Magliocco Cristina; Pugliese Francesco Rocco; Livoli Donatella; Coassin Simonetta; Di Lallo Nicoletta; Liguori Francesca; Pierconti Silvia; Simone Antonio.
Department of Medicine of Acceptance and Emergency, Sandro Pertini Hospital – Roma
Quantification of work load rests in the public administration, which analyzes through such data the relationship between demand and offer. Accordingly, data appraisal consists in the evaluation of the number of units of services completed and the time requirements, being thus often used to plan the requirements for employee units. Our study, which has an observational design, does not focus on this aim, which would probably be long term and ambitious, but instead tries to provide the actual times on average required for each action by healthcare workers in a 6 or 12 hour shift practicing in the emergency room.
The difference between the request of healthcare services from people and the actual provision of them from the National Healthcare Service, particularly in the context of emergency medicine, has brought a substantial overcrowding in the emergency room, in a demand of healthcare services from patients more extensive than in the past, and in an increase in the workload for healthcare personnel.
In our opinion there are many factors explaining this phenomenon; among them, it is useful to emphasize the following:
- Patient features: the number of elderly patients and subjects with comorbidities is increasing, requiring more demanding levels and times of care;
- Lack, or if present only in an incomplete form, of an adequate local network of supportive care (integrated home care, hospice, and so forth);
- Shortage of hospital beds with ensuing increase in the emergency room stay before admission and with increased diagnostic and therapeutic needs;
- New management models aiming at increasing the appropriateness of admissions and reducing total hospital stay;
- Inappropriate emergency room admissions from those who do not use, for several reasons, ambulatory services;
- Expectations of patients and family members, even in keeping with the evolving social and cultural conditions;
- Usage of therapeutic devices of ever increasing complexity, which require increased competence from healthcare personnel.
These changes, on top of leading to a progressive increase in workload, have brought a concomitant increase in the complexity of healthcare delivery. In addition, the increase in emergency room workload is explained by the shift from a management model based on the “admit to work” approach, whereby admissions occur early with diagnosis occurring in the ward, to one based on the “work to admit” method, whereby the most complete diagnosis is sought in the emergency room followed by the admission, if necessary, in the most appropriate division.(1) The adoption of such model at a national level has been substantial, leading to the recognition of its evident economic benefits. Yet, these have not been followed by suitable changes in facilities or human resources, and thus have surely increased healthcare personnel workload, thus impacting on service quality.
Focusing more on the topic of this report, there is already an extensive body of laws and regulations. For the sake of brevity we do not dwell on items pertinent the period before 1992. Before this, several important management approaches were introduced in hospitals and ambulatory services, accompanied by the definition of specific standards, which put in formal relation the number of healthcare operators and the number of hospital beds. This framework is however distant from the concept of healthcare workload. The “revolution” brought by law 502/92 meant that the national healthcare service had been transformed in a series of public companies, leaving many competences to such companies.
The law which introduced the concept of workload is however another one, namely law 29/3 February 1993, in which all public services are forced, by 31 December 1994, to verify workloads. This operation, aimed at reappraising personnel requirements and status, must be, according to the law, repeated every two years. In such law there is the explicit statement that such rules must be applied also to the whole national healthcare service. A few months later another law is passed, 537/24 December 1993, in which additional details are provided on how workloads are defined. Section 3, subsection 5 states “….the appraisal of workloads, which must be conducted taking into account the total volume of actions or operations, provided on average in the last three years, the standard times to complete such actions, and, when pertinent, the degree of coverage of the provided service in relation to the potential or actual request”. The Department of Public Services receives the reports, verifies the appropriateness of the methods used to appraise workloads, and approves or rejects the computations performed by the specific entities. The aim of this potentially conflicting set of laws was the improvement of public services, identifying areas with personnel excess, but the Department of Public Services, possibly disappointed from the received reports or in light of the poor detail of the laws, provided more recommendations in March 1994, published in 2 April 1994. In such recommendations more details are provided on how to define workloads.
Workload is defined as the quantity of necessary work, provided by the different professionals involved, in a reference operative context. This depends from the needs required by the final users, from the activities of the other operative units of the same institution, and from the give production goals; in order to measure workload, we must focus on the demand conditions and those of service provision. For demand conditions we must recognize for each administration:
- the minimal operative unit to which the workload is pertinent;
- the list of activities and products of each operative unit and the corresponding measurements;
- the quantity of acts or products actually required (appraised according to the average of the last three years) or planned in keeping with the objectives assigned to each operative unit;
- to the quantity of acts or products achieved by each operative unit on the average of the last three years;
- the potential initial and final residues appraised while focusing to the last year of interest.
It also specifies: “Focusing on the production conditions, it is necessary to define: standard time to complete each activity, and the qualifications and professional profiles, united per homogeneous area of activity, necessary to accomplish each activity. The methodology may envision periodic changes in the standards, in keeping with procedural changes and technological innovations of production processes. Moreover, it will be important to take into account the time of work dedicated to activities for which standard time cannot be measured, given their specifics (for instance, study time), and the time of work needed for ancillary activities (for instance, call center, waiting room, and so forth). Finally, it is necessary to appraise the number of personnel involved, the number of absences, and the annual patterns of ordinary and extraordinary work, distinguished by operative unit, by qualification and professional profile; the latter united according to functionally homogeneous areas. It is acceptable to perform sample appraisals, when these are focusing on operative units which perform the same activities, but ensuring that potential differences in operative conditions and technological resources are taken into account.” These details of the rule do not need comment as far as the difficulty of decoding is concerned. The rule goes on with the same features and focuses a chapter to the definition of workload. The chapter begins with the phrase. “At the end of its operative use, it is necessary that the definition of workload is provided with sufficient precision”. Those who think that the rule now provides clarifying details are mistaken. Making a specific effort, we can nonetheless recognize some key concepts: “The correct definition of workload thus requires the establishment of operative standards which correspond to the work times deemed necessary and sufficient, given the production conditions, to complete the required operations to achieve the final acts or services…”
Two factors are identified to define workloads:
Measurement of demand quantity:
- Identification of the required products;
- Definitions of the required objects.
- Standard time to unit act;
- Standard time for initial act.
Thus, recalling in a synthetic fashion what stated in the law and in the rule, workloads must be measured given the demand which leads to the definition of a “product” and the “production conditions”, themselves defined based on the measurement of standard times.(2)
The aim of our work has been to identify and quantify (with time units) the activities provided by a single physician in the context of the diagnostic-therapeutic and assistance activities carried out in the Emergency Room. The next step could be to use such data to calculate the personnel requirement, in keeping with the times necessary to provide good quality care according to the new workload. Such model could be applied to all healthcare personnel, including nurses, ancillary personnel and other staff. The path of the patient inside the Emergency Room consists on a number of activities which are repeated several times (one or more times for each patient) by the operators, in order to ensure timely evaluation and the most appropriate treatment of the patient. Waiting times between an activity and the next are basically shaped by the frequency with which such activity is required (which depends on caseload) and by the availability of personnel (medical or nursing) for such activity. If it is possible to measure and at least in part to plan patient flows, to date we have no precise measure of times required by a single medical activity provided in the Emergency Room. Knowledge of these times, combined with the evaluation of the different types of patients referring to the Emergency Room, might provide an estimate of the maximal workload (as time) which each professional can provide, and thus the required workforce.
Analyzing the literature it is evident that there are several useful data to define a method to compute the extent of provided care, and thus the need for medical personnel for Emergency Rooms. There are only isolated works on nursing workload.(1;4) The aim of these studies was mainly to identify a method which could correlate workloads with the number of nurses to be assigned to the different areas of the hospital; the tool used to calculate the unitary requirement is the “CLOC” method.
With “CLOC” method, we mean a system to define and code caring services, with the aim of planning the care and measuring the care requirement and the nursing workload. It consists in a measure of the time needed to accomplish the caring activities by applying the Standard Care Plans (SCP), or defined according to a homogeneous and statistically more frequent group of patients. To meet patient needs, we refer, on top of personalized planning, to the Complementary Care Modules (CCM), the Non-Plannable Activities (NPA), and the Indirect Care Activities (ICA).(3;5)
Definition of the operative phases needed for system implementation: identification of 6 thematic areas (distinguished by group, each group a letter, in each group more services identified by a progressive number) where the nursing activities identified by a specific alphabetic code can be recognized. Area 1: basic needs; Area 2: therapeutic procedures; Area 3: observation, monitoring of patient conditions, collaborative diagnostic activities; Area 4: transfer of the patient and the caring nurse inside and outside the various areas of the Emergency Room; Area 5: indirect care activities which ensure the environmental safety of the patient; Area 6: rights and rules of training.(4)
Indeed, we have verified that in the daily working setting this method is no longer feasible, and those which could be defined as standard measures aiming at measuring the increase in care time (for instance priority code, average stay in the Emergency Room of the patient after diagnosis and/or before admission, actual therapies provided, admission diagnosis) are no longer corresponding to the completeness and uniformity requirements. Moreover, only some data are recorded in a systematic fashion on the used systems and some cannot be acquired directly nor can be standardized. From this, the idea of computing, through the systematic recording of the medical diary, action times specifically provided in the different areas of the Emergency Room, is born. The medical diary, indeed, if systematically and correctly recorded, provides precise data on the completed activities and enables the quantification, in a uniform and complete fashion, of the care workload for each patient.(6)
We have measured times required for each action, in a single 6 and 12 hour shift, both during the day and the night, in the different areas of the Emergency Room of Sandro Pertini Hospital. Our Emergency Room (56,000 accesses/year) is divided in 4 operative areas: red room, where patients with yellow and red codes are evaluated; green and white code area, divided in three boxes; Holding Area, where patients wait for admission of remain in observation; Brief Intensive Observation (OBI).
In the following, we have synthesized in 5 tables the workloads in the different areas stated above.
Results and discussion
The obtained data quantify in minutes the workload that each physician must face, which is evidently greater than the hours available for each shift (360 minutes for 6 hour shifts, and 720 minutes for 12 hour shifts). The Emergency Room area in which the workload is almost proportional to the available hours, albeit slighly higher is the Brief Intensive Observation (table V), where, at odds with other areas, there is a more or less fixed number of patients (10-12). To these figures we must add the “weight” of some variables which are very common in the Emergency Room: cases which require more time, malfunctions in the therapy prescription systems (online prescriptions and certificates), pauses of at least 10 minutes for operator to avoid burnout, and ensuring “humane” relations with patients that are not based on pure bureaucracy.(7)
Our work has highlighted the importance of systematically and punctually completing the clinical chart (GIPSE system, which is active in the Lazio region) and the patient diary, not only for research purposes or to make the clinical documentation more complete, but also and particularly as a unique tool to document the completed clinical activity, despite the randomness and frenetic activity in the Emergency Room. The results obtained so far have however demonstrated that the care activity and the personnel should not be computed only on the number of annual accesses, as recommended by current regulations, but it should also be appropriate to appraise the care complexity of patients and the increase in their stay in the Emergency Room. It is important to think twice on how such situation creates a risky milieu for patients and professionals.
On one hand indeed, the patient cannot receive adequate care or may even be subject to operator’s mistakes, when the work is carried in a hurry. On the other hand, the operator which has an excessive workload may commit an increased number of mistakes, and his or her quality of work, as well as his or her quality of life, are at least compromised.
The correct definition of “workloads” in healthcare should be a necessary tool to define the correct institutional personnel requirements and to uniform working conditions, and thus provided services.
1. Chantal Moiset, Marina Vanzetta. “Misurare l’assistenza: il SIPI dalla progettazione all’applicazione”. Mondadori; 2009. ISBN: 9788838636707
2. Luca Benci. “Implicazioni giuridiche e operative nella sanità pubblica”. Mc Graw Hill; 2010, Milano . ISBN: 9788838636837
3. GRIAC. (Gruppo di Ricerca Infermieristica di Area Critica) “Sistema CLOC: un percorso per la pianificazione dell’assistenza infermieristica e la determinazione del fabbisogno del personale”. McGraw-Hill; 1998, Milano.
4. Giovanna Giussani. “Carico di lavoro: confronto ed integrazione tra la normativa e l’ottica infermieristica”. Scenario (insert) 2/1998.
5. Giancarlo Brunetti, Leonardo Cortini. “Sistema CLOC: undici realtà di area critica a confronto”. Scenario 2/1998 XV – XX.
6. Simone Peruzzi. “Una proposta per la determinazione dei carichi di lavoro in area critica secondo una teoria italiana”. Scenarto (insert) n. 2/1998, XXV-XXX.
7. Caterina Bianciardi, Letizia Bracci, Luca Burroni, Jacopo Guercini, “Lean Thinking in Sanità: da scelta strategica a modello operativo”. Società editrice Esculapio; 2014. ISBN 9788874888153