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Finding the right ratio of physicians and patients is essential for efficiency

Hospitalist Management Advisor, July 1, 2008

Determine the appropriate staffing level for your hospitalist program

As hospital reimbursement from insurance companies continues to drop and physician salaries rise, finding the right physician-to-patient balance is crucial to running a cost-effective hospitalist program.

Richard E. Rohr, MMM, MD, FACP, vice president of medical affairs at Cortland (NY) Regional Medical Center, says hospitalist programs should consider quality of care when creating this balance. “There’s a delicate blend of trying to increase the number of patients your physicians can see on a daily basis with the number of patients your physicians can give safe, efficient care [to],” he says.

The false economy of hospital ratios

When a hospital increases its patient volume, it can lose productivity, lengthen patient hospital stays, decrease patient satisfaction, and change the appropriate level of staff utilization, says Rohr.

“When trying to see more patients in a day, you wind up cutting back on time with a patient or gloss over them superficially, which causes things to get missed,” he adds. “You’re really creating a false economy because you’re seeing more patients than you can handle.”

What the hospital loses in efficiency is not made up in savings on physicians’ salaries in most cases, Rohr says. Having fewer hospitalists, especially ones who are overworked, could decrease the quality of care and raise the chance of mistakes, he says. This can lead to increased length of stays, resulting in lower insurance reimbursement. Additionally, it is likely the hospital will incur more morbidities and mortality, causing long-term costs to skyrocket.

Reconfiguring your physician-patient ratio

There is no easy formula for how many physicians the hospital needs to appropriately staff hospitalist programs, says Shaun Frost, MD, regional medical direc-tor at Cogent Healthcare in St. Paul, MN.

Even if you know how many hospitalists you need in your program to achieve ideal staffing levels, there simply may not be enough hospitalists available because of the national shortage.

“Ensuring that your hospitalist service is properly staffed is a universal challenge for everyone ... in the industry,” says Frost. “There’s a mismatch between jobs in the country and the candidates to fill them, which makes it tough to keep the ratio correct even when you know what level you want to be at.”

Despite challenges to fill hospitalist spots, it is essential to find a staffing level that does not overwork your existing physicians and allows them to pursue other professional activities. When trying to determine the right staffing ratio for your facility, Frost says to examine the following:

  • Daily patient volume (i.e., how many patients are in the program)
  • Daily patient encounters (i.e., how many times the physicians visit with patients each day)
  • Experience level of staff physicians
  • Access to nonphysician care staff such as case managers and midlevel providers
  • Needs in specialty areas in your program (i.e., more ICU patients might require more physicians)
  • Nonclinical expectations of the physicians (e.g., education, publishing papers, committee work)

A closer look at patient volume

Your patient volume is the most obvious indicator of what your staffing level should be. As patient volume increases, it also makes sense to increase the number of physicians. The difficulty in maintaining this ratio is that physician volume and daily patient encounters vary by program, says Frost.

The severity of patients’ illnesses affects how much time the physician spends with each patient and, therefore, greatly affects the patient-physician ratio for your program, he says. The ratio depends on the number of new admissions, surgical consults, and discharges, factors which vary by time, day, or season. For example, hospitals in Florida often see a huge influx of patients, especially older patients, during the winter months as people travel from the northern states for better weather, says Frost. That increase in patient load can be tough and may require the hospitals to hire seasonal staff or locum tenens practitioners.

Because most hospitals don’t enjoy the flexibility of hiring part-time or seasonal physicians, the staffing ratio should account for seasonal fluctuations. The hospitals without part-time physician options sometimes experience understaffing during the peaks or overstaffing during the lulls.

One other thing to consider with volume is strategic growth, says Rohr. If you feel the hospitalists are overworked, it might indicate that there is excess patient volume. That volume means there is the potential for more revenue, a selling point for the hospital administration. The administration is more apt to take advantage of the potential revenue if your program demonstrates its ability to get patients in quickly, treat them, and get them out without complications, says Rohr.

Experience, support, and professional pursuits

Another consideration for targeting the appropriate staff ratio is the level of physician experience. There is often a direct correlation between experience and efficiency, Frost says. He suggests building in extra time for younger physicians to improve when determining the right staffing mixture.

“Younger physicians oftentimes are less efficient in their ability to process work flows, which is just a reflection of inexperience,” says Frost. “As hospitalists move further away from their residency, they develop an enhanced ability to multitask and, over time, they are able to see more patients a day, which can be a relevant consideration when contemplating staffing ratios.”

In addition to looking at individual experience levels, you should consider the program’s overall specialties. Determining how specialized your program is will also alter the need for physicians, says Rohr. For example, if your practice often follows up with surgical consults, you may be able to see significantly more patients than a program that deals mostly with new admissions, since the latter can take up more of a physician’s time.

Physicians’ nonclinical duties vary by seniority, type of facility, and personal desires. To keep physicians happy in their careers, you need to let them have the time to explore other professional pursuits. Giving physicians time to teach or participate in hospital committees will often benefit your program with a better overall physician attitude and retention rate, because they won’t feel the need to leave your program to pursue other ventures, says Frost.

One area that hospitals have the most control over is the amount of support staff they can allot to the hospitalist program, says Rohr. Whether it is adding case managers, midlevel providers such as nurse practitioners or physician assistants, or simply more administrative staff, anything you can do to ease physicians’ responsibilities will make them more efficient at patient care.

In addition, Rohr says he believes in providing physicians with the best technology possible. “Most hospitalists spend only about 35% of their time on the floor speaking with and treating the patient,” Rohr says. “The rest of the time is spent looking at labs and charts, at the nurse’s station, or writing notes.”

Anything you can do to speed up those processes will allow physicians to spend more time with their current patients or see a few more patients per day, he says.

A more efficient hospital

Hospitals still haven’t figured out the best way to utilize hospitalist programs, Rohr says.

Because so many hospitalist programs are now 24/7 operations with in-house as opposed to on-call physicians, hospitals can stabilize, yet raise, the fixed costs. That overnight shift will rarely increase the hospital’s volume, but it still needs to be accounted for when determining ratios.

The ideal situation, Rohr says, is for the hospital to have several physicians work during morning hours to do rounds for labs and tests and set up for the day. Then the remaining shifts can be spread out during the day. However, unless the hospitalist group is very large, this is not often possible because many physicians do not want to work part-time or split shifts.

“Hospitals are still trying to adjust to this new world where they want to provide around-the-clock coverage, but the staffing and the dollars aren’t always there,” says Rohr. “A lot of the responsibility falls on the hospitalist program director to create schedules that work for the physicians and the patients and that work with the budget they are given.”

If the director can’t figure out how to make the schedule and budget work, that’s when programs fail, says Rohr. “I’ve never heard of a hospitalist program failing because there weren’t enough patients,” he says. “They fail because there are too many patients for them to handle, and it leads to poor, inefficient coverage.”

Hospitalist programs’ biggest value to a hospital is the ability to improve efficiency and allow physicians to see and treat patients. If your program isn’t allowing both of those to happen, it’s time to reevaluate your staffing levels, says Rohr.

No simple answer

Despite all the options hospitals have for improving their staffing ratios, there is still no simple answer for what the appropriate level is, says Rohr.

“There are a number of formulas that people have tried to create, but none of them are really good,” he explains. “It’s done on the basis of what your institution can afford and what physicians you can get. It’s difficult to determine this scientifically.”

There are statistics: The reported range of patient encounters per day for a hospitalist is generally 11–18, according to the Society of Hospitalist Medicine, says Frost. It’s a wide range that depends on different aspects of programs.

“Every hospital needs to take all of their individual factors into account and do what’s appropriate for their particular situation,” says Frost.