Field Report:  Anatomy of a Scheduling Crisis

A two-hospital practice in the Mayo Clinic system was short-staffed. Identifying the factors that led to the condition, and finding strategies to alleviate them, have paid off.

ABSTRACT: A two-hospital practice in the Mayo Clinic system found itself short of physicians. Identifying the factors that led to the crisis — and finding the best strategies to mitigate them — has paid off. The authors, who were part of the effort, discovered that every crisis is an opportunity to address root causes and devise solutions that not only solve the current problem but possibly prevent future ones.

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In 2014, all Mayo Clinic Health System practices, including hospital medicine, started integrating across all of our community hospital sites. One of the goals of our hospital medicine integration was to standardize practices across our Midwest clinical sites by defining the role of hospitalist, scope of practice, team structure and processes that would enable us to provide a higher standard of care across every Mayo site.

Albert Lea and Austin are two small communities in southeast Minnesota, located about 20 miles apart and connected by Interstate 90. Mayo Clinic Health System has small hospital medicine practices in both of these communities. The sites require 13.6 full-time-equivalent physicians working two daytime shifts (7 a.m. to 7 p.m. and 7 a.m. to 5 p.m.) and one night shift (7 p.m. to 7 a.m.) at each site, staffing a total of 552 shifts each quarter.

Regular full-time hospitalists (representing one FTE each) are expected to work 40.6 shifts each quarter between the Albert Lea and Austin practices. Supplemental physicians tend to work only if the available shift needs match their availability. EnhanceMed is our internal moonlighting service that allows Mayo Rochester fellows to work outside of their fellowship requirements. Locum tenens physicians work for external staffing agencies that contract with Mayo to pick up available shifts. Clinic physicians have primarily clinic responsibility but are willing to work in the hospital as their schedule allows (see Table 1).

Our “I-90 practice” consistently has struggled with recruitment and retention of hospitalists. Our services chronically have been understaffed, leading to reliance on supplemental and locum physicians for staffing.

FIGURE 1: FULL-TIME EQUIVALENT VS. UNFILLED SHIFTS, PER QUARTER

In fall 2016, Albert Lea was functioning with only four of the required seven FTE hospitalists when it lost one more staff member for personal reasons. Austin initially had six hospitalists, but two full-time hospitalists moved to supplemental status, one hospitalist dropped to 0.75-FTE status and another went on a three-month maternity leave at the start of the first quarter in 2017. Coincidentally, two physicians also had scheduled international travel during that quarter.

Traditionally, the practice relied on "last-minute bonuses" for physicians or nonregular staff to pick up unfilled shifts. But leaders decided to stop paying the bonuses, and the department chair decided to step down, leaving a leadership vacuum.

Consequently, the practice faced an unprecedented scheduling crisis, needing to manage a shift deficit of 210 shifts for the fourth quarter of 2016 and 239 shifts for the first quarter of 2017 (see Figure 1).

The crisis led to pressure on existing staff to pick up extra shifts and a heavy reliance on nonregular staff. Unfilled shifts have strong potential to adversely affect a practice’s financial performance and the morale of the existing staff, and also force patient diversion to our Rochester practice, at least 40 miles away.

Gap Analysis

Our leadership team reviewed the situation by looking at staffing trends and speaking with stakeholders such as staff hospitalists, administrators, locums and nurses.

We also conducted exit interviews with hospitalists planning to leave the practice and organized the information we obtained into acute and chronic categories (see Table 2).

We identified many possible causes for all chronic staffing issues in our I-90 practice.

Poor morale: One of the most serious causes. The practice lacked support mechanisms such as adequate office space and secretarial support to manage daily issues. Many physicians felt a loss of autonomy and control over practice because key issues, such as schedule changes or compensation, were communicated by nonphysicians. The physicians generally felt a lack of respect and unvalued.

Lack of trust: The group held a general mistrust of the administration, perceiving a lack of transparency and communication around recent practice changes, such as resignations and discontinuation of shift bonuses. There also was longstanding displeasure about a decision made three years earlier to place 5 percent of the physicians’ compensation at risk for performance metrics related to patient safety, experience and outcomes.

Other factors included a change in the management structure of Mayo practices and creation of Hospital Service Line leadership in the region. This resulted in a lack of clarity on the roles of service-line and regional leadership regarding authority, responsibility and managing practice-related issues.

Many physicians didn’t understand Mayo Clinic’s long-term business plan and the changes happening in their practice as a result.

Cultural differences: Historically, the hospitals in Albert Lea and Austin competed with each other before they became a part of the Mayo system. These two sites had different work cultures and histories, and many physicians did not want to work at any other site but theirs.

Practice-related challenges: Both sites had many unresolved issues that were compounded by the resignation of the department chair. Table 3 shows the challenges that contributed to the staffing challenge.

FIGURE 2: UNFILLED SHIFTS FOR START AND END OF QUARTERS

Strategy: The leadership group reviewed the current state, the possible causes of the staffing crisis, and possible solutions to this challenge. We had to come up with a comprehensive solution to manage the issue — both in the short term and the long term. Classifying possible factors into acute and chronic categories helped us better understand these factors and direct our efforts equitably.

Results

We electronically surveyed our I-90 hospitalist group — 12 physicians, including supplemental staff — to understand their willingness to help with our staffing challenges. Ten physicians responded (83 percent response rate).

More than 70 percent wanted more transparency, engagement and support for day-to-day activities from “the administration” and lobbying for clinical associate positions. Many providers (40 percent) were willing to pick up shifts for additional compensation.

The crisis required every stakeholder to pick up shifts as schedules allowed. We were able to reduce the number of unfilled shifts from 210 to 17 for the fourth quarter of 2016, and from 239 to three for the first quarter of 2017 (see Figure 2).

We were able to improve the number of shifts picked up with Rochester fellows, from 12 in the fourth quarter of 2016 to 27 in the first quarter of 2017. Our reliance on locum physicians increased from 59 shifts in the third quarter of 2016 to 131 shifts in the first quarter of 2017, while the number of shifts picked up by clinic physicians dropped from 12 to zero, which might reflect the need in the clinic setting to improve outpatient access for patients (see Figure 3). We also noticed progressive improvement in the shift deficit — from seven in July 2016 to zero by March 2017 (see Figure 4).

Discussion

We reviewed all possible causes of staffing crisis in great detail. We realized that if we did not successfully manage the needs of the practice, we would face a serious risk of losing more providers and aggravating the current scheduling crisis. Strategy was divided into immediate, short-term and long-term.

Immediate: Our strategy was focused on not losing any more providers by engaging in a series of “trust-building” steps while we worked on the short-term and long-term tactics. A web-based survey helped identify the group’s concerns regarding compensation and work requirements. We engaged in a series of talks individually and as a group, to actively listen to the group’s concerns and address questions surrounding compensation change, long-term strategic plan and resultant practice changes.

These crucial conversations were led by a key senior physician leader who engaged hospitalists in decision-making and helped build trust, and improve engagement, morale, sense of belonging and ownership of the program.

Meetings with other key stakeholders were held to secure support and engagement with our future efforts to stabilize the practice and solve the staffing crisis. Engagement with key stakeholders, such as the community division of hospital medicine, service line and regional leadership, and nursing colleagues, created awareness of the need for change and support for the hospital medicine practice.

Short-term: This was a two-pronged effort: improving practice efficiencies and developing tactics to fill unfilled shifts.

We recruited a key physician from the practice to represent and lead the department. That was critical in securing the additional support we needed to work on practice efficiency and on collaboration with nursing and administration leaders to manage day-to-day practice issues.

FIGURE 3: SHIFTS PICKED UP BY STAKEHOLDERS

To improve morale and avoid burnout, we instituted a temporary cap of 12 patient encounters per 12-hour shift and created a "surge plan” with the support of clinic physicians, emergency department physicians, nursing and administrators to help manage unexpected increases in patient-care responsibilities. Clinic physicians helped with rounds on stable patients and some admitted patients during high-census times, freeing up hospitalists to complete their rounds — especially in the intensive care unit. ED physicians helped by holding patients in the ED longer than usual, also allowing hospitalists to complete rounds. The surge plan creates a buffer within which hospitalists can operate efficiently and keep patients without having to transfer them to other facilities.

Engagement, buy-in and discussions with the group helped create work standards related to patient handoffs, bedside rounding with nurses, multidisciplinary rounds and onboarding of new colleagues.

Our collaborative work with the admissions transfer center helped us identify and work on opportunities for improvement of our interdepartmental collaboration and facilitate transfer of appropriate patients among our community practice and academic practice.

We also decided to preferentially staff unfilled Austin shifts over Albert Lea, and staff the 12-hour and night shifts before the 10-hour (daytime) shift. Regular staff was offered up to 30 percent incentive if they picked up shifts above their quarterly requirement. A series of discussions with our EnhanceMed colleagues helped improve communication about shift availability for our Rochester fellows, who also were offered a “travel premium” to help pick up shifts in our practice.

Clear directions were given to our scheduler to be flexible with the needs of our regular staff so they could pick up as many shifts as possible. We announced all available shifts to supplemental, locums or clinic physicians three months in advance, and we were mindful of their needs to maximize the possibility of filling shifts. We negotiated with two physicians who were planning to resign and retained them as supplemental physicians. Flexibility in meeting the needs of our stakeholders — Rochester fellows, supplemental physicians, locum physicians and clinic providers — increased the possibility of their picking up shifts.

Long-term: Our strategy revolved around recruitment of career hospitalists who believe in the Mayo philosophy of care and long-term retention of hospitalists. The Community Hospital Medicine Division standardized its compensation structure to be more market-competitive, and defined the role of a hospitalist in our Midwest practices. It also centralized the recruitment process, engaged in an aggressive marketing campaign, streamlined sourcing of potential candidates, and standardized the interviewing process to help recruit the right candidate to the right practice.

That resulted in hiring five full-time hospitalists in summer 2017. Also, we were able to offer clinical associate positions in our Rochester practice to two physicians.

FIGURE 4: UNFILLED SHIFTS PER MONTH

We continue to work on retention strategies, including the availability of in-house subspecialty support; the addition of nurse practitioners/physician assistants; offering teaching, research and work opportunities at the Rochester academic practice; secretarial support; and quarterly social and physician engagement events. We also have centralized scheduling software and have implemented a single privilege/credential form for all our sites, to facilitate shared staffing and flexibility for shift coverage.

Unfortunately, scheduling issues persist to some degree at some of our sites. We shared our experience with colleagues at our 2017 annual quality conference and hope to apply the learnings as and when the need arises.

Conclusions

As health care organizations respond to the full impact of value-based purchasing, there will be a trend toward doing more with less. Consequently, that will place front-line staff under ever-changing pressures of the work environment. This creates a huge potential for reduced morale, burnout and another scheduling crisis.

Organizations hence have a responsibility to maintain high morale and work on retention of staff — hospitalists or others. We believe that the best way of managing a staffing crisis is to avoid it in the first place. Health care organizations and hospitalist groups will have to focus diligently on sourcing and hiring of the right candidate. This person-job fit might prove to be the best indicator of hospitalist engagement, synchrony with an organization’s values and long-term retention.1

Retention is the key to avoiding future scheduling crises. Newer tools, such as the Hospitalist Morale Index, might be valuable to that end.2

Every crisis is an opportunity to address deeper problems, finding solutions that not only fix the issue at hand but also prevent future ones. Stakeholder analysis, identifying root causes of poor performance, and exploring and creating strategies for improving performance are valuable to manage a staffing challenge. Teamwork is the key ingredient — along with engagement, a shared vision and trust — crucial for a successful crisis management plan. But having appropriate structure and processes is as essential for preventing a crisis as having the right people in place.

Umesh Sharma, MD, MBA, FACP, FHM, is a consultant and a regional chair in the hospital medicine department, and chair of the community hospital medicine division, for Minnesota-based Mayo Clinic Health System.

Amit K. Ghosh, MD, MBA, CPE, is a professor of medicine and enterprise director of international patient relations for Minnesota-based Mayo Clinic.

Christopher R. Gulden, MA, RT(R), is regional operations administrator of hospitals and emergency medicine departments for Minnesota-based Mayo Clinic Health System.

Deepak Pahuja, MD, MBA, FACP, FHM, is chief medical officer for Aerolib Healthcare Solutions, based in Texas.

REFERENCES

1. Hinami K, Whelan CT, Miller JA, et al. “Person-job fit: an exploratory cross-sectional analysis of hospitalists.” J Hosp Med. Feb 2013; 8 (2):96-101.

2. Chandra S, Wright SM, Ghazarian S, et al. “Introducing the hospitalist morale index: a new tool that may be relevant for improving provider retention.” J Hosp Med. Jun 2016; 11(6):425-31.