Abstract
BACKGROUND: Hospital medicine programs use backup ("jeopardy") systems to cover unexpected staffing gaps, but little is known about their structures or optimal practices. OBJECTIVES: To describe jeopardy structures, assess clinician perceptions, and identify potential approaches across a broad sample of hospital medicine groups. METHODS: This multi-methods study, conducted within a national hospitalist consortium, used virtual focus groups and an email survey to (1) describe the presence and structure of jeopardy systems and (2) explore features perceived as fair, equitable, and tolerable. Rapid qualitative analysis identified major themes, while descriptive methods analyzed survey data. RESULTS: Twenty-five individuals participated in focus groups, and 26 completed the survey, representing 31 unique institutions. Participants were primarily physicians in academic hospital medicine groups. Three themes emerged: (1) jeopardy systems are widely used but vary in structure, activation criteria, and compensation, leading to inconsistencies in clinician experiences; (2) many clinicians report stress and dissatisfaction due to unpredictability, perceived inequities in assignment, and concerns about inappropriate use; and (3) strategies to improve fairness, equity and tolerability include structured scheduling, support for sick days, and compensation for the burden of jeopardy coverage. Survey data confirmed high variability in jeopardy systems across institutions. Common practices included jeopardy activation over redistributing patients and compensating clinicians for covered shifts. CONCLUSIONS: Jeopardy systems are essential for hospital medicine staffing but contribute to clinician dissatisfaction due to unpredictability and perceived inequities in coverage. Implementing deliberate scheduling, formalized support for absences, and equitable compensation models may reduce dissatisfaction and improve jeopardy system sustainability.