Table 1 Items to consider with respect to the provision of safe and effective clinical care

Human resource considerations: numbers

• Estimate the number of residents rotating through the service(s)/unit(s) in question at any given time

• Estimate the number of residents rotating through other services that can be called upon to help with the coverage of the service(s)/unit(s) in question

• If needed, determine the type and amount of non-resident human resources needed to address gaps in coverage

• Anticipate and plan for resident illness or other last-minute absences; consider having a backup schedule

Human resource considerations: responsibilities

• Identify and characterize the main tasks to be performed both within and outside of regular working hours in terms of complexity, acuity, and frequency

• Identify the time of peak services and estimate the minimum number of residents required to handle the caseload in a safe and effective fashion

• Consider the most resource-intensive tasks done at night and estimate the minimum number of residents required to manage these tasks in a safe and effective fashion

Allocation of responsibilities across the day and night

• Review the workflow over the entire 24 hours of the day and 7 days of the week

• Characterize the types of tasks to be performed at night

• Determine how many of these tasks are medical emergencies and how many are administrative, psychosocial, or chronic-care related (i.e., Do the tasks require the immediate availability of an in-house resident or can they wait?) [40]

• Take note of tasks that may be better taken care of by the day team that knows the patients best

• Restructure care provision based on the above, and then re-estimate your human resource needs

• Estimate the average caseload at night both in terms of volume and acuity (i.e., Is cross coverage of two or more services by the same team a viable option?)

• Estimate the frequency by which the most resource-intensive tasks (e.g., response to trauma, code blue) occur. If they occur only occasionally, consider negotiating with other services/units to combine their teams with yours to deal with these situations. This will allow you to staff your team based on the requirements of other more-commonly occurring tasks, while allowing some flexibility during times of increased need

• Determine the optimal length of shifts for the service/unit in question (i.e., balance the effect of fatigue from longer shifts with the impact on continuity of care from shorter shifts)

• Estimate the length of handovers as well as their complexity (i.e., Is it best carried out in person, by phone, or in writing?) [31]

• Consider measures to optimize information transfer at handovers (e.g., having more senior residents (fellows) or attending physicians present by phone or video-conference) to focus attention on the patients who are most ill