Time Utilization Among Immunization Clinics Using an Electronic Immunization Registry (Part 2): Time and Motion Study of Modified User Workflows

BACKGROUND

Digital health interventions have the potential to improve the provision of health care services through digitized data collection and management. Low- and middle-income countries are beginning to introduce electronic immunization registries (EIRs) into their routine immunization services to better capture and store childhood vaccination information. Especially in Africa, where 25% of children remain unimmunized or underimmunized, technologies that can help identify children due for a vaccination are particularly important for improving vaccination coverage. However, an improved understanding of the effectiveness of these systems is needed to develop and deploy sustainable EIRs in low- and middle-income countries.

OBJECTIVE

We conducted an interventional pretest-posttest design study that sought to improve time efficiency through workflow modifications in Kenyan immunization clinics. Our aim was to describe how activity times differed after introducing workflow modifications that could potentially reduce the time needed to perform routine data entry activities. Our intent was to demonstrate changes in efficiency when moving from the existing dual-data entry workflow to a future paperless workflow by health facility size and experience length of health care workers (HCWs).

METHODS

We tested how 3 workflow modifications would affect time utilization among HCWs using the EIR at the point of care compared with baseline immunization clinic workflows. Our outcome of interest was the time taken to complete individual activities and a patient's total time in the clinic where we compared the time spent during the baseline workflow with that during the modified workflow. We used a standardized tool to observe and document the immunization clinic workflow. To estimate differences in time utilization, we used bivariate analyses and fit multivariate linear mixed-effects models.

RESULTS

Our study found that for HCWs using an EIR, the introduction of modified workflows decreased the amount of time needed to provide services to children seen in the immunization clinic. With a baseline mean time of 10 minutes spent per child, this decreased by about 3 minutes when the preparation modification was introduced and almost 5 minutes for the paperless and combined modifications. Results pertaining to the EIR's performance and ability to connect to the internet were particularly insightful about potential causes of delays.

CONCLUSIONS

We were able to conduct a concise clinical simulation exercise by introducing modified workflows and estimating their impact on time utilization in immunization clinics using an EIR. We found that the paperless workflow provided the largest time savings when delivering services, although this was threatened by poor EIR performance and internet connectivity. This study demonstrated that not only should digital health interventions be built and adapted for particular use cases but existing user workflows also need to adapt to new technology.

High demand, high commitment work: What residential aged care staff actually do minute by minute: A participatory action study

This article explores staff work patterns in an Australian residential aged care facility and the implications for high-quality care. Rarely available minute by minute, time and motion, and ethnographic data demonstrate that nurses and care staff engage in high degrees of multitasking and mental switching between residents. Mental switching occurs up to 18 times per hour (every 3 min); multitasking occurs on average for 37 min/h. Labor process theory is used to examine these outcomes and to explore the concepts of high demand and high commitment as core components of work intensification. These conditions of work result in high levels of cognitive burden and stress on staff in managing the multitasking and mental switching, exacerbated by lack of knowledge about residents associated with labor force casualization. These new interpretations of data in relation to mental and manual labor can contribute to understanding, and, therefore, problem solving, in the aged care sector.

Is nursing and midwifery clinical documentation a burden? An empirical study of perception versus reality

AIMS AND OBJECTIVES

To measure time spent on clinical documentation and nurses and midwives' perceptions of this aspect of their role.

BACKGROUND

Nurses and midwives rely on accurate documentation when planning care. However, documenting and communicating care can be onerous, time-consuming and at times duplicated or redundant. While documentation provides a record and means of communicating care, it should not detract from the delivery of care.

DESIGN

An observational time and motion study and survey design reported using the Strengthening the Reporting of Observational Studies in Epidemiology guidelines.

METHODS

The study was conducted with Western Australian nurses and midwives working in a private not-for-profit hospital from July-October 2019. An observational study was undertaken to measure the practice of documentation on each shift. Participants' perceptions of clinical documentation were measured using a self-report survey.

RESULTS

A total of 120 hr of observation were undertaken. Total observed time spent on documentation was 28.1% on morning shifts, 22.7% on afternoon shifts and 20.9% on night duty. The mean self-reported time for clinical documentation was 50.4% on morning shifts, 40.7% on afternoon shifts and 37.9% on night duty. Issues with duplication and unnecessary paperwork were identified.

CONCLUSIONS

Although participants tended to overestimate time spent on documentation, it still consumed a significant proportion of time. Frustrations with paperwork may amplify nurses' negative perceptions of documentation. Clinical documentation needs to be reviewed, revised and reduced to release time back to direct patient care and reduce clinician dissatisfaction.

RELEVANCE TO CLINICAL PRACTICE

Clinical documentation is required in all areas of clinical practice and forms an important legal record. Understanding the demands of clinical documentation can assist in reviewing and improving documentation to release time back to direct patient care.

The Impact of Electronic Health Records on the Duration of Patients' Visits: Time and Motion Study

BACKGROUND

Despite the many benefits of electronic health records (EHRs), studies have reported that EHR implementation could create unintended changes in the workflow if not studied and designed properly. These changes may impact the time patients spend on the various steps of their visits, such as the time spent in the waiting area and the time spent with a physician. The amount of time patients spend in the waiting area before consultation is often a strong predictor of patient satisfaction, willingness to come back for a return visit, and overall experience. The majority of prior studies that examined the impact of EHR systems on time focused on single aspects of patient visits or user (physicians or nurses) activities. The impact of EHR use on patients' time spent during the different aspects of the visit is rarely investigated.

OBJECTIVE

This study aimed to evaluate the impact of EHR systems on the amount of time spent by patients on different tasks during their visit to primary health care (PHC) centers.

METHODS

A time and motion observational study was conducted at 4 PHC centers. The PHC centers were selected using stratified randomized sampling. Of the 4 PHC centers, 2 used an EHR system and 2 used a paper-based system. Each group had 1 center in a metropolitan area and another in a rural area. In addition, a longitudinal observation was conducted at one of the PHC centers after 1 year and again after 2 years of implementation. The analysis included descriptive statistics and group comparisons.

RESULTS

The results showed no significant difference in the amount of time spent by patients in the reception area (P=.26), in the waiting area (P=.57), consultation time (P=.08), and at the pharmacy (P=.28) between the EHR and paper based groups. However, there was a significant difference (P<.001) in the amount of time spent on all tasks between the PHC centers located in metropolitan and rural areas. The longitudinal observation also showed reduction in the registration time (from 5.5 [SD 3.5] min to 0.9 [SD 0.5] min), which could be attributed to the introduction of a Web-based booking system.

CONCLUSIONS

The variation in the time patients spend at PHC centers is more likely to be attributed to the facility location than EHR use. The changes in the introduction of new tools and functions, however, such as the Web-based booking system, can impact the duration of patients' visits.

Lanreotide vs octreotide LAR for patients with advanced gastroenteropancreatic neuroendocrine tumors: An observational time and motion analysis

BACKGROUND

Lanreotide and octreotide acetate suspension for injectable (LAR) are both recommended for clinical use in patients with locally advanced or metastatic gastroenteropancreatic neuroendocrine tumors. However, each agent possesses unique attributes in terms of their drug-delivery characteristics. The study objective was to compare overall drug-delivery efficiency between lanreotide and octreotide LAR in gastroenteropancreatic neuroendocrine tumor patients.

METHODS

This study employed an observational time and motion design among patients treated with lanreotide or octreotide LAR across five US cancer centers. Baseline patient data collection included age, disease grade and duration, prior therapies and performance status. Drug-delivery time (drug preparation and administration), total patient time and resource use data were collected for gastroenteropancreatic neuroendocrine tumors receiving lanreotide (n = 22) or octreotide LAR (n = 22). Following each administration, qualitative data on the drug-delivery experience was collected from patients and nurses.

RESULTS

Lanreotide was associated with a significant reduction in mean delivery time (2.5 min; 95% CI:2.0 to 3.1) compared to octreotide LAR (6.2 min; 95%CI: 4.4 to 7.9; p = 0.004). The mean total patient time for lanreotide and octreotide LAR was comparable between groups (32.1 vs. 36.6 minutes; p = 0.97). Nurses reported increased concerns with octreotide LAR related to needle clogging (p = 0.034) and device failures (p = 0.057). Overall, lanreotide had a median satisfaction score of 5.0 compared to a score of 4.0 with octreotide LAR (p = 0.03).

CONCLUSIONS

Lanreotide was associated with significant reductions in drug-delivery time compared to octreotide LAR, which contributed to an improvement in overall healthcare efficiency.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT03017690.

Comparison of patient flow and provider efficiency of two delivery strategies for HPV-based cervical cancer screening in Western Kenya: a time and motion study

Background: Improving patient flow and reducing over-crowding can improve quality, promptness of care, and patient satisfaction. Given low utilization of preventive care in low-resource countries, improved patient flows are especially important in these settings.

Objective: Compare patient flow and provider efficiency between two cervical cancer screening strategies via self-collected human papillomavirus (HPV).

Methods: We collected time and motion data for patients screened for cervical cancer in 12 communities in rural Migori County, Kenya as part of a larger cluster randomized trial. Six communities were randomized to screening in community health campaigns (CHCs) and six to screening at government clinics. We quantified patient flow: duration spent on each active stage of screening and wait times, and the number of patients arriving at CHCs and clinics each hour of the day. In addition, for four CHCs, we collected time and motion data for providers, and measured provider efficiency as a ratio of active (service delivery) time to total time spent at the clinic.

Results: Total duration of screening visits, at CHCs and clinics was 42 and 87 minutes, respectively (p < 0.001 for difference). Total active time lasted longer at CHCs, with a mean of 28 minutes per patient versus 15 minutes at clinics, largely due to differences in duration for group education (p < 0.001). Wait time for registration at clinics was 36 minutes, explaining most of the difference between settings, but sometimes incorporated other health services.

Conclusions: There is a substantial difference in patient flow at clinics compared to CHCs. Shorter duration at CHCs suggests that the model is favorable for patients in limiting time spent on screening. Future cervical cancer screening programs designed for scale-up should consider how this advantage may enhance satisfaction and uptake. For clinic-based screening programs, efforts could be made towards reducing registration wait times.

Characterization of actions taken during the delivery of medication therapy management: A time-and-motion approach

OBJECTIVES

To characterize actions performed by pharmacists and support staff during provision of medication therapy management (MTM) and to compare actions performed according to practice characteristics.

METHODS

A purposeful sample of 7 MTM practices (2 call centers and 5 community practices) was identified and visited by investigators. Pharmacists and support staff were observed during their routine provision of MTM. Investigators characterized "major" (e.g., preparation for a comprehensive medication review) and "minor" (i.e., specific steps in overarching major action) actions with the use of a time-and-motion approach.

RESULTS

A total of 32 major and 469 minor actions were observed. Practices were characterized as Later Maturity Level or Early Maturity Level on the basis of their self-reported MTM appointment volume, self-assessment of the extent of integration of chronic care model principles, and payer mix. Later Maturity Level practices were more likely to deliver follow-up medication therapy reviews and comprehensive medication reviews (CMRs) as opposed to targeted medication reviews (TMRs) and to receive physician referrals for MTM. Later Maturity Level practices were also more likely to use paid interns than pharmacy rotation students. CMR activities observed at Later Maturity Level practices lasted a median of 30.8 minutes versus 20.3 minutes for CMR activities at Early Maturity Level practices. Similarly, TMR activities observed at Later Maturity Level practices were longer: a median of 31.0 minutes versus 12.3 minutes. At Later Maturity Level practices, pharmacists spent a greater proportion of time providing patient education, while support staff spent a greater proportion of time on tasks such as capturing demographics and introducing or explaining MTM.

CONCLUSION

MTM activities were longer at Later Maturity Level practices, and these practices were more likely to use paid pharmacy interns and to receive physician referrals for MTM. This work provides a foundation for future research.

Using lean manufacturing principles to evaluate wait times for HIV-positive patients in an urban clinic in Kenya

As human immunodeficiency virus (HIV) treatment programs expand in Africa, delivery systems must be strengthened to support patient retention. Clinic characteristics may affect retention, but a relationship between clinic flow and attrition is not established. This project characterized HIV patient experience and flow in an urban Kenyan clinic to understand how these may affect retention. We used Toyota's lean manufacturing principles to guide data collection and analysis. Clinic flow was evaluated using value stream mapping and time and motion techniques. Clinic register data were analyzed. Two focus group discussions were held to characterize HIV patient experience. Results were shared with clinic staff. Wait times in the clinic were highly variable. We identified four main barriers to patient flow: inconsistent patient arrivals, inconsistent staffing, filing system defects, and serving patients out of order. Focus group participants explained how clinic operations affected their ability to engage in care. Clinic staff were eager to discuss the problems identified and identified numerous low-cost potential solutions. Lean manufacturing methodologies can guide efficiency interventions in low-resource healthcare settings. Using lean techniques, we identified bottlenecks to clinic flow and low-cost solutions to improve wait times. Improving flow may result in increased patient satisfaction and retention.

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.

Observation of a Pharmacist-Conducted Group A Streptococcal Pharyngitis Point-of-Care Test: A Time and Motion Study

BACKGROUND

Acute pharyngitis is among the most common infectious diseases encountered in the United States, resulting in 13 million patient visits annually, with group A streptococcus (GAS) being a common causative pathogen. It is estimated that annual expenditures for the treatment of adult pharyngitis will exceed US$1.2 billion annually. This substantial projection reinforces the need to evaluate diagnosis and treatment of adult pharyngitis in nontraditional settings.

OBJECTIVE

The objective of this research is to quantify the amount of pharmacist time required to complete a point-of-care (POC) test for a patient presenting with pharyngitis symptoms.

METHODS

A standardized patient with pharyngitis symptoms visited 11 pharmacies for POC testing services for a total of 33 patient encounters. An observer was present at each encounter and recorded the total encounter time, divided into 9 categories. Pharmacists conducted POC testing in 1 of 2 ways: sequence 1-pharmacists performed all service-related tasks; sequence 2-both pharmacists and pharmacist interns performed service-related tasks.

RESULTS

The average time for completion of a POC test for GAS pharyngitis was 25.3 ± 4.8 minutes. The average pharmacist participation time per encounter was 12.7 ± 3.0 minutes (sequence 1), which decreased to 2.6 ± 1.1 minutes when pharmacist interns were involved in the testing (sequence 2).

CONCLUSION

Although additional studies are required to further assess service feasibility, this study indicates that a GAS POC testing service could be implemented in a community pharmacy with limited disruption or change to workflow and staff.

The impact of a preloaded intraocular lens delivery system on operating room efficiency in routine cataract surgery

Purpose

The aim of this study was to evaluate the operational impact of using preloaded intraocular lens (IOL) delivery systems compared with manually loaded IOL delivery processes during routine cataract surgeries.

Methods

Time and motion data, staff and surgery schedules, and cost accounting reports were collected across three sites located in the US, France, and Canada. Time and motion data were collected for manually loaded IOL processes and preloaded IOL delivery systems over four surgery days. Staff and surgery schedules and cost accounting reports were collected during the 2 months prior and after introduction of the preloaded IOL delivery system.

Results

The study included a total of 154 routine cataract surgeries across all three sites. Of these, 77 surgeries were performed using a preloaded IOL delivery system, and the remaining 77 surgeries were performed using a manual IOL delivery process. Across all three sites, use of the preloaded IOL delivery system significantly decreased mean total case time by 6.2%–12.0% (P<0.001 for data from Canada and the US and P<0.05 for data from France). Use of the preloaded delivery system also decreased surgeon lens time, surgeon delays, and eliminated lens touches during IOL preparation.

Conclusion

Compared to a manual IOL delivery process, use of a preloaded IOL delivery system for cataract surgery reduced total case time, total surgeon lens time, surgeon delays, and eliminated IOL touches. The time savings provided by the preloaded IOL delivery system provide an opportunity for sites to improve routine cataract surgery throughput without impacting surgeon or staff capacity.

Researching participant recruitment times

Conducting research in emergency departments is relatively new, and there are a number of ethical and practical challenges to recruiting patients in these settings. In 2008, the Emergency Medicine Research Group Edinburgh (EMERGE) was set up at the Royal Infirmary of Edinburgh emergency department to support researchers and encourage the growth of research in emergency medicine. As part of a review of their working methods, the group's clinical nurse researchers undertook a small study to identify participant recruitment times. The results showed a significant difference between perceived and actual recruitment times, which has implications for planning staff numbers and budgets. This article describes the evaluation process and methods of data collection, and discusses the results.

The activities of hospital nursing unit managers and quality of patient care in South African hospitals: a paradox?

BACKGROUND

Improving the quality of health care is central to the proposed health care reforms in South Africa. Nursing unit managers play a key role in coordinating patient care activities and in ensuring quality care in hospitals.

OBJECTIVE

This paper examines whether the activities of nursing unit managers facilitate the provision of quality patient care in South African hospitals.

METHODS

During 2011, a cross-sectional, descriptive study was conducted in nine randomly selected hospitals (six public, three private) in two South African provinces. In each hospital, one of each of the medical, surgical, paediatric, and maternity units was selected (n=36). Following informed consent, each unit manager was observed for a period of 2 hours on the survey day and the activities recorded on a minute-by-minute basis. The activities were entered into Microsoft Excel, coded into categories, and analysed according to the time spent on activities in each category. The observation data were complemented by semi-structured interviews with the unit managers who were asked to recall their activities on the day preceding the interview. The interviews were analysed using thematic content analysis.

RESULTS

The study found that nursing unit managers spent 25.8% of their time on direct patient care, 16% on hospital administration, 14% on patient administration, 3.6% on education, 13.4% on support and communication, 3.9% on managing stock and equipment, 11.5% on staff management, and 11.8% on miscellaneous activities. There were also numerous interruptions and distractions. The semi-structured interviews revealed concordance between unit managers' recall of the time spent on patient care, but a marked inflation of their perceived time spent on hospital administration.

CONCLUSION

The creation of an enabling practice environment, supportive executive management, and continuing professional development are needed to enable nursing managers to lead the provision of consistent and high-quality patient care.

Impact of computerized provider order entry on pharmacist productivity

PURPOSE

To examine the impact of computerized provider order entry (CPOE) implementation on average time spent on medication order entry and the number of order actions processed.

METHODS

An observational time and motion study was conducted from March 1 to March 17, 2011. Two similar community hospital pharmacies were compared: one without CPOE implementation and the other with CPOE implementation. Pharmacists in the central pharmacy department of both hospitals were observed in blocks of 1 hour, with 24 hours of observation in each facility. Time spent by pharmacists on distributive, administrative, clinical, and miscellaneous activities associated with order entry were recorded using time and motion instrument documentation. Information on medication order actions and order entry/verifications was obtained using the pharmacy network system.

RESULTS

The mean ± SD time spent by pharmacists per hour in the CPOE pharmacy was significantly less than the non-CPOE pharmacy for distributive activities (43.37 ± 7.75 vs 48.07 ± 8.61) and significantly greater than the non-CPOE pharmacy for administrative (8.58 ± 5.59 vs 5.72 ± 6.99) and clinical (7.38 ± 4.27 vs 4.22 ± 3.26) activities. The CPOE pharmacy was associated with a significantly higher number of order actions per hour (191.00 ± 82.52 vs 111.63 ± 25.66) and significantly less time spent (in minutes per hour) on order entry and order verification combined (28.30 ± 9.25 vs 36.56 ± 9.14) than the non-CPOE pharmacy.

CONCLUSION

The implementation of CPOE facilitated pharmacists to allocate more time to clinical and administrative functions and increased the number of order actions processed per hour, thus enhancing workflow efficiency and productivity of the pharmacy department.

Impact of an electronic medication management system on hospital doctors' and nurses' work: a controlled pre-post, time and motion study

OBJECTIVE

To quantify and compare the time doctors and nurses spent on direct patient care, medication-related tasks, and interactions before and after electronic medication management system (eMMS) introduction.

METHODS

Controlled pre-post, time and motion study of 129 doctors and nurses for 633.2 h on four wards in a 400-bed hospital in Sydney, Australia. We measured changes in proportions of time on tasks and interactions by period, intervention/control group, and profession.

RESULTS

eMMS was associated with no significant change in proportions of time spent on direct care or medication-related tasks relative to control wards. In the post-period control ward, doctors spent 19.7% (2 h/10 h shift) of their time on direct care and 7.4% (44.4 min/10 h shift) on medication tasks, compared to intervention ward doctors (25.7% (2.6 h/shift; p=0.08) and 8.5% (51 min/shift; p=0.40), respectively). Control ward nurses in the post-period spent 22.1% (1.9 h/8.5 h shift) of their time on direct care and 23.7% on medication tasks compared to intervention ward nurses (26.1% (2.2 h/shift; p=0.23) and 22.6% (1.9 h/shift; p=0.28), respectively). We found intervention ward doctors spent less time alone (p=0.0003) and more time with other doctors (p=0.003) and patients (p=0.009). Nurses on the intervention wards spent less time with doctors following eMMS introduction (p=0.0001).

CONCLUSIONS

eMMS introduction did not result in redistribution of time away from direct care or towards medication tasks. Work patterns observed on these intervention wards were associated with previously reported significant reductions in prescribing error rates relative to the control wards.

Strategies for optimizing clinic efficiency in a community-based antiretroviral treatment programme in Uganda

We address a critical aspect of antiretroviral therapy (ART) scale-up: poor clinic organization leading to long waiting times and reduced patient retention. Using a before and after study design, time and motion studies and qualitative methods we evaluated the impact of triage and longer clinic appointment intervals (triage) on clinic efficiency in a community-based program in Uganda. We compared time waiting to see and time spent with providers for various patient categories and examined patient and provider satisfaction with the triage. Overall, median time spent at the clinic reduced from 206 to 83 min. Total median time waiting to see providers for stable-ART patients reduced from 102 to 20 min while that for patients undergoing ART preparation reduced 88-37 min. Improved patient flow, patient and provider satisfaction and reduced waiting times allowed for service delivery to more patients using the same staff following the implementation of triage.

Time associated with intravenous zoledronic acid administration in patients with breast or prostate cancer and bone metastasis

Purpose

Intravenous (IV) zoledronic acid (ZA) is commonly used to delay skeletal complications secondary to bone metastases. However, the time associated with ZA administration may represent a significant burden to healthcare providers and patients. This study assessed the time associated with IV ZA infusion in patients with bone metastases secondary to breast or prostate cancer (BC or PC) in the clinic setting.

Methods

Eligible BC or PC patients with bone metastases scheduled to receive IV ZA were observed at seven US-based oncology clinics. Trained observers recorded the time for preinfusion tasks, ZA drug preparation, intravenous infusion, and follow-up activities.

Results

Data are reported for 39 patients (BC: 24; PC: 15). Mean administration time was 69 (standard deviation [SD] 42) minutes for all patients combined, 72 (SD 47) minutes for BC, and 65 (SD 33) minutes for PC. Activity times were comparable between tumor types. Mean time for preinfusion tasks (eg, assessment of vital signs, blood draw) and ZA preparation were 12 (SD 20) minutes and 2 (SD 1) minutes, respectively. Mean time required for intravenous infusion (ZA infusion and hydration, when provided) and follow-up activities were 54 (SD 31) minutes and 2 (SD 1) minutes, respectively.

Conclusion

Infusion time was the greatest time commitment associated with IV ZA administration, representing 78% of the total time on average. Time for preinfusion activities varied substantially. Overall, the mean time for ZA administration represents a notable time burden for healthcare providers and patients.