Am I productive? A triad of system barriers

A recent twitter posting prompted a discussion which took on a number of directions

The resulting discussion can be found here. The concept of productivity caused me reflection during and after the twitter chat; in particular on the theme of individual performance.

Obviously in the big scheme of things the number of patients I see on any given shift has absolutely no bearing on the overall productivity of the NHS. But is my own work rate or output in any way correlated? And more importantly are the metrics themselves even comparable?

What is productivity? Wikipedia describes it as thus:

Productivity is a measure of the efficiency of production. Productivity is a ratio of production output to what is required to produce it (inputs). The measure of productivity is defined as a total output per one unit of a total input.

Is this in anyway meaningful for the health sector? The Kings Fund (@thekingsfund) give a range of possibilities but I am still left asking: Am I productive?

I think back to my last weekend shift. I work in a busy Paediatric Emergency Department which links to a tertiary children’s hospital. I think of myself as having been productive if I see x number of patients (for me x is 20 but I am not sure the number is transferrable as a comparison measure). Although the actual case-mix is very variable virtually every weekend contains a number of specific events/presentations which has a large bearing on my self-productive rating (and sense of achievement by the end of the shift).

  • The state of the department prior to my arrival. A weekend shift runs from 12pm-10pm and there is a back log of reviews to clear (I am a relatively senior registrar) even before I can see new patients. Any productivity I bring in respect of patient decisions or interventions is not additional benefit it is based on prior inputs (or patient presentations in a health care sense) to my arrival. Is it efficient to potentially reduce my de novo productivity at the outset of my shift? 
  • The number of emergency cases (defined as patients requiring immediate, potentially life saving, intervention). A prolonged resuscitation requires multiple resources and, regardless of the efficiency of the team, drains time from seeing other patients.
  • The number of complex non-emergency dischargeable (CoNED) cases (bear with me on this…). Appreciating the subjective nature of ‘complex’ these are cases which do not immediately  fit a pattern which an experienced health care professional would recognise.  I suppose it is self evident that lots of complex cases will require more time and therefore less patient turnover per clinician. However in an emergency department once it is clear a patient needs to be admitted you become less productive if you spend effort utilising resources that could be done by the inpatient team. Conversely from a patient perspective there are some investigations or managements if commenced early save time later in the patient journey. So there is a balance between ‘fast tracking’ and the overall length of stay. Additionally you must also have insight that this is a complex case; often reviews on patients on behalf of juniors reveal patients who were thought not be complex but in fact are (and vice-versa!). Ultimately the ability to manage a complex case requiring admission is a skill which improves with experience and I am not sure affects my overall productivity . However if a complex patient does not need to be in hospital this may be particular time leeching. From a 4 hour target perspective (see @drmarknewbold‘s brilliant blog on this) it may well be easier to admit but this is not always in the patients best interest. The number of CoNEDs is in part a function of the success of modern medicine and the ability of health services to provide effective and prompt follow-up.

I am very happy to concede that the number of patients seen is not a brilliant metric for productivity and that emergency medicine is only a small part of the NHS workload. I believe, the triad of, the current capacity of system, the number of serious cases and the number of complex cases not requiring referral to another provider is an important factor in determining productivity. The solution therefore may not depend on the individual. That will certainly not stop me working very hard to get x as high as it safely can be.

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