Building flexibility into the schedule

Published in the May 2019 issue of Today’s Hospitalist

CONVENTIONAL WISDOM HOLDS that if you don’t maintain a seven-on/seven-off schedule, you’ll never be able to recruit (or hold onto) young doctors right out of training. Those physicians, the party line goes, want a completely predictable schedule they can map out months in advance.

But last month, the hospitalists with Essentia Health St. Mary’s Medical Center in Duluth, Minn., inaugurated a new flexible schedule option. The new system allows fulltime doctors to work the same number of shifts per month as their seven-on/seven-off colleagues, but they can work those shifts in varying blocks over the course of the month.

According to Margo Furcht, who manages the hospitalist program, one-third of the 40-member group is opting for that flexible option, and the group’s young physicians are the most interested.

“They’re the ones who don’t necessarily have children,” Ms. Furcht says. “They like having that flexibility because they’re very active.”

To find out what hospitalist groups are offering in the way of flexible scheduling, we spoke to four hospitalists or group administrators, each of whom described different scheduling options that have worked for their group. While there are many differences among them, there is one common thread: All their groups are pretty much fully staffed, and they no longer have to pay locums to fill scheduling holes. Further, they all credit schedule flexibility—at least in part—for their success with recruitment and retention.

Essentia Health-St. Mary’s Medical Center
Two-thirds of the hospitalists in Ms. Furcht’s group are for now, at least, sticking with seven-on/seven-off. But she says she wouldn’t be surprised if more eventually opt for what the group refers to as the modified schedule once they see the experience of their colleagues.

The group decided to offer a more flexible option because some physicians were grumbling. “Physicians felt restricted with only seven-on/seven-off,” Ms. Furcht explains. “They wanted the option to take longer vacations or vacations at other times than that schedule would allow.”

“Physicians felt restricted with only seven-on/seven-off.”

~ Margo Furcht
Essentia Health-St. Mary’s Medical Center

Flexibility should also relieve some pressure for doctors who want to take off shifts they’re scheduled to work. Previously, those physicians had to trade shifts with others to cover those days off, another big complaint about seven-on/seven-off.

With the modified schedule, full-time physicians have to work 182 shifts over the course of the year, the seven-on/ seven-off total. Doctors choosing the modified track, however, can schedule their day rounding shifts (nights are covered by dedicated nocturnists) in three, four, seven, 10, 11 or 14 day blocks. They can work a four-shift block early in the month, for instance, followed by a 10-day block later.

Or they can break their workload up into more than two blocks of days over the course of the month, as long as the team has adequate patient coverage. Or physicians can work only 10 shifts one month, then flex up to 18 in some month later in the fiscal year.

How it works
Ms. Furcht is using QGenda scheduling software to keep track of how many shifts physicians work. To come up with the schedule, doctors provide certain information such as the minimum and maximum days they want to work in a row, the minimum number of days they want off in between, and specific days they want off.

The software tracks doctors’ shift totals, which Ms. Furcht will share with them quarterly to make sure they meet their yearly minimum. As for weekend shifts, “The idea is that everyone will do the same number of weekends, although I haven’t gone in and counted them yet,” she says. “Right now, it’s on the honor system because it’s so new. If you take a weekend off here, you’re supposed to pick up one somewhere else.”

To provide some breathing room in the schedule, the group opted to keep one shift—an afternoon admitting shift—open. That way, doctors who want to pick up extra shifts can tack an admitting shift or several onto the beginning or end of a block they’re already scheduled. The idea is that working admitting shifts won’t compromise any continuity in patient care.

But how about full-time doctors working only three-day blocks: Doesn’t that affect continuity? “That’s important,” Ms. Furcht admits, “but retention is really important too, and that provides continuity for our hospital. We’re working very hard to retain the group we have, and we thought this might be one way to do that.”

Baptist Health
As Gretchen Guess, hospitalist administrator and dyad partner for the 90-member hospitalist group at Baptist Health in Jacksonville, Fla., explains, the current modified schedule option the program offers is actually simpler than the several different types of schedules the group tried to juggle—ultimately, unsuccessfully—for years.

Complicating the entire schedule, then and now, is the fact that instead of requiring doctors to work a specific number of total shifts a year to be considered full time, Baptist allows hospitalists to work anywhere between 10 and 20 shifts a month to be eligible for benefits.

“People have to kind of marry each other.”

~ Gretchen Guess
Baptist Health

Here’s the scheduling menu the group used to offer: In addition to seven-on/seven-off, the doctors could work a “parent schedule” of between two and four shifts a week, covering only one weekend a month. Or they could choose what Ms. Guess calls a “traditional” Monday-Friday schedule, with no weekends.

But when she came onboard three years ago, that scheduling mix was not working. For one, doctors working seven-on/ seven-off felt “traditionalists” weren’t pulling their weight covering weekends. “I walked into a lot of tension,” she recalls. “The doctors doing all the weekend coverage felt, ‘I want to see my family too.’ ”

Another big problem: There were wide fluctuations in the number of rounders at the big Baptist Medical Center Jacksonville campus. (The group also covers two smaller hospitals.) “Some days, we’d have 14 rounders,” Ms. Guess says, “but we’d have 18 on others, going daily between high- and low-panel sizes.”

A job-sharing program
To solve those problems, Ms. Guess and the hospitalist group decided over time to scrap its traditional Monday-Friday schedule with no weekends. To do so, they had to go back to the physicians working either the parent or traditional schedule and explain that those doctors would need to start covering one weekend every other month and two weekends during alternate months. (The physicians understood the reason for that change and—in time—they all agreed.) Since then, all new hires must cover two weekends a month if they opt for what the group now calls its “modified” schedule.

The modified schedule, says Ms. Guess, is basically a job-sharing program. “People have to kind of marry each other,” she points out, partnering with another physician who wants to divide one schedule. Some paired hospitalists, for instance, each work five-on/five-off, while two sets of doctors have one partner working five-on/nine off while the other works nine-on/five off. Once doctors identify a partner willing to share a schedule, Ms. Guess works out the (very complicated) schedule. Sometimes, to ensure equal coverage, doctors have to compromise a bit on their number of days off or how many days they want to work in one block.

While more than 70% of the group still sticks with straight seven-on/seven-off, “a little more than 25%” have chosen the modified job-sharing schedule. Who does that more flexible schedule appeal to? “Parents of young children, millennials and those who used to work the traditional schedule,” says Ms. Guess.

She is convinced the modified schedule has helped with recruiting; physicians she’s helped hire have told her as much, and no other program in her market offers such an option.

IU Health, Indianapolis
Chris Hilbish, ACNP, MSN, clinical director for the physician and APP hospitalists at Indianapolis’ IU Health Methodist Hospital and University Hospital, has a slightly different take on seven-on/seven-off. While most physicians may be OK working that schedule, “doctors don’t want to work 12 hours a day.”

So while day physicians in her group are scheduled for 12hour shifts, “at 4 p.m. on weekdays, 2 p.m. on weekends, most of the team can leave if they’re finished.” Out of 15 weekday rounders, only three have to stay on call until 7 p.m. Typically, individual rounders have to remain until 7 p.m. only once a week.

“Doctors don’t want to work 12 hours a day.”

~ Chris Hilbish, ACNP, MSN
IU Health

That is a major satisfier, says Ms. Hilbish, as is hospitalists’ ability to partner with another doctor and work together to modify their schedule, similar to the Baptist group in Florida. Two physicians commit to being schedule partners for a four-month block; while they all have to work the same number of shifts (including weekend shifts) per year, they figure out the schedule they want for the next four months and give that schedule to the group’s program coordinators to input.

Ms. Hilbish estimates that 90% of group members take advantage of the ability to work with another doctor to customize their schedule. “Probably 60% of their schedule is seven-on/ seven off,” she says, “while the other 40% is some adjustment for time off they want,” often for extended vacations or trips out of the country.

She sometimes helps doctors pair up; two hospitalists who are each parents of students in the same school district, for instance, may not want to partner because they’ll both want the same spring break off. Doctors who like to work long stretches are well-known to other group members.

“That flexibility is really important to our physicians,” says Ms. Hilbish, “so we make it work.”

The next challenge: offering part time
Meanwhile, the 35 APPs who work with the hospitalists have steadfastly refused to work seven-on/seven-off because none of them wants to work every other weekend. Instead, all the APPs have adopted this schedule of 10-hour shifts: Monday through Friday one week, Monday through Sunday the next, then the third week off. That way, they work only every third weekend.

Doctors and APPs—who see patients independently—also pair up at least for a year, although most of those partnerships have lasted much longer. Individual doctors work with one primary APP three weeks a month, then with only one other primary APP during the APP partner’s week off.

The group’s big remaining scheduling challenge ahead is how to begin offering clinicians part-time slots.

“That’s what we get the most complaints about, and while we offer part time in our preop clinics, we just haven’t been able to make it work,” Ms. Hilbish notes. “Part-time people can be very challenging to schedule because they tend to have very specific days when they can work, instead of being flexible enough to fit in to what we need.”

But “more and more are requesting it,” she adds, “and we need to figure it out or we’re going to eventually lose some of our older APPs, which we don’t want to happen. And once you open it up to the APPs, you have to open it up to the physicians as well.”

Meriter Hospital
For the hospitalist group at Meriter Hospital in Madison, Wis., having access to part-timers is one reason that full-time physicians—there are 28—can have flexible schedules.

Having a healthy mix of both part- and full-time doctors is just one part of maintaining a very heterogeneous group. And hospitalist Jeremy Jaskunas, MD, who used to be the group’s medical director, thinks that heterogeneity is key to group stability.

“A rigid schedule will favor one demographic over another.”

~ Jeremy Jaskunas, MD
Meriter Hospital

“If you have a group made up of hospitalists with different career goals and stages, ages, cultures and religions, gender and motivations, then you’re going to have diverse scheduling preferences,” Dr. Jaskunas says. That diversity is a big reason he and his colleagues have steered clear of mandating seven-on/seven off for the past 10 years.

“A rigid schedule will favor one demographic over another,” he points out. So with a rigid schedule, even when you’re able to hire doctors at different life or career stages, the schedule will appeal to only a subset of them. “The rest won’t be happy and they’ll leave.”

Dr. Jaskunas says that the one rule his program follows is to never make scheduling promises to physicians when they interview. “Everyone is told that we’ll solicit their scheduling preferences and we’ll do our best to accommodate them,” he explains. “But we also point out that we can’t guarantee any exact schedule and that everyone has to be willing and able to work all shifts.”

That said, nocturnists cover most nights (as they do for the other groups in this article), so he pulls only about four night shifts a year. Without dedicated night coverage, he doesn’t see how groups could handle flexible scheduling.

“A night shift really limits what shifts you can work in the days before or after,” Dr. Jaskunas points out. “Nothing is more disruptive to a schedule than all members of a group equally sharing nights.”

Very low turnover
In terms of scheduling choices, group members can work just 12-hour day shifts in five-to-seven day blocks (with five being the minimum), 10-hour admitting/swing shifts, or a mix of different shifts in blocks of variable lengths. Members have to hit a certain number of shifts per year, and everyone has to cover two weekends a month.

Because the group pays by shift (in addition to performance bonuses), a hospitalist subcommittee has hashed out the compensation for each type of shift. The subcommittee also determined what exactly constitutes a weekend shift; does Friday night or Sunday night count? “We’re always vigilant about trying to maintain fairness.”

While the group used to use QGenda, they’ve since switched to ShiftAdmin.com. “As we’ve grown, the scheduling puzzle has become bigger and more complicated. It’s challenging to honor so many people’s preferences together, but so far we’ve managed to do so.”

The proof that flexibility contributes to group stability, he believes, is in group turnover, which he characterizes as “very, very low. I honestly can’t remember a time when someone left the group to work somewhere else in Madison.”

Edward Doyle is Editor of Today’s Hospitalist.