Peterson 1994, Peterson 1998). Staff coming in to work at night need to have adequate information to address emergent issues that arise; assuming that a house officer is well-trained, and should be able to handle anything that comes up is inadequate. Fewer errors will occur if a structured sign-out process exists, supplemented with a paper-based or (better yet) a computer-based hand-off tool.

In the HWHHSG Intern Sleep and Patient Safety study, our first effort to eliminate 24 hour shifts for interns, integrating an effective sign out tool was challenging.  The computerized template we developed was never fully adopted, and the effectiveness of the planned evening sign-out was frequently suboptimal.  Further, in our study, the night-call intern was often unaware of historical details regarding patients admitted by the day-call intern and sometimes performed poorly when describing these patients on morning rounds. This led to a widespread impression that communication on the intervention schedule was problematic, making the improvements in patients' safety we observed all the more remarkable. Several possible solutions to this issue exist, including the addition of formal evening rounds for the entire team at each hand off. Such improvements, coupled with the elimination of extended work shifts, could further improve patients' safety, by concurrently reducing the risks both of errors due to sleep deprivation and hand-off errors.
Optimizing the Verbal Handoff
Evening Rounds
The addition of formal evening rounds can reduce the risk of verbal miscommunications at evening hand-off, ensuring that physicians coming on duty are fully apprised of the most comprehensive, up-to-date information about their patients.  Critical elements of any sign-out include its comprehensiveness and structure.  Both the presence of a supervising physician and the structure of formal rounds can help to ensure these.  While evening rounds may be an excellent means of reducing handoff errors, however, the timing of their implementation can pose difficulties.  The timing of rounds needs to be at the time of shift transition, to allow both outgoing and incoming house staff to participate.  For example, morning rounds at 8:00 AM, followed by evening rounds at 8:00 PM would be needed if, as is optimal from a sleep and consecutive work standpoint, house staff on night shifts are limited to approximately 12 to 13 consecutive hours of work. Rounds centered between 7:00 PM and 11:00 PM allow the incoming “night call” resident the opportunity to take a nap in the afternoon prior to work and keep the night call duration optimal (Schedule A).  Rounds at this time may be difficult for attending physicians, however, particularly in traditional academic models where attendings are available in person only during the day, and field issues that arise at night by phone from home.
Raster plot showing the timing for morning and evening rounds with the two shifts described in the text

An alternative might be to move evening rounds up to 5:00 PM in order to allow attending physicians or senior clinical fellows to be present in person and then depart at a normative hour (Schedule B).  This option, however, has the substantial disadvantage of extending the night shift to about 18 hours (5:00PM through completion of rounds the next morning, at approximately 10:00 AM), thereby substantially increasing the risk of attentional failures and errors among the night housestaff, and limiting their opportunity to sleep.


A further challenge of evening rounds to a schedule is that the burden of sleep debt may be shifted to attending physicians and senior house staff.  Adding formal evening rounds to a schedule would mean that attending physicians would need to remain at work each day to facilitate both sets of rounds.  This would mean long daily work shifts for supervising physicians, which would likely lead to both acute and chronic sleep debt in this group, unless evening rounds are split between partnering supervising physicians working slightly different schedules (for example, an attending who arrives at 8am and goes home at 5pm paired with a fellow who arrives at 11am and goes home at 9pm). 

Senior Resident Led Sign-Out
A compromise between formal rounding and unstructured sign out may be to initiate a semi-formal evening rounds led by senior residents.  In this scenario resident groups would be responsible for ensuring a smooth transition from one call group to the next.  Prior to implementation of such a strategy, residents would require intensive team management training in order to execute hand-offs effectively.  This method has not been tested and studies should be done prior to implementation of this sign out procedure to examine the impact on patient safety.

A second compromise might be to consider participation of supervising physicians by phone on evening rounds where only the house staff are present in person.  Phone rounds, however, are at risk of being more superficial and brief than in-person rounds, which may decrease the quality of the sign-out process.  Both attending physicians and house officers employing phone rounds would need to be trained in team management and the delivery of structured sign-outs, and would need to be especially structured in their management.  Which of these options are considered needs to be determined in each medical setting on an individual basis.

The Department of Defense (DoD) in collaboration with the Agency for Healthcare Research and Quality (AHRQ) have developed an evidence-based teamwork system aimed at optimizing patient outcomes by improving communication and other teamwork skills among health care professionals. Please visit the TeamSTEPPS™ website for more information about this program and ready-to-use materials and training curricula.

http://www.ahrq.gov/qual/teamstepps/

Optimizing the Written Hand-off
Electronic Documentation and Communication
Computerized sign-out tools have been shown to improve the quality of patient care by reducing hand-off errors.  One group found that using a thoroughly developed computerized rounding tool improved the quality of sign out and continuity of care while also reducing work hours by 3 per week (Van Eaton 2005).  Efforts to measure the effects of a blended strategy using computerized sign out tools,  efforts to optimize team functioning, and improvements of verbal signout systems are ongoing.