Practice Economics

Volume Control, Part II


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.)

My own preference would be to do just that: Accept a reduction in compensation in return for protection against really busy and stressful days. I’m not suggesting others should agree with me, and in my experience, most don’t. (My own practice partners don’t agree with me on this one.) So I’m not really recommending it as a best practice, but I want to ensure that you don’t forget it is an option. And keep in mind you could adjust staffing by degrees; some settings might add a half-time physician or a nonphysician provider to try to find the sweet spot between having enough staff on duty every day to handle surges in volume and the cost of that staffing to the employer—or the hospitalists themselves.

Of course, 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. Let’s turn our attention to the interplay between fixed day-shift durations and surge staffing.

Fixed-Shift Schedules Inhibit Surge Capacity

I think it usually is best to avoid fixed durations for day shifts. It might be necessary to require at least one daytime rounder to stay at least until a specified time (e.g. the arrival of the night-shift doctor), but in most cases it is reasonable for some rounders to leave when their work is done. They might need to continue responding to pages until the start of the night shift, but it usually isn’t necessary to have all rounders in the hospital until a predetermined end of the shift.

The problem is that when shifts have a fixed duration, the providers will focus on the start and stop time of their shift and might be unwilling to work beyond it. If instead there are no clearly fixed start and stop times for each day shift, then the hospitalists are likely to be willing to simply work longer on busy days, as long as they can work shorter on slow days. This is probably the most effective method of surge capacity, and it fits well with staffing each day with more providers than are required for the average patient volume.

Simply having the rounding doctors work longer on busy days must be done within reason. And there is a really wide range of opinion about what is reasonable. I think it is reasonable if a hospitalist works two or three hours longer than usual for three or four consecutive busy days, as long as the hospitalist is allowed to work less on days that are not very busy. But just what is a reasonable maximum daily amount of work for even one day is a topic that can lead to passionate debate. You’ll have to decide the details of what is and isn’t acceptable in your group.

Unit-Based Assignments

Aside from fixed-duration day shifts, unit-based assignment of hospitalists is the most common practice inhibiting surge capacity. Not long ago I worked with a practice that followed very strict unit-based assignments, which significantly inhibited “load-leveling,” and thus surge capacity. On any given day the patient volume for the whole practice might be very reasonable, but because it was never distributed evenly among the rounders, there was a very good chance that at least one doctor was drowning in work. And because of the strict approach, the other doctors didn’t come to the rescue.

I think the only reasonable approach is to deviate from such a strict unit-based assignment, at least a little. One rounder could be a utility doctor who doesn’t have her own unit and instead roams throughout the hospital, having been assigned patients based on the workload of each of her unit-based colleagues. TH

Dr. Nelson has been a practicing hospitalist since 1988 and is cofounder and past president of SHM. He is a principal in Nelson Flores Hospital Medicine Consultants ( and codirector and faculty for SHM’s “Best Practices in Managing a Hospital Medicine Program” course. This column represents his views and is not intended to reflect an official position of SHM.

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