The Incubator
The Incubator
🟠CHNC 2023 COVERAGE - Chatting about staffing models with the WiN group
Ever wondered about the complexity behind neonatology staffing models? Grasp the chance to learn from our esteemed guests - Kerri Machut, Steve Olsen, Milenka Cuevas-Guaman, and Christine Bishop - as they unveil the secrets learned from their intensive workshop on this critical subject. Our conversation takes a deep dive into the pressing matter of fostering transparency and formulating sustainable neonatologist staffing models. Together, we reveal the calculation conundrum of clinical FTEs, the puzzling discrepancy between neonatology and other aligned fields, and the stark variation in how pediatric work hours are assessed. Additionally, we grapple with the methodological challenges of accounting for non-clinical duties in determining FTEs.
As always, feel free to send us questions, comments, or suggestions to our email: nicupodcast@gmail.com. You can also contact the show through Instagram or Twitter, @nicupodcast. Or contact Ben and Daphna directly via their Twitter profiles: @drnicu and @doctordaphnamd. The papers discussed in today's episode are listed and timestamped on the webpage linked below.
Enjoy!
Are we on? Okay, all right. Well, welcome back everybody. We've got a big group here to discuss the kind of straight off, hot off the press workshop, improving transparency and developing sustainable neonatologist staffing models. This is a very hot topic, obviously, in the community, so you guys are coming from all over the country. I'll let you introduce yourselves and tell us where you're coming from, and then we'd really just want to hear about the lessons learned.
Speaker 2:Carrie McHugh Laurie children's Chicago.
Speaker 3:Chris Bishop, I'm a children's hospital Pittsburgh.
Speaker 4:I'm from Houston, texas, children's.
Speaker 5:And Steve Olson from Children's Mercy, kansas City.
Speaker 1:Okay, well, you know this has been a buzz, actually, I'd say I mean in the last five years, but certainly, I think, through the pandemic, I think people are really trying to reevaluate what does work life balance look for them and what does work life balance look for like for a group or practice or a unit? So every day, I feel like every week, I feel like somebody's asking the question on social media or through, you know, interactive platforms. So what did you guys tackle in the workshop today?
Speaker 2:Well, we tried to do several things, I think, when we think about staffing and the issues that are really with current state, a lot of it is around transparency, so that was the first thing that we really tried to address.
Speaker 2:There are a few published models out there. However, there's a lot of variability. That's the other big threat to this, and so Steve and I both walked through our center's examples of how we kind of plan and strategize to handle staffing and when we talk about clinical FTEs or full-time equivalents. So that was kind of the first part of the workshop. Everybody had to exercise to be able to calculate their own FTE using the Lurie and Mercy models as examples.
Speaker 1:So can you tell us a little bit about what that variability looks like? You know you were saying the current state, so what is the situation people are finding themselves in?
Speaker 2:I think with variability there's a lot of different types of variability too. So I think center to center people are thinking about this in a lot of different ways, some of them more officially, some of them less officially. I think different centers calculate clinical time in different ways. Some people use an hours model, some people use a weeks per year model. Some people do count call into their clinical time, some people don't. Some people adjust for different factors. So there's a lot of that that happens and it really hand-purses us as a field across the country because we can't advocate collectively for some of the changes that we're hoping to. There's also variability in how things are done between neonatology and other aligned fields so critical care, cardiac intensivist, emergency medicine. Even how those fields work through staffing and what they project as their hours or clinical needs are actually often quite variable from how neonatology is expected to work.
Speaker 1:And so some of that is that, say, an FTE and emergency medicine may be significantly less hours than an FTE and neonatology 28 to 32 hours per week.
Speaker 2:Clinical hours is the standard for emergency medicine.
Speaker 1:For a full FTE? Correct, okay. And what about our colleagues?
Speaker 3:in the PICU. Thank you, yeah, that's well, that's. It goes back to this very variable and some pick you belong to departments of pediatrics, some belong to other departments, but overall it seems like it is less and it's with different offsets and call models and things that are that seem to be a little bit more amenable to sustainability and work-life balance.
Speaker 2:There was an Amspidek paper that came out earlier this year I think Klein was the lead author and journal journal pediatrics that did look at the median hours. And so for a point eight, clinical FTE which is typically standard for neonatology it was over 1600. And I believe for those other fields it was typically less than it was like in the 12 to 1400 hour per year range.
Speaker 1:And I'm recalling that there's often a big difference between the pediatric work hours and our adult colleagues. Why do you guys think that is?
Speaker 3:Money. The honest is reimbursed. There are a lot, it's multifactorial, clearly, but it's a lot of. It has to do with reimbursement how reimbursement is set up and how how work is valued and paid for.
Speaker 4:I mean, we still, you know pediatrics still seen as small because they're kids, yeah, and that even goes farther to neonatology. You know, your babies like even at some point I remember hearing this and when they were building a new unique, you like, why do you need a big bed? That's right. Right. Why do you need this?
Speaker 1:big room.
Speaker 4:I mean, and then you're forgetting that it's just not the baby right and the size that matters for the room and what that room needs to have. But that's what people think outside.
Speaker 5:You know, I think about two different challenges with neonatology. One is, historically we used to work hundreds of hours a week when it comes down to it, and because the neonatologist was not in house for call the round, go back to their offices, do all the research in the afternoon, and so the RBU benchmarks and all of those hour benchmarks got way out of proportion to what we're doing now. The other challenge is does one hour equal one hour? Does one hour in a level four equal one hour in a level three or level two? If you're on, you know, home call versus in house call, it's all an hour, but are they equal?
Speaker 1:And, of course and you guys are tackling this also when you did your FTE calculations with the group, that are our non clinical duties seem to be growing right. We're doing just as much or more in the unit, but we're having a lot of other non clinical duties. Can you talk a little bit about what that looks like? What are those non clinical duties that people should be thinking Gosh, this should be part of my FTE, you know the workshop that we just did with the attendees to this meeting.
Speaker 3:that was the second part of it. We really wanted to get feedback from them. We did some serving that will be able to use for data for future decision making and publications, and those were the questions that we were asking. You know what are the things that and we asked our attendees to tackle that in you know like 10, 15 minutes, which is really.
Speaker 2:Here's the problem of new netology, and you know what they rose to the occasion, right.
Speaker 3:They were really thought when we had a great groups and mixes of people in it and it what it really comes down to is people now there's new promotion pathways, right, and people are doing all these different things and we're still only giving off sets for very traditional things. And so when the groups you know that tackled that question, brought up a lot of the things that are actually part of promotable pathways, like QI or leadership things and things like that, and so, you know, coming to a consensus on that and talking about what might need to be reimbursed or what we think should have offsets is one piece of it. And there are things that I think that many of us think would be very reasonable, like being a unit director. Program director there's already, a fellowship, program director there's already determined, but some of these other things. But then making the leap to how do we make that happen is really going to be the important next step.
Speaker 2:But that also comes back to the variability. So, for instance, the role of a CHNC since we're here of a site leader, that's a role within the organization that every center then has and some centers give protected time for that and others don't, and in the end it impacts ability to be productive academically, ability to focus clinically when you are working and having to straddle those things and ultimately really your joy and satisfaction with your career. And those types of things, if they're not adequately addressed, really will get to sustainability issues for our field.
Speaker 1:Would you guys talk about how some of these things, like, say, being a site leader for the CHNC, brings value to the unit and the hospital, and how we should be advocating for protected time?
Speaker 2:Go ahead.
Speaker 5:I think we all don't have to be convinced that it brings value. Sure, the question is, who else do we? Have to convince that it brings value.
Speaker 2:And how do we fund it? Because again, like Chris mentioned, it all comes back to money. And one thing we weren't able to really get to because the workshop really was a lot of fun, there was a lot of interest, a lot of value that really took away from it. But one thing we hinted at in the closing was how do all of these workforce characteristics and metrics actually matter to clinical outcomes? And if we could better demonstrate that link, that's where we might be able to really prove the value. And if we have, say, better continuity of care, does that actually lead to shorter lengths of stay and translate into something that's more fundable or punchline is actually? So far, no data has shown that.
Speaker 5:I just to say because.
Speaker 2:I did do a study on that, but these are all the things that I think really could have potential impact. If the workforce is healthier, hopefully it turns into our babies also being healthier and our science being healthier and more robust.
Speaker 1:Was anybody surprised by their FTE calculation? I think yes.
Speaker 2:It's complex and it was hard for both Steve and I in the limited time that we had to really walk people through. There were a lot of questions, a lot of head scratching, a lot of why do you do it this way?
Speaker 4:And it's confusing, but I think also yes, but I think what it come out from that, or at least what I think they took, is that it has to be done Right. Like Amir, are you going to put more value to in your unit Value? To level 4, or value to level 2, or why do you do those difference? And then at the end, then it'll be more equitable.
Speaker 3:One of the common themes was how do we define these things? And it may be that we define certain big picture ideas for everyone and that at an institutional level or a more local level, it needs to be defined more specifically for that place. And then we talked about it's important to have flexibility, Important to say well, we've done this this way for the past 10 years and even though we've added four new hospitals and an entire group of APPs and we don't have any more residents or something like that, you have to have that flexibility also.
Speaker 3:But getting those big picture concepts, some sort of agreement on that is, I think, really where we're going to be able to affect change.
Speaker 1:And so for units who are struggling with this, which many of us are, you're really advocating for it. It doesn't matter necessarily how you weight certain things, but that everybody's doing it the same way and gets the same credit for doing different things in the unit. Is that right?
Speaker 4:Yes, I mean you as a division. You will know what is has more value or costs more points, whatever you want to call it or more hours to dedicated units or dedicated roles, Because we don't know, Maybe you are also like a front-law provider If you don't have APPs, you are going to be able to see less and other units are going to be able to see more.
Speaker 4:Let's get a little closer. Oh, it's awesome. So I think everybody has to figure out in their world what it means, but we still should have a target. It doesn't mean that you're going to go 365 days.
Speaker 2:Right. The first step is really just making sure that you're counting. The second step will be reducing the variability in how we count. I think if we just make sure that people are thinking through their systems and they are at least accrediting these things or counting these different roles, that's the first step for a system that might be struggling.
Speaker 5:I think the only thing I was going to add is none of us are independent, solitary neonatologists. We're all part of a group and if we can improve the overall health and well-being of our group, we're all going to be better yeah totally agree.
Speaker 1:So I've had the opportunity to talk with some of you on this topic before, so I know the answer. But for the listeners, do you think that there is a role for standardizing staffing models on a national level?
Speaker 2:I do. I mean, that's what I was kind of trying to hint at, and so, again, there are a lot of groups working on this. So the three of us are working with a team Christiana, domin and Emily Miller. We have a grant through the AP, with many advisors one of whom is Steve that help us, and we're putting together a summit to try to decrease some of this variability and advocate for some of that national collaboration and standardization that you're seeing, as well as the swan group, of which Steve's and I remember that's a group of division directors primarily I'm not a division director but that is also trying to to solve this issue.
Speaker 1:And I see you have a very interesting survey here for the group.
Speaker 4:You want to try to answer. What is that?
Speaker 1:I'm not going to answer, but were there any interesting discussions on any particular? I'm sure there was, but any questions that stood out that were really a point of discussion?
Speaker 3:We're all slipping.
Speaker 2:This was a great idea that Chris and Malenka had, so they should speak about it. But it was part of our grant and we did part of that grant funds and data collection. We did. We're doing interviews and qualitative analysis.
Speaker 4:I'll go with the one that I remember the most. It was question number five, which was what is the maximum number of consecutive in hospital hours? And you know, not only just should do on level three, level four I was surprised to find that a lot of people are still OK with 25 to 30 hours consecutively.
Speaker 1:Yeah right, Especially given the data on, you know, in increased mistakes with prolonged calls, especially those overnight calls, more car accidents, worse health outcomes for physicians who do those prolonged calls.
Speaker 4:Yes, and also because we asked we asked them to think about the ideal. So I really don't.
Speaker 1:It's what they would pick, they were picking it. There's still continuous to be that ideal.
Speaker 3:Which which feeds into another question which I think is interesting Should a neonatologist take in house night call while on service and then round post call and people asked for clarification of the question Does that mean like round and leave? Does that mean round and then?
Speaker 1:stay there. You're on service. You may stay all day.
Speaker 3:Right, like how, and we just said, please, just like, look at just whatever the question reads, whatever that means to you, and there was a there were a good portion of people that said it depends, and that probably speaks to a lot of things.
Speaker 3:It probably speaks to knowing that if you, if you don't round post call when you're on service, then people thinking all of my on my, all my in house call will then be when I'm not on service, which will then, you know, completely interrupt potentially the time that I'm working on my academic things or the other things. And so we have a system that already lends itself to certain things. We had primarily mid career folks. It was almost like a bell curve of, you know, early career to mid career and late career, and so, you know, you have people who have been practicing and in the system for a while. And I think a really interesting question to think about is sort of at the other ends of the bell curve, the folks that are saying I just don't even want to take call anymore because health wise, you know, for health reasons. Or the new grads who are coming in and saying I have never worked 36 hours straight before.
Speaker 1:I've never had to. I don't want to start doing that now, right.
Speaker 3:And like why am I going to get a job where I have to do that? So I think those are really interesting things that we have to consider.
Speaker 2:And she had put in a free text word cloud question at towards the end of what's the greatest challenge to staffing and in etiology and a big one was generational tension, which I. That was really insightful and certainly Tell us more. Well, this is part of the live polls. It was just kind of a quick. There weren't discussion points around that, because this is the data that, again under IRB protection, we're collecting towards publication. But the concept there, I think, is that there are different generational beliefs about work-life balance or personal-professional life balance, and there's also different generational needs, right? So not only does maybe the older neonatologists not want to work overnight anymore, but there are also a young mother who's nursing doesn't want to do that either, and so there's just different needs for different folks.
Speaker 4:I think it also comes, in that regard, back to flexibility, because if we say everybody has to work seven weeks and everybody has to do three 24-hour calls, whatever that means, then there's no flexibility in the system. Then how are you going to have part-time people or accommodate for health reasons? So we need to be thinking outside the box and we need to be also going with what neonatology is going. It's getting more complex, more things are falling on the attending right For many reasons. I mean, we can talk about the reasons, but it's how to create sustainability from now on. If we don't deal without now, we don't know what our career is and it's really not for us. We might have 20 more years, but for the incoming generation.
Speaker 3:And the babies. And the babies, the meagerness and the families and making sure that we're taking care of our patients.
Speaker 1:Any. I have two questions. My second to last question is are there any resources for people who are interested in learning more about staffing models as it stands?
Speaker 2:Yes, so there are quite a growing number of publications on this topic. Our group has written on this. The SWAN group is working on a manuscript for that now. So if you put it in, I mean through PubMed. I think when we did the podcast with you earlier we did put some of those resources collected so they would be referenced on that. There's been a few more that have come out this summer that are also good to add to that, and that's pretty much where things live at the current state.
Speaker 1:And when can we expect the data of the collection you're doing now?
Speaker 4:Well. So we are analyzing right now and hopefully we'll get the publication out by January, february that's kind of our goal, ok, and sooner, maybe sooner. But then I think the other big step is the summit, and so the summit will be in June and hopefully from that we can give you better tools Obviously still advocacy tools. We're not going to solve the problem, but hopefully we can give you better tools so you can talk to your higher ups, whatever that means, in your place.
Speaker 1:Any closing thoughts.
Speaker 3:I think people just need to keep thinking about this and talking about it, and talking about it at their own institution and supporting transparency about these things, helping our incoming recent grad junior colleagues understand these concepts so that they can ask the right questions and figure out what they want and, as they're looking for jobs, so that they can sort of speak this language and go in with their eyes wide open. So I think, to all the listeners out there, just educating yourself about it and starting the conversation at your own institution is a great place to start.
Speaker 4:And I think for us since this goes not just probably to neonatologists is how do we recruit the next generation? And so talking about these out loud and in simple terms and it might get us actually recruitment of more people and more ideas, and that's what we need to keep doing.
Speaker 1:Well, carrie, steve, malinka and Christine, thank you so much for your advocacy and we're really looking forward to seeing the publication. Awesome Thanks for having us. Thanks, everybody, thank you.
