ABSTRACT The study analysed time utilization by a sample of 111 physicians, nurses and midwives in 62 primary health care facilities in Jordan. The providers’ activity over each shift was coded at 3-minute intervals using an activity sampling technique and patient–provider contact times were recorded. Overall, health providers spent the nearly half their time (48.7%) as ‘down time’ (waiting, breaks and non-work related activities), with 29.1% as clinical activities and 22.1% as non-clinical work-related activities. Physicians had higher clinical and down times than nurses and midwives; waiting for patients accounted for half the down time. The mean physician–patient contact time was 3.08 minutes. An appointment system is recommended to reduce down times for health providers and increase consultation times.

RESUME Cette étude a analysé l’utilisation du temps par un échantillon de 111 médecins, infirmières et sages-femmes dans 62 établissements de soins de santé primaires en Jordanie. L’activité des prestataires durant chaque période de travail successive a été codée à des intervalles de 3 minutes à l’aide d’une technique d’échantillonnage des activités et le temps de contact entre le patient et le prestataire a été enregistré. Globalement, près de la moitié du temps (48,7 %) des prestataires de santé était un « temps d’inactivité » (attente, pauses et activités non liées au travail), 29,1 % de leur temps étant consacré à des activités cliniques et 22,1 % à des activités non cliniques et non liées au travail. Les médecins avaient un temps clinique et un temps d’inactivité plus élevés que les infirmières et les sages-femmes ; le temps passé à attendre les patients représentait la moitié du temps d’inactivité. Le temps de contact moyen du médecin avec le patient était de 3,08 minutes. Un système de fixation de rendez-vous est recommandé pour réduire le temps d’inactivité des prestataires de santé et augmenter le temps de consultation.

In 1998, the population of Jordan was estimated at 4.755 million [1]. In the same year, Jordan spent approximately JD 454 million (US$ 647 million) on health care services [2] which represents 9.12% of the gross domestic product. Per capita health care expenditure was approximately JD 94 (US$ 132) [2].

A comprehensive study, ‘Rationalizing staffing patterns and cost analysis of primary health care services’ was carried out in the year 2000 to assist the Jordanian Ministry of Health (MOH) in making more efficient use of available resources by identifying and analysing staffing patterns, as well as estimating and analysing the various economic and financial costs of providing services.

The objectives of this study were to analyse time utilization in primary health care by type of provider, activity, type of facility and patient volume at facilities; and measure the characteristics of provider– patient contact.

MOH primary health care facilities in Jordan are divided into 3 categories: village clinics, primary health care centres (PHCs) and comprehensive health centres (CHCs).

The village clinic is located in a single room and a provider, usually a physician from a PHC, visits on scheduled days. A male nursing-aide assigned permanently to the clinic informs the local community of the clinic hours and organizes the waiting list for patients. The clinic also provides the necessary drugs.

The PHC offers general practice and maternal and child health care provided by physicians, nurses and a midwife. Administration is usually performed by the physician and a secretary, with patient-based manual medical records. The most important functions of the PHC are immunization, dental care provided by a dentist and a pharmacy which supplies the most important drugs, usually according to World Health Organization recommendations.

The CHC is the highest level facility in the primary health care service, staffed by several physicians, nurses including midwives and an administration team including accounting and secretarial personnel, with a family-based manual record system. In addition to general medicine and family medicine, the CHC offers emergency services including minor surgery and specialty services provided by MOH specialists either on a permanent basis in the centre or on a rotational basis. The emphasis is on immunization, dental services, pharmacy, laboratory services and radiology.

For this study, facilities were categorized into 3 groups: low, medium and high volume based on the total number of patients seen in that year in all MOH primary health care facilities. Facilities with a number of patient visits below the 33rd and above the 66th percentiles were considered low and high volume respectively, while those falling between the 33rd and 66th percentiles were considered medium volume facilities.

The study sample was selected in simple random fashion using SPSS version 7.5 software, taking into consideration 2 variables: volume of patients (high, medium and low) and geographic distribution. The number of facilities selected out of the total of MOH primary health care facilities was 62: 12 CHCs (out of 42) and 50 PHCs (out of 336). Village clinics were excluded from this study since the services of the providers is intermittent and is supplied by the PHCs. However, village clinics were included in another paper about staffing costs [3].

A list of providers working in the sampled facilities was provided by MOH. From this list, a random sample of 111 providers was selected to be observed, representing all categories of personnel included in the study: physicians, registered nurses, practical nurses and midwives.

A separate record was made of each contact with a patient: the start time, end time, visit type (see Table 1) and code.

To minimize inter-observer bias, and to verify and correct any mistakes in coding, one physician reviewed all forms to ensure that the final coding of activities was uniform and correct.

Analysis of results was carried out by using the SPSS-X statistical package. Analysis of variance (ANOVA) was used to assess, at the 95% confidence level, the statistical significance of differences between groups.

Overall, health providers spent nearly half their time as down time (48.7%), with 29.1% as clinical time and 22.1% as non-clinical time.

Down time was higher in PHCs than CHCs (50.1% versus 43.5%) (Table 2). The two highest components, ‘waiting for patients’ and ‘left the shift early’ were higher in PHCs than CHCs. Down time was the highest in low volume facilities (52.3%), followed by medium and high volume facilities (50.8% and 42.9% respectively). ‘Waiting for patients’ was the highest category of down time in medium volume facilities, followed by high and low volume facilities. Again, ‘left the shift early’ was highest in low volume facilities, followed by high volume and medium volume facilities in that order.

Table 4 shows the mean contact time per patient by provider, type of facility and patient volume of facility. Midwives and nurses had significantly higher mean contact time per patient than did physicians (5.93 and 5.12 min respectively versus 3.08 min). The mean contact time between patient and provider was higher in CHCs than PHCs (4.00 versus 3.60 min), and higher in facilities with a low volume of patients than those with a high volume of visits (4.85 versus 3.22 min).

Excess service capacity can be measured through standard time–motion studies, provider interviews, patient flow analysis, self-administered timesheets and activity sampling technique [4]. Even though activity sampling is resource-intensive and requires skilled staff, it was chosen for this study as it was considered to be the most accurate and objective method [4,5]. Due to the intrusive nature of the observation of providers of care for lengthy periods, we were unable to assess the extent of variability between the field workers. However, variability is likely to be low because of the objective nature of the codes. For example, an observer might record that the provider was consulting with a colleague about a patient; they were not required to judge the outcome of the conversation or whether the consultation was needed.

One of the most important findings of this study was the high proportion of service providers’ time (almost half overall) that was down time. This varied by type of facility and provider. In PHCs, physicians’ down time accounted for more than 55% of their observed time, with only 30% of time on clinical activities, whereas in CHCs they spent 42% of their observed time on clinical activities. In CHCs and PHCs, nurses spent only about one-quarter of their time on clinical activities, whereas in CHCs midwives spent almost 40% of their time on clinical activities. As to type of facility, down time was higher in PHCs than CHCs. The two highest components, ‘waiting for patients’ and ‘left shift early’ were higher in PHCs than CHCs.

The overall down time of providers was inversely related to the volume of patients attending the facility. When analysed in more detail, ‘waiting for patients’ was the highest in medium volume facilities, followed by high and low volume facilities. Again, ‘left shift early’ was the highest in low volume facilities, followed by high volume and medium volume facilities in that order. From all these results, it could be concluded that the flow of patients may be considered at the basis of all other down time components. Clinic hours are fixed by the MOH as 08.00–16.00 hours and we have reported that 90% of patients are seen in the morning between 9.00–12.00 hours [6]. A provider who does not have anything to do and remains idle is tempted to engage in activities not related to the functions of the job. It is unlikely that a provider would leave while there are patients still waiting to be seen.

Certain categories of down time are avoidable while others may be difficult to prevent. For all 3 categories of providers, waiting for patients was the highest component of down time, the second was leaving the shift early, which was highest among physicians, (28% their down time), whereas midwives and nurses appeared to be more observant of working hours. In theory, time wasted waiting for patients could be reduced by the adoption of an appointment system to spread clients across the day. Campbell has also shown that appointment systems correlate with higher client satisfaction [7]. In Jordan, however, there may be resistance from patients, because some of the medical conditions seen in primary health care centres are, or believed by patients to be, urgent in nature and therefore patients may not be willing to wait or ask for an appointment. The health-seeking behaviour and habits of Ministry of Health clients in Jordan need further exploration before adopting an across-the-board appointment system. One solution would be to offer both systems in parallel. In relatively large health centres where several general practice clinics are operating, an appointment system can work jointly with walk-in clinics. In high-volume facilities, special clinics (e.g. for diabetes) can be operated on an appointment basis. An appointment system may be more successful in specialty clinics and conditions of a non-urgent nature such as obstetrics, well baby, family planning, diabetes, hypertension and other chronic disease clinics.

It is noteworthy that during a 1-day shift, physicians had contact with a mean of 36 patients and spent a mean of 3.08 min with each patient. Nurses saw a mean of 11 patients during the day and spent 5.12 min with each. The midwife had contact with the smallest number of patients (10 per day) and spent the longest time (5.93 min) with each patient. It is seems likely that physicians’ contact time with patients is too short to reach an accurate diagnosis and provide appropriate treatment, instructions, health education and proper counselling [8].

The mean contact time between patient and provider was inversely proportionate to the volume of visits in the facility. Some types of services influence the length of contact time, especially when extensive explanations or examinations that take a long time to perform are needed [5]. Overall, contact times in primary care facilities in Jordan appear to fall short of the optimum for quality care. Howie et al. [9] have shown that, when compared with short consultations (5 minutes or less), long consultations (10 minutes or more) were associated with the doctors dealing with more of the patients’ psychosocial and long-term health problems, and carrying out more health promotion in the consultation. The same study also showed that patients reported greater satisfaction with longer consultations. In a survey of general practitioners in England, 72% believed that a longer time with patients would improve their standard of care and lower prescription rates [10]. A systematic review of average consultation length from studies covering the period 1966–99 concluded that when doctors spend more time with patients the consultation was more likely to include important elements of care [11]. Longer consultation times can be used to build a strong client–provider relationship, give clients time to ask questions and give providers an opportunity to educate their clients on pertinent issues.

Any change in the present primary care systems should concentrate on decreasing or eliminating the waiting time of the patients, increasing the contact time between the patient and provider and ensuring that all elements of patient satisfaction are met, especially allowing the patient to ask questions and the provider to explain the nature of the disease and its management [7]. However, changing the system does not ensure that either providers or patients will abide by the new rules. Thus, even if an appointment system is implemented which allocates a longer contact time, it is not guaranteed that a physician who is used to completing a visit within around 3 minutes will allocate 10 or 12 minutes to provide the patient with the necessary components of quality care. This may require continuous education of professionals and sometimes retraining in management procedures. At the same time, it is imperative to conduct an intensive educational campaign to change the behavioural pattern of the community in seeking health care.

11. Wilson A, Childs S. The relationship between consultation length, process and outcomes in general practice: a systematic review. British journal of general practice, 2002, 52(485):1012–20.