Hospitals require 24/7 coverage for most clinical services, and
doctors' offices need after-hours coverage for urgent issues. Everyone
in the organization needs to know who is covering for any of those
services or physicians at any time. When every group has its own
schedule formatted differently, posted in different places,
and often outdated quality of care and productivity suffers.
every process has an owner
Active support from the process "owner" is a critical
success factor for any process change. But some processes span many
departments and do not have an acknowledged owner. Problems with
those processes may go unaddressed indefinitely. On-call scheduling
was one of those processes: badly broken, frustrating everyone,
and not getting fixed.
built a large on-call scheduling application in a prior work-life,
Steve decided to take a chance and test the notion that "if
you build it, they will come." After collecting and analyzing
numerous existing schedules, he designed a process based on three
"layers" of data:
(departments, physician groups, specialties, etc.)
(each group has one or more schedules)
(each schedule has one or more providers, while providers often
participate in multiple schedules)
group, each schedule and each provider has a "profile"
containing data about that item.
users see a short menu (shown at right), with most-frequently
used items listed first. The photo gallery
[a.k.a. "Rogues' Gallery"] is intended for those patients
who (for example) appear in the emergency department and can't
remember the name of their primary care physician or nurse practitioner.
For regular users, the provider profile
automatically defaults to the current user's profile, if any.
on-call search assumes that the user needs to know who to call right
now for a specific group or individual physician (shown below).
individual clinician's name may be input or a group/department
may be selected from a list.
Now" literally means who is covering at this moment. During
regular office hours when no one is on call, this selection will
return results indicating that no one is on call. This confused
some users, who actually wanted to know who was going to be on
call later in the evening, so we added the "Today and Tomorrow"
determine who is covering during the next 24 hours, select "Today
determine who is on call for any date/time in the future, input
the date (or select from the calendar) and time.
show the hours of coverage by date, name of covering provider, and
pager number (above) is linked directly to a pop-up
paging window (shown below). The user only needs to click
the pager number, input the alphanumeric message, and click "Page."
display the photo gallery, the
user simply selects the group or department from a list, and all
available photos for clinicians who are part of that group/department
are displayed (shown below). The computer monitor can be swiveled
around for the patient to indicate whether they recognize anyone.
provider stipulates regular office hours in their provider profile.
However, exceptions will occur for vacations, education, teaching,
etc. The Out of Office page
(shown below) gives each provider a mechanism for redirecting calls
during these times, without having to change their profile or change
an on-call schedule. This is a very flexible tool that makes it
easy for the provider to ensure coverage on a moment's notice.
(listed below) are not restricted, since the schedules do not contain
any sensitive information. The reports include two audit tools to
ensure complete coverage for each schedule, summary reports for
providers and groups, and a list of changes to schedules.
Everyone with superuser privileges can edit any profile or
any schedule. This was a deliberate design choice to foster
cross-coverage and collaboration among all the groups (and
it has worked out well). Superusers see the extended menu
shown at right, with additional tabs for editing schedules,
and a subset of maintenance functions.
For example, superusers can only grant user or superuser permissions,
and can only view the holiday list, etc.
with admin or support
permissions (generally IT staff) have full ability to grant
permissions, edit lists, and send group pages (described later
in this article).
schedule profile contains all
the meta-data for each schedule. (Part of a profile is displayed
below. To see the full profile, click
the image below.) A few of the many features in the schedule
shift has its own mini-profile, listing days and hours of coverage,
and any providers on the "short list" for that shift
hours are assumed to cross from one day to the next if indicated
by start/end times (e.g., coverage from 07:00 to 07:00 runs from
7am one day to 7am the next day)
schedule has a "short list" of providers who will appear
in the picklist when editing that schedule. Whenever a schedule
is being edited and a new provider is selected, the superuser
has the option of adding that new provider to the short list for
reminders are e-mailed to schedule owners when gaps exist, as
described in the "Schedule Gaps" section.
the image above to see the full schedule profile]
group profile contains all
the meta-data for each group. (Part of a profile is displayed below.
To see the full profile, click
the image below.) A few of the many features in the group profile
to restrict group to specified groups of users (group does not
appear in picklist for other users)
call categories, with each category linked to a specific schedule
(which, in turn, can have multiple shifts)
ability to customize the message that users will see
the image above to see the full group profile]
provider profile contains all
the meta-data for each clinician who participates in any on-call
schedule. (Part of a profile is displayed below. To see the full
profile, click the image below.)
Features in the group profile include:
to restrict group to specified groups of users (group does not
appear in picklist for other users)
office hours when no on-call coverage is needed
provider attends at any of the three hospitals, in which services/units,
and for what level of care
provider practices at any ambulatory care sites
provider participates in any specific on-call rotations
for paging for ADT Event Alerts
(see below for more detail)
for receiving e-mailed reminders when scheduled to be on-call
for contact information
the image above to see the full provider profile]
Event Alert Paging Preferences allows each provider personal
control over the types of events for which they will be paged, and
when (shown below). For each type of event, the provider can select
the provider role(s) and times of day (if any) when they would like
to receive alerts via pager.
can also set temporary pager options
as an override to their normal preferences. These preferences are
defined in exactly the same way as normal preferences, but have
a specific time span.
on-call schedules is done with a user-friendly calendar
format (shown below). There are several key features of this process:
is an option to use a date range instead of the calendar format
superuser editing the schedule may select specific dates by checking
individual boxes, or select blocks of dates with the buttons around
shift of schedule coverage may have a backup and alternative provider,
in addition to the primary
may be made to all providers at once, or only to one type of provider
some cases, the calendar format is less efficient for editing. The
date range edit screen allows quick
selection of dates in common-used combinations (shown below).
the date range to be edited has been selected, the actual
edit is completed (shown below). This step has several
may use the "typical" day and time coverage contained
in the schedule profile for the days of week selected for editing
may override the schedule profile with new times for these specific
three picklists of providers (Primary, Backup, Alternate) are
based on the "short list" in the schedule profile for
this schedule and/or schedule shift.
providers may be added to the schedule at any time, either by
searching the Intranet list of all workers or by manually adding
a new person or group.
Audit button on the editing
pages opens the audit report (shown below). By default, this report
displays the next 30 days of the selected schedule, including the
primary, backup and alternate providers currently scheduled for
each shift in the schedule. This report serves two purposes:
coverage to discover any gaps or errors
printable format that can be posted or handed out
Most health care organizations use one or more answering services
to screen after-hours calls for providers. Centralizing the on-call
schedules eliminated the need for each group to fax updated on-call
schedules to the answering service used by group. One or more individuals
at each answering service was granted remote access to the intranet
and trained in using the schedule changes
report. This was a win/win, because the groups no longer
had to worry about communicating changes to their answering service,
and the answering service no longer had to figure out exactly what
had changed when they received an updated schedule.
Two types of e-mailed reminders are sent:
who is on-call during the next two days receives a daily e-mail
reminder with details of their schedule (unless they opt out via
enterprise switchboard operators receive an e-mailed update every
four hours IF any changes have been made to on-call schedules
a quick tool to reach all on-call providers in an emergency, certain
individuals are granted a special permission level and an additional
tab is displayed on their menu (shown at right). This allows them
to send a brief alphanumeric page to everyone who is on-call at
that moment OR to everyone who will be on-call at any time during
some number of hours in the future.
Because there was no clear process owner or champion, the webdev
group took every possible step to make implementation go smoothly:
every schedule and input the first month's data for each group,
and trained that group's superuser in how to edit. This made the
transition to the automated process as painless as possible for
each group, and ensured consistent design across groups.
site visits as necessary to answering services for orientation
and training, and facilitated remote access for each service.
with enterprise switchboard operators to ensure smooth transition
from faxed schedules to automated process.
with emergency departments to ensure that ED physicians and staff
were comfortable with the new process.
with physician leaders in various groups to ensure buy-in for
all superusers to work collaboratively, learning from each other
and cross-covering as necessary.
the information technology department (IT) really understands
the business, IT can play a leadership role in developing and
implementing an automated improvement to a key business process.
providing the tool is not enough. Implementation was a roaring
success in large part because IT did the initial configuration
and inputting. This followed another rule of successful process
process change to be successful, it must be easier to do it the
new (right) way than the old (wrong) way. The automated process
was much less work than the manual process, and implementation
was painless for the superusers.
Posted 2 May 2008