The case study hospital is a 360 bed tertiary private hospital located in Western Australia. It is one of only two existing tertiary hospitals providing emergency services for southern Perth suburbs.
The Hospital Emergency Department (ED) averages 23,000 presentations per annum, but has seen as many as 25,500 in 20091,2,3,4. Managed by a FACEM Director, it is staffed by specialist emergency physicians and procedural general practitioners. Hospital patient administration data demonstrates that the ED refers an average of 5000 patients to inpatient specialists for admission each year of which 65% require emergency surgical management5.
The Hospital lists 143 anaesthetists on its specialist credentialing register, all being visiting medical practitioners (VMPs). Despite not being employees, they are signatories to the organisation’s By-laws which include provision for participation in oncall rosters. Geographically, there are no onsite or locally based anaesthetic practices servicing the Hospital. The majority of anaesthetists are based approximately 20 kilometres away in the northern suburbs and visit for elective lists, primarily during business hours.
The Hospital’s specialist groups have traditionally organised their own voluntary rosters in support of ED patients, however, surgeons have reported increasing difficulty in encouraging anaesthetists to attend the Hospital for ED derived patients. As a result, the Hospital has coordinated a voluntary afterhours anaesthetic roster for the last decade.
A review of the rostered availability for anaesthetists in 2008 demonstrated that the number volunteering to provide afterhours cover was declining. Roster data showed an average of 15 days each month with no afterhours anaesthesia cover. A concurrent review of the Hospital’s clinical incident database (RISKPRO) highlighted an average of 4 patients each week who received delayed surgery (greater than 48 hours after admission) as a result.
Feedback from the ED doctors and procedural specialists confirmed their ongoing frustration associated with the lack of reliable anaesthetic cover for ED patients6. Appropriate cases were being referred by the ED to oncall surgeons where the Hospital had both theatre time and nurse workforce available. Despite this, surgery was not always possible due to a lack of anaesthetist availability. Anaesthetic roster audit demonstrated that there was no cover for approximately 50% of each month leading to patients waiting until an anaesthetist already onsite became available or they were transferred to a public hospital. Public health facilities relayed their concern around being “forced” to accept private transfers which impacted their already busy emergency services.
A review of emergency general surgical literature identifies increased mortality where there is a delay between onset of symptoms and definitive surgical treatment, especially in the elderly7,8. Outcomes are further impacted by the availability of adequate infrastructure and appropriately trained and experienced clinicians9. While these findings are not generally supported for trauma surgery10, the SJGMH casemix consists of minimal trauma, with the majority of emergency surgical patients being elderly, suggesting a lack of anaesthetic cover potentially impacts quality of care.
Based on this information, the Medical Advisory Committee determined that patients were not best served under these circumstances. They recommended to the CEO that I, as the recently appointed Director of Medical Services, develop and implement an urgent solution.
Initially, I identified the scope of the issue and its historical context, starting with a review of all previous correspondence and actions already employed to address this longstanding challenge. Previous strategies included negotiating with several of Perth’s anaesthetic groups in an effort to contract them to provide an oncall service, however, none of these groups were able to guarantee the availability of their members.
Concurrently, I identified and met with key stakeholders. Of note, the majority were non-employees and included patients and their families, the VMP anaesthetists, several surgical VMP specialty groups and relevant specialist college bodies. Internal stakeholders included the hospital CEO and executive team, Medical Advisory Committee (MAC), Emergency Department team, Theatre Manager, nursing and allied health staff (anaesthetic technicians), public relations staff, quality and safety team and corporate support staff. During development of the stakeholder communication strategy, I discovered that while there were several specialty medical groups meeting regularly, there was no anaesthetic craft group at the Hospital.
Once I had a clear understanding of the history, context and scope of the issue, I undertook directed research including a review of the Australian and New Zealand College of Anaesthetists and the Australian Society of Anaesthetists consensus statements around safe working conditions and oncall service provisions11,12. I also undertook a literature review of anaesthetic oncall processes in support of emergency surgery, while benchmarking these processes in other local and interstate private hospitals, especially those with emergency departments. The benchmark hospitals included the Cabrini and Epworth Hospitals in Melbourne, the Wesley Hospital in Brisbane and Mercy Hospital in Perth. I also reviewed external feedback from patients and their families regarding their experience referencing Press Ganey patient survey data13-17.
The next stage of my action plan involved working with the quality manager to identify and analyse hospital data addressing ED patient demand and distribution. Data included extracts from the patient administration system, the clinical incident database and financial reports. Forensic data review assisted in defining the extent of the issue and the magnitude of clinical, reputation and financial risk should the situation continue unchanged. This analysis process was completed during a 3 week period with some action items commencing prior to completion of the full review.
My first implementation action was to establish an anaesthetic craft group. I identified and sought the support of a clinical anaesthetic champion who became the Head of Department (HOD). The new HOD and I identified a group of 12 representative anaesthetists to attend an inaugural meeting. The first meeting was convened within a further 4 weeks and the HOD and I actively engaged the attendees to share the issue and seek their concerns and suggestions for a way forward. Regular follow up meetings were scheduled, however ongoing discussion and review of proposals was managed in the interim using email and phone communications to rapidly progress potential solutions.
While I focussed on working with the newly formed anaesthetic craft group, I regularly consulted with and reported back to other key stakeholders including the Medical Advisory Committee (MAC), the Chief Executive Officer (CEO), Hospital Executive Committee, surgical craft groups and the ED to keep them informed of progress. I principally used a personal face to face approach, but I also used the Medical Newsletter, group emails and other written forums as the process matured.
Non-anaesthetist stakeholders displayed clear consensus around their ongoing frustration associated with the lack of reliable anaesthetic cover6, 13-21. In contrast, when I engaged the anaesthetists and raised the risks associated with having a 50% populated anaesthetic roster, they acknowledged the problem, but seemed less concerned with the impact on others. They remained unwilling to participate on a voluntary basis with their key reasons being:
Once the anaesthetists’ concerns were tabled, the first priority was to manage them with reference to verifiable data, advisory guidelines and the literature.
living more than 20Km from the hospital and not wishing to travel extended distances afterhours,
concern that working overnight would render them too fatigued for their following day elective lists, losing them significant income,
concern that if they were too fatigued to attend a following day elective list on several occasions, they may be perceived as unreliable by surgeons and may permanently lose lists. They did not want to be “forced” to work unsafe hours to retain their livelihoods,
perceptions around poor remuneration for afterhours emergency lists,
many already having compulsory oncall commitments associated with public hospitals and not wanting to be exposed to additional afterhours roster duties; and
perceiving that any roster would not be fair and include all credentialed anaesthetists.
The Australian and New Zealand College of Anaesthetists (ANZCA) statement on fatigue for anaesthetists describes eight principles, with number 7 acknowledging health facilities have a responsibility under legislation to provide a safe work environment11. Five responsibilities are included which require anaesthetists who have worked out of hours to ensure they are free of all clinical duties on the subsequent day11.
The Australian Society of Anaesthetists statement on afterhours work references the previous document and notes that hospitals should adequately compensate anaesthetists who participate in an oncall roster and that any roster should be applied equitably to all12.
A general review of the literature did not reveal many papers specifically addressing oncall arrangements for emergency anaesthetic services. Several studies have examined nurse based roster principles, however these roster systems are often not directly applicable to the physician workforce, especially in a VMP context22,23. Other models are focussed on the provision of emergency surgical support afterhours or focus on junior doctor rosters24,25,26.
Griffiths undertook an observational study of nine anaesthetic registrars to test their cognitive performance after seven consecutive work nights and compared their performance with seven day shift colleagues27. Not surprisingly there was a statistical decline in the performance of detection and identification tasks27. While the paper confirmed the effects of fatigue, it did not propose any applicable solutions.
Mellin presented the European Union of Medical Specialists Guidelines for rostering specialists28. These were general in nature and were designed for an employed specialist model. They reiterated the obligation of employers to ensure the work / rest balance of rosters to minimise the risk of fatigue for anaesthetists28.
Ridley studied oncall provision for ICU services by anaesthetists in a UK setting. He did note that colleague specialists were not keen to increase their oncall commitment if they perceived their colleagues were not similarly available29.
Benchmarking other private hospitals revealed a range of voluntary and compulsory arrangements for the rostering of anaesthetic VMPs. Several eastern states models made no provision for oncall allowances and advised anaesthetists they would only be credentialed for private elective lists if they regularly participated in an afterhours roster. One local hospital with an obstetric anaesthetic roster moved to a compulsory roster based on the number of elective sessions accessed in hours.
Considering the concerns tabled at the first anaesthetic group meeting and with this research to hand, I briefed the new anaesthetic HOD prior to the second craft meeting. A key part of the engagement strategy was for the HOD to deliver information and facilitate discussion rather than it being seen to come from hospital administration. I supported him to present this information to his colleagues by taking on an “in attendance” role so the issue was seen as a shared hospital and anaesthetist responsibility.
Initially, after some subtle (and sometimes not so subtle) threats that all the anaesthetists would resign their credentialing if the hospital “conscripted” them to participate in oncall arrangements, we were able to calmly work with them to generate several proposals to address their principle concerns. The HOD and I focussed on creating a positive atmosphere of engagement, open discussion, idea sharing and genuine partnership. We acknowledged that while we could not address every concern to the satisfaction of every anaesthetist, the hospital was determined to deliver a better outcome for patients. Over a 2 month period the following roster strategy was negotiated:
This negotiated solution was unanimously endorsed by the anaesthetic craft group members and communicated to all credentialed anaesthetists in a co-signed communication from myself and the HOD. This model was also endorsed by the Hospital executive and the MAC.
The Hospital increased its oncall allowance and paid a higher rate on public holidays,
The Hospital guaranteed any uninsured patient bad debts,
The roster finished at 2300 hours each night, allowing sufficient rest for anaesthetists to protect their next day lists. For the few patients presenting after 2300 (2 on average per week), the oncall surgeon could either manage these patients conservatively, source their own anaesthetist or transfer the patient,
All credentialed anaesthetists would be compulsorily rostered to share the oncall commitment equitably. A simple formula allocating between 1 and 4 oncall sessions in each quarter was derived with the allocation being proportional to the number of elective lists undertaken,
School holiday periods remained rostered on a voluntary basis,
Rosters would be updated real-time and made available via the internet,
Anaesthetists who wanted to volunteer for additional oncall shifts beyond their minimum allocation could nominate their preferred days or times and would receive priority allocation,
Anaesthetists could swap allocated shifts, but it was their responsibility to organise their replacement,
All newly credentialed anaesthetists were to be automatically allocated 1 oncall session per quarter,
Any anaesthetist who was not contactable or available for their allocated oncall shift would be queried up to a maximum of three times. If they did not have good reason to have missed their sessions, they would receive a formal warning from the CEO on advice from the MAC that their credentialing status would be reviewed in line with the Hospital By-laws,
Anaesthetists were empowered to take a greater consultative role in accepting ONLY genuine emergency cases after hours in collaboration with surgeons. I undertook to provide additional support for anaesthetists when they felt they were being asked to attend afterhours for non-urgent surgery.
The new roster model was initially implemented as a 3 month pilot. The HOD and I sought active feedback from anaesthetists during this period and oncall anaesthetic roster coverage was made a standing agenda item for the MAC. Patient, ED doctor and other staff feedback, both verbal and written was also sought during the trial period.
Despite some initial risk, during the 4 years following implementation of the new process, only 5 anaesthetists resigned their credentialing through rostering dissatisfaction. During the same period and in the full knowledge there is a compulsory roster, an additional 35 anaesthetists were credentialed. The new general anaesthetic roster delivered 98% population and averaged 80% cover during school holidays. Patient and coding data indicate that the number of patients waiting more than 48 hours for urgent surgery fell to an average of 2 per month and average length of stay for emergency surgical admissions decreased by 2 days.
Monitoring of patient satisfaction results demonstrated an increase in overall hospital scores with the mean result increasing from a base of 69.5 to 74 after implementation14-17. VMP satisfaction scores also increased from 83.3 to 84.46,18-21. While these mean scores are comprised of multifactorial elements and are not based solely on the anaesthetic rostering or oncall service provision, they are an indicator of patient and doctor satisfaction before and after the strategy was implemented. Further detailed examination of these reports demonstrated an increase in overall anaesthetist satisfaction rather than an expected decrease after the new roster commenced. Importantly, the satisfaction survey results do not demonstrate any overall decrease in patient or doctor satisfaction since the change was implemented.
Clinical incident data was continually monitored at anaesthetic and surgical craft groups. There was no evidence of negative clinical incident trends or patient disadvantage under the new roster arrangements.
Based on these follow up results, the initial pilot was continued as an operational model with only minor modification. The issue of anaesthetic oncall cover remains a standing business item for review on the MAC and anaesthetic craft group agendas.
RACMA Competency Review
This Management Case Study invokes all seven CanMEDS Role Competencies30, however, I have chosen to focus on the following four as the key competencies that I believe allowed me to lead a team based solution to this clinical service challenge.
Overall this case study highlights the interrelationship of these competencies. While they are considered here as distinct concepts, infact they coalesce to form a core from which medical administrators draw to deliver our unique and specialised function.
Medical Leader – Recognised a difficult situation, acknowledged past efforts but re-engaged stakeholders to facilitate shared problem ownership and an agreed way forward. This approach employed patience and a personal face to face, transformational leadership style.
Medical Expert – There was a need to become familiar with benchmark experience and successful models in an environment of risk assessment and management. This included the provision of information to manage the risk of losing anaesthetists from the Hospital against the need to provide a safe service.
Communicator – This competency was key to acknowledging and understanding all stakeholder perspectives and to creating a new environment for communication. The new communications framework facilitated appropriate information sharing strategies, generating a partnered way forward.
Collaborator – This competency was closely linked to the communication and leadership competencies in that it was through the identification and active engagement of stakeholders that a working solution was achieved.
Practice Reflection & Learnings
Considering the key issues of this case and the process that lead to a resolution, I have discerned the following regarding my personal learnings and skill development:
Dr Anthony Robins
During the process, I applied Mezirow’s central function of validating what I thought I knew by reflecting on my knowledge perspective and seeking to learn alternate perspectives from the other stakeholders31. During the process I employed conceptual and theoretical reflectivity to critically assess my assumptions while learning from stakeholder feedback, data and literature. On review, the process I employed has closely followed Taylor’s REFLECT Model to review, learn, reflect, implement and follow up my action strategy32. Using reflective practices helped me to create the space to re-examine a longstanding issue from a perspective that was not my own. As a medical administrator, I facilitated reflection in others that eventually led to a successful outcome.
After the process, I have used reflection to consider and embed my practice. While valuing prior work, I also needed to actively seek out prior perspectives. I better understand the value of data, feedback and literature, but must not underestimate the value of clinical champions in medical change. I need to seek out opportunities to create tailored communication frameworks that will best identify and deliver a strategy and most of all I need to follow up change outcomes ongoing.
1Case Study Hospital Annual Report 2010/11.
2Case Study Hospital Annual Report 2009/10.
3Case Study Hospital Annual Report 2008/09.
4Case Study Hospital Annual Report 2007/08.
5Robins AM. SJGHM Emergency Department, Executive Briefing Paper. WA: Case Study Hospital, 2010 Jan.
6Press Ganey Associates. Case Study Hospital Doctor Satisfaction Report 2007. Bundall, QLD: Press Ganey Associates Inc, 2007.
7Arenal JJ, Bengoechea-Beeby M. Mortality associated with emergency abdominal
surgery in the elderly. Canadian Journal Of Surgery. Journal Canadien De Chirurgie [Can J Surg], 2003 Apr; Vol. 46 (2), pp. 111-6.
8Pearse RM, Dana EC, Lanigan CJ, Pook JA. Organisational failures in urgent and
emergency surgery: A potential peri-operative risk factor. Anaesthesia [Anaesthesia], 2001 Jul; Vol. 56 (7), pp. 684-9.
9Peden CJ. Editorial: Emergency surgery in the elderly patient: a quality improvement
approach. Anaesthesia [Anaesthesia], 2011 Jun; Vol. 66 (6), pp. 440-5.
10Busse JW, Bhandari M, Devereaux PJ. The impact of time of admission on major complications and mortality in patients undergoing emergency trauma surgery. Acta Orthopaedica Scandinavica [Acta Orthop Scand], 2004 Jun; Vol. 75 (3), pp. 333-8.
11Australian and New Zealand College of Anaesthetists. Statement on Fatigue and the Anaesthetist. Melbourne, VIC: Australian and New Zealand College of Anaesthetists Inc, 2001 (Revised June 2007).
12Australian Society of Anaesthetists. Position Statement – The Provision of “Out of Hours” Anaesthetic Services. Edgecliff, NSW: Australian Society of Anaesthetists Inc, May 2008.
13Press Ganey Associates. Case Study Hospital Emergency Department Report 2007. Bundall, QLD: Press Ganey Associates Inc, 2007.
14Press Ganey Associates. Case Study Hospital Inpatient Satisfaction Report 2007. Bundall, QLD: Press Ganey Associates Inc, 2007.
15Press Ganey Associates. Case Study Hospital Inpatient Satisfaction Report 2008. Bundall, QLD: Press Ganey Associates Inc, 2008
16Press Ganey Associates. Case Study Hospital Inpatient Satisfaction Report 2009. Bundall, QLD: Press Ganey Associates Inc, 2009.
17Press Ganey Associates. Case Study Hospital Inpatient Satisfaction Report 2010. Bundall, QLD: Press Ganey Associates Inc, 2010.
18Press Ganey Associates. Case Study Hospital Doctor Satisfaction Report 2008. Bundall, QLD: Press Ganey Associates Inc, 2008.
19Press Ganey Associates. Case Study Hospital Doctor Satisfaction Report 2009. Bundall, QLD: Press Ganey Associates Inc, 2009.
20Press Ganey Associates. Case Study Hospital Doctor Satisfaction Report 2010. Bundall, QLD: Press Ganey Associates Inc, 2010.
21Press Ganey Associates. Case Study Hospital Doctor Satisfaction Report 2011. Bundall, QLD: Press Ganey Associates Inc, 2011.
22Brunner JO, Edenharter GM. Long term staff scheduling of physicians with different experience levels in hospitals using column generation. Health Care Management Science [Health Care Manag Sci], 2011 Jun; Vol. 14 (2), pp. 189-202.
23Silvestro, R., Silvestro, C. Towards a model of Strategic Roster Planning and Control: an empirical study of nurse rostering practices in the UK National Health Service. Health Services Management Research, 2008; Vol. 21, pp. 93-105.
24Cox MR, Cook L, Dobson J, Lambrakis P, Ganesh S, Cregan P. Acute Surgical Unit: a new model of care. ANZ Journal Of Surgery [ANZ J Surg], 2010 Jun; Vol. 80 (6), pp. 419-24.
25O'Grady G, Loveday B, Harper S, Adams B, Civil ID, Peters M. Working hours and roster structures of surgical trainees in Australia and New Zealand. ANZ Journal of Surgery [ANZ J Surg], 2010 Dec; Vol. 80 (12), pp. 890-5.
261Wysocki AP, McGowan B. Revising the surgical registrar on-call roster. ANZ Journal Of Surgery [ANZ J Surg], 2010 Jul-Aug; Vol. 80 (7-8), pp. 490-4.
27Griffiths JD, McCutcheon C, Silbert BS, Maruff P. A Prospective Observational Study of the Effect of Night Duty on the Cognitive Function of Anaesthetic Registrars. Anaesthesia And Intensive Care [Anaesth Intensive Care], 2006 Oct; Vol. 34 (5), pp. 621-8.
28Mellin-Olsen J, O'Sullivan E, Balogh D, Drobnik L, Knape JT, Petrini F, Vimlati L. Guidelines for safety and quality in anaesthesia practice in the European Union. Section and Board of Anaesthesiology, European Union of Medical Specialists, European Journal Of Anaesthesiology [Eur J Anaesthesiol], 2007 Jun; Vol. 24 (6), pp. 479-82.
29Ridley SA. Editorial: Critical care rosters and workload. Anaesthesia [Anaesthesia], 2004 Oct; Vol. 59 (10), pp. 946-7.
30Royal College of Physicians and Surgeons of Canada. CanMEDS 2005 Framework. Ottawa: Royal College of Physicians and Surgeons of Canada, 2005.
31Mezirow J. A critical theory of adult learning and education. Adult Education, 1981; 32 (1), pp. 3-24.
32Taylor BJ. Reflective Practice for Healthcare Professional. 2010; 3rd ed. Berkshire: Open University Press.
The Royal Australasian College of Medical Administrators
Dr Anthony Robins, , p685