Working the Numbers (no board scores, just patients)

[Hayduke]

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I'm a guy still in training, but trying to focus more on my productivity. Here's my question for my senior residents and attendings. How do you know how many patients you are seeing per hour?

I'm now a PGY-2. At my place, second and third years run their protion of the department. At shift change you 'take the board'. This can include anywhere from 5 to 16 patients you are responsible for while they await bed assignment or they complete their workup. While many of these become time consuming soul vacuums, I feel like I couldn't really count them in my pile if this was the real world.

So how do you figure productivity? Do I only get credit for the folks I initially pick up? Or, do I get credit for disposition?

Thanks.

 

[EM_Rebuilder]

I'm a guy still in training, but trying to focus more on my productivity. Here's my question for my senior residents and attendings. How do you know how many patients you are seeing per hour?

I'm now a PGY-2. At my place, second and third years run their protion of the department. At shift change you 'take the board'. This can include anywhere from 5 to 16 patients you are responsible for while they await bed assignment or they complete their workup. While many of these become time consuming soul vacuums, I feel like I couldn't really count them in my pile if this was the real world.

So how do you figure productivity? Do I only get credit for the folks I initially pick up? Or, do I get credit for disposition?

Thanks.

I am a 1st year in a 2,3,4 so techinally below you... so take this for what its worth.

For personal sake/counts, I think any patient that you are currently the 'doctor' of should count toward your numbers. In other words, if the patient codes, who is getting the shoulder tapped on.

In 'the real world', as I understand, your 'number' of patients during/over shift change depends on that particular group practices. It matters to us because of billing, espically 'number' bonuses. Some places count only patients YOU dispo'd. Some places include only patients initially seen by you. I would assume someplace somewhere attempts to divide a patient up between signup/dispo'd, but I have not heard of that yet. So, in the real world, if you are at a place that counts on initial see only, you have to watch your colleagues dont pile up patients and sign CRAP loads out to you...as you wont get paid for that anyways....and paybacks are hell. On the otherhand, if you get paid on dispos, I would assume less signouts, but hanging around longer after shifts to get that LAST lab back so you get your piece of the pie.

 

[docB]

In my group you get credit for the patient's you dispo. That's really more due to issues with the billing company than some actual reason. It has some good and bad ramifications which I won't go into here because they are not germane to this thread's topic.

Speaking of the OP's topic I agree with what Jarabacoa said here:

My chairman as a resident said that administration should look to start adding shifts whenever the patient load went above 2.3-2.5/hour as that was getting dangerous. I agree with the above poster, that people tend to exaggerate their numbers (especially those SDN members that tend to post a lot in an effort to convince people that their program is the best there is). Some residents will count patients that a junior resident have presented to them, or that a student presented to them, and that they saw for 2 minutes, and then presented to an attending. They count it as one full patient when they did no documentation, no counseling to the patient and never answered a single question that the patient had.

If you are seeing lots of fast-track patients, and lots of junior resident’s patients, then your numbers are going to look really good. However, if you are admitting 30% of your patients, some to the ICU, there is no way that you can see much more than 2 patients per hour and keep up on documentation without residents or midlevels helping you out.

While in residency I would count patient's you were the primary for (started and finished) and add about half a patient for patient's you picked up, signed out or where you had to get more involved in the care of a junior's patient.

Most attendings in the community need to be able to see 2-3 patients per hour to be effective. More if they are less acute and/or you have PAs, scribes, admission coorinators, etc. Less if you have high acuity or your ancillary services are poor.

 

[southerndoc]

My group also counts patients dispo'd. The last name on the chart is the one that gets credit for seeing the patient.

If it's something simple that is delayed (scripts are written and just waiting on social services to arrange for free scripts, repeat troponin pending if negative goes home discharge information on the chart and given to the nurse), etc., then usually the person will just follow up on it and allow the original person credit for the dispo.

 

[roja]

I think what you are going to see is really dependent on why you are looking at it.

There are various 'outcomes' that you can be measuring:
-what's being counted in a fee for service situation (the ones as above... who gets counted in your tally at dispo)
-what you are learning to 'manage' (ie the situations where you are signed out patients you are now taking care of)
-if you are learning to manage juniors (ie in an academic setting). it doesn't matter so much that you aren't making all the hands on stuff, you are still ultimately responsible for what you are being presented. Trust me, those seniors know what they have to do, not do, etc and if they forget to do or tell something, they are talked about). Part of the academic learned skill is how to balance teaching, supervising and managing patients.
It is harder than it looks. trust me.

Regarding acuity, while numbers are a nice average a severity index for ED's is now being talked about. We all know that simpler patients are easier to handle. So your 'volume' should increase. Sicker patients, your volume should be lower. The mythos of the 'average' is that over time, it all averages out.

There is no real answer to your question. you have to look at your local environment.
(IE where I was for residency, the volume was significant and what was considered slow wouldn't be considered slow where I am now).

 

[docB]

I think what you are going to see is really dependent on why you are looking at it.

There are various 'outcomes' that you can be measuring:
-what's being counted in a fee for service situation (the ones as above... who gets counted in your tally at dispo)
-what you are learning to 'manage' (ie the situations where you are signed out patients you are now taking care of)
-if you are learning to manage juniors (ie in an academic setting). it doesn't matter so much that you aren't making all the hands on stuff, you are still ultimately responsible for what you are being presented. Trust me, those seniors know what they have to do, not do, etc and if they forget to do or tell something, they are talked about). Part of the academic learned skill is how to balance teaching, supervising and managing patients.
It is harder than it looks. trust me.

Regarding acuity, while numbers are a nice average a severity index for ED's is now being talked about. We all know that simpler patients are easier to handle. So your 'volume' should increase. Sicker patients, your volume should be lower. The mythos of the 'average' is that over time, it all averages out.

There is no real answer to your question. you have to look at your local environment.
(IE where I was for residency, the volume was significant and what was considered slow wouldn't be considered slow where I am now).

I agree. That's the academic keeping the community guy honest (it never occured to me there might be a different endpoint than the FFS dispo😛).

It's also a good point that managing juniors is a lot like supervising PAs (usually the juniors aren't as good at the procedures and need more supervision) which is good training in itself.