Abstract
Society of Diagnostic Medical Sonography
White Paper Series
© Copyright 2018. Society of Diagnostic Medical Sonography, Plano, Texas. All Rights Reserved.
On-Call and Callback Issues in Sonography
Many employers, in a wide range of industries, need to increase staffing on short notice to address variable demands on services, and thus place certain employees “on-call” to return to work when not regularly scheduled for work. The use of on-call staffing is commonplace in hospitals, police, and fire departments, as well as industries such as electricity providers, equipment repair, etc. A callback to work may require the on-call staff to work a few minutes or hours, or in some cases, to travel out- of-state for weeks or months (e.g., for an ice storm that takes down electricity service to millions of customers).
Working as a sonographer can be a demanding, but rewarding career in the medical field. The work is complex, challenging, and vital to the successful diagnosis and treatment of many medical conditions. On-call requirements can have pros and cons for employees - some like the opportunity to be paid for on-call and view callback time as a welcome financial boost. Others see on-call requirements as a burden (e.g., based on health concerns such as lack of sleep, stress, or ergonomic injury; limitations on mobility/activity; or negative impact on work/life balance).
In 2016, approximately 40% of diagnostic medical sonographer ("sonographer") positions included on-call requirements. 1 While on call, a sonographer may need to report for an examination at any time of the day or night, and facility policies often dictate that the sonographer must arrive in a timely fashion (e.g., 30 minutes). The life of a patient may depend on the punctuality of an on-call sonographer. On-call requirements for sonographers are more common (65%) in hospital settings where demand is variable (e.g., at night) and the typical demand may not justify the same level of staffing on a 24/7 basis. On-call staffing requirements for sonographers are less common in physician offices, outpatient clinics, and freestanding imaging centers.
Sonographer On-Call by Job Setting
Staff sonographers reported an average of 15 hours of on-call time in a typical week, while sonography managers/directors, technical directors, and lead sonographers said they take more on-call time (i.e., 20 to 24 hours). 1 This may be reflective of the administrative, management, or supervision responsibilities of these roles (i.e., determining whether to call-in a sonographer for a particular case, finding a replacement when someone calls in sick, or taking more clinical on- call time because no one else is available due to illness, injury, vacation, etc.). However, it could also be indicative of a facility taking advantage of a salaried employee to avoid hiring additional sonographers. It could also raise questions about the sonography manager/director’s position classification as an employee who is exempt from overtime pay. Taking too much on-call time could also raise concerns about the manager/director’s ability to focus on the strategic, operational, and developmental aspects of their job.
Sonographer Job Function: On-Call Hours
Employment relationships are presumed to be “at-will” in all U.S. states except Montana. 2
At-Will Employment and Its Implications for On-Call/ Callback Issues
Employment relationships are presumed to be “at-will” in all U.S. states except Montana. 2 The at-will employment doctrine allows the employer to establish the parameters of the employment relationship (i.e., job duties, including any on-call responsibilities). Unless an employee is covered by an employment contract for a specific length of time, subject to a collective bargaining agreement as a union member, works for certain public sector employers, or an exception to the at-will doctrine applies (see below), the employee may be discharged from employment at the will of the employer. Likewise, an employee is generally free to leave the job at any time for any or no reason with no adverse legal consequences. Courts have ruled that the employer may make changes to the employment relationship and that an employee may be fired for their unwillingness to take on-call duty, even if not required to take on-call when hired.3,4
There are several common exceptions to the at-will employment doctrine including, but not limited to:
- Refusing to perform an act that is unlawful (e.g., file a fraudulent Medicare claim); - Reporting a violation of the law (e.g., notifying Medicare of fraudulent billing practices); - Performing acts that are in the public interest (e.g., joining the National Guard, performing jury duty, etc.); and - Working in an unsafe environment (e.g., exposure to radiation or hazardous chemicals, filing a complaint with the Occupational Safety and Health Administration, etc.).
- An employer makes oral or written statements that lead the employee to believe their employment will not be terminated, except in specific, extreme situations; - While each case is dependent on the specific facts and circumstances, an implied contract is not generally upheld by courts if an employee handbook specifically states the employment does not create a legal contract between the employer and employee and that the employment is at-will and the employee may be terminated for any reason, not just for cause.
- Both state and federal discrimination statutes prohibit employers from basing employment decisions on the employee’s race, color, religion, sex, national origin, age, disability, or veteran status. Some state statutes may also protect discrimination based on sexual orientation or other protected classes.
- State or federal law may prohibit employers from firing employees in retaliation for engaging in legal, proper, necessary or desirable activities (e.g., reporting child abuse, reporting illegal activities, engaging in union activities, filing for workers’ compensation, and being a whistleblower regarding illegal or specific activities).
- Some states require employers to only terminate for just cause, even if the employee handbook says employees may be terminated for any reason or the employee is subject to an employment contract.
Exempt Versus Non-Exempt Status
Under the federal Fair Labor Standards Act (FLSA), employees are classified as “exempt” or “nonexempt.” Exempt employees typically receive their full salary in each pay period, regardless of the quantity or quality of work performed. Non-exempt employees are paid for each hour they work. 5 They typically only work the established number of hours, but an employer may require them to work additional hours, take on-call time, or be called in for work. However, non-exempt employees are paid for this time and will often be eligible for overtime pay for some or all this time.
Sonographers are generally NOT exempt from on-call or overtime pay under the FLSA. 6 The U.S. Department of Labor (DOL) does recognize sonography as a profession, but does not recognize it to be a “learned profession” because it does not require an advanced specialized academic degree as a standard prerequisite for entrance into the profession. The FLSA exempts individuals who are employed as bona fide “executive, administrative, professional and outside sales employees” from both minimum wage and overtime pay. 7 Thus, some sonographers in executive or administrative positions may be exempt from some FLSA pay requirements. A facility’s Human Resources Department should be able to identify each position’s classification as it relates to FLSA.
NOTE: While sonographers may meet the first three tests outlined by the DOL for a “learned profession,” the fourth test is problematic as the required advanced knowledge “must be customarily acquired by a prolonged course of specialized intellectual instruction in occupations that have attained recognized professional status, which requires an advanced specialized academic degree as a standard prerequisite for entrance into the profession.” So, while sonographers want to be recognized as professionals, obtaining formal recognition by the DOL as a learned profession could have unintended adverse consequences (i.e., all sonographers might be exempted from minimum wage and overtime pay requirements).
8
Factors Affecting Facility Use of On-Call and Callback
On-call staffing may be used to handle peak load demand (e.g., multiple on-call personnel or combination of on-duty and on-call personnel). On-call staffing can also be a cost-effective alternative to hiring additional staff. But there are many internal and external factors that may affect a facility’s use of on-call and callback. A few examples of these factors include:
(7) Radiology services, including portable x-ray and ultrasound on-call 24 hours a day. 9
On-call staffing can also have a significant negative impact on sonographers including, but not limited to:
These factors may be compounded when the employer does not have sufficient staff (e.g., because of resignation, vacation, illness, injury, etc.). These compounding factors may be mitigated, to some degree, with part-time and per diem/traveler staffing use, but some sonographer managers have reported they are unable to get approval for new or per diem staff until an absent employee’s workers’ compensation claim has been fully settled.
Some sonographers are currently under union contracts that may limit or eliminate on-call/callback. Unionization efforts typically occur as part of a larger union effort (i.e., an entire hospital or hospital system) rather than by a few sonographers or a small imaging department who are seeking change. However, there has been recent activity (and court cases) by the National Labor Relations Board (NRLB) related to “micro-unit” representation. 10 If any union activities are undertaken, it is essential that both employees and employers comply with all state and federal requirements (e.g., sonographers should not conduct sickouts, slowdowns, or boycotts, and employers should not interfere with legal union activities, etc.). 11
To ensure new employees understand that on-call and callback are position requirements, a best practice for employers would be to disclose whether on-call/callback are requirements in the position description and job opening advertisement. The employer might also provide an estimated number of on-call hours per week, month, or pay period (based on history, if available). But it would also be important to provide a caveat statement (e.g., in an employee handbook) that the employer may change the requirements for a position at any time, if applicable (e.g., in an employment-at-will state, non-union position, etc.).
Because sonography is a growing profession, employees may have other options if their current employer is unable or unwilling to address sonographer on-call and callback concerns. These options may include, but are not limited to, employment:
At a facility that does not require on-call/callback;
As a sonography educator;
As an application specialist with a sonography-related manufacturer or distributor;
As a contract or per diem sonographer; or
As an entrepreneur by starting a mobile sonography business.
Of course, each of the options listed above has pros and cons, so it is wise to consider all issues and ramifications carefully before choosing the next step in a career path.
Financial Implications of On-Call and Callback Policies
Over-utilization of on-call sonographers can negatively impact the facility’s employees, imaging department, and patient care. But because of the cost and potential for under-utilization of sonographers during some shifts, elimination of on-call responsibilities in many facilities is impractical.
Most acute care providers in the healthcare industry use cost-based pricing, so administrators involved in setting prices must understand the types of costs and cost behavior. On-call service is a semi-variable cost. Typically, the employer pays a fixed amount for staff to be available and then a variable amount depending on the number of times on-call staff came in and the type of services they provided. 12 (p123)
Departments can quickly go over budget by utilizing per diem staff as regularly scheduled staff that were unaccounted-for as full-time equivalents (FTEs) in the facility’s budgeting process. Adding up the number of examinations done per week and dividing by the total number of FTEs yields a ratio that indicates whether a department is doing better or worse than its productivity goal or established benchmarks. 12 (p194)
Employers often fail to consider or under estimate the costs of employee absences due to ergonomic injury, which can be particularly costly to the facility (i.e., workers’ compensation claims, legal expenses, etc.) and negatively impact other department employees (i.e., increased workload, missed breaks/lunches, increased on-call and callback, job dissatisfaction, additional ergonomic injuries, etc.).
A facility may need to consider hiring one or more part-time or per diem sonographers to reduce missed breaks/meals and excessive levels of on-call/callback (e.g., due to long sonographer absences for workers’ compensation injury, increased workload, etc.). The facility must compare the additional financial impact of fixed costs for FTE or part-time/per diem sonographers, reimbursement income from sonography procedures, and the long-term costs for the facility if an ergonomic injury arises because of over-utilization of sonographers (whether from regular work hours or excessive callback).
NOTE: See the Industry Standards for Prevention of Work-Related Musculoskeletal Disorders in Sonography for more information on preventing sonographer injury. These standards and other resources are available on the SDMS website (http://www.sdms.org/resources/careers/work-related-musculoskeletal-disorders) and published in the September/October (2017) issue of the Journal of Diagnostic Medical Sonography (JDMS).
Strategies for Development of Effective Callback Policies
It is important to always recognize that the decision to order a sonographic examination is a medical decision first and foremost and must be based on patient need. Administrative or financial considerations should always be secondary. Thus, a STAT examination order may necessitate a callback of an on-call sonographer. But, if an examination can be ordered as routine (e.g., within 24 hours), the callback policy may dictate that on-call staff not be called in.
A written callback policy can provide facility staff with an objective framework for deciding when to callback a sonographer to perform a sonographic procedure.
A
According to one research article published in the Annals of Vascular Surgery, restricting the number of off-hours venous duplex ultrasound studies for evaluating deep vein thrombosis (DVT) can improve resource utilization without hurting patient care. Researchers from the University of Pittsburgh School of Medicine found that limiting these studies to only those that met certain criteria led to fewer exams and a higher frequency of positive findings. Also, the policy helped the institution maintain sonographer satisfaction and retention, all without any negative patient effects. 13
A review article from the Department of Emergency Medicine, Irvine Medical Center, University of California suggests that limited availability of ultrasound technicians [sic] may result in delayed imaging or in a decision not to image low-risk cases. It concludes that many studies support emergency physicians as capable of accurately diagnosing deep vein thrombosis using bedside ultrasound. 14 Some sonographers report that their facility (e.g., a dedicated vascular lab) does not require sonographers to take on-call shifts because the facility does not see patients outside of scheduled hours, and any emergent cases (e.g., DVT) would be referred to a nearby Emergency Department. Some sonographers have also reported that their facility has a policy that on-call sonographers are not called in after 10:00 or 11:00 pm and diagnostic examinations are deferred until morning.
Some facilities offer dedicated on-call sleeping rooms or the use of vacant patient rooms (if available) to on-call employees to reduce their callback response time. Of course, not every employee wants to sleep at the facility (e.g., family obligations, sleep comfort, etc.) and some sonographers have reported that on-call rooms sometimes may not be properly maintained (e.g., dirty linens, etc.), which can discourage on-call employees from using the rooms. Some facilities have eliminated on-call sleeping rooms due to legal risk concerns (e.g., sexual assaults, use for “other consensual purposes", etc.). Some facilities even pay for on-call sonographers to stay at a nearby hotel if called in a specific number of hours or times in one shift (or where weather might make call-back impossible).
It is important to always recognize that the decision to order a sonographic examination is a medical decision first and foremost and must be based on patient need.
Demanding change without an understanding of the issues and rationale on both sides is rarely successful.
With so many different types of medical facilities, specialty areas, and administrative structures where sonographers may work, each facility will need to determine who should be involved in decisions regarding on-call policies. A few possibilities include:
Sonographers
Medical Imaging Department staff/managers
Radiologists or other physicians who supervise sonographers
Other physician specialists likely to order sonographic procedures
Facility Medical Staff Board members
Emergency Department physicians/managers
Risk Management Department staff/managers
H uman Resources Department staff/managers
Quality Management Department staff/managers
Legal Department staff/managers
Other Department staff/managers that use on-call staff
Patient advocates
Examination of the risks associated with on-call staff should be considered (e.g., if an on-call employee causes or is involved in an auto crash while responding to the facility, lack of sleep causes poor quality examinations that might lead to patient harm or repeated examinations, increasing sonographer ergonomic injuries, etc.). This may include a review of employment costs related to use of on-call sonographers rather than on-duty sonographers, including whether an unreasonable level of on-call or callback time results from position vacancies, leave, etc.
The process of development of objective sonography-related callback procedures may include, but is not limited to:
Anonymous surveys to measure employee satisfaction (including with on-call policies);
Analysis or retention rate and time required to fill vacant positions;
Comparison of on-call staffing in other departments within the same facility and similar departments in other similar facilities, including:
Frequency of on-call shift assignment;
Frequency of callback while on-call;
Facility time and cost of on-call and callback versus part-time or per diem sonographers;
Review of response time, on-call pay, and callback pay standards; and
Types and urgency of examinations performed and the qualifications (e.g., certifcation) of the sonographer (e.g., by sonographic procedure type/code).
Some areas that might be addressed in a facility’s on-call/callback policy include:
Positions impacted (by position title, department, employee);
Scheduling (e.g., weekly, bi-weekly, monthly);
Use of PRN and contract sonographers to avoid overloading sonographers;
How new employees are added to the on-call schedule;
How holidays are managed/shared;
M inimum number of hours to be paid during callback (e.g., 2, 3, 4, etc.);
How on-call schedule replacement/reassignment will be handled, if needed (e.g., due to resignation, illness, medical leave, etc.);
How voluntary on-call schedule changes are documented (e.g., paper or online form, etc.);
Responsibilities and expectations (e.g., swapping scheduled on-call, notification expectations, etc.);
M inimum response time or distance radius;
On-call and callback limitations (e.g., maximum hours worked in 24-hour period, minimum sleep requirements, maximum on-call time per week, etc.);
Availability of sleep rooms, vacant patient rooms, or nearby hotel;
Quality review process (e.g., number of callbacks, types of examinations, policy compliance, etc.)
Conclusion
Many employers do not require their sonographers to take on-call/ callback requirements, while other employers do. Because there are so many different types of medical facilities and administrative structures where sonographers may work and many factors that may impact the sonographer’s daily workload, on-call, and callback, it is critically important that the facility, department directors/managers, and employees work together to find workable solutions for the facility. And what used to work, may no longer be valid or efficient, so a willingness to consider new options or approaches is crucial.
In the final analysis, most sonographers are employed at-will, so it is the employer who is the decision-maker regarding on-call and callback policies. But, employees also have power - the power to seek alternative employment (at-will) if not satisfied with the employer’s policies. Demanding change without an understanding of the issues and rationale on both sides is rarely successful and only increases dissatisfaction and discord in the department. Additionally, no one-size-fits-all solution will work in every sonography department.
Thus, employers should encourage an open and honest discussion of the basis for and positive and negative impact of their on-call and callback policies. Employers must be willing to review the impact of changing circumstances (e.g., position vacancies) on the current policies (e.g., increasing callback, burn out, dissatisfaction, etc.) to ensure the policies are still appropriate, do not harm patients or sonographers, and no better alternatives can be identified.
Case Studies
Case Study #1
The hospital’s Sonography Department’s volume had increased significantly, and the sonographers were unable to keep up. Scheduled exams creeped out to wait times of one week or more. As a result, two facility priorities: (1) access to care, and (2) always doing what is best for the patient, were competing against the hospital’s efforts to control overtime costs. Some clinics had even advised patients to go to the Emergency Department rather than wait for a scheduled exam, an inappropriate use of the Emergency Department’s resources. The manager went to her supervisor and finally got approval for overtime, as needed.
As a team, the Sonography Department committed to doing everything they could and would not allow overtime to be a reason for not scanning a patient today! Because of the team’s efforts, the backlog of scheduled exams was quickly eliminated, sonographers still got their breaks and lunch, and actual overtime was minimal. The manager reported that everyone thought it was great to be able to tell physicians again: “Sure, send them down, we can take care of them now!"
Case Study #2
Our hospital’s on-call policies have changed significantly over the years. For example, when first opened, the hospital’s sonographers took on-call for one-week. While they could be called back numerous times during the week, most callbacks occurred on weekends. As study volumes doubled, the on-call assignments were divided into Monday through Friday and Friday evening through Monday morning. As the hospital’s volume continued to grow, the on-call became two days during the week, and one day on weekends, and so on. The on-call policy changed as the number of sonographers hired increased (but also changed when we had vacancies).
After getting pressure from the Emergency Department for faster turnaround and from administration to control overtime costs, the sonography manager started to keep track of when sonographers were being called back (date/time), for what type of exam they were being called back to perform, how long the call back lasted, etc. We also looked at the ergonomic impact of increased patient volume and vacancies on our sonographers.
Once data had been collected and analyzed, it was clear that the call volume justified hiring additional sonographers in the department and staffing the department from 7:00 am until midnight. Hiring additional sonographers greatly reduced the on-call time and callbacks for each sonographer and significantly increased employee satisfaction.
Case Study #3
Our Sonography Department established a “Call List” with each person’s name on the list, and everyone (including the Sonography Department manager) was treated the same, even for holidays. Seniority did not entitle anyone the best dates/times. Written policies were developed to address eventualities that might impact the list (e.g., illness, family emergency, vacation, trading on-call shifts, etc.).
Each time the Sonography Department manager went to the Call List, the person at the top was the one assigned to an on-call shift. Once they had been assigned and completed the on-call shift, they went to the bottom of the list. However, a sonographer whose name appeared lower on the list could also volunteer to do whatever was needed next, and their name would then go to the bottom of the list.
Actually, the Call List was rarely needed - sonographers routinely volunteered when it was most convenient for them to do so. This made the manager’s decision-making so much easier and decreased any feeling of being imposed upon or taken advantage of because an employee did not have seniority. It really incentivized the volunteer/team system.
Case Study #4
Overall, our hospital experienced an increasing number of callbacks, especially to the 24/7 Emergency Department. We began staffing our department on weekends (typically, each sonographer works 8 hours on one Saturday or Sunday each month). We minimized callbacks by creating dedicated appointments for Emergency Department patients between 6:00 and 7:00 AM; our sonographers preferred coming in an hour early versus being called in at random times overnight. We also worked with the Emergency Department staff and physicians to only callback our sonographers for STAT orders; otherwise, they can schedule the patients into the early morning appointment slots.
Case Study #5
We staff our sonography department from 7:00 AM to 5:00 PM. On-call was a sore subject with our sonographers, and we lost several because of it. We have hired 4 PRN sonographers for coverage after hours and all weekend, and it has worked out well. The PRN sonographers are paid for on- call time plus callback time (paid for a minimum of 2 hours when called in). Each month, the PRN sonographers work out a proposed schedule among themselves and submit it to me for review/ approval. Staff morale has increased across the board.
Case Study #6
We have a sonographer onsite until 10:30 pm, Monday through Friday. On weekends, we have two sonographers each day from 8:00 am to 5:00 pm. This allows us to schedule outpatient and ED patients in one room (sometimes both rooms, which has led us to add another sonographer to cover 2:00 to 10:30 pm to help with peak weekend demand). While these have staffing additions have not eliminated our on-call callbacks, it has significantly reduced them (which the sonographers love).
Case Study #7
There was a time when the loss of staff was costing our department lots of money (and time) for interviews and training. It also impacted staff morale. We prepared a comparison of the costs to pay overtime, call pay, etc. versus staffing all shifts. We found the cost was about the same, but it would be a great move for staff morale and retention. Adding the shifts also helped the day shift reduce the risk of musculoskeletal injury from non-stop examinations. We were able to add new procedures that we could not take on in the past and we now provide coverage 24/7.
Footnotes
Acknowledgements
The SDMS would like to acknowledge and thank Donald Kerns, JD, CAE for his work on the On-Call and Callback Issues in Sonography white paper.
Disclaimer:
This informational resource is provided by the Society of Diagnostic Medical Sonography (SDMS) to facilitate discussion of complex issues affecting the diagnostic medical sonography profession. It is meant to help readers understand an issue, solve a problem, or make a decision.
The information presented does not represent SDMS policy and should not be considered medical or legal advice. The reader should always consult a physician (for medical advice) or an attorney (for legal advice) licensed in their state to discuss their specific facts and circumstances before relying on the information provided in this document.
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