By Beth Duff-Brown
Triage nurses typically assign patients to emergency room doctors who are on call or working a shift. But what if the doctors themselves determine whom among them is better suited to take on the next patient?
Classic economic theory predicts “moral hazard” in teams, which means one member behaves inefficiently because in the end someone else will pay the consequences. Yet many successful organizations promote teamwork.
So how does this puzzle relate to health care?
This is the question that David Chan, a faculty fellow at the Stanford Institute for Economic Policy Research, tackles in his new study in the Journal of Political Economy.
Emergency departments (ED) nationwide cost a combined $136 billion to run each year, significantly impacting the growing health-care sector of the U.S. economy. Visits to the emergency rooms are increasing despite the implementation of the Affordable Care Act, causing them to be overcrowded and underfunded.
Chan, an assistant professor of medicine, studied two organizational models: one in which physicians are assigned patients in a nurse-managed system and one in which the doctors divide patients among themselves in a self-managed system.
“I find evidence that physicians in the same location have better information about each other and that, in the self-managed system, they use this information to assign patients,” Chan writes.
He said that by simply allowing physicians to choose patients, a self-managed system reduces emergency room lengths of stay by 11-15 percent, relative to the nurse-managed system.
“This effect occurs primarily by reducing a `foot-dragging’ moral hazard, in which physicians delay patient discharge to forestall new work,” writes Chan, who is also a core faculty member at Stanford Health Policy.
A triage nurse is often in another room and has a difficult time observing true physician workload, whereas peer physicians who work together can.
“So, for example, if there are two physicians working at a time when there are a whole bunch of patients in the waiting room, then each physician knows that the minute he discharges a patient, he is more likely to get another one,” Chan said in an interview. This might lead the physician to dilly-dally on the release of that patient, knowing that he’ll immediately be signed another before he gets a break.
However, two physicians who can observe how busy the other one truly is will be less likely to stall, even if they want to avoid new patients.
Chan studied a large, academic emergency room that treated 380,699 patients over a six-year period. He looked at length of stay, measuring each physician’s individual contribution. He also observed patient demographics and used the Emergency Severity Index, an ED triage algorithm based on a patient’s pain level, mental status, vital signs and medical condition.
Besides measuring the effect of the self-managed system in this large hospital, Chan combined evidence to support the hypothesis that teamwork improves outcomes because of mutual management with better information.
He found that the only difference in outcomes between the two organizational systems was foot-dragging. Clinical outcomes or even the number of tests ordered were about the same under a self-managed or nurse-managed system.
Moreover, the foot-dragging behavior grows as physicians may anticipate future work by the number of patients in the waiting room, even if they end up seeing the same number of patients.
Finally, physicians refrain from this behavior when being watched by another physician in the same location, even in the nurse-managed system, when that other physician does not otherwise have any role in the physician’s patient care.
“I think the biggest takeaway is that such efficiency gains can be widespread in health care, particularly because there is so much at stake hidden behind information in patient care that is not transparent,” Chan said.
“Even if we don’t fully anticipate all of these gains, we could still achieve a lot by tinkering and using these changes as natural experiments to figure out what works and what doesn’t,” Chan said. “We can further use these results, particularly the evidence pointing at a mechanism, to think of what other innovations might work.”
Beth Duff-Brown is the communications manager for Stanford Health Policy.