The Analysis of Working Load of General Practitioners in the Republic of Kazakhstan

 

Aigul Mergentay1*, Dusentay B. Kulov1, Gulbadan S. Bekembayeva2, Vitaliy V. Koikov3, Baurjan K. Omarkulov4, Saule A. Mussabekova5

1Department of Public Health, Karaganda State Medical University, 36 Gogol Street, Karaganda city, 100008, Republic of Kazakhstan.

2Department of Phtiziology, Astana Medical University,49 Beibitshilik Str., Nur-Sultan City, 010000,

Republic of Kazakhstan.

3Republican Center for Health Development, Ministry of Health of the Republic of Kazakhstan, 13 Imanova, Nur-Sultan City, 010000, Republic of Kazakhstan

4Department of General Practice No. 3, Nursing with a Course of Neurosurgery, Karaganda State Medical University, 40 Gogol str., Karaganda city, 100008, Republic of Kazakhstan.

5Department of Pathology, Karaganda State Medical University, 40 Gogol Str., Karaganda city, 100008, Republic of Kazakhstan.

*Corresponding Author E-mail: merei_merei@mail.ru

 

ABSTRACT:

The article provides results of a chronometric analysis of patients a polyclinic in Kazakhstan, as well as of and analysis and study of the working hours spent by doctors for accomplishment of various labor transactions. The statistical analysis defined the basic factors influencing the duration of reception of patients by general practitioners (GP) doctors. They are: the communicative factor, operating procedures, and document processing. The basic factors influencing the duration of patient reception by GP doctors are the communicative factor or Component 1 (r=0.805), operational procedures or Component 2 (r=0.736), and documentation processing or Component 3 (r=0.528). The forecast of data reception time (by GP doctors), depending on the availability of technical work, the documentation showed us that generally three factors (technical work, internal documentation, and additional procedures) have a very significant effect on the dependent variable (patient reception). It turns out that the time spent for additional inspection of patients, contributes to a more rapid and faithful inspection of results and reduced the patient reception time, on the other hand the presence of technical work and documentation processing helps increase the time of reception be a GP doctor.   

 

KEYWORDS: Patient, Disease, Dispensary observation, Reception time, Population.

 

 


INTRODUCTION:

Background: Today, Kazakhstan’s healthcare system faces the problems of the human resource imbalance, aggravated by the impact of demographic, political, socioeconomic, technological, epidemiological changes1. In connection with this, the planning of staffing needs and staffing evaluation2,3, based on the standards of health experts, workload are the important elements of staff management and should be based on common methodological approaches4,5,6.

 

 

 

 

The main objectives of the labor rationing in healthcare:  

·      To define the labor cost, workload, and staffing levels,

·      To find the optimal proportions for different groups in the performance of their works7,8,9,10,11,

·      To plan certain areas of the health sector.

 

The standard workload of a healthcare professional is obtained as a result of studying the working time, taking into account current and future needs of the population in specific types of medical care. Naturally, this need cannot be satisfactory everywhere, and in some cases, it can be less than optimal both currently and in the near future12,13,14.

 

The established standards are designed to calculate the maximum number of positions, determination of entitlement to perform one’s functions, and their complete use is possible only with the creation of conditions that have been taken at a centralized rationing. Therefore, when using established standards, certain corrections should be made15,16, in some cases with restrictions, taking into account local features and conditions of work, and at the same time, the staff standards of outpatient organizations. Clinics (hospitals) must cover the needs of the population for certain types of medical care17,18.

 

Among other things, the effectiveness of public health organizations, including primary healthcare organizations, depends on the proper organization of work in all its departments and for the entire medical staff19,20,21. In this regard, one of the key areas of the Densaulyk (Health) public health development program (2016-2019) defines “Improving human resources management in the health care industry.” Within this area “a shift in emphasis on the need for older staff regulations and standards to the flexibility of human resource planning and labor, in accordance with the applicable technologies, standardized operating procedures, and the needs of patients”22 is planned.

 

The aim of the study:

to develop an evidence-based approach to improve the workload of general practitioners (GP), taking into account the strategic initiatives of the Densaulyk (Health) public health development program.

 

Main tasks to achieve the objectives:

1.    To study the workload and duration of the working time of GPs.

2.    To identify main factors affecting the duration of reception by general practitioners in primary health care organizations in Kazakhstan.

3.    To set the estimated duration of reception by doctors (GPs), depending on the accounting for certain variables.

 

MATERIAL AND METHODS:

The chronometer research method:

To study the workload and duration of the working time of general practitioners in primary healthcare organizations, we carried out a chronometer study of the working time at a GP clinic in Karaganda. The chronometer research is a method for an analysis and study of the working time needed to perform consistently recurring labor operations8. It consists in drawing up a list of work operations, which are grouped on the basis of the activity type. Four chronometer studies of specialists covered GPs in the observed period in the clinic during the reception of patients within 45 hours 19 minutes (according to the chronometric cards).

 

Sequence of study organization process:

The study of health professionals’ activities continued over the course of three weeks. The study allowed determining the length of labor operation elements. The duration was found by subtracting the start time of each subsequent element by the start time of the previous one. The duration of the first element was obtained by deducting the start time of the observation from the time of its completion23. The calculated results are then transferred to the operation column. Then we grouped the same named elements of the work process. For that purpose, next to the operation name we placed the code (showing to which category the operation belongs). Figures were marked in the diary of the employee. After that, the duration of the same operations was summed. As a result of all the collected data, a summary table, consisting of the work time study, was compiled. At the end of the table, the average of each type of activity, which was the result of research, is provided.

 

Method of continuous analytical study:

it was used to process and analyze the results. We performed a statistical analysis by using SPSS 16. In analyzing the descriptive (descriptive statistics) factor, the correlation and multivariate analysis of variance were performed.

 

Method of descriptive analysis:

used to analyze the timing of the working time of GP doctors in a clinic of Karaganda within 3 weeks.

 

Solid research method:

used to analyze the time spent by doctors (GP) for 256 patients, including 155 adults and 101 children.

 

RESULTS:

Type of the medical staff activity:

·      50% of patients in half of cases visited the doctors due to diseases and for primary consultations;

·      20% of patients of the dispensary contingent applied to the polyclinic concerning recrudescence of processes or for observation;

·      30% of patients visited to receive various medical certificates, prescriptions, etc. (social and medical actions);

·      for patients attending an appointment for paperwork the auscultation and percussion were not carried out;

·      the time for clarification of the anamnesis and complaints of the patient was not spent. But at the same time, such patients required more time to fill up documents (issue of references, sick-lists, appointment cards to procedures, etc.).

·      Irrespective of the visit cause, whether concerning a disease or the to receive a certificate, the medical staff had to enter the patient’s data into the automated information system; therefore, this indicator was also considered by us in the analysis of the time spent for the patient reception.

 

The time spent for registration of patients and introduction of data to the automated information system:

·      46% of general practitioners need from 0.5 to 2 mins;

·      14% of doctors spend from 3.5 to 5 mins;

·      14% doctors spend up to 12.5 mins;

·      the optimum time for nearly half of doctors is about 2 mins;

·      39% of experts during attendance did not enter these data and postponed this procedure until off-duty hours, and that was taken into account when ranging.

 

The time spent for patient data acquisition (pda) and for clarification of patients complaints (cpc):

·      36% of doctors spend from 2 to 7 min for pda and respectively — from 2 to 6 min for cpc;

·      27% spent from 0.5 to 1 min for cpc;

·      33% of doctors spent 1 to 2 min for collecting the anamnesis. That is, 6 mins for one reception and 3-7 min were left for collecting the anamnesis;

·      37% of doctors were visited for various doctor's certificates or paperwork, and therefore no time have been spent for clarification of their complaints and collecting the anamnesis.

 

Time for checkup, measurement of arterial pressure, body temperature, calculation of pulse rate:

·      28% of doctors of VOP spent 0.5 to 1 min;

·      36% of doctors spent 2–3 min;

·      37% of doctors did not measure these indicators, delegating these procedures to nurses;

·      59% of doctors ausculted within 0.5 to 1 min;

·      4% of doctors spent 2-3 min;

·      94% of doctors did not perform a palpation check;

·      6% carried out the procedure within 0.51 minutes.

 

Time for additional actions during the visit, such as a video review of a pharynx of the patient, delivery of medicinal drugs, consultation on administration of drugs, etc.:

Only 6% of doctors, of which 4% spent for it 0.5–2 min, 2% of doctors spent 3 to 5 min.

 

Time for filling in patient documentation:

·      65.5% of doctors spent 0.5–3 min;

·      22.5% spent 4–10 min;

·      24% of general practinioners spent between 11 and 27 min.

 

That is, more than half of the doctors during patient visits spent 0.5 to 3 min for filling in documentation, at the same time, nearly a quarter of doctors spent up to 27 min for filling in patient documentation within a visit. Paper work was subdivided into internal and external correspondence.

 

Time for internal correspondence:

·      58.7% of general practitioners spent 0.5 to 2 min;

·      37% spent 3 to 7 min;

·      4.3% of doctors spent 11 to 15 min.

 

Thus, most of doctors occupation with internal correspondence took 0.5 to 2 minutes of their working hours.

 

Time for external correspondence:

·      57.2% of doctors spent 0.5 to 1 min;

·      42.8% doctors spent 2 to 3 min.

 

Time for commission of technical works:

Only 13% of doctors spent time for it, of which 6 (46.1%) doctors spent 0.5 to 3 min and the rest (53.8%) spent 4 to 6 min.

 

That is, most of doctors (87%) did not spent time during as visit for changing to the gown, preparing the workplace, washing hands, or taking a technical break for room sanitary processing (after infectious patients: measles, rubella, tuberculosis, pediculosis, etc.), and also transitions (in other office), etc. All these events were held by doctors during their off-duty hours.

 

Factors for the analysis:

We carried out a factorial analysis to determine some variables influence on the duration of time of the general practinioners spent for a patient visit. The visit consisted of the time spent for clarification of complaints and the anamnesis, additional actions in the form of pharynx survey of the patient, delivery of medicines, consultation on administration of drugs, etc., and also technical procedures and external correspondence.

 

We could define the factors uniting the variables, which strongly correlate among themselves through the factorial analysis. Variables from different factors do not correlate among themselves. Thus, we have found the complex factors, which explained the observed correlations between the variables.


 

Table 1: Values of the factors influencing duration of patient attendance in polyclinic

Component

Initial Eigenvalues

Extraction Sums of Squared Loadings

Rotation Sums of Squared Loadings

Total

Variance, %

Cumulative %

Total

Variance, %

Cumulative %

Total

Variance %

Cumulative %

1 factor

2.714

19.386

19.386

2.714

19.386

19.386

2.569

18.353

18.353

2 factor

2.423

17.308

36.695

2.423

17.308

36.695

2.041

14.581

32.934

3 factor

1.431

10.223

46.918

1.431

10.223

46.918

1.911

13.654

46.588

4 factor

 

 

 

 

 

 

 

 

 

 


Table 1 clearly shows that three own factors had values exceeding 1. Therefore, we have selected only three factors for the analysis.

 

The first factor explained 19.386% of total dispersion. Such variables as collecting the anamnesis (r=0.805), clarification of patient’s complaints (r=0.553), measurement of temperature, arterial pressure, pulse (r=0.648), prescribing additional analyses, inspections (r=-0.565), and also input of personal data into the information base of the polyclinic (r=0.535) entered the first factor, referred to by us the “communicative component.” The negative value of the indicator of internal documentation processing, in the form of writing doctor’s prescriptions, certificates, and instructions indicates that there is an inversely proportional correlation, that is, less than current time will be spent by the doctor for this work, the doctor will have more opportunities for direct communication with the patient.

 

The second factor explained 17.308% of total dispersion. The second factor, designated by us as “operating procedures” included variables, such as auscultation (r = 0.736), additional measures in the form of throat and skin examination, prescribing and dispensing medicines, etc. (r=-0.638). Also of great importance is “patients' visit duration” (r=- 0.527). Moreover, the negative value of the variable means that if the patient’s cause for visiting the doctor is a disease, the visit time increases due to additional measures taken by the physician. The inversely proportional relationship points to the fact that a patient will be visiting the doctor more often, the patient has disease, and the doctor had to perform additional steps to diagnose the patient and prescribe adequate treatment.

 

The third factor explained 10.223% of total dispersion. The third factor is ‘Work documentation’. There correlated only two variables: the work with internal documents (r=0.528), as well as palpation and percussion (r=0.503), and both variables were positive in sign, that is, the more carefully the patient examination was, the more likely he was visiting the doctor for additional tests or procedures, and prescription of additional drugs. However, it should be noted that in this case, we had a moderate correlation. Documentation processing was associated with variables, such as technical procedures: gown change, workplace preparation, washing hands, or a technical break for the premise sanitization (after infectious patients: measles, rubella, tuberculosis, lice, etc.), as well as moving to another room if needed, etc.

 

 

Figure 1: Diagram of significant factors comprising the communication model between variables.

 

Term Scree Plot, used in this diagram consists of two parts: the word scree, which means rubble, and the word plot, that corresponds to the graphical representation. Such a diagram can separate unimportant factors from the most significant factors. These important factors in the chart have the shape of a slope, the part of the line, which is characterized by a steep rise. In the diagram, such a steep rise is observed for the first three factors. The chart shows that on the slope there is an area of significant factors above the third factor (the fourth, third, second ...), and the region of insignificant factors is located below the fourth factor (the fifth, sixth, seventh, eighth,).

 

While the calculation factor analysis characterizes the strength of relationship between two variables, the regression analysis is used to determine the type of the correlation and provides an opportunity to predict the value of one (dependent) variable based on the value of the other (independent) variable.

 

DISCUSSION:

We analyzed the variables that influence the duration of the patient's medical reception about the disease, dispensary observation of the concomitant chronic diseases, or vaccination, as well as in connection with various social and medical interventions.

 

Estimating the time spent for patient reception (adults, children, pregnant women), making calculations by the method of multinomial logistic regression:

·      For an adult patient examined by a GP doctor for a disease, in case the doctor will not waste time for various maintenance work, further manipulation, and filling internal documentation, the estimated reception time will increase from 56.2% to 60.9%,

·      For children it will almost remain the same,

·      For pregnant women it will decline from 12.5% to 7.8%.

 

That is, the doctor will directly communicate with the patient. Reducing the time spent for the reception of pregnant women, in our opinion, is caused by the fact that the disease is associated with the early deployment of these women, and GP doctors direct them to relevant obstetrician-gynecologist.

·      In dispensary observation, the forecast of time spent for patient reception, in the absence of technical works, additional manipulations, and filling internal documentation, will decrease from 66.7% to 49% for adult population.

·      The predicted values of social and medical actions for adults will increase from 62.5% to 67.9% and for pregnant women by 2%, whereas they will decrease for children from 37.5% to 30.1%.

·      If a general practitioner spends from 0.5 to 2 min to fill in internal documentation, the time of an adult patient’s visit will reduce from 50% to 28.8%.

·      If they spend 3 to 7 minutes, then visit time will increase from 50% to 66.6%. That is, filling in internal documentation during the reception of adult patients with symptoms of a disease needs to be reallocated to nurses.

·      The reception time at medical examination of adult patients in case of additional procedures lasting 0.5 to 2 minutes will reduce from 100% to 31.8%, and among children from 85.7% to 47.9%. It indicates that the time spent for additional survey of patients promotes correct and fast obtaining of examination results.

·        In the presence of technical works, the time of patients' visits will reduce, in case of a disease, for adults from 100% to 61.2% and for children from 100% to 15.5%.

·      When carrying out medical examination, the performance of technical work will also promote reduction of the visit duration of adult patients from 100% to 72.9% and of children from 33.3% to 13.7%.

·      In case of pregnant women, the value will increase in the presence of the variable “filling in internal documentation.” In case of visits of such patients in connection with dispensary observation and filling in internal documentation, the duration of reception by a general practitioner will increase from 16.7% to 32.5%, and when taking social-medical actions, it increases by 8.5%.

 

Table 2. The test results of the likelihood coefficients for significance indicators

Model

Model Fitting Criteria

Likelihood Ratio Tests

-2 Log Likelihood

Chi-Square

df

Sig.

Intercept only

103.284

 

 

 

before

72.033

31.251

18

0.027

 

Table 2 contains the test likelihood ratios, change of the likelihood function for the case when appropriate excluded the main acting factor; these changes are expressed in terms of the relevant test values chi-square. The issue significance level p<0.027 indicates that three factors (technical work, internal documentation, and additional procedures) have a very significant effect on the dependent variable (patient reception).

 

CONCLUSIONS:

Thus, the statistical analysis allowed us to determine the main factors affecting the duration of patient reception by GP doctors. They are: the communicative factor, operating procedures, and document processing. At the same time, most part of the time is spent for the communicative part: communication with the patient, consultation, conversation with him. The second longest time duration (doctor’s appointment with the patient) is the part associated with the implementation of diagnostic activities: examination, palpation, auscultation, and other additional procedures required to clarify the patient's diagnosis. And the third important factor affecting the reception duration is the filling in medical records.

 

When estimating the data acquisition time (by GP doctors), depending on the availability of technical work, we found from the documentation that in general three factors (technical work, internal documentation, and additional procedures) have a very significant effect on the dependent variable (patient reception). The time spent for the additional inspection of patients seems to contribute to a more rapid and faithful inspection of results and reduce the patient reception time. On the other hand, the presence of technical work and documentation processing contributes to increasing the reception duration for GP doctors.

 

CONFLICT OF INTEREST:

The authors declare no conflict of interest.

 

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Received on 27.12.2018          Modified on 21.01.2019

Accepted on 28.02.2019        © RJPT All right reserved

Research J. Pharm. and Tech. 2019; 12(5):2283-2288.

DOI: 10.5958/0974-360X.2019.00381.0