A Stanford interventional radiology practice implemented several workflow changes aimed at decreasing physician and staff burnout.
To address physician and staff burnout, a Stanford interventional radiology practice made several workflow changes that improved efficiency, allowing IRs to head home on time at the end of their workday.
“The burnout rate amongst physicians is high, approaching 40%, and IRs are not immune,” said Nishita Kothary, MD, FSIR, a professor in Stanford School of Medicine’s IR department, which implemented the changes.
IR Division Chief Lawrence V. “Rusty” Hofmann, MD, FSIR, said burnout and wellness have always been his guiding leadership principles. “I have been chief at Stanford for 16 years, and none of the 10 faculty members I’ve hired has left,” he said. “I think wellness and burnout need to be top of mind, almost daily, to ensure that you take care of physicians so they can take care of themselves, their families and their patients.”
But maintaining a work–life balance in an IR practice can be a challenge because practices often perform the scheduled outpatient procedures and then address inpatient emergencies toward the end of the workday. This frequently causes physicians and support staff to work later than planned, Dr. Kothary explained.
The Stanford IR team wanted to find a better way. So, in fall 2019 the department implemented several changes.
First, the team separated procedural rooms for the inpatient population and the scheduled outpatients, which was essential, Dr. Kothary said. One room, close to the intensive care units, was reserved for inpatients so they would not have to wait to be squeezed in at the end of the day.
“IR typically has four to six add-on cases every day, so this room is well utilized,” Dr. Kothary said. The on-call IR was now designated to handle inpatient calls, while the other IRs on service focused on scheduled outpatient procedures. This meant each IR went on call every 10 days, rather than knowing they might work late on any given day.
Next, they focused on using staff in a more efficient manner. Previously, nurses and techs would arrive to work around 7 a.m., but cases didn’t start until closer to 8:30 a.m. “At least in California, labor’s extremely expensive, and the cases would start late even though the techs were coming in early. And we would run late, which meant that staff stayed longer, resulting in overtime,” Dr. Kothary said. “That was the monetary aspect of it: We needed to get better about using our labor efficiently.”
To better ensure cases started on time, morning rounds start times changed from 7:30 a.m. to 7:15 a.m., Tuesdays through Thursdays. They were shortened from 45 minutes to 30 and, to eliminate the frequent problem of rounds that went on too long, specific didactic lectures for trainees were moved to the end of the day. Mondays remained educational days with a later morning start time.
The department also used analytics to improve scheduling. Instead of having one estimated time for a specific procedure, they used their electronic medical system (EMS) to analyze the actual time it took each IR to do certain procedures, on average, and scheduled accordingly. The individual times per IR and per type of procedure are now built into the EMS, which automatically selects the appropriate length of time based on that physician’s history.
“People work differently; they have different speeds,” Dr. Kothary said. “Smart scheduling using the EMS provides accurate historical data that allows accurate scheduling. One can’t assume that it takes them 60 minutes to do chemoembolization, for example, when in reality the data show that they routinely take an hour and 40 minutes.” If the IR expects the case to be more complex, they can override the scheduling system and add more time.
The late start times and longer-than-scheduled cases would cause a cascade of delays throughout the day, which resulted in frustrated patients being forced to wait around for treatment, potentially putting them at risk. In addition, because inpatients are now seen earlier, they aren’t required to fast throughout the full day, which improves their comfort.
An analysis of the changes over a 10-month period, compared with 10 months before the intervention, showed start times improved from 56% on time before the intervention to 72%. Weekday patient volume did not fluctuate significantly. The length of allotted procedural times improved from 71% to 74%.
Perhaps most significantly, outpatient-designated IRs finished their last case by 5 p.m. 87% of the time. In fact, even including the inpatient on-call IR, all rooms finished their last case by 5 p.m. in 81% of the cases—compared to 53% before the intervention. The results, which were presented in the October 2021 issue of the Journal of Vascular and Interventional Radiology, were achieved through an entirely cost-neutral system, without adding staff, rooms or room hours.
“The largest impact to our practice is more predictability,” Dr. Hofmann said. “Life in an IR practice is organized chaos due to the emergent nature of many of our patients’ needs. The more you can structure your practice to deliver predictability, despite the ongoing chaos, the better. With more predictability, we have been able to do more cases in less time and provide more non-clinical time to our physicians.”
