Workload Analysis of Ambulatory Care Nursing: Briarwood Medical Group. University of Michigan Health System Program & Operations Analysis

Transcription

1 Workload Analysis of Ambulatory Care Nursing: Briarwood Medical Group University of Michigan Health System Program & Operations Analysis Final Report Project Clients: Candia B. Laughlin, MS, RN, BC: Director of Nursing, Ambulatory Care Services, UMHS Marie Beisel: Nurse Manager, Ambulatory Care Services, UMHS Mary gay Yocum: Health Center Manager, Briarwood Medical Group Project Coordinator: Mandy McKay: Management Engineer Fellow Industrial and Operations Engineering 481 Team: Mary Jo Luppino Jamie Tompkins Tim Vezino 14 April 2008

2 Table of Contents Executive Summary... 1 Background... 1 Goals and Objectives... 1 Methods... 1 Findings... 2 Recommendations... 4 Introduction... 5 Background... 5 Key Issues... 5 Goals and Objectives... 6 Project Scope... 6 Methods... 6 Findings... 8 Initial Observations, Interviews, and Surveys... 8 Quantitative Data Collection Part 1: General Study Quantitative Data Collection Part 2: Phone Study Quantitative Data Collection Part 3: Detailed Workload Study Quantitative Data Collection Part 4: Task Volume Tick Mark Study Rockwell Phone Log Analysis Recommendations Appendix A: Nursing Workload Survey Nurse Survey... A-1 Appendix B: Nursing Workload Survey Management Survey... B-1 Appendix C: BMG Nursing Operations Flowchart... C-1 Appendix D: Data Entry Sheet for General Study... D-1 Appendix E: Data Entry Sheet for Phone Study...E-1 Appendix F: Data Entry Sheet for Detailed Workload Study...F-1 Appendix G: Data Entry Sheet for Task Tick List Study... G-1 Appendix H: General Workload Sampling Study Results... H-1 Appendix I: Phone Workload Sampling Study Results...I-1 Appendix J: Detailed Workload Study Results... J-1

3 Appendix K: Task Volume Study Results... K-1 Appendix L: Rockwell Phone Log Results...L-1 List of Figures and Tables Figure 1: Simplified Flowchart of RN Operations in BMG... 9 Figure 2: RN Nursing General Workload Task Categories at BMG Figure 3: Task Percentage of Time for General RN Workload Figure 4: RN Phone Related Task Categories Figure 5: Task Percentage of Time for RN Phone Workload Figure 6: Task Percentage of Time for North Side RN Workload Figure 7: Task Percentage of Time for South Side RN Workload Figure 8: Total Documented RN Time per Patient Figure 9: Percent of Outbound Calls Not Reaching the Patient: North Side Table 1: Task Percentage of Time for General RN Workload for North and South Sides Table 2: Task Percentage of Time for RN Phone Workload for North and South Sides Table 3: Task Percentage of Time for RN Workload for North and South Sides Table 4: Documented RN Time per Patient by Department Table 5: Percentage of Time Spent Multi-Patienting by Department Table 6: Task Volume Percentages Stratified By Department Table 7: Outbound Call Distribution Stratified By Department and Nurse Table 8: North Side Outbound Call Distribution Stratified By Time and Call Type Table 9: South Side Outbound Call Distribution Stratified By Time and Call Type Table 10: South Side Outbound Call Workload Percentages by Nurse Table 11: North Side Outbound Call Workload Percentages by Nurse Table 12: North Side Task Percentages by Day Table 13: South Side Task Percentages by Day Table 14: Patient Contacts Per Month at North and South Side Combined Table 15: Phone Call Distribution Stratified By Call Type for North and South Side... 22

4 Executive Summary The University of Michigan Health System (UMHS) is interested in assessing the workload of ambulatory care registered nurses. Nursing workload is unknown and standardized work practices are currently not in place. Therefore, the Director of Nursing requested a team of Industrial and Operations Engineering (IOE) 481 students to quantify the nursing workload at Briarwood Medical Group (BMG). The site is divided between the South side where Internal Medicine (IM) is practiced and the North side where Internal Medicine and Obstetrics and Gynecology (OB/GYN) are practiced. The team conducted and analyzed the studies and developed recommendations for standardized work practices, appropriate staffing levels, and a methodology for ongoing workload measurement in ambulatory care units. Background A workload study was previously performed at the Brighton, Chelsea, East Ann Arbor, and Saline Ambulatory Care sites. This workload study will be performed at each Ambulatory Care site and the results from the study will aid management in developing standardized work procedures, appropriate staffing levels, and ongoing workload measurements across all Ambulatory Care sites within UMHS. A similar workload study was conducted at BMG and the key issues are as follows: The amount of time nurses spend on daily activities is unknown No standardized procedures exist for nursing phone calls to/from ambulatory care units An ongoing workload measurement methodology is required Goals and Objectives The key goal of this project was to identify the amount of time nurses spend on each daily activity. In order to develop recommendations for standardized work, appropriate staffing levels, and a methodology for ongoing workload measurement, the team completed the following: Observed and interviewed nurses to collect current perceptions Conducted a two phase workload study to quantify nursing workload Conducted a detailed workload study to further quantify nursing workload Conducted a task volume study to quantify daily task volume Analyzed data and results to develop recommendations Methods The following methodology was used for this project. Literature Search- Past nursing workload studies were examined to identify the appropriate methodology for each study. In addition, the data sheets from previous studies were used in this project. Initial Observations, Interviews, and Surveys- Nurses were observed and interviewed to gain a better understanding of the nurses daily activities. In addition, the nurses and management of BMG completed a survey about their views on current operations at the site. 1

5 Quantitative Data Collection Parts 1 and 2: Workload Studies- Two workload studies (general and phone) were completed from 1/28/08-2/8/08. Four RN s participated in the study and each received a beeper. Each time the beeper would sound, the RN would indicate the task she was performing on her log sheet. Each study was conducted for one week. Quantitative Data Collection Part 3: Detailed Workload Study - Each nurse performed a workload study for 50 patients, which tracked the duration of each nurse task, the total time spent with each patient, and the frequency of multi-patienting 1. The study was conducted the week of 2/11/08 and was completed when a nurse logged 50 patients. Quantitative Data Collection Part 4: Task Volume Tick Mark Study - This study, completed from 2/18/08-2/29/08, obtained the quantity of tasks performed each day. Each nurse made a tally on the log sheet for each new task performed. Rockwell Phone Log Analysis- The team performed statistical analysis on the data collected from the Rockwell phone data for 2/18/08-2/29/08 as well as the call volumes for August 2007 through December Recommendations- Recommendations were developed for standardized work practices, appropriate staffing levels, and a methodology for ongoing work measurement. Findings The following are the findings identified from the observations, interviews, surveys, workload studies, task volume study, and Rockwell data previously described. Initial Observations, Interviews, and Surveys - The perceptions for the four RNs and the two BMG management personnel who participated are as follows: Nurse Perceptions: Majority of time is spent on phone related activities. Referral requests and forms completion is not within RN job description. Live calls 2 take away from RNs ability to properly triage patients. Management Perceptions: Majority of nurses time is spent on phone related activities. RN Staff have gained "lessons learned" on how to implement and optimize use of the new phone system. This is an ongoing and evolving process. 1 Multi-patienting is when a nurse is handling more than one patient at a time. 2 Live calls are phone calls taken by clerk and then routed directly to the nurse s phone. 2

6 Management would like nurses to be relieved of tasks that do not require a nursing license. Quantitative Data Collection Part 1: General Study The data collection period for Part 1was one week dating from 1/28/08 2/1/08 with a sample size of 469 samples. RNs spend 41% of their time on direct patient care. RNs spend 53% of their time on indirect patient care. Quantitative Data Collection Part 2: Phone Study The data collection period for Part 2 was one week dating from 2/4/08 2/8/08 with a sample size of 471 samples. RNs spend 87% of their time on work related to calls and on-the-phone activities. Quantitative Data Collection Part 3: Detailed Workload Study - The detailed workload study began 2/11/08 and was completed for 50 patients per nurse. This study further examined the tasks for each nurse providing more detail into their daily activities. The major findings from this study were: RNs spend 50.1% of their time on the phone with patients. RNs spend 84% of their time on work related to calls and on-the-phone activities. RNs spend an average of 10.8 minutes per patient on phone and clinic work with a standard deviation of minutes. 80% of North Side patients require less than 18 minutes of RN time. 80% of South Side patients require less than 13 minutes of RN time. Quantitative Data Collection Part 4: Task Volume Tick Mark Study - The task volume study was conducted from 2/18/08-2/29/08 with a sample size of The major findings from the study were: The South Side has a higher percentage of time sensitive outbound calls with 31.0% of their outbound calls being time sensitive compared to 6.1% on the North Side. The North Side has a higher percentage of Non-Urgent Day Of outbound calls with 47.3% compared to 32.1% on the South Side. The North Side has a higher percentage of calls in which the patient could not be reached with 32.6% of outbound calls compared to 20.9% on the South Side. The percentage of North Side outbound calls in which the patient could not be reached peaks around 11:00 AM when 53.7% of patients could not be reached. Rockwell Data Analysis - The Rockwell Data was analyzed for the same two week period as the task volume study (2/18/08-2/29/8). Call volumes over the period from August 2007 through December 2007 were also analyzed. The major findings from the study were: The average number of calls per day that RNs handle at BMG is 144. Outbound calls account for 64.1% of RNs time on the phone. Inbound calls account for 35.9% of RNs time on the phone. 3

7 Recommendations Based on the data analysis, the recommendations were developed for standardized work practices, staffing levels, and ongoing workload measurement. Standardized Work Practices A task force should be created to evaluate all patient documentation templates currently in use at BMG for clarity, conciseness, and standardization. Templates including a patient s contact information should also include the best time to call the patient in order to improve the percentage of calls reaching the patient. Only officially approved templates should be used. General medication refills should be routed to an MA instead of being handled by RNs. Medication refills should be faxed if at all possible rather than called in. Referral appointments outside of BMG should be routed to MAs or Clerks instead of being scheduled by RNs. Clerical staff should receive training on writing clear and concise patient notes as well as proper note routing which could be accomplished with MLearning modules. The quantity and time of available RN-only appointment slots should be reviewed monthly to determine whether more or less appointments are needed. Staffing Levels One Full Time Equivalent (FTE) at BMG was found to be able to handle 192 calls / week Based on Rockwell Phone Logs, BMG should operate with 3.75 FTE Continuous improvement projects should be used to further address the RN role and eliminate non-rn tasks. Ongoing Workload Measurement Training on proper use of Rockwell System to ensure proper task coding Conducting audits of Rockwell data by Management, ongoing. Training on data interpretation for Site Manager Training on general computer applications for all nurses to improve computer skills 4

8 Introduction The management of the Briarwood Medical Group Ambulatory Care unit (BMG) is interested in assessing the RN workload.. Management reports that the Briarwood site lacks standardized work practices for their nurses. In addition, the nursing workload is unknown which makes the facility difficult to staff. Therefore, management would like to know the proportion of time a nurse currently spends on each daily activity, with an emphasis on nursing phone calls. To identify this proportion, the Director of Nursing, Candia Laughlin, requested an Industrial and Operations Engineering (IOE) 481 team to observe and measure the activities of the nursing staff. Based on this analysis, the team developed recommendations for standardized work practices, appropriate staffing levels, and a methodology for ongoing workload measurement in the ambulatory care units. The purpose of this report to present the methodology, findings and recommendations of this study conducted at BMG. Background The Briarwood Medical Group Ambulatory Care site provides outpatient care and is part of the University of Michigan Health System (UMHS). The site is divided between the Internal Medicine (IM) department, referenced here as the South side, and the Obstetrics and Gynecology (OB/GYN) department where Internal Medicine is also practiced, referenced here as the North side. Currently, two registered nurses (RNs) are assigned to each department and four regularly scheduled RNs are on staff. When an RN is absent, management contacts the Central Staffing Resource office and requests a Central Staffing Resource nurse (CSR). Concerns have been raised because the nursing workload, the amount of time a nurse spends on each daily task, of the Briarwood site is unknown. A thorough analysis was requested to determine the proportion of time RNs spend on each daily activity. This analysis has resulted in recommendations to standardize work practices, maintain appropriate staffing levels, and for ongoing workload measurement. A series of similar workload studies have been conducted at various Ambulatory Care sites including Brighton, Chelsea, East Ann Arbor and Saline. These studies were performed by the Program and Operations Analysis Department and two IOE Senior Design teams. This workload study is to be conducted at each Ambulatory Care site within UMHS. The overall goal of this project at BMG was to determine how much time nurses spend on the phone and what kind of work the nurses are doing when they are not on the phone. Key Issues The key issues that were addressed in this study are: The proportion of time nurses spend on daily activities is unknown No standardized procedures exist for nursing phone calls to or from ambulatory care units An ongoing workload measurement methodology is required 5

9 Goals and Objectives The primary goal was to identify the proportion of time a nurse currently spends on each daily activity, with an emphasis on nursing phone calls. Additionally, to develop standardized work for nursing phone calls, determine appropriate staffing levels, and develop a methodology for ongoing workload measurement at all other Ambulatory Care sites, the following tasks have been completed: Observe and interview nurses Conduct a two-phase workload study (random beeper method) o General Nursing Study o Phone Study Conduct a detailed workload study (ladder log method) Conduct a task volume study (task tick list method) Analyze data and present results Develop recommendations to improve site operations Develop an ongoing workload measurement methodology Project Scope The scope of this project included studying the workload of the RNs at the Briarwood site. This project included the RNs from both the IM and OB/GYN-IM departments at the site. The scope of this project did not include the workload of LPNs, physicians, or clerks. Methods The parties involved in this project are the four RNs currently staffed at BMG along with unit CSRs who fill in at BMG when an RN is absent. The team conducted this study similarly to the four previous studies carried out at the Brighton, Chelsea, East Ann Arbor, and Saline Ambulatory Care sites, using the same methodologies such that future comparisons between sites can be made. The common methodology used at each of the sites is described in further detail below. Literature Search A literature search of past nursing workload studies was conducted to identify appropriate methodologies for each of the studies and to obtain the data sheets used in the previous studies. Data sheets for the General Study, Phone Study, and Ladder Log Study as well as the seven- question nursing survey were obtained from Ambulatory Care Nursing Workload Study: East Ann Arbor Health and Geriatrics Center by Leff et al while the data sheet for the Task Tick List Study was obtained from the Management Engineer Fellow Mandy McKay s work at the Saline ambulatory nursing care site. 6

10 Initial Observations, Interviews, and Surveys The nursing staff was observed at the clinic as they performed their daily nursing activities. To supplement the information gathered through observation, all four RNs were interviewed, and asked to fill out a seven-question survey (Appendix A) to gather their perceptions on the current operations. To ensure the study was examined from multiple perspectives, nursing management, as represented by the Nurse Manager and the Briarwood Medical Group Health Center Manager, were also interviewed and asked to fill out a corresponding survey (Appendix B). Quantitative Data Collection Part 1: General Study Part 1 of the project consisted of a random sampling beeper study to gather RN workload data related to direct patient care, indirect patient care, and non-patient care activities. Each of the four nurses was assigned a beeper set to randomly sound on average four times per hour. Each time that the nurse s beeper sounded, she made a tally on the log sheet (Appendix D) next to the task that she was performing when the beeper went off. Data was collected in this study for one week from 1/28/08 2/1/08. Quantitative Data Collection Part 2: Phone Study Part 2 of the project, like Part 1, was also a random sampling beeper study. However, while Part 1 looked at general tasks, Part 2 focused specifically on RN tasks related to the telephone. On phone activities, work related to the call, and non-call related activities were the main task categories studied. The nurse made a tally on the log sheet (Appendix E) next to the task being performed when the beeper sounded. The data collection period for Part 2 was one week dating from 2/4/08 2/8/08. Quantitative Data Collection Part 3: Detailed Workload Study Part 3 of the project consisted of a Detailed Workload Study in which each nurse tracked every action taken for 50 patients on a ladder log sheet (Appendix F). The purpose of this study was to determine the duration of each task, the total time spent with each patient, the frequency of multi-patienting when more than one patient was being handled at the same time, as well as the frequency and duration of interruptions that occurred throughout the day. In this study, the task categories being tracked were calls, work related to calls, non-call related work, and administrative duties. Since the duration of this study depended on the daily patient volumes as opposed to a fixed length of time, the time required to complete this study varied by nurse. Quantitative Data Collection Part 4: Task Volume Tick Mark Study The final part of the data collection was a Task Volume Tick Mark Study. For this study, only the quantities of events were tracked. Each nurse made a tally on the Task Tick List log (Appendix G) whenever a new task was started under the appropriate time interval in which the task began. The major categories for which data was collected were inbound calls, outbound calls, and clinic duties. The duration of this study was two weeks from 2/18/08 2/29/08. Rockwell Phone Log Analysis In conjunction with the Task Volume Tick Mark Study, the team analyzed the Rockwell phone data for all RN incoming and out going calls during the same two week period from 2/18/08 2/29/08 as well as the total call volumes over the period from August 2007 through December

11 Data Analysis After the data was collected, the team calculated statistics such as the percentage of time nurses spend on each type of task within the studies and the length of time spent on each patient, as well as prepared graphs that depict the nursing workload stratified by task type. Comparisons were then made between individual nurses and between the North and South sides of BMG. Recommendation Development Based on the observations and quantitative studies, the team developed standardized work practices, appropriate staffing levels, and a methodology for ongoing work measurement. Findings The observations and interviews, four studies, and Rockwell data have been analyzed and the following findings were identified to help develop overall recommendations for the client. Initial Observations, Interviews, and Surveys - The answers gathered from the nurse and management surveys are summarized below: Nurse Perceptions Nursing Workload: Majority of time is spent on phone related activities. Workload depends on time of day and day of week. Mornings are busiest time. Monday and Friday are busiest days. Overtime is occasionally worked. Referral requests outside of BMG and test requisitions are not included in RN job description. Live Call System: Live calls take away from RNs ability to properly triage patients. Process Improvements: Nurses would like to see non-symptom related live calls eliminated Nurses would like to see clerical staff improve detail of note taking. Management Perceptions Nursing Workload: Majority of nurses time is spent on phone related activities. Nursing workload depends on time of day and day of the week. Live Call System: The Live Call system was put in place to handle patient needs more efficiently; RN Staff have gained "lessons learned" on how to implement and optimize use of the new phone system. This is an ongoing and evolving process. Process Improvements: Nursing management would like to see clerical staff improve conciseness of note taking and improved use of protocols. Nursing management would like to see nurses relieved of tasks that do not require a nursing license. 8

12 The nursing staff was further interviewed and observed to develop a detailed flowchart of RN operations, which can be seen in Appendix C. A simplified flow chart of RN operations can be seen in Figure 1. Figure 1. Simplified Flowchart of RN Operations in BMG Team 8: BMG Ambulatory Care Study 01/28/08-02/22/08 Figure 1 shows the process by which calls enter BMG and are handled by the RNs. Within the process, tasks are passed to other individuals and departments. These tasks include notes forwarded directly to a doctor and non-narcotic medication refills. Additionally, tasks are completed by the RNs which do not require an RN license such as contacting referrals. 9

13 Quantitative Data Collection Part 1: General Study - The data from the study was analyzed. The percentage of time spent on each task for each nurse is displayed in various graphs and tables and can be seen in Appendix H. The percentage of time nurses spend on non-patient care, indirect patient care, and direct patient care is shown in Figure 2. Non Patient Care 6% Direct Patient Care 41% Indirect Patient Care 53% Figure 2. RN Nursing General Workload Task Categories at BMG Team 8: BMG Ambulatory Care Study 01/28/08-02/01/08 N=469 Figure 2 illustrates that nurses spend 53% of their time on indirect patient care, followed closely by patient care with 41%. Non-patient care is the least time-consuming task category, with only 6%. Figure 3 depicts the average percentage of time spent on each task for the entire facility. The shading corresponds to Figure 2 and the respective category the nursing task belongs to. 10

14 Percentage of Time On Phone w/ Patient/Family Patient/Care Information Documenting Coordinating Consulting w/ Physicians Perscriptions Caring for Walk ins Assisting w/ Provider Visit Administrative Personal Time Supervising Performing Nurse Visit Meetings Quality Improvement Task Figure 3. Task Percentage of Time for General RN Workload Team 8: BMG Ambulatory Care Study 01/28/08-02/01/08 N=469 Table 1 shows the above information further stratified by the North and South sides of BMG. Table 1. Task Percentage of Time for General RN Workload for North and South Sides Team 8: BMG Ambulatory Care Study 01/28/08-02/01/08 N=469 Standard Deviation Task North South Average On phone with patient/family 33.02% 36.58% 34.80% 2.52% Documenting 19.81% 9.73% 14.77% 7.13% Looking up patient/care information 18.40% 16.73% 17.56% 1.18% Coordinating 6.60% 10.12% 8.36% 2.48% Consulting with physicians 5.66% 7.00% 6.33% 0.95% Administrative 4.25% 1.56% 2.90% 1.90% Prescriptions 3.77% 6.23% 5.00% 1.73% Assisting with provider visit 3.77% 4.67% 4.22% 0.63% Personal time 2.36% 1.56% 1.96% 0.57% Supervising 1.42% 1.56% 1.49% 0.10% Meetings 0.47% 1.17% 0.82% 0.49% Caring for walk-ins 0.47% 0.39% 0.43% 0.06% Performing nurse visit 0.00% 1.95% 0.97% 1.38% Quality improvement 0.00% 0.78% 0.39% 0.55% Voic 0.00% 0.00% 0.00% 0.00% Staff Education 0.00% 0.00% 0.00% 0.00% Professional development 0.00% 0.00% 0.00% 0.00% 11

15 Key findings from Figure 3 and Table 1 include: The nurses as a whole spend 34.97% of their time on the phone with a patient or their family. The South side spends 3.56% more time on the phone with a patient or patient s family than the North side. The North side spends 19.81% documenting which is 10.08% more time spent documenting than the South side. The North side spends 18.40% of their time looking up patient or care information, whereas the South side spends 16.73% of their time. The South side spends 1.95% of their time performing nurse visits whereas the North side did not report any time spent on visits during the one week data collection period. The nurses did not report spending any time checking voic , staff education, or professional development during the one week data collection period. Quantitative Data Collection Part 2: Phone Study - The data from the second study, the phone study, examines phone related activities. The time spent on each phone related task for each nurse is displayed in various graphs and tables and can be seen in Appendix I. The percentage of time nurses spend on non-call related work, work related to calls, and on phone activities is shown in Figure 4. Non Call Related Work 13% On Phone Activities 41% Work Related to Call 46% Figure 4. RN Phone Related Task Categories Team 8: BMG Ambulatory Care Study 02/04/08-02/08/08 N=471 Figure 4 shows that work related to calls and on-the-phone activities account for the most time, 87%. Only 13% of the time is spent on non-call related work. Figure 5 shows a more detailed tasks list for the percentage of time spent on each task. The groupings for these tasks can be found in Appendix E. 12

16 Percentage of Time In Clinic Care Consulting w/ Provider Talking to Patient/Family Documenting Looking up Patient/Care Info After Call Coordinating Administrative Personal Time Task Leaving Message Supervising On Hold Faxing Talking to Pharmacy On Phone w/ Provider Talking to External Agency Voic On Phone w/ Internal Dept Figure 5. Task Percentage of Time for RN Phone Workload Team 8: BMG Ambulatory Care Study 02/04/08-02/08/08 N=471 Table 2 shows the above information further stratified by the North and South sides of BMG. Table 2. Task Percentage of Time for RN Phone Workload for North and South Sides Team 8: BMG Ambulatory Care Study 02/04/08-02/08/08 N=471 Standard Task North South Average Deviation Talking to Patient/Family 41.30% 31.01% 36.16% 7.28% Documenting 25.00% 16.38% 20.69% 6.10% Looking up Patient/Care Info 10.87% 18.47% 14.67% 5.37% Personal Time 6.52% 1.39% 3.96% 3.63% After Call Coordinating 2.17% 9.76% 5.97% 5.36% Administrative 2.17% 7.67% 4.92% 3.88% Leaving Message 1.63% 2.79% 2.21% 0.82% Talking to Pharmacy 1.63% 0.35% 0.99% 0.91% Consulting w/ Provider 1.63% 3.14% 2.38% 1.06% On Hold 1.09% 1.05% 1.07% 0.03% Faxing 1.09% 1.05% 1.07% 0.03% Supervising 2.17% 1.39% 1.78% 0.55% On Phone w/ Provider 0.54% 0.35% 0.45% 0.14% On Phone w/ Internal Dept 0.54% 0.00% 0.27% 0.38% Voic 0.54% 0.35% 0.45% 0.14% In-Clinic Care 0.54% 6.42% 3.48% 4.15% Waiting for Call 0.00% 0.00% 0.00% 0.00% Talking to External Agency 0.00% 0.70% 0.35% 0.49% 13

17 Key findings from Figure 5 and Table 2 include: Both sides spent the most time talking to patients and families with the North spending 41.3% of their time and the South spending 31.01%. This is a difference of 10.29% between sides. The North side spends 25% of their time documenting, which is 8.62% more than the South side. The South side spends 18.47% of their time looking up patient care information, which is 7.6% more than the North side. Neither side spent any time waiting for a call or talking to an external agency. Quantitative Data Collection Part 3: Detailed Workload Study - The purpose of the Detailed Workload Study was to look at not only the percentage of time nurses spend on each task, but also the volume and duration of the tasks. The study also identified the total amount of RN time utilized per patient. The percentage of time nurses spent on each task category as well as volume and duration of the tasks is summarized below in Table 3. A full analysis of the Detailed Workload Study can be found in Appendix J. Table 3. Task Percentage of Time for RN Workload for North and South Sides Team 8: BMG Ambulatory Care Study 02/12/08-03/07/08 N=419 Table 3 shows that nurses spend 50.1% of their time talking to a patient or family member. Each time a nurse talks to a patient or family member, the task takes on average 6.30 minutes with a standard deviation of 4.36 minutes. The percentage of time RNs spend on each task category is further stratified by department in Figure 6 for the North Side and Figure 7 for the South Side. Administrative Duties and Personal Time, 8.9% Not Specified, 1.3% Non-call related work, 6.2% Talking to Patient or Family, 52.4% Work Related to Call, 31.2% Figure 6. Task Percentage of Time for North Side RN Workload Team 8: BMG Ambulatory Care Study 02/12/08-02/13/08 N=258 14

18 Administrative Duties and Personal Time, 7.0% Not Specified, 0.7% Non-call related work, 6.6% Talking to Patient or Family, 46.2% Work Related to Call, 39.6% Figure 7. Task Percentage of Time for South Side RN Workload Team 8: BMG Ambulatory Care Study 02/12/08-03/07/08 N=161 Key findings from Figure 6 and Figure 7 include: The North Side spends 52.4% of their time talking to patients or family while the South Side spends 46.2% of their time talking to patients or family, which is 6.2% less than the North Side. The North Side spends 31.2% of their time on work related calls while the South Side spends 39.6% of their time on work related to calls, which is 8.4% more than the North Side. The North Side spends a combined total of 83.6% of their time on talking to patients or family and work related to calls while the South Side spends a combined total of 85.8%, which is a difference of only 2.2%. Figure 8 and Table 4 summarize the total amount of documented time RNs spent on each patient during the Detailed Workload Study. 15

19 60 80th Percentile 50 # of Patients Documented RN Patient Care Time (in minutes) 75 Figure 8. Total Documented RN Time per Patient Team 8: BMG Ambulatory Care Study 02/12/08-03/07/08 N=203 Table 4. Documented RN Time per Patient by Department Team 8: BMG Ambulatory Care Study 02/12/08-03/07/08 N=203 Key findings from Figure 8 and Table 4 include: The total amount of documented RN time per patient as seen in Figure 8 is highly skewed left. The North Side spends an average of minutes per patient with a standard deviation of minutes while the South Side spends an average of 8.39 minutes per patient with a standard deviation of 6.18 minutes. 80% of patients on the North Side require less than 18 minutes of RN time. 80% of patients on the South Side require less than 13 minutes of RN time. BMG also was interested in the percentage of time nurses spend working on tasks for more than one patient at the same time which is described as multi-patienting. Table 5 looks at the percentage of time RNs spend multi-patienting stratified by department. 16

20 Table 5. Percentage of Time Spent Multi-Patienting by Department Team 8: BMG Ambulatory Care Study 02/12/08-03/07/08 N=2408 Department Total Time Observed (in minutes) Total Time Multi Patienting (in minutes) % of Time Multi Patienting North % South % Combined % Key findings from Table 5 include: The North Side spends 3% of their time multi-patienting. The South Side spends 1% of their time multi-patienting. The North Side spends a greater percentage of time multi-patienting than the South Side. Quantitative Data Collection Part 4: Task Volume Tick Mark Study - The purpose of the Task Volume Tick Mark Study was to further analyze the volume of tasks RNs perform each day. A summary of the percentages of total task voume for each task type stratifed by department and individual RN can be seen in Table 6. A full analysis of the Task Volume Tick Mark Study data can be found in Appendix K. Table 6. Task Volume Percentages Stratified By Department Team 8: BMG Ambulatory Care Study 02/18/08-02/29/08 N=1460 Key findings from Table 6 include: 70% of observed tasks by volume were outbound calls. The South Side handles a higher percentage by volume of live calls with 27.0% of observed tasks compared to 19.1% of observed tasks on the North Side. 17

21 Since outbound calls accounted for the highest volume of RN tasks, outbound calls were further stratified by call type, department, and RN in Table 7. Table 7. Outbound Call Distribution Stratified By Department and Nurse Team 8: BMG Ambulatory Care Study 02/18/08-02/29/08 N=1022 Key findings from Table 7 include: The South Side has a higher percentage of time sensitive outbound calls with 31.0% of their outbound calls being time sensitive compared to 6.1% on the North Side. The North Side has a higher percentage of Non-Urgent Day Of outbound calls with 47.3% compared to 32.1% on the South Side. The North Side has a higher percentage of calls in which the patient could not be reached with 32.6% compared to 20.9% on the South Side. The percentages for call type were then stratified by the time of day in Table 8 for the North Side and Table 9 for the South Side. Table 8. North Side Outbound Call Distribution Stratified By Time and Call Type Team 8: BMG Ambulatory Care Study 02/18/08-02/29/08 N=586 Table 9. South Side Outbound Call Distribution Stratified By Time and Call Type Team 8: BMG Ambulatory Care Study 02/18/08-02/29/08 N=436 18

22 Key findings from Table 8 and Table 9 include: The percentage of time sensitive outbound calls decreases throughout the day for both the North Side and South Side. The percentage of Non-Urgent Non Day Of calls increases throughout the day in the North Side while the percentage decreases throughout the day in the South Side. To look in to the findings from Table 8 and Table 9 further, the outbound call workload was stratified by nurse for the South Side in Table 10 and the North Side in Table 11. Table 10. South Side Outbound Call Workload Percentages by Nurse Team 8: BMG Ambulatory Care Study 02/18/08-02/29/08 N=436 Outbound Call Type Deborah J Linda S Stacy F Time Sensitive 33% 34% 33% Non-Urgent Day Of 34% 37% 29% Non-Urgent Non Day Of 26% 44% 30% Leaving a Message 27% 54% 19% Table 11. North Side Outbound Call Workload Percentages by Nurse Team 8: BMG Ambulatory Care Study 02/18/08-02/29/08 N=586 Outbound Call Type Linda K Melissa W Stacy F Time Sensitive 0% 53% 47% Non-Urgent Day Of 5% 52% 43% Non-Urgent Non Day Of 1% 23% 76% Leav ing a Message 3% 73% 25% Key findings from Table 10 and Table 11 include: On the South Side, Linda S handles 44% of Non-Urgent Non Day Of outbound calls. On the North Side, Stacy F handles 76% of Non-Urgent Non Day Of outbound calls. The percentage of North Side outbound calls not reaching the patient is plotted as a function of time of day in Figure 9. 19

23 60.0% 50.0% Percent of Calls 40.0% 30.0% 20.0% 10.0% 0.0% 8:00 9:00 10:00 11:00 12:00 13:00 14:00 15:00 16:00 17:00 18:00 Time of Day Figure 9. Percent of Outbound Calls Not Reaching the Patient: North Side Team 8: BMG Ambulatory Care Study 02/18/08-02/29/08 N=586 Figure 9 shows that the percentage of North Side outbound calls not reaching the patient peaks around 11:00 AM with 53.7% of outbound calls not reaching the patient. The RN workload at BMG was then stratified by day of the week for both the North and South sides as seen in Tables 12 and

24 Table 12. North Side Task Percentages by Day Team 8: BMG Ambulatory Care Study 02/18/08-02/29/08 N=586 Key findings from Table 12 include: The task percentage of Live Calls on the North Side is highest on Monday. The task percentage of Non-Urgent Non Day Of calls on the North Side is highest on Wednesday. The task percentage of Non-Urgent Day Of calls on the North Side is highest on Friday. The task percentage of nurse visits on the North Side is highest on Friday. Table 13. South Side Task Percentages by Day Team 8: BMG Ambulatory Care Study 02/18/08-02/29/08 N=436 21

25 Key findings from Table 13 include: The task percentage of Live Calls on the South Side is highest on Monday. The task percentage of Time Sensitive calls on the South Side is highest on Friday. The task percentage of Non-Urgent Day Of calls on the South Side is highest on Monday and Friday. The task percentage of walk in visits on the South Side is highest on Monday. Rockwell Phone Log Analysis - The purpose of the Rockwell phone log analysis was to identify the incoming and outgoing call volumes experienced by BMG. Table 14 shows the total number of patient contacts 3 and working days per month for August 2007 through December Table 14. Patient Contacts Per Month at North and South Side Combined Team 8: BMG Ambulatory Care Study 08/07-12/07 N=104 Table 14 shows that between August and December of 2007, 15,014 patient contacts were made over 104 working days. Dividing the total number of patient contacts by the total number of working days yields an average of 144 patient contacts per day. The standard deviation was 16.8 patient contacts. An analysis of phone call duration stratified by call type of the time period from 2/19/08 through 2/29/08 is presented in Table 15. Table 15. Phone Call Distribution Stratified By Call Type for North and South Side Team 8: BMG Ambulatory Care Study 02/19/08-02/29/08 N=1162 Key findings from Table 15 include: RNs spend 35.9% of their phone time on inbound calls. RNs spend 64.1% of their phone time on outbound call. The average inbound call length is minutes with a standard deviation of minutes. The average outbound call length is minutes with a standard deviation of minutes. 3 Patient Contacts = # of Inbound Calls + # of Outbound Calls 22

26 Recommendations The following recommendations were developed based on the findings from the observations, interviews, surveys, two workload studies, detailed workload study, task volume study, and the Rockwell phone log analysis. Standardized Work Procedures - The following standardized work procedures are recommended for use at BMG, based on reviewing observed procedures with the Nurse Manager and the Health Center Manager. A task force should be created to evaluate all templates currently in use at BMG, in particular, those used by the nurses and clerks. Templates should be efficient in terms of both data entry and data retrieval as well as contain only the necessary information. Templates involving the documentation of patient contact information should also include the best time to contact the patient. Clerks should also verify the contact information of the patient during the call. These two practices combined should decrease the percentage of calls unanswered. Further study would be required to identify by how much the percentage decreases. Explore pros and cons of using only approved Care web templates that have been reviewed by an official template approval process. General medication should not be refilled by RNs. If an RN receives a request for a general medication refill, the request should be forwarded to an MA. Medication refills should be faxed to pharmacies, if possible, rather than called in. Referral appointments outside BMG should not be scheduled by RNs. If a referral appointment is required, a request should be sent to a Referral Coordinator or Clerk. Clerical staff should be trained through an MLearning module to write clear and concise notes as well as how to route notes properly to improve communication within BMG. The quantity and time of available RN-only-appointment slots should be reviewed monthly to determine whether more or less appointment slots should be made available. Staffing Levels - The Detailed Workload Study, data showed that 50.1% of RNs time was spent completing on phone activities, each taking on average 6.3 minutes to complete, which equates to 4.8 calls / hour. One Full Time Equivalent (FTE) working 40 hours per week could then handle 192 calls / week. The Rockwell Phone Log Analysis, data showed that a median of 133 calls / day were handled by RNs at BMG, which equated to 665 calls / week over a five day work week. Using the previously calculated 192 calls per week / FTE, it was determined that BMG needs to operate on 3.46 FTE to handle 665 calls / week. This FTE is 0.38 FTE more than the current 3.08 FTE utilized at BMG. 23

27 Ongoing Workload Measurement System - The following recommendations have been developed to aid in measuring the workload easily at the ambulatory care sites. Training on Use of Rockwell System A disconnect exists between what the Rockwell phone data showed that nurses spent their time on and what nurses spent their time doing based on the data collected. This disconnect is caused by a lack of understanding by the nurses of the full functionality of the Rockwell phones. The Rockwell phones can collect data throughout the entire day for each task the nurses complete on the phone, provided they code the task correctly in the system. With better training and understanding of the Rockwell phone system, the nurses will be able to improve the coding of their tasks, resulting in an accurate depiction of their on-the-phone activities from the Rockwell phone data. Management Audits of Rockwell Data Management needs to evaluate the Rockwell data to ensure the nurses are correctly coding their tasks. It is important to note that the first Rockwell phone management data reports that were shared with the BMG RN staff occurred January This review of data will provide management with whether or not correct procedures are being followed and allow management to address any issues as they arise. Rockwell data should be evaluated monthly and more frequent evaluations in the early stages may be necessary. Additionally, management should review this data with each nurse to provide the nurses with periodic feedback on job performance compared to management expectations. Site Manager Training on Data Interpretation To provide consistent knowledge across all study sites, management may need to review the data provided by the Rockwell phones. The Rockwell phones produce large outputs of data which can be confusing and overwhelming. To reduce confusion and improve efficiency, management may need to go through training on the data interpretation of the phone output. This training will improve management s ability to understand the data and to communicate its significance to the nurses in their performance reviews. General Computer Training To improve overall efficiency, it may be valuable to provide RNs with basic computer training on general computer applications such as Excel and other programs often used by the nurses. If all nurses are brought to the same level of understanding of basic computer software, overall output will be higher. Expected Impact The findings and recommendations of this study will be used in conjunction with the other findings and recommendations from the similar workload studies completed within UMHS. These findings and recommendations are specific to BMG. These recommendations will aid management in the development of nursing standards, help improve nurse scheduling, and allow for rearrangement towards patient centered care across all ambulatory care sites. 24

28 Appendix Appendix A: Nursing Workload Survey Nurse Survey Name: 1. Could you please list activities and tasks you perform regularly? Approximately what percentage of time goes towards each of those activities? 2. Do you think your workload depends on the time of day? Day of week? Month of year? 3. Do you normally have to work overtime to complete your work? 4. Are there any activities that you listed that you feel are not in your job description? 5. Do you like the live call system? Does it affect your ability to do your job? 6. How would you rate the effectiveness of the current scheduling system? What if anything would you change? 7. What, if any, changes do you think would improve your ability to do your job? Please write any additional comments on the back. A-1

29 Appendix B: Nursing Workload Survey Management Survey Name: 1. Could you please list activities and tasks you perform regularly? Approximately what percentage of time goes towards each of those activities? 2. Do you think your workload depends on the time of day? Day of week? Month of year? 3. Do you normally have to work overtime to complete your work? 4. Are there any activities that you listed that you feel are not in your job description? 5. Do you like the live call system? Does it affect your ability to do your job? 6. How would you rate the effectiveness of the current scheduling system? What if anything would you change? 7. What, if any, changes do you think would improve your ability to do your job? Please write any additional comments on the back. B-1

30 Appendix C: BMG Nursing Operations Flowchart Figure C.1 Flowchart of RN Operations in BMG Team 8: BMG Ambulatory Care Study 01/28/08-02/22/08 C-1

31 Appendix D: Data Entry Sheet for General Study Part 1: General Study Primary Care Nursing Workload Study Staff: Department: Date: Instructions: When the random reminder beeper sounds, please place a check mark in the box corresponding to the task performed at the time of the beep, under the time that the beep occurred. Also, please note start, lunch, and end times below. Nursing Tasks: Patient Care: Assisting with provider visit Performing nurse visit Caring for walk-ins On phone with patient/ family Indirect Patient Care Documenting (electronically or on paper) Delegating tasks/ supervising Coordinating for patients Consulting with physicians Looking up patient and care information Coordinating prescriptions (pre/post patient visit) Transcribing from voic Non-Patient Performing administrative responsibilities Participating in quality improvement (QI) projects Other meetings Staff education/competency Participating in self professional development Taking personal time 8:00-9:00 9:00-10:00 10:00-11:00 11:00-12:00 12:00-1:00 1:00-2:00 2:00-3:00 3:00-4:00 4:00-5:00 5:00-6:00 6:00-7:00 7:00-8:00 8:00-9:00 Start Time: Lunch: - End Time: D-1

32 Appendix E: Data Entry Sheet for Phone Study Part 2: Phone Study Primary Care Nursing Workload Study Staff: Department: Date: Instructions: When the random reminder beeper sounds, please place a check mark in the box corresponding to the task performed at the time of the beep, under the time that the beep occurred. Also, please note start, lunch, and end times below. Nursing Tasks: On Phone Activities In process of talking to patient/ family Waiting for next patient call On hold Talking to provider (on phone) Talking to another internal department (on phone) Leaving a message for pt/family Talking to pharmacy or DME Talking to external agency Transcribing from voic Work related to call Documenting (electronically or on paper) Faxing related to the call After call coordinating for patients (non-phone) Consulting with providers (non-phone) Looking up patient and care information Non-Call-Related Performing administrative responsibilities In-clinic care Supervising/delegating/precepting/orienting Taking personal time/self development 8:00-9:00 9:00-10:00 10:00-11:00 11:00-12:00 12:00-1:00 1:00-2:00 2:00-3:00 3:00-4:00 4:00-5:00 5:00-6:00 6:00-7:00 7:00-8:00 8:00-9:00 Start Time: Lunch: - End Time: E-1

33 Appendix F: Data Entry Sheet for General Workload Study T2 P1 T1 P2 F-1

34 Appendix G: Data Entry Sheet for Task Tick List Study Part 4: Task Tick List Primary Care Nursing Workload Study Staff: Department: Date: Instructions: Please place a tick mark in the box corresponding to the task performed at the start time of each task. Also, please note start, lunch, and end times below. **Note: This part of the study keeps track of all calls including numerous calls for the same patient. Nursing Tasks: Inbound Calls Taking a live call (red call or call back) Outbound Calls Talking w/ patient or in regards to patient (**Time Sensitive Call) Talking w/ patient or in regards to patient (**Non-Urgent Call) (DAY OF) Talking w/ patient or in regards to patient (**Non-Urgent Call) (NON DAY OF) Leaving a message (no answer) (mark every call) Clinic Duties Performing walk-in visit 8:00-9:00 9:00-10:00 10:00-11:00 11:00-12:00 12:00-1:00 1:00-2:00 2:00-3:00 3:00-4:00 4:00-5:00 5:00-6:00 6:00-7:00 7:00-8:00 8:00-9:00 Performing nurse visit Assisting a provider Non-patient Related Tasks Start Shift: Lunch: - Break: - End Shift: **Note it is assumed documentation will occur with all calls, including those where a message is left. Therefore, we do not need to tally this information. G-1