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Practice Management  

Hospitalist Staffing Requirements

Determining staffing requirements can seem to be a complex issue, and each site can have different workforce needs. But there is also enough similarity among programs that you probably will not have to reinvent the wheel. There are formulas for determining staffing needs and plenty of models around to look at and build on. Many consultants offer their own. In general, staffing needs to allow for enough time to see each patient approximately twice a day. In practice some patients may need to be seen only once daily, but others may need more frequent visits. In addition, staffing needs should take into consideration enough time to do appropriate admissions/discharges, review ancillary data, meet with family members, communicate with primary care doctors and other referring doctors, and to complete paperwork.

I. Some general advice

All hospitalist programs need to answer these questions before they can move onto the nitty-gritty of determining how many full-time equivalent physicians (FTEs) they will need.

A. What does the practice want to accomplish? Does it want to provide 24 hour coverage, seven days a week, 365 days a year? Or does it just plan to cover days? Or nights? Or weekends and holidays?

B. Know your community. Know your referral sources and your competition. Who else sees hospitalized patients at your hospital? How are ER admissions handled? What is the acceptance of primary care groups in town? What are the policies of your major insurance companies and HMOs? Are there any limitations (insurance coverage, privileges) on your ability to accept all patients referred to you?

C. Will the hospitalists have duties other than seeing patients, such as teaching, taking outpatient rotations, or doing hospital administration? Will you be responsible for case management or for staffing hospital committees (e.g. P&T, UR, QA, Patient Safety)

D. Are there seasonal issues in your community that would affect demand for hospitaListserveices? For example, is there a big influx of seniors to your town in the winter, or exodus in the summer? Does the flu season lead to an increased number of admissions in the winter months?

E. What are your preferences for scheduling? 10-hour or 12-hour shifts? Five-day or 14-day shifts?

F. How will salaries be determined, and if not simply by the individual's billings, how much are you willing to pay--including benefits and how will the group earn enough money to cover the staffing expense.

II. Specific models

There have been several presentations nationally concerning staffing analysis. Below you will find a sampling of three different approaches to establishing staffing needs for a hospitalist program.

A. Nelson Model

To utilize this model you will:

  • Need to Know: Total Number of Annual Admissions and Consults your hospitalist practice will handle
  • Need to Assume: Each hospitalist has a daily census of 10 patients and average length of stay (LOS) is 4.8 days per patient

This strategy starts by determining the workload one hospitalist can do. As detailed by Dr. John Nelson, co-founder of SHM, at a 1998 meeting in Scottsdale, Ariz., begin by assuming that the average census is 10 patients per hospitalist, each with an average length of stay (ALOS) of 4.8 days. If you presume that work will be performed 365 days a year, this means one hospitalist can accomplish approximately 760 admissions/consultations per year.

The next step is getting the total number of admissions/consultations for the year and then dividing that figure by 760 to learn how many FTEs would be required. (See Expected Volumes section in Starting a Hospitalist Program in another section of the Resource Center.) Since the denominator of 760 would be lower if someone other than a hospitalist is responsible for night and weekend admissions, Dr. Nelson recommends dividing the admissions/consults annually by 500-800 to give a range of FTE required to provide seven-day/week coverage.

A sample staffing calculation:

  • Admissions: 3,000
  • ALOS: 4.8 days
  • Each hospitalist handles 760 admissions/consultations per year
  • 3000 admissions/760= 3.95 FTEs
  • Rounding this up=4 FTEs
  • If each hospitalists handled 600 admissions/consultations per year, then 3000/600= 5 FTEs

B. Wachter/Lurie Model

To utilize this model you will:

  • Need to Know: Total Number of Annual Admissions and Consults your hospitalist practice will handle and the average length of stay (LOS)
  • Need to Assume: Each hospitalist has a daily census of 10 patients

Another staffing strategy appeared in Effective Clinical Practice (vol. 2 #3,1999). (add link to full-text of article) Drs. Jon Lurie and Robert Wachter calculated the number of hospitalists needed on the basis of annual admissions and average length of stay. They then converted the admissions and ALOS numbers into an average daily census by using the following formula: annual admissions x length of stay/ 365 days = number of patients/day

They then calculated the number of hospitalists needed by dividing the average daily census by the number of patients per hospitalist. To this number (rounded up to nearest FTE), they would add one additional hospitalist if night and weekend coverage is needed.

  • A sample staffing calculation:
  • Admissions: 3,000
  • ALOS: 4.5 days
  • Average census: 3,000 x 4.5/365 = 37 patients/day
  • Assume 10 patients per hospitalist = 3.7 hospitalists needed
  • Add one additional hospitalist to help with nights and weekends = 4.7 FTEs needed

Round off = 5 hospitalists needed to cover this service load

C. Hoffey Model

To utilize this model you will:

  • Need to Know: Total Number of Annual Admissions and Consults your hospitalist practice will handle
  • Need to Assume: Each hospitalist works 5 days per week, 46 weeks per year, has a 10 hour work day, and spends 2,56 clinical hours per admission or consultation

This strategy starts with a model of how hospitalists realistically schedule their work. William Hoffey, Ph.D., a consultant to hospitalists, assumes that one FTE physician works 5 days per week and 46 weeks per year for a total of 230 workdays per year per hospitalist. His model also assumes that each physician has a 10-hour workday but that only 6.5-7.5 hours are spent providing direct clinical care for a total of 1,610 hours of clinical care provided by one FTE hospitalist per year

If each FTE hospitalist spends 2.56 clinical hours per admission or consult (his firm's estimation), he determines the staffing requirement by taking the total number of admissions/consults per year, multiplying that figure by 2.56 and then dividing that total by 1,610.

A sample staffing calculation using this method would be:

  • Assume Admissions and Consultations of 3000/year
  • Assume 2.56 clinical hours per case
  • 3000 X 2.56= 7680 clinical hours of work needed
  • Assume each hospitalists hours works as listed above
  • 5 days X 46 weeks X 7 hours= 1610 clinical hours per year
  • 7680/1610= 4.77 FTEs needed for 3000 admissions

Rounded off to 5 FTE

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