Hospitals continue to make great strides in using technology to improve clinical operations and outcomes. Automated disinfection systems to eliminate harmful microorganisms. Telehealth to make healthcare more accessible, especially to people in rural areas. The march towards using hardware and software innovations to control costs, improve results and add value continues unabated.
But there’s one area that has not seen much advancement and that’s patient assignments – the process of assigning patients to physicians or nurses once they are admitted.
On the surface, this process seems pretty straightforward. Each day a certain number of rounding physicians or unit nurses must be assigned to a certain number of patients in order to provide the level of quality care that is expected. Make sure everyone is covered, don’t miss anybody and make sure the process works smoothly day-in- and day-out.
PROBLEMS WITH PATIENT ASSIGNMENTS
There’s only one problem. There’s nothing straightforward about a typical clinical day.
Some patients are sicker than others, requiring far more time and energy spent on them to help them recover and go home. Sometimes patient assignments account for that; many others they don’t.
There are also complexities associated with balancing workloads so they are fair and equitable. Let’s face it. Nobody likes to take a disproportionate amount of care compared to others, especially if the assignments are based more on “feel” or emotion than hard evidence.
Another issue associated with patient assignments is continuity of care. Research studies are clear that discontinuities can lead to suboptimal care. For example, one study showed that discontinuities, coupled with a lack of previous knowledge about a patient’s care, may lead to excessive diagnostic tests by hospitalists. Their also believed to diminish patient satisfaction.
Let’s not forget the impact heavy workloads can have on physicians and nurses. Excessive or unsafe workloads cause a number of cascading effects. For example, 22% of hospitalists surveyed said they delayed admitting or discharging a patient until a subsequent shift because of unsafe workloads. And there’s growing recognition of the problem within hospital medicine. Forty percent of those same physicians surveyed said they experienced unsafe workloads at least once a month.1
Heavy workloads lead to other costs as well. In one study, it was demonstrated that heavy or unsafe workloads resulted in length-of-stays (LOS) increasing from 5 to 7.5 days, which resulted in added costs between $5,000 and $7,500 per Medicare patient.2
Heavy workloads impact physician satisfaction as well, contributing to burnout and turnover. This is not trivial, since replacing a single physician can cost as much as $500,000 to $1 million.3
SUBOPTIMAL PATIENT ASSIGNMENTS LEAD TO SUBOPTIMAL CARE
Even something relatively simple related to patient assignments can have tremendous consequences.
For example, what if patients have the same last name on an assignment list and a physician with no prior knowledge or experience with either patient orders up the wrong lab tests for the wrong patient?
Or what if patient assignments don’t take geography into account and physicians or nurses are running from one location to another trying to get their work done. What if a patient “fires” a physician or nurse and the patient assignment process doesn’t take that into account?
The truth is—suboptimal patient assignments can have significant clinical and financial consequences to a healthcare system and it’s not being adequately addressed.
The patient assignment process is one of the most underappreciated and underutilized functions in hospital medicine today.
It’s not that people aren’t trying to make the process operate more efficiently.
Some units and departments spend an hour or more matching up patients with providers. While they are often limited in the different variables they can apply to the matching process, they still come up with a reasonable (and sometimes balanced) assignment list.
Others have simply given up. Instead of trying to spend time taking in any factors that could optimize the assignment process, they just assign providers across the board, giving each physician or nurse the exact number of patients for that shift, regardless of a patient’s condition.
Still others have applied patient acuity tools, which apply a numbering system to identify a patient’s condition. Some have even developed an in-house method of trying match the right patient with the right provider.
ALTERNATIVE APPROACHES TO PATIENT ASSIGNMENTS
The problem with all of these approaches is this – none of them fully optimize the process of matching the right patient with the right physician or nurse. Few, if any, can handle multiple protocols, and a number of them are challenging and time consuming to use. Patient acuity tools are useful, but they only address one issue—a patient’s condition. They do not deal with any geography or continuity of care concerns. They also have no effect on other issues that might arise, like the problem of patients having the same last name.
USING SOFTWARE FOR PATIENT ASSIGNMENTS
Patient assignments are ripe for an overhaul using software. Instead of being able to handle just a few variables that might be applied to balancing assignments, rules-based algorithms could handle dozens of variables at the same time. Thus, not only could geography be applied to coming up with an optimal list, but each patient’s condition, continuity of care, and numerous other protocols could be applied. In fact, a software program that allowed for a unit or department to customize its list of protocols would be the ideal situation.
Think of it this way.
If a hospital medicine unit had 20 physicians to handle 300 patients and had 20 different variables from which to craft the ideal patient/physician match — the creator or creators of the list would have to deal with 120,000 decision points. Manually, it can’t be done. With a software program – no problem.
Computers are also extraordinarily faster than humans with calculations. Thus, even with a dozen different variables being applied to the making of patient assignments, computations using software would take minutes instead of an hour or longer.
Finally, specially designed software for patient assignments would also have the capability of not only producing a fast list based on the customized criteria, but that same list could then be electronically distributed to all care team members, making the coordination of care that much better and operationally efficient. Finally, imagine the patient assignments for physicians was electronically linked to the list developed for nurses or any other care team members, such as case managers and therapists. That way, everybody would know who was assigned to each patient and could easily contact that person in case of a problem, question, or emergency.
Care coordination still has a long way to go in healthcare, but it is getting better. One way it could improve is to apply sophisticated software to patient assignments. Suboptimal patient assignments don’t do anybody any good. They eat up administrative time, they contribute to heavy workloads, they fail to take advantage of continuity of care, and they add unnecessary costs, either from added length-of-stays, lower productivity or unneeded tests and procedures.
It’s time to re-think patient assignments and make it a function that leads to better quality care. Applying automation and computer intelligence would be good start.
1Michtalik HJ, Yeh HC, Pronovost PJ, Brotman DJ. Impact of attending physician workload on patient care: a survey of hospitalists. JAM Intern Med. 2013;173(5):375-377.
2Elliott DJ, Young RS, Brice J, Aguiar R, Kolm P. Effect of hospitalist workload on the quality and efficiency of care. JAMA Intern Med. 2014 May;174(5):786-93. doi: 10.1001/jamainternmed.2014.300.
3Sanafelt TD, Hasan O, Drybye LN, et al. Changes in burnout and satisfaction with work-life balance in physicians and the general US working population between 2011 and 2014. May Clin Proc. 2015:90(12):1600-1613.
MedAptus has developed automated and intelligent patient assignment software for physicians and nurses — called ASSIGN for Physicians and ASSIGN for Nurses. Both are built on the proprietary, rules-based software platform – ASSIGNCARE – that expertly matches the right patient with the right nurse or physician by applying multiple and customizable protocols.
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