If you ask a group of hospitalists how many patients they can manage per shift without feeling overburdened, you're likely to get answers ranging from 10 to 20 or more. That's because there is no one ideal census number, experts said.
“There is a point beyond which patient care suffers, when hospitalists are not able to make good decisions and keep track of everything,” said Kevin J. O’Leary, MD, FACP, associate chief of hospital medicine at Northwestern Memorial Hospital and associate professor of medicine at Northwestern University in Chicago. “But that threshold varies depending on the model of care and the support around the hospitalist.”
For example, hospitalists typically see more patients per shift in the observation unit than in the intensive care unit, said Dr. O’Leary. And a hospitalist on the overnight shift might feel just as busy as her colleague on the daytime rounding shift but generate fewer relative value units (RVUs) because she's handling emergencies that aren't captured as billable encounters.
Most hospitals do distribute workload using formulas based on average daily census, but there are no conclusive data establishing a threshold beyond which patient safety may be at risk, experts said. As a result, each hospital must devise a formula that works for its particular setting, said John Nelson, MD, FACP, a hospitalist at Overlake Hospital in Bellevue, Wash., and partner in Nelson Flores Hospital Medicine Consultants.
“It's hard to acknowledge the effect that different settings have on workload, so people get wedded to survey averages,” said Dr. Nelson. “But the nature of work varies significantly in a 25-bed critical access facility versus a community hospital with no teaching responsibilities versus a teaching institution where hospitalists are training residents and working in the ICU.”
What's the right formula?
Instead of zeroing in on how many patients a physician sees, some hospitals are focusing instead on the type of work they perform. For example, Thedacare, a community health system with five hospitals in Wisconsin, tracks productivity in terms of units of service (UOS), based on the average time it takes to complete various tasks during a typical shift.
“We observed providers doing the work and came up with average times for different tasks,” said Jill Menzel, Thedacare's hospitalist program business unit manager. “Then every morning we do our billing sheets to decide how many units of service we did the previous day and divide that by the number of clinical hours we worked and that's our productivity measurement.”
Less time-consuming activities such as comanagement (15-20 UOS) or inpatient hospice (15 UOS) are assigned fewer UOS while more complex tasks, such as new consults (50 UOS) or admissions (75 UOS), are higher on the scale.
Administrators also track hospitalists' own assessments of their workload, said Ms. Menzel. Each day hospitalists are asked whether their workload is manageable. “Yes” answers are coded green while “no” answers are coded red and investigated further.
“We track the reasons why they are red,” said Ms. Menzel. “They could have an OK workload in terms of units of service but they might have some tough family meetings or really high-acute patients. Our goal is to be 85% green, knowing there will be bad days.”
Based on that tracking system, Thedacare has discovered that 40 to 45 units of service per hour feels appropriate to most physicians and uses that threshold to flag potential problems that might not be apparent based solely on census numbers. For example, when UOS data indicated that a physician on night duty was overwhelmed at one campus, a midlevel practitioner was added to cushion the transition between shifts.
In a census-driven system, physicians on a given shift split the patient load down the middle, but that often leads to an uneven workload because patients vary in complexity, said Benjamin Duffy, DO, hospitalist lead at Thedacare's Appleton Medical Center in Appleton, Wis. Thedacare's system resolves that issue by dividing up the work by complexity rather than number.
“If I have five comanagements and no ICU patients and my partner is seeing three ICU patients and no comanagements, his workload is considerably higher than mine,” he explained. “So I should take the additional work from overnight, not equally distribute it between us over the day. It can take us from five or 10 minutes to see a high blood-pressure comanagement patient versus an hour to see a very sick patient in the ICU. If you're just counting numbers, it's not going to capture that.”
Thedacare also uses its data to identify trends over time and makes changes accordingly. Recently, it became apparent that the workload was increasing disproportionately at one of Thedacare's two campuses, said Dr. Duffy.
When Thedacare broke down the UOS data into hourly segments, they discovered that physicians at the busier campus were working the equivalent of 15-20 minutes more per hour than their colleagues at the other campus. They responded by hiring a midlevel provider and shifting some physician hours from the lower- to the higher-volume campus.
Maximizing team efficiency
While hospitalists differ on how to measure and manage their workload, many agree that it's often excessive, according to a recent survey published in the January 2013 JAMA Internal Medicine. Forty percent of respondents said that their typical inpatient census exceeded safe levels at least monthly and 20% said that their average workload likely contributed to patient transfers, morbidity or mortality. About one-quarter of respondents said workload interfered with their ability to adequately discuss treatment options with family members and caused them to order unnecessary tests, consults or procedures because they didn't spend enough time assessing patients in person.
Using teams to their full potential is one way to alleviate the perceived overwork without reducing the hospital's overall census, said Henry J. Michtalik, MD, assistant professor and hospitalist at Johns Hopkins University in Baltimore and lead author of the survey, as well as a follow-up study on the factors affecting workload.
“We need to recognize that health care is provided as a team,” said Dr. Michtalik. “Midlevels are part of that team. They can assist in lesser acuity and complexity issues and leave higher complexity cases to the physicians.”
Midlevel clinicians are also highly effective in specialized units where they deal with similar issues every shift, as opposed to pediatrics or general internal medicine, said Dr. O’Leary.
“They work well in observation units, chest pain evaluation units, or working alongside a hospitalist on discharge planning,” he said. “We have them in our perioperative service and our oncology comanagement hospitalist service, where they see the same conditions over and over.”
Washington University Medical Center (WUMC) in St. Louis, Mo., uses nurse coordinators to alleviate some of the administrative burden on physicians, said Mark Thoelke, MD, chief of hospital medicine at WUMC. Nurse coordinators handle tasks such as computer work at admission and discharge, medication reconciliation, and obtaining records from other hospitals.
“It's work that needs to be done and is important to patient care but that doesn't necessarily need to be done by a physician,” said Dr. Thoelke. “As we've gone to more physician order entry and documentation, the time spent on the computer continues to grow and that squeezes out time we can spend with patients.”
WUMC targets a workload of 12-15 patients per day per physician, depending on whether he or she has support from residents. The lower number applies when physicians are working on the frontline hospitalist service without housestaff while the higher number is used when hospitalists are serving as attendings on the teaching service.
Appleton Medical Center assigns nurse practitioners and physician assistants flexible hours during the day so they can be called upon when needed, said Dr. Duffy.
“Because our census is more fluid over the last couple of years we've had to become more fluid in our staffing models,” he said. In addition to using UOS data and the green/red coding described earlier, the hospitalists also employ a triggering system that kicks in automatically whenever the hospital census gets too high for existing staff to handle.
“It used to be that we wouldn't even realize that we were getting in over our heads,” said Dr. Duffy. “Our system triggers a [census] number that the administrative staff monitors. If the census goes over that number they call us and ask if we need help from physicians or midlevels. So I have many fewer days now when the work is excessive.”
Look, listen and feel
Thedacare's solution to workload imbalance at its two Appleton campuses was driven by clinician input, said Dr. Duffy. Knowing what's happening on the front line is key, he said, as “it's always a team decision when important things are changed.”
Northwestern Memorial Hospital also has made positive changes based on physicians' suggestions, said Dr. O’Leary. A few years ago after the hospital implemented electronic medical records, physicians complained that the lack of computer stations were adding to their workload because they often had to wait to use computers. Dr. O’Leary sent pictures of people waiting in line at nursing stations to senior management, and additional computers were installed soon after.
To truly know what's happening on the wards, program directors have to experience it, said Dr. Thoelke.
“I work alongside my physicians so I am experiencing the same volumes and can act as a player-coach in leading my division,” he said. “You can look at RVUs, but you always have to look a bit deeper than that to fully understand the amount of work being done by physicians.”
Administrators also need to feel what it's like to work on the floor by actively engaging in clinical time to see what the flow of work is like, Dr. Michtalik said.
“It's one thing to hear something in a meeting versus going and actually seeing patients and functioning through the system,” he said. “There has to be an understanding of the overall systems in place but also an understanding of what's happening on the front line those that are actually functioning in that environment have the greatest insight into what can be done to affect the issues.”
Thedacare's UOS productivity data are a good starting point for initiating a discussion about workload with clinicians, said Ms. Menzel. “If you're showing physicians the data and it doesn't tell them the story the way they see it, you [both] can start looking at it in a different way,” she said. “You need to have the data to help show physicians where the workload is, and then they can help you find solutions.”
Hospitalists who responded to the JAMA survey made it clear they felt that workload issues could potentially affect patient safety, said Dr. Michtalik. Now, it's imperative that hospital leaders address those issues and establish informed rules for balancing workload rather than leaving it to government regulators.
“If a benchmark is set at 4,000 RVUs per year, that doesn't say whether you have separate admitting teams, a separate procedure service, whether you are seven on/seven off. These factors put context to the actual numbers,” he said. “We have a duty to openly address this difficult and complex issue—if we don't, we may have regulations and guidelines imposed on us rather than by us.”