Quality Improvement Reports

Improving compliance with requirements on junior doctors' hours

BMJ 2003; 327 doi: https://doi.org/10.1136/bmj.327.7409.270 (Published 31 July 2003) Cite this as: BMJ 2003;327:270
  1. Hilary D Cass, director of postgraduate medical education (cassh{at}gosh.nhs.uk)1,
  2. Isabel Smith, lead in clinical audit and improvement1,
  3. Cheryl Unthank, senior clinical site practitioner1,
  4. Colin Starling, New Deal project manager1,
  5. Jane E Collins, chief executive1
  1. 1Great Ormond Street Hospital for Children NHS Trust, London WC1N 3JH
  1. Correspondence to: H Cass
  • Accepted 15 May 2003


Problem Compliance with UK regulations on junior doctors' working hours cannot be achieved by manipulating rotas that maintain existing tiers of cover and work practices. More radical solutions are needed.

Design Audit of change.

Setting Paediatric night rota in large children's hospital.

Key measures for improvement Compliance with regulations on working hours assessed by diary cards; workload assessed by staff attendance on wards; patient safety assessed through critical incident reports.

Strategies for change Development of new staff roles, followed by change from a partial shift rota comprising 11 doctors and one senior nurse, to a full shift night team comprising three middle grade doctors and two senior nurses.

Effects of change Compliance with regulations on working hours increased from 33% to 77%. Workload changed little and was well within the capacity of the new night team. The effect on patient care and on medical staff requires further evaluation.

Lessons learnt Reduction of junior doctors' working hours requires changes to roles, processes, and practices throughout the organisation.


  • Contributors HDC was responsible for overall strategy, leadership in design of new rotas and accompanying new role development, and produced the first draft of paper. IS was responsible for design and implementation of the audit and for analysis of the audit analysis. CU was responsible for development of the role of clinical site practitioner and leadership and management of the night team. She was involved at all stages of development of the new system from conception through implementation. CS was responsible for operational implementation of the new rotas, managing all detail of final design and coordination. JEC had overall leadership for the implementation of this project. All authors contributed at each stage of drafting of the paper. HDC is the guarantor.

  • Funding None.

  • Competing interests All authors are involved in achieving compliance with regulations on junior doctors' hours. Failing to achieve compliance places a financial burden on the organisation, which JEC is responsible for.

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