Published in the November 2013 issue of Today’s Hospitalist
PROBABLY THE HOLY GRAIL that all groups are searching for is figuring out doctors’ ideal workload. What level of productivity is satisfying without making physicians crazy?
Three years ago, the Wisconsin-based health care system ThedaCare was struggling with that question. But one thing quickly became clear: Neither the number of patient encounters nor the traditional work relative value unit (wRVU) metric was nuanced enough to accurately measure hospitalists’ work.
Jill Menzel, then the newly-hired business manager for the 21-provider hospitalist group at two ThedaCare hospitals, decided to borrow from her background as an engineer for manufacturing companies. She focused squarely on hospitalists’ key clinical activities.
“We looked at the top 10 things hospitalists do, which isn’t perfect, but it’s helpful,” Ms. Menzel says. The team studied how long it took group members to do each task, then calculated the average amount of time each activity took.
They found, for instance, that an average admission required 60 minutes, while rounding on each patient took an average of 30 minutes. After collecting the data, Ms. Menzel and the program’s physician lead, James McGovern, MD, devised a new productivity metric called a “unit of service.”
The goal of tallying each physician’s units of service, she explains, is to “equalize the amount of work across providers per shift.” The metric also allowed the group to create a snapshot “almost to the hour “of what work hospitalists, NPs and PAs are doing and where.
That’s given the group the ability to target quality improvement to lighten doctors’ loads and keep their workdays manageable.
How it works
Each service unit is basically a minute, predicated on 60 minutes of work. An average admission is therefore 60 units of service, while a critical care patient evaluation, per the system, is 40 units of service. (See “A new way to track productivity.“) The most intensive task turned out to be a collaborative-care patient admission, which involves a multidisciplinary team of a physician, nurse, pharmacist and care manager, and which came in at 75 units of service.
The group tallies service units for each provider from the previous day, based on the billing data clinicians submit. The group then divides service units for each doctor by the number of clinical hours worked to assess his or her productivity.
Ms. Menzel and her administrative staff gather and “chart” those daily data, which takes about 10 minutes per day per clinician. Doctors are credited with the average number of service units for each activity, instead of having service units adjusted daily for an admission that may take longer. But Ms. Menzel stays on top of outliers, just in case higher-than-average numbers suggest a persistent problem to fix.
Charting data daily identifies bottlenecks and, more rarely, lulls. “We look at the data by doctor, shift, and day of the week or month to see what kind of work the hospitalists are doing, and where and when that work is hitting,” says Ms. Menzel. “That allows us to adjust staffing to accommodate peaks and valleys during the day or week.”
Numbers tell the story
Based on the data, for instance, ThedaCare added four NPs and PAs over the past three years to help handle workload increases.
The data also revealed an increasing number of late-afternoon admissions at one hospital, a consistent pattern that warranted adding a designated admitter from 11 a.m. to 7 p.m. The group has also used the data to change how physicians distribute new admissions every morning and to create a “surge” system to pull in staff to cover higher volume.
What service units offer over the typical wRVU, Ms. Menzel maintains, is much more detail about how hospitalist work is changing and when those changes occur.
“As an engineer, I wanted to understand the business and workflow,” she says, “and I couldn’t do that with RVUs. Instead, I worked with the team to help tell a story about the work doctors do every day.”
“Color-coding” workdays
ThedaCare also implemented a second metric to look at hospitalist perceptions of their workday.
At the end of each shift, each hospitalist is interviewed briefly by a staff member and asked to classify that day’s workload as “red” or “green.” A red day is one in which the workload felt unmanageable, while green indicates a manageable one. If the hospitalist reports a red day, she or he is asked to briefly cite the reasons why.
“This question “was your workload manageable? “is much more useful than asking them if they had a good day,” Ms. Menzel said.
When the red/green metric was introduced, some hospitalists “rolled their eyes,” Ms. Menzel recalls. But over time, even skeptics have come around because they’ve seen the daily anecdotal reports translate into action.
“They know that if there are a lot of red reports over several weeks, we will look at the schedule and make adjustments,” says Ms. Menzel. “They know we’ll do something with the data we collect.”
Frequent sharing of data
The data are also broadly and frequently shared. Unit-of-service data “by hour, day, shift and campus “are posted and reviewed weekly in a team huddle with the hospitalists. Red- and green-day data are posted daily and reviewed monthly.
And after years of collecting unit-of-service numbers, the hospitalist group has realized that 45 units of service per clinical hour is the so-called “sweet spot.”
“It seems to be the ideal number for people to be effective without too much downtime or overload,” Ms. Menzel says, “and 45 minutes of estimated clinical work an hour is where we see the highest number of green days.”
Using both service-unit and red/green data, the department realized that one campus tended to admit far more high-acuity patients than the other. The second campus, in contrast, manages more patients with complex social or family issues “which figure prominently in hospitalists’ “red-day” reports.
The data also uncovered noticeable patterns in hospitalist comanagement. “We get consult requests on certain days because that’s when surgeons do more procedures,” says Ms. Menzel. The group is examining whether that warrants modifying hospitalists’ schedules.
Hospital administrators are paying attention, too. Ms. Menzel notes that she must report department productivity and meet related goals, “like everyone in the system, but these data help me explain our business.”
“I’ve found that the administration understands the nursing process well, but not the hospitalist process,” she says. “The data give me a common way to speak their language.”
Bonnie Darves is a freelance health care writer based in Seattle.
