ABSTRACT
In an Emergency department of a tertiary hospital, Time and motion study creates a method to determine the correct time required for completion of a certain task. It can be effective for performance evaluation, for planning purpose, to uncover problems and create solutions and can also be used for time cost analysis. This study was undertaken in emergency departments of different tertiary hospitals of Lahore to observe the time consumed in comparison to work done. Thus, fulfilling the learning objectives of respective study and knowing how it is being implemented in Pakistan. It was an observational study including several patients from different tertiary hospitals. The data collection form was developed and data collected was then observed, analyzed and graphically presented. Normal and standard times at each individual step were compared statistically. Although, the results of respective study conclude that Time and Motion study is nowhere found in the local tertiary level hospitals and need to be introduced to all health care professionals. Emergency department facilities can be greatly improved by time wastage reduction and by pharmacist presence in Emergency Department pharmacy as well as ward, performing his duties efficiently in improved patient care, decreasing Emergency Department workload and increasing productivity. This project summarizes that Time and Motion Study with involved pharmacist interventions has become a necessary tool for businesses to be successful today and can very effectively be employed in all public and private hospital setups of Pakistan for improved patient care.
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DOI: 10.3923/jms.2013.555.562
URL: https://scialert.net/abstract/?doi=jms.2013.555.562
INTRODUCTION
A tertiary care or tertiary referral hospital is fully departmentalized specialty hospital equipped with all the services in the field of Medicine, Pediatrics, Obstetrics and Gynecology, Surgery, their subspecialties Oncology, psychiatry and ancillary services. An emergency department, located in a tertiary level hospital, also known as an accident and emergency department, or casualty department is a medical treatment facility specializing in acute care of patients who present without any prior appointment by their own means or by an ambulance.
Despite all the proficiency and experience of the hospital staff, Emergency Department still face difficulties dealing with complex patient tracking and information processing systems. Contributing factors producing high-risk environments detrimental to patient safety are various exacerbating conditions like congested waiting and treatment areas, suboptimal workflow and inadequate communication systems. In such conditions, endemic patient overcrowding results in a charged and highly dynamic working environment in which the patients quality of life may be compromised by the extraneous demand on time (McNutt et al., 2002).
Time and motion study in an Emergency Department creates a method to determine the correct time required for completion of a certain task. Time and motion study can be effective for performance evaluation, for planning purpose, to uncover problems and create solutions and can also be used for time cost analysis. The standard Time and Motion study procedure is to define and document the standard method. Then the task is divided into work elements. Each job is studied thoroughly. Time for each work element is calculated to obtain the observed time for the task. Then average time for each task is computed. Finally, the workers pace relative to standard performance is evaluated and rating is also done. Then determine the normal time and finally apply an allowance to the normal time to compute the standard time. The allowance factors are actually needed to compute standard time (Groover, 2011).
Every passing year report over 20 million attendances at A and E department in all tertiary hospitals (Aacharya et al., 2011) A study published at Emergency Medicine Journal proved that a common occurrence seen worldwide in emergency department overcrowding is when function of a department is hindered by an inability to treat all patients in an adequate manner. Overcrowding results in inadequate patient care leading to a poorer patient outcome (Trzeciak and Rivers, 2003; Lewin Group, 2002).
The study on waiting times, in a pediatric emergency department, showed that time spent in the waiting room was decreased by the severity of the patients illness. But, time increased by both the nonavailability of a nurse and the nonavailability of an examining room.
Time spent in the examination room waiting for the physician was dependent on the availability of the physician and the number of patients concurrently registered in the emergency department and also on the severity of their complaint (Liptak et al., 1985).
An analysis of estimation of patient flow across emergency department has proved useful in detecting these factors and is being used to plan emergency department reorganization (Miro et al., 2003).
A business efficiency technique, Time Motion study (T and M), to ensure the job being evaluated does not include any unnecessary motion by the personnel, to end goofing off and to establish a fair days work constitution. Time study proceeds in the direction of establishing standard times, Motion study in turn evolved for improving work methods (Burroughs et al., 2005).
An integrated use of Time and motion study (T and M) is required to achieve rational and reasonable results. Time motion study is generally employed for repetitive tasks and describes a method for quality standard establishment, breaking a complex task into numerous simpler steps (Pigage and Tucker, 1954). A type of work measurement technique, T and M study describes a careful time measurement of the task using a time measuring instrument that is adjusted for any observed variance from normal pace and allows adequate time for all activities.
T and M study in an emergency department irrespective of the physiological cost to the hospital personnel sought to maximize the productivity. T and M study addresses the quality issues and efficiency to measure time on a specified task, work quality and patient safety (Karsten, 1996).
To efficiently utilize their time and for a variety of other reasons, hospitals are developing a growing interest in changing their information systems to support patient processes in a more direct way from manual to electronic. This requires the task to be actively delivered and performed to the right person at the right point in the right time with the right information and the necessary application functions needed for performing these tasks (Reichert et al., 2000).
In this scenario, tertiary hospitals require implementation of technology in turn changing the cognitive behavior of clinicians and way of collaboration of hospital teams in providing patient care irrespective of time. Information systems and other electronic devices do not merely accelerate function but may restructure the performance of a particular task in a minimal effective time involved (Gordon et al., 2001; Bates et al., 2003).
Electronic documentation and Computerized Provider Order Entry (CPOE) provide an infrastructure that supports improved patient safety, improved information flows and smoothed patient care processes (Asaro and Boxerman, 2008).
A recent study presented at AHRQ Patient Safety and Health IT conference in June 2006 supports the idea that Pharmacists as members of an inpatient care team, is responsible to improve all aforesaid process measures including time. Pharmacists ensure a needed layer of safety in such vulnerable environment and provide a cost saving benefit to the Emergency Department. Pharmacists clinical activities and responsibilities include medication reconciliation or medication history, order clarification, dosing, interdisciplinary Emergency Department rounding, Emergency pharmacy formulary management, monitoring, therapeutic substitutions, discharge prescription review and control, safe medication practices, junior staff education. In turn reducing medication errors, drug utilization review, providing on-time drug information, 4 preparation, pharmacokinetic consultations, medical staff in-services, emergency resuscitation team participation, research assistance, order entry, medication dispensing and formulary interchanges (Fairbanks et al., 2006; Fairbanks, 2006; Lada and Delgado, 2007; Koepfer, 2002).
A research study, presented at American Society of Health System, concluded the same idea as this study explaining. Pharmacists busy in administrative work of an emergency department are responsible for developing resource materials and providing or developing critical care medication guide. Pharmacists are also involved in developing pediatric dosing guidelines and patient education materials to ensure consistency with inpatient discharge instructions.
In some cases, workers prove to be a barrier for time and motion study by misinterpreting its objectives and may not cooperate. In addition, workers may also change the rate at which they work (Koehler, 1992).
The time and motion study for pharmacists activities in a geriatric hospital showed the same results that the pharmacists time is mainly allocated to clinical activities. However, still a large proportion of time is taken up by administrative activities which can be conducted by non-pharmacist personnel, allowing more time for patient care (Wirth et al., 2009).
An article published at New York in 1997 believed the same idea that for an effective time and motion study, observers must be also be competent, observers must be able to determine the difficulty of the job and must be able to decide what a normal performance is (Stuttaford, 1997). Pharmacists serve as a liaison between Pharmacy and Emergency Department of a tertiary hospital playing their key role in patient care and reducing time consumption at all motion steps involved. This study is to carry out a time and motion study in the emergency department of different tertiary hospitals by direct observation of all activities being performed and to identify and quantify activities undertaken by pharmacists.
MATERIALS AND METHODS
A descriptive study was conducted to elicit time motion study with involved pharmacist interventions in an emergency department of a tertiary hospital.
Aims and objectives: The objective of this study is to observe significance of time motion study in Emergency Department of hospital. Another important objective is to identify various factors that may lead to wastage of time resulting in delayed patient care. Recommending various means of adopting/implementing time motion study in Emergency Department of hospital is found significant. Other objectives are to compare average time, normal time and standard time involved in each task and to analyze and observe pharmacist interventions in an emergency department.
Location of study: The study was conducted in different tertiary care hospitals including Services hospital, Sir Gangaram hospital, Mayo hospital, Fatima memorial hospital, Children Hospital and Punjab Institute of Cardiology, Lahore, Pakistan.
Duration of study: 15 January, 2012-31st October, 2012.
Sample size: A sample size of 100 patients was selected for respective study.
Inclusion criteria: The target population includes all the patients coming to the emergency department including man, women and children.
Exclusion criteria: All the patients visiting hospital departments other than emergency department were excluded from the study.
Plan of work: Data from a group of 100 patients, of different public and private sector tertiary hospitals, was collected, studied and analyzed. A data collection form was developed to include all the motion steps and pharmacist interventions. Data collected was then analyzed and following formulas were applied to calculate normal time and standard time which was presented as graph. Results were computed and conclusion was finally drawn:
Normal time | = | (Elemental average time) (rating factor) |
Nt | = | (t) (RF) |
Normal cycle time | = | NT = Nt |
Standard time | = | (normal cycle time)(1+allowance factor) |
ST | = | (NT) (1+AF) |
RESULTS
Results of respective study were computed statistically in form of an elaborated table and its respective graphical representation. Table 1 describes all the motion steps observed and analyzed in an emergency department relating patients suffering of different diseases or ailments, graphically represented in Fig. 1.
Average, normal and standard time of each motion step was computed statistically involving Rating Factor (RF) for normal time and Allowance Factor (AF) for standard time computation.
Table 1: | Time utilized in all the motion steps observed and analyzed in an emergency department in minutes |
NT: Normal time, ST: Standard time |
Average time for each individual motion step i.e., time spent in an Emergency Medical Officer room, from Emergency Medical Officer room to bed, time consumed for a test, time required for starting a treatment, time wasted in surgical and medicine availability and time utilized for patient counseling and others was found to be much more greater than expected normal time and standard time computed statistically for that individual motion step.
Fig. 1: | Time utilized in all motion steps observed and analyzed in an emergency department |
In Table 1 total time for each patient is also calculated. Total time is varying depending upon the steps performed. Standard time for each individual step is higher than normal time e.g., 110.565 is the standard time for undergoing a test while 105.3026 is the normal time for this step. Figure 1 shows that standard time of most of the steps is greater than their average and normal time. These steps are represented graphically.
DISCUSSION
This is a time motion study conducted in various tertiary hospitals of Lahore by observing and noting the time of activities of patients starting from their entry to emergency department of the hospital up to their discharge from hospital or being shifted to indoor department. This study can be helpful in performance evaluation, uncover problems, create solutions and can be used for time cost analysis.
The whole process was divided into several steps including making entry slip, EMO room, from EMO room to bed, to undergo a test, starting treatment, availability of surgical, availability of medicines, getting discharged, getting discharge medicine from pharmacy and patient counseling. Then the total time for the whole process was calculated. Formulas were applied and average time, normal time and standard time were calculated. Pharmacist role and interventions were also observed.
No person, health care provider or professional was having knowledge of time motion study in the emergency department of the tertiary hospital of Lahore. Even no one was aware of this terminology. Implementation of time motion study is of much importance to improve the efficiency of emergency department and in turn the quality of life of a patient.
Results showed that most of the steps were performed quite efficiently but still a lot of time gets wasted. Being health care provider, it is required to reduce this time for efficient patient care.
Average time of all these activities is near to the normal time which shows that the time taken by a patient is nearly equal to the time spent by a normal operator in performing those activities.
Standard time of most of steps is quite near to the normal and average time. There is a difference between the standard time and normal and average time calculated spent in E.M.O. room, in undergoing a test and in getting discharged.
More or less, patients have to wait at each and every step. Sometimes they have to face congested waiting and treatment areas. Complex systems and poor literacy rate is another reason. Although, in almost all the hospitals, proper directions are provided but still time gets wasted in reaching the proper place. Like a study by Matthew et al. (2010) explained that Hospitalists spend less time with patients and Multi-tasking occurred frequently (Matthew et al., 2010).
Sometimes time is wasted due to repetitive actions. Inadequate communication systems can also be a reason. Time is also wasted in waiting queue for undergoing a test and then getting their reports.
Time is also wasted due to unskilled staff and junior doctors. The staffs were overburdened. Presence of skilled staff and senior highly educated and experienced doctors and pharmacists and sufficient number of staff and Para medical staff can greatly reduce this time. This will also be helpful in saving many lives and improving quality of life of many patients.
In most of hospitals, MO rooms and EMO rooms were quite spacious. Congested rooms also lead to wastage of time and also patients do not feel comfortable and convenient in moving through.
Pharmacists are also responsible for reducing the time wastage. Pharmacists were mainly performing administrative activities in the pharmacy. Among all the visited hospitals, only in Children Hospital pharmacy setup was greatly developed and pharmacists were performing their actual job of prescription monitoring and patient counseling along with prescription handing and other administrative activities.
Manual data entry system is adopted in majority of the hospitals but computerized system is evolving rapidly. This change and advancement is playing important role in reducing the time wastage as a study by Tim Benson also focused the use of computerized system by General practitioners and hospital doctors (Benson, 2002). This system will not only reduce time due to speedy data entry but also by improving the communication and data transfer between different sections of the emergency department and among various related departments, as supported by Yen K. and others in a study proving that the addition of computer physician order entry in turn decreases nurses time talking with other staff for patient care (Yen et al., 2009).
In emergency department of almost all the hospitals, laboratory, radiology department and pharmacy were near to or within the emergency department. This short distance also reduces the time wastage in starting treatment of a patient.
Patient counseling is one of the important roles and duty of pharmacist but it is done by physician and by nurses. Patients also rely and trust more on information and counseling provided by the physician. Pharmacists have to improve this aspect.
In no hospital pharmacist was present in the emergency department ward. Presence of pharmacist in the ward can benefit patients greatly and reduce many prescription errors.
Knowledge of time motion study should be spread and time motion study should also be implemented to improve the working of the emergency department. By adopting above mentioned systems and measures, the health care system of emergency department of tertiary hospital can be improved.
CONCLUSION
From this study it can be concluded that no one is having any knowledge of time motion study in the emergency department of different tertiary hospitals of Lahore. There are many ways to improve it and creates new ways to manage emergency conditions more efficiently. Time wastage reduction can greatly help in improving emergency department facilities. Time is mainly wasted due to congested areas, complex system and inadequate communication, poor literacy rate, waiting queues, repetitive actions and presence of junior and inadequately experienced professionals. Absence of pharmacist in emergency ward is also an important aspect. Presence of pharmacist can benefit the patient in several ways including prescription monitoring and patient counseling which is one of the important jobs performed by the pharmacist. By reducing the time wastage and presence of pharmacist in emergency ward can improve emergency department facilities to a greater extent.
ACKNOWLEDGMENT
I acknowledge with pleasure, the guidance in preparing this project report, of Allah Almighty and after that my respected teacher Mam Fatima Amin and all others whose abundant support helped me, completing this project report.
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