Volume Control, Part II

John Nelson, MD, MHM

Last month I began looking at ways hospitalist practices can manage unpredictable increases in patient volume, also known as surge staffing. I provided my view of a “jeopardy” system and a patient volume cap for hospitalists. While both are potentially very effective, they have a high cost and in my view are imperfect solutions. This month I’ll examine some less common strategies to provide surge staffing. Although less popular, I think these options are more valuable.

Schedule More Providers

I’ve worked with a lot of practices and am struck by how patient volume for nearly all of them falls within a reasonably predictable range. While no one can predict with certainty which days will be unusually busy or slow, nearly all practices have a range of daily encounters that is roughly half to 1 1/2 of the mean. For example, if a practice has a mean of 60 billable encounters per day, it probably ranges from about 30 to 90 encounters on any given day. (The larger the practice, the more likely they are to conform to this range. Small practices, with average daily encounters fewer than 20, have a much wider range of daily volumes as a percent of the mean.)

Despite knowing that volumes will vary unpredictably, most practices provide the same fixed “dose” of provider staffing every day—that is, the single most common model for staffing and scheduling is to provide a fixed number of day-shift doctors (“rounders”) who work a fixed number of hours. For example, with an average of 60 billable encounters a day, a hospitalist group might decide to staff with four day-shift rounders working 12-hour shifts. This equates to a fixed 48 hours of daytime staffing. This is reasonable until the busy days arrive. Those four doctors will be much busier than average when there are 90 patients to see in a day, and will probably have a hard time seeing 22 or 23 patients each during their 12-hour shift. If such a busy day occurs more than a couple of times annually, then the practice should probably make some changes.

If I were willing to reduce my compensation and average daily workload, then I would expect to be freed from the expectation that all rounding doctors work 12-hour shifts.

One approach to solving this type of staffing predicament is to add a fifth day-shift rounder. In other words, when making staffing decisions, consider giving more weight to the busiest days than the average day. This sounds fine until thinking about the practice budget. It will be pretty expensive to add doctors every day just so there are enough on duty when things get really busy. But if the hospitalists are willing to accept reduced compensation, then it might be financially reasonable to go ahead and add staff. This is easiest to do when the hospitalists are paid a significant (e.g. ≥50%) portion of their income based on their productivity, which will enable the hospitalists themselves to have a lot of say about when it is time to add staff. (Being paid on a nearly fixed annual salary means that it is the finance person who usually has the say about when it is time to add staff. And you can bet he’ll be making staffing decisions based on the average daily encounters, rather than the busy days.)

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