With the inadequate dentist to patient ratio in the rural areas, the dental manpower1-3 is multi-skilled and renders all possible treatments in these peripheral areas. Thus, the outreach units serving the masses in these areas require the most time effective manpower that will help in efficient patient care in satellite centres.4 Time management is the key for efficient patient care in any hospital and is important for documentation, diagnosis, management of the treatment plan, and in carrying out the treatment procedures.5-7 As empirical evidence is lacking in oral health care services, the authors decided to uptake a work sampling analysis for the dental surgeons working in a non- profitable peripheral dental centre in order to determine the most efficient manpower.8 Thus, the research was undertaken with the objective of determining the most time efficient work force for direct patient care for these peripheral centres. Secondary objective was to determine the time spent in each treatment procedure in proportion to total time involved in direct patient care. Third objective, was to recommend an appropriate range of sample for further similar studies in peripheral centres.
Ethical clearance was obtained from the institutional Ethics Committee. The study area was a peripheral outreach dental centre with average OPD of 448 patients per month. The unit of observation were the dental graduates and the postgraduate doctors working in the unit on a scheduled basis. Purpose of the research was explained to all the participants under study and informed consent was obtained from each. However, the day of observation was not disclosed to the participants in order to avoid any Hawthorne’s Bias. Time involved in direct patient care was recorded using a standardised stop watch. It involved the time of preparation of the tray for direct patient care till the end of treatment. Traditional method for time measurement by a trained observer was used, as self reported measurements could have lead to, imprecise and potentially biased measurements. 9
During procedure any time spent in the conversation with the patient was not omitted. On random days observations were made for 2 post graduates and 2 graduates over a period of one month. The element of direct patient care was considered appropriate to be under study for the peripheral centre which includes, communication with the patients, medical activities, read in patient record, other patient care and waiting for the patient. However, waiting time was not considered for the comparison of the two manpower’s present in the peripheral centre. Sample size estimation for number of observations was not done as the research was first of its kind in dentistry and followed convenient sampling. In order to obtain comparable timings for different procedures, a standardisation was done for cases which were included for the observations. The protocol formed included the most frequent procedures performed in the peripheral unit. Total 117 observations were made for different procedures done for standardised patients. 28 observations were made for extraction of teeth, 19 for the access opening of posterior molars, 15 for biomechanical preparation, 17 for obturation and 11 for complete oral prophylaxis for patients with less than 1/3rd of the tooth covered with stains and calculus and 27 observations were recorded for Class I and Class II cavity restorations. SPSS (statistical package for the Social Sciences) version 19 was used for descriptive data analysis. Results were obtained considering the binomial distribution of work sampling analysis. The proportion of time utilised for each procedure in the total direct patient care time was used, to calculate the number of observations for each treatment procedure using the formula below, in order to give ideal timings and observations for further similar research in peripheral dental hospitals. (ISE 531 - Work sampling)
Estimate of time spent in particular treatment procedure = p
Absolute accuracy desired (Aa) = 5%
Confidence in results desired = 95% (Z=1.96)
Number of observations = N
Z is score from normal distribution
(distance from mean, in standard deviation units)
Determine: N = z2 p(1-p)/Aa2
Mean timings were found to be highest for all treatment procedures amongst graduates when compared to the postgraduates. (Table 1) Thus, the postgraduate doctors are efficient in saving time and make the unit work more efficiently, leading to decreased waiting hours for the patient and enhancing the patient experience. The complete direct patient care involved 3187.989minutes/53hours during the total observation period. (Figure 1) Based on the proportion of time obtained, number of observations required for observing these treatment procedures, in a rural set up, were computed for further research. Due to sample variation that may arise because of different sampling population, confidence intervals were calculated for each proportion of time in order to give a range according to which the number of observations can vary in each peripheral study unit.(Table 2)
Table 1: Timings of treatment procedures for postgraduates and graduates
Figure 1: Proportion of time for each treatment procedure in direct patient care
Table 2: Number of observations required for further research in peripheral dental centre for each treatment procedure
The mean time of extraction for mobile teeth was 17.19 min while for other conditions considering extractions was 34.24 minutes revealing an expert need for latter cases of extractions. The anterior teeth due to the anatomical variation of being single rooted for most cases had lower mean timings when compared to the posterior molar teeth.
Work sampling analysis is a method of obtaining information about men or machines in less time and lower cost10. The analysis targets, activity and delay sampling, performance sampling and work measurement. However, this research took only work measurement into account as indicated by the objectives. It was appropriate to determine, an ideal workforce in these centres as well as estimate the number of observations required for observing these treatment procedures due to the poor dentist to patient ratio in peripheral hospitals. Direct patient care was the only component considered and was adequate to meet the objectives of this research. Direct patient care is also appropriate to give ideal timings for treatment procedures in dentistry contrary to the fact that peripheral centre infrastructure is much inferior when compared to a tertiary care hospitals in turn demanding a more efficient manpower. Work sampling was ideal for work measurement as the categories of tasks performed was less in number but this study could not overcome the limitation of work sampling as repetitive action by a participant could lead to more number of observations of a single task when compared to the others. 11 Maximum observations were recorded for extractions as it was the most frequent treatment procedure being performed. Secondly, many treatment procedures in the protocol could not be observed as these procedures were not given to graduates or were unequally distributed amongst the work force. Thus, procedures like crown cutting and impression making, although included in the research protocol were omitted from data analysis. Due to paucity of literature, lack of representative sample for the research was also an indentified limitation. However, this research was able to give a basis of estimating a sample for further similar empirical researches in dentistry.
It is concluded that specialised work force is more efficient in a peripheral centre as, supporting auxiliaries are less in number and more efficient time management leads to more productive dental services by these outreach units. Similar analysis, can be conducted for estimating the appropriate work force for all peripheral government dental care centres, as the research was done for a private non-profitable dental unit. Further research with activity and delay sampling and performance index can be made use of by profitable dental hospitals working for rural masses.