Activities of the oral health teams in primary health care: a time-motion study

BACKGROUND

Efficient planning of the oral health workforce in Primary Health Care (PHC) is paramount to ensure equitable community access to services. This requires a meticulous examination of the population's needs, strategic distribution of oral health professionals, and effective human resource management. In this context, the average time spent on care to meet the needs of users/families/communities is the central variable in healthcare professional workforce planning methods. However, many time measures are solely based on professional judgment or experience.

OBJECTIVE

Calculate the average time parameters for the activities carried out by the oral health team in primary health care.

METHOD

This is a descriptive observational study using the time-motion method carried out in five Primary Health Care Units in the city of São Paulo, SP, Brazil. Direct and continuous observation of oral health team members occurred for 40 h spread over five days of a typical work week.

RESULTS

A total of 696.05 h of observation were conducted with 12 Dentists, three Oral Health Assistants, and five Oral Health Technicians. The Dentists' main activity was consultation with an average duration of 24.39 min, which took up 42.36% of their working time, followed by documentation with 12.15%. Oral Health Assistants spent 31.57% of their time on infection control, while Oral Health Technicians spent 22.37% on documentation.

CONCLUSION

The study establishes time standards for the activities performed by the dental care team and provides support for the application of workforce planning methods that allow for review and optimization of the work process and public policies.

Emergency department physicians' distribution of time in the fast paced-workflow-a novel time-motion study of drug-related activities

Background In the emergency department physicians are forced to distribute their time to ensure that all admitted patients receive appropriate emergency care. Previous studies have raised concerns about medication discrepancies in patient's drug lists at admission to the emergency department. Thus, it is important to study how emergency department physicians distribute their time, to highlight where workflow redesign can be needed.Aim to quantify how emergency department physicians distribute their time between various task categories, with particular focus on drug-related tasks.Method Direct observation, time-motion study of emergency department physicians at Diakonhjemmet Hospital, Oslo, Norway. Physicians' activities were categorized in discrete categories and data were collected with the validated method of Work Observation Method By Activity Timing between October 2018 to January 2019. Bootstrap analysis determined 95% confidence intervals for proportions and interruption rates.Results During the observation time of 91.4 h, 31 emergency department physicians were observed. In total, physicians spent majority of their time gathering information (36.5%), communicating (26.3%), and documenting (24.2%). Further, physicians spent 17.8% (95% CI 16.8%, 19.3%) of their time on drug-related tasks. On average, physicians spent 7.8 min (95% CI 7.2, 8.6) per hour to obtain and document patients' drug lists.Conclusion Emergency department physicians are required to conduct numerous essential tasks and distributes a minor proportion of their time on drug-related tasks. More efficient information flow regarding drugs should be facilitated at transitions of care. The presence of healthcare personnel dedicated to obtaining drug lists in the emergency department should be considered.

Differences in Documented and Actual Medication Administration Time in the Emergency Department: A Prospective, Observational, Time-Motion Study

INTRODUCTION

Retrospective studies suggest that a rapid initiation of treatment results in a better prognosis for patients in the emergency department. There could be a difference between the actual medication administration time and the documented time in the electronic health record. In this study, the difference between the observed medication administration time and documentation time was investigated. Patient and nurse characteristics were also tested for associations with observed time differences.

METHODS

In this prospective study, emergency nurses were followed by observers for a total of 3 months. Patient inclusion was divided over 2 time periods. The difference in the observed medication administration time and the corresponding electronic health record documentation time was measured. The association between patient/nurse characteristics and the difference in medication administration and documentation time was tested with a Spearman correlation or biserial correlation test.

RESULTS

In 34 observed patients, the median difference in administration and documentation time was 6.0 minutes (interquartile range 2.0-16.0). In 9 (26.5%) patients, the actual time of medication administration differed more than 15 minutes with the electronic health record documentation time. High temperature, lower saturation, oxygen-dependency, and high Modified Early Warning Score were all correlated with an increasing difference between administration and documentation times.

DISCUSSION

A difference between administration and documentation times of medication in the emergency department may be common, especially for more acute patients. This could bias, in part, previously reported time-to-treatment measurements from retrospective research designs, which should be kept in mind when outcomes of retrospective time-to-treatment studies are evaluated.

Impact of an electronic health record on task time distribution in a neonatal intensive care unit

BACKGROUND

An Electronic Health Record (EHR) has been introduced to four Irish maternity units, with further implementations planned. Previous studies indicate that healthcare professionals are concerned that EHRs may increase time spent on documentation and medication-related tasks.

OBJECTIVE

To determine the impact of an EHR on task time distribution in a Neonatal Intensive Care Unit (NICU).

METHODS

A pre-post, time and motion study. An electronic data collection tool was used to collate time spent on direct care, professional communication, reviewing charts, documentation, and medication-related tasks. Interruptions and contact with the patient zone were quantified. Statistical significance was assessed using two-sample proportion tests, two-sample t-tests, and two-sample Wilcoxon rank-sum tests. A Bonferroni correction set significance at p ≤ 0.0025.

RESULTS

63 doctors and nurses participated, with 169.23 h of data collected. There were no significant changes to nurses' task time distribution. The proportion of time spent by doctors on professional communication increased from 15.4% to 26.0% (p < 0.001). Significant increases to median task times were seen for both doctors and nurses. Interruptions to tasks decreased post-implementation (p < 0.001), as did frequency of contact with the patient zone (p < 0.001).

CONCLUSION

The EHR did not redistribute time towards documentation and medication-related tasks. A reduction in interruptions to tasks may streamline workflow. Decreased contact with the patient zone may improve patient safety through reduced potential for pathogen transmission.

"How do we use the time?" - an observational study measuring the task time distribution of nurses in psychiatric care

Background

The nurse’s primary task in psychiatric care should be to plan for the patient’s care in cooperation with the patient and spend the time needed to build a relationship. Psychiatric care nurses however claim that they lack the necessary time to communicate with patients. To investigate the validity of such claims, this time-motion study aimed at identifying how nurses working at inpatient psychiatric wards distribute their time between a variety of tasks during a working day.

Methods

During the period of December 2015 and February 2016, a total of 129 h and 23 min of structured observations of 12 nurses were carried out at six inpatient wards at one psychiatric clinic in southern Sweden. Time, frequency of tasks and number of interruptions were recorded and analysed using descriptive statistics.

Results

Administering drugs or medications accounted for the largest part of the measured time (17.5%) followed by indirect care (16%). Relatively little time was spent on direct care, the third largest category in the study (15.3%), while an unexpectedly high proportion of time (11.3%) was spent on ward related tasks. Nurses were also interrupted in 75% of all medication administering tasks.

Conclusions

Nurses working in inpatient psychiatric care spend little time in direct contact with the patients and medication administration is interrupted very often. As a result, it is difficult to establish therapeutic relationships with patients. This is an area of concern for both patient safety and nurses’ job satisfaction.

Operational characteristics of antiretroviral therapy clinics in Zambia: a time and motion analysis

BACKGROUND

The mass scale-up of antiretroviral therapy (ART) in Zambia has taken place in the context of limited infrastructure and human resources resulting in many operational side-effects. In this study, we aimed to empirically measure current workload of ART clinic staff and patient wait times and service utilization.

METHODS

We conducted time and motion (TAM) studies from both the healthcare worker (HCW) and patient perspectives at 10 ART clinics throughout Zambia. Trained personnel recorded times for consecutive discrete activities based on direct observation of clinical and non-clinical activities performed by counselors, clinical officers, nurses, and pharmacy technicians. For patient TAM, we recruited consenting patients and recorded times of arrival and departure and major ART services utilized. Data from 10 clinics were pooled to evaluate median time per patient spent for each activity and patient duration of stay in the clinic.

RESULTS

The percentage of observed clinical time for direct patient interaction (median time per patient encounter) was 43.1% for ART counselors (4 min, interquartile range [IQR] 2-7), 46.1% for nurses (3 min, IQR 2-4), 57.2% for pharmacy technicians (2 min, IQR 1-2), and 78.5% for clinical officers (3 min, IQR 2-5). Patient workloads for HCWs were heaviest between 8 AM and 12 PM with few clinical activities observed after 2 PM. The length of patient visits was inversely associated with arrival time - patients arriving prior to 8 AM spent 61% longer at the clinic than those arriving after 8 AM (277 vs. 171 min). Overall, patients spent 219 min on average for non-clinical visits, and 244 min for clinical visits, but this difference was not significant in rural clinics. In comparison, total time patients spent directly with clinic staff were 9 and 12 min on average for non-clinical and clinical visits.

CONCLUSION

Current Zambian ART clinic operations include substantial inefficiencies for both patients and HCWs, with workloads heavily concentrated in the first few hours of clinic opening, limiting HCW and patient interaction time. Use of a differentiated care model may help to redistribute workloads during operational hours and prevent backlogs of patients waiting for hours before clinic opening, which may substantially improve ART delivery in the Zambian context.

Impact of IPMOE on nursing tasks in the medical ward: A time-motion study

Introduction

The In-patient Medication Order Entry System (IPMOE) was first implemented in the medical ward of Princess Margaret Hospital, Hong Kong. It was a local developed close-loop system including prescription, dispensing and administration modules. Evaluation on its impact on nursing tasks would be important for practice improvement and subsequent system enhancement.

Objective

The study was conducted to quantify the nursing times across medication-associated tasks for paper-based MAR and computer-based IPMOE, including change in the tasks and time patterns before and after IPMOE implementation.

Methods

This was a prospective observation study in medical wards before (Jan 2014–Jun 2014) and after (Mar 2015–Jun 2015) the implementation of IPMOE. We conducted 8-hr observation studies of individual nurses with a customized application to time various pre-categorized nursing tasks. Statistical inferences and interrupted time series analysis was performed to identify the change in the intercept and trends over time after implementation.

Result

The average number of medication-related tasks was significantly reduced from 61.07 to 29.81, a reduction of 31.26 episodes per duty (P < 0.001, 95% CI 22.9–39.63). The time for the medication-related tasks was reduced from 32 min (SD = 21.57) to 26.57 min (SD = 11.35) and the medication administration time increased from 37.93 min (SD = 14.78) to 44.37 min (SD = 19.45), but there was no overall significant difference in the time spent on each duty (P = 0.315) between the two groups. An improving trend in the delayed effect was observed (P = 0.03), which indicated a run-in period for new application was needed in clinical setting.

Conclusion

Our study had shown the time motion observation could be applied to measure the impact of the IPMOE in a busy clinical setting. Through classification of activities, validation, objective measurement and longitudinal evaluation, the method could be applied in various systems as well as different clinical settings in measure efficiency.

Measuring time utilization of pharmacists in the Birmingham Free Clinic dispensary

Background

Free and charitable clinics are a critical part of America’s healthcare safety net. Although informatics tools have the potential to mitigate many of the organizational and service-related challenges facing these clinics, little research attention has been paid to the workflows and potential impact of electronic systems in these settings. In previous work, we performed a qualitative investigation at a free clinic dispensary to identify workflow challenges that may be alleviated through introduction of informatics interventions. However, this earlier study did not quantify the magnitude of these challenges. Time-motion studies offer a precise standard in quantifying healthcare workers’ time expenditures on clinical activities, and can provide valuable insight into system specifications. These data, informed by a lean healthcare perspective, provide a quality improvement framework intended to maximize value and eliminate waste in inefficient workflow processes.

Methods

We performed a continuous observation time-motion study in the Birmingham Free Clinic dispensary. Two researchers followed pharmacists over the course of three general clinic sessions and recorded the duration of specific tasks. Pharmacists were then asked to identify tasks as value-added or non-value-added to facilitate calculation of the value quotient, a metric used to determine a workflow’s level of efficiency.

Results

Four high-level workflow categories occupied almost 95 % of pharmacist time: prescription (Rx) preparation (39.8 %), clinician interaction (21.5 %), EMR operations (14.8 %), and patient interaction (18.7 %). Pharmacists invested the largest portion of time in prescription preparation, with 21.8 % of pharmacist time spent handwriting medication labels. Based on value categorizations made by the pharmacists, the average value quotient was found to be 40.3 %, indicating that pharmacists spend more than half of their time completing tasks they consider to be non-value-added.

Conclusions

Our results show that pharmacists spend a large portion of their time preparing prescriptions, primarily the handwritten labeling of medication bottles and documentation tasks, which is not an optimal utilization of pharmacist expertise. The value quotient further supports that there are many wasteful tasks that may benefit from workflow redesign and health information technology, which could result in efficiency improvements for pharmacists.

Electronic supplementary material

The online version of this article (doi:10.1186/s12913-016-1787-6) contains supplementary material, which is available to authorized users.

Exploring Dental Providers' Workflow in an Electronic Dental Record Environment

BACKGROUND

A workflow is defined as a predefined set of work steps and partial ordering of these steps in any environment to achieve the expected outcome. Few studies have investigated the workflow of providers in a dental office. It is important to understand the interaction of dental providers with the existing technologies at point of care to assess breakdown in the workflow which could contribute to better technology designs.

OBJECTIVE

The study objective was to assess electronic dental record (EDR) workflows using time and motion methodology in order to identify breakdowns and opportunities for process improvement.

METHODS

A time and motion methodology was used to study the human-computer interaction and workflow of dental providers with an EDR in four dental centers at a large healthcare organization. A data collection tool was developed to capture the workflow of dental providers and staff while they interacted with an EDR during initial, planned, and emergency patient visits, and at the front desk. Qualitative and quantitative analysis was conducted on the observational data.

RESULTS

Breakdowns in workflow were identified while posting charges, viewing radiographs, e-prescribing, and interacting with patient scheduler. EDR interaction time was significantly different between dentists and dental assistants (6:20 min vs. 10:57 min, p = 0.013) and between dentists and dental hygienists (6:20 min vs. 9:36 min, p = 0.003).

CONCLUSIONS

On average, a dentist spent far less time than dental assistants and dental hygienists in data recording within the EDR.

[Identifying Usability Level and Factors Affecting Electronic Nursing Record Systems: A Multi-institutional Time-motion Approach]

PURPOSE

The usability, user satisfaction, and impact of electronic nursing record (ENR) systems were investigated.

METHODS

This mixed-method research was performed as a time-motion (TM) study and a survey which were carried out at six hospitals between August and November 2013. The TM study involved 108 nurses from medical, surgical, and intensive care units at each hospital, plus an additional 48 nurses who served as nonparticipating observers. In the survey, 1879 volunteer nurses completed the Impact of ENR Systems Scale, the System Usability Scale, and a global satisfaction scale. Qualitative and quantitative analyses were performed.

RESULTS

The mean scores for the ENR impact, system usability, and satisfaction were 4.28 (out of 6), 58.62 (out of 100), and 74.31 (out of 100), respectively, and they differed significantly between hospitals (F=43.43, p<.001, F=53.08 and p<.001, and F=29.13 and p<.001, respectively). A workflow fragmentation assessment revealed different patterns of ENR system use among the included hospitals. Three user characteristics-educational background, practice period, and experience of using paper records-significantly affected the system usability and satisfaction scores.

CONCLUSION

The system quality varied widely among the ENR systems. The generally low-to-moderate levels of system usability and user satisfaction suggest many opportunities for improvement.