Quantifying Qualitative Care: Patient and Staff Needs on UMHS 4B

Telemetry Care Unit

Final Report

Prepared For: Francene Lundy Managing Director, MS Carrie Phillips Nurse Manager Jenifer Seymour Nurse Supervisor

University of Michigan Health System 1500 E. Medical Center Dr.

Ann Arbor, MI, 48109

Ian Perry – Industrial Engineer Expert & Lean Coach Rama Mwenesi - Junior Industrial Engineer

Tanja Fessell – MQS Lean Coach

Prepared By: IOE 481 Team #3

Robert Greenfield IOE Senior Jainabou Barry IOE Senior Benjamin Bennett IOE Senior

University of Michigan Industrial and Operations Engineering Department

1205 Beal Avenue Ann Arbor, MI, 48109

Date Submitted: December 15th, 2015

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TABLE OF CONTENTS

EXECUTIVE SUMMARY ..................................................................................... 1

BACKGROUND ............................................................................................................ 1 METHODOLOGY .......................................................................................................... 1 FINDINGS .................................................................................................................... 1 CONCLUSIONS AND RECOMMENDATIONS .................................................................... 2

INTRODUCTION TO PATIENT CARE ON UNIT 4B ...................................... 3

BACKGROUND OF UNIT 4B ............................................................................... 3 KEY ISSUES ................................................................................................................. 4 GOALS AND OBJECTIVES ............................................................................................ 4 PROJECT SCOPE .......................................................................................................... 4

METHODS USED TO STUDY UNIT 4B PATIENT CARE .............................. 4

LIMITATIONS OF USEFULNESS ...................................................................... 8

SUMMARY OF FINDINGS AND CONCLUSIONS FROM UNIT 4B ............. 9 FINDINGS FROM OBSERVATION STUDY ....................................................................... 9 FINDINGS FROM NURSING SURVEY ........................................................................... 10 FINDINGS FROM BEEPER STUDY ............................................................................... 12 FINDINGS FROM BEEPER STUDY VS. OBSERVATION STUDY ...................................... 13 FINDINGS FROM HISTORICAL DATA .......................................................................... 15

RECOMMENDATIONS ...................................................................................... 18

EXPECTED IMPACT .......................................................................................... 20

APPENDIX ............................................................................................................ 21  

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LIST OF FIGURES AND TABLES

FIGURE 1: PATIENT ACUITY TOOL ................................................................................4 FIGURE 2: DISTRIBUTION OF MOST-TIME CONSUMING TASKS FOR BEDSIDE NURSES .....9 FIGURE 3: BREAKDOWN OF CHARGE NURSE TASKS ....................................................10 FIGURE 4: BREAKDOWN OF RESPONSES FROM SURVEY QUESTION ..............................11 FIGURE 5: ESTIMATED TIME PER TASK FROM NURSING SURVEY .................................11 FIGURE 6: PERCENTAGE BREAKDOWN FOR BEDSIDE NURSE TASKS ............................12 FIGURE 7: PERCENTAGE BREAKDOWN OF CHARGE NURSE TASKS ..............................13

TABLE 1: BEEPER STUDY INCONSISTENCIES .................................................................8 TABLE 2: CORRELATIVE ANALYSIS OF HISTORICAL DATA ..........................................16 TABLE 3: CORRELATIVE STUDY OF WORKED HPPD VS. ADMISSIONS, DISCHARGES,

MCN, AND DC ......................................................................................................17

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EXECUTIVE SUMMARY Telemetry Unit 4B is the second most filled unit by almost every other service within UMHS and the workloads within the unit are believed to be overwhelming available nurses. Currently, Unit 4B’s HPPD (Hours Per Patient Day) value, which reflects the unit’s patient-to-nurse ratio, is 11.2 and is above the University of Michigan Hospital’s upper management recommended HPPD value of 9.3 for the unit. According to the Nurse Manager, such a decrease in the unit’s HPPD value will gravely affect the time-restricted ability of nursing staff to uphold a quality of care safe enough for the patients to be in. The primary goal of Unit 4B management is to conduct a time-study of common nursing tasks performed within the unit to determine what the unit’s HPPD value should be.

Background: Unit 4B Current Staffing Policies and Model The Telemetry Unit 4-B of the University of Michigan Hospital System is a 28-bed unit that cares for post-surgery patients by monitoring patient’s health status and providing hourly nurse-patient care. Te unit receives overflow patients from other units and majority of the units activities do not revolve around telemetry.The unit operates under a 3:1 patient-RN ratio during the morning shift and 4:1 ratio in the night shift. The assigned charge nurse determines the patient assignments based on the “self-determined” acuity level of the patient.

Methodology

In September of 2015, the IOE student team and Unit 4B management initiated a case study project designed to determine what HPPD value is appropriate for the unit given their current staffing model and provide more accurate time-study, survey, and observational analyses of the patient care activities performed within the unit. The objectives outlined within the initial project proposal included the following:

● Conduct a series of time studies on nursing task, including transfer-related tasks ○ Observation Studies: 43.7 hours with 33.8 bedside nurse observation hours and 9.9

charge nurse observation hours over three weeks ○ Beeper Studies: 192 total hours over two weeks

● Administer a survey to the 22 nursing staff and determine which nursing tasks are perceived to be the most difficult, which tasks are perceived to take the longest, and which days of the week for day and night shifts tend to be busiest

● Analyze weekly HPPD data charts to obtain the past year’s daily production hours, worked HPPDs, and unit censuses from December 21, 2014 through September 26, 2015

● Conduct correlative analysis between the staff’s perception of how long tasks should take, the time study results for each task, and the acuity level listed for each type of patient, for which certain tasks are required for care

Findings

Observation Study MiChart documentation and patient assessment and monitoring are the most-time consuming tasks contributing to HPPD for bedside nurses. MiChart Documentation took 3.4hrs per 12-hour bedside nurse shift and Patient Assessment/Monitoring-related tasks average 3.29hrs per 12-hour bedside nurse. Bed briefing and Huddle preparation are the two most time consuming task for day shift Charge Nurses, with bed briefing taking 27% of time during 12-hr shift and huddle preparation taking 17% of time . However, evening Charge Nurses spent 42% of time assisting the bedside nurses with tasks and 12% of time during 12-hr shift staffing new patients.

Nurse Surveys

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Tasks with the greatest variability are estimated to take the longest time to complete. Patient and family training, admit and discharge, medicine administration and MiChart Documentation had 19% or more respondents estimating the task takes longer than 20 minutes while the variation of time estimates ranged over 1-20 minutes, suggesting patient acuity has significant impact on time on tasks. Bedside Nurses assigned 3 patients during shift are indifferent about having adequate time to attend to patients compared to 79% of nurses assigned 4 patients expressed having adequate time to attend to patients.

Beeper Study MiChart Documentation, on average takes 27% of time during a 12-hr shift. However, MiChart Documentation takes more time of the night shift nurses who spend 30% of time on documentation compared to the day shift nurses who spend 24% time on documentation. Charge Nurse spent 25% of time on paperwork, phone calls and communication. The second most time consuming tasks for charge nurses during all shifts are administrative unit tasks and staffing new patients. No significant gap was noticed in the time on tasks for day and night shifts.

Beeper Study vs. Observation Study The top three most time-intensive tasks identified were congruent in both studies, included: (1) MiChart Documentation, (2)Medication Administration, (3) Patient Assessment/Monitoring. More specifically, MiChart Documentation was the most time intensive task category, demanding 27.19% of surveyed time within the unit, or the equivalent of 45.67 Hrs per week across all the beeper study participants (3.26 Hrs/shift). The team identified the top two most time-intensive, non-value added task categories on Unit 4B as (1) Personal Break Time and (2) Miscellaneous Activity. The total non-value added hours were determined to be 12.88 hours out of the 265.9 average productive hours from historical data. Productive Hours should only include tasks that deal with direct care to give HPPD more effective meaning. Cross-examination of Observation Data with Beeper Study data with newly defined PH tasks determine that the recommended HPPD for Unit 4B should be 10.57.

Historical Data From December 21, 2014 through September 26, 2015, the unit has been operating on an average Working HPPD (WHPPD) of 11.26 with a variance of 0.06 and an average midnight census of 23.94. The average productive hours on the unit was 265.99 hours. Conclusions and Recommendations

The team recommends that the HPPD value be reduced to a value of 10.57, provided that the Nursing Department agrees to standardize its calculation of Productive Hours as not including Union-mandated personal break time, required unit host time, and average nursing miscellaneous activity time. The task that required the most time allocation was Michart documentation for bedside nurses and paperwork, phone calls, and communication for charge nurses. A reduction in these tasks, through education and value assessments will allow the time spent on these tasks towards patient care, thus allowing for a decrease in the HPPD. The team has reason to believe the skew is due to the new, and unpredictable updates on the Michart system, in addition to the system’s click-heavy interface compounded by the many types of documentation needed for each patient. Thus, as nurses become more acquainted with such software, time allocated to documentation will decrease. We cannot determine any other margin of improvement at this time that will warrant a HPPD level below 10.57. Any realignment of Unit 4B’s budgeted HPPD rate will require at least one, and possibly both of the following actions:

1. Altering the mix of patients and care providers on Unit 4B 2. Altering the budgeted level of direct patient care on Unit 4B 3. Redefine which activities are comprised within “Productive Hours” on the nursing units 4. Standardize and level nurse-to-patient assignments

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The recommendations, if implemented, will positively impact Unit 4B by improving the nurse allocation and assignment process, reducing inpatient-care variability for nurses, providing baseline data for all nurse-related tasks on unit 4B, and providing a more accurate HPPD value. Future work that should be done on Unit 4B to make the unit more efficient are:

1. Standardization for PH calculations across Nursing Department 2. Develop tool for objectively assessing acuity levels 3. Develop automated tool for objective staff-assignment process 4. Create template for Shift Change meetings

INTRODUCTION TO PATIENT CARE ON UNIT 4B The Telemetry Unit 4-B of the University of Michigan Hospital System is a 28-bed unit that cares for post-surgery patients by monitoring patient’s health status and providing hourly nurse-patient care. Current workloads at the Telemetry Unit 4-B are believed to be overwhelming available nurses. The University of Michigan Hospital’s Board of Directors plans discontinue telemetry-care within the unit and recommends that, because of 4B’s shift in function, that they increase their nurse to patient ratio by decreasing 4B’s Hours Per Patient Day (HPPD) value, a major factor in deciding the daily budget for RN staffing, from 11.2 down to 9.3. The client believes that such a decrease in the unit’s HPPD value will gravely affect the time-restricted ability of nursing staff to uphold a quality of care safe enough for the patients to be in. Therefore, the Nurse Manager of Unit 4B would like conduct a time-study of common nursing tasks performed within the unit to better understand workload in order to determine what the unit’s HPPD value should be. The Nurse Manager of Unit 4B requested an Industrial and Operations Engineering (IOE) 481 Student Team from the University of Michigan to determine what HPPD value is appropriate for Unit 4-B given the unit’s current staffing model.

BACKGROUND OF THE 4B UNIT

The Telemetry Unit 4-B, at the University of Michigan Hospital main function is to care for postoperative patients and monitor patient’s health status. The Unit is the second most filled, in terms of patient bed occupancy, within the hospital and receives overflow patients from many other units on a regular basis. Due to the high transfer volume of various types of patient populations from other hospital units, the nursing staff expressed that the majority of the Unit 4-B’s activities do not revolve around telemetry-related tasks. Rather, the transferred, intensive condition patient populations take priority over earlier scheduled, stable condition telemetry patients. The current staffing model for the unit has a 3:1 patient-to-nurse ratio during the day and afternoon shifts from 7AM to 7PM and a 4:1 patient-to-nurse ratio during the day shift from 7PM to 7AM. Given that Michigan nursing is a union-backed career; new, less experienced nurses are required to work night shifts.

The nursing staff expressed that many of the intensive care patient population arrive at Unit 4B at night, adding serious workload stress to the new nursing staff at a higher patient-to-nurse ratio. In addition, the constant spillover from other units increases the overall unfamiliarity with patient-care tasks the nurses will need to perform given the large variation of different types of patients admitted and or transferred into the unit. On average, the time a nurse needs to check in on a patient is 1 to 1.5 hours, and many patients are taken care of on an hourly basis, from 5 to 30 minutes each hour. Prior to being staffed on the Unit, all nursing staff undergoes orientation where they specialize in a type of patient care. Once they begin their work at the hospital, they are expected to handle all patient assignments they’re given, and the unit attempts to even out patient assignments based on the acuity of the tasks required to properly take care of each patient. The acuity, or perceived level of task difficulty per patient, is subjective and is not

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based on time study data, so assignments can often be unequivocally distributed amongst the staff. A staffing level decrease has been requested, but the client’s hope is that this project will determine the HPPD level required to effectively carry out all tasks on the Unit, which is estimated at a 10.8.

Patient acuity level assignments on Unit 4B

When patients arrive to Unit 4B, the on-duty Charge Nurse (CN) assigns the patient an acuity level based on their specific care requirements and heuristic evaluations.[1] The patients are assigned an acuity level based on a ascending 1-4 scale, where ‘1’ indicates the least time-intensive patient type and ‘4’ indicates the most time intensive patient type. Acuity 4 patients are generally Q1HR-Q2HR and require 15-30 minutes of direct care per hour. The acuity assignments are made using guidelines from an ‘Acuity Tool’ developed on Unit 4B; and the acuity level is logged into the census records using the ‘Charge Report.[1] The CN then makes daily shift assignments to RNs based on the current mix of patients.[1] Based on our team’s observation within Unit 4B, the acuity tool is applied inconsistently and is outdated, having last been updated on February 21, 2012. Patient acuity assignments are subjectively based on the on-duty CN’s experience within the unit. Figure 1 displays Unit 4B’s current acuity tool, which is supposed to assist on-duty CN’s to most accurately identify and assess an incoming patient’s care difficulty and time-intensity level:

Level 1 Level 2 Level 3 Level 4 Meds generally given as scheduled

May have feeding tube but tolerating well

Needs 2 or more assist with ambulating

Cardiac monitoring with q1 titration

Small to moderate dressing changes required only as scheduled

Meds as scheduled. May have PCA for pain

May be incontinent of urine or stool (<3x in 12hr)

Fluctuating SAT requiring vigorous pulmonary hygiene

Less than 20 minutes of teaching required

Moderate to large dressing(s) changes required

Dressing(s) may need reinforcement or frequent changes

Fresh trach

SAT WNL 20-30 minutes of patient/family teaching required

Suctioning Q2 or less AWS protocol first 48 hours Q1-2 vitals

Good family support May require tasks associated with a routine DC /Admit

Q2 flap check (use discretion)

Suction q1/constant secretions

SAT WNL (or recovers quickly if it decreases with activity)

Cardiac gtt without q1 titration

VS q1

Good family support Fresh pot-op requiring full admission

Leeches and flap check q1

New Admit – may have arrived from ED but is stable, or may have arrived from PACU but procedure was done under conscious sedation

AWS protocol after first 48 hours

Sitter

Cardiac monitoring IVIG/Chemo/Blood 2nd dose

Restraints

Q2 flap check (use discretion) >40 minutes of patient/family education

First dose IVIG/Chemo

Q4 Suction Anxious patient/family who needs constant reinforcement

Insulin gtt

Figure 1: Patient Acuity Tool

In theory, Figure 1 is used with the on-duty’s greatest discretion to help create equal assignments. However, more tenured nurses within Unit 4B no longer consult the Acuity Tool and usually assign patient acuity based on experiences with similar patients.

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Nursing assignments on Unit 4B

The RNs are typically assigned two to four patients to care for during a given shift, depending on the type of shift (day or night) and the assigned patient’s acuity level. The underlying assumption to these assignments is that more acute patients with higher acuity levels will require more attention. Consequently, these high-acuity patients are more likely to be assigned to a 1:2 or a 1:3 nurse-to-patient assignment, given the increased time commitment to higher acuity patients within patient assignment groupings. The reasoning for the latter is that nurses need to be able to delegate their patient care time (productive hours) in a way that accommodates the patient’s healthcare needs, without too much need to rush and increase the chance of mistake. The alternative assignments are where a nurse is assigned to care for three to four patients during a given shift.

Key Issues

The following issues are driving the need for this project:

● Upper management feels the need to decrease the HPPD from 11.2 to 9.3-9.4 because they are going to take away the telemetry portion of the care on 4B

● The telemetry portion of the care on 4B is not what takes up a majority of 4B’s time. Although 4B is described as the Telemetry Unit, they accept any postoperative patients who require continuous cardiac monitoring and conduct many nursing tasks not included in the unit’s description

● The Nurse Manager of Unit 4-B is concerned that the decrease in HPPD will reduce the quality and safety of patient care because staff will not have the time capacity to care for the needs of all patients, especially high intensity patients as determined by the acuity tool

Goals and Objectives

To determine what HPPD value is appropriate for Unit 4-B given their current staffing model the student team will achieve the following tasks:

● Conduct a series of time studies on nursing task, including transfer-related tasks ● Administer a survey to the nursing staff and determine which nursing tasks are perceived to be

the most difficult, which tasks are perceived to take the longest, and which days of the week for day and night shifts tend to be busiest

● Conduct correlative analysis between the staff’s perception of how long tasks should take, the time study results for each task, and the acuity level listed for each type of patient, for which certain tasks are required for care

Project scope

This project focuses only on the Unit 4B of the Taubman Center of the University of Michigan Hospital. The scope of the project includes all the tasks completed by nurses on duty, each nurse’s experience level, and the acuity level for each patient in the unit.

Tasks that do not pertain to the University of Michigan Hospital Unit 4B are not included in this study. Specifically, the project does not include the patient or nurse's perception about the quality of care. Also, the project scope does not examine improving admission, discharge, patient satisfaction, and or transfer times and processes.

METHODS USED TO STUDY UNIT 4B PATIENT CARE

To complete these objectives, the IOE team first began weekly meetings and observational shadowing on Unit 4B in late September of 2015. Included below is an outline of the proposed approach to the patient care work measurement studies developed at that time.

Literature Search

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The team utilized past IOE 481 projects, scholarly journals, and articles about optimizing staffing models and time studies. A study completed in 2013, Patient Care Analysis for UMHS 8D Intermediate Care Unit, has provided the team with significant guidance for the format of our study and an understanding of the scope of this project.

Preliminary Surveying The team developed a preliminary survey that helps identify nursing unit experience with varying types of patients expected on the unit and the tasks required to assist them. The preliminary survey data allowed the team classify the experience level of the nurses on the floor, determine how Unit 4B nurses perceive their workloads to be, and enable our team to identify key tasks that are reported to take up the most of RN time. A sample copy of the distributed survey is located in the appendix. 26 nursing staff out of the 47 total staff completed the survey and 22 responses were analyzed.

Preliminary Observations The team performed preliminary observations in Unit 4B to understand the day-to-day tasks of a Unit 4B CN and RN and better understand the unit’s workflow. Team members noted the tasks completed, the acuity of each patient assigned to the observed nurse, and the time the observed nurse allotted to each task. Each team member completed Unit 4B nurses for 8 hours per week for 2 weeks, for a total of 48 hours of observation by the entire IOE student team. A copy of the observation collection sheet is located in the appendix.

Historical Data Analysis: HPPD Weekly Reports

The team obtained the weekly HPPD data charts to obtain the past year’s daily production hours, worked HPPDs, and unit censuses. By analyzing this information, the team has gained insight into how correlative the current HPPD value of Unit 4B is to the average, daily patient census and average, daily production hours within the unit.

HPPD Budget Calculations

Currently, Unit 4B is staffing above the UMHS Board of Directors’ recommended HPPD budget. Based on the unit’s ‘Worked HPPD” records from the past year (2015), Unit 4B averages a (‘worked’) HPPD value of 11.26 and has a current HPPD budget of 11.2. The HPPD value is calculated as the equivalent hours of total patient care provided to each patient, each day; and is based on the number of nurses (��) and technical aides (��) on staff compared to the number of patients (���������)  on the unit. Equation 1 presents a general calculation for HPPD.[1]

���� = (��!��)∗���������������

(1)

As a simplified example, if there are a total of 24 nurses and 6 technical aides (techs) working 8 hours a day and there are 19 patients on the unit; the equivalent HPPD = [ ((24 + 6) * 8) / 19 ] ≈ 12.63.[1] Unit 4B employs the use of a “Worked HPPD” to gain a better understanding of what the HPPD level is on a daily basis, supported by the number of productive hours worked over the midnight patient census. Productive hours are determined by the number of people staffed that day (during a 24hr period), solely including technical assistants and RNs. For example, the following calculations are used to determine the Worked HPPD for any given day (where PHrs = Productive Hours):

Night-Shift PHrs = (8 RNs Staffed +2 Tech. Assistants Staffed) x (8 hr Shift) = 10*8 = 80 PHrs Day-Shift PHrs = (10 RNs Staffed + 3 Tech. Assistants Staffed) x (12 hr Shift) = 13*12 = 156 PHrs Unit Host PHrs = 8 PHrs Back half of Evenings PHrs = (8 RNs Staffed + 2 Tech. Assistants Staffed) x (4 hr Shift) = 10*4= 40 PHrs

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Total PHrs = Night Shift PHrs + Day Shift PHrs + Unit Host PHrs + Back Half Evenings PHrs Total PHrs = 80 PHRs + 156 PHrs + 8 PHrs + 40 PHrs = 284 PHrs Working HPPD for that day = Total PHrs/Midnight Census = 284 PHrs/26 Patients = 10.92 HPPD

Within the aforementioned calculations, there is an underlying mathematical assumption that every hour someone is staffed per shift within Unit 4B counts as a productive hour. The Unit Host PHrs are comprised of hours worked by a support role within the unit, whom stocks the nurse servers, takes care of equipment that is unit owned, and works with volunteers, among other things. The department of nursing considers these hours direct care hours, so they are counted in the hospital’s productive totals. The HPPD calculation on Unit 4B is based on staffing during three, 8-hour intervals that are labeled ‘Day Shift, ‘Evening Shift’ and ‘Night Shift.’ Many of the nurses on the unit work 12-hour shifts for three days a week, on average, however, schedule swapping between RN’s makes determining the Hshift value very difficult, given that not all RN’s and technical aids are working the same shift although they might have started the same shift together. Since Unit 4B’s census is taken at midnight during the night shift - the same time period during which the unit receives many of its trache patients, the Npatients value is also difficult to consistently determine. The team summarized the daily HPPD calculation on Unit 4B using 280 days of recent census data. The data is sectioned into bimonthly averages of production hours, patient census, worked HPPD, HPPD variance, and percentage variance.

Beeper Study

The team will conducted a beeper time-study on the daily activities of Unit 4B CNs and RNs to determine the time spent on each task throughout the each type of nurse's workday. The team developed a self-collection tool that asked nurses to quantify the time spent on each task and was used to validate the preliminary survey and observation data. This data collection period occurred from November 18th-November 25th, excluding November 22nd which was made up on November 29th. For shifts 7a-7p and 7p-7a, 1 CNs and 3 BNs participated in the study by ticking the task they were completing at the time the beep/vibrate went off. Data Analysis The data collected from the time study, observation study, and preliminary survey enabled our team to quantify the current workload by calculating an hours per patient day (HPPD) value for the unit. Using statistical analyses, our team can calculated the correlation between the type of patient, the patient’s acuity , the time needed need to adequately care of a patient, the nurse’s experience level, and the time spent by a nurse on a task.

Recommendations After quantitative analysis of the preliminary observation, preliminary survey, and time study data on Unit 4B, the team determined the optimal HPPD for the unit and recommend the next steps that Unit 4B can manage in order to meet the newly budgeted HPPD value. HPPD Calculation Currently, ‘direct care’ includes bedside care (meds -prep and administration, ambulating, dressing changes, bathing and bed changes, etc.), the time for connecting with the medical team(s) (paging, running to pharmacy, teaching patient and/or family), and all documentation activities (including updating care plans). Given that productive hours consist of time only related to direct care, it should be calculated as so. As of now, productive hours include all the time worked by shift of staffed nurses and technical aids throughout the day. The inclusion of personal break time and miscellaneous tasks performed by nurses that do not relate to direct care are inflating Unit 4B’s productive hours and the product is a higher overall HPPD value. Within this report, our team will assert a novel assumption that productive hours only include work hours directly related to bedside care (meds -prep and administration, ambulating, dressing changes, bathing and bed changes, etc.), the time for connecting with the medical team(s)

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(paging, running to pharmacy, teaching patient and/or family), and all documentation activities (including updating care plans) both in definition and in calculation. Our team will utilize the latter definition to calculate a new, recommended HPPD value for Unit 4B.

LIMITATIONS OF USEFULNESS This section will highlight the limitations of our recommendations for the unit based on data collection methods and unforeseeable limitations beyond the team's control. Limited representation of unit nurse population on from surveys The surveys administered on the unit had 22 completed responses out of the 46 staffed nurses on the unit. The IOE team did not randomly select the respondents, so the team is unaware if the selected respondents accurately represent the staff population on unit 4B. Incomplete beeper study cards during collection period The beeper study was conducted with the staffed nurses during the collection period shift. The IOE team did not randomly select the staff who will complete the study, so the team is unaware if the selected participants represent the entire population. Of the collected surveys, the years worked on unit 4B and acuity levels of patients were not fully completed. The table below highlights the incompletion rate of the collected sheets:

Type of inconsistency Percentage of BN responses Percentage of CN responses

Incomplete Acuity levels (2 or less)

17.57% n/a

Completed acuities 3/4 42.72% n/a

Completed acuities 4/4 39.71% n/a

Incomplete “years of experience”

17.57% 16.67%

Average ticks on collection card

47.7 ticks ±21.5 42.3 ticks ±5.7

Table 1: Beeper Study Inconsistencies

As we can see from the data above, almost 18% of the acuity responses were not completed, which can skew the data analysis. The beeper study was conducted with beepers that were programmed to beep/vibrate approximately 4 times per hour, however some collection cards had less than 2 ticks per hours. Data collection occurred around Thanksgiving holiday season Due to the length of the observation period, the team completed the beeper study from November 18th-November 25th. The proximity of the collection period to the thanksgiving holiday may impact the representation of patients present on the unit compared to the general population. On Sunday, November

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22nd, data collection did not occur so it was rescheduled to Sunday, November 19th. This may skew the data by showing a different week patient arrival and discharge.

SUMMARY OF FINDINGS AND CONCLUSIONS FROM UNIT 4B

1. Findings from Observation Study A. MiChart documentation, patient assessment and monitoring are the most-time consuming tasks contributing to HPPD

Figure 2: Distribution of most-time consuming tasks for bedside nurses (Observation Study) 33.8 Hours

Conclusion: Chart 1 is comprised of 43.7 total hours of observation. There were 9.9 hrs were spent observing Unit 4B’s Charge Nurses (CNs) and 33.8 hrs were spent observing the unit’s Bedside Nurses (BNs). In the appendix, the distribution of all tasks during the shift are highlighted. MiChart task documentation required the majority of RN shift time throughout the duration of the observation study, taking approximately 3.4hrs per 12-hour bedside nurse shift on unit 4B. The lack of update standardization, through which the MiChart system is updated on a predictable and consistent basis on a given time table throughout the year, within the MiChart system makes it impossible for nurses on Unit 4B to adequately retrain themselves on the added nuances to the platform. As highlighted in Appendix, The incrementing learning curve per MiChart update, in addition to the system’s click-heavy interface (interface in which there are many tabs to go through to complete given work) may increase task documentation time across all shift types. With regards to Patient Assessment/Monitoring-related tasks, it is expected that direct patient care take up the majority of RN/CN shift time. In this particular case, Patient Assessment/Monitoring-related tasks average 3.29hrs per 12-hour bedside nurse shift on Unit 4B. The “Other” category was expanded in the beeper study to fully capture which tasks in this category is taking up time during the nursing staff’s work hours.

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B. Bed briefing and Huddle preparation are the two most time consuming task for day shift Charge Nurses. However, evening Charge Nurses spend the most time on bedside assistance and staffing new patients

Figure 3: Breakdown of Charge nurse tasks (Observation Study) 9.9 hours

For day-shift Charge Nurses, Bed Briefing takes approximately 3.22 hours per 12-hour day shift and Huddle Preparation and Meeting takes approximately 2.13 hours per 12-hour day shift. The latter is an indication that Unit 4B may want to consider standardizing the way nurses handle bed briefing and huddle preparation events. Establishing time limitations and templated agenda items for each event may substantially decrease the time it takes to complete these tasks. For evening Charge Nurses, staffing to accommodate new patients takes approximately 1.56 hours per 12-hour night shift, given that the process is completed by hand. Our team recommends that Unit 4B automate patient staffing via Microsoft Excel, employing the use of a macro to instantly handle leveled patient assignments with reasonable acuity workload across on-duty nurses. This would shorten the time it takes to staff new patients from 1.56 hours per day to merely minutes. The evening charge nurse spends 4.92 hours per 12-hour night shift assisting the bedside nurses with their tasks, while the day charge nurse spends 2.18 hours per shift on assisting the bedside nurses with their tasks. This huge difference may be a result of the 1:4 bedside nurse to patient ratio during the evening shift requiring more assistance from the charge nurse compared to the 1:3 bedside nurse to patient ratio during the morning shift.

2. Findings from Nurse Surveys

A. Bedside Nurses assigned 3 patients during shift are indifferent about having adequate time to attend to patients compared to 79% of nurses assigned 4 patients expressed having adequate time to attend to patients.

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Figure 4: Breakdown of responses from survey question "Given the number of patients and their

respective acuities, do you feel you have adequate time to attend to them?" (22 Respondents)

Conclusion: Without an objective tool for assessing patient acuity, the variability of patients assigned will affect the workload on the nursing staff. Given that the morning shift nurses are normally assigned 3 patients, with higher acuity levels, it can be concluded that the workload can be unmanageable at times. Developing an objective tool will develop a realistic expectation of care required per patient for any day and/or shift. B. Tasks with the greatest variability are estimated to take the longest time to complete

Figure 5: Estimated time per task from nursing survey (22 respondents)

Conclusion: The acuity level of patients significantly affects the perception of time needed per tasks. Developing an objective tool will allow for a realistic expectation of care required per patient for any day and/or shift.

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3. Findings from Beeper Study

A. MiChart Documentation consumes greatest amount of time for Bedside Nurses on all shifts while night shift nurses spend more time on MiChart Documentation than day shift nurses

Figure 6: Percentage breakdown for bedside nurse tasks (Beeper Study) 192 hours

Conclusion: Documentation is a necessary, yet sometimes cumbersome activity. MiChart updates and/ or policies should be updated to reduce amount of time spent by nurses on documentation to allow for allocation to actual patient care. Note: Toileting and showering was the 4th most-time consuming tasks for both day and night shift nurses. B. Charge Nurse spent majority of time on paperwork, phone calls and communication

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Figure 7: Percentage breakdown of charge nurse tasks (Beeper Study) 192 observation hours

Conclusion: The amount of paperwork and phone call should be reduced significantly to allow for more capacity to care for the patients. A systemic change must be made in the types of communication the charge is completing and a value assessment of all tasks. 4. Findings from Beeper Study vs. Observation Study A. Productive Hours should only include tasks that deal with direct care to give HPPD more effective meaning Conclusion: As stated in the methods section, the team has asserted a novel assumption that productive hours only include work hours directly related to bedside care (meds -prep and administration, ambulating, dressing changes, bathing and bed changes, etc.), the time for connecting with the medical team(s) (paging, running to pharmacy, teaching patient and/or family), and all documentation activities (including updating care plans) both in definition and in calculation for the recommended HPPD value. The standardization of calculating productive hours in this manner will also be recommended to the UMHS Nursing Department, so that the UMHS Board of Directors gains better insight from hospital unit HPPD levels. Discluding personal break time and time spent on miscellaneous unit activities from logged productive hours aligns with the Nursing Department’s Union agreement with UMHS that all nursing staff must get time to have lunch and a reasonable amount of break time, particularly during 12 hr shifts on the unit. In addition, Unit 4B unit host hours will be excluded from the report’s newly asserted definition of PH, given that it does not relate to direct patient care.

B. Cross-examination of Observation Data with Beeper Study data identifies: (1) Personal Break Time, (2) Miscellaneous Activity, and (3) Nurse Shift Change Meetings as the top three non-value added factors on Unit 4B Conclusion: When cross-examining the observation and time study data sets, prominent similarities and dissimilarities were evident based on the distribution of time spent on tasks. Due to the lower number of responses(50) and statistically significant amount of voided beeper study forms(42), inferential data

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preference was given to the observational data set, even though the data was comprised of 43.7 hrs of observations in contrast to 168 hrs time span of the beeper study. The top three most time-intensive tasks identified were congruent in both studies, included: (1) MiChart Documentation, (2)Medication Administration, (3) Patient Assessment/Monitoring. More specifically, MiChart Documentation was the most time intensive task category, demanding 27.19% of surveyed time within the unit, or the equivalent of 45.67 Hrs per week across all the beeper study participants (3.26 Hrs/shift). Within the observation study, the team observed the most time intensive task category to be MiChart Documentation, demanding 28% of the observed time within the unit, or the equivalent of 47.04 Hrs per week across all observation study participants (6.72 Hrs/day). The team determined Medication Administration & Documentation to be the second-most time-intensive task category according to the beeper study, demanding approximately 17.85% of surveyed time within the unit, or the equivalent of 29.99 Hrs per week across all the beeper study participants (2.14 Hrs/shift). The third-most time-intensive task category was Patient Assessment & Monitoring, demanding 27.5% of surveyed time within the unit, or the equivalent of 46.20 Hrs per week across all observation study participants (6.60 Hrs/day). In contrast to the beeper study, Patient Assessment & Monitoring demanded 12.01% of surveyed time, less than half asserted by the observation study. The inconsistency between studies has been reconciled by the change in task category definition between the two studies, as the beeper study differentiated the “Patient Care (except airway)” task category from the Patient Assessment & Monitoring task category and the observation study did not. The beeper study found that “Patient Care (except airway)” task category demanded 11.82% of surveyed time, which was noted as the third-most time intensive task on the unit, or the equivalent of 19.86 Hrs per week across all the beeper study participants (1.42 Hrs/shift). The sum of “Patient Care (except airway)” and Patient Assessment & Monitoring task categories, the resulted in 23.8% of surveyed time, which is only a 3.4% difference between the observation study equivalent. The results from the observation study indicated Medication Administration & Documentation demanded 17.5% of surveyed time, or the equivalent of 29.4 Hrs per week across all observation study participants (4.20 Hrs/day). The measurements displayed by Table 2, are positively correlated and are regarded as statistically reliable given our report’s findings. The team identified the top three most time-intensive, value-added task categories on Unit 4B as (1) MiChart Documentation, (2) Medicine Administration & Documentation, and (3) Patient Care. Greater discrepancies were identified between the observation study and the beeper study’s analysis of how much time personal breaks and miscellaneous unit activities account for. On the one hand, the observation data cites that the “Other” task category, comprised of personal break time and non-direct care activities, demanded 16% of surveyed time, or the equivalent of 26.88 Hrs per week across all the observation study participants (3.84 Hrs/day). On latter, the beeper study data indicated that “Other” and “Personal Break Time” task categories only consisted of 7.75% of surveyed time, nearly half the percentage time cited within the observation study, or the equivalent of 13.02 Hrs per week across all beeper study participants (55.8 minutes/shift). The discrepancy cannot be reconciled by task category definition differences between the two studies, and since the beeper study data set consisted of a significant amount of human data-entry error, our study must rely upon the observation studies statistical inferences. From the observation study, the “Nurse Shift Change Meeting, ”and “Receiving Report” were calculated to demand 4% and 4.5% of surveyed time respectively. For the beeper study, the equivalent time for “Nurse Shift Change Meeting” demanded 3.62% of the surveyed time, 6.72 hrs per week across all beeper study participants (26 minutes/shift). For the observation study, the equivalent time for “Receiving Report” was determined to be 7.56 Hrs per week across all beeper study participants (1.08 Hrs/ per day). The measurements are displayed in Table 2, and are regarded as statistically reliable given our report’s findings. The team identified the top three most time-intensive, non-value added task categories on Unit

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4B as (1) Personal Break Time, (2) Miscellaneous Activity, and (3) Nurse Shift Change Meetings. The latter tasks are not included with our newly asserted definition of PH. C. Cross-examination of Observation Data with Beeper Study data with newly defined PH tasks determine that the recommended HPPD for Unit 4B should be 10.57

- Remap task percentages that and disclude certain tasks categories based on new definition of PH - Calculate the new HPPD (as recommendation)

Conclusion: Given Personal Break Time, Miscellaneous Activity, and Nurse Shift Change Meetings task categories are not considered to involve direct care, they will be excluded from the report’s newly asserted definition of PH and our HPPD calculations. Task categories with consistent time percentages across both the observation study and the beeper study will be averaged to determine a representative sample time that our team can recommended a more accurate HPPD value for Unit 4B. Meaning, the representative Nurse Shift Change Meeting time will be determined as follows:

Beeper Study Time Indication for Nurse Shift Change Meeting Category: 0.96 Hrs/day Observation Study Time Indication for Nurse Shift Change Meeting Category: 1.08 Hrs/day Average Nurse Shift Change Meeting Time per day = (0.96 Hrs/day)(1.08 Hrs/day) = 1.0368 Hrs/day

The discrepancy between “Personal break” time and “Miscellaneous activity” time on the unit between the observation study and the beeper study, we asserted that statistical preference be given to the observation study given the significant amount of human input error on the beeper study forms and our data collecting methods. Thus, the representative “Personal break” and “Miscellaneous activity” times was calculated to be (3.84 Hrs/per day) within the observation study. The team noted earlier unit host time will be excluded from the PH, given that it does not fulfil the definition of direct care, the total time excluded from the PH per day should be approximately 12.88 (Hrs/ per day). We assume that the average unit host time per day is 8 hrs within our approximation. Since the team determined how much time should be excluded from the daily PH, it is possible to calculate a new, representative HPPD value for Unit 4B. Utilizing the unit’s current average midnight census (MCN) and productive hours from the 280-day historical HPPD data set sample, the new HPPD was determined by the following calculation:

Unit 4B HPPD = (Average Unit 4B Productive Hours/ Average Unit 4B Midnight Census) Unit 4B HPPD = (PH - 12.8768 Hrs)/MCN Unit 4B HPPD = (265.9964 Hrs - 12.8768 Hrs)/23.9392 Unit 4B HPPD = (253.1196)/23.9392 = 10.5734

Thus, by asserting the current PH definition within HPPD calculation, the recommended HPPD for Unit 4B should be approximately 10.57 under our new circumstances, that the Nursing Department not include daily unit host, personal break time, and averaged miscellaneous hours within their PH calculations. 5. Findings from Historical Data

A. From December 21, 2014 through September 26, 2015, the unit has been operating on an average Working HPPD (WHPPD) of 11.26 with a variance of 0.06 and an average midnight census of 23.94. The WHPPD is positively correlated to the number of discharges, the number of admits, the admit variance, the discharge variance, and the outbound transfers for both one-tailed and two-tailed significance tests.

Correlative Comparison Significantly Correlated:

One-Tailed Test Significantly Correlated:

Two-Tailed Test Are they directly

related? HPPD vs. Inbound Transfers Significant Not Significant Somewhat HPPD vs. Outbound Transfers Not Significant Not Significant No

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HPPD vs. Production Hours Not Significant Significant Somewhat HPPD vs. Midnight Census Not Significant Significant Somewhat HPPD vs. Total Transfers Significant Not Significant No HPPD vs. Approx. Daily Census Not Significant Significant Somewhat Production Hours vs. Inbound Transfers Not Significant Not Significant No Production Hours vs. Outbound Transfers Significant Significant Yes Production Hours vs. Total Transfers Significant Not Significant Somewhat Production Hours vs. Midnight Census Significant Significant Yes Production Hours vs. Approx. Daily Census Significant Not Significant Somewhat HPPD vs. # of Admits Significant Significant Yes HPPD vs. # of Discharges Significant Significant Yes HPPD vs. Admit Variance % Significant Significant Yes HPPD vs. Discharge Variance % Significant Significant Yes

Table 2: Correlative Analysis of Historical Data

Conclusion:

Through analyzing the HPPD data sets dated between December 21st, 2014 through September 26th, 2015, our team determined that the WHPPD is positively correlated with the number of admits, the number of discharges, the admit percentage variance, the discharge percentage variance, the number of outgoing transfer, and the midnight patient census for both one-tailed and two tailed significance tests. Correlative significance tests assess the statistical relevance and importance of the correlation coefficient ‘r,’ ultimately determining if two data sets are ‘positively’ correlated or not. Our team performed both the one-tailed, a statistical test in which the critical area of a distribution is one-sided so that it is either greater than or less than a certain value, but not both, and the two-tailed, a statistical test in which the critical area of a distribution is two sided and tests whether a sample is either greater than or less than a certain range of values.[3] Within our calculations, we assumed that comments not citing discharges, admit, and or transfer activity for that day meant that there were no events of that type.

The significance tests help our team determine the correlative relevance between admittance rates (AR), discharge rates (DR), production hours (PH), WHPPD, the number of inbound transfers per day (TI), the number of outbound transfers per day (TO), the total number of transfers per day (TT), the midnight patient census (MCN), the approximated day census (ADC), the daily admit percentage variance (APV), and the daily discharge percentage variance (DPV). We determined the following patterns within the historical data set analyses: (1) Daily WHPPD is more positively correlated with the AR, with a coefficient of determination (r2) of 7.34%, than the DR, with a r2 of 2.69%; (2) Daily WHPPD is more positively correlated with the MCN, with a r2 of 64.16%, than the ACD, with a r2 of 31.70%; (3) The transfer activity that occurs on Unit 4B doesn’t really affect its daily WHPPD (highest r2 of 2.11%); (4) Daily WHPPD was more positively correlated with APV, with a r2 of 8.82%, than ADV, with a r2 of 3.35%; (5) The average amount of APV during the time period was -30%, indicating that Unit 4B encounters a high rate of admit rate change over the course of the year and such change would be very difficult to predict, and therefore difficult to prepare for, especially if understaffed; (6) Daily HPPD is

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only positively correlated with PH, with a r2 of 2.90%, given a two-tailed test, indicating that the way PH is defined operationally does not correlate enough with HPPD, rendering the measure ineffective when budgeting time for ‘direct care.’

In addition, our team determined that the way PH is defined and calculated significantly changes the HPPD. If personal break time, MiChart task documentation, and Unit 4B host hours are included as direct care, the usage of HPPD as a measure of hours per patient day becomes more or less insignificant. The unit should continue collecting WHPPD data sets and more formally collect discharge, admit, inbound transfer, and outbound transfer data rather than inserting them into the comments. Average patient acuity should also be included within the data set to further enable Unit 4B’s ability to determine a correlative significance between important factors like PH and WHPPD and patient acuity more regularly.

B. Variable census contributes to increased HPPD

Correlative Comparison Significantly Correlated:

One-Tailed Test Significantly Correlated:

Two-Tailed Test Are they directly

related? HPPD vs. # of Admits Significant Significant Yes HPPD vs. # of Discharges Significant Significant Yes HPPD vs. Admit Variance % Significant Significant Yes HPPD vs. Discharge Variance % Significant Significant Yes HPPD vs. Midnight Census Not Significant Significant Somewhat HPPD vs. Approx. Daily Census Not Significant Significant Somewhat

Table 3: Correlative Study of Worked HPPD vs. Admissions, Discharges, MCN, and DC Note: *MCN: Midnight Census, *DAC: Day Approximate Census, *HPPD: Worked HPPD

Conclusion: Through an inferential analysis of the 280-day sample of Unit 4B’s HPPD data from December 21st, 2014 through September 26th, 2015, our team has concluded the following: (1) The daily arrival rate of admitted patients into Unit 4B and the unit’s Worked HPPD values are positively correlated; (2) The daily discharge rates of admitted patients leaving Unit 4B and the unit’s Worked HPPD values are positively correlated; (3) The daily percentage variance of patients admitted into the unit and the unit’s Worked HPPD values are positively correlated; (4) The daily percentage variance of patients discharged from the unit and the unit’s Worked HPPD values are positively correlated. In each case, the Pearson correlation statistic r was greater than its respective critical value. Since the correlative data is statistically significant, our team may accept the hypothesis that there is a positive and direct correlation between Unit 4B’s Worked HPPD and the number of unit admits, the number of unit discharges, the unit’s admit variance, and the unit’s discharge variance, at the p ≤ 0.05 significance level. The average variance of Unit 4B patient admittance is approximately 30%, whereas the average variance of Unit 4B patient discharge is 0.04%, meaning that Unit 4B admit rates are highly variable, but unit discharge rates are not. In addition, the Worked HPPD values were found to be positively correlated with Unit 4B’s midnight censuses and the unit’s day approximated censuses given a two-tailed significance test. The day approximate census was calculated by subtracting the midnight census (MCN) from the patient discharge rate (D) and adding the patient admission rate (A) from that day ( MCN - D + A). The MCN’s coefficient of determination (COD), the factor that measures the likelihood of future events falling within the

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predicted outcomes of what the MCN will be, is approximately 65%, which is rather reliable given the high variability of the patient admittance rate within the unit. This means that Unit 4B may be able to predict MCN values for oncoming weeks and better schedule staffing around these insights.

RECOMMENDATIONS

The team recommends that the HPPD value be reduced to a value of 10.57, provided that the Nursing Department agrees to standardize its calculation of Productive Hours as not including Union-mandated personal break time, required unit host time, and average nursing miscellaneous activity time. The task that required the most time allocation was Michart documentation for bedside nurses and paperwork, phone calls, and communication for charge nurses. A reduction in these tasks, through education and value assessments will allow the time spent on these tasks towards patient care, thus allowing for a decrease in the HPPD. The team has reason to believe the skew is due to the new, and unpredictable updates on the Michart system, in addition to the system’s click-heavy interface compounded by the many types of documentation needed for each patient. Thus, as nurses become more acquainted with such software, time allocated to documentation will decrease. We cannot determine any other margin of improvement at this time that will warrant a HPPD level below 10.57.

Patient-to-Nurse Assignment Problems and 4B’s Options

The project described in this report was designed to measure the direct patient-care requirements on Unit 4B, and to identify the optimal and appropriate HPPD value for the unit. Any realignment of Unit 4B’s budgeted HPPD rate will require at least one, and possibly both of the following actions:

5. Altering the mix of patients and care providers on Unit 4B 6. Altering the budgeted level of direct patient care on Unit 4B 7. Redefine which activities are comprised within “Productive Hours” on the nursing units 8. Standardize and level nurse-to-patient assignments

Altering the mix of patients and care providers on Unit 4B

Direct care nursing budgets are expressed as the rate of ‘hours per patient-day’ (HPPD), which is calculated as the equivalent hours of total patient care provided to each patient, each day.[1] Reduction of the HPPD rate, given the current definition and calculation of the unit’s productive hours, can only be achieved by reducing staff, increasing the patient-to-nurse ratio assignments, and/or decreasing the average acuity level of incoming patients admitted into the unit. Given that the unit cannot predetermine which patients are admitted, since admittance is need-based only and there exist high patient admission rate variance, Unit 4B cannot, realistically, decrease the average acuity level of incoming patients. Reducing staff is always the last measure within a lean environment, and it is better to employ current state and future state maps of Unit 4B processes to identify non-value added time to eliminate rather than resorting to staff reduction, which does not promise any long-term reduction in inefficiency. Increasing patient-to-nurse ratio assignments is the current solution proposed by the UHS Board of Directors and has been deemed unsafe by Unit 4B’s Nurse Manager.

Altering the budgeted level of direct patient care on Unit 4B An alternative to reducing the number patient care providers is to increase the current HPPD budget to reflect the necessary level of care.[1] To obtain an objective measurement of the patient care work requirements on Unit 4B, the unit’s management team partnered with a IOE 481 student team to perform studies on Unit 4B’s operations to better determine the unit’s workload. Currently, Unit 4B has 35.48 full-time equivalent (FTE) RNs budgeted for direct nursing patient care. FTE is a way to measure a worker's involvement in a project, or an assigned task for his or her organization.[2] The definition of FTE is the number of working hours that represents one full-time employee during a fixed time period, such as one

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month or one year.[2] Unit 4B has 41 RNs that are scheduled to solely work 12 hr-shifts, and have 7 RNs that have mixed shifts, involving both 12 hr and 8hr assignments within their weekly schedule.

Budgets vary amongst all of the nursing units in the medical center, and they are intended to reflect the appropriate amount of direct care required to treat patients on a given unit.[1] These budgets are based on established norms and simplifying assumptions.[1] However, previous (and current) methods of assigning patient acuity remain subjective, based on the Charge Nurse’s experience on the unit. Such a statistical variance within patient assignment data could, and often times does, lead toward either an over-assumption or an under-assumption of the direct care that’s needed for the patient.

A typical assumption is that patients being treated for high acuity injuries will require a higher rate of direct care.[1] To obtain an objective measurement of the patient care work requirements on Unit 4B, the Unit 4B management team partnered with a University of Michigan, Industrial and Operations Engineering (IOE) 481 student team, Team 3, to perform studies on the unit’s operations. The purpose of the Team 3’s project was to provide a quantitative measurement of patient care activity, and to provide an objective assessment of Unit 4B’s ability to provide a safe, high quality level of care with their current HPPD budget and the proposed HPPD budget made by UMHS Board of Directors.

Redefine which activities are comprised within “Productive Hours” Through our engineering team’s analysis and observation of Unit 4B, we determined that the main factor in determining the unit’s “Worked HPPD” levels is very loosely defined within UMHS. Worked HPPD (WHPPD) is the HPPD level for any given day within the unit. Productive Hours (PH) are considered to be comprised of any amount of time that is worked on the unit that contributes to ‘direct care.’ Unit 4B determines the WHPPD by taking the PH for that given day and dividing them by the unit’s midnight patient census (MCN), so WHPPD = PH/MCN. Given the loose definition of what amount of time, from the total amount of worked hours on the unit, actually fits the definition of ‘direct care,’ current PH calculations are usually calculated by the total number of hours worked by RNs and technical aids that day, despite the time it takes to attend to MiChart documentation and other staffing activities that don’t directly deal with the patient (or relate to patient work at all). Currently, ‘direct care’ includes bedside care (meds -prep and administration, ambulating, dressing changes, bathing and bed changes, etc.), the time for connecting with the medical team(s) (paging, running to pharmacy, teaching patient and/or family), and all documentation activities (including updating care plans). Productive Hours need to be more clearly and strictly defined by the nursing department within UHS to give HPPD budgets and WHPPD values operative meaning, without including miscellaneous unit tasks that, although they may be important, do not directly relate to patient care.

Standardize and level nurse-to-patient assignments Lastly, Unit 4B may be able to reduce their HPPD if they consider standardizing which nurses are assigned to certain types of patients in addition to more strategically leveling workload across available nursing staff. Instead of employing a wide range of patient acuities to establish equivocal workload, the unit should consider aligning patient requirements with specific staff skill and experience. For example, it may be more efficient to only assign trache patients to certain nurses that are better equipped at handling the required direct care tasks at a 1:2 nurse-to-trache patient ratio and assigning less experienced nurses patient acuities 1 through 2 at a 1:3 or 1:4 nurse-to-patient ratio.

RECOMMENDATIONS ON IMPROVING HPPD

1. Inquire about the standardization the calculation of unit productive hours across the Nursing Department to exclude RN break time, average department miscellaneous time, and unit host time

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a. The standardization and strict definition of PH brings further meaning to what HPPD represents and better enables Unit 4B, the greater Nursing Department, and the UMHS Board of Directors the ability to know what time is and is not being accounted for when budgeting for FTEs.

2. Begin more formally documenting day-to-day inbound transfers, outbound transfers, discharges, admits, and average midnight census patient acuity

3. Develop tool for objectively assessing the acuity level of patients. 4. Develop automated tool for objectively assigning nurses patients for staffing-assignment

processes 5. Investigate MiChart update standardization and formal education on pre-confirmed dates so that

the unit may better prepare and train for system changes 6. Enforce time limits for Nurse Shift Change meetings and create a priority template for nurses to

follow when discussing unit/patient handoff a. Ex: Patient hand-off should take 2 minutes and cover patient info X, Y, and Z b. Ex: Charge Nurse hand-off should take 10 minutes and cover unit info X, Y, and Z

7. Develop protocol that can reduce time spent on MiChart Documentation to allocate time towards patient care

EXPECTED IMPACT The recommendations, if implemented, will positively impact Unit 4B by improving the nurse allocation and assignment process, reducing inpatient-care variability for nurses, providing baseline data for all nurse-related tasks on unit 4B, and providing a more accurate HPPD value. Future work that should be done on Unit 4B to make the unit more efficient are:

1. Standardization for PH calculations across Nursing Department 2. Develop tool for objectively assessing acuity levels 3. Develop automated tool for objective staff-assignment process 4. Create template for Shift Change meetings

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APPENDIX Nursing Survey

1. How long have you been an RN? _ 2. How long have you been on 4B? _ 3. What shift(s) do you normally work? Days Eves Nights Day/Eve Day

Night 4. How many patients are you normally assigned? 3 4

Direct Care

Let us know, on average, how long (in minutes) does it take for you to perform the task. Think of it as time at the bedside doing the task or monitoring the patient because of what you have just done. If you have never performed the task, please mark NA (not applicable).

Nurse Response

Office use only

Airway suctioning & lavage Airway cleaning – includes inner cannula Incentive Spirometry P & PD Incision care without dressing Flap assessment (Doppler or Vioptic) – includes Poke Donor and/or graph site assessment Dressing change simple Dressing change complex (packing; extensive area; premed required etc)

Heat Lamp therapy Wound Vac – assessing the dressing; checking the suction Leech Therapy – application and monitoring during the therapy Drain Care (NG; Dobhoff; PEG; Jtube; Gtube) - site assessment, cleaning & emptying

Tube Feeding – continuous (set up) Tube Feeding – intermittent Medication administration – simple – includes piggyback Medication admin complex – requires crushing; sliding scale; meds >q4hrs; cardiac drip

PCA/Epidural – includes pulse 02 monitoring; increased vital signs;

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check at hand off Blood Administration IVIG Administration Insulin Drip – checking the chemstick and adjusting the drip Heparin Nomogram – includes ordering/checking the lab and modifying the drip rate

Patient/Family Education simple Patient/Family Education complex – per episode Emotion support to patient or family Ostomy care/management simple Ostomy care/management – complex (example: leaking) Dignicare – placement and/or maintanance Pericare – includes Foley; butt care ISC Foley insertion Bladder Scan Measuring and emptying outputs (all outputs) Turns & positioning - simple Turns & position – complex (requires lift team or multiple people or lift equipment)

General daily skin assessment (Braden) Mobility simple – pt requires one person assist Moblity complex – requires multiple people and/or equipment Vital Signs MAWS – intentional hourly rounding with specific checks/assessments

Pain Assesment/reassessment) Shift Assessment (Head to Toe) Shift Report Telemetry – strip interpretation Restraint monitoring/patient checks – non violent Restraint monitoring – VIOLENT Patient surveillance (for restless; confused or cognitively impaired patient)

Stroke assessment – includes Depression Cognitive Screen; Swallow Screen

Specific Neurological Assessment for patients with Neuro diagnosis Patient experiencing a seizure episode In this section, please estimate the total the time, in minutes to complete the

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task for one patient Admission documentation Discharge documentation Plan of Care Note Progress Note (fall or incidental comments) Restraints Note Flow Sheets (tabs) Wound Navigator Care Plans Patient Education Indirect time estimates Paging Organizing your day (worksheet; coordinating with tech; letting charge know of any concerns )

10:00 AM Huddle Random phone calls (families/pharmacy/PFANS etc) or coordinating with other ancillaries

Answering call lights Calling/receiving report for adm/transfers

5. What is the average acuity level per patient or per assignment? __________

6. Do you feel that you have an adequate amount of time to attend to your assigned patients during your shift, given the number of patients you are assigned and their respective acuities? �Yes �No

On-Unit Observation Collection Sheet

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HPPD Weekly Report Summary (12/21/14 - 9/26/2015)

Bepper Study Collection Cards

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Distribution of time per tasks for bedside nurse during observation study

MiChart Documentation times on Bedside Nurse

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Pareto chart on Beeper Study bedside nurse analysis

Pareto Chart for Beeper Study Charge Nurse Analysis