How to handle colleagues not pulling their weight

[Mount Asclepius]

This seems backwards. This just encourages people to pick up patients and do a half-ass HPI, exam, workup, and plan. The next doc also has minimal incentive since they're not going to get the RVUs. If it were reversed then I think that'd be better all the way around. You could argue that the original doc still wouldn't have an incentive to pick up these patients at the end of their shift since they won't get RVUs but that just means there will be less sign outs, which we both agree are suboptimal for everyone. I would just prefer the outgoing doc to place a few basic orders to get things rolling and then I can do my own HPI and exam and go from there. I think this model is ideal since it'll minimize sign outs but also not have significant impact on throughput as long as basic orders are being put in. You'll also have a lot more people getting out on time instead of diddling their thumbs after their shift.

We don’t really sign out patients in my group so it isn’t a problem. Patients in ED observation being the exception. We’ve had new hires use to a culture of signing out come in and quickly let them know that the expectation is different in our group. I’ve found that they’ve changed their practice and were satisfied with our group culture.

I guess I should also clarify that there really aren’t patients that you need to get orders going on in our setup. We have robust nursing protocol orders. So if any unseen patients are in the waiting room they usually have basic orders already placed by the triage nurse. It’s not as ideal as physician based orders, but empowering out nurses to place basic orders on patients has been effective.

In hearing responses there seems to be much more variation in practice than I imagined based on the type of ED and coverage (and I’ve worked previously in multiple different settings). I think this really depends on your group setup. I’ve just personally found my setup ideal.

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[RustedFox]

I'll pop in to say that the "half-assed sign out" is entirely avoidable.

When I take sign out, it comes in two flavors:

1. "I only put in a workup for this patient to stop the clock, see this patient."

or:

2. "Lab X and imaging study Y are pending. This is the plan in-place."

That's it. Either write no note, or a damn good one.

 

[BoardingDoc]

This seems backwards. This just encourages people to pick up patients and do a half-ass HPI, exam, workup, and plan. The next doc also has minimal incentive since they're not going to get the RVUs. If it were reversed then I think that'd be better all the way around. You could argue that the original doc still wouldn't have an incentive to pick up these patients at the end of their shift since they won't get RVUs but that just means there will be less sign outs, which we both agree are suboptimal for everyone. I would just prefer the outgoing doc to place a few basic orders to get things rolling and then I can do my own HPI and exam and go from there. I think this model is ideal since it'll minimize sign outs but also not have significant impact on throughput as long as basic orders are being put in. You'll also have a lot more people getting out on time instead of diddling their thumbs after their shift.

Meh, my group works the same as @Mount Asclepius. It works for us because it doesn't incentivize you to stay late for crap. If I have 3 lvl 5 patients all waiting on a covid swab or a UA or some crap before they can be dispoed, I don't want to stay another hour or two just so I don't lose those bills, and it isn't like doc #2 is doing any appreciable work in those cases.

Agree, that you could theoretically run into the issue where people pick crap up at the end of their shift and sign out a big workup still in progress and then you're doing the work as the doc taking signout but not getting paid. In practice, that doesn't happen (at least in our group). As I posted elsewhere, I don't pick up complex patients in my last 1.5-2 hrs of my shift. Nor does anyone else.

 

[BoardingDoc]

I'll pop in to say that the "half-assed sign out" is entirely avoidable.

When I take sign out, it comes in two flavors:

1. "I only put in a workup for this patient to stop the clock, see this patient."

or:

2. "Lab X and imaging study Y are pending. This is the plan in-place."

That's it. Either write no note, or a damn good one.

Agree. This is literally the only way signout should ever happen. Either you hand me a binary "If this then that" dispo, or I'm just going to go see the patient and make my own plan. While I just mentioned that the doc taking signout doesn't get the billing in the group, if I write a new full chart as the doc taking signout, I'm the one that takes over the billing. This almost never happens, except when something utterly unexpected and requiring some legit work happens and the 2nd doc clearly deserves the bill.

 

[JacobMcCandles]

We don’t really sign out patients in my group so it isn’t a problem. Patients in ED observation being the exception. We’ve had new hires use to a culture of signing out come in and quickly let them know that the expectation is different in our group. I’ve found that they’ve changed their practice and were satisfied with our group culture.

I guess I should also clarify that there really aren’t patients that you need to get orders going on in our setup. We have robust nursing protocol orders. So if any unseen patients are in the waiting room they usually have basic orders already placed by the triage nurse. It’s not as ideal as physician based orders, but empowering out nurses to place basic orders on patients has been effective.

In hearing responses there seems to be much more variation in practice than I imagined based on the type of ED and coverage (and I’ve worked previously in multiple different settings). I think this really depends on your group setup. I’ve just personally found my setup ideal.

I know every group is different and many new hires don't know any better but having a no sign out culture with the expectation of staying several hours late every shift sounds awful. Clearly just a personal opinion but there's no way I could go from a group where getting out on time is normal and expected to a group where there's no sign out and everyone stays several hours late.

 

[thegenius]

Fair points. I initially thought immediately after I posted that comment that I should edit it to clarify that in my group/model only the original EP seeing the patient gets the billing (other than overnight ops billing which is shared). You're both right in that it is group dependent with various models present. In an SDG productivity based environment, I'd bet though it skews more so towards a single physician receiving the entire compensation, but there are perhaps good models out there where it is split.

For real? That seems at high risk for abuse or getting bad signouts.
"Hi, I'm signing out the folliwng 4 patients who I happened to see in the past hour. Pt one might be having a stroke, please f/u on Neuro recs; pt 2 is old, frail and weak and is getting a massive workup, pt 3 has a dislocated shoulder, and pt 4 is having active chest pain"

 

[BoardingDoc]

For real? That seems at high risk for abuse or getting bad signouts.
"Hi, I'm signing out the folliwng 4 patients who I happened to see in the past hour. Pt one might be having a stroke, please f/u on Neuro recs; pt 2 is old, frail and weak and is getting a massive workup, pt 3 has a dislocated shoulder, and pt 4 is having active chest pain"

Again, all theoretically possible but something I've never seen in practice. Those 4 patients would all still be actively managed by the primary MD until the signout became: 1 had a stroke and is being admitted. 2 has a benign workup. Still hasn't peed. Needs to be admitted either way as they're old and failing at home. Click admit once UA back. 3's shoulder is back in place and they're discharged on the board. Tech is busy getting them a sling. Patient 4 is better with nitro and is being admitted.

We have enough coverage that the doc who's leaving would either 1: have decided to pick all of these up in the last hour because they know they're likely going to stay late to dispo them and will get a bunch of money, or 2: would not have picked them up and the other doc would have.

People who try to give the signout you posited would not be with our group for very long. If you wanna make a bunch of extra money, go ahead and be option 1 above. If you want to leave on time, you can do that too. I almost always pick option #2 unless the fam is out of town or something and I have literally nothing else to do except make an extra $500-$1000.

 

[BoardingDoc]

I'm bumping this thread because I'm upset that some people at several sites I work at are slow/lazy and are somehow just allowed to be slow despite metric tracking because every site I work at is short staffed despite it being a major city. It's so bad that at 2 sites, the midlevel working with us will sometimes just stop seeing patients and will have to get reminded by nurses to pickup patients. It's unbelievable. I can't in good conscience just sit in my chair watching a colleague get slammed while I just kick back.

There's a guy who trained at the same program as me. Now the chief of an ED in the southwest. He gave a talk during residency about how his shop has a system where new patients are automatically assigned to docs/pas in a round robin type system. No one signs up for anything. It's all done automatically. I don't know how it works when volume is crazy high but it apparently works well for them in terms of addressing this very issue.

I personally like the carrot approach instead of the stick which is why I really like our "eat what you kill" model. You don't want to see anyone in the last 2 hrs of your shift? Sounds good, I'll happily take an extra $1000 for the shift seeing "your" patients.

Also, the simplest option in your case is obviously to just fire this PLP. They apparently can't even get the "pretend" part right.

 

[WhatJobDoIPick]

Heavily production based compensation is the only way.

I saw admin doc saw 4 patients on their shift once.

 

[Mount Asclepius]

There's a guy who trained at the same program as me. Now the chief of an ED in the southwest. He gave a talk during residency about how his shop has a system where new patients are automatically assigned to docs/pas in a round robin type system. No one signs up for anything. It's all done automatically. I don't know how it works when volume is crazy high but it apparently works well for them in terms of addressing this very issue.

I personally like the carrot approach instead of the stick which is why I really like our "eat what you kill" model. You don't want to see anyone in the last 2 hrs of your shift? Sounds good, I'll happily take an extra $1000 for the shift seeing "your" patients.

Also, the simplest option in your case is obviously to just fire this PLP. They apparently can't even get the "pretend" part right.

I think I’m familiar with the same hospital/system. Used to be hospital employed, but I believe now staffed by Sound as of 2023 if we’re discussing the same location. Round robin system works well for distributing patients equitably with easy job seeing <2 pph, but no incentive to work harder and pay reflective of a hospital employed position. I strongly prefer the eat what you kill approach. Collaboration and communication amongst partners key in distributing patients though.

 

[NYEMMED]

There's a guy who trained at the same program as me. Now the chief of an ED in the southwest. He gave a talk during residency about how his shop has a system where new patients are automatically assigned to docs/pas in a round robin type system. No one signs up for anything. It's all done automatically. I don't know how it works when volume is crazy high but it apparently works well for them in terms of addressing this very issue.

I personally like the carrot approach instead of the stick which is why I really like our "eat what you kill" model. You don't want to see anyone in the last 2 hrs of your shift? Sounds good, I'll happily take an extra $1000 for the shift seeing "your" patients.

Also, the simplest option in your case is obviously to just fire this PLP. They apparently can't even get the "pretend" part right.

I’ve worked for a system like this. It can be soul crushing.

Yes it makes sense on a business side.
In actuality you have shifts running from critical to critical while the other guy gets knee pains

 

[BoardingDoc]

I’ve worked for a system like this. It can be soul crushing.

Yes it makes sense on a business side.
In actuality you have shifts running from critical to critical while the other guy gets knee pains

True, but statistically you will be "the other guy" half the time that imbalance happens.

To reiterate though, this isn't my preferred solution. Keep what you kill in a busy dept is the only way to go in my mind. Turns out, if you incentivise people to work harder, they frequently do! And if you don't, they don't. Who woulda thought?

 

[xaelia]

I’ve worked for a system like this. It can be soul crushing.

Yes it makes sense on a business side.
In actuality you have shifts running from critical to critical while the other guy gets knee pains

My experience with round-robin at Kaiser was that it felt "fair" 95% of the time. It wasn't perfect, but it was alright. The greater problem was that they'd put your name on up to 3 PPH, and the rhythm of the shift was that you'd end up with 6 patients in around ~1.25 hours, followed by a steady stream of 2-3 PPH for the next 5-6 hours. AND, any triage 2 would "break" the cap on patients for whichever unlucky doc was next in the queue etc. AND they started assigning you patients before shift start so you were loaded up and ready to go from minute one.

You could exert some control over whether you remained in the round-robin if you were wrapped up with a giant mess (critically ill patient, complex lac repair, whatever) ... but then you'd have the old/slow docs abusing the "pause" status, because, you know, working is hard.

So, yeah, round-robin is not a magical answer – the devil is in the details, but it can make things more fair.

 

[emergentmd]

Again, all theoretically possible but something I've never seen in practice. Those 4 patients would all still be actively managed by the primary MD until the signout became: 1 had a stroke and is being admitted. 2 has a benign workup. Still hasn't peed. Needs to be admitted either way as they're old and failing at home. Click admit once UA back. 3's shoulder is back in place and they're discharged on the board. Tech is busy getting them a sling. Patient 4 is better with nitro and is being admitted.

We have enough coverage that the doc who's leaving would either 1: have decided to pick all of these up in the last hour because they know they're likely going to stay late to dispo them and will get a bunch of money, or 2: would not have picked them up and the other doc would have.

People who try to give the signout you posited would not be with our group for very long. If you wanna make a bunch of extra money, go ahead and be option 1 above. If you want to leave on time, you can do that too. I almost always pick option #2 unless the fam is out of town or something and I have literally nothing else to do except make an extra $500-$1000.

I interviewed at a place like this and it was a no go for me. So I asked one of the docs, what happens if you have a slow doc having 10 WTBS and a fast doctor sipping coffee? They said they would move some over, which defeats the purpose or they just wait, another poor option.

Unless there was a carrot for higher output, I would just be as fast or slow as the doc I am working with. Be a hero and see pts fast will result in slower docs just letting you do everything

 

[WhatJobDoIPick]

I interviewed at a place like this and it was a no go for me. So I asked one of the docs, what happens if you have a slow doc having 10 WTBS and a fast doctor sipping coffee? They said they would move some over, which defeats the purpose or they just wait, another poor option.

Unless there was a carrot for higher output, I would just be as fast or slow as the doc I am working with. Be a hero and see pts fast will result in slower docs just letting you do everything

Non-productivity based EM compensation results in a race to the bottom.

When I joined the hospital employed pyramid scheme that was my last job I quickly became the first or second most productive, yet in bottom third of compensation.

Me to chair "now if you look at my numbers you'll see that I am very very productive. I would like a raise."

Chair "Aw shucks. We don't compensate based on productivity."

Guess what happened to my productivity afterwards.

 

[EctopicFetus]

I’m 100% rvu based. Love it. I love being on with the slow docs. Have to staff at 40th or so percentile of your docs. Have to leave some room for busy days. Still it works. On a “slow” shift I make enough on a
Busy shift I’m happy cause I made good dough. Key is behaving and sharing charts.

I would rather incentivize people to work hard than to be lazy. Would rather create a system that is desirable to people who work hard than one that encourages people to be lazy.

 

[Janders]

I’m 100% rvu based. Love it. I love being on with the slow docs. Have to staff at 40th or so percentile of your docs. Have to leave some room for busy days. Still it works. On a “slow” shift I make enough on a
Busy shift I’m happy cause I made good dough. Key is behaving and sharing charts.

I would rather incentivize people to work hard than to be lazy. Would rather create a system that is desirable to people who work hard than one that encourages people to be lazy.

There are downsides to 100% RVU (or any close relative).

But I 100% prefer it to my former position which was 99% hourly and 1% “bonus” partially based on productivity.

Talk about walking into a bunch of charts in the rack for 2-3hrs, angry patients, angry nurses and frankly suboptimal care…

 

[WhatJobDoIPick]

There are downsides to 100% RVU (or any close relative).

But I 100% prefer it to my former position which was 99% hourly and 1% “bonus” partially based on productivity.

Talk about walking into a bunch of charts in the rack for 2-3hrs, angry patients, angry nurses and frankly suboptimal care…

Yup, nothing is perfect, and there should be a floor to protect against uncharacteristically low volumes, because after all we should be paid for our time.

Old job was essentially as you describe 99/1. I can't tell you how badly this breeds laziness. If people see 1.6 PPH it's a ton. Wait times through the roof. Lots of LWBS (oh wait it's "eloped" cause they were seen by a provider in triage 6 hours ago LOL). Angry patients, lazy nurses. Admins solution is to throw more physician hours at an already backlogged system, because they can't comprehend that the systems issues are non-physician factors (consultants, delays, radiology etc)

While we're at it, let's tie nursing compensation to productivity too. Time from orders to collection, time to urine, time from med orders to administration, time from DC order placed to discharge. Let them feel the burn.

 

[s/p epilepticus]

While we're at it, let's tie nursing compensation to productivity too. Time from orders to collection, time to urine, time from med orders to administration, time from DC order placed to discharge. Let them feel the burn.

DTU or "Door to Urine" time is a nursing metric I can get behind.

 

[Janders]

While we're at it, let's tie nursing compensation to productivity too. Time from orders to collection, time to urine, time from med orders to administration, time from DC order placed to discharge. Let them feel the burn.

I have always wanted to figure a way to offer RN staff (and the techs too while we are at it) with bonus pay for productivity. There is a massive difference between the nurse that is in there churning quickly with you, a competent one that does the job as expected and one that disappears for times, plays on their phone 20 minutes before hanging meds, dodges assignments and holds discharges for 30min to avoid an empty bed space.

Yes the poor ones often are eventually drummed out, but I wish the superstars could get $x bonus a shift because THEY are moving meat, improving satisfaction and decreasing LWBS by working extra hard (and often skipping their "breaks").

 

[EctopicFetus]

I have always wanted to figure a way to offer RN staff (and the techs too while we are at it) with bonus pay for productivity. There is a massive difference between the nurse that is in there churning quickly with you, a competent one that does the job as expected and one that disappears for times, plays on their phone 20 minutes before hanging meds, dodges assignments and holds discharges for 30min to avoid an empty bed space.

Yes the poor ones often are eventually drummed out, but I wish the superstars could get $x bonus a shift because THEY are moving meat, improving satisfaction and decreasing LWBS by working extra hard (and often skipping their "breaks").

I also agree here. The RVU issue can be managed by leveling it over time. For example some groups do a running 12 months. Others do it over a quarter.

There is cherry picking as a problem but you hope you don't have a ton of turds. Need people who will behave or have a system where you can spank someone.

I have my few RNs I love.. they get things done, no excuses and move the meat. others its like I want to claw my eyes out.

 

[Janders]

You know how some docs have scribes?
In the dark times of so many patients and so few nurses, I had this pipe dream of coming to work with my personal side kick nurse.

Get one of the ones I love working with, pay them cash $100/hr, give them two gurneys and two chairs in a corner somewhere, and we churn patients in our personal miniPod while I also continue to see patients in the slogged in Ed. Basically start converting all those lwbs and 5hr waits to revenue.

 

[Mount Asclepius]

I’ve thought for a long time about the idea of our group just directly employing the nurses and how much that would improve both the quality of our shifts as well as productivity.

 

[DOswag]

True, but statistically you will be "the other guy" half the time that imbalance happens.

To reiterate though, this isn't my preferred solution. Keep what you kill in a busy dept is the only way to go in my mind. Turns out, if you incentivise people to work harder, they frequently do! And if you don't, they don't. Who woulda thought?

Non-productivity based EM compensation results in a race to the bottom.

When I joined the hospital employed pyramid scheme that was my last job I quickly became the first or second most productive, yet in bottom third of compensation.

Me to chair "now if you look at my numbers you'll see that I am very very productive. I would like a raise."

Chair "Aw shucks. We don't compensate based on productivity."

Guess what happened to my productivity afterwards.

I’m 100% rvu based. Love it. I love being on with the slow docs. Have to staff at 40th or so percentile of your docs. Have to leave some room for busy days. Still it works. On a “slow” shift I make enough on a
Busy shift I’m happy cause I made good dough. Key is behaving and sharing charts.

I would rather incentivize people to work hard than to be lazy. Would rather create a system that is desirable to people who work hard than one that encourages people to be lazy.

Ah this is America and I love it, although there are some systems in place that do incentivize laziness (not trying to get into any sort of political discussion or debate). But by and large we like to try to incentivize hard work and productivity because that tends to produce better results in the long run for everyone. I love coming to visit the ER forum from time to time.

 

[xaelia]

Non-productivity based EM compensation results in a race to the bottom.

I'm not sure how common RVU- or productivity-based compensation is outside of the U.S./Canada. The rest of the world's societies have not collapsed.

 

[thegenius]

Yup, nothing is perfect, and there should be a floor to protect against uncharacteristically low volumes, because after all we should be paid for our time.

Old job was essentially as you describe 99/1. I can't tell you how badly this breeds laziness. If people see 1.6 PPH it's a ton. Wait times through the roof. Lots of LWBS (oh wait it's "eloped" cause they were seen by a provider in triage 6 hours ago LOL). Angry patients, lazy nurses. Admins solution is to throw more physician hours at an already backlogged system, because they can't comprehend that the systems issues are non-physician factors (consultants, delays, radiology etc)

While we're at it, let's tie nursing compensation to productivity too. Time from orders to collection, time to urine, time from med orders to administration, time from DC order placed to discharge. Let them feel the burn.

And that's where hybrid models come in, which is probably the best model out there. About 60% of our pay is RVU protected (e.g. salary) and 40% is RVU. We have a pretty wide variation of pay in our group, over $100/hr from most productive to least productive.

 

[WhatJobDoIPick]

I'm not sure how common RVU- or productivity-based compensation is outside of the U.S./Canada. The rest of the world's societies have not collapsed.

Up to you if you want to be paid your worth or not.

 

[EctopicFetus]

Up to you if you want to be paid your worth or not.

Half the people don’t want to be paid their worth n they want to be paid the worth of the other half.