How a new administrative role is helping improve patient care

The increasing complexity of acute medical care has created a significant administrative burden for acute medical units (AMUs), much of which has traditionally been undertaken by junior doctors. This has become a common cause for concern for medical trainees and University Hospital Southampton Foundation Trust sought to address the problem by creating a ”doctors’ administrator” role (DA). 

The first of its kind in the UK, this role attempts to increase the amount of time available for junior medical staff to spend with patients. It was of particular importance to University Hospital Southampton FT that the doctors’ assistants worked on a seven day basis to support the unit during busy weekend periods. 

Administrative load

The development of electronic discharge summaries and ward round check lists have been shown to improve quality of documentation, but can also contribute to this administrative load. This, in turn, may delay the clinical assessment of patients.

Extra time taken by junior doctors doing this type of administrative work means that less time is available for patients and clinical duties. 

”It focused on the administrative tasks which could be completed by an administrative lead”

In order to address this, some AMUs have appointed physician associates (PAs) or emergency nurse practitioners (ENPs) to undertake roles such as history taking, clinical examination and practical procedures. Such roles may have a key role to play in future delivery of the service on AMU; however, the lag time for training and current recruitment challenges means that such roles are not likely to provide an immediate seven day solution to this problem.

University Hospital Southampton FT sought a more immediate solution to these challenges by focusing on the administrative tasks which could be completed by an administrative lead rather than the medical staff.

On 31 December 2014, three whole time equivalent, band 3 level staff were recruited to the DA role to provide a seven day service from 8am-6pm.

Two of the doctors’ administrators were scheduled to be present on the AMU ward during each weekday and one was scheduled to work weekends. Prospective cover for leave and sickness was also planned for.

Two of those appointed had previously worked for UHS as ward-clerks – one had also been a health care assistant at the trust. The third appointee had a purely administrative background outside the health service. 

Training

All appointees undertook a six week period training which included a medical terminology course. A competency framework was also agreed with the lead AMU consultant and their competencies assessed by the divisional clinical lead.

As part of this competency framework, the DAs had to be closely supervised by an experienced clinician when training and completing electronic discharge summaries (EDS).

A senior AMU consultant also acted as mentor to the DAs following their appointment, meeting regularly to discuss any challenges they encountered during their working practice.

“As our systems have become more efficient, the proportion of patients discharged directly from the AMU has risen progressively”

Each day the DAs attend morning post-take ward rounds (PTWR) which includes the completion of a checklist. Following this they complete discharge summaries for any patient to be discharged directly from the AMU.

Any results unavailable at the time of PTWR are followed up by the assistants and passed to medical staff for action.

Other duties undertaken include equipment stocking of the procedure room and data collection for audits conducted on the AMU.

All of the above tasks would previously have been performed by junior medical staff, who now have significantly more time to spend on clinical duties. 

Benefits of the role

During May-July 2015 an evaluation of the AMU service at the trust was undertaken. During this period, a total of 777 electronic discharge summaries (EDS) were completed by the DAs.

All summaries were checked and signed by one of the doctors on the AMU and discussions with the doctors indicate that the quality of information given by the DAs was high, with very few requiring amendment to be made prior to signing.

As our systems have become more efficient, the proportion of patients discharged directly from the AMU has risen progressively, exceeding 40 per cent over the past six months. This means that the numbers of EDS which need to be completed have increased.

The timely completion of these discharge summaries was necessary to maintain patient flow, but was also taking medical staff away from essential clinical duties. Creating this administration role tackles the issue head on. 

No significant errors

Previous observation of junior doctors on the AMU has demonstrated that an electronic discharge summary will take 15 minutes to complete, excluding the prescription of take home medication. So by taking on this task the DAs have potentially saved over 16 hours of time per week for the medical staff, which can therefore be invested in providing direct clinical care for patients.

This has been reflected in reduced time from admission to medical review for patients referred directly to our AMU, during the evaluation period, compared to the same period last year. Although the cost of mistakes made in discharge summaries was a potential risk, a monthly audit of forms completed by the DAs revealed that no significant errors or inaccuracy had led to a loss of income.

As it stands the DAs do generally spend more time completing an EDS compared to the junior doctors (30 minutes vs 15 minutes on average). This is primarily due to lack of familiarity with medical terminology. However, the DAs are already showing progess and it is anticipated that this will improve further as they become more experienced and familiar with the terminology.

”The DAs also tend to have more time to devote to searching through the notes to identify relevant co-morbidities and secondary diagnoses”

Although there is a cost attached to creating this role, University Hospital Southampton FT found that the estimated cost of £80,000 per annum for a seven day service was considerably less than would have been had the trust hired PAs or ENPs, who are usually appointed at band 6 or 7. Also by having the DAs operate on a seven day basis the trust is able to ensure consistency during weekend periods when the AMU is often the busiest. 

The DAs also tend to have more time to devote to searching through the notes to identify relevant co-morbidities and secondary diagnoses. Previous internal audit had identified significant income loss to our organisation of up to £10,000 per month due to inadequate information being included on EDS following discharge from AMU; this was a key factor in justifying the costs of these new roles.

In a short space of time, the doctors’ administrators at University Hospital Southampton FT have become integral and valued members of the multiprofessional team on AMU, supporting medical staff by undertaking a range of administrative tasks. This has enabled junior doctors to focus more on their clinical duties, which are essential to their training and experience on the AMU. 

Dr Juliane Kause is consultant physician and divisional lead and Caroline Smith is clinical services manager, University Hospital Southampton FT. Dr Chris Roseveare is consultant in acute and general medicine and a former consultant at Southampton