Key words gynecology - EWTD - doctors - shift model - university hospital
Schlüsselwörter Frauenheilkunde - Ärzte - Arbeitszeitmodell - Universitätsklinik
Background
Working times for doctors at hospitals are an ongoing topic of debate. In Germany,
weekly working hours of more than 50–60 h were reported [1 ], [2 ], whereas in the US weekly working hours
were restricted to 80 h for residents [3 ], [4 ]. The trend towards more female doctors and a general
change in the attitude of younger doctors concerning their work-life-balance [5 ], [6 ] challenges the working
patterns in hospitals. University hospitals are especially concerned as they have
to
balance the three aspects of patient care, research, and teaching. In the field of
Gynaecology and Obstetrics significantly longer daily working times at German
university hospitals as compared to other hospitals were observed [7 ], reaching an average of 10 h/day.
The strike for better working conditions of German doctors working at university
hospitals in spring 2006 led to a new collective wage agreement (TV-Ä university
hospitals) becoming effective on November 1st, 2006. Similar wage agreements were
found for other hospitals in Germany, too. Two months later, the regulations of the
European Working Time Directive (EWTD) [8 ] became
mandatory in Germany. Together, both conditions had the following impact on working
time for hospital doctors at university hospitals: 1) weekly working time of 42
hours for a full time employee, 2) average weekly working time limit (AWTL) between
42 and 48 hours, 3) individual agreement to increase AWTL up to 54 hours under
certain conditions (so called opt-out), 4) maximum daily working time of 10 hours
(10 h-dwt), and 5) extension of this limit up to 12 hours under certain
conditions.
The Executive Board of the University Hospital Tübingen therefore decided to design
new shift models for doctors with the aim to achieve both, compliance to the EWTD
and stability of labour costs. In this report we will answer the question if these
two targets could be reached on a medium term perspective.
Methods
In collaboration with the head of the University Hospital for Gynaecology and
Obstetrics (UHGO) as well as the responsible senior and junior doctors for staffing
and shift planning, a project team considered carefully possible weaknesses of the
pre-existing shift model in 2007. This was also done in the university hospitals for
General, Visceral, and Transplantation Surgery, Neurosurgery and Anaesthesiology.
All four were considered as pilot departments before other departments became
involved. A detailed description of the methodology used can be found elsewhere
[9 ].
The pre-existing model was characterized by a single shift for all doctors lasting
from 7:30 to 16:45 h during the week (ending 15:00 h on Fridays) followed by three
on-call shifts (one senior and two junior doctors). On weekends the 24 h on-call
shifts had full shift segments between 8:00–10:00 h for ward rounds. The delivery
rooms were covered with three shifts consecutively throughout the week.
The UHGO has its proper building with 107 beds, 6 operating theatres (4 for
inpatients, one for outpatients, and one for obstetrics), 6 delivery rooms, and an
elaborated structure of outpatient clinics. Per year, approximately 8300 inpatients
and 19 500 outpatients are being treated, 2800 babies delivered, and the
specialisation in gynaeco-oncology results in 700 primary mamma carcinomas treated.
The designed shift model is therefore rather complex and the result is shown in
[Fig. 1 ]. The main changes were as follows:
Fig. 1 New shift model for doctors in the University Hospital of
Gynaecology and Obstetrics Tübingen, Germany becoming effective in April 2008.
BD: on-call duty in house, RD: on-call duty at home (dotted boxes). Orange:
service hours. Blue: shift of junior doctors (AssA). Green: shifts of
experienced doctors (FA). Yellow: Shifts of senior doctors (OA). IVF: in vitro
fertilization.
12 hour shifts
The pre-existing three shift model for the delivery rooms was changed to a two
shift model on weekends and holidays with a shift length of 12 h 30 min.
including breaks. This allowed a reduction of the frequency of weekend shifts as
foreseen in § 7 section 3 TV-Ä university hospitals. In some very specialised
outpatient clinics and on one gynaecology ward long shifts lasting 11 h 30 min
and 12 h 0 min, respectively, were introduced, too.
Late shift
For the gynaecology wards a late shift (12:30–21:00 h) was established that was
run by one senior and two junior doctors to allow a prolonged operating theatre
time until 20:30 h. This prolongation of the operating theatre hours was an
adaptation to the pre-existing reality. Due to the high demand for complex
operations there was a regular excess of the former operating theatre hours up
to 3–4 hours, leading to violations of the former working times.
Adapted shift lengths
For the wards and the outpatient clinics adapted shift lengths between 8.4 h and
10 h plus breaks were introduced. On weekends a full shift from 9:30–18:00 h was
established to cover the time with the heaviest workload, followed by an on-call
shift both of which were run by one senior and one junior doctor.
Based on these modifications all doctors could be asked whether they wanted to
work more than 48 hours/week (so called opt-out). The survey was done after
introduction of the new shift model. The number of doctors needed to run the new
shift model was calculated a priori with a supposed average of 50 h/week per
doctor. Due to the prolonged operating theatre hours and the new operating
theatre for outpatients it was assumed that more patients could be treated and
thus financing the extra staff should be achievable.
Research and especially teaching are integrated elements within the shift model.
For research, we reduced the number of physicians (i.e. the academic medical
staff) a priori by 10 % reflecting the 10 % proportion of funding from the
medical faculty for academic research to the overall budget of the University
Hospital of Gynaecology and Obstetrics. This means that the shift model reflects
the time needed for patient treatment and teaching and in part, research
activities.
Statistics: AWTL, 10 h-dwt, and opt-out data are reported as numbers of subjects
with denominators and percentages. Monthly staff costs of both junior and senior
doctors before and after implementation of the new shift model, and percentages
of surpassed 10 h daily working time in 2009, 2010, and 2011 were evaluated by
analysis of variance (ANOVA). When ANOVA indicated an overall difference,
multiple comparisons were performed using the Tukey-Kramer method. To correct
for the planned increase in surgical capacity, the costs were calculated
relative to the case-weights gained by the department within the German
Diagnosis Related Groups (DRG) system. Case-weights are a typical element of a
DRG system as they represent the economic severity of an inpatient case. The
DRG-catalogue lists a specific case-weight for every DRG ranging for example in
2011 from 0.502 for an uncomplicated vaginal delivery (DRG O60D) to 7.088 for a
radical vulvectomy (DRG N01A). Multiplying the case-weight with the base-rate
(2985.50 Euro in 2011) one gets the bill the hospital can claim the health
insurance company of the patient. Therefore, the more patients or the more
complex patients were treated within the UHGO, the higher were the earnings to
compensate e.g. for higher staffing costs. For comparison of possible effects of
the new shift models, a control group was used consisting of the departments of
Neurology, Radiooncology, Ophthalmology, Ear-, Nose-, and Throat- (ENT), and
Dermatology whose shift models were unaltered between 2007 and 2011. The
statistical analysis was done with JMP 8.0.2 (SAS Institute, Cary, NC).
Results
A calculated number of 53.1 FTE-doctors were necessary to cover all services of the
UHGO after introduction of the new shift model. However, not all increase in staff
was attributable to the regulations of the EWTD as an additional operating theatre
for day surgery as well as prolonged shifts to run one operating theatre until
20:30 h had to be covered with staff, too. In 2007 44.7 FTE-doctors were working in
the UHGO, increasing in 2009 to a mean of 52.5 FTE-doctors, 50.8 in 2010, and 54.5
in 2011. Concurrently, 17 % (9/54) of doctors were working part-time in 2009, rising
to 23 % (15/66) in 2010, and to 25 % (15/61) in 2011.
Opt-out
In 2009 75 % (30/40) of doctors voted for opt-out, 74 % (39/53) did so in 2010,
and 61 % (30/49) voted for opt-out in 2011.
AWTL
In 2009 36 out of 40 doctors (90 %) were able to respect their AWTL rising to
51/53 (96 %) in 2010, and 48/49 (98 %) in 2011, as shown in [Fig. 2 ].
Fig. 2 Average weekly working hours of the doctors working in the
University Hospital of Gynaecology and Obstetrics Tübingen, Germany, per
31.12.2011. Light grey boxes: limits with opt-out, dark grey boxes: limits
without opt-out; part-time employees consecutively within the dotted frames.
Adherence to the individual limits in all but one case (no. 30).
10 h-dwt
The proportions of shifts that surpassed the 10 h-threshold in relation to all
shifts with a maximum length of ten hours were 7.4 % (524 out of 7112) in 2009,
1.2 % (103 out of 8241) in 2010, and 2.6 % (238 out of 9092) in 2011 ([Fig. 3 ]), with significant differences between 2009
and 2010 as well as 2009 and 2011 (p < 0.001, Tukey-Kramer), and between 2010
and 2011 (p = 0.02, Tukey-Kramer post-hoc test).
Fig. 3 Percentage of surpassed 10 h daily working time (10 h-dwt) in
relation to the total of shifts with a length up to 10 h for each month of
the years 2009 to 2011 (after implementation of the new shift model).
Significant decline from 2009 to both, 2010 and 2011. Significant increase
from 2010 to 2011.
Staff expenditures
As shown in [Fig. 4 ] the average monthly staff
expenditures per case-weight for the years 2007, 2009, 2010, and 2011 were
593.04 Euro, 643.95 Euro, 603.30 Euro, and 677.79 Euro, respectively. There was
no statistically significant difference between the years 2009 or 2010 vs. 2007,
yet 2011 was significantly more expensive than 2007 (p = 0.02, Tukey-Kramer). In
absolute terms, staff expenditures for doctors rose from a mean of 384 136.20
Euro per month in 2007 to 476 899.20 Euro in 2009, 450 069.60 Euro in 2010, and
504 193.10 in 2011. This represents a 31.3 % raw increase from 2007 to 2011
(27.3 % when corrected for the four percent increase in tariffs during that
time). Likewise, performance increased from a mean of 650.3596 case-weight
points per month in 2007 to 746.0169 in 2009, 750.5321 in 2010, and 752.5701 in
2011 (15.7 % increase 2007 to 2011).
Fig. 4 Monthly staff expenditures per caseweight point before (2007)
and after the implementation of the new shift model (2009–2011) in the
University Hospital of Gynaecology and Obstetrics Tübingen. Only 2011 was
significantly more expensive as compared to 2007 (p = 0.02), whereas 2010 as
well as 2009 vs. 2007 were not.
In contrast, the control group had staff expenditures per case-weight of 687.74
Euro in 2007, 710.87 Euro in 2009, 731.69 Euro in 2010, and 796.78 Euro in 2011,
the differences being non-significant (p = 0.34).
Discussion
With this study we have shown for the first time how a German UHGO was able to comply
with the regulations of the EWTD and the subsequent wage agreement. The increase of
7.8 FTE (2007 vs. 2009) in medical staff required to run the new shift model was
unambiguous, yet the compliance to AWTL as well as 10 h-dwt were already very good
in the first full year after implementation (2009: 90 and 92.6 %, respectively) and
could even be improved over the years (2011: 98 and 97.4 %, respectively). As
pointed out the increase in staff was in a large part attributable to extended
operating theatre hours and a new day surgery theatre.
The resulting increase in patients being treated along with rising case-weights
during the observation period have kept the ratio of staffing costs for doctors to
case-weight points stable. When comparing the staffing costs per case-weight point
of the UHGO with the internal control group, no differences were evident. This
effect has also been shown for the University Hospital for Neurosurgery in Tübingen
[10 ] indicating that the strategy of adapting the new
shift models to the needs of operating hours for patient care and thus allowing a
higher turnover was successful.
In the UHGO, only the year 2011 was strikingly more expensive than the previous
period probably because the average number of doctors in 2011 (54.5 FTE) was highest
of all post-implementation years and, on the contrary, the year-to-year increase in
case-weight points per month was only moderate (2.0380). The estimated 53.1 FTE
required to run the new shift model seemed to be rather well confirmed by the
evaluation. Interestingly, the number of opt-out votes declined between 2009 and
2011 from 75 to 61 %, a phenomenon that could also be observed in the Department of
Anaesthesiology of the University Hospital Tübingen [11 ].
An explanation might be the increasing wish to limit weekly working hours to a
subjectively acceptable level. When looking at the rising proportion of doctors
working in part time (17 % in 2009 to 25 % in 2011) this becomes very obvious as
eleven out of 19 of the non opt-out voters were working in part time in 2011 ([Fig. 2 ]). However, so far no investigation of doctorsʼ
motivation to opt-out has been performed in Germany. In the context of decreasing
opt-out votes and rising proportions of doctors working in a part-time scheme it is
remarkable that the compliance to the regulations of the ETWD has again been
increased in the UHGO of Tübingen. However, both effects may have also influenced
the relatively pronounced increase in staff costs per case-weight point in 2011
because more doctors (persons) were employed thus rising staffing costs
disproportionately.
As shown elsewhere shift models with more than only one single shift seemed to be
more effective in preventing violations of the 10 h-dwt [9 ] which has now been demonstrated over a three-year post-implementation
period.
However, there are several study limitations. Firstly, in this exploratory study no
gynaecology and obstetric internal control group was available. The pool of five
other independent Departments (Ear-, Nose-, and Throat-, Dermatology, Radiooncology,
Neurology and Ophthalmology) with so far no alteration of shift models should
nevertheless serve as a reasonable control group. Secondly, this is only a single
site observation and one might speculate whether the results are reproducible in
external UHGO departments. Thirdly, we can only present cost and revenue data on a
before and after basis. The former paper-based documentation of individual working
times in the pre-implementation period made it impossible to report on AWTD and
10 h-dwt by 2007. Fourthly, there were several highly experienced senior
gynaecologists who were employed with so called off-tariff contracts. In Germany,
the EWTD applies in general for all doctors that are employed by a hospital and not
only for those in post-graduate training. It is sometimes difficult for highly
specialised senior doctors to comply with the working time regulations, especially
in a university hospital setting where working tasks cover patient care, research,
and studentsʼ education. We can thus only speculate how their AWTL and 10 h-dwt were
respected.
In fact, we are now able to present robust administrative data that are neither based
on surveys nor on subjective descriptions allowing us to improve and adapt the shift
model to changing needs of both, doctors and hospital alike. The methodology
presented here can serve as a basis for interventional studies in other
hospitals.
The concern of decreasing caseloads and therefore less training of residents in
Gynaecology and Obstetrics due to EWTD regulations was expressed several times.
Comparing the caseloads before and after implementation of the 80 h-workweek, Short
et al. found no differences for gynaecological cases, yet obstetric cases in
residentsʼ training declined after implementation [12 ].
Smith found no negative effects on resident technical expertise [13 ]. We did so far not analyse possible changes in
caseload for residents in Tübingen or control for prolongation of residency
programmes but this is impending. At present, we have no hint that the new shift
model had a negative impact on these issues in our institution.
We hope that this report adds some more objective information to the discussion
whether and how the EWTD regulations do affect clinicians and hospitals alike.
Practical implications
Adherence to the EWTD and the regulations of the collective wage agreement
for doctors working at German university hospitals can be achieved by
carefully adapting new shift models to the needs of both, patient care and
doctors working at an UHGO.
The necessary increase in doctors and thus staffing costs can be balanced by
an increased patient turnover resulting in more revenues. That way, the
proportion of staff costs per case-weight point in the German DRG-system
remains stable.
Acknowledgement
We would like to thank all the members of the project team that designed and
implemented the new shift model at UHGO, namely Mr. Rau, Mrs. Gesche, Mrs. Hack, Dr.
Wilke, Dr. Dehner, Mr. Wütz-Botsch, Dr. Abele, Dr. Rothmund, Dr. Hübner, Dr.
Hoffmann and Dr. Walter.
