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  • All physicians involved in clinical care at the Eye Centre of the Medical Centre—University of Freiburg were invited to participate in a 14-day study of their work time in October 2014. The Eye Centre has three wards with 34, 17, and 9 beds, respectively. It provides care for 5,500 inpatient episodes per year with a mean length of stay of 3.2 days and a case-mix index of 0.73. Furthermore, 22,000 surgical interventions are carried and 65,000 outpatient contacts are served per year. The top-five documented inpatient main diagnoses from the International Classification of Diseases (ICD-10) in 2013 were H40 Glaucoma (23%), H25 Senile cataract (15%), H33 Retinal detachments and breaks (10%), H02 Disorders of the eyelid (9%) and H35 Other retinal disorders (7%). A handheld device specifically for the purpose of work-sampling studies was used, consisting of a pager and documentation forms. The pager gave random request during 30-minutes intervals, upon which participants documented their current place and type of activity. The study included each physician’s whole workday, starting and ending in the locker room with changing clothes. On-call duties were excluded, such as at the weekend and during the night. Four types of activities were surveyed. Direct care comprised all activities in contact with the patient, such as admissions and operating procedures. Indirect care comprised activities dedicated to one or more specific patients without their presence, such as medical reports and other documentations. General clinical time comprised activities not attributable to specific patients but required for the delivery of clinical care, such as staff scheduling and organisation. The category ‘other’ comprised all non-clinical activities, such as moving between units, research, teaching and breaks. The surveyed places were three wards, a general unit of operating rooms (OR), a unit of OR for outpatient surgical interventions and a general outpatient unit. Research units and other places not dedicated to clinical care were surveyed in order to exclude time spent there from analysis of resource use. Furthermore, participants documented their level of seniority. Assistants were medical graduates absolving a five-year specialist training in Ophthalmology, consultants were physicians who have completed their specialist training and seniors were appointed as directors of specific entities at the Centre. The study was anonymous, its intention was described in advance and representatives of staff were involved early in the development of its design in order to reduce observer effects. Consent was given in advance and confirmed with handing in the documentations. Furthermore, the study and its methodology were approved by the works council of the University Medical Centre Freiburg and by the ethics committee of the Albert-Ludwigs-University of Freiburg. Total number of patient days, surgical intervention and outpatient contacts were derived from the patient administration database. Estimated proportions were multiplied by total work time and the product was divided by the number of output units to calculate minutes of resource use per unit of output. Average personnel costs at the Eye Centre of the Medical Centre- University of Freiburg, including non-wage labour costs were used to monetarily value estimated staff time. Confidence intervals of work time proportions and associated hospital costs were calculated. Adjacent observations were not independently distributed but correlated by proximity, since the likelihood of an activity being observed has been influenced by the previously documented activity. Therefore, robust standard errors were calculated to adjust for autocorrelation between subsequent observations by clustering each working shift. Listwise deletion was used to address missing places or types of activities since the number of missing observations was very small (<1%) and negative effects on validity of results were unlikely [18].
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