Who Should See the Patient? On Deviations from Routine Patient-Provider Assignments in Hospitals

Traditional principles in operations management and organizational theory suggest that standardizing assignments of tasks to individuals can have substantial benefits and boost performance. However, in various organizations including hospitals, individuals are not forced to follow recommended assignments, and thus, deviations from routine task assignments are often observed. This is due to the conventional wisdom that professionals should be given the flexibility to deviate from routine assignments when they perceive it to be advantageous. It is unclear, however, whether and when this conventional wisdom is true. We use evidence on the assignments of generalist and specialists to patients in our partner hospital (a children’s hospital), and generate insights into whether and when hospital administrators should disallow such flexibility by enforcing routine assignments. To perform our analyses, we identify 73 top medical diagnoses and use detailed patientlevel electronic medical record (EMR) data of more than 4,700 hospitalizations. In parallel, we conduct a carefully-designed survey of physicians and utilize it to identify the routine provider type that should have been assigned to each patient. Using these two sources of data, we examine the consequence of deviations from routine provider assignments on three sets of performance measures: operational efficiency (measured by length of stay), quality of care (measured by the occurrence of a 30-day readmission and adverse events), and cost (measured by total charges). Taken together, our findings suggest that allowing providers to deviate from routine assignments is beneficial for task types (patients’ diagnosis in our setting) that are either (a) well-defined (improving operational efficiency and costs), or (b) require high contact (improving costs and adverse events, though at the expense of lower operational efficiency). For other task types (e.g., highly complex or resource-intensive tasks), we find that routines should be enforced: deviations are either detrimental or yield no tangible benefits. To understand the mechanism behind our results, we make use of mediation analysis and find that utilizing advanced imaging (e.g., MRIs, CT scans, or nuclear radiology) plays an important role in how deviations impact performance outcomes. Our findings also provide evidence for a no free lunch theory: while for some task types deviations are beneficial regarding some performance measures, they can simultaneously degrade performance in terms of other dimensions. To provide clear recommendations for hospital administrators and assist them in deciding when and how to enforce routine assignments, we consider counterfactual scenarios corresponding to imposing the routine assignments fully or partially, and perform cost-effectiveness analyses. Our results indicate that enforcing routine assignments either for all tasks or only for resource-intensive tasks is cost-effective, with the latter being the superior policy. Finally, by comparing deviations during weekdays and weekends, early shifts and late shifts, and high congestion and low congestion periods, our results shed light on some environmental conditions under which deviations occur more in practice.