To measure the work performed by hospitalists, the model needs to recognize that there are differences in the labor components that have been identified (i.e., they are “weighted” differently). “Conventional wisdom” describes the work that hospitalists perform in terms of the number of patients seen per day (e.g., 15 patients per day). However, the work involved in a hospitalist seeing the following categories of patients is very different:
- Admitting a patient
- Rounding on a patient already admitted
- Discharging a patient
- Performing a consultation
Kaiser Permanente Hawaii developed the example in Box 4 to illustrate differences in the work required for admissions, rounding, and discharges, and how reductions in LOS do not lead to corresponding reductions in physician staffing levels.
There are basically two options in weighting the different elements of work performed by a hospitalist: time or relative value units (RVUs). Although the amount of time it takes to do a task seems to be the most sensible measurement of labor, it can be fraught with obstacles. The amount of time it takes a physician to round on a patient, for example, is not straightforward:
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- Are all the patients located on one floor?
- Does the physician have to chase down test results routinely?
- Are all physicians the same, taking the same average amount of time to see a patient?
- Are all patients the same? Do older patients take more time due to social and medical complexity?
These are all factors that affect time. Furthermore, individuals are limited by their own experiences and frame of reference. Acceptance of a specific time allocation (e.g., a discharge takes 45 minutes) by those not doing the work is subjective. Despite these obstacles, it is valuable for hospitalist leaders to attempt to quantify the amount of time required to do inpatient work. Figure 3 shows example times used by a Kaiser Permanente-Hawaii medical group.
A hospital medicine program leader can use RVUs as a compliment to or as an alternative to time as the basis of weighting the work components performed by hospitalists. RVUs may account for patient acuity in a way that is hard to measure using time as the basis of measurement. Figure 4 illustrates RVUs by CPT-IV code.
Physician Capacity
The best practices for determining physician capacity are summarized in Box 5.
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When determining the work capacity for a hospitalist (typically defined by the number of hours worked per year), it is critical to clearly define the unique aspects of the hospital medicine program that affect work capacity. These factors include: