"How should I explain the physician work style reform that began in April 2024 to our hospital clients?" "The system is complicated, and it's difficult to clearly explain the differences between A, B, and C levels and night and day shift permissions..."
On April 1, 2024, caps on overtime work finally came into effect for physicians. This "physician work style reform" is a major, unavoidable change for the medical industry.
However, the reform goes beyond simply reducing work hours. Deep-rooted issues, such as the complex requirements for exceptional levels, the long-standing culture of long working hours, and serious labor shortages, are intertwined, making it difficult to grasp the essence of the issues and develop effective solutions based on superficial information alone.
This article will address the following challenges:
- Accurately understand the outline and key changes of the physician work style reform that began in April 2024.
- Identify three fundamental issues unique to the medical field that are behind the lack of progress in reform: organizational culture, staffing shortages, and attendance management.
- Learn specific measures that hospitals and medical institutions should take immediately to comply with the new system in five steps.
- Get hints on approaches that are practical not only for large hospitals but also for small and medium-sized hospitals with limited resources.
- Organize complex systems and issues, and confidently propose improvement measures to clients.
This article is aimed at those facing the challenges listed above. It provides an easy-to-understand explanation of the core issues surrounding the physician work style reform facing Japan's healthcare system.
By reading this article, you'll gain a comprehensive understanding of the system, real-world challenges, and concrete solutions, empowering you to confidently take the next step to protect the future of your medical institution.
What is the Work Style Reform for Doctors? A clear explanation of the changes that will take effect in 2024
The "Workstyle Reform for Doctors" refers to a series of initiatives aimed at correcting doctors' long working hours, ensuring their health, and protecting the quality and safety of medical care. For many years, Japan's medical system has been supported by doctors' self-sacrificing long working hours, but a nationwide reform initiative has been launched to build a sustainable medical care system.
In particular, the cap on overtime work, which came into effect on April 1, 2024, is an urgent and important issue for all medical institutions.
Why is work style reform for doctors necessary now?
The urgent need for reform of working practices for doctors stems from a serious reality. In many cases, some doctors were working over 100 hours of overtime per month, far exceeding the threshold for death from overwork.
Such harsh working conditions not only undermine the physicians' own physical and mental health, but also increase the risk of medical errors due to impaired judgment caused by fatigue, ultimately threatening the quality and safety of medical care received by patients.
The ultimate goal of this reform is to improve this situation and create an environment in which physicians can continue to work in good health, thereby ensuring the stable provision of high-quality medical care into the future.
What changed from April 2024? The biggest change is the cap on overtime work.
The biggest change in this reform is that for the first time, legal limits on overtime work have been established for doctors (Labor Standards Act). Specifically, the following limits have been set for overtime and holiday work hours:
・General rule (Level A): Up to 960 hours per year
・Exceptions (Level B, Collaborative Level B, and Level C): Up to 1,860 hours per year
This regulation places a legal obligation on medical institutions to accurately track the working hours of doctors and manage them so that they do not exceed the upper limit. Furthermore, for doctors who are expected to unavoidably work more than 100 hours of overtime per month, additional health measures such as interviews to check their health status are required, and strict compliance is required.
[By level] What are the differences in targets and conditions for levels A, B, and C?
The limit on overtime work for doctors is not the same for all doctors, but is divided into several "levels" depending on the function and role of the medical institution. The first step in taking measures is to understand which level your hospital falls under, or what level you are aiming for.
It is important to note that medical institutions cannot freely choose between Level B and Level C. It is important to understand that these are special measures designated after a review by the prefecture based on objective criteria such as the degree of contribution to local medical care and the content of the training program.
What is "night and day duty permission"? Requirements for excluding it from working hours
Another important keyword in managing overtime work is "night and day duty permission." This is a system that, by obtaining permission from the chief of the local Labor Standards Inspection Office, can exempt night and day duty work, whose main job is to be on standby, from the working hour regulations of the Labor Standards Act.
If this permission is obtained, the hours worked on night and day shifts will not be counted towards the upper limit on overtime work (such as 960 hours per year), making this a realistic time management option for many medical institutions. However, there are strict requirements for obtaining permission.
- Normal medical work will not be performed, and the work will be "intermittent" (rarely dealing with emergency cases, etc.).
- Facilities such as private rooms and beds will be provided to allow for adequate sleep at night.
- Night shift allowance will be paid in an amount of at least one-third of the average daily wage of workers engaged in similar work.
Applications must be made on an individual medical institution basis, and the basic premise is that "freedom from work is guaranteed." Correctly understanding and utilizing this system is essential for promoting work style reform.
[TIPs] Career development for "young doctors" who are subject to C level
Level C is primarily aimed at clinical trainees and residents in their first five years after graduation. This is an extremely important period for doctors to intensively acquire specialized skills. Therefore, due to the need to experience many cases, exceptionally long overtime work is permitted.
However, this does not simply mean accepting long working hours. Medical institutions are required to formulate and implement plans to reduce working hours to protect the health of young doctors while ensuring the quality of their training programs. Work style reform is also an opportunity to explore new education and training models that allow young doctors to balance their career development with their work-life balance.
Reforms in the way doctors work are being implemented are not progressing... Three fundamental issues facing the medical field
Even if you understand the outline of the system, you will encounter many obstacles when you try to move forward with the reform. Why is it that work style reform in the medical field is not progressing as expected?
Behind this lie three deep-rooted issues specific to the medical field that cannot be solved by laws and systems alone.
Issue 1: Organizational culture where long working hours have become the norm and doctors' attitudes
In the medical field, there is a deeply rooted culture of self-sacrifice, where doctors believe they should work themselves to the bone for the sake of their patients. In particular, veteran doctors, having endured long working hours when they were younger, tend to expect their junior colleagues to work in the same way.
Another major obstacle to reform is the culture of "忖度" (guessing what others think), which makes employees feel guilty about leaving early while their colleagues are busy working, and makes it difficult for them to request overtime work from their superiors. As long as the idea that "taking time off is bad" is widespread throughout an organization, simply changing the system will not bring about much change in reality.
Challenge 2: Serious staff shortages and on-site resistance to task shifts
The fundamental problem is that many medical institutions, especially those in rural areas and small and medium-sized hospitals, have an absolute shortage of doctors. If they try to maintain a 24/7 medical system with a limited number of doctors, the burden per person will inevitably increase.
One solution to this problem is recommended: "task shifting/sharing" (transferring or sharing some of a doctor's work to nurses, pharmacists, medical administrative assistants, etc.), but this is not easy either.
Coordinating at the on-site level requires a great deal of effort and time, as there is resistance from other professions, such as "Only doctors can do that job" or "I'm worried that my job will be taken away," as well as a lack of training to take on new tasks.
Issue 3: Inaccurate work hour management and the reality of unpaid overtime
The first step in work style reform is to accurately grasp current working hours, but this is one of the most difficult challenges in the medical field.
There are many cases where employees do not have time cards and instead rely on self-reporting, or where tasks such as emergency calls, conference preparations, and paper writing are not counted as working hours.Without objective data on working hours, it is impossible to even analyze who is working how much, or where there is room for improvement in work.
Unless the reality of this "invisible working hours (unpaid overtime)" is made visible, reforms will remain nothing more than a pipe dream.
Five concrete steps that hospitals and medical institutions should take now
Reforming the way doctors work is a complex task that requires a lot of effort, but there is no need to be pessimistic. By taking steady steps one by one, we can be sure that we will find a way forward.
Here, we will explain the specific measures that hospitals and medical institutions should take immediately, divided into five steps.
Step 1: Accurately understand and visualize physician working hours
All reforms begin with understanding the current situation. The first priority is to accurately grasp and visualize the working hours of all doctors using an objective and reliable method.
Implement an attendance management system that utilizes IC cards, PC log-on/off records, smartphone apps, etc., and accumulate data on who is doing what work, when, where, and what kind of work. This will reveal unpaid overtime and work imbalances that have been overlooked until now, and lay the foundation for considering specific improvement measures.
This is also the first step in evaluating the cost-effectiveness, which many companies find challenging when introducing IT tools.
Step 2: Reviewing the 36 Agreement and setting upper limits on working hours for each doctor
In order to comply with the new upper limit regulations, it is essential to review the labor-management agreement (36 Agreement) based on Article 36 of the Labor Standards Act. The contents of the agreement that applies to all doctors in the hospital must be updated to comply with the new upper limit (960 hours per year in principle) and submitted to the Labor Standards Inspection Office.
Furthermore, if there is a doctor who is subject to Level B or Level C, a 36 Agreement must be concluded that includes a special clause to apply the 1,860-hour annual limit to that doctor individually.
It is important not only to renegotiate the agreement, but also to plan shift management and work allocation that does not exceed the maximum hours, in accordance with the working conditions of each doctor.
Step 3: Promote task shifting/sharing to streamline operations
The most effective way to directly reduce the workload of doctors is to promote task shifting/sharing. For example, the following initiatives can be considered:
- Preparation of medical certificates: A medical administrative assistant will prepare a draft, and the doctor will only need to make a final check and sign.
- Venous blood sampling and establishing routes will be carried out by nurses who have received special training.
- Medication instructions: Pharmacists will be more actively involved in ward operations and will provide explanations to patients.
The key to success is not to simply promote the process from the top down, but to set up a working group involving all relevant departments, carefully explain the purpose and benefits of the business transfer, and gain the understanding and cooperation of those on the ground. This will also lead to reforms in organizational culture.
[TIPs] The first step in task shifting that can be done even in small and medium-sized hospitals
There's no need to give up and think, "We don't have enough manpower, so task shifting is impossible." Even if a large-scale transfer of work is difficult, it's possible to start with small steps.
For example, simply creating a rule that "administrative staff should first handle the initial phone calls that doctors make" will increase the amount of time doctors can concentrate on their medical practice. In addition, the Ministry of Health, Labor and Welfare's portal site, "IkiSapo," publishes a collection of case studies that can be searched by hospital size, so you can refer to the efforts of hospitals of a similar size to your own. First, start by taking stock of the tasks that are most familiar to you.
Step 4: Implementing "additional health measures" to protect the health of doctors
In addition to managing working hours, it is also a legal obligation to take measures to ensure the health of doctors. In particular, for doctors who fall under the special standards (Levels B and C) and cannot avoid working long hours, the following "additional health measures" must be thoroughly implemented.
- Shift intervals: In principle, at least 9 hours of rest will be ensured between the end of one shift and the start of the next.
- Limits on continuous work hours: In principle, employees will not be allowed to work more than 28 hours continuously, such as after a night shift.
- Compensatory rest: If an interval between shifts cannot be ensured, an alternative rest (day off) will be provided at a later date.
- Interview guidance: For doctors who work more than 100 hours of overtime per month, an interview guidance session will be held with an industrial physician or other professional to check and provide guidance on their physical and mental condition.
These measures are not only a legal obligation but also an important safety net for maintaining physician performance and ensuring medical safety.
Step 5: Share the need for reform throughout the House and foster a culture
To make the four steps above effective, it is ultimately essential to change the organizational culture. It is important for management to send a strong message throughout the hospital that "reforming the way doctors work is our most important management issue" and demonstrate their seriousness about the reform.
It is also effective to create a positive atmosphere by holding training sessions for staff in all departments to share the purpose and necessity of the reforms, and by awarding departments and individuals who have successfully reduced working hours. Let's spread the new value of "high-quality work done on time is what is valued" throughout the hospital and foster a culture of sustainable reform.
Summary: Now is the time to take the first step toward reform to protect the future of doctors and hospitals
In this article, we explain the "Workstyle Reform for Doctors," which began in earnest in April 2024, from the key points of the system to the deep-rooted issues facing the medical field and specific measures.
Finally, let's review some key points.
・Key points of the system: In principle, doctors' overtime work will be limited to 960 hours per year, with an exception of 1,860 hours per year. It is essential to accurately understand the system tailored to the circumstances of your hospital, including A, B, and C levels and permission for night and day shifts.
・On-site challenges: Three deep-rooted problems are hindering reform: a culture that condones long working hours, a serious staff shortage, and inaccurate attendance management.
・Specific measures: The key to success is to start with the foundation of everything, making working hours visible, and then move on to reviewing the Article 36 Agreement, task shifting, health measures, and fostering a culture.
Reforming the way doctors work is not just a burdensome obligation to comply with regulations or regulations. It is an important management investment for the future, protecting the health and livelihoods of exhausted doctors, ensuring the quality and safety of medical care, and ultimately ensuring that hospitals themselves continue to be chosen by the local community.
Why not take the first step towards reform by accurately understanding the actual working hours at your hospital?
