The virtual patient encounter--units of service in the electronic age.

If work is not being completed, is it because the staff is not working efficiently or because there are simply too few staff to complete the work? Units of service (UOS) are a common reference tool in health care management. The expected UOS per staff member or hours per UOS may be examined to determine staffing needs.

In a typical clinic setting, a common UOS is the physical physician-patient encounter. However, this may not be the proper unit for modern clinics. Increasingly, medicine is turning to other forms of patient contact such as telephone, e-mail, and even Internet access. For each clinic visit there may be three to four phone calls. (1) While these do not necessarily involve the physician, they do represent work for the staff.

In one study, 49 percent of parents of pediatric patients indicated they would like to communicate with their physicians by e-mail. (2) As utilization of these nontraditional modalities continues to increase, the idea of the patient visit as the UOS becomes blurry.

Determining the UOS for a clinic

In anesthesiology, the use of preoperative evaluation centers (PEC) is growing as these centers lower costs by reducing delays and cancellations on the day of surgery. (3) While there are many ways to staff such centers, at the Medical College Hospital in Toledo, Ohio, we chose to use specially trained nurses overseen by an attending anesthesiologist.

The patients in the PEC are initially evaluated by nurses (RNs) and complicated cases are referred to the attending anesthesiologist. Additionally, nurses contact patients by telephone who are not referred to the PEC for a screening interview and medical histories are obtained from the patients' surgeons or their primary physicians and documented in the medical records.

Each patient's chart is reviewed by one of the attendings prior to the day of surgery in order to identify any issues that may indicate an inadequately prepared patient.

In the past, the PEC staff felt that they were over-worked; yet their management reports showed that their hours/UOS were higher than desired, suggesting that they were either less efficient or simply under-worked.

Suggestions were made to increase the activity of the PEC by seeing additional patients from other areas. The staff didn't think this was feasible because of the workload, yet hospital management believed the reports showed that the staff was under-worked.

The solution to this apparent disparity came from asking the right question: What is the correct UOS in this setting?

There are various ways to assess workload such as asking managers to use their professional judgment, asking the staff to assess the number and skill mix, or by doing an activity analysis that breaks down nursing care into tasks, although this focuses only on what is done, not what should be done. (4)

Understanding activities

The first step was to assess the actual tasks performed in the PEC. In addition to physically evaluating patients, the staff spent significant time:

* Phoning patients for medical screening and information

* Calling primary care providers for medical information

* Phoning surgeons' offices for information or to alert them to potential problems

* Faxing consents for release of information

* Contacting the attending anesthesiologist for advice on laboratory testing (often to get authorization to cancel unnecessary testing ordered by referring physicians)

* Collecting the information from these disparate sources into organized medical records

Even patients who were seen by the attending anesthesiologist after initial assessment created more work for the PEC staff, since the nurse typically accompanied the physician into the examination room.

We believe that involving the PEC nurses in the attending's assessment of the patient improves both their functioning as they learn what our decision trees are and their job satisfaction as they are encouraged to participate in the patient's entire care. It became obvious on our analysis of workload that actual patient visits represent only a small part of the work in the PEC.

The next step was to track the amount of time spent on each activity in the PEC. The PEC staff tracked both the number and duration of the nursing activities.

After the first few days, we realized that tracking this level of detail for all activities would unduly interfere with the functioning of the PEC. We simplified the tracking process to include two basic paths for PEC patients:

1. The actual patient

2. The "virtual" patient who was only seen through the proxy of medical records or phone calls

It was readily determined that much of the process was similar--collating materials and information, assembling the chart, etc. were tasks common to both pathways. Based on our sampling of the first few days, we noted that virtual patients took an average of 45 minutes per patient while actual patients took 60 minutes of staff time to complete their medical record. The results of a two-week survey are shown in Table 1.

This analysis revealed some interesting findings.

First, the hospital administration was using budgeted visits rather than actual visits to determine effort (hours/UOS). Indeed, if actual PEC visits were used the hours/UOS would be 3.45, an even more inefficient clinic!

Next, the PEC staff was legitimately feeling hard at work. When the hours of the PEC clerk are subtracted so that only nursing effort is analyzed, the hours/UOS (new system) is 0.85, about what would be expected from the time predicted (0.82 hours of nursing activity/chart) by the weighted average of virtual (0.75 hour) and actual visits (1 hour).

This suggested that the nurses in the PEC were spending nearly all their time processing patients and their materials. Clearly, choosing an appropriate measure of workload better reflected the true activity of the PEC.

Measuring activity

How can we measure workload, and by extension, productivity? The problems in measuring productivity include varying definitions of the term "nursing productivity" as well as the lack of consideration of less tangible aspects of nursing care. (5) Even the term "unit of service" may have different meanings in different settings. (6)

Several methods of measuring nursing workload have been reported. In some settings, such as intensive care units, workload is related to the number of patient admissions and the staffing is computed based on this number modified by acuity levels. However, this may be an inaccurate measure of nursing work. (7)

For outpatient clinics, the number of patients seen (modified by new or follow-up visit status) may be used. Over time, a change in practice patterns from inpatient care to outpatient care can lead to errors in assessing workload if the formula is not updated, just as we discovered in the change from actual visits to virtual visits. (8) A summary of commonly used indicators for UOS is given in Table 2.

Interestingly, none of these reported measures takes into account the virtual patient--the one "seen" either by e-mail, telephone, or record review. With the rising use of these alternative forms of contact, physician executives should develop measurement systems that capture these efforts when assessing staff workload.

One of the duties of the physician executive is to help the institution match its resources with the care it seeks to provide. Accurate measurement of the activity in a clinic is essential to accurately assess productivity and staffing needs. Staff that feels overburdened at work may have higher turnover, lower morale, and worsened performance.

As a result, we must be sure that we do not choose a UOS out of tradition or ease of counting. Patient visits may be an important part of the workload, but this number may not capture all the efforts in a specific setting, especially one that evaluates virtual patients.

As medicine moves to more alternative patient encounters, activity measurement systems must be adapted to account for new activities. Rational assessments of clinician effort should be selected so that accurate distribution resources may occur. Identifying appropriate units of service is the first step in this process.

Table 1. Comparison of workload under two systems

                 Hospital System       New System
                 (Actual visits only)  (Actual + Virtual visits)
PEC Visits        71                    71
Virtual Visits     0                   164
Total UOS        101                   194
(1 X actual +    (hospital budget)
0.75 X virtual)
Hours Worked     245                   245
Hours/UOS          2.43                  1.26

Table 2 Common measures of the nursing unit of service

Patient days
Home Care visit or case
Ambulatory care visit (clinic)
Procedure completed
Resident day
Number of patient contacts
Time to complete procedure
Number of cases or procedures

References

1. Kennedy KM and Henzke LJ. "They call more than they visit: Improving operations to provide excellent telephone service." Group Practice Journal, February 2004, 45-51.

2. Baraff LJ, Wall SP, Lee TJ, and Guzy J. "Use of the Internet and e-mail for medical advice and information by parents of a university pediatric faculty practice." Clinical Pediatrics, July 2003, 557-560.

3. Pollard JB, Zboray AL, and Mazze RI. "Economic benefits attributed to opening a preoperative evaluation clinic for out-patients." Anesthesia and Analgesia, 1996, 83, 407-10.

4. Needham J. "Accuracy in workload measurement: A fact or fallacy?" Journal of Nursing Management, March 1997, 5, 83-7.

5. Holcomb BR, Hoffart N, and Fox MH. "Defining and measuring nursing productivity: a concept analysis and pilot study." Journal of Advanced Nursing May 2002, 38(4), 378-86.

6. Zelman WN. "Cost per unit of service." Evaluation and Program Planning, Jan. 1987, 10, 201-7.

7. Adomat R, and Hicks C. "Measuring nursing workload in intensive care: An observational study using closed circuit video cameras." Journal of Advanced Nursing, May 2003, 42(4), 402-12.

8. Lynn SE. "The development of a time-based nursing information system in dermatology outpatients and day therapy areas." Journal of Nursing Management, May 2002, 10, 153-60.

RELATED ARTICLE: IN THIS ARTICLE ...

A patient, preoperative evaluation center can reduce delays and cancellations, but it's critical to measure staff workload and determine the best ways to coordinate care. See how one clinic in Ohio is succeeding with this effort.

By Alan P. Marco, MD, MMM, CPE, FACPE

Alan P. Marco, MD, MMM, CPE, FACPE, is associate professor and chairman of the department of anesthesiology at Medical College of Ohio in Toledo, Ohio. He can be reached at 419-383-3556 or [e-mail].

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