October 1999
Volume 63 |
Number 10
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WHAT'S NEW IN ...
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| ... Mitigating
the Frustrations of Drafting the Call Schedule |
Richard M. Flowerdew, M.D.
The on-call rotation is a subject that everyone has a strongly
held, non-negotiable and conflicting opinion among anesthesiology
colleagues. Unfortunately, call is a fact of life, and some luckless
soul has the thankless task of producing the "call schedule."
Fortunately, schedulers do not appear to have a shortened life
expectancy as the replacement scheduler may be even more unfair
(all schedulers are unfair by definition) than the existing scheduler.
The task has increased in complexity as groups expand,
locations increase in size and diversity, unique arrangements
evolve, hospitals merge and subgroups, either by location or specialty,
become a more common mode of practice. The biggest challenge may
be meeting the requirements of the growing group of aging anesthesiologists
for whom reduction of call duties may be a primary concern. These
changes are occurring in a period of a reduced number of residents,
longer work hours and elective surgery on weekends as hospitals
and surgical centers try to improve their productivity. In terms
of quality of life, the call schedule is one of the dominant factors
probably second only to the actual type of practice.
Our ever-expanding group of 34 anesthesiologists was faced
with resolving call issues at different locations when we agreed
to supply services to a community hospital about 20 miles away.
Until that time, our primary practice was a tertiary care center
with a minimum call team of an "in-house" anesthesiologist, resident,
nurse anesthetist and back-up anesthesiologists. Call had been
strictly equal across the board. In complete contrast, the community
hospital had a single on-call anesthesiologist who was not required
to be in house but available for the 30-minute c-section. We also
decided to limit the number of rotators to the community hospital
to a maximum of 12 persons to maintain continuity of care. The
problem was not only to equalize the call obligations between
all the players but also, more importantly, to convince them that
it was, indeed, equal; "...justice must be seen to be done."
The solution was to create a relative call value scale,
a concept with which anesthesiologists are already familiar from
ASA's Relative Value Guide. This was a practical solution as the
physicians in our group are paid on a salary basis rather than
on a productivity (i.e., number of cases) basis. The reference
point was a normal day's work at the tertiary care center as this
was a task to which everyone could relate. All call tasks were
defined as a multiple or fraction of this reference point. The
total value of call at each location could then be easily determined
by adding up the value of all the tasks. Each individual's portion
of the call burden was then apportioned. The primary goal was
for each individual to have the same number of call points over
a given period, but the secondary goal was to maintain the distribution
(especially weekend call) at each location as uniform as was reasonably
possible.
There were several important details. The first was using
a unit concept rather than a dollar figure. As soon as a specific
dollar is mentioned, other forces come into play that hamper consensus-building.
Defining call as a unit permits the cash value to float with revenues
rather than give a particular call a specific cash value that
may, over time, become completely out of proportion.
The second key element was the need for a high value call
task that is common to all physicians. This was the mechanism
by which intrinsic inequities in the different locations could
be balanced. Essentially this represented the common currency
of the system. Staffing numbers at the locations need to be calculated
so that all the physicians have some obligation to this central
task. An alternative approach is to use a financial balancing
process (using the units as the methodology for calculation) when
there is no practical common call task.
The third element is some form of accounting system. If
a cash system is used, it is quite straightforward to do a retrospective
calculation. However, if the intent is to keep the call points
approximately equal or in a predefined ratio, some form of prospective
allocation of call is required to balance the account after the
fact. Furthermore, each individual will have a different obligation
to each task depending on his/her unique situation. With small
numbers of people and tasks, the calculations and distributions
can be done manually. However, for larger groups and multiple
tasks, a computer program is a necessity, if only for one's sanity.
The relative call system has several secondary goals in
addition to the primary goal of creating a fair call schedule.
These include part-time employees who may have different call
loads from their daily workload, a mechanism for compensating
for excessive administrative commitments by giving it a call value
and calculating the value of call for individuals who wish to
go off call. The relative call system could also be used for valuing
research, teaching and other nonclinical but essential tasks.
All these values can be added into the total call value units
to give the total call obligations. It is quite simple, if a little
tedious, to work out each individual's actual distribution.
The call schedule controls people's lives. It has to be
done in an equitable manner. It can also be a vehicle for compensation
for other tasks, especially for the increasing number of nonclinical
tasks that are essential for the functioning of the group, but
there is reluctance to directly reimburse that individual. A similar
concept with similar goals was described by Lynda F. Venters1
in relation to the redesign of the group's income distribution
system. Her group used productivity units to cover all the different
types of "work." However, not many groups may be able to make
that big of a leap. The relative value for call may be seen as
an intermediate step.
Where are the problems? The biggest is probably making
the system overly complex. Any individual in an organization has
some additional responsibilities, but not all of them need to
be given a value. There are some tasks, not necessarily the same
for each individual, that need to be done for the good of the
community and should not expect reward. It is more important to
concentrate on the major issues/tasks rather than the minutiae
of every single detail.
In a similar manner, you cannot permit people to "nit-pick"
the system to death. Interminable arguments about whether a task
is worth 1.25 or 1.20 units is not going to make a measurable
difference to the outcome, especially if each individual is generating
about 5 call units per month. With a reference call of 0.75 units,
a single reference call would rapidly correct for small differences.
Finally, it should be recognized that no system will be
perfectly fair, but provided you can "satisfy most of the people
most of the time," you have achieved an acceptable outcome.
Richard M. Flowerdew, M.D., is an Attending
Anesthesiologist, Maine Medical Center, Portland, Maine.
Reference:
1. Venters LF. "Is your income distribution
program outdated?" ASA NEWSLETTER. 1998;
62(7):26-30.
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