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HM13 Session Analysis: Is 15 Patients a Day the Right Number?


 

I attended the practice-management session with an intriguing title, “Hospitalist Workload: Is 15 the Right Number?” My own group, as I am sure many are, is struggling with this very question.

Henry Michtalik, assistant professor and hospitalist from Johns Hopkins and associate faculty at the Armstrong Institute for Patient Safety and Quality talked about physician perceptions of workload and the impact of that perception on patient safety. He noted that 40% of physicans report that their typical census exceeds “safe” levels at least monthly. Multiple factors impact that perception, including the physicians’ years of experience and the presence of housestaff, as well as the total amount of clinical time yearly. Other factors that can influence this perception include the type of hospital, the ancillary team make-up, and the patient’s payer mix and acuity. Twenty percent of physicians reported that workload negatively impacted the hospitalist’s ability to discuss the plan of care or delayed discharge.

The JAMA Internal Medicine article from April 2013 that he wrote also noted, most interestingly, that fixed census caps decreased the odds of reporting an unsafe census by 34%. Bring ’em on!

Daniel Elliott presented data from his role as acting associate chair for research and co-director of ambulatory research and Clinical Outcomes at Chistiana Care Department of Medicine in Wilmington, Del. He undertook a study designed to answer the question: What is the impact of increased workload on clinical outcomes? He looked at key variables of length of stay, continuity, 24-hour average occupancy, and turn-around time (i.e., time between ordering a test until the time completed on five most commonly ordered tests by hospitalists).

What he learned is that a higher physician workload is associated with increasing LOS, but notably this association decreases as hospital occupancy increases, meaning that a less-busy hospital means that LOS is a hospitalist dependent variable and MORE sensitive to workload. Conversely, a more busy hospital’s LOS is hospital dependent and LESS sensitive to physician workload. This reveals the importance in collaboration between hospitals and hospitalists, as they both contribute to outcomes that impact LOS.

Jill Menzel program manager for the hospitalist program business unit for Thedacare, said her group utilizes a balanced approach to evaluate workload, looking at safety/quality by evaluating 30-day readmission rates, financial stewardship by evaluating productivity (which she defines as units of service divided by the number of hours worked), and by evaluating people’s perception of the manageability of their workload, all surrounding the central tenet of the customer. They don’t look at a RVU metric, but instead focus on tracking the average amount of time to do work by provider. This tracking method allows them to accurately see where more help was needed and get it there.

And finally John Nelson, a hospitalist in suburban Seattle and practice management consultant summed up the session with the information that there is no clear correlation between a specific workload and burnout or stress, but there definitely IS a correlation between perceived workload and burnout. The take-home message? If you feel as if you are working too hard, then you are. A specific number is not clear.

Basically, there is no right number. But there is some data noting that higher workload leads to increased LOS, and that if you feel like you are working at an unsafe level your patients may be at risk of a longer hospitalization with less communication and more unnecessary tests, and you may personally be at risk for burnout. TH

Tracy Cardin is a nurse practitioner in the section of hospital medicine at the University of Chicago Hospital.

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