Last year, just weeks into his job as president and CEO of Atlantic City, N.J.-based AtlantiCare, Michael Charlton had an initial glimpse into the challenges faced by on-call staff at his new organization.
The health system was examining opportunities to rein in costs, including adjusting on-call pay. This pay covers on-call employees in areas such as the cardiac catheterization lab and operating rooms, who often work during nights and weekends to ensure 24/7 coverage for facilities.
"A decision was made that we can save money with on-call pay, and we did not necessarily socialize this properly with team members," Mr. Charlton told Becker's. "And it caused a bit of a stir. And I happened to walk into it. I said to the team, 'Bring everyone together and I'll show up at the meeting.'"
During the meeting, he received feedback about the challenges of on-call work, such as the disruption of being called off at times, or employees needing to factor in their schedule when planning for their lives and the lives of their family members. He absorbed the feedback and continues to think about how to achieve operational excellence while also satisfying clinical personnel.
"I got home at 7 p.m. or 8 p.m. [the day of the meeting], had something to eat, answered some emails and set my clock for 1 a.m., as if I was on call. I got up at 1 a.m., drove to the corporate office in sweatpants, rushing to get there in the allotted time," Mr. Charlton said.
"Now I'm here. It's 1:35. I'm thinking, 'This is terrible. I usually get up at 4 a.m. or 4:30 a.m. and get ready for work.' Then it hits me, if I really got called in, I'd be doing a case right now. I can't just go home. I've got to do something, so I drive around for an hour and a half at 2 a.m. And I'm tired. I come home at 2:30 a.m., get in bed, and my alarm goes off at 4:30 a.m. I have to get up, shower, answer emails and get back at 6 a.m. to the cath lab team and other team members to tell them what our resolution's going to be."
That solution was not cutting the on-call pay and paying for activation, meaning they are paid for the load of responding to on-call events.
Then Mr. Charlton started spending time in the emergency department at night, keeping in mind the mantra, "Be visible, be kind."
"We have an inner city hospital. You can't really see what's going on at 3 p.m., but you can on Friday or Saturday night at 2 a.m. It's a hospitality town. There's a lot of drinking and gaming and, unfortunately, violence too," he said.
He recalled one night when the water was contaminated citywide, and the hospital had to shut off water, and there were also multiple shooting victims seeking care in the ED.
"You look around and come to the conclusion that how healthcare has been run for so long is broken," Mr. Charlton said. "The administration walks out of the building at 6 p.m. on Friday. Yet, Saturday and Sunday, what's there? You still have all the patients. You still have all the staff. You may have some procedural volume declines, but emergent care is being taken care of. What's the difference? There is no administrator support there.
"Spending that time at night I got to understand those big giant buildings. I mean, they're aircraft carriers; it takes a lot to keep them running 24/7. Who's there to support the clinical staff? Who's there to support nursing staff? Who's there to make difficult decisions while they're trying to make clinical decisions?"
All of these questions motivated Mr. Charlton to continue spending time at facilities at night. He said this also led to the next iteration of work of ensuring there is administration in the building every night and on weekends, whether that's administrative fellows, nurse administrators or others.
"So that same apparatus that runs the structure five days a week, 10 hours a day is there the rest of the time," Mr. Charlton said. "All of that came from that feedback [from team members]. It wasn't all positive feedback. There was a lot of negative feedback, a lot of concerns that came out of nursing, physicians, techs. Because at the end of the day, when they're challenged and there's nobody there supporting them, after a while that gets old. But it led us to a good place."
Now, he said his presence during the night shift is more structured than when those efforts began.
"There are times if my wife and I are out to dinner late like 8 p.m. or 9 p.m., I might drop her off, because I live down the street from one of our campuses. It's a little more detailed and structured when I show up at the EDs or at 2 a.m. I'm trying to gain clarity on a situation. I may have seen something. I may have had a conversation with somebody. There may have been a challenge. And you just want to get that firsthand experience."
He added that his approach is not a new concept. For example, there is the lean management philosophy of leaders "going to the gemba" — a Japanese term for "actual place" — a principle that involves direct observation to improve work processes.
"If you look at Japanese management theory, it's standard is to walk the floor. It doesn't say walk the floor 8 to 4," he said. "I look at it as two shifts here, [7 a.m. to 7 p.m. and 7 p.m. to 7 a.m.], and they're equally as important."
Mr. Charlton, who helms an organization with more than 6,500 team members, challenged other healthcare leaders to have a similar mindset: "Tell me why having administrators and administrative support and running these buildings 24/7 for the betterment of patient quality, safety, tell me why it's wrong?"
He added: "We talk about retention, employee engagement and employee satisfaction and how to solve those challenges. The answer is boots on the ground. It's being there, engaging with the people doing the work to understand their challenges.
"We say here all the time, 'Business is going to move at the speed of relationships,' and you can't build relationships behind the desk looking at a computer and leaving when everyone's still working."