Productivity, and the ability to do our jobs well

There are few aspects of our jobs that impact our patients and our own enjoyment of our work more than productivity expectations do. How did the current requirements come about and what goals are really reasonable?

The industry standard for productivity

Whittier has always told staff that its productivity expectations are based on the “industry average” across all health centers. Actually, the Health Resources and Services Agency (HRSA), which oversees the federal funding of community health centers, collects reams of data from every health center, including staffing and productivity information. Here’s what their data show:

We’re not sure where Whittier’s numbers come from, but they’re clearly not the industry average. Some community health centers in Boston aim for a higher productivity expectation than the average. But the highest we’ve heard of in Boston for physicians is 2.5 pts/hour. One medical director we spoke with called the Whittier expectation of 3.0 for physicians a “fantasy”.

And Whittier has much less robust clinical support staffing than most clinics (a subject for another day), making the expectations at Whittier even more burdensome.

Financial cost of decreased productivity

But wouldn’t lower productivity expectations be a financial drain on the health center? Actually, the financial penalty to a health center for lower productivity is less than one would think.

For instance, assume a health center department has a patient demand requiring that its physicians see 12 pts/hour. That could be accomplished through either 1) 4 physicians seeing 3.0 pts/hr, 2) 5 physicians seeing 2.4 pts/hour, or 3) 6 physicians seeing 2.0 pts/hour.

If we subtract provider expenses (salary at $180,000/year; benefits; pension; Medicare and SSI) from revenue generated by a primary care provider ($150/visit), we get the following net annual surpluses generated by these three different providers:

Notice that, no matter what the productivity, each provider is generating a significant amount of positive revenue for the health center. Secondly, the difference in annual income generated by a physician whose productivity is 3.0 vs. 2.4 is only 13%. Yet the difference in the quality of care for the patient and the work life for the provider would be fairly sizable, as we all know from our own work experiences.

A professional staff union is also in place at another health center in Baltimore, the Chase-Brexton Health Center. Last year they negotiated a decrease in productivity expectations, which were also unrealistically high at their center. Providers there say that the change has greatly improved work life, workflow, and patient care. And their health center is still financially sound. Could it be that happy patients and staff improve the bottom line?

Importance of support staffing

It might be possible to see more patients than the industry standard if support systems were strong, including adequate support staffing and well-designed workflows, but these are also problematic at Whittier. Here’s how Whittier compares with support staffing at other community health centers:

*In primary care, the ratio of clinical support staff (nurses and medical assistants) to providers at CHCs in Massachusetts2 is 3.6 to 1 in Massachusetts but only 1.5-2 to 1 at Whittier. And adult and family primary care providers have been without any case managers, one of the most important support roles in primary care, for the past several months.

In the absence of sufficient provider supports, high productivity causes an unrelenting stress on providers and nurses. Normally, providers need to rely on support staff to keep tabs on and to help with pulling together numerous loose ends, especially when they’re seeing patients as frequently as every 15 minutes.

The problem is compounded by the frequent reassignment (or resignation) of support staff, often without providers’ input, so that providers and assistants often aren’t able to spend the time they need to learn how to best work with each other. How should anyone, patient or practitioner, have a reasonable expectation of developing healing or sustainable relationships without the support of an effective, cohesive team around them?

Burnout inevitably results from high productivity expectations, combined with inadequate staffing, turnover, and incohesive teams. The Agency for Healthcare Research and Quality4 describes it in this way:

“Work conditions, such as time pressure, chaotic environments, low control over work pace, and unfavorable organizational culture, were strongly associated with [providers] feelings of dissatisfaction, stress, burnout, and intent to leave the practice.”

A contract offers the opportunity to insist on more realistic productivity expectations and improved staffing. Together, they can provide a better work environment for providers, staff, and patients.

3 Average productivity per clinical hour worked. assuming 5 weeks vacation (productivity would be lower if less weeks of vacation) and 32 clinical hours of work per week (for a full-time provider)

4 Agency for Healthcare Research and Quality, Physician Burnout, Publication: 17-M018-1-EF

April, 2019