Original article

Work-Time Distribution of Physicians at a German University Hospital

Dtsch Arztebl Int 2017; 114(42): 705-11; DOI: 10.3238/arztebl.2017.0705

Wolff, J; Auber, G; Schober, T; Schwär, F; Hoffmann, K; Metzger, M; Heinzmann, A; Krüger, M; Normann, C; Gitsch, G; Südkamp, N; Reinhard, T; Berger, M

Background: The effective utilization of staff resources is of decisive importance for the adequate, appropriate, and economical delivery of hospital services. The goal of this study was to determine the distribution of working time among doctors in a German university hospital—in particular, in terms of type of activities and time of day.

Methods: The distribution of working time was determined from 14-day samples taken in seven clinical departments of the Medical Center—University of Freiburg. In each 14-day sample, the activities being carried out at multiple, randomly chosen times were recorded.

Results: A total of 250 doctors (participation rate: 83%) took part in the study. A total of 20 715 hours of working time was analyzed, representing twelve years of full-time employment. Overall, 46% of working time in the inpatient sector was spent in direct contact with patients, with relevant differences among the participating clinical departments: for instance, the percentage of time taken up by patient contact was 35% in pediatrics and 60% in oral and maxillofacial surgery. Patient contact was highest (over 50% overall) in the period 8 a.m. to 12 noon.

Conclusion: The amount of working time taken up by activities other than direct patient contact was found to be lower than in previous studies. It remains unclear what distribution of working time is best for patient care and whether it would be possible or desirable to increase the time that doctors spend in direct contact with patients.

Personnel costs account for around 60% of total expenditure in German hospitals (1). Effective deployment of staff is crucial if a hospital is to function effectively and economically. This becomes particularly relevant in times of shortage of qualified medical personnel (2, 3) and the kind of financial constraints currently prevailing in many institutions (4).

In the setting of industrial production, the importance of studies investigating the time spent working has decreased sharply, owing to the minimization of variance in resource consumption by standardization and automation (5). In contrast, many hospital processes can be neither standardized nor automated, among other reasons because the needs of an individual patient are hard to predict (see [6]).

Organization theory usually describes two methods for investigating work-time:

  • In the method of continuous observation, the activities of the staff members concerned are recorded without interruption (7). This almost always means that the staff under investigation are continuously accompanied by another person. An advantage of this technique is that detailed information on the type and duration of the various tasks can be documented (8). Disadvantages are the high cost and the impracticality of surveying the work of a large number of people.
  • In the method of work sampling, a sample of activities is used to estimate the overall distribution of work-time (9). The samples are taken at random times to avoid distortions due to temporal patterns. The proportions of total working time taken up by various individual tasks and the statistical confidence levels are calculated from a sample with an assumed random distribution. The technique was developed in the 1930s for use in industrial production processes (9) and has become an acknowledged method for the measurement of working time in the hospital setting (1016). Reviews of studies on physicians’ (17) and nurses’ (18) workloads show, however, that this method has not so far been widely used in European hospitals.

Valid data on the distribution of work-time are necessary for assessment of whether highly qualified medical personnel are being deployed effectively and in accordance with their competencies. One aspect that has been a focus of public debate is the amount of working time that medical staff spend not in direct contact with patients, e.g., completing obligatory documentation (19).

This article presents the results of a study carried out in various departments of the Medical Center—University of Freiburg from June 2013 to October 2016. The goal of the study was to establish the prevailing work-time distribution of physicians in different disciplines in terms of tasks and times of day. Specifically, we wanted to investigate what proportion of working time was dedicated directly to patients and how much time was spent on other activities. Some of the results from individual departments have already been published in scientific journals (2022), but this is the first presentation of the overall findings. No study of this type and size has previously been carried out in the German-speaking countries.

Methods

The component studies in seven individual departments of the hospital were each carried out over a period of two weeks. A portable device emitted an acoustic and visual signal at random times within 30-minute periods. Every time the signal went off, the participants noted where they were and what they were doing. The study covered the whole work-time of all clinically active staff members. Night shifts were excluded. Table 1 shows how the different tasks were classified. A more detailed description of the methods can be found in the eBox.

Classification of types of activities
Table 1
Classification of types of activities
Methods
eBox
Methods

Results

Table 2 shows the departments that partipicated in the study with the numbers of staff, observations, and working hours covered. A total of 41 430 observations were recorded, corresponding to 20 715 hours of work or 12 net work-years. Overall, 83% of the physicians in the seven departments took part in the study. The participating physicians showed almost the same distribution into interns (45%), qualified specialists (24%), and senior physicians/department heads (31%) as all physicians employed in the departments concerned (43%, 26%, and 31% respectively).

Numbers of participants, observations, and working hours in each department
Table 2
Numbers of participants, observations, and working hours in each department

Table 3 presents the amount of time spent on the various types of tasks by the doctors in each discipline. The figures include both persons with varying tasks and workplaces and those who, for example, worked only with outpatients. Overall, direct inpatient care took up 24% of the physicians’ time. Indirect inpatient care and general tasks related to inpatients together acounted for 28% of the total time. Activities related to outpatients occupied one third of total work-time. This included all work carried out for the benefit of these patients, i.e., direct care, indirect care, and general clinical tasks. Outpatient work was excluded from the following analyses so as to examine inpatient activity in detail. The remaining 13% of the physicians’ working time were spent on “other activities,” e.g., research, teaching, moving from place to place, and breaks.

Distribution of the physicians’ total working time (%) with 95% confidence intervals
Table 3
Distribution of the physicians’ total working time (%) with 95% confidence intervals

Figure 1 illustrates the distribution of the three types of inpatient-related activities in the various departments. Overall, tasks involving direct contact with patients occupied most time (46%). However, more than half of the total time was occupied with activities not involving the patient, i.e., indirect care and general tasks. The disciplines varied in the proportions of time spent on the three kinds of activities. While direct patient care took up only 35% of the total time in the Center for Pediatrics, the corresponding figure in the Department of Oral and Maxillofacial Surgery was 60%. It should be noted that the overall distributions were calculated as the weighted mean of the values in the individual disciplines on the basis of the number of observations. The overall data thus depended on the size of the individual departments.

Distribution of inpatient work-time in the participating departments
Figure 1
Distribution of inpatient work-time in the participating departments

Figure 2 shows the distribution of inpatient-related activities over the course of the working day. The time spent on direct care was highest between 08:00 and 12:00, at well over 50%. This fell to around one third between 16:00 and 18:00. The proportion of time devoted to indirect patient care, i.e., tasks such as documentation and writing discharge letters, was about one quarter between 08:00 and 10:00 and increased during the day to about 40% from 16:00 onwards. The amount of time occupied by general ward activities was usually inversely related to direct patient care, i.e., it went down at times of intensive direct care and rose at less intensive times.

Distribution of inpatient work-time at different times of day with 95% confidence intervals
Figure 2
Distribution of inpatient work-time at different times of day with 95% confidence intervals

A portion of the multimoment work sampling findings could be validated using a second data source. In the Department of Psychiatry and Psychotherapy, the exact times at which individual and group therapy sessions began and ended were documented in the electronic records, and the definition of one subcategory of direct care corresponded precisely with these sessions.

Analysis of the multimoment data revealed that over a 7-day week the mean daily duration of individual and group therapy measures per patient was 8.11 min/day (95% confidence interval [95% CI] 6.98–9.39 min). This was calculated by dividing the total time per day by the number of patients and included only sessions lasting at least 25 min, as only these were documented in the electronic record for billing purposes. Other treatments by, for example, psychologists or nurses were not included.

The overall treatment times documented in the electronic records came to 8.24 min per patient and day. While the multimoment samples show the time distribution during the 14-day study phase, the electronic records for a whole calendar year were evaluated to establish how accurately the samples reflected the situation over a longer period. The differences between the multimoment findings and the electronic records were neither statistically significant nor substantial in economic terms. It is uncertain, however, to what extent the results might apply to other types of activities or other departments or hospitals.

Discussion

The aim of this study was to ascertain how hospital physicians’ work-time is divided among different tasks and different locations. Overall, 46% of inpatient working time was spent in direct contact with patients. More than half of doctors’ inpatient work-time was occupied by tasks carried out away from the patients. The amount of time taken up by direct patient care varied from 35 to 60% among the disciplines studied.

Results in comparison with earlier studies

Our results can be compared with those of earlier studies. In 2010, Tipping et al. published a systematic review of the literature on empirical real-time analyses of hospital physicians’ work-time distribution (17). They found 11 studies with sometimes inconsistent definitions of tasks in direct contact with the patient, only one of which was carried out in a German-speaking country (Austria [23]). The majority of the studies examined found much lower proportions of time spent on direct patient care than in our data. This discrepancy may result from differences in clinical practices between Germany and the countries in which the studies identified by Tipping et al. were performed. Another possible reason is that eight of the studies were over 20 years old; the most recent was published in 2009. Trends such as consolidation of services, shorter hospital stays, and more diagnostic and therapeutic procedures per unit of time therefore could not be taken into account. Moreover, there were differences in the methods of data acquisition. For example, only three of the studies reviewed used the multimoment work sampling method. In all others, the physicians’ activities were documented continuously.

In a study published in 2002, Blum and Müller (24) investigated the amount of time spent on documentation by 1010 hospital physicians. The data were acquired by means of a questionnaire, rather than empirically in real time. For surgeons, documentation took up an average 162 minutes each day (34% of an 8-h shift), while internists needed 195 min /day (41%). As mentioned by the authors, however, doctors’ work shifts are often longer than 8 hours. Also for this reason, Blum and Müller’s data are not directly comparable with ours. Furthermore, in our study the time spent on documentation was not recorded specifically; rather, it was subsumed in the category of tasks without the direct presence of the patient.

Limitations

One strength of the study we present here is its wide scope. With 250 participating hospital physicians and a cumulative observation time of 12 net work-years, it has no precedent in the German-speaking countries. A limitation of the study is the relatively restricted depth of detail of the data acquired. For the sake of clarity and ease of handling, it was necessary to aggregate the types of activities in all participating departments into five categories. This enabled the study question to be adequately addressed and meant that the methods could be generically designed and readily explained.

There are three further potential limitations of internal validity that have to be heeded in all empirical realtime analyses. First, the study period is not necessarily representative for future time points when decisions have to be made. We countered this limitation by selecting study periods in which no unusual circumstances, e.g., vacation time or congresses involving absence of a significant number of medical staff, were anticipated. After the observation period, we asked the participants whether there had been any unusual circumstances during the survey. This questioning revealed an unusually high level of sickness among the staff of the Department of Dermatology and Venereology, prompting us to repeat the study there.

Second, participation in the study was voluntary and not all physicians wanted to or could take part. The work-time distribution of those who took part may have differed from the non-participants. However, with regard to the comparably large number of physicians involved, the participation rate was relatively high (83%). Moreover, we achieved an adequate cross-section of interns, qualified specialists, senior physicians, and department heads.

The third potential limitation of internal validity can be caused by the Hawthorne effect (25, 26). This is the tendency for people to change the way they behave when they know they are participating in a study. To minimize the Hawthorne effect, the data were rendered strictly anonymous, the clinical staff in each department were involved in the planning of the study at an early stage, and all participants were clearly informed about the aims of the study and the methods, specifically the guaranteed anonymity.

Furthermore, the results of our study cannot necessarily be generalized to all hospital services in Germany. Although we succeeded in including a relatively broad spectrum of disciplines the study was restricted to the Medical Center—University of Freiburg, so in particular it is unclear to what extent the findings apply to institutions that are not connected with a university.

Implications

No consensus has yet explicitly been reached, either for specific medical disciplines or in general, on how physicians’ time should be divided among various types of tasks to achieve optimal patient care. It has been shown, however, that lack of time for direct patient contact is a major cause of job dissatisfaction for hospital doctors (27, 28). Especially dissatisfaction with the burden of administrative tasks and documentation is an important contributor to work-related stress and emotional exhaustion (29). Furthermore, hospital patients subjectively place a high value on physicians having sufficient time for ward rounds and personal discussions, but are often dissatisfied with the amount of time dedicated to them (30). From the aspect of health care economics, there are signs that if physicians spend insufficient time with individual patients the result may be excessive use of referrals to specialists and of diagnostic and therapeutic procedures, thus leading to an overall increase in health care expenditure (31).

Current social trends mean that doctors’ work-time will become a scarcer resource in the foreseeable future. Demographic developments will augment the lack of physicians (32). A change in patients’ attitude will necessitate more involvement of patients and their relatives in medical decision-making (33, 34). At the same time, doctors’ own expectations are changing; they are increasingly demanding flexible working hours and a better balance between work and leisure time (35, 36). Furthermore, the amount of medically and legally required documentation has been steadily expanding for some time (37). Against the backdrop of these social developments, effective use of physicians’ work-time will become even more important in the future.

Conclusion

The study presented here has shown empirically that only a relatively small proportion of hospital physicians’ work-time is available for direct care, confirming the subjective impression of doctors themselves and their patients. More time for direct care can be created only by reducing other duties. Physicians’ work activities should correspond to their qualifications. Non-medical tasks should be carried out to a greater extent by appropriate staff, e.g., documentation assistants, medical controllers, and social workers. The constant increase in obligatory documentation by physicians should be halted or restricted to what is absolutely necessary. This would have positive effects for hospital patients, their doctors, and the health care system as a whole.

Conflict of interest statement

The authors declare that no conflict of interest exists.

Manuscript submitted on 21 February 2017, revised version accepted on
26 June 2017

Translated from the original German by David Roseveare

Corresponding author
Dr. Jan Wolff

Zentrum für Psychische Erkrankungen (Department)

Klinik für Psychiatrie und Psychotherapie,
Universitätsklinikum Freiburg

Hauptstr. 5,
79104 Freiburg, Germany

jan.wolff@uniklinik-freiburg.de

Supplementary material
eBox:
www.aerzteblatt-international.de/17m0705

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Department of Psychiatry and Psychotherapy, Medical Center—University of Freiburg, Faculty of Medicine, University of Freiburg, Germany: Dr. Wolff, Prof. Normann, Prof. Berger
Evangelical Foundation Neuerkerode, Braunschweig: Dr. Wolff
Central Reporting Unit, Medical Center—University of Freiburg, Germany: Gerd Auber, Tobias Schober, Felix Schwär
Department of Dermatology and Venereology, Medical Center—University of Freiburg, Faculty of Medicine, University of Freiburg, Germany: Dr. Hoffmann
Department of Gynecology, Medical Center—University of Freiburg, Faculty of Medicine, University of Freiburg, Germany: Prof. Gitsch
Oral and Maxillofacial Surgery, Medical Center—University of Freiburg, Faculty of Medicine, University of Freiburg, Germany: Prof. Metzger
Center for Pediatrics, Medical Center—University of Freiburg, Faculty of Medicine, University of Freiburg, Germany: Prof. Heinzmann
Department of Neonatology, Städtische Kliniken München GmbH: Prof. Krüger
Department of Orthopedics and Trauma Surgery, Medical Center—University of Freiburg, Faculty of Medicine, University of Freiburg, Germany: Prof. Dr. med. Südkamp
Eye Center, Medical Center—University of Freiburg, Faculty of Medicine, University of Freiburg, Germany: Prof. Reinhard
Distribution of inpatient work-time in the participating departments
Figure 1
Distribution of inpatient work-time in the participating departments
Distribution of inpatient work-time at different times of day with 95% confidence intervals
Figure 2
Distribution of inpatient work-time at different times of day with 95% confidence intervals
Key messages
Classification of types of activities
Table 1
Classification of types of activities
Numbers of participants, observations, and working hours in each department
Table 2
Numbers of participants, observations, and working hours in each department
Distribution of the physicians’ total working time (%) with 95% confidence intervals
Table 3
Distribution of the physicians’ total working time (%) with 95% confidence intervals
Methods
eBox
Methods
1. Statistisches Bundesamt. Gesundheit – Kostennachweis der Krankenhäuser – Fachserie 12 Reihe 6.3 [Internet] 2015. www.destatis.de/DE/Publikationen/Thematisch/Gesundheit/Krankenhaeuser/KostennachweisKrankenhaeuser.html. (last accessed on 7 June 2017)
2. Blum K, Löffert S: Ärztemangel im Krankenhaus – Ausmaß, Ursachen, Gegenmaßnahmen – Forschungsgutachten im Auftrag der Deutschen Krankenhausgesellschaft. Deutsches Krankenhausinstitut 2010.
3. Buxel H: Krankenhäuser: Was Pflegekräfte unzufrieden macht. Dtsch Ärztebl 2011; 108: A 946–8.
4.Berger R: Krankenhausrestrukturierungsstudie 2016. www.rolandberger.com/de/Publications/pub_krankenhaus_restrukturierung_2016.html. (last accessed on 7 June 2017)
5. Fehrle M, Michl S, Alte D, Götz O, Fleßa S: Time studies in hospitals. Gesundheitsökonomie Qual 2013; 18: 23–30.
6. Amalberti R, Auroy Y, Berwick D, Barach P: Five system barriers to achieving ultrasafe health care. Ann Intern Med 2005; 142: 756–64 CrossRef
7. Barnes RM: Motion and time study. New York: Chapman and Hall; 1937.
8. Finkler SA, Knickman JR, Hendrickson G, Lipkin M, Thompson WG: A comparison of work-sampling and time-and-motion techniques for studies in health services research. Health Serv Res 1993; 28: 577–97 MEDLINE PubMed Central
9. Tippett LHC: Statistical methods in textile research. Part 3—a snap-reading method of making time-studies of machines and operatives in factory curveys. J Text Inst Trans 1935; 26: T51–70 CrossRef
10. Campbell JK, Ortiz MV, Ottolini MC, Birch S, Agrawal D: Personal digital assistant-based self-work sampling study of pediatric interns quantifies workday and educational value. Acad Pediatr 2017; 17: 288–95 CrossRef MEDLINE
11. Roche MA, Friedman S, Duffield C, Twigg DE, Cook R: A comparison of nursing tasks undertaken by regulated nurses and nursing support workers: a work sampling study. J Adv Nurs 2017; 73: 1421–32 CrossRef MEDLINE
12. Schuld J, Bobkowski M, Shayesteh-Kheslat R, Kollmar O, Richter S, Schilling MK: Benchmarking surgical resources—a work sampling analysis at a German university hospital. Zentralblatt für Chir 2013; 138: 151–6 MEDLINE
13. Myny D, Van Goubergen D, Limère V, Gobert M, Verhaeghe S, Defloor T: Determination of standard times of nursing activities based on a nursing minimum dataset. J Adv Nurs 2010; 66: 92–102 CrossRef MEDLINE
14. Radcliffe J, Smith R: Acute in-patient psychiatry: how patients spend their time on acute psychiatric wards. Psychiatr Bull 2007; 31: 167–70 CrossRef
15. de Keizer NF, Bonsel GJ, Al MJ, Gemke RJ: The relation between TISS and real paediatric ICU costs: a case study with generalizable methodology. Intensive Care Med 1998; 24: 1062–9 CrossRef
16. Bee PE, Richards DA, Loftus SJ, et al.: Mapping nursing activity in acute inpatient mental healthcare settings. J Ment Health 2006; 15: 217–26 CrossRef
17. Tipping MD, Forth VE, Magill DB, Englert K, Williams MV: Systematic review of time studies evaluating physicians in the hospital setting. J Hosp Med Off Publ Soc Hosp Med 2010; 5: 353–9 CrossRef
18. Blay N, Duffield CM, Gallagher R, Roche M: Methodological integrative review of the work sampling technique used in nursing workload research. J Adv Nurs 2014; 70: 2434–49 CrossRef MEDLINE
19. Müller K, Blum U: Krankenhausärzte: Enormer Dokumentationsaufwand. Dtsch Arztebl 2003; 100: A-1581 VOLLTEXT
20. Wolff J, McCrone P, Patel A, Auber G, Reinhard T: A time study of physicians’ work in a German university eye hospital to estimate unit costs. PLoS One 2015; 10: e0121910 CrossRef MEDLINE PubMed Central
21. Wolff J, McCrone P, Berger M, et al.: A work time study analysing differences in resource use between psychiatric inpatients. Soc Psychiatry Psychiatr Epidemiol 2015; 50: 1309–15 CrossRef MEDLINE
22. Wolff J, McCrone P, Patel A, Normann C: Determinants of per diem hospital costs in mental health. PLoS One 2016; 11: e0152669 CrossRef MEDLINE PubMed Central
23. Ammenwerth E, Spötl HP: The time needed for clinical documentation versus direct patient care. A work-sampling analysis of physicians’ activities. Methods Inf Med 2009; 48: 84–91 MEDLINE
24. Blum K, Müller U: Dokumentationsaufwand im Ärztlichen Dienst der Krankenhäuser – Repräsentativerhebung des Deutschen Krankenhausinstituts. Krankenh 2003; 7: 544–8.
25. Hart CWM: The Hawthorne experiments. Can J Econ Polit Sci 1943; 9: 150–63 CrossRef
26. Parsons HM: What Happened at Hawthorne? New evidence suggests the Hawthorne effect resulted from operant reinforcement contingencies. Science 1974; 183: 922–32 CrossRef MEDLINE
27. Buxel H: Arbeitsplatz Krankenhaus: Der ärztliche Nachwuchs ist unzufrieden. Dtsch Arztebl 2009; 106: A-1790 VOLLTEXT
28. Merz B, Oberlander W: Ärztinnen und Ärzte beklagen die Einschränkung ihrer Autonomie. Dtsch Arztebl 2008; 105: A-322–4 VOLLTEXT
29. Tanner G, Bamberg E, Kozak A, Kersten M, Nienhaus A: Hospital physicians’ work stressors in different medical specialities: a statistical group comparison. J Occup Med Toxicol 2015; 10: 7 CrossRef MEDLINE PubMed Central
30. Möller-Leimkühler AM, Dunkel R: Zufriedenheit psychiatrischer Patienten mit ihrem stationären Aufenthalt. Nervenarzt 2003; 74: 40–7 CrossRef MEDLINE
31. Sirovich BE, Woloshin S, Schwartz LM: Too little? Too much? Primary care physicians’ views on US health care. Arch Intern Med 2011; 171: 1582–5 CrossRef MEDLINE PubMed Central
32. Heinrich D, Löhler J: Auswirkungen aktueller Trends in Gesellschaft, Medizin und Politik auf die Zukunft der HNO-Heilkunde. HNO 2016; 64: 213–6 CrossRef MEDLINE
33. Bergelt C, Scholl I, Härter M: Chancen und Barrieren partizipativer Entscheidungsfindung in der Onkologie. Forum 2016; 31: 140–3 CrossRef
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