Problems with Punctuality

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Creating a culture that respects clocks—and colleagues

Dear Director: I have a couple docs who routinely show up late to work, and I don’t know how to get them to understand the importance of showing upon time. Help!

My daughter’s lacrosse coach told the kids (and parents) at the first practice that his expectation was “Early is on-time,on-time is late, and late is unacceptable. ”He wanted kids there 15 minutes early to get geared up, warmed up, and ready to go. Most of us probably had similar expectations during residency. WhereI trained, we had rounds that didn’t start until everyone was there. If you were late, you held up the entire group and kept people from going home.

Certainly, as important as not holding up the group or the doc we’re relieving, is not holding up the patient. Unless you’re in a very quiet ED, there are likely patients waiting to be seen by the oncoming doc. I like walking into a few charts in the rack so I can have something to do when I get to work and “frontload” my day’s productivity.

While the culture of how long patients sit waiting for the next doc probably varies by site, certainly being late for a shift causes undue delay for patients and may force an outgoing doc to pick up a sick patient and stay longer than had been necessary.

DOES EVERYONE HAVE DOCS SHOWING UP LATE?

So how big a problem do we have with docs coming in late and how upsetting is it to your colleagues? I did a very non-scientific study of a convenience sample of about 65 anonymous ER docs. Although 76% said they typically arrive 5-15 minutes before the start of their shift, which is enough time to log on to the computer and get settled, 16% said they aim to arrive the minute their shift starts, and another 6% said they’re routinely late. That means at my workplace at least about 1 in 4 docs aren’t taking their work as seriously as they should and aren’t being very courteous to their colleagues.

While most docs (68%) said it’s extremely rare for them to be late for a shift, 15% said they’re late to more than 20% of their shifts. Of those surveyed, 81% said they have colleagues who regularly aren’t ready to work at the startof their shift, and 86% said it does bother them when people don’t show up on time.

The much higher percentage reported by colleagues indicates the impact on others is probably greater than the sum of each infraction. I remember counseling one doc about his low productivity, which had financial implications, and talking about seeing lots of patients during the first couple of hours of a shift. He said he arrives and there’s never any patients to see. I pointed out that was because he was routinely showing up late, so the docs that were working didn’t leave the patients placed in rooms 5-10 minutes before the start of the new shift because they never knew how long it would be until he showed up.

WHAT CAN WE DO?

Generally, we’re treated as the professionals that we are (I’ve only punched a clock in one ED), but we still do shift work  and shift work requires a commitment to showing up ready to work on time. As a director, it’s important to establish an on time culture and a culture of accountability. This starts with the on-boarding process of new docs and is exemplified every time the chair comes to work.

Remember: You can’t hold your docs accountable if you don’t hold yourself accountable. Since we all frequently stay late after shifts, I suspect some docs may not realize what a big deal it can be to show uplate. Although I think most docs probably wouldn’t say anything to a colleague who showed up late, I think it’s entirely appropriate for someone to ask what happened and remind their colleague that if they’re going to be late, they should at least call ahead to let the doc they’re replacing know.

If full-timers are uncomfortable saying something to a colleague, they should definitely notify the chair who has the responsibility to handle the mater. While the chair generally knows the comings and goings of people, he or she may not know how frequent an issue it is. Like giving any kind of feedback, I think there are three different levels, ranging from casual to formal. My most casual is just a quick mention of it in passingwhen I first “catch” someone starting late. Just a “Hey!, What happened?” or “Issue with parking?” that lets the person know it’s noticeable that they’re late.

The second level involves a meeting that’s less formal than my office. We’ll walk to the doctor’s
lounge, get a drink or a snack, and I’ll say something about how I notice they’re showing up late on a regular basis. I ask if there’s anything else going on they want to talk about, and we try to get to the root of issue to see if it can be corrected. The third level is the formal, office meeting, typically with a performance improvement plan and an action plan that shows the consequences for showing up late. If the doc didn’t realize there was an issue before, it should be crystal clear at this point, as these meetings tend to be uncomfortable for all.

DOING A 360

The most success I’ve had in getting people to adjust their habits is by using 360-degree evaluations. The purpose of a 360-degree evaluation is to get feedback from allthe people that each provider works with. While some places may include hospitalists and specialists, I typically use docs, APPs, nurses, techs, and secretaries. I use 10-12 questions, where a subset are reserved for just your peers to evaluate you.

I’ve asked docs to rate each other on a scale of 1-5 including “showing up and being ready to work on time.” With this question, it’s very easy to see who occasionally is late and who is always late. Other questions I’ve used focus on specific issues that have been brought to my attention. For instance, when I hear that our techs are having a hard time getting a doctor to review and sign off on triage EKGs, I ask the staff how responsive is each particular doctor in reviewing EKGs and taking referral call-ins.

Depending on how you use your APPs, you might want to consider asking them about each doc and
how well they supervise the APPs (are they available for help, micromanage cases, educated, belittle, ignore?). Sometimes I put questions on the 360 because I’m looking for data to support my hypothesis, and other times I’ve been incredibly surprised by the feedback. Some of the feedback has included issues such as Dr. Smith frequently is rude to nurses or Dr. Jones doesn’t explain things well to patients so nurses spend more time in the room reviewing discharge instructions than with other doctors. Having feedback scores and comments you can give to providers can be extremely powerful.

Over the years, I’ve had a few docs who routinely weren’t ready to go at the start of the shift. One routinely showed up 8 minutes late. You could almost set your watch to her. The other typically showed up a few minutes late but then would spend 15 minutes getting coffee and talking to nurses before digging into the waiting patients. Charts piled up for both of these docs, but neither knew how frustrated the staff was with their behavior until each saw their 360 scores.

I’ve done 360s by sending out Excel spreadsheets and more recently through free on-line survey tools. There are also programs you can purchase. Once I have the link, I send a cover letter to the staff explaining the process, stating I value their input and feedback, and asking for honest and professional opinions. I always include an end date and send a couple reminders over the 3-week period the survey is open. Once the data is calculated, the most important step is finding the time to meet with each individual and provide the feedback.

While the meetings for the high performers are easy, sometimes giving feedback to the low performers can be very difficult for both of us. It’s important to understand the feedback and discuss potential ways to change behavior. I’ve seen comments about doctors yelling down the hall when nurses thought it wasn’t necessary and when reviewing the situation with the docs, they agreed, and said that was a with they could change.

In general, I’m a fan of unblinded data, but due to the extreme personal nature of the 360, I blind the data and give everyone a copy of the scorecard so they can review it after the meeting with me. Each of the docs who were late were surprised by the scores they received on their 360 and admitted they didn’t realize how often they were late nor the impact it had on the staff and ED. They both agreed to come in early going forward. However, at the next 360, they were disappointed that their scores didn’t improve to among the highest in the group since they were now early for every shift. It’s important to realize that subjective opinions people give may lag behind the reality of behavior change. Both docs continued to show up early and ultimately were recognized by the group.

CONCLUSIONS

Showing up late can lead to patient care delays, flow issues, and decreases in patient and provider satisfaction. The chair needs to create a culture of being on-time by providing feedback to docs who are late. A 360-degree evaluation is a great tool to get feedback from peers.

ABOUT THE AUTHOR

EXECUTIVE EDITOR Dr. Silverman is Chairman of Emergency Medicine at the Virginia Hospital Center. He also serves as the Chief Performance Officer with Emergency Medicine Associates, a founding partner of Alteon Health. Dr. Silverman’s practical wisdom is available in an easy-to-use reference guide, available on Amazon. Follow on Twitter @drmikesilverman

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