Improving compliance with requirements on junior doctors' hoursBMJ 2003; 327 doi: https://doi.org/10.1136/bmj.327.7409.270 (Published 31 July 2003) Cite this as: BMJ 2003;327:270
- Hilary D Cass, director of postgraduate medical education ()1,
- Isabel Smith, lead in clinical audit and improvement1,
- Cheryl Unthank, senior clinical site practitioner1,
- Colin Starling, New Deal project manager1,
- Jane E Collins, chief executive1
- 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.
The UK government introduced a new deal for junior doctors in 1991 to reduce working hours and improve living conditions, but few hospitals fully meet these requirements. The junior doctors' contract of December 2000 made non-compliant posts prohibitively expensive,1 yet between September 2000 and March 2002, national compliance increased only from 62% to 68%.2 In August 2004, trainee doctors will come within the statutory remit of the European Working Time Directive.3 A requirement for 11 hours rest in 24, combined with a European court ruling on doctors working patterns,4 means that full shift working will become inevitable for all resident doctors.
Outline of problem
Before this study, night cover of medical paediatric specialties at our hospital was provided by four senior house officers and seven middle grade doctors through partial shift rotas using additional non-training grade doctors. Diary monitoring indicated that the 11 on-call doctors worked at low intensity but with sufficient overnight interruptions to disrupt continuous rest. A clinical site practitioner, an experienced intensive care nurse (grade H/I), had the role of senior clinician for the hospital and was able to filter about 60% of bleeps; pan-hospital commitments reduced the capacity to filter a greater proportion. Compliance with junior doctors' working hours was only 33% overall and 0% for medical paediatric trainees. This paper outlines our approach to redesigning night cover across the medical paediatric specialties (excluding intensive care) to improve compliance without compromising patient care, medical training, or quality of life of our junior doctors.
Strategy for change
We perceived that simplistic rota readjustments were ineffectual and that a definitive solution required organisation-wide changes in work practices and attitudes. We used the Modernisation Agency's toolkit for local change to facilitate preliminary redesigning of roles.5 The basic principle of the toolkit is that grass roots staff are best placed to identify inefficiencies and brainstorm solutions. We held a one day workshop to enable clinical teams to plan new roles that could maximise clinical time. The changes included clinicians'assistants to take on many of the administrative tasks carried out by doctors and nurses, developments in protocol and supplementary prescribing by nurses and pharmacists, and an extension in the role of clinical site practitioners.
These developments made it possible to plan more radical rota changes. We substantially reduced the number and tiers of doctors working overnight, increased cross specialty cover, and slightly reduced the number of junior doctors available by day. We proposed a new night team of two clinical site practitioners with three full shift, middle grade doctors and a fourth sleeping doctor as back-up for emergencies. A clinical site practitioner would lead the new night team, chair a formal handover, and assign work in an organised way.
Senior house officers would be removed from overnight duties but provide cover from 8.30 to 10 pm seven days a week. This would give them more daytime experience, with better access to teaching and outpatient work. Our hospital does not have an accident and emergency department, but senior house officers have always had substantial on-call experience in other settings, so they would not lose important experience overnight. To ensure that middle grade doctors in monospeciality training retained adequate subspecialty exposure, we aimed for a 10 week cycle: one week of nights, one week off, and eight weeks of days.
Box 1: Role of clinical site practitioner
Expertise in assessing and caring for seriously ill children—clinical assessment, cannulation, venepuncture, defibrillation, management of cardiac arrest, intraosseous needle insertion, ordering investigations, pain control, 12 lead electrocardiography, line repair, interpretation of radiographs, etc
Clinical and managerial support for junior nursing and medical staff
Site overview—managing resources, staffing, and bed issues across the trust.
Dealing with complaints, child protection, advice to parents, advice to other hospitals
Assessment of children and adults who present at the hospital expecting accident and emergency facilities
Coordination of major incident strategy
The rota still required non-training grade doctors, but we wanted to move away from a junior medical workforce on short term contracts for whom we had no developmental responsibility. We therefore planned to appoint nine staff grade doctors whom we would actively support to gain the experience needed to return to the training grades or to progress within the staff and associate specialist structure to associate specialist level.
Widespread consultation highlighted concerns that a reduction in on-call staff at night could compromise patient safety and that full shift rotas would be detrimental to training and quality of life of junior doctors. Consultants thought that reduced subspecialist expertise at middle grade would increase their overnight workload. Implementation of the new system was dependent on overcoming these concerns.
Audit of workload before changing the rota
Two questions were raised through the consultation. Could five members of staff manage the overnight workload? Would there be occasions when more than three doctors or more than five total staff were needed at the same time for emergencies? Full details of the design of the study and control charts used to examine the performance of the night rota are available on bmj.com.
We employed two medical students to walk the wards for 28 nights, obtaining independent information about each event requiring a resident doctor or clinical site practitioner between 10 pm and 8am. Events were graded according to urgency (box 2) and recorded as a time line on a tally chart partitioned into half hour intervals (see fig A on bmj.com). To calculate workload, we rounded up attendances to the nearest half hour and highest grade of activity.
Nightly activity varied widely (table). There was a consistent bulge in overall activity from 10 pm to 1 am (see fig B on bmj.com) because of completion of necessary but non-emergency tasks after daytime events; emergency activity (grade 4) was more evenly distributed. Eleven doctors accounted for just over 70% of total activity and, on average, spent 1.3 hours a night attending the wards. The clinical site practitioner spent an average of 6.2 hours. On four occasions over 28 nights, three doctors were engaged in emergency activity at the same time; four doctors were engaged simultaneously on three occasions. Each of these events involved an overlap between senior house officers and specialist registrars—that is, the senior house officer had called the specialist registrar to assist in an emergency. There was just one occasion lasting 1.5 hours when five staff were needed for simultaneous emergencies. The results indicated that a team of three full shift doctors, with two clinical site practitioners and a fourth sleeping doctor would have ample capacity to manage the total overnight workload.
Key outcome measures
We evaluated the new rota from four perspectives:
Compliance with regulations on junior doctors' working hours, assessed by diary cards
Overnight workload, measured as time spent by staff on the wards, graded for urgency
Patient safety, assessed using critical incident reporting
Informal evaluation of the effect on medical staff through one-to-one interviews, group meetings, and forums, and a training review by the Royal College of Paediatrics and Child Health before and after implementation of the changes
Effects of change
Compliance with regulations on junior doctors' working hours increased to 100% across the paediatric medical rotas and from 33% to 77% across the trust.
Capacity and management of overnight workload
Eight weeks after introduction of the new rota we repeated the audit of workload. The back-up doctor was used only once in 28 nights (to replace a sick doctor). Total workload changed little (table), and the bulge in activity from 10 pm to 1am persisted (see fig B on bmj.com). The proportion of emergency work decreased by 10%, and doctors' overall workload fell from 71% to 47%, as might be predicted by removal of the senior house officers and addition of a second clinical site practitioner. Individual doctor's total workload increased from an average of 1.3 to 3.3 hours a night. As before, five staff were involved in emergency activity simultaneously just once, for two half hours.
Box 2: Grades of activity
= Could or should be done before 10 pm (eg finishing routine ward round, writing up notes from day)
= Should be done but any time (eg writing forms for morning, checking results)
= Should be done within the hour (eg clerking new admission, reviewing child with fever, taking blood, prescribing antibiotics)
= Should be done immediately (eg assessing child with fits, hypotension, respiratory changes)
Over both periods of 28 nights, five staff were required together for simultaneous emergencies for five out of a total of 1120 half hours (20 half hours a night, 56 nights), a frequency of 1 in 225 half hours or 0.004%. Use of the fourth sleeping doctor is thus likely to be required very rarely and more often for staff illness than to help with emergency activity.
Critical incidents involving junior doctors are routinely reported to HDC. In the 12 months before the changes, two such incidents were reported; both resulted from clinical errors of judgment by middle grade doctors at night. In the six months since the changes there have been three reported incidents; one involved a doctor declining to resite a cannula in a hypoglycaemic infant 5 minutes before a shift change and two involved doctors leaving the hospital without attending handover. There were no resultant adverse effects on patients.
Although continuity of care at night has improved, continuity by day is now harder to maintain in some units. We are reviewing how clinical teams function with a less continuous middle grade presence.
Effect on junior medical staff
Senior house officers are generally happier with the new rota and think that they benefit from increased daytime educational opportunities. Despite initial resistance, most middle grade staff are also happy with the new system, although complaints persist about doing the work of senior house officers at night. They report greater breadth of experience through seeing a wider range of patients and the opportunity to learn from each other's specialist knowledge. Set against this, they are unhappy about reduced exposure to their own subspecialty, feeling that they lose two weeks in each 10 week cycle. These views, elicited through internal mechanisms, have been consistent with those expressed to the royal college visiting committee. Seven of the nine staff grade doctors intend to stay for at least two years, depending on the future of the staff and associate specialist structure, and they think that the trust provides good development opportunities.
Guidance from the clinical site practitioners has improved the junior doctors' handover and team working skills. After initial surprise, rather than resistance, at being managed by a senior nurse, the doctors are positive about the experience. The increased contact between different teams has led to a more vibrant doctor's mess, highlighted as important to maintaining morale and cohesion in the face of reduced hours and shift working.6 We did not measure consultant's workload at night, but anecdotal reports suggest that any effects have been much less than feared.
Lessons learnt and next steps
A night team of five has ample capacity to cover workload including emergencies. However, several problems persist. Radical, centrally driven change disem-powers clinical teams until local ownership is re-established; this caused some friction and disengagement, even though experience over the preceding two years had shown that local modifications could not meet the regulations on working hours.
Some important governance issues have emerged. For example, patient notes usually contain an outline of the day's events but rarely a management plan. We are now striving to ensure that junior doctors record plans, thus enabling appropriate action by the night team. Clinical protocols and guidelines need to be accessible on the hospital intranet (currently in progress), and induction to sister specialties needs improving to support the broader cross cover arrangements. We need to decide whether doctors on full shift should be able to sleep during quiet periods, when nurses cannot. The role changes necessary to support the rota-changes (such as clinicians assistants) are still at an early stage of development and need evaluation. Most importantly, the effect on patients is hard to measure and is only crudely assessed by incident reporting.
Finally, we are concerned that regulation and monitoring of junior doctors' hours is being implemented in an inflexible manner. We worry that the critical incidents that have occurred recently indicate that we are jeopardising professional responsibility through over-regulation. Our experiences are not unique, and the issue requires widespread national discussion.
Key learning points
Meeting requirements on junior doctors' hours requires development of new roles and work practices, alongside radical restructuring of night rotas
A new rota with fewer doctors and increased use of clinical site practitioners increased compliance of medical paediatric rotas from 0% to 100%
Initial assessments suggest most staff are happy with the new rota and safety of patients is not compromised
An example of the tally sheet, an evaluation of use of control charts, and further data on workloads are available on bmj.com
We thank Judy Hargadon and the changing workforce team for help in implementing the changes and Sophie Petit-Zeman for editing advice and suggestions.
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.
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.