Site selection
We operated under the assumption that the work of primary care is invariant across VA facilities, but that the allocation of the work to specific job titles would vary by facility. Six VA medical centers participated in the study, based on the following criteria identified by an expert advisory panel as likely to influence staffing patterns and the work conducted in primary care: medical school affiliation (more likely to perform precepting tasks), size (smaller facilities are less likely to have specialty personnel in primary care, such as social workers or nutritionists), past history as primarily a psychiatric inpatient unit (likely to affect the amount of mental health work performed in primary care), and the implementation of advanced clinic access in primary care. Also known as open scheduling or same-day scheduling, Advanced Clinic Access refers to a process popularized by the Institute for Healthcare Improvement (IHI) to reduce appointment congestion, no-shows, and appointment wait times, and was deemed likely to affect workflow patterns. Of the available sites meeting these criteria, the final sites were selected on the basis of feasibility of scheduling and travel and the availability of participants. Table
1 lists how the six sites compare on these and other characteristics.
Table 1
Site characteristics and number of focus group participants by site
| 1 | 2 | 3 | 4 | 5 | 6 | Total |
Site characteristics
|
Advanced clinic access implementation | Y | Y | N | N | Y | N | |
Inpatient/residential psychiatric facility | Y | N | N | Y | Y | N | |
Academically affiliated | Y | N | Y | Y | Y | Y | |
Number of employees | 1006 | 859 | 2183 | 1211 | 2907 | 608 | |
Average patient commute (miles) | 4.63 | 15.53 | 8.4 | 17.15 | 3.6 | 22.14 | |
Number of focus group participants
|
Physician | -- | -- | 4 | 5 | -- | 5 | 14 |
PA/NP | 6 | -- | 6 | -- | -- | 6 | 18 |
RN | 7 | 4 | -- | -- | -- | -- | 11 |
LVN | 3 | -- | -- | 5 | 5 | -- | 13 |
Clerk | -- | 3 | -- | -- | 6 | -- | 9 |
Health technician | -- | -- | -- | 7 | -- | 5 | 12 |
Total | 16 | 7 | 10 | 17 | 11 | 16 | 77 |
Participants
Seventy-seven primary care personnel from six primary care job titles (Physician, Nurse Practitioner/Physician Assistant, Registered Nurse, Licensed Vocational Nurse, Health Technician, and Clerk) across the six sites participated as subject matter experts (SMEs) in a total of 15 two-day focus groups. Separate focus groups were conducted for each job title (six to eight SMEs per focus group). The study's local principal investigator at each facility nominated suitable participant candidates, targeting incumbents with at least one year of experience and a record of high performance in their current position. To minimize facility burden, no more than three focus groups per site were conducted. To minimize any biases that may have ensued from the presence of a supervisor during the focus group, supervisory personnel (e.g., chief of staff of primary care) were excluded from the focus groups. Table
1 displays the distribution of job titles sampled at each facility and the number of SMEs participating in the focus groups. The same personnel who participated in focus groups also participated in a subsequent validation phase. For the verification (survey) phase, 224 out of a possible 619 employees across the six sites participated (36.19% response rate).
Procedure
Various techniques exist for conducting a job analysis, including work-oriented methods such as task inventories and FJA [
30,
31], and worker-oriented methods such as skill-based surveys (e.g., the Position Analysis Questionnaire)[
32] and the critical incidents technique [
33]. For this study we employed FJA and its accompanying framework, Work-Doing Systems Theory [
31]. Developed by Sidney Fine, this framework posits a dynamic interaction of three components of organizational systems: (1) the work organization (its purpose, goals, objectives); (2) the worker (capacities, experiences, education and training); and (3) the work content (the functions, sub-functions, activities, tasks and associated performance standards). FJA is the specific methodology used to describe the work content in the work-doing system.
FJA was particularly suited to accomplish our objective of developing a tool for making evidence-based staffing and work reallocation decisions for several reasons. First, recent research has shown that task-based job analytic techniques like FJA are more reliable and less biased than more generalized work activity techniques, such as competency modelling [
34,
35]. Second, worker-oriented techniques, whose chief purpose is to identify the dimensions required for performing a job well without detailing the tasks involved in performing the job, are inappropriate for work reallocation purposes because they do not capture the work content itself. Finally, FJA is a well-established methodology, with decades of research and use across many industries (including health care) to support it [
30,
31,
36‐
40], as well as the technique with the widest range of applications due to the amount and variety of detail available for each task statement.
FJA methodology has been extensively documented elsewhere [
31], and thus is only briefly explained here (Additional file
1 presents a brief primer). FJA uses task statements as the basic building blocks of human resource management and organizational strategic planning. Task statements explicitly incorporate the three components of work-doing systems using the following elements:
-
Who (the worker)?
-
Performs what action (work content)?
-
With what tools, materials or work aids (work content)?
-
Upon what instructions (including the requisite knowledge, skills, abilities, (worker characteristics) and performance standards for task performance)?
-
To accomplish what organizational outcome or result (work organization)?
Tasks are also rated according to functional skill requirements that define the complexity of performance across cognitive, interpersonal, and physical dimensions, as well as potential consequence given an error in performance [
41] (a brief description of the scales is provided in Table
2; see [
31] for full descriptions). These ratings provide focus for what workers do in terms of the relative simplicity or complexity in their performance of the work content [
40]; thus, the ratings provide additional guidance for decisions about task assignment. For example, tasks may be assigned to maximize the unique skills and expertise of workers (promoting employee growth and satisfaction), as well as to ensure competent personnel perform the work (enhancing quality of care and patient safety). Indeed, the rich array of information at the task level highlights the utility and flexibility in aligning the work with the requisite worker characteristics in service to the important organizational objectives. The advantage of this conceptualization is a more comprehensive architecture on which to examine current work patterns within the VA.
Table 2
Brief scale descriptions
Things: Physical interaction with and response to tangibles – touched, felt, observed, and related to in space; images visualized spatially. |
Data: Interaction with information, ideas, facts, statistics, specification of output, knowledge of conditions, techniques; mental operations. |
People: Live interaction among people, and between people and animals |
Worker Instructions: The degree to which a task is completely prescribed by instructions to the worker, vs. left completely to the discretion of the worker. |
Reasoning Development: Knowledge, ability to deal with theory versus practice, abstract versus concrete, and many versus few variables. |
Mathematical Development: Knowledge and ability to deal with mathematical problems and operations from county and simple addition to higher mathematics. |
Language Development: Knowledge and ability to speak, read, or write language materials from simple verbal instructions to complex sources or written information and ideas. |
Worker Technology: Means and methods employed in completing a task or work assignment - tools, machines, equipment or work procedures, processes or any other aids to assist in the handling, processing or evaluation of things or data. |
Worker Interaction: When working with others (through direct or indirect contact), workers assist them, coordinate their efforts with them and adapt their style and behavior to accommodate atypical or unusual circumstances and conditions. This effort results in achievement of employer goals to given standards. |
Human Error Consequence – Degree of responsibility imposed upon the performer with respect to possible mental or physical harm to persons (including performer, recipients, respondents, co-workers, or the public) resulting from errors in performance of the task being scaled. |
The present study used a modified FJA protocol composed of three phases: task generation, task validation, and task verification (traditional FJA only requires the first two). In task generation, FJA analysts facilitate focus groups with subject matter experts (SMEs, that is, incumbents of the job being analyzed) to co-create a list of task statements that describe the work performed by the incumbents. In task validation, the analysts edit the task statements for compliance with FJA syntax; SMEs and then review the task statements to ensure that they still accurately reflect the work they perform, and that at least 85% of the work they do is captured by the task statement list. Finally, because we were interested in the universe of tasks of a system of work (i.e., primary care), not simply a single job, a third step, task verification, was added to the process. In this step, incumbents reviewed their own task statements and the task statements of other primary care personnel to check for overlap and ensure no tasks had been missed.
Task generation
Two-day focus groups were conducted with the SMEs using a standard FJA focus group protocol [
31] to generate tasks descriptive of their work. For each job title, task lists were generated de novo at the first site a given job title was encountered. For each subsequent site, SMEs reviewed the list of generated tasks, made edits as necessary, and generated any new tasks not already on the list.
Task validation
To ensure the reliability and validity of the task statements, three certified functional job analysts (all part of the research team) reviewed and edited the tasks to arrive at a consensus on the wording of each. To arrive at a consensus, each task was reviewed relative to nine criteria, such as whether the actions in the task statement logically result in the task statement's stated output, or whether performance criteria can be inferred from the language of the task statement. A full list of these criteria is presented in Additional file
1. Similar tasks that were generated by multiple focus groups were merged into a single task, to avoid redundancy in the task bank. SMEs then reviewed the edited tasks to ensure that they (a) accurately represented the work they did, (b) described the work clearly, and (c) captured at least 85% of the work performed by the job title in question. With the exception of the health technician tasks, which captured approximately 60% of the work they performed, all task banks met the above criteria. Health technicians were present in only two facilities, where they functioned in lieu of clerks but with the added responsibility of several clinical tasks not normally performed by clerks. Thus, we concentrated on their clinical tasks during their focus groups, which reduced the percent of work tasks captured by their focus group.
Task verification
The analysts rated the validated task statements along the ten work content dimensions prescribed by FJA:
data (cognitive complexity),
people (interpersonal complexity),
things (physical/motor complexity),
reasoning, mathematics, language,
worker instructions, (autonomy),
worker technology (complexity of methods employed in completing a task),
worker interaction (complexity of interactions with other co-workers required to complete the task), and
human error consequence (HEC, the seriousness of consequences resulting from completing the task incorrectly). The scales are briefly described in Table
2 and documented in detail elsewhere [
40,
42]. However, it is important to note that for the purposes of this paper, we use the term complexity to mean
the complexity of interactions with respect to the scale in question. For example, a low data scale rating implies that the worker interacts with data in a very simple way, such as copying, as opposed to synthesizing data (the data itself can be complex – however if the
interaction with the data is simple, then the task would receive a low rating on the scale).
A survey containing the finalized task bank across all job titles (n = 243) was distributed by the local principal investigator to all primary care personnel at each facility. Participants verified whether or not they performed each task (task endorsement), indicated how frequently they performed each task (frequency), and how long it took them to perform each task (duration).