Average vs. Threshold Encounter Volume

John Nelson writes…

Daily encounters are a good metric for financial analyses, but I think they’re not so good when thinking about quality of care or hospitalist career longevity.

Most groups track the average number of encounters per hospitalist each day (or rounding) shift.  And everyone wants to know what it the right or SHM recommended average number of daily encounters.  When does an increasing average encounter volume begin to impair quality of care? 
I often hear people say something like “SHM says a hospitalist should see X patients daily.”  In fact, SHM doesn’t have an official position regarding the optimal or appropriate daily patient volume for a hospitalist.  SHM’s biannual survey of hospitalist practice provides good data regarding what patient volumes are typical for hospitalists, but that isn’t the same thing as what volumes are best for patient outcomes or hospitalist career longevity.

No great data exist to demonstrate what patient volume threshold begins to adversely affect quality, or increase hospitalist burnout.  There are some small studies (e.g., here and here and others) that shed some light on the issue but don’t really provide a definitive answer.  Of course the lack of research data doesn’t keep people from being convinced they know what the uppermost safe patient volume is, and arguing passionately for their point of view.  And that is just fine.  There are a lot of thoughtful people who have a lot of experience with the issue and their opinions are worth something.

And I’ll offer my opinion.  I think that seeing more than 20 billable encounters in a day with any regularity is not a good idea.  I prefer to see more like 12 – 15 encounters most days.

A better question than what is an optimal or safe average daily encounter volume might be to ask how often volume it exceeds a threshold you’ve chosen.  When thinking of patient safety and hospitalist burnout, I’m less concerned with the average number of daily encounters, and more interested in how often the hospitalist has to see more than 20 encounters in a day.  I think most hospitalists should see 20 (maybe 18 instead?) encounters in a day no more than about once or twice a month, regardless of what their average daily encounter volume is.

Don’t make too much of the threshold of 20 (or 18) that I’ve chosen since I don’t have any great data to support it.  I’m sure there are some individuals who could safely see more than 20 patients daily on a regular basis, but my experience suggests they’re the exception rather than the rule.

2 Comments

  1. Jairy Hunter on April 1, 2009 at 9:12 am

    Thanks for pointing out that the survey data is simply that: survey data. How many times do our Administrators and others with a passing knowledge (sometimes even of what we do on a day-to-day basis) use SHM “numbers” as benchmarking club. Often I hear the statistics misquoted as “the National Average” as if somehow SHM’s (good and valuable as it is) has now been elevated to an overarching standard for everyone to strive and adhere to.

    I echo your call to focus on these encounter numbers from a patient safety and hospitalist “burnout” perspective; too often the emphasis from above is on billable encounters. “How many patients are you seeing a day?” is code for “How much are you billing per day,” in Admin-speak.

    I would also encourage every group, no matter how small or how inextricably married to (“owned by”) its hospital, to find a way to at least track its own encounters data, and apply whatever metrics might be important. Even small discrepancies between a group’s own data and a hospital’s need to be understood so the group can receive proper credit (however that is interpreted). Often I find that Decision Support may not understand small nuances in the way your data should be collected, and the shortcomings of their measurements, which could make a difference when the CEO basically has 5 minutes to absorb the take away message regarding how much work your group is doing month-to-month.

  2. Charles Hodges on May 12, 2009 at 1:44 pm

    I want to echo the points that John Nelson makes. Although I do not have his experience I have been a hospitalist for 10 years and a director for 8 years. The 12-15 number of total encounters per day (admissions + consults + followup visits) is reasonable and viable long-term.

    I would favor the threshhold of 18 as a maximum, although numbers do not always speak to the acuity of the patient. Our small community hospital in Raleigh has a very high CMI, which translates into longer visits of all types. This also does not include the unforseen family conversations, recalls back to the worsening patient, unexpected abnormal lab results, etc.

    Our group has managed to have excellent retention of personnel, largely because of the attention paid to factors such as ADE (average daily encounters), length of shifts, and number of night shifts in a month.

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