Published in the February 2015 issue of Today’s Hospitalist
HERE’S A NEW AND GROWING TREND in how hospitalist groups across the country are covering gaps in their schedule: More than half either ask or require doctors to put some of their time off at jeopardy in case a colleague is out or patient census surges.
Some jeopardy systems are informal and little more than a phone call to a rotating list of colleagues. Others use complex formulas to determine when workloads warrant calling someone in.
Some groups reimburse physicians for being on call, while others pay only if doctors actually end up working. And while physicians in some programs rebel against jeopardy systems, others embrace them.
Thérèse Franco, MD, the hospitalist at Seattle’s Virginia Mason Medical Center who devised a “surge” back-up system for her group, says her colleagues fall into the latter category. “I think people have been in the kitchen enough when it’s hot, so we like to help out,” says Dr. Franco.
But at the other end of the spectrum, a jeopardy program put in place at Baptist Hospital in Miami was so unpopular that it crashed within months.
“It had a lasting effect on group morale,” admits Tomas Villanueva DO, MBA, the former medical director of the hospitalist program who is now assistant vice president and medical director of Baptist Health Medical Group. “Doctors would say, ‘This is supposed to be my week off. I had to change my lifestyle for the group’s benefit, and there is nothing in it for me.’ ”
Such implosions lead even proponents of jeopardy systems to stress certain ground rules: Come up with guidelines for when back-up systems will be triggered, and get physician buy-in. And when jeopardy is being used too often, find other solutions.
Desperate for coverage
In her 10 years as a consultant, Leslie Flores, a partner with Nelson Flores Hospital Medicine Consultants in La Quinta, Calif., says it is only in the last several years that she has been asked about back-up systems. Many groups interested in jeopardy systems, she says, have become a victim of their own success: Hospitalists in these groups have taken on so many of the admissions at their hospitals that they can’t handle unexpected absences or census surges.
Even when capacity is not an issue, Ms. Flores adds, groups want to cut their locum expenses at a time when fewer primary care physicians are willing or able to cover shifts. Add in small moonlighting pools, and you have groups desperate for coverage.
And programs that rely on block schedules are less able to adjust to surges by simply having more (or fewer) people work longer or shorter days. “As long as people are wedded to a shift-worker mentality,” Ms. Flores says, “most groups will want to have some sort of a back-up system in place.”
Hospitalist interest in jeopardy systems is also tied to “the culture of the group and how well it is staffed,” she says. “If daily staffing is pretty comfortable, you may not need a back-up system, compared to a group where staffing is pretty thin or you rely on a lot of locum tenens coverage.”
In such programs, Ms. Flores points out, “locums cannot show up at the last minute” to cover a sudden staff shortage. At the same time, “I think jeopardy works better when there is a clear trigger and a low probability that the back-up person will get called in.”
Who’s paid for jeopardy?
According to data from the latest Society of Hospital Medicine survey, 39% of adult medicine hospitalist groups maintain voluntary systems where clinicians can choose to be on the back-up schedule or not.
Another 18% have mandatory systems, while 43% have no formal system in place. Surprisingly, the survey found that more than one-quarter of groups (28%) with jeopardy systems provide “no additional compensation” to hospitalists for either being on back-up or being called in to work. By contrast, 59% pay physicians when called in but not for being on the schedule. Only a few groups “11% “reward doctors for both being scheduled and for actually working.
Dr. Franco’s group is one of those few. Virginia Mason’s mandatory jeopardy system began in 2013 after a cutback in regularly scheduled shiftwork. “Surge” hospitalists are paid a small stipend to be on call one week every six months, and they earn the locum pay rate if called in. How often is the jeopardy system used?
While Dr. Franco says that it varies, “it can be fairly frequent.”
At Providence St. Patrick Hospital in Missoula, Mont., on the other hand, hospitalist section chief Charlotte Nelson, MD, characterizes her group’s mandatory jeopardy system as “basically an insurance policy.” Both the hospitalists and hospital tolerate because it is used so infrequently “less than a dozen times in 2013.
That’s because jeopardy is used only when doctors are sick or have a family emergency. “We do not call people in if the census is high,” Dr. Nelson points out. “None of us wants to be called in, so we are more likely to work a little longer on busy days.”
Physicians are paid a flat fee for every day on call. They earn an hourly rate higher than their usual salaried rate if they are called in. They don’t, however, get to count the RVUs billed during those shifts toward their productivity goals. But doctors can trade their jeopardy days among themselves, so people who don’t mind working more can.
“Jeopardy is not a huge burden,” says Dr. Nelson. “Fortunately, we have never reached a census point that is unbearable for more than a day or two.”
Incentives and ground rules
The jeopardy system at Middlesex Hospital in Middletown, Conn., is a combination of both mandatory and voluntary.
Hospitalists who volunteer for weekday jeopardy shifts earn credit toward their citizenship incentive instead of an on-call stipend. When hospitalists are called in, they’re paid for the time they work. If they end up working full shifts and not just a few hours during the late afternoon or early evening, those shifts count toward productivity bonuses.
All group members do have mandatory jeopardy two or three weekends a year. “People don’t love it,” says Rachel Lovins, MD, chief of hospital medicine, “but everyone knows what it is like to be the person on weekends. Now you know that if you are overwhelmed, someone else is going to come in and help you.”
Dr. Lovins credits the group’s acceptance of the jeopardy system to the fact that it was homegrown and agreed to by group members.
“We had a long meeting about being a team player, and we came up with a whole bunch of behaviors that everybody signed off on,” she notes. To guard against jeopardy being overused, for instance, the group agreed on situations when doctors will stay beyond their normal shift and help with a high census.
If more than five patients need to be admitted when the night shift ends, for example, the hospitalists covering nights stay to do one or two of those admissions.
“At night, doctors usually work only nine-hour shifts,” Dr. Lovins points out, “so we feel it is reasonable for them to stay another two hours. And they get paid.”
In addition, she says, the group took the decision to call in back-up out of the hands of the rounding hospitalists. Instead, hospitalists pass that request to the “chief in charge,” who makes the decision and the phone call.
At Virginia Mason, Dr. Franco helped develop guidelines that dictate when to trigger the jeopardy system. Those guidelines are used twice a day “at 7 a.m. and 2 p.m. ” to assess the group’s admitting capacity. That assessment is made by the group administrator and a “charge MD,” which is what the group calls its doctor of the day handling jeopardy. “The goal is to bring some objectivity to when to call in the surge,” Dr. Franco explains.
“The way our group worked before was that we never had hard-and-fast numbers,” she points out. “We just said something like, ‘I have three family meetings and a procedure today, so I can’t help.’ Pitching in with more time was at the discretion of individual providers.”
Relying on a charge MD and guidelines also brings some standardization. As Dr. Franco notes, some hospitalists would feel guilty about ever bothering a colleague at home, while others would be more comfortable calling for help early on.
Now that the surge system has been operating a year, Dr. Franco is analyzing how well it is working. What has happened, she points out, is that charge MDs have called in surge hospitalists in situations not supported by the guidelines. To maintain continuity, for instance, surge doctors who have already been called in for two or three days are sometimes called in again to discharge the patients they’ve been treating.
“We didn’t want a bunch of patients to have a different doctor every day,” Dr. Franco says.
Problems with overuse
Bryan Huang, MD, associate chief of the hospital medicine division of the University of California, San Diego, has run into those kinds of continuity issues. His group never had a problem with its longstanding jeopardy system until a year and a half ago, when it went from being used rarely to regularly.
Due to census surges and unexpected physician absences, doctors on jeopardy were called in roughly 60 days for census reasons and another 60 for personal or family reasons, adding up to nearly one-third of the year. To try to reduce that burden, the group sometimes put physicians on jeopardy for only two- or three-day stretches, instead of a week.
But “patients could have a different doctor three days in a row, which is never good for patient flow or discharging,” points out Dr. Huang, who thinks lack of continuity can be as damaging as heavy patient loads. “We ultimately went back to scheduling back-up for a week at a time.”
Chronic overuse was also the reason the jeopardy system at Miami’s Baptist Hospital failed, and failed fast. When four of the group’s 50 hospitalists took maternity leave at various times in 2013, existing staff agreed to fill vacant shifts. The group sweetened its productivity bonus and, for a few months, doctors happily banked the extra dollars and productivity credits.
What the group didn’t anticipate, says Dr. Villanueva, was that people would get tired. Unfortunately, they got tired right when several hospitalists were on leave at the same time and when snowbirds were arriving. At that point, it was too late to bring in a locum or other temporary staffer.
“Pretty much everything you would expect to go wrong did,” he points out. E-mails asking for people to step in went unanswered. Every shift was too busy, patient satisfaction scores plummeted and lengths of stay grew longer. The only alternative administration could come up with, he says, was to institute mandatory jeopardy, with hospitalists taking turns being available to work an off week two or three times that year. They were not paid for being on call, but would earn moonlighting pay if they came in.
The result was an even bigger disaster. “They resented it,” says Dr. Villanueva, who says the system was put in place without the hospitalists’ buy-in. People gave notice before the group scrapped the jeopardy system within four months.
Since then, Dr. Villanueva says, the group has reorganized. What before felt like a large, impersonal group of 50 now operates as four smaller teams where people seem to pitch in more for each other.
Group members can also offload some patients to ICU staff when they’re extremely busy, and they can pull an admitting hospitalist out of the ED to do rounds.
The group also beefed up financial incentives, creating a pool to pay doctors to work overtime and increasing productivity bonuses.
The group is also considering a “hybrid” schedule where some may choose to work more but shorter days, rather than a strict seven-on/seven-off block. “I think that schedule will help a lot,” Dr. Villanueva says, “and we won’t need a back-up schedule.”
In Milwaukee, Rupesh Prasad, MD, says his hospitalist group at Aurora Sinai Medical Center discussed the idea of starting a jeopardy system. But they decided to not go with one, due to prior experiences of some group members.
“On paper, jeopardy systems are pretty good, and there is quite a bit of variation in our number of admissions between winter and summer,” Dr. Prasad says. But based on his experience at another hospital, “jeopardy affects morale and hospitalist satisfaction.”
Because his nine-member group is part of a much larger health care system, group members can draw on a big pool of potential moonlighters when they are short-staffed. And, Dr. Prasad says, he likes the idea of scheduling shorter swing shifts to help with crunch times.
In San Diego, Dr. Huang notes that his group has now up-staffed. As a result, census surges requiring extra coverage are rare, and jeopardy is much more manageable. He still thinks jeopardy systems may be the best of all the less-than-optimal options for busy practices that provide 24/7 coverage.
“There needs to be some sort of contingency in place,” he says. “People get sick and family emergencies happen, especially in a big group.” But “back-up systems can’t take the place of proper staffing.”
Figuring out that balance is a fine line. “Back-up is less expensive because we are not paying for all the benefits of another employee, but the issues are burnout and morale.” And when jeopardy is used too often, Dr. Huang adds, “it starts to feel like this was not part of the job that I signed up for. I signed up for 26 weeks, and here I am being asked to work 27 or 28 weeks involuntarily.”
Deborah Gesensway is a freelance writer who covers U.S. health care from Toronto.
WHAT CRITERIA DO GROUPS USE to decide when to call in a doctor on jeopardy? At Seattle’s Virginia Mason Medical Center, activating the back-up surge system is determined by guidelines put in place a year ago.
During daily huddles at 7 a.m. and 2 p.m., the group administrator and a “charge MD” “the doctor managing the jeopardy system that day “work together to assess the program’s admitting capacity. They take into account the current census and total number of patient encounters of the various housestaff and float teams. If the admitting capacity at either time is determined to be only zero, one or two admissions, the charge MD calls in the scheduled back-up physician.
When the admitting capacity at 2 p.m. is three or more, the charge MD tries to assess the anticipated number of admissions (including transfers and direct admissions) between 2 p.m. and 7 p.m. To do so, he or she talks to the ED charge nurse or uses the ED tracking board.
If the total number of expected admissions is more than the total afternoon admitting capacity plus two, a surge physician is called in to work 5 p.m.-9 p.m. Otherwise, the charge MD texts “no” to the surge physician to let him or her off the hook.
“It’s not all about the numbers,” explains Thérèse Franco, MD, the Virginia Mason hospitalist who helped develop the algorithm being used. “There can be one patient who makes a day a disaster. But the functional cap helps because everybody was uncomfortable with ambiguity.” At the same time, the guidelines are meant to be flexible, Dr. Franco notes. “There are many times when the charge MD overrules the algorithm and calls in the surge.”