February 28, 2022

HOMERuN Collaborative: Jeopardy Policies in Hospital Medicine

The Hospital Medicine Reengineering Network (HOMERuN) is a national network of Hospital Medicine investigators at 12 academic medical centers (AMCs) and 50 affiliated sites.

Organizers and Facilitators: Kirsten Kangelaris, Gopi Astik, Luci Leykum, Angela Keniston, Annie Linker, Matthew Sakumoto, Shradha Kulkarni, Marisha Burden, Jeffrey Schnipper, Andy Auerbach, and the Workforce Planning Working Group

Challenges Faced Systems of Jeopardy policies vary considerably to meet local staffing needs Several sites staff 2 or more layers of jeopardy (size dependent, often increased in COVID); nearly all sites have some form of jeopardy, though not all 24 hours a day. The alternative is often a moonlighting scramble. Some institutions redistribute workload among those working prior to activating jeopardy. Jeopardy uses: Sick call and surge call are often treated differently in terms of planning, compensation, and staffing. Few sites receive paid “sick days” as part of their policy. At most sites the jeopardy days used for sick days are “paid back” by person using them, generally by signing up for moonlighting shifts; another rare approach is that the person covering jeopardy is uncompensated for some shifts to avoid need to have a payback system. Variability in number of weeks required on jeopardy coverage across institutions. Duration of jeopardy blocks are variable across sites (from 1-2 days to over 10 consecutive days). Jeopardy compensation varies from uncompensated to the moonlighting rate. Some sites compensate at a reduced rate for time on jeopardy call if not called in, other sites view jeopardy time as non-compensated “citizenship.”  For those on quarantine or with childcare issues, some sites shuffled duties for faculty to cover MOD which can be conducted remotely. A common sentiment across many sites is that jeopardy is “obligatory” and a source of job dissatisfaction: “Everybody hates it,” “people get angry when they are called in” were representative quotes.

"People hate jeopardy. It’s been one of our main pressures for trying to get adequate staffing and I think has been a huge factor in burnout."

Developing Jeopardy systems that are perceived as fair, equitable, and tolerable is a common challenge across institutions Clinical FTE is often considered in amount and type of jeopardy covered in consideration of equity (though at some sites more clinical FTE has more jeopardy, which is viewed as inequitable by some). There are widespread concerns about overuse of jeopardy and/or inappropriate uses of jeopardy. For example, calling jeopardy for childcare needs is a point of contention in many groups. Approaches to minimize overuse vary and include requiring payback for shifts called out or having an operational leader in charge of the “appropriateness” of the reason for calling jeopardy. Payback was viewed by some as equitable because it is agnostic of reason needing to call out. Everyone “owes their full amount of clinical time.” Concerns about patient care discontinuity with the shorter blocks of jeopardy and faculty burnout with longer blocks. At several sites, more senior faculty not required to cover certain shifts (e.g., nights, direct care) or “grandfathered” out of jeopardy leading to perceived inequities. The uncertainty of being called in on jeopardy was a major cited source of intolerability — some institutions pay for time on call for jeopardy to ameliorate this. Considering the burden of jeopardy based on days by funding a “backup rate” for weekend and holiday days whereas no additional pay on weekdays. Weeks of jeopardy call are a portion of the clinical FTE in some sites (e.g., 1/10th normal clinical FTE for the same time).

"I would like us to stop staffing for our averages and start staffing for our maximums, understanding that we are going to be underutilized on most days, but that we would be able to absorb (within our system) the ability to care for that number of patients without having to use jeopardy. And the same even for sick leave, to absorb, to have roles in the hospital that are able to flex."

Best Practices and Proposed Changes Normalize the need for occasional sick days: Covered sick pay or PTO to support use of jeopardy without having to pay back. Backup childcare for children of health care workers for emergency situations. Remote work options if needed (e.g., MOD can be done from home). Establish guidelines on appropriate jeopardy use (e.g., childcare needs); this will need to be balanced with clinician autonomy and privacy protections to build a culture that supports people to call out when they need it. Eliminate uncertainty for those on jeopardy by having them come in to work regardless of need (with compensation) versus compensate standby time on jeopardy even if not called in to work shifts. Ensure that jeopardy burden is equitably staffed: Minimize “grandfathering” out by seniority, prorate time by clinical FTE versus equal coverage by all. Clinical volumes anticipated a few months in advance can prevent last minute use of jeopardy and prioritize moonlighters (e.g., retainer models), staff for maximum rather than minimum in patient volumes.

Key Takeaways Variability in systems across institutions: The number of layers of jeopardy, amount of weeks of jeopardy per year, who covers it and compensation varies widely. Jeopardy is widely viewed an obligatory part of the job that is a common source of dissatisfaction.  Promote culture to support those needing jeopardy: Childcare coverage, PTO for sick days, flexibility in duties, e.g., remote duties, nonclinical duties when overstaffed, establish guidelines for appropriate use of jeopardy call but minimize individual scrutiny of use. Compensate and improve tolerability and equitability of jeopardy: Address uncertainty, compensate for standby and shifts, ensure that jeopardy burden is equitably staffed and covered; minimize use by incentivizing moonlighting (retainers), staff for maximums to absorb volume.

Become a Site for the RELIANCE Study: Roflumilast or Azithromycin to Prevent COPD Exacerbations

Purpose of RELIANCE: Both roflumilast and azithromycin have been shown to reduce the risk of COPD exacerbations compared to placebo. However, there has not been a head-to-head comparison of these two FDA-approved medications. RELIANCE is intended to support hospital efforts to reduce the risk of all-cause hospitalization and premature deaths in individuals with COPD.  RELIANCE is Seeking Community-Based Hospitalists: Hospitalists are critical in the development of post-discharge care plans and medications used by people with COPD. We found from preliminary work that identification of people with COPD while they are hospitalized is an efficient recruitment method for RELIANCE. Benefits and Compensation: $500/year honorarium for being a community partner (paid after registration) plus $200 per patient enrolled. Option to participate in clinical roundtables with COPD thought leaders. Contribute topic ideas for future grant proposals or publications related to hospitalist care. Community Partners will not be investigators / authors, but will be acknowledged in the RELIANCE publication.  Please reach out to Tiffany.Lee@ucsf.edu if you are interested in participating and would like more information about RELIANCE.

Our next meeting will be on March 11, 2022.

Check out the HOMERuN COVID-19 Knowledge Base for more details. If you would like to join the HOMERuN Collaborative calls, please reach out to Tiffany.Lee@ucsf.edu.