Time-Based Productivity Measures for Academic Anesthesiologists

Time-Based Productivity Measures for Academic Anesthesiologists John R. Feiner, M.D. Associate Professor UCSF Department of Anesthesia and Perioperative Care

Background • Both private and academic practices have debated different systems to fairly: • Divide clinical workload • Credit clinical workload • Distribute bonuses based on clinical productivity

Academic Practices • Most academic practices have used an “Availability” system • Faculty are “credited” a day’s work when scheduled for a “Clinical Day” no matter how much clinical work is actually performed

The Clinical Day • Does the “Clinical Day” really reflect clinical work? • How much variation in day length is acceptable before we abandon the idea that “every clinical day is equal”

Day (non-call) Locations

Figure 1 Legend • The graph is a random week in May, 2001 • The y axis shows the length of the work day: the total amount of time spent providing anesthesia care (from the billing record) • Each open circle shows individual anesthesiologists in a “day” location--anesthesiologists on call were excluded • Extreme variation in work day length is notable

“General OR” Only

Figure 2 Legend • The graph is exactly the same as Figure 1 except: • Each open circle shows individual anesthesiologists assigned to work in the general OR at UCSF Moffitt-Long Hospital--subspecialties are excluded! • The extreme variation in work day is still present

Specialty Services

Figure 3 Legend • The x-axis shows the various subspecialties in the UCSF system at UCSF Moffitt-Long and Mt. Zion Hospitals • The y axis shows the average length of the work day ± SD (time spent providing anesthesia care) averaged over last year, 7/1/2000 through 6/30/2001 • Differences between services are apparent, but variation (high standard deviation) within is service is notable

Individual’s “Day”

Figure 4 Legend • Subspecialty services are shown on the x-axis • The y axis shows the average work day (measured by total credit) • Both individual anesthesiologists (open circles), and mean ± SD for the service are shown • Variation within the service is more prominent than any apparent differences between services--the variation shown in the random days (Figs. 1 and 2) do not “average out” over an entire year

“Over”

Figure 5 Legend • Subspecialty services are shown on the x-axis • Our system use the same clinical commitment as the clinical day system, with 8 hours expected each day • Instead of “Clinical Days” over a faculty member’s clinical commitments (%FTE), excess work is measured as hours over the commitment • The y-axis shows hours over clinical commitment, both for the service (mean ± SD) as well as individual anesthesiologists (open circles) • Significant variation is demonstrated within services, and differences between services • The difference between services represent significant understaffing on some services

“Call” Hours After 18:00, Before 7:00, weekends and holiday

Figure 6 Legend • Subspecialty services are shown on the x-axis • The y-axis shows hours performing anesthesia after 6:00 p.m., before 7:00 a.m. weekends and holidays, both for the service (mean ± SD) as well as individual anesthesiologists (open circles) • This definition provides a measure of “call” performed, whether assigned to call or not • Despite attempts to “even out” the scheduled call within services, substantial variation appears throughout each subspecialty, with some difference between subspecialties

Productivity: “Credit” • The majority of credit is the time spent providing anesthesia • Our system still allows adjustments to credit • Additional 15 minutes for starting a case • 30% bonus for “call” credit

Who is Rewarded? • In a “Clinical Day” (Availability) system, the shortest day is rewarded most • Staff get the same “credit” but more time • In a “productivity” based system, the “longest” day is rewarded most

Motivations • Motivations follow rewards • If the greatest reward is for the shortest day, staff are motivated to work less

Advantages: Choice • Productivity System: • Researchers may prefer a shorter day • Younger faculty may want more work if tied to bonuses • “Clinical Day” • Who would want the longer day?? • Who would go home first??

Advantages: Finances • More homeostatic: if credit goes up, then billing (relative to the number of faculty) is increasing • If bonuses/profit sharing is to be based on a productivity measure, then this relationship is essential • This relationship does not necessarily exist for the “Clinical Day”: if a service has lower volume, days will be shorter, not necessarily fewer

Advantages: Specialties • Allows comparisons between subspecialties • Has decreased (not eliminated) debates between various specialties about “credit” • Increased case volume in a subspecialty group is automatically compensated

Advantages :Benchmarking • Increased workload is not necessarily due to more days: it may be due to longer days • Will you really know how hard your faculty is working without looking at the time?

Advantages: Hospital • The fact that anesthesiologist are not compensated unless performing anesthesia is important in debates with: • Surgery department • Hospital administration • The “motivational” aspects of a productivity system are key

Problems with a Time-Based System • Difficulties with services which are not time-based: • Preop • OB • Pain • ICU has time-based component

Conclusions • The length of the “Clinical Day” is too variable: It does not measure productivity • A time-based productivity system tends to reward faculty working the hardestA “Clinical Day” system rewards the shortest day

References • Feiner JR, Miller RD, Hickey RF: Productivity versus availability as a measure of faculty clinical responsibility. Anesthesia and Analgesia 2001; 93: 313-8 • Abouleish AE, Zornow MH, Levy RS, Abate J, Prough DS: Measurement of individual clinical productivity in an academic anesthesiology department. Anesthesiology 2000; 93: 1509-16

Time-Based Productivity Measures for Academic Anesthesiologists