The classic business quote says “you can’t manage what you can’t measure.”
With physician burnout becoming epidemic, I was part of a meeting recently with medical leaders focused on physician shift scheduling and discussing the best way to measure a “good schedule” in healthcare. Can you quantify the elements that make a physician shift schedule more balanced? Are measureable elements that indicate patient safety sometimes the very same ones that drive physician burnout? Is there a danger to measuring the wrong elements?
Handoff continuity scoring, as defined in a 2011 report published in the medical journal Critical Care by researchers from the Georgia Institute of Technology, is one of the more established schedule measurements in the healthcare sector. Handoff continuity tracks how many different physicians treat a patient during a hospital stay. Too many handoffs can create potential for miscommunication and lower patient satisfaction, but what about for physicians and preventing burnout? More consecutive days for physicians means stress and poor work-life balance, which can also impact quality of care.
Our researchers showed how handoff continuity is tied to choppy shift schedules in different healthcare organization settings. (Watch the full session here.) Real hospital data showed that handoff continuity varied greatly between different facilities, even within the same academic system, and was impacted by seasonality:
“We want to identify the fluctuations. In February, March, and April, we have some low points, and we can identify where there might be some trouble areas. For this example, there was some seasonality in play during this time at the hospital. Patients were coming in during this period due to flu season, so there was an increased volume of patients. To handle that, the organization had to allow any physician to sign up to take on shifts, and this led to many on-off types of shifts, choppiness in the schedule where physicians would have one-day shifts at the cost of continuity,” said Alvin Cheng.
An increasingly complex mix of measurements emerged as physicians weighed in during the session about the differences of handoff continuity in the hospitalist and emergency medicine session, the impact of shift length, and the additional difficulty of stepping shifts over several days to match circadian rhythms. A few select comments:
● Maryam Shapland, MD: “In terms of shift work, the length of shift should be measured, too, because if you have really short shifts for physicians, then let’s say you’re seeing patients in an 8-hour shift and every other physician has an 8-hour shift; there’s a lot more handoffs in that 8-hour shift than if you do a 10- to 12-hour shift because then you’re seeing that patient more continuously. The likelihood of you seeing a patient more continuously is higher within that 10-hour shift versus the 7- or 8-hour shift. But of course, that is balanced by how long physicians want to work, too, in the ER. Some people do, but a lot of physicians don’t want to work 12 hours in a row.”
● Siddhartha Nambiar, an operations researcher from NC State University: “Factors contributing to the workload go beyond just the ideas of the severity of the patients or how long the schedules are. For instance, I know a team at my university had done a large survey of providers, and some of the main factors that came up were things like lack of autonomy in the hospital, non-clinical responsibilities, and things like that.”
● Mike Hoaglin, MD: “Other inputs could include the physical plant and how well stocked and placed things are in an environment. As far as the team continuity, I was thinking that the other healthcare providers that you mentioned—nurses, techs, and things—they have their own schedule that tends to be a little bit more fixed, I think, that they do to try to maintain continuity. So if you take into account the number of handoffs of nurses and other staff as it pertains to a patient, that may also influence perhaps some sort of score that has to do with patients’ continuity with providers.”
● Richard Fury, MD: “I will say that there is some concentration in healthcare to try to match the staff levels to the clinicians’ schedules, so when there are lots of clinicians, usually that translates into some patient volume. Now patient clinic is measured and then the staffing—nurses, MAs, whomever—is measured to that so that they’re trying to balance the staffing levels to have adequate number of staff to do the duties necessary in the clinic or the hospital but also not to overstaff so that they don’t have twice as many nurses or twice as many MAs as necessary for the clinicians’ schedule.”
Feeling overwhelmed yet? This is where we get to the Pandora’s Box issue and why the concept of “measurement to manage” is so difficult in healthcare. As soon as one measurement is tracked, a dozen more related factors emerge that complicate how we think of the result as “good.”
Healthcare’s mind-bending complexity is both a challenge and an opportunity for our sector. Not just physician scheduling, but the goals of value-based care, ACOs, and fraud-prevention are all tied to our ability to use data to decide what is “good.” The great news is that there are enormous margins for improvement just waiting to be found. More great news: We don’t have to go it alone anymore.
We have the power of computer science and artificial intelligence to help us manage this complexity. Health organizations such as Kaiser are leading in this realm, leveraging data to find the triple aim of improving outcomes, improving care experience, and reducing cost. Combinatorial optimization is designed exactly for situations where there isn’t a straight answer to what makes something “good.”
What we need to do as a healthcare sector is embrace the complexity. We should invite more data, more continuity scores, more schedule measurements, more physician preferences, and more staffing details to the discussion of how to build a schedule that fights burnout and improves patient access. We need to open, not avoid, Pandora’s Box.
Suvas Vajracharya, Ph.D., is founder and CEO of Lightning Bolt Solutions, which automatically generates 3 million hours of balanced physician shift schedules for hospitals each month. Prior to founding the company, he worked as a staff scientist at the Los Alamos National Labs, scheduling massively parallel supercomputers.
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