C l i n i c a l R e p o r t A n A u d i t o f t h e P h y s i o t h e r a p y S e r v ic e s a t t h e Jo h a n n e s b u r g H o s p i t a l ACKNOWLEDGEMENT: The authors would like to thank all the physiotherapists at the Johannesburg Hospital and the University of the Witwatersrand for their help with this audit. A B S T R A C T : In 1998 the Gauteng D epartment o f Health notified the Physiotherapy Departm ent o f the Johannesburg hospital that the num ber o f physiotherapy posts would be cut fro m 43 full-tim e p osts to 22 full-tim e posts. This cut in workforce made it essential to re-evaluate the services rendered in order to m eet the needs o f the hospital. An audit o f the num ber o f inpatients on a given day was conducted in June 1998. In addition to this the num ber o f patients requiring physiotherapy and the time needed to treat them was determined. A second study established the time spent by physiotherapists in direct patient care, indirect patient care and “social” activities. From the results o f this audit it was established that 22 full-tim e physiotherapists would not be able to provide a comprehensive physiotherapy service. Since the completion o f this audit the num ber o f physiotherapists at the Johannesburg hospital has decreased fu rth e r with no re-appointments due to cuts in the Gauteng health budget. It is the opinion o f the authors that many hospitals in South Africa are in sim ilar positions and that more studies need to be done at hospitals to determine the need f o r physiotherapy in other hospitals. KEYWORDS: AUDIT, GAUTENG HEALTH DEPARTMENT, PH YSIO TH ERAPY SERVICES DE CHARMOY S, MSc (Physio)' EALES CJ, PhD2 'physiotherapy Deportment, U niversity o f the W itw atersrand Physiotherapy Department, U niversity o f the W itw atersrand I n 1998 the Gauteng D epartm ent o f Health notified the physiotherapy departm ent at Johannesburg hospital that their total num ber o f physiotherapy posts would be cut from 43 full-tim e posts to 22 full-tim e posts. This drastic cut in w orkforce made it essential to re-evaluate the services rendered in order to meet the needs of patients. A new and different way o f delivering physiotherapy services would need to be established. Some services would have to be downscaled or omitted completely. In order to establish the physiotherapy needs o f the Johannesburg hospital, an audit was done o f the existing service. T he first step was to determ ine the physiotherapy needs o f patients in the hospital on a given day. METHOD: On W ednesday 24 June 1998 an audit o f the physiotherapy services at the Johannesburg hospital was conducted. The total num ber of patients in each unit was determ ined and all patients requiring physiotherapy were identified. T he time required for physiotherapy for each patient was established in terms of treatm ent units. Patients in each area (such as neurology, paediatrics, and orthopaedics) were assessed by a senior physiotherapist working in the area and a m em ber of the university staff who teaches and supervises students within that clinical area. T he following key areas were identified: • paediatrics; • surgical w ards, including traum a, plastic surgery, cardiothoracic surgery and the general surgical wards; • m edical wards, including oncology; • intensive care units; • orthopaedics; out-patients were ex­ cluded; • neurology; out-patients were excluded; • exercise rehabilitation; one out-patient clinic included. The outpatient departm ent (OPD) was not included, as this was the first area from which the physiotherapy services were withdrawn when the staff numbers were cut. The reasons being that the hos­ pital is an acute care facility and at that stage there were alternative hospitals in the near vicinity of the Johannesburg hospital that could supply an out-patient service. The following param eters were used on the inform ation sheet: 1. The num ber o f patients w ithin a specific ward. 2. Diagnoses o f patients. 3. W hether or not physiotherapy was indicated. 4. If the patient required physiotherapy then the choice o f physiotherapy could be docum ented in the following way: respiratory, musculoskeletal, ambulat­ ing/exercise, neurological rehabilita­ tion or sim ply “check” . A check was considered attention paid to a patient who would not benefit from phy­ siotherapy at that particular time but who would be continually assessed to determ ine the need for physiotherapy should it arise (for instance patients in the im m ediate post-operative period). CORRESPONDENCE: Sue de Charm oy Physiotherapy D epartm ent University o f the W itwatersrand 7 York Road Parktown 2193 Tel: (011) 488-3450 (w) (011) 678-8592 (h) Fax: (011)4 8 8 -3 2 1 0 Email: 159suz@ chiron.wits.ac.za S A Jo u r n a l o f Ph y s io t h e r a p y 2000 V o l 56 No 1 21 R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) mailto:159suz@chiron.wits.ac.za TABLE 1: A comparison between patient and unit counts of hospital staff and lecturing staff Lecturing Staff Hospital Staff Total Patients PT Patients Units Contacts Total Patients PT Patients Units Contacts P a ed iatric s 1 1 9 4 9 7 2 4 9 1 3 9 2 7 4 5 3 5 S u rg ical 1 8 7 51 7 3 5 3 1 1 2 6 6 9 6 7 6 M e d ic a l 2 0 0 9 8 6 7 6 0 1 9 8 1 1 8 2 6 7 1 3 9 IC U 3 4 2 6 6 3 4 0 3 3 21 4 7 2 8 O rth o p a e d ic s 6 4 5 7 8 0 5 8 6 4 6 0 9 6 61 N e u ro lo g y 1 0 2 6 8 1 4 6 7 5 1 0 3 6 5 1 3 9 91 Ex R eh ab 8 0 7 8 2 7 1 4 7 9 7 5 2 2 1 3 Total 786 425 528 349 728 432 712 443 PT: P h y s io th e ra p y IC U : Intensive C a r e U n it Ex: R eh ab : Exercise R e h a b ilita tio n 5. The num ber o f treatm ent units was then established - a unit was consid­ ered a treatm ent session lasting up to 15 m inutes, thus if “2” was recorded it indicated that a half-hour o f treat­ ment was considered necessary. 6. Finally, staff mem bers also recorded the num ber o f physiotherapy treat­ ments (contacts) the patient should have in a day. That is if the num ber of units read 4 and the num ber of contacts was 2 then the patient would require tw o h alf-h o u r treatm ent sessions totalling one hour. The two assessors assessed the p a­ tients independently so that there could be no collusion when determ ining phy­ siotherapy needs. All units recorded were simply direct patient care i.e. “hands on” treatment. T he ho sp ital p h y sio th e ra p ists’ e sti­ m ates w ere totalled for each area as were those of the lecturing staff. The results of the two groups were then com ­ pared (see Table 1). The information obtained was then used to determ ine the num ber of phy­ siotherapists required to provide the nec­ essary service. Assuming that physio­ therapists worked eight hours a day “hands on” and disregarding all other form s o f patient interaction, then one could deduce that it would be possible to cover 32 units per day (8hrs x 4 units per hour). To calculate the physiothera­ py needs, the total num ber of treatment units for the hospital was divided by 32 to w ork out the num ber o f physio ­ therapy “hands on” hours required to provide the service. Such an eight-hour day did not take into consideration adm inistrative duties or interactions with other team members. It was proposed that a more realistic figure o f direct patient care be deter­ mined. The second part o f this study involved establishing how m uch direct patient care the physiotherapists at the Johannesburg hospital were doing in a day. In order to do this the physiothera­ pists were categorised as executive staff (the p h y siotherapists running the h o s­ pital service), chiefs, senior physiothera­ pists and jun io r physiotherapists. Physio­ therapists were random ly selected from each of these categories and assigned an assessor who was either a m em ber o f the hospital staff or a lecturer. T he assessor random ly selected a day to follow the physiotherapist. The assessor stayed with the physiotherapist throughout the day and docum ented the tim e spent in minutes on the following categories: 1. D irect patient care, which involved direct hands on treatm ent for the patient. 2. Indirect patient care, w hich involved ordering appliances, telephone conver­ sations related to the patient, attending ward rounds, student supervision etc. 3. Social - this involved tea, lunch, social telephone conversations i.e. anything not related directly to patient care. 4. The data was then collated and the minutes o f the day spent on each activity calculated. The three activi­ ties could then be presented as a percentage o f the total time at work. (Table 2). RESULTS AND DISCUSSION: There was a discrepancy in the total num ber of patients in the paediatric and surgical wards as counted by the two independent assessors. In the paediatric unit the hospital staff m em ber assessed an extra two wards that the lecturer did not assess. In the surgical unit the difference in total num ber o f patients (75) was due to the hospital staff m em ­ ber not assessing three o f the wards due to tim e constraints. The differences in num ber o f patients for physiotherapy, units and num ber o f contacts are largely accounted for by the discrepancy in the medical and surgical wards. 22 SA Jo u r n a l o f P h y s io t h e r a p y 2000 V o l 56 No 1 R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) TABLE 2: Percentage time spent during a working day Direct Indirect Social Executive (F /T ) 5 0 % 2 2 % 2 8 % C h ie f (F /T ) 50% 4 2 % 8 % S e n io r (F /T ) 55% 3 7 % 8 % S e n io r (P /T ) 23% 6 8 % 9% Junio r (P /T ) 4 4 % 4 4 % 1 2 % Junio r (F /T ) 4 3 % 4 3 % 1 2 % Limited reg istratio n (P /T ) 4 7 % 4 1 % 1 2 % Mean 45% 42% 1 3 % F/T: Full-tim e P/T: P art-tim e W hen com paring the results of the lecturing staff with the hospital staff there was good correlation (the perfect correlation being 1.00) between the total num ber o f patients in the hospital (0.87); the num ber o f physiotherapy patients (0.93); and the num ber o f contacts (0.74). However there was a poor corre­ lation for the num ber o f treatm ent units (0.34). This poor correlation was attri­ buted to the large discrepancy in the assessm ent o f the units o f treatm ent thought to be required in the medical and surgical wards. The discrepancy in these counts m ay be due to different schools of thought. An older hospital therapist assessed the m edical wards and this therapist’s figures may reflect the treatm ent scenario that was possible in prev io u s years w hen there was less em phasis on outcom e and more resources available. The lecturer may have had a more realistic appraisem ent in term s o f the availability of resources. The same may be the case for the surgical wards however it is difficult to draw conclusion as not all the surgical w ards w ere com pletely assessed by both assessors. The next step o f the audit investigated the time actually spent by the physiothe­ rapists on various activities during a day. As can be seen from Table 2, physio­ therapists at the Johannesburg hospital spent an average o f 45% o f their time treating patients, and 42% of their time in indirect patient care. In order to deter­ mine the num ber of physiotherapists required to treat the identified patients, we could assume that each physiothera­ pist could render 16 units o f direct patient care a day as 50% o f their tim e is spent on direct “hands on” patient care. A total o f approxim ately 620 units (528 + 712 = 1240/2) needs to be com ­ pleted on a given day. This would mean that 39 full time physiotherapists would need to be em ployed to adequately meet the physiotherapy needs of the Johannes­ burg hospital. The above figures merely reflect time spent with the patient versus other acti­ vities. We can draw no conclusions from them about the quality o f w ork produced within the “tim e” frames. It is o f con­ cern that the physiotherapists are spend­ ing an equal am ount of tim e treating the patient as they are on indirect patient care. One o f the reasons cited for this by the therapists is the decrease in the num ­ ber o f nurses. This has resulted in more dem ands on physiotherapists tim e doing what the nursing staff had previously done. Furtherm ore it does not fit in with the actual job description o f each cate­ gory that all levels o f physiotherapists are doing the same am ount o f direct patient care. As the prospect o f 39 posts at the Johannesburg H ospital is unlikely it would seem on the current post struc­ ture that each physiotherapist would have to be involved w ith direct patient care 88% o f the tim e w hich translates to seven hours a day. This is an addi­ tional three hours o f direct patient care per day per physiotherapist in addition to w hat they w ere doing at the tim e of this study. State em ployees have to w ork 8 1/2 hours in a day to allow for lunch and tea but it does m ean th at no tim e w ould be available for indirect patient care. In order to give an ad e­ quate physiotherapy service it is essen ­ tial that a certain portion o f the day is allo cated to c o n su ltatio n w ith team m em bers re the requirem ents o f the patient, w ard rounds and further devel­ opm ent o f the physiotherapist as a pro­ fessional. Such a situation w ould there­ for be unacceptable. It would thus seem that the staff situa­ tion in 1998 was not sufficient to meet the needs of the physiotherapy service required at the time o f this audit and fur­ ther steps have to be taken in order to make the current service more efficient to meet the dem ands for physiotherapy. The next step of this audit will be to look at essential services, tim e m anagem ent of staff and effective levels o f com m uni­ cation, in an attem pt to change the cur­ rent situation into a realistic and viable physiotherapy service. Since the com pletion of this audit the num ber o f physiotherapists at the Johan­ nesburg hospital has decreased even further with no re-appointm ents due to financial constraints in the G auteng health budget. The Johannesburg hospi­ tal is used in this audit as an example. It is the opinion of the authors that all the hospitals in South A frica are in a similar position and that further studies need to be done at other centres to deter­ mine the need for physiotherapy in spe­ cific areas. B ased on the outcom e o f this survey a com pletely new look at the structuring o f p h y sio th erap y services in state departm ents is required in order to try and provide a reasonable, efficient and practical service. SA Jo u r n a l o f Ph y s io t h e r a p y 2000 V o l 56 No 1 23 R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. )