Automating Healthcare
Solving business problems with savvy automation
 


On-call Schedules

Business problem
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 When every group has its own schedule — formatted differently, posted in different places, and often outdated — quality of care and productivity suffers.

Not 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.

Having 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:

  • Groups (departments, physician groups, specialties, etc.)
  • Schedules (each group has one or more schedules)
  • Providers (each schedule has one or more providers, while providers often participate in multiple schedules)
  • Each group, each schedule and each provider has a "profile" containing data about that item.
Ordinary 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.

The on-call search assumes that the user needs to know who to call right now for a specific group or individual physician (shown below).

  • An individual clinician's name may be input or a group/department may be selected from a list.
  • "Right 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" option.
  • To determine who is covering during the next 24 hours, select "Today and Tomorrow."
  • To determine who is on call for any date/time in the future, input the date (or select from the calendar) and time.

Search results show the hours of coverage by date, name of covering provider, and pager number.

The 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."

To 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.

Each 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.

On-call schedule reports (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.

Superusers
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, profiles, notes and a subset of maintenance functions. For example, superusers can only grant user or superuser permissions, and can only view the holiday list, etc.

Those 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).

The 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 profile include:

  • Multiple shifts
  • Each shift has its own mini-profile, listing days and hours of coverage, and any providers on the "short list" for that shift
  • Coverage 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)
  • Each 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 that shift/schedule.
  • Automatic reminders are e-mailed to schedule owners when gaps exist, as described in the "Schedule Gaps" section.


[Click the image above to see the full schedule profile]

The 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 include:

  • Ability to restrict group to specified groups of users (group does not appear in picklist for other users)
  • Multiple call categories, with each category linked to a specific schedule (which, in turn, can have multiple shifts)
  • Extensive ability to customize the message that users will see


[Click the image above to see the full group profile]

The 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:

  • Ability to restrict group to specified groups of users (group does not appear in picklist for other users)
  • Typical office hours when no on-call coverage is needed
  • Whether provider attends at any of the three hospitals, in which services/units, and for what level of care
  • Whether provider practices at any ambulatory care sites
  • Whether provider participates in any specific on-call rotations
  • Preferences for paging for ADT Event Alerts (see below for more detail)
  • Preference for receiving e-mailed reminders when scheduled to be on-call
  • Preferences for contact information


[Click the image above to see the full provider profile]

ADT 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.

Providers 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.

Editing on-call schedules is done with a user-friendly calendar format (shown below). There are several key features of this process:

  • There is an option to use a date range instead of the calendar format (see below)
  • The superuser editing the schedule may select specific dates by checking individual boxes, or select blocks of dates with the buttons around the calendar.
  • Each shift of schedule coverage may have a backup and alternative provider, in addition to the primary
  • Updates may be made to all providers at once, or only to one type of provider

In 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).

Once the date range to be edited has been selected, the actual edit is completed (shown below). This step has several key features:

  • Updates may use the "typical" day and time coverage contained in the schedule profile for the days of week selected for editing
  • Updates may override the schedule profile with new times for these specific dates.
  • The three picklists of providers (Primary, Backup, Alternate) are based on the "short list" in the schedule profile for this schedule and/or schedule shift.
  • New 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.

The 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:

  • auditing coverage to discover any gaps or errors
  • handy, printable format that can be posted or handed out

Answering service access
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.

E-mailed reminders
Two types of e-mailed reminders are sent:

  • Anyone 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 their profile)
  • The enterprise switchboard operators receive an e-mailed update every four hours IF any changes have been made to on-call schedules

Emergency blast e-mail
As 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.

Implementation
Because there was no clear process owner or champion, the webdev group took every possible step to make implementation go smoothly:

  • Built 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.
  • Made site visits as necessary to answering services for orientation and training, and facilitated remote access for each service.
  • Worked with enterprise switchboard operators to ensure smooth transition from faxed schedules to automated process.
  • Worked with emergency departments to ensure that ED physicians and staff were comfortable with the new process.
  • Met with physician leaders in various groups to ensure buy-in for automated process.
  • Encouraged all superusers to work collaboratively, learning from each other and cross-covering as necessary.

Lessons learned

  • If 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.
  • Simply 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 change:
  • For 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

   


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On-call Schedules
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