Patient-related Tasks Research Articles

Impact of legal documentation requirements on physician practice using a regional specialty hospital as an example: an inventory

Doctors in German hospitals are critical of their working conditions. They complain about long working hours, inadequate remuneration for their work, poor training and development opportunities, and increasing time spent on administrative tasks. As these points of criticism are largely based on subjective perception, in the present study we documented in detail the workflows of physicians in a major regional hospital, determined the time taken for the workflows, and performed a statistical evaluation of the data. Nine doctors from the specialties of internal medicine, surgery, and anesthesia/intensive care medicine were observed during their shifts for a total period of 216 hours at an urban hospital in Germany. All of the tasks performed by the doctors were recorded in an observation protocol. The time spent daily on documentation by doctors of all specialties was on average 93.1 ± 23.4 minutes, accounting for 19.4 % of a doctor's working hours. The specialists who spent the longest period of time on documentation were internists (120.2 ± 15.0 minutes; 25 %). During an eight-hour working day, computers were used on average for 123.5 ± 44.4 minutes; surgeons spent the shortest period of time on computers (71.5 ± 16.6 minutes). The direct patient-related work time (excluding the time spent on operations) was considerably lower (33.8 + 22.7 minutes; 7 %) than thetime spent daily on documentation, increased to 80.7 ± 62.9 minutes when the time expended on actual surgical tasks was taken into account, and was then similar to the time spent on documentation (93.1 minutes). This pilot study was the first to determine, in real time, the work processes of doctors from different specialties at a German hospital. We noted a disparity between administrative and patient-related tasks in the in-patient setting. Legal and economic requirements exert a negative impact on medical care. We need to develop strategies for effective utilization of medical resources and for ensuring a high standard of medical care.

‘Optimising Time for Effective Patient Care’: Work-sampling Analysis

Modern healthcare is increasingly complex with the growing demand of multidisciplinary care and the demand for high efficiency, but also healthcare professionals seem to be confronted with an increasing need for high-quality, timely, patient care. Current study was planned with aim to formulate guidelines for effective utilization of dental healthcare personnel and reduce patient waiting time in a peripheral dental healthcare center. A work sampling study was conducted during April 2014 on seven participating dentist posted and patients visiting at outreach dental healthcare center. A snapshot of clinical and administrative activities was recorded by trained investigator over 48 hours. A 14-item classification system was applied to categorize tasks performed by dental health care personnel (DHCP) into five categories and six categories for patient-related tasks. A total of 2,303 observations documented for dentist and 378 for patients. Documentation activities accounted for 5% and infection control for 3% and idle time for 5%. On an average, 33% of patient’s time was spent in waiting area whereas only 7% while delivering health education. To conclude, work sampling is a feasible method for defining the work experience of DHCP and for measuring the impact of administrative changes imposed to improve education or healthcare delivery.

Workload and GP burnout: a survey and register-based study in Danish general practice.

Burnout is common among GPs. Previous studies have indicated an association between high workload and burnout among doctors. To assess the risk of burnout among single-handed GPs in Denmark in relation to self-reported and register-based workload. Questionnaire data from 312 Danish single-handed GPs and register data on their patients and provided services. Burnout was measured using the Maslach Burnout Inventory-Human Services Survey (MBI-HSS). A composite burnout score of quartile points was calculated. The questionnaire provided information on working hours. Register data included number of services and patient list size. Association between composite burnout score and workload was estimated with binomial regression analyses adjusting for the GP's age and sex, and social deprivation score of their patient lists. Working >5 days a week in practice increased the risk of a high burnout score (adjusted risk ratio [RR] = 2.34, 95% confidence interval [CI] = 1.62 to 3.37). Spending >7.5 hours a day on patient-related tasks increased the risk of a high burnout score. The highest score was among GPs spending 8.5-9.5 hours a day on patient-related tasks (adjusted RR = 2.01, 95% CI = 0.90 to 4.51), although not statistically significant. There was no association between number of services and risk of burnout. Working 5 days a week in practice significantly increased the risk of burnout in Danish single-handed GPs. Spending >7.5 hours a day on patient-related tasks tended to increase the risk. We found no association between a high number of services and increased risk of burnout.

Exploring cognitive stress-related tasks of Intensive Care Unit nurses –A comparison study

The aim of this study is to explore nurse activities leading to high cognitive stress for intensive care unit (ICU) nurses. The quantification of stress-related nurse activities has been acquired before and after the working shift, with a general gap in analyzing the whole shift. To address this gap, the task analysis of stress-related nurse activities during whole shift was conducted for two participants. The administration tasks (processing clinical data, exchanging professional information and ordering examination), and communicating with patients were most performed when under high cognitive stress. Future work should investigate the contribution of administration and patient-related tasks to high cognitive stress for ICU nurses.

Finding your feet: student participation during initiation of international clinical placements : Student participation during initiation.

IntroductionInternational placements challenge students to find the right level of participation, as local practices, language and time pressure may affect their engagement in patient-related tasks or team activities. This study sought to unpack the initiation process during international clinical placements with the ultimate aim to achieve active student participation.MethodsFollowing a constructivist grounded theory approach, we conducted two individual interviews with 15 undergraduate healthcare students (before departure and whilst on placement). To identify emerging themes, we applied an iterative process of data collection and constant comparative analysis. Several team discussions informed further analysis, allowing us to reach a more conceptual level of theory.ResultsFrom our findings we constructed a four-phase model of healthcare students’ initiation of international clinical placements, which brings into focus how the phases of ‘orientation’, ‘adjustment’ and ‘contribution to patient care’ build up towards a ‘sense of belonging’. We identified several factors that induced active student participation in practice, such as a favourable workplace setting, opportunities for learning and a local support network.DiscussionActive student participation is aimed at different goals, depending on the four phases of initiation that eventually lead to a sense of belonging and support workplace learning.Electronic supplementary materialThe online version of this article (10.1007/s40037-020-00561-9) contains supplementary material, which is available to authorized users.

Incorporating Physician Input Into a Maintenance of Certification Examination: A Content Validity Tool.

As part of the American Board of Internal Medicine's (ABIM's) continuing effort to update its Maintenance of Certification (MOC) program, a content validity tool was used to conduct structured reviews of MOC exam blueprints (i.e., test specification tables) by the physician community. Results from the Cardiovascular Disease MOC blueprint review are presented to illustrate the process ABIM conducted for several internal medicine disciplines. Ratings of topic frequency and importance were collected from cardiologists in 2016 using a three-point scale (low, medium, high). The web-based survey instrument presented 188 blueprint topic descriptions, each combined with five patient-related tasks (e.g., diagnosis, treatment). Descriptive statistics and chi-square analysis were employed. Responses from 441 review participants were analyzed. Frequency and importance ratings were aggregated as a composite statistic representing clinical relevance, and exam assembly criteria were modified to select questions, or items, addressing clinically relevant content only. Specifically, ≥ 88% of exam items now address high-importance topics, including ≤ 15% on topics that are also low frequency; and ≤ 12% of exam items now address medium-importance topics, including ≤ 3% on topics that are also low frequency. The updated blueprint has been published for test takers and provides enhanced information on content that would and would not be tested in subsequent examinations. It is linked to more detailed feedback that examinees receive on items answered incorrectly. The blueprint review garnered valuable feedback from the physician community and provided new evidence for the content validity of the Cardiovascular Disease MOC exam.

The workday of hospital surgeons: what they do, what makes them satisfied, and the role of core tasks and administrative tasks; a diary study

BackgroundMany surgeons report passion for their work, but not all tasks are likely to be satisfying. Little is known about how hospital surgeons spend their days, how they like specific tasks, and the role of core tasks (i.e. surgery-related tasks) versus tasks that may keep them from core tasks (e.g., administrative work). This study aimed at a more detailed picture of hospital surgeons’ daily work - how much time they spend with different tasks, how they like them, and associations with satisfaction.MethodsHospital surgeons (N = 105) responded to a general survey, and 81 of these provided up to five daily questionnaires concerning daily activities and their attractiveness, as well as their job satisfaction. The data were analyzed using t-tests, analysis of variance, as well as analysis of covariance and repeated measures analysis of variance for comparing means across tasks.ResultsAmong 14 tasks, surgery-related tasks took 21.2%, patient-related tasks 21.7% of the surgeons’ time; 10.4% entailed meetings and communicating about patients, and 18.6% documentation and administration. The remaining time was spent with teaching, research, leadership and management, and not task-related activities (e.g. walking between rooms). Surgery was rated as most (4.25; SD = .66), administration as least attractive (2.63; SD = .78). A higher percentage of administration predicted lower perceived legitimacy; perceived legitimacy of administrative work predicted job satisfaction (r = .47). Residents were least satisfied; there were few gender differences.ConclusionsSurgeons seem to thrive on their core tasks, most notably surgery. By contrast, administrative duties are likely perceived as keeping them from their core medical tasks. Increasing the percentage of medical tasks proper, notably surgery, and reducing administrative duties may contribute to hospital surgeons’ job satisfaction.

Challenges in an X+Y ambulatory model.

Internal medicine training requires significant exposure to ambulatory practice. Ensuring continuity of patient care is challenging, especially with intermittent ambulatory resident assignments. A popular scheduling model is an X+Y block system where residents rotate for Xweeks on inpatient rotations followed by Yweeks on ambulatory clinics. Although benefits exist with the X+Y model, it has drawbacks, particularly for continuity of care: residents struggle to obtain follow-up test results and return patient calls promptly. To provide patients with seamless continuity the programme assigned two Managing Clinic Continuity Care Residents (MCCCRs) to cover all tasks. The MCCCRs were soon overwhelmed by the number of tasks and became dissatisfied with the workflow, however, resulting in a low task-completion rate. In our 4+1 model residents are divided into five cohorts, we created mini-practice groups (MPGs) consisting of one resident from each cohort. Each week the resident in the clinic is assigned to act as the Practice Clinic Continuity of Care Resident (PCCCR) for the MPG. This individual is responsible for addressing the patient tasks of the other four residents in the MPG. For optimal performance, the previous two MCCCRs are now assigned for oversight only each week. We tracked task-completion rates weekly and surveyed residents for satisfaction. Following the redistribution of responsibilities, the task-completion rates improved from 75 to 97%. The MCCCR satisfaction rate for the workflow increased from zero to 63%, and the on-time note completion rates increased from 21 to 67%. Modification of the X+Y model using the MPG structure ensured the timely completion of patient-related tasks, and improved the overall experience for both patients and providers. Modification of the X+Y model using the MPG structure ensured the timely completion of patient-related tasks, and improved the overall experience for both patients and providers.

Delivery of Community-Based Palliative Care: Findings from a Time and Motion Study.

Background: Use of palliative care has increased substantially as the population ages and as evidence for its benefits grows. However, there is limited information regarding which care activities are necessary for delivering high-quality, interdisciplinary, community-based palliative care.Objectives: This study aims to identify and measure the discrete clinical and administrative activities completed by a multidisciplinary team in a hospice provider-led model for providing community-based palliative care.Study Design: A time and motion study was conducted at three care settings within a large hospice and palliative care network and a process map was drawn to describe the personnel and activities recorded.Methods: Researchers recorded activities performed by clinical and administrative staff. Activities were categorized into those related to patient care, administrative duties, care coordination, and other. A process map of palliative care delivery was created and descriptive statistics were used to calculate the proportion of time spent on discrete activities and within each activity category.Results: Over 50 hours of activities were recorded during which the clinicians interacted with 25 patients and engaged in 20 distinct tasks. Physicians spent 94% of their time on tasks related to patient care and 1% on administrative tasks. Nurse practitioners and registered nurses spent 82% and 53% of their time on patient-related tasks and 2% and 37% on administrative tasks, respectively.Conclusion: The delivery of palliative care is interdisciplinary and involves numerous discrete tasks and activities. Understanding the components of a community-based palliative care model is the first step to designing incentives to encourage its spread.

Hausarztzentrierte Versorgung in Baden-Württemberg – Konzept und Ergebnisse der kontrollierten Begleitevaluation

Pursuant to Section 73b, volume V of the German Social Security Code (SGB V), the agreement on family doctor-centred care (HzV), which went into effect in Baden-Wuerttemberg on July 1, 2008, provides for spatially inclusive and comprehensive medical coverage. The most important elements of the agreement are: the voluntary registration of family practices and patients, the strengthening of the coordinative function of family practices, the fulfilment of certain training, quality and qualification requirements, the standardised remuneration system and the use of specified practice software for billing and the prescription of drugs. The aim of this complex intervention is to strengthen family medicine, improve health care, in particular for patients with chronic disease, and to limit primary health care costs while improving its quality wherever possible. This first controlled nationwide evaluation examines the question whether these objectives were met in the early phase (2008 to 2011) and, if so, to what extent. Four work packages were defined: 1. differences in health care processes (utilisation, contact to specialists, hospitalisations, drug prescriptions); 2. developments in practice teams and of patient satisfaction; 3. deployment of specially trained health care assistants in family practices (VERAH); 4. implementation of the DEGAM (German Society of General Practice and Family Medicine) heart failure guideline. To the extent that it was possible to use the statutory health insurance company AOK Baden-Wuerttemberg's routine data, an adjusted comparison of the target variables was made for HzV- and non-HzV-insured patients between the first and second or between the third and fourth quarters of 2008, and between the first and second or third and fourth quarters of 2010. HzV participants were older, had a higher disease burden (Charlson Index 1.45 vs. 1.19), and were attended to more intensively than patients receiving routine care (1.7 more contacts with the family doctor per half-year). The number of non-referred contacts to specialists fell by 12.5%. An increase in the number of referrals and hospitalisations was not observed. Participation in structured treatment programmes was substantially higher, e.g. 15% vs. 7.5% (non-HzV) in DMP diabetes mellitus Type 2. In the HzV, the rise in medication costs due to family physician prescriptions (ignoring the effect of discount agreements) was lower by 2.5%, and the me-too rate was significantly lower. Higher remuneration contributed to greater satisfaction among HzV physicians despite the perceived increase in the workload. In a survey of 2,535 patients HzV participants showed a high rate of patient satisfaction overall, and physical examinations and services aimed at preventing illness were regarded particularly favourably. A survey of 294 VERAH showed that they more often accepted patient-related tasks such as home visits, geriatric assessments, patient training, and vaccination and preventive management. Family physicians were prepared to delegate responsibilities and, as a result, felt disburdened. In accordance with the latest DEGAM guideline patients with heart failure enjoyed an improvement to an overall high level in their drug therapies with ACE inhibitors, AT1 antagonists and beta blockers. Further improvement resulting from medical quality circles and training was not observed. The results confirm the findings of international studies: in particular, HzV benefits patients with chronic disease, and patients receive improved health care when they participate in the Baden-Wuerttemberg HzV. All four evaluation modules reveal that changes towards the intended direction are taking place. Family doctors assumed more responsibility for coordination. These findings reflect the early start-up phase and the development phase of HzV in Baden-Wuerttemberg. These effects, together with those of other prioritised topics, will be continuously monitored as part of an accompanying evaluation process.

An observational study of emergency department intern activities

To describe how intern time is spent, and the frequency of activities performed by interns during emergency department (ED) rotations. Prospective observational study of 42 ED interns from three Melbourne city teaching hospitals during 5 months in 2006. Direct observations were made by a single researcher for 390.8 hours, sampling all days of the week and all hours of the day. Proportion of time spent on tasks and number of procedures performed or observed by interns. Direct patient-related tasks accounted for 86.6% of total intern time, including 43.9% spent on liaising and documentation, 17.5% obtaining patient histories, 9.3% on physical examinations, 5.6% on procedures, 4.8% ordering or interpreting investigations, 3.0% on handover and 4.9% on other clinical activities. Intern time spent on non-clinical activities included 4.2% on breaks, 3.7% on downtime, 1.7% on education, and 1.3% on teaching others. Adjusted for an 8-week term, the ED intern would take 253 patient histories, consult more senior ED staff on 683 occasions, perform 237 intravenous cannulations/phlebotomies, 39 arterial punctures, 12 wound repairs and apply 16 plasters. They would perform chest compressions under supervision on seven occasions, observe defibrillation twice and intubation once, but may not see a thoracostomy. The ED exposes interns to a broad range of activities. With the anticipated increase in intern numbers, dilution of the emergency medicine experience may occur, and requirements for supervision may increase. Substitution of ED rotations may deprive interns of a valuable learning experience.

The changing division of labour between nurses and nursing assistants in New Brunswick.

In 1989, the professional nursing organization that represents nurses in New Brunswick adopted baccalaureate entry to practice in nursing. This decision coincided with a major restructuring of provincial health care. Consequently, there has been a reorganization of health care worker roles which affects nurses and nursing assistants. This paper explores the changing division of labour between nurses and nursing assistants in the province of New Brunswick, Canada. The study used archival material, from the period 1978-1990, of three nursing organizations that played a significant role in initiating baccalaureate entry to practice. Interviews with 19 key people involved in the decision to upgrade nurse education were conducted. Data from the archival material and interviews were analysed jointly. There are ongoing tensions between nurses and nursing assistants. Although nurses would like a support worker, they remain ambiguous about the role of nursing assistants in health care and which tasks should be delegated to this group. Nursing leaders are concerned about the ease with which some patient-related tasks are moved to nursing assistants. In the past, these concerns have led nursing leaders to attempt to limit nursing assistant responsibilities through both legislative means and ways of organizing nursing labour (primary nursing). As a result of health care reforms and baccalaureate entry to practice for nurses, nursing assistant responsibilities are currently expanding. Upgrading nurse education, which came into effect in 1996 with the closure of diploma schools in New Brunswick, is likely to entrench the role of nursing assistants in health care because of the economic value of their work during a period of restructuring and rationalization of health care.