Ways to evaluate staff.

Evaluating how staff use their time can be done in different ways. One approach is to ask staff members to record how they spend their time. Another way, called "patient flow analysis," collects time data from clients, by having each staff member enter time of arrival and departure on a form carried by the client as the client moves through the clinic. Yet another approach, more expensive and time-consuming, is known as a "time-motion" study, based on actually observing how personnel spend their time. In general, the time-motion approach to cost analysis, in which staff are observed, tends to be more accurate, says John Bratt of FHI, who has coordinated several large cost studies. Unproductive staff time tends to be recorded more accurately using this approach. A recent study compared the provider interview and patient flow analysis approaches to actual time observed in clinics, a time-motion model. "The provider interview approach was particularly weak, substantially overestimating contact time with clients and underestimating nonproductive time," says Bratt, who coordinated the study with the Population Council. "The magnitude of error in these estimates calls into question the validity of studies that use provider interviews for measuring staff time." The researchers were hoping the study would provide a way to substitute less costly methods of time measurements for time-motion studies. "But the outcome indicates that these other methods perform far less well than does the time-motion method," Bratt says. "We are now looking at ways to use time-motion in a small number of sites and extrapolate from that to the full system. But we need to do more research to see if that is as reliable."