Care Team Assistants as a Strategy to Reduce Physicians’ Administrative Task Burden

Physicians increasingly perform administrative tasks that can lead to inefficiencies in patient care and reduced joy in work.^1,2 When physicians perform work that is not at the top of their license, health care settings waste a scarce resource: human capital.³ In 2016, Takei et al described the introduction of a care team assistant (CTA) program, a workforce comprised of young professionals aiming to gain hospital experience before applying for a health profession school, to address the challenges of excessive administrative work burden on residents.⁴ This follow-up report aims to quantify the task load performed by CTAs and measure CTA impact on the inpatient experience of residents and hospitalists as it relates to their administrative burden, job satisfaction, and delivery of care.

This report details a CTA program established in 2016 at a 603-bed urban pediatric hospital. At the time of this study, there were 4 general pediatric resident service (GPRS) teams, each staffed by a CTA from 7:45 am until 4:15 pm 5 days a week. All inpatient resident teams have CTA support but not on nights or weekends. Hospitalist-only teams have recently added CTA support (1 CTA covers 2 hospitalist-only teams), but the time-motion study only captured CTA time on a resident service.

The time-motion study was conducted on an embedded CTA team member within a GPRS team. The supervising CTA first shadowed and interviewed the CTA to identify specific activities routinely performed. We generated broad categories and subcategories of activities based on the interview and published time-motion studies of hospitalist physicians.⁵ Two overarching categories were established: rounding support and care coordination. Rounding support subcategories included timing rounds, calling nurses, setting up interpreter services, and inviting family participation. Care coordination subcategories included communicating with primary care physicians, obtaining outside hospital records, scheduling follow-up appointments, and collecting data for quality improvement (QI) projects.

To gather observational data on the CTA’s activities, a CTA supervisor shadowed a CTA in real time. Observations were recorded using a macros-enabled Microsoft Excel time and motion tracker to ensure accuracy and reliability (see Supplemental Figure 4).⁶ All observations were grouped into predetermined categories, and notes were taken detailing the activity for each recording. All notes were then reviewed to ensure tasks were appropriately categorized.

Concurrently, we distributed a 15-question survey to better understand the impact of CTAs on the inpatient experience of residents and hospitalists working as front-line clinicians (see Supplemental Figure 5). This survey is administered annually to evaluate issues that funders of the program hope to address, including interruptions in workflow, job satisfaction, and administrative task burden. Questions are reviewed annually with residency and hospital operations leadership and revised to improve clarity for programmatic evaluation. At the time of the survey, 184 residents and 121 hospitalists worked with CTAs. All front-line physicians who received the survey regularly interact with CTAs; however, the time between each physician’s last CTA encounter and their survey completion will vary given differences in clinical schedules. The verified survey was distributed and recorded using research electronic data capture software.⁷ The survey was conducted over a 4-week duration with weekly email reminders sent to encourage participation. Responses to questions were summarized using descriptive statistics. The study was reviewed and deemed exempt by the institutional review board.

The dataset reflects the time spent (in minutes) on CTA activities on 15 nonconsecutive days on a GPRS team. On average, CTAs devoted about 6 hours daily to rounding and care coordination. Time allocation and breakdown for each task along with averages and standard deviations are outlined in Table 1. Our results highlight that CTAs spend an average of 173 minutes/day with family-centered rounding and an average of 196 minutes/day on care coordination.

A total of 149 residents and hospitalists completed the survey (response rate of 49%). The percentage of respondents spending less than 1 hour on administrative tasks increased from 20% when a CTA is not present to 93% when a CTA is present (Figure 1). A total 99% percent of respondents reported that CTAs allow them to spend more time caring for patients, 97% of respondents reported that CTAs aide in patient discharge care coordination, and 99% reported overall improved job satisfaction by having a CTA on the care team (see Figure 2).

With the increasing complexity of hospitalized pediatric patients and the upcoming reduction of inpatient rotations for pediatric residents, hospitals must balance maximizing hospital throughput with ensuring comprehensive inpatient pediatric care. The project’s findings suggest that implementing a CTA program positively impacts the physician’s experience of delivering care. By reducing residents’ and hospitalists’ administrative task burden and improving their joy in work, CTAs allow physicians to practice at the top of their license.

An unexpected positive impact that resulted from utilizing CTAs in our institution includes their expansive QI data collection across multiple teams for several projects. Specifically, for a family-centered rounds (FCR) project that is studying interpreter use for families who prefer a language other than English (PLOE), they have been instrumental in collecting data on whether interpreters were used and the duration during rounds. It was quickly noted that in addition to recording data, CTAs could also be utilized to improve care delivery. They are now being leveraged to help ensure in-person and video interpreters are available during rounds for families who PLOE. Their data collection for the FCR project alone has led to multiple published manuscripts,^8,9 local and national workshops, and oral and poster presentations. Hiring research assistants would have been impractical given the short duration of these tasks on multiple teams. More importantly, our CTAs are now a part of the solution for the gap in care delivery discovered in this QI project.

There are also imputed economic advantages associated with the CTA program, particularly when considering its potential to increase the capacity of care teams. The cumulative effect of adding CTAs across multiple teams allowed for resident teams to increase capacity by 10%. Consequently, the necessity of deploying an additional hospitalist team to manage this subsumed patient volume diminished, thereby reducing operational costs for the hospital equivalent to the cost of a 24/7/365 hospitalist team in terms of salary, benefits, and administrative overhead. Hospital operations was the first source of funding for CTAs on resident teams, as this group of accounting units would have borne the cost of the additional hospitalist team. The CTAs positive impact on resident experience and care delivery then led to individual units (pediatric intensive care unit, neonatal intensive care unit, and oncology) funding their own designated CTA, contributing to the overall growth and sustainability of the program.

A few limitations within this study should be noted. The scale of 15 observation days is comparable with other published time-motion studies;^10,11 however, increased data collection days and observing more than one CTA may have provided more accurate patterns of work. Additionally, the time-motion portion of this study does not account well for multitasking and did not quantify the task load of CTAs on our hospitalist-only teams. Given the ability of one CTA to support several hospitalist teams, an improved understanding of the workflow of hospitalists with and without a CTA may help in the decision to fund such a role.

The Hawthorne effect is inherent in this type of observed time-motion study and may have contributed to the CTA requesting more tasks of the team. Direct observation may also have led the CTA to be more efficient than traditionally seen on a normal workday, leading to longer downtime than anticipated. There may also be a modest social desirability bias in the supervisor wanting to see a successful program but was likely mitigated by utilizing the time-motion tracker.

Future directions of the CTA program will include finding ways to utilize their unallocated downtime noted throughout the day. While listening to family centered rounds, CTAs often extract care coordination tasks to be completed based on discussions with families. While this study shows there is room to leverage a more active role, productivity during rounds must be balanced with the invaluable educational opportunity that rounding with the team provides our CTAs, many of whom will become future physicians. Downtime seen in the afternoon indicates there is room for more efficiency in our use of personnel. It is worth remembering that while “efficiency remains important, the ability to adapt to complexity and continual change is imperative.”¹² Given the variation of work over time in the inpatient setting, agility is valuable, and low-level inefficiency can contribute to overall programmatic flexibility and success.

Since this study’s completion, the program has already increased efforts to utilize CTA downtime during and after rounds in other QI-related projects. These include CTAs delivering social-needs screening surveys to families during and after rounds,¹³ encouraging voter registration in adolescent patients, and measuring talk-time ratios with providers and family members.¹⁴ Shifting their unallocated time into more QI and health-equity efforts will further benefit the institution and provide the CTAs with career-enhancing opportunities.

In summary, our findings highlight the multifaceted benefits of implementing a CTA program in pediatric hospital medicine. As embedded team members, they have enough elasticity in daily activities to absorb multiple short-term tasks that reduce team task burden, ensuring physicians can practice at the top of their license. Beyond the evident improved team efficiency and job satisfaction for residents, the program holds promise for offering a similar benefit to hospitalist teams and contributing to hospital-wide QI initiatives.

We wish to acknowledge the Children’s Hospital of Philadelphia Section of Hospital Medicine, the General Pediatrics Residency Program, and the entire Care Team Assistant Program for their support of this work.

CTA

care team assistant

GPRS

general pediatrics resident service