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

[Pages:30]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 Jainabou Barry Benjamin Bennett

IOE Senior IOE Senior IOE Senior

University of Michigan Industrial and Operations Engineering Department

1205 Beal Avenue Ann Arbor, MI, 48109

Date Submitted: December 15th, 2015

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 timerestricted 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. Crossexamination 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 telemetryrelated 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-tonurse 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 timeintensity level:

Level 1 Meds generally given as scheduled

Level 2 May have feeding tube but tolerating well

Level 3 Needs 2 or more assist with ambulating

Level 4 Cardiac monitoring with q1 titration

Small to moderate dressing changes required only as scheduled Less than 20 minutes of teaching required SAT WNL

Good family support

Meds as scheduled. May have PCA for pain

May be incontinent of urine or stool (40 minutes of

patient/family education

Q4 Suction

Anxious patient/family

who needs constant

reinforcement

Figure 1: Patient Acuity Tool

Fluctuating SAT requiring vigorous pulmonary hygiene

Fresh trach

AWS protocol first 48 hours Q1-2 vitals Suction q1/constant secretions VS q1

Leeches and flap check q1 Sitter

Restraints

First dose IVIG/Chemo Insulin gtt

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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