overtime due to shjflreport i/ - University of Michiganioe481/ioe481_past_reports/w0006.pdf• A long-term option would be to document all patient information on a computer system

Redesigning Shift Reportingat UMHHC

.

i/ overtime due to shjfl report

Tanya Coffey Jo

April 14, 2000

Tabk ofContents

Executive Summaiy 1

Introduction and Background 4IntroductionPurposeBackground and environment affecting the project

Approach and Methodology 5

Current Situation 7Shift report methodologyOvertime Data

Alternatives and Hypothesis Considered 8

Findings and Summaiy 9Observation summaryFoote HospitalOvertime cost analysisCost-benefit analysis of VoiceCare

Conclusions 14

Recommendations 15

AppendicesGanttChart ASurvey BVoiceCare Data CShift Reporting Flow-Chart DSurvey Results EUMHHC Overtime Data FCost-Benefit Analysis - GSummary of Comments HFishbone Diagram IDistribution of Comment By Unit 3

Efive Summmy

Introduction

This project is a detailed account of our analysis of the current methods of shift reportingused in the inpatient nursing units at UMRHC, evaluation of alternative systems andrecommendations for altering the shift reporting process. We were requested by HeatherWurster, Director of Patient Services and Janet Goldberg, Nurse Manager in theDepartment of Nursing at the University of Michigan Hospital and Health Centers toevaluate the shift reporting process on inpatient nursing units with an emphasis onreducing the incidental overtime occurring among nursing staff Nursing in all twenty-eight units is experiencing shift reporting longer than the allotted 30 minutes, whichresults in overtime for nurses and less time for patient care. By examining the status quoand other options, we propose several options for streamlining the shift reporting processand in turn, reducing the incidental overtime and nursing staff overtime costs occurringdue to shift reporting.

Background

Due to the differences among units there is a large variance in both the methods used toconvey patient information and the time it takes to complete shift report. The methodsused include verbal, written and taped reports that may or may not include general and/orone-on-one reports. The variance in methods and information given among units createsa problem when staff is transferred to a different unit or when a nurse is covering a shiftin a unit that they do not normally work in. This contributes to the incidental overtimecosts for nursing staff Annualized incidental overtime for all inpatient nursing units inincrements of 30 minutes or less is approximately $145,980. This is less than 5% of the$3 million annual nursing overtime expenditures for UMHHC.

Methodology

• Selecting five pilot units from UMMHC was our first step in assessing the shiftreporting methodologies currently being used. These units represented all of theinpatient units and were selected based on acuity level, current method of report,and estimated overtime due to shift report. The units selected were SB, 6D,7MW, 8A, and WHBC.

• Observation and staff interviews of each pilot unit were the next step. Withineach unit we observed at least two different shift changes at different times. Indoing so, we were able to observe differences not only between units, but alsodifferences between shifts of the same unit. Off-going and on-coming nurseswere interviewed after each observation.

• A survey was conducted in order to verify’ that the input from the pilot units wasrepresentative of all inpatient units at IJMI-IHC.

/I ( . Collection of data on overtime costs was the next step. The Nursing Finance

Department was able to furnish data for overtime in increments of a half-hour orless for each unit for the 6-month period from July 1 — December 31, 1999. Thisdata was then annualized in order to be useflul in cost benefit analyses to be laterconducted.

• Literature and Internet search for alternative shft reporting systems: Thisincluded collecting information on available telecare systems designed tofacilitate the shift reporting process.

• Site visit to Foote Hospital: We were able to observe a telecare system currently

beingused and discuss the benefits and shortfalls of the system with staff

• Review and evaluation ofshft reporting methods: Using all data and observationsgathered we began to evaluate different types of methods of shift report that couldbe implemented as a hospital wide method. The terms used in evaluating eachoption included cost-benefit analyses, staff reception to method, estimation ofeffectiveness in reducing time required to complete shift report, and affect onpatient care.

• Development of recommendations for shift reporting procedures: The final stepwas to develop recommendations based on our findings.

Findings

Based on observations at the five pilot units, four out of the five pilots took longer thanthirty minutes to complete their shift report. Below is a summary of what units wereobserved, the type of report used and the average length of report observed.

Unit Method Length of report5B One-on-One 35-40 minutes

WHBC One-on-One 40-45 minutes7W Taped 30 minutes6D Group and One-on-one 45 minutes8A Group and One-on-one 45 minutes

In addition to the observation data collected from UMHHC, we made observations atFoote Hospital to evaluate the VoiceCae system. Their pilot units were theWomen/Newborn unit and 5 South, a general care unit. After using VoiceCare for ninemonths, nurses were surveyed to determine their satisfaction. Based on the nurse’ssatisfaction and the pilot unit trial, Foote proposed to implement VoiceCare in all units oftheir facility excluding ICU’s and the secure unit. The proposal for implementation listeda positive impact on patient care, an increase in staff productivity and a reduction inovertime costs as benefits to be attained. Over the trial period on the pilot units theClinical Nurse managers estimated an average decrease in overtime of 2.2 hours per dayper unit, which would lead to a reduction of $5,279 per month in overtime costs.

2

Subjective data was also collected from nurses from eighteen inpatient units to determinethe type of report used, their overall satisfaction with their unit’s method of shift report,and average report time.

Conclusions

From the survey data, the interviews conducted and the observations made, it is apparentthat lack of standardization not only between, but also within the units is a majorcontributor to the length of shift reporting. This lack of standardization leads to aninefficient shift reporting process, where the information being passed from one nurse toanother can be inconsistent, unnecessary, incomplete, or repeated from the kardex.

Recommendations

Initially we were asked to evaluate VoiceCare, and at this time, we do not recommendpurchasing this system. The following are the recommendations we do make:

Our first recommendation is to standardize the shift report process.Standardization will eliminate unnecessary information, decrease repetition ofinformation from the kardex and reduce the amount of time taken to give thereport. Standardization should be achieved by input from nurse managers as wellas the nursing staff

• Our second main recommendation is that patient assignments be made by thecharge nurse of the previous shift.

• Other recommendations include:• Reduce the amount of non-patient related chatting among the nurses

during the shift report• Eliminate the scheduling of patient procedures during the shift report• Technicians and nurses should not be doing shift reporting simultaneously• Reduce the number of interruptions from doctors, staff and visitors

• A long-term option would be to document all patient information on a computersystem. This would permit hospital staff to enter in all patient information andthe program would have the capability of formatting the necessary informationneeded for charting, the kardex and shift reports.

3

Final Report

duction and Baund

Introduction

This project report is a detailed account of our analysis of the current status of the shiftreporting methods for inpatient nursing units used at UIvIHHC, evaluation of alternativesystems and recommendations for altering the shift reporting process. Initially theproject focus was to analyze the feasibility of using the VoiceCare system at UMHHC tostreamline the shift reporting process. Due to an overestimation of the actual cost of theincidental overtime occurring, it became apparent that the VoiceCare option was notlikely to offer the amount of savings as initially anticipated. The project was thenexpanded to include developing other recommendations for decreasing the length of timerequired for shift reporting and by doing so decrease the amount of overtime costs.

Purpose

We were requested by Heather Wurster, Director of Patient Services and Janet Goldberg,Nurse Manager in the Department of Nursing at the University of Michigan Hospital andHealth Centers to evaluate the shift reporting process on inpatient nursing units with anemphasis on reducing the incidental overtime occurring among nursing staff Shiftreporting currently has an allotment of 30 minutes at each of the three major shiftchanges (7a.m., 3p.m. and 11p.m.). However, nursing in all twenty-eight units areexperiencing longer shift reporting which results in overtime for nurses and less time forpatient care. By examining status quo and other options, we propose several options forstreamlining the shift reporting process and in turn, reduce the incidental overtimeoccurring due to shift reporting and the overall cost of overtime for nursing staff

Background and Environment affecting theproject

Currently there are multiple formats for shift report including written, or verbal at everyshift change. Shift changes include the normal 7a.m., 3p.m. and 11p.m. changes, as wellas those that occur at odd times for staff working 4 or 12 hour shifts. The nurses arefamiliar with their current methods and may be resistant to change. The differencesamong units contribute to a large variance in both the methods used to convey patientinformation and the time it takes to comple’e shift report. The methods used includeverbal, written and taped reports that may or may not include general andlor one-on-onereports. The variance in methods and information given among units creates problemswhen staff is transferred or covering shift in a unit that they do not normally work in.This contributes to the incidental overtime costs for nursing staff Annualized incidentalovertime for inpatient nursing units in increments of 30 minutes or less is about$145,980, which is less than 5% of the $3 million annualized nursing overtimeexpenditures for LJMI-IHC.

4

Appnach and Methodology

There were several phases involved in this evaluation (refer to Appendix A). The projectsteps include:

• Selecting pilot units• Observations ofpilot units shift report process• Interviews with selected nurses• Complete survey of all nurses• Obtain overtime data from the ANSOS system• Site visit of hospital currently using VoiceCare• Complete literature search• Review of alternative systems• Determination of best practice• Summary of alternatives and complete cost-benefit analysis

The first phase of our evaluation of the current nurse shift reporting methods was toobserve pilot unit’s shift report and interview the nurses. This consisted of both detailedobservations of a few carefully selected units and an overall view of eveiy unit in theUMHHC, through data collection. The five pilot units selected were chosen based on theacuity level, current method of report, and overtime cost attributed to shift reporting.Using these selection criteria, these units collectively represented all of the units in thehospital reasonably well so that we could assess different reporting methods, and howeffective it would be as a hospital-wide method. The units we selected along with thereason why each was selected can be found in Table 1 below.

Table 1: Pilot UnitsPilot Unit Reason Selected

5B Adult General Care Unit; only one-on-one reporting6D Adult Intensive Care Unit; group and one-on-one reporting7W Pediatric General Care Unit; tape-recorded report used8A Adult High Acuity Unit; highest incidental overtime cost

WHBC Women’s Health and Birthing Center; unique patient information

We observed shift report during at least two different shift change times for each of thefive pilot units so we could evaluate the differences not only between units, but alsobetween the three shifts at each unit. Both the off-going and the on-coming nurses wereinterviewed after each observation to gauge how the nurses felt about the current shiftreport method in their unit, any areas of shift report they felt needed improvement andany comments they had on the different methods of shift reporting we were assessing.

Our next step was to consider all remaining units of the hospital in our study of shiftreport. A survey was distributed to all inpatient units of UMHHC, addressing issues suchas level of satisfaction with current reporting methods, comments on other methods ofshift reporting, an estimation of how much time shift report takes and any additionalconcerns related to our study. (Refer to Appendix B for a copy of the survey.)

5

In addition to subjective information, we needed to collect concrete data to assist inweighing different methods of reporting. Overtime data was acquired with the assistanceof Pat Williams and Rhonda Schoville from the Nursing Finance Department for allnursing units. Specifically, we needed an estimate of overtime costs associated with shiftreport for each unit. Williams and Schoville advised us to look at the overtime costs forall reported overtime that was 30 minutes or less and also all reported overtime that wasone hour or less. Based on observations and the experience of Wurster and Goldberg, wedetermined that shift report rarely required more than 30 minutes of overtime. Most ofthe overtime beyond 30 minutes would most likely be attributed to patient care.However, we acquired a report for one hour or less of overtime because Williams andSchoville noticed that the amount in this bracket was only marginally higher than the 30minute or less bracket. Therefore even if all overtime of up to an hour were included, thecost benefit analysis would not change significantly. The overtime reports generatedwere a summaiy for July 1, 1999 — December 31, 1999. This time frame was chosenbecause it was the most recent 6-month time frame available. The decision was made toevaluate only 6 months of overtime data because shift report methods can and havechanged over time, and this data would give the most accurate representation of thecurrent situation and the current methods. The costs summarized were then annualized.

Using the subjective input from the nurses, observations, and the information related toovertime costs all options of shift reporting were considered on the basis of how welleach may work as a hospital-wide system and whether a telecare system would be cost-effective. The first system evaluated was one called VoiceCare. The Nursing Directorbrought this system to our attention early on in the project. VoiceCare suppliedinformation on how much the system would cost and how the system worked (seeAppendix C). Foote Hospital in Jackson, MI had already implemented the VoiceCaresystem, so an observation and interview was set up with staff on two of their units.

A literature search was done to see what other systems were available on the market.Another system, Executone, whose fhnctionality and costs were comparable to those ofVoiceCare, was also examined. Aside from these two programs, which were specificallydesigned to handle shift reporting, LabLine was also examined. LabLine is a system thatis currently being used at UIvll-IHC to report results of lab tests to patients. We lookedinto LabLine to see if it had the capability of expanding into covering the needs of shiftreporting using a telephone.

We found that unit 6C had recently begun a new system of report. Instead of reportingverbally, 6C had moved into a written report. We observed how this method worked andspoke with some of the nurses in the unit to gauge how well it was working, and how thismethod might be improved or used as a best practice.

The final step was to do a cost-benefit analysis of the alternative report methods and lookfor correlations between overtime costs and other factors. The cost-benefit analysis wasaccomplished by calculating the net present value (NPV) of the different implementationalternatives offered by the VoiceCare system.

6

Cunent Situation

Sh!ft report methodology

Currently, there are 4 different methodologies of shift reporting. These methods are:• Group report• One-on-one report• Tape-recorded report• Written report

Group reports are generally done in two ways:• In the first method, the charge nurse or designated team leader of the offgoing

shift reads off general information concerning each patient to all the nurses ofthe incoming shift. This general information is taken from a sheet of paperthat the off going nurses used to write about the patients they were assigned.

• The other method of group report involved all of the incoming nurses togather in a room and each off going nurse would take turns coming into theroom and giving a report on each of their assigned patients.

In the one-on-one reports, an off going nurse will give a report to an incoming nurse witha matching patient assignment. Because an off going nurse may not have an exactmatching patient assignment with an incoming nurse, an incoming or off going nurse willoften have to speak to several nurses before their one-on-one report is finished. One-on-one reports are implemented either by themselves or prefaced by a group report.

Tape-recorded reports involve each off going nurse giving their patient reports before theactual shift change. Sometimes there are two tapes for the off going nurses to recordtheir reports on for convenience. The actual shift report is similar to the second methodof group reporting where all of the incoming nurses are gathered in one room and theylisten to the patient reports that have been recorded by the off going nurses.

In the written reports, there is one form asking for certain patient information that thenurses fill out during the course of their shift. At the end of the shift, this form isphotocopied for all of the incoming nurses. The actual shift reporting only involves theincoming nurses reading the form and taking notes from it. A flowchart of shift reportingmethods can be found in Appendix D.

Overlime Cost

Annualizing the nursing overtime expenditures from July 1999 - February 28th 2000gives approximately $3 million spent per year. The data collected from the payrolldepartment from July 1 — December 31 1999 for all nursing overtime in increments ofone hour or less and one-half hour or less showed $116,069 and $72,990 respectively.Annualizing these figures we get $232,138 for one hour or less and $145,980 for one-halfhour or less.

7

MtemandflthesisComàkred

Three alternatives are considered for shift reporting. They include:• Telecare• Written Report• Taped Report

The first alternative considered is telecare. InTeleCare, Inc. markets a product,VoiceCare, directed toward improving the way in which nurse shift reporting occurs.The system is like an elaborate voicemail system. It is phone based and nurses dial into asecure database to access and input patient information. The options it provides issummarized below:

1. Record Reporta. Add Addendumb. Re-record report, in sequence ifdesired

2. Listen to Reporta. Listen to report, in sequence if desiredb. Listen to addendumsc. Replay entire reportd. Move back or forward 5 seconds at a time

3. Patient Table Menua. Admit Patientsb. Transfer Patientc. Discharge Patientd. Record Patient Namee. Recover beds£ Swap Patientsg. Censush. Move Patient

4. Messages Menua. Record messages for othersb. Listen to messages

i. Interruptii. Erase

iii. Repeativ. Listen to next message

c. Delete all messagesd. Notif,r by paginge. Appointments

5. You can return to the main menu from anywhere in the system

8

Another alternative considered is written report. Units would create a form, which willencompass all necessary and relative patient information. Nurses then fill out theirpatient information when they have time during their shift. At shift change, copies of thisform would be made for all oncoming nurses. Oncoming nurses review their patientinformation and if they have any questions, they can ask the off going nurse before theyleave. This type of reporting also incorporates standardizing information that isdisseminated.

Taped reports are also considered. Typically, there are two tape recorders located in aunit so two nurses can tape report simultaneously. At shift report time, all oncomingnurses listen to report and transcribe any pertinent information that they need. There isgenerally time available after the taped report to ask any additional question of the offgoing staff

:F’indnigs andH•4

Observation Summary

Unit 5B

Type of report: One-on-oneGeneral length of shift reporting: 35-40 minutesGeneral observations:

• Patients are pre-assigned• Some nurses are unprepared at beginning of shift change• Some chatting about other subjects

Unit 6D

Type of report: Group and One-on-oneGeneral length of shift reporting: 45 minutes

• General observations:• Patient assignments and negotiations delay shift report• Shift report starts late due to employees not being ready on time

Unit 7West

Type of report: Tape-recorded (Group)General length of shift reporting: 30 minutesGeneral observations:

• Incoming nurses listen to detailed reports on all patients• 2 tapes used in report• Addendum’s from nurses are added in between patient reports• Room was quiet while tape is playing• Nurses getting information from kardex while waiting for report• Nurses who do not have time to tape give an oral report instead

9

Unit 8A

Type of report: Group and One-on-oneGeneral length of shift reporting: 45 minutesGeneral observations:

• Patients are pre-assigned by charge nurse• Patient assignment negotiations take up some time• Some waiting around to give or receive reports

Women Health and Birthing Center

Type of report: One-on-oneGeneral length of shift reporting: 40-45 minutesGeneral observations:

• Patients are divided by labor, postpartum• Patients are pre-assigned by charge nurse• Very interactive report• Lactation consultant gives individual reports to nurses• Some waiting for nurses to be available to give report• A lot of chatting among some nurses, none among others

Foote Hospital

W. A. Foote Memorial Hospital in Jackson, Michigan implemented VoiceCare in two oftheir units in September of 1995 for a trial period to evaluate the system. The two unitswere the Women/Newborn Unit, comparable to WHBC, and 5 South, a general care unit.After the pilot units used the VoiceCare system for nine months, nurses were surveyed todetermine their satisfaction. A summary of their survey results can be found in Table 2.

Table 2: Foote Survey SummarySurvey Question W/N 5SRecommend VoiceCare for use in other units 62%Improvement of Quality of report 38% 65%Less time to give report 93%Less time to get report 65% 89%Prefer VoiceCare method of reporting 47% 85%

Based on these results, Foote proposed to implement VoiceCare in all units of theirfacility excluding the ICU’s and the secure uiit. The proposal for implementation listeda positive impact on patient care, an increase in staff productivity and a reduction inovertime costs as the benefits to be attained. The positive impact on patient care resultsfrom increasing nurse availability for patients as well as providing a means for theClinical Nurse Managers and Case Managers to review all patient reports and patientstatuses at their convenience. The increase in staff productivity and reduction ofovertime costs were also due to the decrease in the length of time required to receiveand/or give report. Over the length of the trial period on the pilot units the Clinical Nursemanagers estimated an average decrease in overtime of 2.2 hours per day per unit, whichwould lead to a reduction of $5,279 per month in overtime costs.

10

Survey Data

The information we were able to collect and compile from the surveys was divided intothree sections: methods feedback, average report time, and overall satisfaction withcurrent report method. In the methods feedback section, nurses could comment onwhether they like or dislike the three main reporting methods: group report, one-on-onereport, and tape-recorded report. From there, we divided the responses into two classes:those nurses who use the method and those who do not. Regardless ofwhether theresponding nurses were currently using the method, or ifthey had used that method in thepast, we included them in the user class because their experiences are both first-hand withthe particular method in question. The average reporting time is a subjective measure ofhow long the nurses think the report usually takes and we tallied how many nursesselected each of the time brackets available on the survey. If a nurse checked off two ormore brackets, we added a tally to all brackets selected. Similarly, the overallsatisfaction section was tallied according to the number of nurses who selected eachvalue as their rating. If a nurse wrote in a value that was in between two that were listed,such as 6.5, we added a tally to both 6 and 7. (Refer to Appendix E for survey results)

The distribution of methods used by the respondents is displayed in Figure 1 below. Thisshows how many of the respondents currently use or have previously used that particularmethod or combination ofmethods.

Figure 1: Distribution of Methods used by Respondents

Group, Ot1Ofl One-on-oneone&Taped / 13%

26%

One-on-one &Taped Group & One-

6% on-one

Group & Taped 48%

7%

The following table shows by report type the percentage of total units using that type andthe percent of st&ff that prefer that type. The percentage of total units does not add up to100%, because some units use multiple types. One-on-one report had the highestpreference at 89%.

Table 3: Percent Use and LikeReport % of Total % Like

Group Report 78% 75%

One-mi-One 83% 89%Taped 33% 71%

11

Figure 2 below summarizes overall shift report length. Some respondents did not reply tothis part of the survey, or responded more than once. The percentages were calculated asthe number of nurses selecting the time period over the total number of time periodsselected. The largest percent of staff spend an estimated 30 to 45 minutes on shift report;this represents 49% of respondents.

25%

10%

5%

0%

Figure 2: Shift Report Length

40%

30%

20%

1%

60%

50%

0%

<15 15-30 3045 >45

Shift report length (minutes)

Figure 3 below summarizes overall satisfaction with shift report. Staff responded byranking satisfaction on a scale from 1 to 10, with 10 indicating complete satisfaction withmethod of shift reporting used. A score of 8 had the largest response with 20.8% of thenurses scoring their report at this level.

Figure 3: Shift Report Satisfaction

20%

a15%

a

17.3%

20.8% 20.2%

7.1%

2.4% 3.0% 3.6%

10.7%

1 2 3 4 5 6 7 8 9 10

Rating of report

12

Figure 4 below summarizes the average satisfaction score per unit. Two units, 5C and6M, had 2 or less responses and are not valid. Of the remaining units 8B had the highestscore at 8.8 and 8C had the lowest score at 4.3.

Figure 4: Shift Report Satisfaction

JIlLUnit

Overtime Costs Analysis

We chose to use overtime data for 30 minutes or less as a guideline in evaluating theovertime costs associated with nursing shift reports from our observations in the pilotunits and the subjective data collected from the surveys. 30 minutes are allocated in eachshift for reporting, and in observing the shift reports in the pilot units; we did not see anyreports take longer than one hour. Because there are many different reasons why nurseswork past the end of their shift, we used the subjective data from the survey to measurehow much overtime was dedicated to shift reporting. In the 176 surveys that werecompleted out of the 840 surveys distributed, 53% responded that shift reporting tooklonger than 30 minutes. From that data, we chose 53% to analyze how much of theovertime in increments of 30 minutes or less was due to the shift change reports.(Appendix F contains the original overtime data)

Cost - BenefitAnalysis of VoiceCare

We evaluated both the service contract and purchase options given by VoiceCare forimplementation of their system at UMHHC. VoiceCare recommended a 72-line systembased on the average daily census of 583 for all hospitals. The number of linesincorporated into the system is the maximum number of nurses that can use the system atthe same time. Due to the number of nurses that may be attempting to retrieve report atthe 7am shift we also looked into the pricing options for the 128-line system.

VoiceCare offers two options for implementing their telecare system at a facility. Thereis a purchase option that requires an initial capital outlay for the hardware and software, a

13

fee for support of the software and hardware and the provision of phone lines for thesystem. The service contract option requires an initial training and installation fee, thenan annual fee for the life of the contract, and the provision of phone lines. We wereadvised by Marilyn Lanzon, of Telecommunications, after discussing the VoiceCaresystem with her, that the support requirements from Uvfl{HC would require one full-timeemployee (FTE), this cost was included in the cost-benefit analysis.

When calculating the benefits of VoiceCare, namely reduction in nursing overtime costs,we used a 3% inflation rate in salary over the five-year life of the analysis. The savingspredicted by using the VoiceCare system are given as 53% of nursing overtime data inincrements of thirty-minutes or less. The initial capital outlay for the purchase optionwas depreciated on a straight-line basis over five years. The costs of the phone lineswere given by MCIT, as $21/month/line, this cost was also inflated 3% each year overthe life of the analysis. The estimated salary of a technical FTh employed by UME{HC tomaintain the phone lines and system was $30,000. An additional 30% was added to thisfigure to account for benefits that would be provided to this FTh by UMHHC. The costof this employee was also inflated at a rate of 3% per year. In calculating the Net PresentValue (NPV) of the options available for implementing the VoiceCare system, an 8%opportunity cost of capital was used. Table 3 below is a summary of the different optionsavailable and their calculated NPV. (Table of all calculations can be found Appendix G).

Table 3: NPV for VoiceCare optionsNPV 72-Line 12S-Line

Service Contract $8,702 ($76,811)Purchase Option ($12,490) ($109,817)

Conclusions

Lack ofStandardization

From the survey data and interview observations, it is apparent that lack ofstandardization both between and within the units is a major contributor to the length ofshift reporting. This lack of standardization leads to an inefficient shift reporting processwhere the information being passed from one nurse to another is inconsistent,unnecessary, incomplete, or repeated from the kardex. When the nurses were askedabout factors leading to the delay of the shift reporting process, starting late was the mostprevalent cause. The preparation of the nurses for the shift report is also vital, if thenurses are not ready at the shift change, the entire process is delayed, and the shift reportdoes not run as smoothly. (See Appendices H & I for graphical displays ofcomments/problems associated with shift reporting.)

I c14

Survey CommenL

According to the survey data, the major factors leading to an unnecessarily lengthenedshift report are starting late, irrelevant information being passed along and non-patientrelated chatting. The delayed start of shift reporting cannot always be helped due tonurses busy tending to patient needs. These factors contribute to the lack ofstandardization in shift reporting. In general the staff are satisfied with their shiftreporting methods, though they do see room for improvement in streamlining the process.

CostAna’ysis

With the assumption that all of the overtime due to shift reporting will be eliminated withthe implementation of VoiceCare, the cost benefit analysis of VoiceCare shows us thatthe only feasible option would be the purchase of 72 line service contract option. Thefeasibility of this option is due to the fact that it is the only option with a positive netpresent value (NPV). The NPV of this option is $8,702.90, which is modest compared tothe overtime costs from shift reporting. Although VoiceCare recommended a 72-linesystem for UMHHC, the practicality of only having 72 lines is questioned. Ideally, everynurse should be able to use the system at anytime of day without having to wait. With 28in-patient units, approximately 2.6 nurses in each unit could use the system at any giventime. However, increasing the number of lines in the system to 128 leads to a negativeNPV in both purchase and service contract options.

Rmmend

While asked to evaluate VoiceCare, we cannot recommend purchasing it at this time.The system would not be a cost effective addition to the shift reporting process atUMHHC. Some of the benefits of the VoiceCare system can be attained without thecapital outlay required to purchase and implement a telecare system.

We have developed other recommendations for decreasing the time it takes to do shiftreport, and therefore the incidental overtime costs. Our first recommendation is tostandardize the shift report process. Through standardization, there will be a clearerpicture of the information needing to be passed on from the nurses in the off going shiftto the nurses in the oncoming shift. Standardization will eliminate unnecessaryinformation, decrease repetition of information from the kardex and reduce the amount oftime taken to give the report. Standardization should be achieved by input from nursemanagers as well as the nursing staff

Our second main recommendation is that patient assignments be made prior to the shiftreport. With the assignments already made, oncoming nurses do not have to concentrateon all of the patient reports, giving them more time to prepare for the care they will needto give to their assigned patients before their shift begins and again eliminating time spentin the shift report. Also, nurses should be encouraged to accept their patient assignmentsthey are given rather than negotiating for trades.

15

Some secondary recommendations are:• Reduce the amount of non-patient related chatting among the nurses during

the shift report would allow the reporting to run smoother and reduce theamount of time nurses must wait to give one-on-one reports.

• Eliminate the scheduling of patient procedures during the shift report, sonurses will not have to take time away from their report to prepare theirpatient for the procedure.

• Technicians and nurses should not be doing their shift reportingsimultaneously.

• Reduce the number of interruptions from doctors, staff and visitors wouldallow the shift reports to flow with greater ease.

• Further analysis of the new written shift reporting method on 6C

An option to consider for a long-term design would be to document all patientinformation on a computer system. Using a program to eliminate the need to repeatinformation from the patient chart, kardex, and shift report would reduce the amount oftime taken to record information and allow more time for patient care. This would pennithospital staff to enter in all patient information and then the program would have thecapabilities to format the necessary information needed for charting, the kardex, and shiftreports.

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Gantt Chart ASurvey BVoiceCare Data CShift Reporting Flow-Chart DSurvey Results EUMHHC Overtime Data FCost-Benefit Analysis 0Summaiy of Comments HFishbone Diagram IDistribution of Comment By Unit J

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We want to help make shift change reports better for you! Please take a

few minutes to complete this questionnaire. An envelope Is available to

Placethem In when you complete the irvey.

Thank you for your time! Unit:

Heather Wurster, RN, MPH

Director, Patient Care Services Shift:

1. We are aware that many forms of shift change reports are used. With that in mind, which of thefollowing does your unit use in shift change reports? (Check all that apply and rank in order of use.)

rank comments:Group report fl

_____________________________________________

One-on-one reports fl

__________________________________________________________

Tape-recorded reports []

__________________________________________________________

a. If group reports are used, do you feel that they are an integral part of your unit’s shift change report?

why?yes LI

_________________________________________________

noLI

_______________

b. If one-on-one reports are used, do you feel that they benefit patient care?

why?yes

______________________

no[]

_______________

c. If tape-recorded reports are used, do you feel that they are successl in your unit’s shift change reports?

why?yes LI

_________________________________________

nofl

____________

2. On average, how long does it take for eeryone in your unit to complete a shift change report?

why?15 mm or less [] 30-45mm LI

____________________________

15-30 mm LI 45 mm or more LI

________________________________

3. Rate on a scale of 1-10 (1 being lowest, 10 being highest) of your satislàction with your unit’s shiftchange report.

1[]2[] 3[]4[J 5[]6[] LI 8LI 9LI101 I

4. Please comment on any bamers that present your unit’s shift change report from moing smoothly.

5. Please comment on any improvements you feel could be made in your unit’s shift change report.

Implementing the VoiceCare’ SystemUniversity of Michigan Medical Center

Service Contract Option

System Size Install/Training Fee 2 Year Contract 3 Year Contract 5 Year Contract(3 days onsite) (service fee) (service fee) (service fee)

60-lines $10,500 $3,125 month $2,417 month $1,850 month


68-lines$11,000 $3,356 month $2,598 month $1,992 month







C 148-lines $13,500 $5,284 month $3,967 month $2,9l4month


Hospital must provide the requisite number of phone lines for the system (see details below). With aservice contract, comprehensive support is provided for all system hardware and software, includingyearly upgrades to the VoIceCare’ software, throughout the term of the contract. At the end of thecontract period, the contract can be extended.

Purchase Option

System Size List Price *Number of Phone Cost of 2’ Year ofLines from Hosiital Comprehensive Suonort

60-lines $73,500 61 $12,000

64-lines $76,160 65 $12,500

68-lines $78,540 69 $13,000

72-lines $80,640 73 $13,000

128-lines $113,920 129 $16,500

132-lines $116,160 133 $16,500

136-lines $118,320 137 $17,000

140-lines $120,400 141 $17,000

144-lines $122,400 145 $17,500

148-lines $124,320 149 $17,500

152-lines $126,160 153 $18,000

*These include I DID line which is connected to the modem provided with the VoiceCaresystem. Thenumber of phone lines available to the system control the maximum number of simultaneous users. Forinstance, a 72-line VoiceCare system allows up to 72 users to access the system simultaneously.

The purchase price includes all hardware (except for phone lines and cables), all software, initial datainput, installation and testing, 3 days of onsite training and 12 months of comprehensive support. Afterthe first year, several continuing support options are available.

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Cost Benefit Analysis

$73,524.00$77,369.40$3,845.40

$88,245.88$80,851.02($7,394.86)

$90,409.42$84,489.32($5,920.10)

$92,637.86$88,291.34($4,346.52)

$94,933.15$92,264.45($2,668.71)

I NPV= ($12,490.01)IYear 0 Year 1 Year 2 Year 3 Year 4

$77,369.40 $80,851.02 $84,489.32 $88,291.34 $92,264.45$16,128.00 $16,128.00 $16,128.00 $16,128.00 $16,128.00

$0.00 $13,000.00 $13,390.00 $13,791.70 $14,205.45$18,396.00 $18,947.88 $19,516.32 $20.1 01.81 $20,704.86$39,000.00 $40,170.00 $41,375.10 $42,616.35 $43,894.84

72 line purchase option ($80,640)

OvertimeDepreciated System CostCost of support from VCCost of phone lines (73)Cost of support person (UM)

Total CostPredicted Savings

72 line service contract option

OvertimeAnnual System CostCost of phone lines (73)Cost of support person (UM)

Total CostPredicted Savings

I NPV = $8,702.90 IYear 0 Year 1 Year 2

$77,369.40 $80,851.02 $84,489.32$11,000.00 $24,324.00 $24,324.00$18,396.00 $18,947.88 $19,516.32$39,000.00 $40,170.00 $41,375.10

$68,396.00 $83,441.88 $85,215.42$77,369.40 $80,851.02 $84,489.32$8,973.40 ($2,590.86) ($726.10)

1 NPV= ($109,817.72)IYear I

$80,851.02$22,784.00$16,500.00$33,483.24$40,170.00

$112,937.24$80,851.02

($32,086.22)

Year 2$84,489.32$22,784.00$16,995.00$34,487.74$41,375.10

$115,641.84$84,489.32

($31,152.52)

128 line purchase option ($ 113,920)Year 0

Overtime $77,369.40Depreciated System Cost $22,784.00Cost of support from VC $0.00Cost of phone lines (129) $32,508.00Cost of support person (UM) $39,000.00

Total Cost $94;292.00Predicted Savings $77,369.40

($16,922.60)

128 line service contract optionYear 0

Overtime $77,369.40Annual System Cost $13,000.00Cost of phone lines (129) $32,508.00Cost of support person (UM) $39,000.00

Total Cost $84,508.00Predicted Savings $77,369.40

($7,138.60)

Year 3$88,291.34$24,324.00$20,101.81$42,616.35

$87,042.16$88,291.34$1,249.18

Year 3$88,291.34$22,784.00$17,504.85$35,522.37$42,616.35

$118,427.57$88,291.34

($30,136.23)

Year 3$88,291.34$32,184.00$35,522.37$42,616.35

$110,322.72$88,291.34

($22,031 .38)

Year 4$92,264.45$24,324.00$20,704.86$43,894.84

$88,923.70$92,264.45$3,340.74

Year 4$92,264.45$22,784.00$18,030.00$36,588.04$43,894.84

$121,296.88$92,264.45

($29,032.43)

Year 4$92,264.45$32,184.00$36,588.04$43,894.84

$112,666.88$92,264.45

($20,402.44)

I NPV ($76,811.47)lYear I

$80,851.02$32,184.00$33,48324$40,170.00

$105,837.24$80,851.02

($24,986.22)

Year 2$84,489.32$32,184.00$34,487.74$41,375.10

$108,046.84$84,489.32

($23,557.52)

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Documents

overtime due to shjflreport i/ - University of Michiganioe481/ioe481_past_reports/w0006.pdf• A long-term option would be to document all patient information on a computer system