* * Anonymous Doc: Misaligned Incentives

Thursday, April 19, 2012

Misaligned Incentives

We've been told to try and get our patients discharged before 11AM.

In fact-- we've been promised CUPCAKES if our team gets the most patients discharged before 11AM.

(This is not sufficient incentive to do anything, by the way.)

See, the hospital wants patients out early so they can get as many new patients admitted as early as possible, to start making money on them. Patients about to be discharged don't have procedures the day of discharge, so there's no money to make. Earlier they leave, the better.

But as soon as someone like me discharges a patient, we have room to get a new one-- and the last thing we want is to get four or five or six new patients in a day, and have to deal with all of those admissions notes.

So, in a perfect world, from my point of view, I want to discharge my patients late in the day, so there isn't time for me to get new ones. Since I'm not allowed to be given new admissions after 4:00 (they go to a different service), my goal is to keep all of my patients until 4:00, and then discharge them afterwards.

Of course, then I end up getting overnight admissions... which still take time the next morning... but not as much time, because someone has done some of the work for me overnight.

If the hospital wanted to align incentives, perhaps they could pass along some of the money they would gain along to residents like me... you want to pay me $200 for everyone I discharge before 11AM, suddenly you would see a lot more early discharges. $100, even. Maybe $75.

But for a chance at cupcakes? No thanks. I'll buy a cupcake if I want a cupcake.

(But I won't buy it from the kiosk in the lobby, because the kiosk in the lobby just got closed by the health department. Would you feel comfortable being a patient in a hospital that can't keep its lobby kiosk sanitary enough to remain open? Hint: YOU SHOULDN'T.)


  1. At my work they would put up this giant posterboard and put up docs names that were especially good at d/c-ing patients by 11. As if that made anybody do anything any different. As a nurse the best case scenario for us is staggered discharges starting early afternoon. NOT before 11. They started timing us for how long we took to discharge patients after the orders were in, even if something was holding up the discharge, like test results or transportation set-up for SNFs. They thought WE were sitting on the discharges (yeah, somedays I would, if I had 4 discharges and actually wanted to eat before my shift was over). Pre 11 am seems to only benefit the hospital. Not even the patient wants to leave that early, lol.

  2. If this is supposed to be funny, you missed the mark!

  3. Wait I'm confused. Why did you delete my comment?

  4. Old MD Girl: I didn't delete any comments-- what did the comment say?

  5. I think it was something about communism vs. capitalism, and why nothing ever gets done with the former. It's entirely possible that I was hallucinating at 2AM while feeding my kid and I mistyped the WV letters though. No worries.