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

BACKGROUND: Little is known about how physician time is allocated in ambulatory care. OBJECTIVE: To describe how physician time is spent in ambulatory practice. DESIGN: Quantitative direct observational time and motion study (during office hours) and self-reported diary (after hours). SETTING: U.S. ambulatory care in 4 specialties in 4 states (Illinois, New Hampshire, Virginia, and Washington). PARTICIPANTS: 57 U.S. physicians in family medicine, internal medicine, cardiology, and orthopedics who were observed for 430 hours, 21 of whom also completed after-hours diaries. MEASUREMENTS: Proportions of time spent on 4 activities (direct clinical face time, electronic health record [EHR] and desk work, administrative tasks, and other tasks) and self-reported after-hours work. RESULTS: During the office day, physicians spent 27.0% of their total time on direct clinical face time with patients and 49.2% of their time on EHR and desk work. While in the examination room with patients, physicians spent 52.9% of the time on direct clinical face time and 37.0% on EHR and desk work. The 21 physicians who completed after-hours diaries reported 1 to 2 hours of after-hours work each night, devoted mostly to EHR tasks. LIMITATIONS: Data were gathered in self-selected, high-performing practices and may not be generalizable to other settings. The descriptive study design did not support formal statistical comparisons by physician and practice characteristics. CONCLUSION: For every hour physicians provide direct clinical face time to patients, nearly 2 additional hours is spent on EHR and desk work within the clinic day. Outside office hours, physicians spend another 1 to 2 hours of personal time each night doing additional computer and other clerical work. PRIMARY FUNDING SOURCE: American Medical Association.

Cognitive workload changes for nurses transitioning from a legacy system with paper documentation to a commercial electronic health record.

OBJECTIVE: Healthcare institutions worldwide are moving to electronic health records (EHRs). These transitions are particularly numerous in the US where healthcare systems are purchasing and implementing commercial EHRs to fulfill federal requirements. Despite the central role of EHRs to workflow, the cognitive impact of these transitions on the workforce has not been widely studied. This study assesses the changes in cognitive workload among pediatric nurses during data entry and retrieval tasks during transition from a hybrid electronic and paper information system to a commercial EHR. MATERIALS AND METHODS: Baseline demographics and computer attitude and skills scores were obtained from 74 pediatric nurses in two wards. They also completed an established and validated instrument, the NASA-TLX, that is designed to measure cognitive workload; this instrument was used to evaluate cognitive workload of data entry and retrieval. The NASA-TLX was administered at baseline (pre-implementation), 1, 5 and 10 shifts and 4 months post-implementation of the new EHR. RESULTS: Most nurse participants experienced significant increases of cognitive workload at 1 and 5 shifts after "go-live". These increases abated at differing rates predicted by participants' computer attitudes scores (p = 0.01). CONCLUSIONS: There is substantially increased cognitive workload for nurses during the early phases (1-5 shifts) of EHR transitions. Health systems should anticipate variability across workers adapting to "meaningful use" EHRs. "One-size-fits-all" training strategies may not be suitable and longer periods of technical support may be necessary for some workers.

Assessing the validity of prospective hazard analysis methods: a comparison of two techniques.

BACKGROUND: Prospective Hazard Analysis techniques such as Healthcare Failure Modes and Effects Analysis (HFMEA) and Structured What If Technique (SWIFT) have the potential to increase safety by identifying risks before an adverse event occurs. Published accounts of their application in healthcare have identified benefits, but the reliability of some methods has been found to be low. The aim of this study was to examine the validity of SWIFT and HFMEA by comparing their outputs in the process of risk assessment, and comparing the results with risks identified by retrospective methods. METHODS: The setting was a community-based anticoagulation clinic, in which risk assessment activities had been previously performed and were available. A SWIFT and an HFMEA workshop were conducted consecutively on the same day by experienced experts. Participants were a mixture of pharmacists, administrative staff and software developers. Both methods produced lists of risks scored according to the method's procedure. Participants' views about the value of the workshops were elicited with a questionnaire. RESULTS: SWIFT identified 61 risks and HFMEA identified 72 risks. For both methods less than half the hazards were identified by the other method. There was also little overlap between the results of the workshops and risks identified by prior root cause analysis, staff interviews or clinical governance board discussions. Participants' feedback indicated that the workshops were viewed as useful. CONCLUSIONS: Although there was limited overlap, both methods raised important hazards. Scoping the problem area had a considerable influence on the outputs. The opportunity for teams to discuss their work from a risk perspective is valuable, but these methods cannot be relied upon in isolation to provide a comprehensive description. Multiple methods for identifying hazards should be used and data from different sources should be integrated to give a comprehensive view of risk in a system.

Designing for distractions: a human factors approach to decreasing interruptions at a centralised medication station.

OBJECTIVE: To decrease interruptions around a centrally-located, centralised, open paediatric medication station. METHODS: Several established human factors methodologies were used to study paediatric medication administration, including cases with 'walk through' and verbal protocols; semi-structured interviews, including critical incident analysis; hierarchical task analysis; and observation. RESULTS: Inexpensive barriers were constructed that protected the tasks likely to lead to errors if interrupted. Meanwhile, sight lines were maintained preserving a family-friendly sense of accessibility of nurses, staff situation awareness and collegiality. Interruptions were significantly reduced and staff attitudes towards the station were significantly improved. DISCUSSION: Targeted barriers may prove useful in other interruptive and chaotic hospital workspaces. They do not require costly training, can be achieved inexpensively and may reduce distractions and interruptions during tasks vulnerable to error. Additionally, the human factors methodologies employed can be applied to other safety improvement projects.

Interruption handling strategies during paediatric medication administration.

BACKGROUND: Interruptions are a part of many hospital settings. During medication administration, interruptions have been shown to lead to medication errors. Understanding interruption management strategies during medical management could lead to the design of interventions to reduce and mitigate related errors. METHODS: Semi-structured interviews with paediatric nurses in an in-patient setting were used to identify types of interruptions, strategies for safe medication administration and interruption management, as well as factors influencing the interruption management strategy choice. Nurses also worked through use cases and provided verbal protocols about their strategies. To confirm and refine a framework for interruption handling, on-the-job observations were also conducted. RESULTS: Four case studies of medication administration highlight four interruption handling strategies. Three allow the interruption: 1) the primary task is suspended so that the higher priority secondary task may be engaged immediately; 2) multi-task by dividing attention between the primary and secondary tasks; and 3) mediating the interruption with an action that supports resumption of the primary task. The fourth blocks the interruption, keeping attention on the primary task (blocking). Interviews and on-the-job observation suggest that nurses dynamically assess the primary and (interrupting) secondary tasks. They prioritise task execution based on both risk and workflow efficiency assessments. Specific interruption handling depends on both task and experience related factors. CONCLUSIONS: Paediatric nurses have developed sophisticated strategies to manage interruptions and maintain patient safety and work efficiency during medication administration. To support a more resilient healthcare system, interruption management strategies should be supported through process, task support tools and education.

Does the process map influence the outcome of quality improvement work? A comparison of a sequential flow diagram and a hierarchical task analysis diagram.

BACKGROUND: Many quality and safety improvement methods in healthcare rely on a complete and accurate map of the process. Process mapping in healthcare is often achieved using a sequential flow diagram, but there is little guidance available in the literature about the most effective type of process map to use. Moreover there is evidence that the organisation of information in an external representation affects reasoning and decision making. This exploratory study examined whether the type of process map - sequential or hierarchical - affects healthcare practitioners' judgments. METHODS: A sequential and a hierarchical process map of a community-based anti coagulation clinic were produced based on data obtained from interviews, talk-throughs, attendance at a training session and examination of protocols and policies. Clinic practitioners were asked to specify the parts of the process that they judged to contain quality and safety concerns. The process maps were then shown to them in counter-balanced order and they were asked to circle on the diagrams the parts of the process where they had the greatest quality and safety concerns. A structured interview was then conducted, in which they were asked about various aspects of the diagrams. RESULTS: Quality and safety concerns cited by practitioners differed depending on whether they were or were not looking at a process map, and whether they were looking at a sequential diagram or a hierarchical diagram. More concerns were identified using the hierarchical diagram compared with the sequential diagram and more concerns were identified in relation to clinical work than administrative work. Participants' preference for the sequential or hierarchical diagram depended on the context in which they would be using it. The difficulties of determining the boundaries for the analysis and the granularity required were highlighted. CONCLUSIONS: The results indicated that the layout of a process map does influence perceptions of quality and safety problems in a process. In quality improvement work it is important to carefully consider the type of process map to be used and to consider using more than one map to ensure that different aspects of the process are captured.