Provider Workload Research Articles

A two-phase approach to scheduling multi-category outpatient appointments – A case study of a women’s clinic

In this paper, we propose a two-phase approach for designing a weekly scheduling template for outpatient clinics providing multiple types of services. In many outpatient clinics, various service types are categorized to address the operational challenge of substantial changeover time between certain pairs of services. In the first phase of our approach, a mixed-integer program is formulated to assign service categories to clinic sessions during a week and determine the optimal number of appointments reserved for each service type in each clinic session. The objective in the first phase is to balance the workload of the providers among clinic sessions. In the second phase, a stochastic mixed-integer program is formulated for each clinic session to assign each contained appointment with a starting time based on several time-based performance measures. To solve the formulated stochastic program, we develop a Monte Carlo sampling based genetic algorithm. The two-phase approach is tested numerically with cases derived from a real women's clinic. Our results demonstrate that the two-phase approach can efficiently find promising weekly appointment scheduling templates for outpatient clinics. In addition, our results suggest that the best suboptimal scheduling templates found become more sensitive to the weighting coefficients of the time-based measures as the provider workload increases.

Provider Workload and Quality of Care in Primary Care Settings

Primary care providers are increasingly under pressure to do more with fewer resources. We examined the effect of workload on patients' experiences of quality of care, measured through approximately 44,000 patient experience surveys in a sample of 222 primary care clinics in the Veterans Health Administration. We tested the extent to which relational climate, a measure of teamwork, moderated the relationship between workload and patient ratings of quality of care. Our outcome measures included patient complaints, time spent with provider, and overall visit quality. Workload was negatively associated with patients' quality of care ratings and relational climate moderated the relation between workload and quality of care ratings. Patients seen in clinics with higher workload and greater relational climate reported better care compared with patients in clinics with higher workload but lower relational climate. Findings highlight the importance of relational climate as an important teamwork factor when managing and developing clinic policies, practices, and procedures in resource-constrained settings.

Telehealth—An Effective Delivery Method for Diabetes Self-Management Education?

Diabetes is a chronic disease that is often comorbid with cardiovascular disease, hypertension, kidney disease, and neuropathy. Its management is complex, requiring ongoing clinical management, lifestyle changes, and self-care. This article examines recent literature on telehealth and emerging technological tools for supporting self-management of diabetes and identifies best practices. The authors conducted a PubMed search (January 2008-2012) that was supplemented by review of meeting materials and a scan of the Internet to identify emerging technologies. Fifty-eight papers were reviewed; 12 were selected for greater analysis. This review supports earlier findings that the delivery of diabetes self-management and training (DSME/T) via telehealth is useful, appropriate, and acceptable to patients and providers. Best practices are emerging; not all technology is appropriate for all populations--interactive technology needs to be appropriate to the patient's age, abilities, and sensitivities. Telehealth is scalable and sustainable provided that it adds value, does not add to the provider's workload, and is fairly reimbursed. However, there are multiple barriers (patient, provider, health system) to remotely provided DSME/T. DSME/T delivered via telehealth offers effective, efficient, and affordable ways to reach and support underserved minorities and other people with diabetes and related comorbidities. The new generation of smartphones, apps, and other technologies increase access, and the newest interventions are designed to meet patient needs, do not increase workloads, are highly appropriate, enhance self-management, and are desired by patients.

Satisfied patients, pharmacists patients, pharmacists at Phoenix VA

Satisfied patients, pharmacists patients, pharmacists at Phoenix VA

Slack Resources and Quality of Primary Care

Research generally shows that greater resource utilization fails to translate into higher-quality healthcare. Organizational slack is defined as extra organizational resources needed to meet demand. Divergent views exist on organizational slack in healthcare. Some investigators view slack negatively because it is wasteful, inefficient, and costly, whereas others view slack positively because it allows flexibility in work practices, expanding available services, and protecting against environmental changes. We tested a curvilinear relationship between organizational slack and care quality. The study setting was primary care clinics (n=568) in the Veterans Health Administration. We examined organizational slack using the patient panel size per clinic capacity ratio and support staff per provider ratio staffing guidelines developed by the Veterans Health Administration. Patient-level measures were influenza vaccinations, continuity of care, and overall quality of care ratings. We obtained 2 independent patient samples with approximately 28,000 and 62,000 observations for the analysis. We used multilevel modeling and examined the linear and quadratic terms for both organizational slack measures. We found a significant curvilinear effect for panel size per clinic capacity for influenza vaccinations and overall quality of care. We also found support staff per provider exhibited a curvilinear effect for continuity of care and influenza vaccinations. Greater available resources led to better care, but at a certain point, additional resources provided minimal quality gains. Our findings highlight the importance of primary care clinic managers monitoring staffing levels. Healthcare systems managing a balanced provider workload and staff-mix may realize better patient care delivery and cost management.

Barriers and facilitators for preventing Adverse Drug Reactions of Long Latency: A qualitative study

To understand the practices medical care providers and health care staff utilize in managing and preventing Adverse Drug Reactions of Long Latency (ADRLLs) among their patients on medications such as glucocorticoids. Qualitative study of key informant interviews. Denver Department of Veterans Affairs (VA) Medical Center. Fourteen physician providers and health care staff (nurses and pharmacists) in primary care and rheumatology. A trained interviewer conducted semi-structured interviews in which providers and health care staff were asked about their processes for tracking and averting ADRLLs. PARTICIPANTS were asked about barriers and facilitators to monitoring ADRLLs and solicited for suggestions to improve existing processes. Interviews were analyzed using ATLAS.ti software. Providers overwhelmingly commented on barriers, rather than facilitators. Six core themes emerged regarding ADRLL management barriers: patient noncompliance, provider workload, complications coordinating care, provider unfamiliarity with ADRLLs, lack of a standardized monitoring system, and communication failures. Ideas to improve the monitoring of ADRLLs fell into two domains: improving automated computer generated reminders or assigning a specific person to monitor potential ADRLLs. Interviewees strongly endorsed a more systematic approach to ADRLL management, either through less intrusive computer-generated system reminders or through a dedicated staff person, such as a pharmacist, who could more closely monitor potential ADRLLs. There was disagreement among interviewees about who is responsible for monitoring ADRLLs (specialists versus primary care providers, VA versus non-VA providers, residents versus attending physicians).

Acceptability and feasibility of integration of HIV care services into antenatal clinics in rural Kenya: A qualitative provider interview study

The aim of this study was to explore the perspectives of healthcare providers on the advantages and disadvantages of integrating HIV care services, including highly active antiretroviral therapy (HAART), into antenatal care (ANC) clinics in rural Kenya. We conducted a qualitative study using in-depth interviews and thematic analysis; 36 healthcare providers from six health centres in Nyanza Province, Kenya participated. Effects on service providers included increased workload due to the incorporation of specialised HIV services into ANC clinics. Providers observed that integration results in decreased patient time spent at the health facility, increased efficiency and closer provider-patient relationships; all leading to increased patient satisfaction. Providers also said that women would be more likely to receive HAART and adhere to their treatment as a result of improved confidentiality and decreased stigma. However, a minority of providers noted that integration could result in longer appointment times for HIV-positive women at ANC clinics leading to inadvertent disclosure. Integration could lead to strengthened ANC, postpartum care, prevention of mother-to-child transmission and HIV care for women and their families. However, integration efforts need to take into account potential negative effects on ANC provider workload, disclosure and the quality of care.

Cross-border Childbirth Between Mainland China and Hong Kong: Social Pressures and Policy Outcomes

Using secondary data analysis, this paper examines the societal impact of mainland Chinese expectant mothers who gave birth in Hong Kong (HK). In 2009, 45.4% of live births were born to this group of women, compared to 10.2% in 1995. These women agreed unanimously that giving birth in HK would secure the future of their child with permanent residency, access to free education, subsidised health care, social welfare benefits and a better standard of living. For parents who choose to have more than one child, cross-border birthing can provide an opportunity to bypass China’s one-child policy. This rising trend has put heavy pressure on the already stretched obstetric services at the expense of local women. The Hospital Authority (HA) responsible for public hospitals acknowledged that in the 2004-5 financial year, 1 670 mainland women failed to pay HK$12.64 million (USD1.63m) in hospital bills; and in 2005-6, 2 138 women defaulted HK$28.58m (USD3.68m). In response to protests at this situation and the lack of an effective policy, HA introduced an obstetric package in February 2007. Non-local expectant mothers must now pay HK$39 000 (USD5 000) in advance to cover one antenatal visit, delivery service and delivery-related hospitalisation for three days; non-compliant women would be charged HK$48 000 (USD6 154). Mainland women who are over 28 weeks’ gestation are now denied entry at immigration checkpoint if they do not have a prior booking. Between February and December 2007, an HA audit showed a 229% increase in booking for public hospitals alone and secured HK$257.4m (USD33m) in fees. Non-compliant cases and last-minute hospital admissions were significantly reduced. In addition to the high bill settlement rate, this policy has provided a steady workload and training opportunities for many health care providers. If these new citizens remain in HK, they may contribute to the prosperity as well as alleviating the ageing population of HK.

A Budget Impact Analysis of Telemedicine-based Collaborative Care for Depression

Patients with depression use more health services than patients without depression. However, when depression symptoms respond to treatment, use of health services declines. Most depression quality improvement studies increase total cost in the short run, which if unevenly distributed across stakeholders, could compromise buy-in and sustainability. The objective of this budget impact analysis was to examine patterns of utilization and cost associated with telemedicine-based collaborative care, an intervention that targets patients treated in small rural primary care clinics. Patients with depression were recruited from VA Community-based Outpatient Clinics, and 395 patients were enrolled and randomized to telemedicine-based collaborative care or usual care. Dependent variables representing utilization and cost were collected from administrative data. Independent variables representing clinical casemix were collected from self-report at baseline. There were no significant group differences in the total number or cost of primary care encounters. However, as intended, patients in the intervention group had significantly greater depression-related primary care encounters (marginal effect=0.34, P=0.004) and cost (marginal effect=$61.4, P=0.013) to adjust antidepressant therapy for nonresponders. There were no significant group differences in total mental health encounters or cost. However, as intended, the intervention group had significantly higher depression-related mental health costs (marginal effect=$107.55, P=0.03) due to referrals of treatment-resistant patients. Unexpectedly, patients in the intervention group had significantly greater specialty physical health encounters (marginal effect =0.42, P=0.001) and cost (marginal effect =$490.6, P=0.003), but not depression-related encounters or cost. Overall, intervention patients had a significantly greater total outpatient cost compared with usual care (marginal effect=$599.28, P=0.012). Results suggest that telemedicine-based collaborative care does not increase total workload for primary care or mental health providers. Thus, there is no disincentive for mental health providers to offer telemedicine-based collaborative care or for primary care providers to refer patients to telemedicine-based collaborative care.

Simulation to Assess the Safety of New Healthcare Teams and New Facilities

: Our institution recently opened a satellite hospital including a pediatric emergency department. The staffing model at this facility does not include residents or subspecialists, a substantial difference from our main hospital. Our previous work and published reports demonstrate that simulation can identify latent safety threats (LSTs) in both new and established settings. Using simulation, our objective was to define optimal staff roles, refine scope of practice, and identify LSTs before facility opening. : Laboratory simulations were used to define roles and scope of practice. After each simulation, teams were debriefed using video recordings. The National Aeronautics and Space Administration-Task Load Index was completed by each participant to measure perceived workload. Simulations were scored for team behaviors by video reviewers using the Mayo High Performance Team Scale. Subsequent in situ simulations focused on identifying LSTs and monitoring for unintended consequences from changes made. : Twenty-four simulations were performed over 3 months before the hospital opening. Laboratory debriefing identified the need to modify provider responsibilities. National Aeronautics and Space Administration-Task Load Index scores and debriefings demonstrated that the medication nurse had the greatest workload during resuscitations. Modifying medication delivery was deemed critical. Lower Mayo High Performance Team Scale scores, implying less teamwork, were noted during in situ simulations. In situ sessions identified 37 LSTs involving equipment, personnel, and resources. : Simulation can help determine provider workload, refine team responsibilities, and identify LSTs. This pilot project provides a template for evaluation of new teams and clinical settings before patient exposure.

Towards a personalised approach to aftercare: a review of cancer follow-up in the UK

Due to growth in cancer survivorship and subsequent resource limitations, the current UK position of follow-up services is unsustainable. With people living longer after a cancer diagnosis, supported self-management for ongoing treatment-related chronic conditions is a fundamental component of aftercare services. Alternative models to traditional hospital aftercare require consideration in terms of clinical effectiveness and cost-effectiveness. 'Evidence to Inform the Cancer Reform Strategy: The Clinical Effectiveness of Follow-Up Services after Treatment for Cancer' (Centre for Reviews and Dissemination 2007) has been updated using a number of quality-controlled databases. Correspondence with experts was also sought to identify current initiatives. The review highlights a shift towards patient empowerment via individualised and group education programmes aimed at increasing survivor's ability to better manage their condition and the effects of treatment, allowing for self-referral or rapid access to health services when needed. The role of specialist nurses as key facilitators of supportive aftercare is emphasised, as is a move towards technology-based aftercare in the form of telephone or web-based services. The challenge will be replacing traditional clinic follow-up with alternative methods in a cost-effective way that is either as equally effective, or more so. To establish this, more rigorous trials are needed, with larger sample sizes and longer follow-up assessments. Increasing patient confidence to initiate follow-up specific to their needs is likely to increase the workload of primary care providers, who will need training for this.

Palliativmedizin und fortgeschrittene, nicht heilbare Erkrankungen

Advanced incurable and life-threatening diseases of internal organs such as chronic obstructive pulmonary disease (COPD), heart failure, and terminal kidney failure are associated with considerable burden for the patients caused by pronounced symptoms (e.g., dyspnea, anxiety, depression) and unmet psychosocial needs. Nevertheless, in Germany addressing palliative medicine in the context of these disorders and co-treatment of these patients by cross-sector partnership with specialized palliative care physicians are not very developed. Against the background of an international perspective and current guidelines, general aspects of palliative care needs (symptom control, communication, advance care planning, etc.) are discussed together with the resultant implications for potential cooperation between internal medicine and palliative care as well as special aspects of the individual diseases (e.g., prognosis or implications of certain treatment options such as "automatic implantable cardioverter-defibrillator", AICD). Timely involvement of the specific expertise of palliative care medicine can ensure that the workload of the primary providers (and their teams) is reduced and better cross-sector management (hospital and home) of the severely ill patients and their families is achieved.

The Use of Computer Decision Support Systems for the Critical Care Environment

Abstract : As the workload of primary care providers continues to increase, the use of automation in the intensive care unit (ICU) environment has been touted as a way to increase effectiveness of patient care and standardize practice, while reducing the number of complications associated with the use of manually implemented approaches.1 4 Medical computer decision support (CDS), or computer decision assist, applications are a type of information technology system that embed the expertise of experienced care providers and/or standards of care into a computerized system. They can be implemented at any care level including prehospital, emergency departments, operating rooms, and ICUs. These systems provide information on patient care issues as an adjunct to standard treatments used during the patient s stay. For example, a typical CDS system may provide alerts when a combination of patient parameters fall out of range and recommend changes in drug rates to the care provider to bring the patient parameters within acceptable limits. By providing clinicians with these types of applications, patient care is improved in 2 ways. First, they provide a tool for learning and quality improvement. These systems provide the ability to push the expertise of more experienced care providers to clinicians who may not be fully trained or may be unfamiliar with current evidence based practice (EBP) guidelines. Second, as a decision support adjunct, these systems provide additional information that may not be otherwise available or easily obtainable to experienced care providers. Computer decision support systems improve the provider s ability to manage multiple sources of data, allow for trending analysis, and provide the ability to fuse data from multiple sources. Furthermore, these tools allow for advanced information processing that can be used in predictive modeling of patient outcomes.

Growth Rates in Pediatric Diagnostic Imaging and Sedation

Workload has increased greatly over the past decade for anesthesia providers administering general anesthesia and/or sedation for pediatric diagnostic imaging. Data from an academic medical center were studied over a 12-yr period. Growth in the number of children 0-17 yr of age undergoing magnetic resonance imaging (MRI) and/or computerized tomography (CT) scans who received care from anesthesia providers was compared with the increase in the total number of MRI and CT procedures performed in children. Anesthesia providers included anesthesiologists, residents, Certified Registered Nurse Anesthetists, and student Certified Registered Nurse Anesthetists. Toward the end of the study, a team of sedation nurses was employed by the hospital to administer moderate sedation. They provided an alternative to anesthesia providers from the anesthesia department, who usually administered general anesthesia. Use of sedation nurses versus anesthesia providers, and the relationship to scan duration and patient age, were studied over a 6-mo period. The number of children receiving care from anesthesia providers for MRI and CT scans grew at the same 8%-9% annual rate as the number of scans performed. The percentage of children receiving anesthesia care did not change over the 12 yr. Creation of a nurse sedation team that provided moderate sedation did not alter the number of children receiving care from anesthesia providers but did increase the total number of children receiving hypnotics. Anesthesia was rarely used for scans shorter than 30 min in duration. Increases in scan duration were associated with increased utilization of anesthesia providers for both MRI and CT after stratifying by age. An age of 3-5 yr was associated with the highest rates of anesthesia care. Future workload for anesthesia providers administering general anesthesia and/or sedation for pediatric diagnostic imaging will depend on trends in the total number of scans performed. Workload may also be sensitive to factors that increase scan duration or alter the percentage of patients in the 3-5 yr age group. It may additionally depend on reimbursements from insurance companies.

Design, Development and Evaluation of Pictographic Instructions for Medications Used during Humanitarian Missions

Objectives: To develop, design and evaluate pictographic instructions for medications used during humanitarian medical missions. Methods: We developed and designed pictographic medication instructions based on the storyboard pictogram concept and then evaluated the pictograms during an itinerant medical mission in Gabon. We evaluated patients' comprehension of both the individual pictograms and the storyboard template at the time of dispensing or at short-term follow-up. Patients were asked questions to assess their comprehension of the indication, dose, route of administration, frequency and auxiliary instructions. Demographic data, including age, sex and mother tongue, were also collected. During the follow-up interview, we assessed the patients' understanding and recall of the pictographic instructions. Results: Pictograms were tested with 525 patients at the time of dispensing; 47 of these patients were also seen at short-term follow-up (the day after dispensing). Most of the pictograms tested achieved the European Commission standard for comprehension of greater than 80%, but were slightly below the American National Standard Institute criterion of greater than 85% comprehension. The use of pictograms caused a moderate increase in workload for the health care providers. Conclusions: The use of a pictographic storyboard was valuable for medication counselling in a humanitarian aid setting; however, the use of pictograms increased the workload of the health care providers who supplied the counselling.

Extended administration of erythropoiesis-stimulating agents for optimising the management of renal anaemia: what is the evidence?

Erythropoiesis-stimulating agents (ESAs) have transformed the management of anaemia in patients with chronic kidney disease (CKD), reducing transfusion requirements and leading to improved quality of life. However, effective anaemia management with current ESAs is labour-intensive and time-consuming. Approaches are required to simplify anaemia management and reduce the burden on healthcare systems. There is increasing interest in extending the administration interval of ESAs. This would result in considerable time-savings, reducing the workload of healthcare providers and potentially reducing healthcare system costs. Time saved could be utilised in improving other aspects of patient care, such as implementation of guidelines, or treating more patients. Potential benefits of extended administration intervals for patients include a less demanding regimen and fewer injections, which could lead to improved adherence to treatment. This article reviews studies of the efficacy of current ESAs in maintaining stable haemoglobin (Hb) levels when used at extended administration intervals of up to once monthly. Patients who are already stable on more frequent ESA therapy and who respond well to treatment may be able to maintain stable Hb with extended dosing regimens with established ESAs. However, few patients with CKD currently receive ESAs once-monthly in clinical practice. New agents with long half-lives offer the potential for extended dosing regimens in all patients with CKD.

RENAL ANAEMIA: RECENT DEVELOPMENTS AND FUTURE DIRECTIONS FOR IMPROVED MANAGEMENT

The global burden of chronic kidney disease (CKD) and associated anaemia is substantial. With the increasing numbers of patients that are likely to be affected in the future, approaches are required to improve anaemia management without increasing the workload of renal units. Advocating early treatment may improve patient outcomes and nurses are in an ideal position to identify and manage anaemia at an early stage in patients with CKD. In addition, adopting a multidisciplinary approach, alongside nephrologists, diabetologists, cardiologists, social workers, nutritionists and pharmacists, may allow nurses to detect and treat anaemia earlier in patients with CKD. Maintaining awareness of factors associated with decreased erythropoiesis-stimulating agents (ESAs) efficacy (e.g. iron deficiency or poor nutritional status) is also important. To reduce the burden on healthcare providers, anaemia management could be simplified by extending the administration interval of ESAs. Recent studies have explored the clinical efficacy of administration of currently available agents at intervals of up to once monthly in highly selected, stable patients. The use of an ESA that can control anaemia while maintaining haemoglobin levels within guideline ranges with extended administration intervals in all patients without the need for additional screening or stepwise dose adjustments with attendant monitoring may help improve patient care while reducing the workload of healthcare providers.

Renal anaemia: Recent developments, innovative approaches and future directions for improved management (Review Article)

The morbidity, mortality and economic burden of chronic kidney disease (CKD) and associated anaemia are substantial. With the increasing numbers of patients who are likely to be affected in the future, approaches are required to improve anaemia management without increasing the burden on health-care professionals. A multidisciplinary approach to treatment, where early initiation of erythropoiesis-stimulating agents (ESA) is encouraged, may improve patient outcomes. Recent studies also suggest that the early use of iron therapy in patients with CKD not on dialysis may be associated with beneficial effects on haemoglobin levels. Another strategy to reduce the burden on health-care providers is to simplify anaemia management by extending the administration interval of ESA. Indeed, recent studies have explored the efficacy of extending the administration interval of ESA in clinical practice in CKD patients on dialysis and not on dialysis. The ability to maintain haemoglobin levels within guideline ranges at extended administration intervals may improve patient care and reduce the workload of health-care providers.

2005 APA Gold Award: Improving Treatment Engagement and Integrated Care of Veterans

2005 APA Gold Award: Improving Treatment Engagement and Integrated Care of Veterans

Multiple measures of anesthesia workload during teaching and nonteaching cases.

In this study, we sought to examine several measures of anesthesia provider workload during different phases of anesthesia care and during teaching and nonteaching cases. Clinical work was assessed in real-time during 24 general anesthetics performed by consenting anesthesia providers. Workload was measured using physiological (provider heart rate), psychological (self-assessment and observer rating), and procedural (response latency to an alarm light and workload density) techniques. Clinicians' heart rates, observer and self-reported workload scores, and nonteaching workload density were consistently increased during anesthetic induction and emergence compared with maintenance. In nonteaching cases, workload density correlated with heart rate and with psychological workload. Workload density during teaching cases did not decrease during the induction and was significantly greater than during nonteaching cases. Alarm-light response latency (a measure of clinical vigilance) was significantly prolonged during the teaching compared with nonteaching cases. These results suggest that intraoperative teaching increases the workload of the clinician instructor and may reduce vigilance during anesthesia care. Additionally, multiple workload measures may provide a more comprehensive profile of the work demands of clinical cases. Psychological, physiological, and procedural workload measures during routine general anesthesia cases documented the increased work demands of induction and emergence. Intraoperative teaching increased workload and decreased vigilance, suggesting the need for caution when educating during patient care.