Context Inpatient general paediatrics is provided by a variety of medical staff, including Paediatric trainees, General Practice trainees and Foundation doctors. This project considered how to provide safe patient care and a supported training experience through optimising medical productivity.
Problem In light of reconfiguration of paediatric services, there is a need to make efficient use of medical staff as a resource, at the same time as providing quality training. Junior staff noted that time was spent on activities other than patient contact. End of placement and GMC surveys identified that trainees failed to attend the recommended number of study days and clinics due to service demands. This project was undertaken to identify inefficiencies in the working patterns of general paediatric juniors, measure the impact on patient care and training, and highlight opportunities for quality improvement.
Assessment of problem and analysis of its causes In an 8 h shift, trainees spent 48 min on average directly interacting with patients and 25 min in teaching. This lack of patient contact time could not only result in poor patient care but could also impact on the skills and knowledge of trainees. This may effect quality of care in the future. A multidisciplinary focus group and anonymous interviews were held to establish staff views about the causes of these problems. These issues could be resolved by implementing non-urgent jobs books on wards and redesigning rotas.
Intervention New rotas were designed aiming to prioritise patient contact time, protect training opportunities and match staffing patterns to the clinical needs of the children. Full entitlement of study leave was also allocated. Attention was brought to the topic of interruptions with ward staff, and non-urgent jobs books introduced to maximise medical productivity.
Study design Ethnographic data was collected by shadowing 10 trainees over 5 weeks, verbal consent was obtained. Their intended and actual tasks were recorded each minute, as well as the number of times they were interrupted. Over 5000 min of data was collected.
Strategy for change Results of the shadowing data were presented at a clinical governance meeting (those who could not attend were provided information by email). New rotas underwent a formal consultation process with trainees, as well as Wales Deanery and the Welsh Assembly Government. The jobs book will be introduced at the same time as new rotas are implemented in March 2015.
Measurement of improvement The same method of data collection will be used to collect ethnographics following implementation of changes. Mean time spent on each activity will be compared. Number of interruptions and the extent to which actual versus intended task is affected will be analysed. Time spent training will also be recorded. The improvement cycle can then be repeated.
Effects of changes The new rota has been designed but not yet implemented, therefore the effects at the point of abstract submission are not yet known. However it is anticipated that the effects will be more patient contact, less frequent interruptions and greater opportunities for training. These results will be available by April 2015.
Lessons learnt Large scale service improvements require careful consideration of human factors and engagement from all stakeholders involved to successfully overcome barriers to change.
Message for others Rotas not designed around patients or trainees lead to low levels of patient contact, an inefficient service, and fewer opportunities for training. Consult staff widely and early in a quality improvement process.
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