Monday, March 31, 2008

The Effect of Nurses on Patient Flow

When it comes to health care wait times and ER wait times nurses play a major role. Our office conducted a survey several years ago and asked all staff, including doctors, to list their role in patient care. Surprisingly, every group listed patient flow near or at the top of the list. We wanted to know what effect each group really had on patient flow so we data mined 596 patient records and examined their wait times once in the office. Specifically, this was for consultation regarding a general anaesthetic for a minor procedure in the office. When the patient has their medical history completed (on an Electronic Medical Record) the nurse that records it is stamped with the date & time. This particular part of the study examined the effect nurses had on patient flow. The nurses, in our office, play a wide variety of roles. Once the patient is registered they walk them to the consultation area, take x-rays if needed, complete a medical history (and hunt down any medications from families and pharmacies) and frequently bring the patient to the front again for treatment planning.

Based on this patient pool, the nursing role used approximately 42% of the time and caused 42% of the variation in the patients’ appointment. This figure, however, will be highly dependant on the procedure being completed and adds little to our understanding of what causes wait. The more telling number is the effect of nursing seniority. There is a relationship between less experience and more waiting. In the graph below the most senior nurse is ranked as #1 (roughly 15 years experience in the office) and the least senior is ranked #11 (roughly 1 year). As the seniority increases the office wait time goes down (it is approximately flat after 3 years of experience). The R2 value roughly translates to the amount of variation that can be explained by the factor being examined. In this case, roughly 26% of the variation that is seen in then nursing wait times can be explained by the seniority of the nurse. Remember that the nurse accounts for 43% of the total time with the patient so seniority accounts for approximately12% of the variation in wait time.

In our case it is the nurse that assumes the major role in the office with patient interaction. Since experience plays such a major role, there should be a mandate in each office to train the person that fills similar roles well. Does your office train the person by osmosis or is there a thoughtful training program? I’d recommend the following strategy:

Decide which tasks make up the majority of the work for the nursing role
-Which computer skills will be needed?
-If procedures are involved (surgical/interventional) provide some training so the person has context
-Create a learning program that educates at a reasonable pace
-Provide and maintain reference materials for study
-Especially drug references and procedures
-Create training that comes in a variety of formats
-Create goals within a timeframe so that people have something to work towards

As an example our office:
-There are 2 week, 3 month and 1 year objectives
-Nurses learn the procedures during the same time that they start doing the consultations for the patients. This way they learn the “important” questions to ask
-Drugs frequently used during the procedures are specifically listed and they are asked to learn more about their pharmacology
-Drugs that can cause surgical problems (anti-coagulants, bisphosphonates, cardiac, etc…) are specifically listed as well
-There is a learning program from basic to more complex objectives

It’s beyond the scope of this particular blog to list all the objectives but health care wait times have a real and linear relationship to nursing skill and experience. Being aware of how important the nursing role is, and providing sufficient training is important. It is even more important if you’re clinic or hospital suffers from high turnover (>20%) as this means few of your nurses are likely to be highly proficient. Value their experience, assist them in learning and do not underestimate the impact of high turnover.

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