Introduce Yourself?

My name is Alex Nevard,

This blog is all about things I have done in my Senior Clinical Fellow year, most likely to talk about the rostering side of things.

Currently I’m an ST5 on an OOPTE for 2 years at Leeds Emergency Departments, I do a lot of undergraduate teaching, mentoring, lecturing, examing and any other kind of educational activity that you can think of, but along the way I fell into being the rota co-ordinator.

It turns out that I really enjoy it. A combination of spreadsheets, having control over my life and being able to make other people happy really appeals to me. Along the way I have fallen into a self rostering rabbit hole and wondered if other people could learn from what I have learnt.

Always happy to answer questions about anything I have done this blog details the process I’ve been through over the last year and will hopefully show where I am trying to go from here!

Foreword

For longer than the nine years that I have been a doctor, the rolling rota has been the standard rostering method. Unfortunately, this standard is a brute force technique which allows for minimal flexibility and correspondingly results in unnecessarily negative morale.

Styles of working have changed over time. An increase in out of hours demand and an uptake in less than full time working have put the traditional rolling rota model under pressure.  It was never designed to be flexible and its continued existence seems to punish those that want to work more flexibly. 

Over the last few years people have begun to challenge the status quo. I first became aware of alternatives to the rolling rota when watching a video by EM consultant Dr Rob Galloway. His Risky Business lecture in 2017 talked about the benefits of a “self-rostering” rota, I was intrigued.  A self rostering post from St Emlyns in March 2017 talked further about the benefits, it including pictures of clever spreadsheets and ways of making it come together for a large group of doctors.  This, I thought, was something that I could make work for ED registrars.

Unfortunately, both these rota systems were designed to allow consultants to work flexibly in an annualised fashion.  The consultant contract is worked out really quite differently to a junior doctor.  Junior doctors can probably work less flexibly than consultants, we need to work a specific amount of in-hours time to constitute training.  If we work more out of hours time than predicted we should be paid more as stated in our contracts so our hours are fairly fixed. 

Dr Tom Bircher published his “How to Self Roster for Registrars” blog post in February 2018 and summarised it in a poster on self rostering at EMTA ’18 in Cardiff.  He showed that you can flexibly roster a group of registrars, meet their training and personal needs, provide better cover for a department and decrease your locum costs.  While I use a different method in my rostering to Dr Bircher I certainly leaned heavily on his work in persuading various consultants that a different style of rostering can work.

I started in Leeds Emergency Department as a senior clinical fellow in September 2018.  While I do a lot of undergrad education my other hat has been the rota coordinator.  When I started, I altered the method by which the senior clinical fellows (6 HSTs on a 60:40 split contract) were put on their rota, from rolling with minimal flexibility to a self rostering system.  We were able to better cover the gaps in the HST rota, allow the fellows to meet their non-clinical commitments and make everyone happier in the process.

In May, I got the go ahead to implement the same style of rota to the entire registrar body.  To put this into context for Leeds, that is 34 registrar level doctors, a mix of Senior Clinical fellows, HSTs, Staff grades and PEMHSTs.  This is a mixture of full time and less than full time trainees.  Some of our staff grades are on fairly bespoke contracts and a mixture of both the 2016 contract and the pre-2016 contract.  Leeds, although it is one trust, runs 3 emergency departments (St James’, Leeds general infirmary and Leeds Paediatric emergency department) which all have specific staffing needs.  If I can make it work for this place there is no excuse why it can’t be rolled out everywhere!

What follows is the “how to” guide of what I did.  My plan is to write a brief summary that anyone can skim over but then delve into some really quite fine points, because the fine points are often what makes the difference to trainees.

A Note on Healthrota

A lot of the things I will describe will relate to healthrota.  I’m not sponsored by them, they don’t give me anything nice to use or promote their product.  I will praise its features where I think they are good, I will critique where I think there are problems.  The team I get to chat to though are great and have been very receptive to feedback and everything I write will be true at the time of publication.

My Method of Creating a Self-Rostering Rota, an overview

Simplify the rota – removed historical shifts, and made everything as homogenous as possible as it will make hour calculations as easy as possible

Acquired every doctor’s work schedule – obtained the work pattern of every doctor.  The majority of trainees may work 100% and this will be easy but all the LTFT trainees should have a pattern as well.  This may be thought of as unnecessary, however, work patterns may vary from trainee to trainee and doctor to doctor.  As such, acquiring schedules should be done regardless of if you are doing self rostering or not and should not represent any extra work for the department.

Declared that things are going to change – informed staff of upcoming changes four months in advance.  Some people may need reassurance or the chance to discuss what these changes will mean.  Many trainees may be moving in from another area of the country or moving trust and as such will need informing on the upcoming changes in advance, especially the first time this is done. 

Set a date that people can begin self rostering and write down a list of FAQs that people ask – as people invariably have the same questions, a manual was created with a list of common questions, queries and answers.  The manual was sent out to all trainees at the same time. It also included a list of all regional training days so people could book these well in advance of their actual dates.  The rota was planned for 16 weeks followed by a review.  This is because the rota patterns runs for 16 weeks at a time.  There is no reason why it couldn’t be done for any other number, 26 weeks may be far more ergonomic.

Sent out access to healthrota – while other systems are available, healthrota is the system at use in Leeds.  Everyone’s rota slot was pre-populated with nights and weekends.  These were pre-filled  to reduce the amount of work required. With an otherwise blank rota it is very easy to swap nights and weekends around.  We managed to easily rearrange nights and weekends for everyone who needed it

Any trainee who doesn’t want to self rota was permitted to opt out –  should a trainee not want to self rota, for instance, if they wanted their rota in advance as far as possible, this isn’t a problem.  If a few trainees want fixed patterns, we simply populate their slot with the appropriate rota they had agreed with medical staffing.  If 3 or 4 trainees want to do this it isn’t a problem but if there are too many the resulting lack of flexibility would become an issue.  Anecdotally, a few trainees were concerned that a flexible rota might adversely affect LTFT working but the opposite has been found to be true so far and requests have been accommodated easily.

Arranged for drop-in rota clinics – Although Dr Bircher advocates for meetings in his self-rostering guide to arrange the rota, for a 3 department trust with so many trainees this approach would be impractical.  Rota clinics were found to be effective in such an environment. 

With nights and weekends rearranged, everyone was encouraged to request annual leave and study leave.  My promise was that, if people requested it prior to me doing the rest of the rota, they would get the time off.  If they didn’t and then they requested it after the rota was finished, I would do my best to approve it but couldn’t guarantee their leave.  People made all kinds of requests, 4 weeks off to go to India for Diwali – sorted!  One of our less than full time trainees wanted to take all their days off in one chunk so they could go do some remote medicine – easy.  One of our trainees wanted to swap working Fridays for Saturdays for childcare reasons – not a problem.  Flexible working worked.

Late shifts were then distributed to cover the department as evenly as possible.  At Leeds we aren’t allowed to take annual leave on late shifts so it’s quite easy to distribute these shifts to get as much department cover as possible. Once everyone had had their late shifts allocated, people simply had the correct number of day shifts and non clinical shifts populated into the rota. That was then it done.  It was about a day’s work to write the rota, some time was spent before and after answering e-mails and creating resources but hopefully as people become better with the systems this time should decrease.

How To: Preparation is key

Further Detail

While a lot of the pleasure from a self rostering rota comes from the idea that you can say yes to a lot of trainee requests, the work behind the rota starts some time earlier.  Like many tasks the preparation beforehand is crucial and will make a large difference to the implementation of the rota when it comes out.

Simplifying the Rota

Rotas changeover time and with change that comes many evolving shift times and patterns.  A rota sometimes can represent a historical record of how a department used to be.  Some departments have different start times depending upon days of the week.  Or odd shifts on certain days because there used to be teaching on that day.  The teaching has disappeared but the 13:20 start time hasn’t.

I’m lucky in Leeds, we use a predominantly 3 shift system for the registrars.  A 4th shift time has just been introduced (something I didn’t want) but for the most part we have 3 shifts.

  1. Day 8:00 – 17:00
  2. Late 15:00 – 0:00
  3. Night: 23:30 – 8:30
  4. Mid 12:00 – 21:00

There are also 12 non clinical (NC) days in a 16 week period.  We do 5 weekends – 2 nights, 2 days and 1 lates.

It’s a nice rota even before we add self rostering into the mix.  As there are so few shift types and every shift is the same length, it certainly makes life easier when self rostering.  If you are considering going self rostering I would recommend going one step further and redesigning your rota template to something with 9 hour shifts and standard start and finish times regardless of weekdays or weekends.

Why 9 hour shifts?  Well under the new JD contract a 9 hour shift gives you a 30 minute break while a 10 hour shift gives you two 30 minute breaks and so therefore 9 hours is the most efficient use of staffing.  The midnight finish is also beneficial, 2 am finishes start to incur extra rules from the junior doctor contract and the less of those we incur the better.

How To: Part 2, Preparation is Still Key

Changing From a Rota Pattern to a Shift Allocation Quota

Once we have a standard template such as that shown above, we can start to progress with the rota.  Instead of thinking of it as a set pattern, think of what we have now as a certain number of shifts to allocate.  From the pattern above we know that we have every 16 weeks:

Weekday day shifts: 24
Weekday mid shifts: 8
Weekday late shifts: 11
Weekday night shifts: 8
Weekend days: 4
Weekend lates: 2
Weekend nights: 4

And non-clinical days: 12

Simple you say, and it kind of is, however not everyone works full time so the LTFT trainees need their pattern agreeing first.  Is a 60% trainee going to work 60% of all kinds of shifts?  60% of weekends?  Split weekends?  This all needs to be discussed and decided with them.

If doing this rota has taught me one thing it’s don’t assume that what you like from a rota is what the next person does.  Many LTFT trainees I’ve spoken to have been happier to work OOH shifts or weekends because it fits in better with care arrangements or social lives.

Dr Andy Webster has been amazing at providing the template for every trainee and has certainly saved me a lot of work.  For example, here is the template for one of our 60% trainees:

So, the rota is now simplified into easier and more consistent shift types, and all less than full time trainees have got a rota that meets their holistic needs.  Even if no change was made from here on your trainees will still thank you for what you have done!

Minimum Staffing Levels

Next, before you can build a rota you’ll need to know how many people to allocate to each shift.  In smaller departments this might be simple: 2 day regs, 2 late regs and 1 night reg is your minimum staffing but it is worth considering how “future proof” this model will be.  For bigger departments or cross sites it will become gradually more complicated.  Again, simplicity is key.  At Leeds we went for “4 days regs, 4 late regs, 2 night regs” as our minimum staffing for week days with no special rules.  This provides a clear goal of what the rota needs to provide.

When you have done your minimum staffing levels and have your rota templates you should be able to see if what you are setting yourself up to do is possible.  For example, we fall short of being able to cover all of our weekday lates by about 10% based on everything I’ve worked out.  Knowing this before compiling the rota is important as a) some empty late slots can be expected, b) expectations can be set that the rota, while improving staff coverage won’t mean that there are surplus registrars on every shift and c) it can help manage recruitment of extra members of staff to meet the requirement.

Give People an Opt Out!

We are nearly at a point where we can start writing a rota!  But before we do check with your trainees this is what they want, before we went live we offered people the option to stay on the old rolling rota.  One trainee did, this is absolutely fine, as I said before I’ve learnt not to assume that what I want from a rota is what other people would want. 

We added the one trainee’s rota in and away we went.

One trainee won’t stop us having a flexible rota, we could probably accept 3 or 4 trainees not wanting to be flexible but any more than that and you would rapidly lose the ability to deliver what you needed to. 

The “we could probably accept 3 or 4” isn’t scientific it’s a gut feel and a number reflecting our 34 person registrar rota.  Smaller departments would need more a similar percentage buy in from members.

How To: Finally Let’s Get to Write a Rota

Finally Let’s Get to Write a Rota

So, we have our pallet of doctors’ shifts to allocate, shifts needed each day and we know what we can and can’t achieve, it is time to create our masterpiece.

Stage one – using healthrota we set up an account for everyone and then pre-populated nights and weekends into the rota!

“What!?“, I hear you scream, “This is meant to be self rostering and you told people what nights they were going to work?  I’ve read nearly 3000 words of drivel to find out nothing has changed.”

Fair point, but working from a completely blank canvas is hard and we needed a starting point.  If people had no problems with the dates that their weekends and nights fell I left them alone, if they needed moving I could move them anywhere in the 16 weeks that allowed as at this point there were no zero days to consider and no swaps to negotiate.  This bit was relatively easy!

Next people populated their annual leave and study leave into the rota, no swaps were needed and everything was readily approved, people started booking flights and I panicked a little on the inside, if this didn’t work, then I was either going to ruin an ED department or lots of people’s holidays.

Breathe:  I’ll admit that this was a little bit nerve wracking and at one point I nearly handed it back and went this is too much for one person, then I made myself a cup of Yorkshire Tea had a jammy dodger and pulled myself together – “We can do this!”, I thought.

Now we have a rota with nights, weekends, annual leave and study leave in, adding lates is next.

Lates are relatively easy to add (in Leeds, at least) as you can’t take leave on them and they are of a fixed amount.  I slotted them in around everything people had asked for and got a pretty good cover through the department.  It’s always hard to know what people want, a horrible week of 5 lates or lots of semi horrible weeks of 2 lates, I filled the rota in as best I could and everything went well.  My heart rate settled and the whole thing actually started to come together.

In-Hours Shifts – Harder Than You Think

So, you’ve now got a rota that should hopefully cover all OOH working, all forms of leave and give everyone their leave requests:  now the easy part, bosh in some day shifts and we’re done!

Except how many day shifts do you give people?

On a rolling rota you would take annual leave or study leave on either NC days, Mid shifts or Day shifts but that isn’t how the self-rostering rota works. Instead, you request your annual leave in an empty space not knowing what kind of shift you would have been working.

We’re going to have to figure out how many different types of shifts there are left.

A little bit of maths was needed and so I built this calculator:

It proportionally removes in hours shifts for every day of annual leave or study leave day taken.  Regional training days are slightly trickier as they should be taken on non-clinical days but also should be taken using study leave so I factored that in too (I think that this info is from the gold guide guidance)

Once you’ve got the number of days, mid and NCs for each registrar figured out they go onto the rota and then it is all done.

Tweaks are made as you go along to make sure department coverage is sufficient and then you should have a balanced rota, giving everyone all the leave they wanted, all the weekends off they asked for and the department as close to fully staffed as was possible!

Little Niggles and suggestions.

Can people still take leave after the rota is published?

Absolutely, but we revert back to rolling roster rules, if the department has enough staff you can have the day off, if not then you’ll need to swap

Any Problems Encountered?

Not really no. The prep work I did before starting, along with having practised for a year on a smaller 6-person rota, really helped.  I wouldn’t want to start on a 30+ person rota, but it appears more than doable.

The different style was a shock for some people, I think, despite all the information I tried to provide beforehand, but I think it is a change for the better.  Things like NC days no longer needed to be on a Tuesday caught a few people out who had got used to having these days pre-assigned as not being clinical at work.  There was no reason why a NC day had to be on a Tuesday, this is an example of historical obsolescence. West Yorkshire regional training days fall on a Tuesday, now if you give everyone a Tuesday as a NC day you increase the number of people who could definitely go.  I found out all the teaching days in advance, passed them on to people to apply for and gave them the day off.  After this all NC days could be wherever we want.

Some people have counted up their NC days and told me they hadn’t been given enough. Giving a very transparent method of calculating how I adjust the NC days based on annual and study leave requests seems to have helped with this.

Recommendations

Working face-to-face with people always seems to work better.  I like the idea of a rota meeting however this rota took me a full day to write when everyone had submitted their requests.  I can only imagine that trying to fit 30 registrars in a room for a day would not go down well and is also a waste of people’s time and the department’s money.

Instead I organised rota clinics, times when I would be available to talk and sort any problems out.  Lots of people came, some with just a question whilst with others we wrote most of their rota out while we talked.  I also offered phone and skype calls for people not in Trust.  This helped keep everything as fair as could be.

Can People “Game” the Rota? I suppose technically they can, in the same way they could game a rolling rota, this is why I have spent so much effort in putting in processes that keep things fair.  It also means that when I hand over this system to the next person who wants to do it, people are used to a particular process and

Thoughts and Conclusions.

This Rota Isn’t Self-Rostering, You Are a Fraud and Have Sold Me a Lie!

That’s funny you sound just like my internal voice!

First off, what is self-rostering?  Having kept a close eye on the #twittersphere – it didn’t happen in EM unless you put it on twitter – there are quite a few people trying different models of non-rolling rotas.  Currently with a 30 person rota there is not a solution that exists to allow people to truly self-roster.

True self-rostering to me means choosing your shifts and hours, completely independently, without any external supervision and meeting the department need.  I think there are a few reasons why this hasn’t happened yet.

Firstly, the rules governing rotas, what is and isn’t allowed, are complicated. The amount of time it would take to develop a technological solution that could cover all eventualities would be immense.   Healthrota does very well at meeting this, it certainly has kept me from rostering too many shifts close together or breaking rules accidently.  It also allows a lot of the day to day stuff to be managed a lot better, people can swap shifts without having to talk to anyone and request leave easily.

Secondly, people would have to be provided with the information on how many shifts they have to work. This would need to be a dynamic number based on annual leave, study leave etc and no technological solution to this currently exists.  In fact the biggest current downside to healthrota is I need at least 1 spreadsheet open at the same time to plan the rota because the program doesn’t give me all the information I need.

Thirdly, all departments work differently. This means that while a rota software company might be able to build a bespoke system for your department, a department down the road may have completely different needs.  This means another bespoke system and bespoke systems cost money.  Excel spreadsheets work well in creating bespoke solutions for departments but they don’t create true self-rostering systems as they need someone to data input – mainly a rota co-ordinator.

In Conclusion:

  • Moving away from rolling rotas, however you do it, is good and more than doable .
  • It helps not hinders trainees especially LTFT trainees.
  • It helps not hinders departments.
  • It is a lot of work and at times scary.
  • You’ll need support – alcohol is not support.
  • It is worth it.
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