1. Preamble: Commitment to quality care

1.1 It has been long established that medical officers are at times required to work for extended periods of time in a stressful work environment with inadequate rest and recovery periods. Medical officers are frequently called upon to carry out their duties in a fatigued state due to long periods on-duty with inadequate provision for rest and recovery. This practice exerts a very heavy cost on both the health and work performance of the medical officer. It also exposes the patient to a greater hazard and unnecessarily increases the risk of an adverse medical incident.

1.2 While the adverse effects on medical officers has been subject to considerable research little attention has been given to the statutory responsibilities of the employer to ensure there is a safe system of work which ensures an appropriate level of protection to both the employee and the patient.

1.3 Improvements to occupational health and safety for medical officers is considered to be consistent with the commitment to quality care of patients.

2. Policy framework

2.1 It is recognised that the promotion of a positive occupational health and safety culture is a shared responsibility involving all the stakeholders in the hospital system including the medical profession, hospital administrators, government bodies and the community. The emphasis of the strategy is to seek to achieve lasting improvements on the basis of consultation and co-operation between the stakeholders.

2.2 An important aim of the strategy is to place the management of occupational health and safety within the context of an integrated approach to improving the quality of the working experience within the commitment to best practice in the health care industry. An essential aspect of the responsibility is to ensure medical officers are not required to perform their work in a fatigued condition that exposes either the patient or the medical officer to a greater hazard and increased risk of an adverse incident.

2.3 Key components of the strategy

2.3.1 Three key elements are central to developing the strategy, namely:

• establishing a safe system of work consistent with the statutory duties of occupational health and safety legislation;
• organisational commitment to develop and supervise the safe system of work; and
• medical officers' commitment to ensure the safe system of work is implemented at the workplace.

2.3.2 Underlying the three key components is the requirement to ensure occupational health and safety for medical officers is seen as an integral part of the hospital management system. Long term and lasting improvements in occupational health and safety for medical officers is dependent upon adopting, at the senior management level, the following approach:

• Planning to improve: Adopting a systematic approach which clearly recognises the hazards that are generated by the present system of work which is over-dependent upon extended hours of work. Therefore, to achieve qualitative improvement it is essential to establish priorities from the medical officers' perspective, and set performance standards with quantifiable objectives.
• Organising to succeed: Developing the appropriate consultative structures that recognise the particular employment situations of medical officers within the organisation and accommodates their work regime.
• Hazard control: Ensuring the hazards medical officers face from extended hours of work are clearly identified, the risks assessed and the appropriate control measures developed and in place.
• National policy objectives: Developing a set of key national policy objectives that will form the basis of a national strategy. The core key policy objectives will focus on the hours and conditions of work under which medical officers are required to perform their duties.
• Key result areas: Agreeing on a small number of indicators related to work regime that will provide the key result areas.
• Communicating the message Establishing appropriate channels for communicating on occupational health and safety issues that recognise the particular work situations of medical officers.
• Action plans: Setting for each jurisdiction, including the Commonwealth, a plan of action based on the National Strategy that will translate the objectives into concrete activities with positive outcomes.
• Monitoring and reviewing performance: Ensuring there is a system in place to monitor the implementation of the strategy, measuring the outcomes and determining the effectiveness of the strategy for improving the occupational health and safety culture for medical officers.

3. Safe system of work

3.1 An essential focus of the strategy is to ensure that medical officers are required to carry out their duties under a safe system of work. In particular, that the system of work should not create the circumstances that result in medical officers being in a physical or mental condition that presents a hazard to themselves, fellow employees or the patients. It is therefore essential that appropriate standards be agreed upon for the following issues:

• maximum number of hours per shift;
• minimum uninterrupted rest breaks within a shift;
• minimum uninterrupted periods between shifts;
• consecutive shifts and shift patterns;
• adequate minimum breaks between shift changes to ensure appropriate rest and recovery;
• night shift rosters should provide adequate rest and recovery periods to overcome adverse effects resulting from sleep deprivation;
• adequate rest and recovery periods to be taken at night; and
• frequency of on-call commitments of medical officers to enhance the value of rest and recovery periods, therefore guidelines should be developed with regard to the frequency and duration of call outs.

3.1.1 In developing the system of work listed above attention has to be given to the research outcomes on the impact on medical officers' performance of extended hours of duty.

3.2 Hazard management

3.2.1 As part of the development of a safe system of work with regard to current medical officers' work practices, the employers undertake a commitment to:

• identify the hazards to which the system exposes medical officers;
• evaluate the hazards and seek to control them; and
• establish standards that reflect a safe system of work.

3.2.2 The current reliance on medical officers undertaking prolonged periods of work results in unacceptably high costs both to the individual doctor and also the standard of patient care.

3.3 Hazard identification

3.3.1 An initial step in the management of the hazards is to:

• review the research, both Australian and overseas, on medical officers' extended hours of work;
• identify the hazards to which medical officers and patients are exposed under the current system;
• review existing policies, procedures and work practices to ensure they are relevant and appropriate and meet statutory duty of care; and
• undertake a safety audit on the work practices and system of work for medical officers.

3.3.2 There is a large body of research identifying the hazards of the current system of medical officers' work practices.

3.3.3 In reviewing the present situation the employer, in consultation with medical officers, should evaluate the hazards the current system of work has produced for medical officers and patient care. In evaluating the hazards attention is to be given to recognising both the long and short term impact on both medical officers and patient care. Evaluation of the hazard should include the following:

• analysis of a random sample of adverse medical outcomes and determine the extent to which the system of work has contributed directly and indirectly to the incident;
• examination of organisational policies with regard to the work regime of medical officers to ensure extended hours are avoided;
• extent to which current work practices for medical officers meet the statutory requirements under the relevant occupational health and safety legislation; and
• review of current industrial awards and enterprise agreements to ensure that employment conditions are consistent with occupational health and safety objectives.

3.4 National code of practice

3.4.1 When developing a systematic approach to promoting a safer system of work for medical officers consideration should be given to promoting a national occupational health and safety code of practice. A code of practice adopted by the national health and safety accreditation body, Worksafe, would be the best approach. However, to put in place a nationally agreed code of practice will require some time and may be strongly resisted by some of the stakeholders. As an interim measure the AMA should develop and adopt a code of practice and seek to initiate the formal process of national accreditation.

3.4.2 The occupational health and safety code of practice would ensure the following:

• the hazards of extended hours of work are clearly identified;
• risk associated with inappropriate shift patterns are stated;
• provides models for the safe system of work;
• identifies standard operating procedures for safe work practices;
• establishes monitoring procedures;
• indicates the occupational health and safety responsibilities for employees, front line supervisors and management;
• provides information on appropriate level of training for occupational health and safety; and
• provides for the collection of data on occupational health and safety incidents involving medical officers.

3.4.3 The purpose of the occupational health and safety code of practice would be to complement the clinical protocols already adopted and in place.

4. Organisational commitment

4.1 Promoting improvement in occupational health and safety requires the commitment of management. Therefore, the strategy should address the following:

• accountability;
• communication;
• allocation of resources; and
• monitoring and reviewing performance.

4.2 Accountability

4.2.1 At the hospital management level the following objectives be established:

• promoting occupational health and safety for medical officers is a cooperative objective;
• corporate commitment is directed towards the development of a systematic approach that prevents problems emerging; and
• clear identification of the organisational responsibilities and accountability for medical officer occupational health and safety.

4.2.2 Management and supervisors of medical officers have to become aware of their responsibilities to promote a safe system of work as part of the corporate responsibilities. Maintaining a work schedule that depends upon medical officers not being exposed to extended hours of work is a management responsibility.

4.3 Communication

4.3.1 The strategy recognises that as medical officers are fully tasked, special attention has to be given to communicating the corporate objectives for occupational health and safety. In particular, attention should be given to the following:

• review the communication links within the organisation to ensure medical officers are not excluded due to their work regime;
• ensure the roles and responsibilities for reporting on occupational health and safety issues are clearly identified for medical officers;
• circulation of information on the corporate objectives of occupational health and safety for medical officers - including how the strategy has been developed;
• the consultative procedures include medical officers or their representatives;
• the occupational health and safety objectives for medical officers that have been established; and
• explain how performance will be monitored and reviewed.

4.4 Allocation of resources

4.4.1 An essential responsibility of management is to ensure that an appropriate level of resources is available to ensure occupational health and safety is adequately promoted. In particular, attention should be given to:

• provision of training in occupational health and safety issues relevant to the workplace;
• allocation of time to participate in consultative mechanism; and
• allocation of specialist resources to assist medical officers to contribute more effectively to developing a proactive approach to occupational health and safety.

4.5 Key result areas

4.5.1 As part of the overall strategy to achieve the implementation of national occupational health and safety objectives for medical officers a number of key result areas are important. The key areas are:

• hours worked per shift with reference to the following indicators: average, maximum, minimum of time over an agreed period;
• pattern of uninterrupted rest breaks within a shift with reference to average, maximum and minimum over an agreed period of time;
• pattern of breaks between shifts with reference to average, maximum and minimum;
• pattern of shifts before an extended period of rest. The extended period of rest to be defined as a minimum of 48 hours uninterrupted rest with no on-call or standby provision; and
• the balance between day and night shifts with a reference to ensure that night schedules do not induce prolonged night sleep deprivation. The balance to be determined to ensure successive night shifts do not exceed an agreed maximum before an extended rest and recovery period.

4.6 Monitoring and reviewing performance

4.6.1 The success of a hospital's occupational health and safety program depends upon devoting time and resources to ensure the corporate objectives are being achieved. This requires a systematic approach to analysing performance in key areas. In particular, attention should be given to ensure the following is undertaken:

• review patterns of work;
• monitoring incidents, reporting and recording procedures;
• analysing incidents records and statistics;
• reviewing the results of incident investigations;
• checking that measures for hazard control are implemented; and
• reviewing the accountability system and auditing the hazard inspections conducted by safety personnel.

5. Medical officers' commitment

5.1 Action plan

5.1.1 It is recognised that the issue of extended hours for medical officers is both complex and deeply entrenched in the traditional hospital culture. Therefore, acceptance and realisation of national occupational health and safety for medical officers will not occur overnight. It may require an extensive effort over an extended period of time. Some objectives may only be achieved over some years. Therefore, to assist the long term implementation of the national objectives it may be more appropriate to seek to implement the strategy in agreed stages over a period of time. An approach of this nature may make it both easier for the employer to accept and the Australian Medical Association to negotiate. The suggested action plan is as follows:

• a target date for the full implementation of the national strategy to be set for the end of the year 2000;
• the phase-in period to be achieved in three stages based on the following years - 1996, 1998 and 2000;
• stage 1 is to be focussed on developing at the state/territory level, an awareness campaign of the background issues and need for national approach. The campaign will seek to develop the support upon which it is intended to develop the national approach;
• stage 2 should seek to extend the campaign from beyond the state/territory level to a more co-ordinated national approach. In addition to putting in place the support at the national level stage 2 should also seek to draft the proposed national code;
• the final stage will seek to achieve the adoption of a national code of practice as an accredited code for the health industry;
• an essential component of stage 1 will be to ensure each state/territory plays the key role of developing a high level of support within its membership base;
• each state/territory to set specific goals within the phase-in period consistent with the overall goals for the three stages;
• particular attention to be given to developing support within the membership base and the medical profession for the objectives and tactics; and
• maintaining the support of the community at large could be a critical factor in achieving the overall objectives.

5.2 Complement existing research

5.2.1 As part of preparing the case for a national code of practice it would be very useful to have more reliable research reports on the impact of extended hours on the system of work. The research to date has focussed on a narrow range of issues that have not adequately addressed the system of work. To overcome this deficiency as part of the first stage the AMA should seek to undertake qualitative research on the system of work for medical officers. This would require that a number of case studies be undertaken focussing on the system of work at the workplace level. While it is not appropriate to spell out at this stage all the details of the case studies, it is important to emphasise that the focus of proposed research is on the system of work of which extended hours is an important issue but not the only issue.

5.3 Medical officers have a critical role in contributing to promoting a safe workplace. At present it is unclear as to the extent to which medical officers fully appreciate the hazards to which the current arrangements may be exposing them. There is the need for the AMA to ensure there is a greater appreciation of these issues by medical officers. In particular medical officers should be aware of the:

• adverse impact on work performance resulting from fatigue and sleep deprivation;
• occupational health and safety hazard to themselves and patient care;
• importance of having a safe system of work;
• recognition of the potential hazards and associated risks arising from extended hours of work; and
• requirements to report incidents and near misses.

5.4 Promoting a safe workplace

5.4.1 An important element of the national strategy is to provide for a greater opportunity for medical officers to contribute to promoting a safer system of work at the workplace. At present while the legislation provides in most states and territories for consultative workplace arrangements, nevertheless, there is little evidence to indicate the level of involvement. The proposed case studies would provide more information on this aspect. At a more general level there is a need to increase the active involvement of medical officers in these issues at the workplace.

5.4.2 Particular attention needs to be given to creating opportunities for medical officers to contribute to enhancing the safety of the present arrangements. As a demonstration of their commitment to promote a safe workplace medical officers should:

• participate in the consultative forums;
• elect a representative and support the health and safety committee;
• exercise reasonable care to protect the health and safety of others while at work;
• follow reasonable instruction employers give in relation to health and safety at the workplace;
• comply with health and safety policies and other written arrangements for health and safety at work;
• make available information to management and health and safety representatives to keep them informed about issues of concern;
• assist in hazard identification and evaluation and review of the workplace; and
• participate in regular, formal and informal health and safety meetings.