Measuring Clinical Workflow to Improve Quality and Safety

This chapter aims to illustrate the methodologies of time and motion research, the observation of clinical care activities in the field and its limits, strengths and opportunities. We discuss how such studies can be used to address questions related to the quality of care and to examine the relationships between clinical workflow and safety. Further, the chapter provides specific examples of the application of time and motion studies, the practical challenges and results obtained.

Time and motion studies of National Health Service cataract theatre lists to determine strategies to improve efficiency

AimTo provide a quantitative assessment of cataract theatre lists focusing on productivity and staffing levels/tasks using time and motion studies.MethodsNational Health Service (NHS) cataract theatre lists were prospectively observed in five different institutions (four NHS hospitals and one private hospital). Individual tasks and their timings of every member of staff were recorded. Multiple linear regression analyses were performed to investigate possible associations between individual timings and tasks.Results140 operations were studied over 18 theatre sessions. The median number of scheduled cataract operations was 7 (range: 5–14). The average duration of an operation was 10.3 min±(SD 4.11 min). The average time to complete one case including patient turnaround was 19.97 min (SD 8.77 min). The proportion of the surgeons’ time occupied on total duties or operating ranged from 65.2% to 76.1% and from 42.4% to 56.7%, respectively. The correlations of the surgical time to patient time in theatre was R2=0.95. A multiple linear regression model found a significant association (F(3,111)=32.86, P<0.001) with R2=0.47 between the duration of one operation and the number of allied healthcare professionals (AHPs), the number of AHP key tasks and the time taken to perform these key tasks by the AHPs.ConclusionsSignificant variability in the number of cases performed and the efficiency of patient flow were found between different institutions. Time and motion studies identified requirements for high-volume models and factors relating to performance. Supporting the surgeon with sufficient AHPs and tasks performed by AHPs could improve surgical efficiency up to approximately double productivity over conventional theatre models.

The Costs of Home-Based ART Initiation and Mobile Refill in Uganda

Background Antiretroviral therapy (ART) is effective at reducing HIV-associated morbidity, mortality, and transmission, but 20 million people who meet WHO eligibility criteria for ART are not in care. While decentralized care is a promising strategy to expand ART access, the costs of implementing a community-based model on a large scale remain unknown. Methods The DO-ART study is a randomized trial of community- vs. clinic-centered ART delivery in South Africa and Uganda using 12-month viral suppression as the primary outcome. We evaluated the costs of home-based ART initiation and refill in southwest Uganda using time-and-motion studies, staff interviews, and budgetary analysis. Costs categories included medications, supplies, personnel, building and utilities, start-up, vehicles, and community mobilization. We used a programmatic perspective with a 3% discount rate and removed research-associated costs. Results The largest cost categories included medications, supplies, and salaries, constituting 41%, 27%, and 17% of the total cost, respectively. Time-and-motion studies revealed that each outreach worker could serve an average of three patients per day in a fully decentralized model. In a scenario of providing home-based ART to 1400 patients aross seven sub-counties, the yearly per-patient cost was estimated to be $304 (2016 USD), which is similar to literature reports of the costs of facility-based ART provision. Conclusion These estimates suggest that home-based ART may be a realistic delivery option, especially if it is found to be effective at improving viral suppression. Further research is needed to evaluate how this intervention can most efficiently scale to provide widespread ART access over a large geographic area. Disclosures All authors: No reported disclosures.