Providers often reported that their average workload contributed to incomplete discussions with patients and families, the ordering of unnecessary tests or procedures, a delay in admissions or discharges, worsened patient satisfaction, poorer handoffs, and other problems. “We might be in a situation where we’re focusing on increasing the number of patients being seen or having high census numbers, which could be, paradoxically, actually increasing the costs of healthcare,” Dr. Michtalik says.
For a recent survey posted on the-hospitalist.org, 51% of respondents picked 11 to 15 as the most appropriate patient census for a full-time hospitalist, while another 35% selected 16 to 20. Far fewer deemed it appropriate to see either more than 20 patients a day or 10 or less, suggesting that hospitalists recognize the need for equilibrium.
A “Resounding” Success Story
David Yu, MD, MBA, SFHM, FACP, medical director of the adult inpatient medicine service at Presbyterian Medical Group in Albuquerque, N.M., says there’s no “magic number” for an ideal daily patient census, and cautions against fixating on national averages and metrics.
“For example, seeing 15 patients in an inner-city hospital—like we are, where the patients are ill and they have really incredibly high levels of social and medical issues like placement—versus seeing 15 patients in an affluent suburban hospital, it’s comparing apples and oranges,” he says.
When Dr. Yu became medical director in January 2010, he says, “we were in crisis,” with the rounding team’s average patient census ranging from 18 to 20 per day. Some hospitalists weren’t seeing their last patients until 4 or 5 p.m., losing the opportunity for timely discussions with specialists to help reduce their patients’ length of stay. By neglecting to send patients home when appropriate, Dr. Yu says, the hospital was losing thousands of dollars in revenue through the failure to open up beds for new admissions. “That’s the classic example of dropping a dollar to pick up a quarter,” he says.
Dr. Yu and his team launched a comprehensive quality-improvement (QI) project that incorporated unit-based rounding centered on the hospital’s geography, and hired more full-time equivalents. As a result, the service now employs 46 FTEs, making it one of the largest nonacademic HM programs in the country. Meanwhile, the average daily census has dropped to a more manageable 11 to 13 patients, plus a few admissions.
We have clinicians who report that they don’t even get a lunch break. That’s not safe, and that’s not lending itself to a work environment that’s satisfying for the practitioners.
—Ruth M. Kleinpell, PhD, RN, FAAN, FCCM, professor of nursing, Rush University Medical Center, nurse practitioner, Mercy Hospital and Medical Center, Chicago
Most significantly, average length of stay has decreased from 4.9 to 4.6 days with increased patient satisfaction and no significant change in the readmission rate, even as the hospital has added $2.5 million to the contribution margin (the revenue minus the variable costs). “So we took the focus on productivity and just elevated it higher to overall organizational finance,” Dr. Yu says. “We answered the age-old question: Is it better and financially more productive for the organization to lower the average starting census and to pay for the extra physician? And the answer is a resounding yes for us.”