Best Practices In Brief
From a November 2, 2003 Hours Reform Conference in Los Angeles
On November 2, 2003, the Committee of Interns and Residents/SEIU, the American Medical Association Resident Fellow Section, and the California Medical Association Resident Physician Section sponsored a conference focused on developing and implementing innovative strategies to reduce resident work hours. The following list of best practices was composed at the conference’s end based on the experiences shared by conference participants:
Procedure Team - designated surgical team, which responds quickly to the need for patient procedures. Team members rapidly improve their skills and their log book numbers, while remaining residents save valuable time in their day; another plus is that patient care needs are often attended to more quickly.
Elective Surgery Cases Assigned by Resident Schedule — Elective cases are booked based on the surgical residents’ on-call schedule, so that residents will be able to maximize their time in the OR doing the cases they need for their training; by concentrating hours, residents are more rested and better able to learn at other times.
Set Up a Hospital Hotline to Monitor Hours — Some Medical Directors and GME offices have set up anonymous in-house hotlines for residents to call if they have concerns about working too many hours on a particular rotation, but feel they are getting no support from their program.
Day Float System - Tuesdays through Fridays, the Day Float Team takes the first admits of the morning, so that the other residents do not have to come in to work until 10:30 am.
Night Float Expanded to 7 Days - Night float gets one guaranteed day off a week, when the resident on Rheumatology elective is pulled on Thursday nights. Saturday and Sunday nights, the night float only has to come in if and when the ward team ‘caps’ (this could be at 4 am).
Round With Post-Call Resident First - Hospitalist rounds first individually with the post-call resident(s); then with the rest of the team. This helps to get the post-call resident out as early as possible and give some extra time for the other residents to do work before rounds.
Round with Attendings between 9-11 PM - Granted, by moving away from the traditional morning rounds, this constitutes a major change in attending physician culture. But residents who have tried it say there are several advantages: increased hospital efficiency (by allowing the team to get a big jump on the next days discharges); and evening out resident workloads and teaching time so that more is accomplished during non-prime hours.
Round with a Laptop Computer — Providing each team with a laptop computer that can be wheeled from one patient to another in order to write discharge notes and orders at the bedside greatly speeds up the paperwork that residents are deluged with.
Schedule < 80 Hours Per Week- Base schedules to aim for 60 hours per week, rather than 80. Leaving a healthy “cushion” gives residents the flexibility to attend conferences, stay for an interesting case, or to follow an interesting patient.
Hire a “Resident Assistant” - Hospitals such as D.C. Children’s Medical Center and Johns Hopkins have hired resident assistants to help housestaff with discharge paperwork, ordering tests, etc.
Hiring Ancillary Staff - Hiring more ancillary staff to take the work burden off residents is often a key way to reduce hours — for example, more transport workers, phlebotomists, a person to do visual acuity exams in the Ophthalmology clinic.
Website Improves Education / Patient Care - One Family Medicine program put every grand rounds powerpoint for the last three years on the department’s website. They also included the top 20 diagnoses at the hospital; click on each one and the residents get the top 10 best articles on the subject. Patient handouts, in twelve languages, are also easily printable from the website, which saves resident time and improves patient care.