Rota Design Research Articles

Supervision, scheduling, satisfaction and shared working: how experiences of junior doctors relate to excess mortality within the NHS

BackgroundWe sought to explore associations between trainee doctor perception and excess patient mortality. MethodsData from two publicly available databases reflecting mortality and components of trainee satisfaction within 81 NHS healthcare institutions between the years 2012 and 2019 were analysed. Pearson's correlation coefficients were calculated. ResultsAll domains of trainee perception were correlated with excess mortality. Clinical supervision out of hours (R=–0.44; p<0.0001), teamwork (R=–0.36; p<0.0001) and clinical supervision at any time (R=–0.35; p<0.0001) were most strongly correlated. Most associations remained consistent year on year. ConclusionTrainee doctor perceptions of clinical supervision, rota design and teamwork within the NHS are consistently correlated with excess patient mortality. Further exploration of these associations could identify opportunities for interventions to reduce excess patient mortality. Given the clinical significance of our findings, organisations should consider rapid implementation of evidence-based interventions where they exist.

Implementing Nutritional Strategies in the Workplace

The lifestyle of a health professional is mired with long hours, undue stress, shift work, poor sleep, inactivity, and unhealthy eating, despite their knowledge and expertise in what habits promote or preserve health. Healthcare workplaces are largely environments with underfunding, poor infrastructure, overcrowding, and limited or no access to health and well-being resources. The British Medical Association published a charter for minimum standards for facilities and preventing fatigue which has recommendations for access to freshly prepared food, extended hours for canteens and healthier options. 1 Most health professionals report high levels of stress and burnout. Burnout is believed to be directly associated with poor patient outcomes and compromised safety. 2 While better rota design, managed workloads, improved infrastructure, physical activity, psychological safety, and dignity at work are important determinants of employee health and well-being – access to a nutritious diet, water and education on healthy habits is a crucial component. Organisations including the National Health Service have a social responsibility to encourage healthier habits provide access to healthy eating within their premises and even offer incentives, not only to the patients they serve but also to their staff. This article explores the simple interventions that have been shown to be effective- and links to their evidence.

Hospital Mortality and Trainee Experiences: How General Medical Council Survey Findings Correlate With Summary Hospital-Level Mortality Indicator.

This study aimed to investigate whether components of junior doctor satisfaction are associated with patient mortality within the United Kingdom. We conducted a cross-sectional study of publicly available data (the General Medical Council [GMC] National Survey and the Summary Hospital-level Mortality Indicator [SHMI]) pertaining to subjective physician trainee satisfaction and patient mortality within 80 United Kingdom-based healthcare institutions. The direction and strength of correlation between components of the GMC National Survey and relative patient mortality as described by the SHMI were calculated. Additional outcomes included mean GMC survey scores for reported domains and mean SHMI by healthcare institution. SHMI for included healthcare institutions ranged from 0.69 to 1.21 (mean [SD], 1.01 [0.1]). Mean GMC domain scores ranged between 44.61 and 88.62 (mean [SD], 71.16 [10.84]). Statistically significant correlations were observed for clinical supervision, clinical supervision out of hours, rota design, overall satisfaction, and teamwork. After application of Bonferroni correction, statistically significant correlations remained for both clinical supervision and clinical supervision out of hours. There is a significant association between components of subjective trainee satisfaction and patient mortality within the United Kingdom. Further investigation to examine these relationships, perhaps to target intervention, may prevent avoidable patient harm.

Enhanced faculty development: using the GMC survey to run a trainer development workshop

AimsTo investigate whether the General Medical Council (GMC) National Training Surveys (NTS) can be analysed to create a trainer development workshop that improves postgraduate training.BackgroundAs part of its role in quality assurance of medical training, the GMC conducts an annual survey of trainers and trainees. The Trainer survey, part of the NTS, consists of 47 questions which are grouped into 11 indicators of quality. At Surrey and Borders Partnership NHS Foundation Trust, we were keen to use the comprehensive data in the NTS to improve training. We analysed each question to create a workshop to engage trainers in discussion about improving the experiences of trainers and trainees.MethodOur analysis of the NTS used data from the online reporting tool to calculate the scores that were obtained for each question in the 2018 NTS. A question was discussed at the workshop if it performed poorly relative to other questions in the indicator; to provide useful information; or to clarify ambiguity. Indicators where interesting comparisons can be drawn between the views of trainers and trainees were also discussed. The 90-minute workshop was led by the Leadership and Education Fellow and Director of Medical Education. Attendees were subsequently sent an online survey.ResultThe workshop consisted of an introduction to the NTS; group discussion on which indicators were felt to be important, good- or poor-performing; discussion of specific questions; and a review of feedback from trainees.12 questions and 3 indicators (Handover, Supportive environment, Rota design) were discussed. 11 questions were chosen for poor performance, which sought to contextualise the results within the experience of attendees. 8 questions were chosen to provide information, such as resources and current initiatives. 3 were chosen to clarify ambiguity. Many questions met several criteria.17 attendees responded to the online survey. 64.7% agreed or strongly agreed that the NTS asks questions that are important for them. 76.5% agreed or strongly agreed that the NTS can be used to improve the trainer experience.In the subsequent NTS, there was an improvement in 9/11 indicators in the Trainer Survey, with four green flags denoting performance in the top quartile of trusts nationally.ConclusionThe NTS can be used to structure a workshop that trainers feel can improve their experience. Our strategy demonstrates the value of analysing the NTS dataset intelligently to engage trainers in improving training.

1012 Surgical Trainee Satisfaction Variations with Seniority and Region: An Evaluation of General Medical Council National Training Survey

Abstract Aim The General Medical Council (GMC) National Training Survey invites all doctors in training and this study evaluates satisfaction in surgical training and variations with speciality, seniority, and training region. Method All survey results were obtained from the GMC website. Responses of trainees, ranging from foundation training to registrar, were collected and categorised by speciality, training stage and location. Results 9465 surgical trainees completed the study in 2019. The highest indicators were Educational Supervision (97.68), Clinical Supervision (87.42) and Clinical Supervision (out of hours) (87.28). The lowest were Workload (44.60), Rota Design (56.00) and Local Teaching (59.31). Highest and lowest ranking specialities were oral and maxillofacial surgery (84.25) and vascular surgery (73.95). Satisfaction varied significantly across training stages, with speciality trainees highest (82.58) overall and foundation year 1 lowest (70.03). London scored highest (77.95) and Northern Ireland, Scotland and Wales collectively scored 77.13. Within England, South England ranked highest in five specialities but only orthopaedics and neurosurgery showed significant national variations. Conclusions Our data show variations in training satisfaction across many training cohorts. Satisfaction increases with surgeon seniority. Trainers and educational boards should target interventions to improve the quality of training for all grades of trainees and ensure appropriate curriculum coverage and address specific concerns.

To bed or not to bed: the sleep question?

BackgroundSleep deprivation and fatigue from long-shift work impacts doctors' personal safety, inhibits cognitive performance and risks clinical error. The aim of this study was to assess the sleep quality of...

Is there a national variation in cardiothoracic trainees' satisfaction? Evaluation of the United Kingdom General Medical Council national training surveys.

The national training surveys was first started in 2006, with an aim to determine the quality of the national training standard. All trainees working in a General Medical Council approved training post are required to complete the survey. We aimed to evaluate cardiothoracic trainees' satisfaction and determine whether there is variation in the United Kingdom. The national training survey report in cardiothoracic surgery from 2012 to 2019 was obtained from the General Medical Council website. The cardiothoracic centers were divided based on their geographic locations. Comparisons in all 18 indicators in the national training surveys report were made between the four counties (national) and four local education training boards (LETBs) in England (Regional). Centers with less than 4 years of data were excluded from this study. Thirty-three cardiothoracic centers are included in this study The top three areas that trainees are most satisfied are clinical supervision (out of hours) (91.65), clinical supervision (90.65), and educational supervision (88.27). On the other hand, trainees are less satisfying with the handover (62.63), rota design (61.91), and workload (45.07). It is worth noting that workload is the only area of less than 60%. In addition, there is no national variation in all 18 indicators CONCLUSION: Our data suggested that there is no difference in overall trainee satisfaction in the United Kingdom. However, there are differences in various indicators between England and the three other nations. Individual hospital should reflect on trainees' evaluation on the national training surveys report and improve on specific areas if deemed unsatisfactory.

Taking back control: a better deal for junior doctor engagement in rota design using e-Delphi and Assignment Problem Algorithm.

The British Medical Association and NHS Employers published a guide to good rostering practice, which emphasised the need for a collaborative approach, in which the views of junior doctors should be taken into account when designing a rota.1 The guidance, however, did not provide tools for promoting junior doctor engagement in this process. Lack of structured consultation strategy and low level of satisfaction contribute to the prevailing narrative that junior doctor's input is undervalued, resulting in ’a crisis in junior doctor engagement’.2 This case study presents the utility of e-Delphi exercise for consultation and Assignment Problem Algorithm to improve satisfaction by matching work patterns to doctors’ preferences. Following review of workload and medical staffing, Medway Maritime Hospital undertook a redesign of its medical registrar (MR) rota in October 2018. With support from the Medical Staffing Department, a new rota was drafted by …

Taking back control: a better deal for junior doctor engagement in rota design using e-Delphi and Assignment Problem Algorithm

The British Medical Association and NHS Employers published a guide to good rostering practice, which emphasised the need for a collaborative approach, in which the views of junior doctors should be taken into account when designing a rota.1 The guidance, however, did not provide tools for promoting junior doctor engagement in this process. Lack of structured consultation strategy and low level of satisfaction contribute to the prevailing narrative that junior doctor's input is undervalued, resulting in ’a crisis in junior doctor engagement’.2 This case study presents the utility of e-Delphi exercise for consultation and Assignment Problem Algorithm to improve satisfaction by matching work patterns to doctors’ preferences. Following review of workload and medical staffing, Medway Maritime Hospital undertook a redesign of its medical registrar (MR) rota in October 2018. With support from the Medical Staffing Department, a new rota was drafted by …

Can a tool developed for industry be used to assess fatigue risk in medical rotas? A pilot study of foundation doctors’ rotas in a tertiary centre

ObjectivesTo determine the feasibility and ease of using a pre-existing health and safety executive fatigue risk calculator to assess doctors’ rotas.DesignObservational.SettingA large tertiary-referral teaching hospital in the UK.Participants95 anonymised foundation...

A qualitative investigation of Foundation Year 2 doctors’ views on the European Working Time Directive

PURPOSE - The purpose of this paper is to examine the personal views and experiences of Foundation Year 2 doctors operating under the European Working Time Directive (EWTD). DESIGN/METHODOLOGY/APPROACH - In total, 36 Foundation Year 2 doctors from a single UK-based Deanery participated in this semistructured interview study. FINDINGS - Findings indicated that Foundation doctors typically welcomed a regulation of working hours, but reported frustration at the manner in which the Directive had been implemented. Participants reported concerns at reducing hours by removing out-of-hours working in order to meet EWTD requirements. Out-of-hours shifts were highly valued owing to their increased opportunities for autonomous clinical decision making. By contrast, day-shifts were regarded as heavily administrative in nature and were perceived as service provision. Foundation doctors discussed the unique nature of the out-of-hours working period which appeared to provide specific learning opportunities as doctors draw on time management and prioritisation skills. ORIGINALITY/VALUE - Given the challenges the EWTD presents, careful rota planning is essential. First, the authors would encourage the restructuring of day-shift work to provide a greater emphasis on hands-on skills experience in a supportive, supervised environment. Second, where possible, Foundation doctors might benefit from the opportunity to engage in some out-of-hours working, such as with multi-professional "Hospital at Night" teams. Third, the authors would encourage junior doctor involvement in rota design and planning which may increase their perceived autonomy and therefore buy-in of working practices.

Hospitals should increase consultant presence and reduce elective work at August trainee changeover

Hospitals and deaneries should make sure that enough consultants are available and should reduce the amount of elective work when junior doctors collectively move jobs each August, the chief medical officers of England, Wales, Scotland, and Northern Ireland have recommended. Hospitals and deaneries should also be more flexible in rota design during this period and provide departmental inductions for trainees as well as corporate health and safety inductions, as per recommendations put forward by the Academy of Medical Royal Colleges. Since the introduction of Modernising Medical Careers in 2007 most grades of junior doctor change jobs in the first week in August. This approach has been associated with a 6% rise in mortality among patients admitted on the first Wednesday in August …

Workforce planning and flexible working in the NHS of the future

Within a few years, predicted to be between 2017 and 2022, the majority of the medical workforce will be female. 2 Already in 2010 there were 46% more female foundation year one (F1) doctors than male. 2 The age distribution of the current workforce has also altered significantly, with the recent rise in output from medical schools, with many of today’s workforce yet to start their families. Thus, in future, even traditionally male-dominated intensive hospital specialities with unpredictable out-ofhours work will have to adapt to ensure they can attract and retain enough of the future predominantly female workforce to maintain their out-of-hours cover at a safe and sustainable level in European Working Time Directive (EWTD) compliant rotas. Of course, the need for flexible and variable ways of working at different career stages is equally important for men and women, with family commitments or childless – we are all striving for a manageable work-life balance which enables us to keep ourselves fit and care for children or elderly relatives. Many of us have already experienced great changes in our working patterns, from the old days of working one night in every two on call to current EWTD limited rotas. We are all acutely aware of the need for improved working patterns that are more family friendly – essential if the National Health Service (NHS) is to retain doctors with family commitments, and ensure that future generations are able to contribute to the NHS, often at variable levels at different stages, throughout their whole career. In order to make certain that the UK medical school intake, currently about 60% women, translates into a motivated workforce who have a free choice of flexible, variable and individualised career pathways, we need to ensure that such career options are more easily and widely available than at present – while operating within the increasing financial constraints that are already in place. We have seen these workforce changes coming for some time and several reports have addressed possible solutions: The 2008 Medical Women’s Federation Making part time work report 3 recommended that ‘employers and Royal Colleges should work together to ensure that rota design can routinely incorporate part-time workers, and medical directors should support and promote innovative job design’. Baroness Deech in 2009 recommended that the medical workforce planning apparatus took account of the increasing number of women in the medical profession; her report stated that ‘NHS Medical Education England and the Centre for Workforce Intelligence should ensure that workforce models for the future clearly delineate the effect of a rising number of women in the workforce so that appropriate advice for the workforce planning apparatus can be given.’ 4

390 days, 7 hours, 9 minutes and counting ...

I have had the opportunity over the past few weeks to attend two national events that explored the implications of the implementation of the next stage of the European Working Time Directive (EWTD) when the maximum number of hours worked by doctors in training will be reduced from 56 h currently to 48 h. The previous reduction in junior doctors' hours in 2004 to 58 h/week was largely achieved by means of a number of initiatives that included employment of more doctors, radical rota design and service reconfiguration. However, the most significant issue from the point of view of doctors in training was the almost universal implementation of shifts. While this change in working pattern did enable compliance with the Directive, there were other consequences. The first of these was the sudden …

Covering ENT out of hours: how confident are senior house officers?

The implementation of the European working time directive has led to an increase in cross-speciality out-of-hours cover. This survey illustrates ENT out-of-hours cover arrangements and assesses the implications for senior house officers (SHOs) responsible for managing emergencies. A telephone survey of 100 ENT departments was conducted, asking the on-call SHO about departmental structure, on-call rota design, their previous ENT experience, access to SHO training and their confidence in managing emergencies. 44 per cent of departments used only ENT SHOs on the on-call rota. 73 per cent always had an ENT middle grade on call. In 60 per cent of hospitals, the ENT consultant was sometimes on call with only a non-ENT SHO. At the time of the study, 5 per cent of SHOs had no ENT experience, no access to training, were not confident in managing simple emergencies and were on-call without middle-grade cover. The current junior on-call structure for ENT has implications for patient management.

Rota design

Rota design

Restricted feeding and human intestinal plasma cell development.

Small intestinal mucosa from 129 necropsies and 15 surgical specimens from infants aged from birth to 21 months was examined for the presence of cells containing IgA, IgM, and IgG using the PAP immunoperoxidase technique. Immunoglobulin containing cells were nearly always absent in infants under 1 week of age but occurred in the second week of life in infants who had had milk feeds. At this time, IgM containing cells were predominant, but IgA containing cells were more numerous by the sixth week. IgG containing cells were generally sparse. Parenterally fed infants who had received little or no intestinal milk showed significantly fewer immunoglobulin containing cells than those who had been fed normally, irrespective of gestation. Lack of stimulation by food and bacterial antigens may contribute to immunoglobulin containing cells failing to occur in these parenterally fed neonates.