Mirela Prgomet

Allocation of Physician Time in Ambulatory Practice: A Time and Motion Study in 4 Specialties

Ambulatory care in the United States has been subject to dramatic pressures in the past decade to cut costs, meet regulations, and transition to electronic health records (EHRs). Effects on ambulatory care are still unknown, and unintended consequences are gradually gaining recognition, including additional time spent documenting care (1) and performance metrics (2), impaired communication with patients (3), and increased career dissatisfaction (4) and burnout (57) among physicians. In the context of rapid change, dissatisfaction among physicians with how their time and skills are used is widespread and growing. Fifty-four percent of U.S. physicians experience some sign of burnout (5), an increase from 46% (6) over a 3-year period, 2011 to 2014, (P< 0.001). Time spent in meaningful interactions with patients and the ability to provide high-quality care are powerful drivers of physician career satisfaction (4). Conversely, physician dissatisfaction has centered on the changing content of their work, with more time spent on paperwork and the computer (7) and less time available for direct clinical face time with patients (4). Correlations between increases in EHR task load and physician burnout and attrition have also been shown (7, 8). This study was undertaken because there are minimal quantitative data on how physicians time is allocated in ambulatory care. Prior studies predate the widespread use of EHRs and the current regulatory environment (914). Our goal was to describe time allocation and practice characteristics (including EHR use and documentation support services) for physicians in the era of EHRs and federal incentive and penalty programs. In other words, what is work like for physicians in the ambulatory trenches? Methods Study Participants The American Medical Associations (AMA) annual study of physician characteristics and distribution in the United States (compiled from the AMA Physician Masterfile) and discussions among the researchers informed the decision to study 2 types of primary care practices (family medicine and internal medicine), 1 medical specialty (cardiology), and 1 surgical specialty (orthopedics). These specialties and practice types had higher numbers of physicians than other specialties outlined in the report and were therefore selected to ensure a participant base that was representative of a large and inclusive number of physicians. Once the specialties were determined, 4 states (Illinois, New Hampshire, Virginia, and Washington) were selected to fulfill the second criterion of a geographically diverse sample. No other factors were considered in the recruitment. Sixteen practices were formally recruited using stratified nonprobability sampling based on predetermined categories (specialty and geographic location). Four accepted but later withdrew. Recruitment continued until withdrawals were replaced and the target number of each specialty and geographic location was reached. Approval was obtained from the relevant institutional review boards. The final number of participants was based on availability during the days of scheduled observation. Data Sources and Measurements This study used 2 instruments for capture of work activity: direct observation by trained observers using a time and motion approach during office hours, and a self-reported diary for after-hours work. All direct observation data were collected from 7 July 2015 to 11 August 2015 on weekdays between 7:00 a.m. and 8:30 p.m. Any physician or patient could decline to be observed; this time was recorded as closed to observation. No patient identifier or health information was recorded. Direct observations were limited to clinical office days. Work at home (sampled through voluntary diaries) and hours removed from the clinical schedule (for example, administrative afternoons or research days) were excluded. Clinical work outside the ambulatory clinic was also excluded (for example, laboratory work or procedures performed outside the clinic). Most of the physicians had more than 35 scheduled patient contact hours per week. We did not measure the number of patients seen per hour, their medical complexity, or the quality of the care provided. No time data were collected for support staff. Observations were performed by medical students (observers) with extensive experience working or observing in ambulatory clinics. The Work Observation Method by Activity Timing (WOMBAT) was used (15). This is a technique for undertaking direct observational studies of health professionals that has been applied in a range of settings (1624). The WOMBAT software allows researchers to customize the work classification used to capture multiple dimensions of work. After extensive pilot observations, a physician work task classification was devised and incorporated into the WOMBAT tool (Supplement). The final classification had 12 broad, mutually exclusive work task categories. These categories were later grouped into 4 activities for analyses: direct clinical face time between physician and patient or physician and staff, EHR and desk work, administrative tasks, and other tasks (Table 1). All 12 tasks could be conducted in parallel (multitasking); for example, a physician could review documents while in transit. Supplement. Supplemental Information Table 1. Definitions of Physician Work Activities and Tasks All observable actions were mutually exclusive and strictly defined. Observers coded what physicians were doing, where they were doing it, with whom they were engaged, and the information tools they used for the activity. Data were uploaded to a secure server each night. Observers underwent intensive training in the WOMBAT technique and task classification using lecture formats, training videos, and practice sessions in live clinics. Observation sessions were limited to no more than 2 hours to maintain optimal observer vigilance. Observers worked in pairs and rotated in and out of data collection sessions in a synchronized manner to minimize missed data. Before fieldwork began, the 10 observers undertook interrater reliability testing based on an approximately 45-minute video of ambulatory care practice scenarios that were designed to cover 12 defined work tasks. Because there is no universally agreed-on method to assess interrater reliability for time and motion studies, one observer who demonstrated the best understanding of the task definitions was designated as the standard. The scenario video observation time was split into 934 three-second intervals that were allocated into 10 broad task categories by each observer. The scores ranged from 0.83 to 0.96, and the average score for task category agreement was 0.91, indicating strong agreement between observers in classifying tasks (25). Table 2 summarizes the percentages of time spent on tasks recorded by the observers. Table 2. Interrater Reliability for Reference Testing Video Self-Reported Diary of Work All participating physicians were invited to self-report after-hours work activity for 7 consecutive days. Each physician was provided a diary for recording time spent on EHR activities and total time (Supplement). Collected data were reviewed for completeness. All task times were aggregated to identify the total time spent on work at home. Time spent using the EHR was complete and unambiguous. Our data analysis segmented total time and time using the EHR on off-duty evenings as well as when the physician was on call. Statistical Analysis Descriptive statistics are presented to show how participating physicians distributed their time across different activities and tasks. The percentage of time spent by participating physicians on a specific activity or task was calculated by dividing the time spent on the activity or task by the total observation time; 95% CIs of these percentages were calculated based on the large sample normal approximation. We also calculated scores (26) to measure interobserver reliability. Data were analyzed using SAS, version 9.4 (SAS Institute). Role of the Funding Source This study was funded by the AMA, which employs 4 of the authors (C.S., S.R., L.G., and M.T.). Authors from the AMA collaborated with Dartmouth-Hitchcock on the design of the study and subsequent analysis of the reported results. Researchers from Dartmouth-Hitchcock conducted the study and provided reports on the results. Results Participant Characteristics In this study, 57 physicians from 16 practices in 4 states were observed (Table 3). A total of 23416 tasks were recorded over 430 hours of observation. Among the 57 physicians, 79% (n= 45) were men and 82% (n= 47) were aged 31 to 60 years. Physicians were distributed across family medicine (n= 12 from 4 practices; 116 hours), internal medicine (n= 19 from 5 practices; 142 hours), cardiology (n= 11 from 3 practices; 63 hours), and orthopedics (n= 15 from 4 practices; 107 hours). The median number of hours of observation was 8 (range, 1 to 25 hours). Forty-six percent of participating physicians (n= 26) had documentation support services available (dictation for 21 and documentation assistant services for 5). One practice did not have an EHR system, and 7 EHR systems were used in the remaining 15 practices: Epic (7 practices), Allscripts (3 practices), athenahealth (1 practice), Centricity (1 practice), NextGen (1 practice), SRS (1 practice), and eClinicalWorks (1 practice) (Table 3). Excluding the paper-based practice, 91% of practices had met stage 2 of the Centers for Medicare & Medicaid Services meaningful use criteria and intended to participate in stage 3. Table 3. Participant Characteristics Work Activities During Office Hours The observational data reflect both examination room and nonexamination room time (for example, workstation or office). Physicians in our study spent 33.1% of this total time on direct clinical face time: 27.0% with patients in the examination room, and 6.1% with staff when the patient was not present (for

Effectiveness of continuous or intermittent vital signs monitoring in preventing adverse events on general wards: a systematic review and meta‐analysis

Vital signs monitoring is an old hospital practice for patient safety but evaluation of its effectiveness is not widespread. We aimed to identify strategies to improve intermittent or continuous vital signs monitoring in general wards; and their effectiveness in preventing adverse events on general hospital wards.

Implementing Information and Communication Technology to Support Community Aged Care Service Integration: Lessons from an Australian Aged Care Provider

Introduction: There is limited evidence of the benefits of information and communication technology (ICT) to support integrated aged care services. Objectives: We undertook a case study to describe carelink+, a centralised client service management ICT system implemented by a large aged and community care service provider, Uniting. We sought to explicate the care-related information exchange processes associated with carelink+ and identify lessons for organisations attempting to use ICT to support service integration. Methods: Our case study included seventeen interviews and eleven observation sessions with a purposive sample of staff within the organisation. Inductive analysis was used to develop a model of ICT-supported information exchange. Results: Management staff described the integrated care model designed to underpin carelink+. Frontline staff described complex information exchange processes supporting coordination of client services. Mismatches between the data quality and the functions carelink+ was designed to support necessitated the evolution of new work processes associated with the system. Conclusions: There is value in explicitly modelling the work processes that emerge as a consequence of ICT. Continuous evaluation of the match between ICT and work processes will help aged care organisations to achieve higher levels of ICT maturity that support their efforts to provide integrated care to clients.

Impact of commercial computerized provider order entry (CPOE) and clinical decision support systems (CDSSs) on medication errors, length of stay, and mortality in intensive care units: a systematic review and meta-analysis

Objective: To conduct a systematic review and meta-analysis of the impact of commercial computerized provider order entry (CPOE) and clinical decision support systems (CDSSs) on medication errors, length of stay (LOS), and mortality in intensive care units (ICUs). Methods: We searched for English-language literature published between January 2000 and January 2016 using Medline, Embase, and CINAHL. Titles and abstracts of 586 unique citations were screened. Studies were included if they: (1) reported results for an ICU population; (2) evaluated the impact of CPOE or the addition of CDSSs to an existing CPOE system; (3) reported quantitative data on medication errors, ICU LOS, hospital LOS, ICU mortality, and/or hospital mortality; and (4) used a randomized controlled trial or quasi-experimental study design. Results: Twenty studies met our inclusion criteria. The transition from paper-based ordering to commercial CPOE systems in ICUs was associated with an 85% reduction in medication prescribing error rates and a 12% reduction in ICU mortality rates. Overall meta-analyses of LOS and hospital mortality did not demonstrate a significant change. Discussion and Conclusion: Critical care settings, both adult and pediatric, involve unique complexities, making them vulnerable to medication errors and adverse patient outcomes. The currently limited evidence base requires research that has sufficient statistical power to identify the true effect of CPOE implementation. There is also a critical need to understand the nature of errors arising post-CPOE and how the addition of CDSSs can be used to provide greater benefit to delivering safe and effective patient care.

Vital signs monitoring on general wards: clinical staff perceptions of current practices and the planned introduction of continuous monitoring technology

OBJECTIVEnEarly detection of patient deterioration and prevention of adverse events are key challenges to patient safety. This study investigated clinical staff perceptions of current monitoring practices and the planned introduction of continuous monitoring devices on general wards.nnnDESIGNnMulti-method study comprising structured surveys, in-depth interviews and device trial with log book feedback.nnnSETTINGnTwo general wards in a large urban teaching hospital in Sydney, Australia.nnnPARTICIPANTSnRespiratory and neurosurgery nursing staff and two doctors.nnnRESULTSnNurses were confident about their abilities to identify patients at risk of deterioration, using a combination of vital signs and visual assessment. There were concerns about the accuracy of current vital signs monitoring equipment and frequency of intermittent observation. Both the nurses and the doctors were enthusiastic about the prospect of continuous monitoring and perceived it would allow earlier identification of patient deterioration; provide reassurance to patients; and support interdisciplinary communication. There were also reservations about continuous monitoring, including potential decrease in bedside nurse-patient interactions; increase in inappropriate escalations of patient care; and discomfort to patients.nnnCONCLUSIONSnWhile continuous monitoring devices were seen as a potentially positive tool to support the identification of patient deterioration, drawbacks, such as the potential for reduced patient contact, revealed key areas that will require close surveillance following the implementation of devices. Training and improved interdisciplinary communication were identified as key requisites for successful implementation.

Vital signs monitoring and nurse-patient interaction: A qualitative observational study of hospital practice

BACKGROUNDnHigh profile safety failures have demonstrated that recognising early warning signs of clinical and physiological deterioration can prevent or reduce harm resulting from serious adverse events. Early warning scoring systems are now routinely used in many places to detect and escalate deteriorating patients. Timely and accurate vital signs monitoring are critical for ensuring patient safety through providing data for early warning scoring systems, but little is known about current monitoring practices.nnnOBJECTIVEnTo establish a profile of nurses vital signs monitoring practices, related dialogue, and adherence to health service protocol in New South Wales, Australia.nnnMETHODSnDirect observations of nurses working practices were conducted in two wards. The observations focused on times of the day when vital signs were generally measured. Patient interactions were recorded if occurring any time during the observation periods. Participants (n=42) included nursing staff on one chronic disease medical and one acute surgical ward in a large urban teaching hospital in New South Wales.nnnRESULTSnWe observed 441 patient interactions. Measurement of vital signs occurred in 52% of interactions. The minimum five vital signs measures required by New South Wales Health policy were taken in only 6-21% of instances of vital signs monitoring. Vital signs were documented immediately on 93% of vitals-taking occasions and documented according to the policy in the patients chart on 89% of these occasions. Nurse-patient interactions were initiated for the purpose of taking vital signs in 49% of interactions, with nurse-patient discourse observed during 88% of all interactions. Nurse-patient dialogue led to additional care being provided to patients in 12% of interactions.nnnCONCLUSIONnThe selection of appropriate vital signs measured and responses to these appears to rely on nurses clinical judgement or time availability rather than on policy-mandated frequency. The prevalence of incomplete sets of vital signs may limit identification of deteriorating patients. The findings from this study present an important baseline profile against which to evaluate the impact of introducing continuous monitoring approaches on current hospital practice.

Stepped-wedge cluster randomised controlled trial to assess the effectiveness of an electronic medication management system to reduce medication errors, adverse drug events and average length of stay at two paediatric hospitals: a study protocol.

Introduction Medication errors are the most frequent cause of preventable harm in hospitals. Medication management in paediatric patients is particularly complex and consequently potential for harms are greater than in adults. Electronic medication management (eMM) systems are heralded as a highly effective intervention to reduce adverse drug events (ADEs), yet internationally evidence of their effectiveness in paediatric populations is limited. This study will assess the effectiveness of an eMM system to reduce medication errors, ADEs and length of stay (LOS). The study will also investigate system impact on clinical work processes. Methods and analysis A stepped-wedge cluster randomised controlled trial (SWCRCT) will measure changes pre-eMM and post-eMM system implementation in prescribing and medication administration error (MAE) rates, potential and actual ADEs, and average LOS. In stage 1, 8 wards within the first paediatric hospital will be randomised to receive the eMM system 1u2005week apart. In stage 2, the second paediatric hospital will randomise implementation of a modified eMM and outcomes will be assessed. Prescribing errors will be identified through record reviews, and MAEs through direct observation of nurses and record reviews. Actual and potential severity will be assigned. Outcomes will be assessed at the patient-level using mixed models, taking into account correlation of admissions within wards and multiple admissions for the same patient, with adjustment for potential confounders. Interviews and direct observation of clinicians will investigate the effects of the system on workflow. Data from site 1 will be used to develop improvements in the eMM and implemented at site 2, where the SWCRCT design will be repeated (stage 2). Ethics and dissemination The research has been approved by the Human Research Ethics Committee of the Sydney Childrens Hospitals Network and Macquarie University. Results will be reported through academic journals and seminar and conference presentations. Trial registration number Australian New Zealand Clinical Trials Registry (ANZCTR) 370325.

A work observation study of nuclear medicine technologists: interruptions, resilience and implications for patient safety

Background Errors by nuclear medicine technologists during the preparation of radiopharmaceuticals or at other times can cause patient harm and may reflect the impact of interruptions, busy work environments and deficient systems or processes. We aimed to: (a) characterise the rate and nature of interruptions technologists experience and (b) identify strategies that support safety. Methods We performed 100u2005hours of observation of 11 technologists at a major public hospital and measured the proportions of time spent in eight categories of work tasks, location of task, interruption rate and type and multitasking (tasks conducted in parallel). We catalogued specific safety-oriented strategies used by technologists. Results Technologists completed 5227 tasks and experienced 569 interruptions (mean, 4.5 times per hour; 95% CI 4.1 to 4.9). The highest interruption rate occurred when technologists were in transit between rooms (10.3 per hour (95% CI 8.3 to 12.5)). Interruptions during radiopharmaceutical preparation occurred a mean of 4.4 times per hour (95% CI 3.3 to 5.6). Most (n=426) tasks were interrupted once only and all tasks were resumed after interruption. Multitasking occurred 16.6% of the time. At least some interruptions were initiated by other technologists to convey important information and/or to render assistance. Technologists employed a variety of verbal and non-verbal strategies in all work areas (notably in the hot-lab) to minimise the impact of interruptions and optimise the safe conduct of procedures. Although most were due to individual choices, some strategies reflected overt or subliminal departmental policy. Conclusions Some interruptions appear beneficial. Technologists self-initiated strategies to support safe work practices appear to be an important element in supporting a resilient work environment in nuclear medicine.

Little Things Matter: A Time and Motion Study of Pharmacists' Activities in a Paediatric Hospital.

How healthcare providers distribute their time can impact on the quality and safety of care delivered, and this has been widely studied in hospitals providing care to adult patients. Children are different to adults and the workflow of healthcare providers in paediatric settings is largely unknown. The aim of this study was to quantify how clinical pharmacists working in a paediatric hospital spend their time. A direct observational time and motion study was conducted where two independent observers shadowed seven pharmacists covering eight wards for over 60 hours. Pharmacists spent the majority of time performing medication review (32.6%), followed by communication, non-clinical tasks, supply, medication discussion and in-transit. They were interrupted 3.5 times per hour and spent 4.4% of observed time multi-tasking. This is the first study to quantify how pharmacists in a paediatric hospital distribute their time. These results could act as useful baseline data against which to measure the impact of innovations, such as electronic medication management systems, on pharmacists workflow.

Response to Catherine Pettiford

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