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Dear Director, My chairman has started handing out data about each individual’s productivity. I have received a lot of grief from her because I see 1.5 patients per hour while our group average is 2.0 pts/hr. I told her that I see less because I’m seeing all the sickies while others cherry pick the easy cases. I’ve been told I need to pick it up but I don’t want to compromise my care of these sick people. What should I do?
Signed,
Doing All the Heavy Lifting

 
Dear Heavy Lifter,

As much as I would love to clone my most productive providers, I recognize that docs come in all sizes and speeds. Some can see three patients an hour while others see less. It’s interesting to note that while 25 years ago, three patients per hour may have been the norm, today that number is closer to two per hour. This depends on the medical complexity, if you have a fast track that siphons off the quickie cases and what your pediatric percentage is, as kids can come and go through the system faster than adults. Regardless, you raise some important points about throughput efficiency.

The RVU:
As you point out, you handle the sickest patients so it’s unfair for a director to look at only pts/hr. One must consider acuity. The way that most of us define it is the Relative Value Unit (RVU). The Resource-Based Relative Value Scale (RBRVS) was developed by a Harvard economist in the 1980s, signed into law as part of the Omnibus Reconciliation Act of 1989 and became effective in 1992. A subcomponent of this is the RVU, which correlates to every CPT (billing) code and is based on a combination of physician work, including mental effort, time and judgment, as well as malpractice expense and business overhead. Each ED chart is coded for a particular level (1-5 with 5 being most complex or at a critical care level) and the coding is done based on documentation (remember to hit all 10 review of systems for a level 5 chart), including medical complexity. From there, you might get more RVUs if you appropriately document procedures. The bottom line for you is that everything has an RVU attached. Therefore, while you can look at pts/hr, RVUs generated per hour is more indicative of the work each provider performs, as it takes into account volume and acuity.

How do I define slow?
On the clinical side, without knowing any data, I suspect my group is like your group. Physicians have preferences for who they want to work with . . . and it’s almost never the slower docs. When I evaluate our doctors, I look at the patients per hour as well as the RVUs generated per hour. Sometimes, low RVUs/hr are a result of bad documentation (not appropriately documenting all the services you provided) or cherry picking low-acuity cases. Thus, RVUs per patient is another metric worth reviewing.  Other times it’s impacted by an inefficient ED (beds filled with boarders while the waiting room overflows) or a handful of very slow shifts. For these reasons it’s important to document all the services rendered and evaluate this from month to month and quarter to quarter.

My fastest docs typically see only  2-3 more patients a shift than the average provider. While that doesn’t seem like a lot, picking those patients up at critical points in the shift can have a significant impact on patient flow. In your case, it probably means seeing about 1 patient more every 2 hours you work. I’m an advocate for picking up more patients earlier in your shift as you’re fresher and typically not bogged down with managing multiple patients.

Light a Fire:
While it’s important to provide high quality care and an excellent patient experience, as well as completing paperwork, sometimes docs do just need to speed up. I’ve seen many physicians come to work exactly on time only to spend the first 15 minutes of their shift drinking coffee and getting ready to work. Others will sit down and spend 10 minutes in between patients documenting and contemplating the work up when what they really should be doing is picking up the next patient to be seen.

What you can do:
Part of the responsibility of the ED medical director is to make sure that the department functions efficiently for the providers and that they give you the proper and regular feedback that you need to improve. Have your documentation evaluated so that you’re getting the credit you deserve on each patient. You’ve got to be honest with yourself.  Do you really see all of the “sickies,” or is that just a way to explain less productivity?  Continue to see the sick people, but try for that extra patient every couple of hours. Consider where you can save time throughout the day—show up on time ready to work, chart as you go, don’t let charts sit in the rack and pick up that extra patient when you’re thinking about it but would rather not. Then look at the data over the next few months to see that you’re on track to be a top performer. 
 
Michael Silverman, MD, is chairman of emergency medicine at Harbor Hospital in Baltimore, MD and is on TEAMHealth’s Medical Advisory Board.
 

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