University of Michigan Health System Program and Operations Analysis

Analysis of Nurse Practitioner Workload in Interventional Radiology

Final Report

December 11, 2006 To: Susan Fisher, Lean Project Manager, Administrative Specialist, Radiology Sheri Curnes, Project Coordinator, Senior Management Engineer

Richard J. Coffey, Director, Program and Operations Analysis From: IOE 481 Project Team, Program & Operations Analysis Department

Jaime Bell, Senior IOE Student Tina Lian, Senior IOE Student

Table of Contents Page

Executive Summary 1 Introduction and Background 3

Goals and Objective 3

Key Issues 3

Project Scope 3

Support Required 4

Approach and Methodology 4

Conduct Literature Search 4

Shadow, Survey, and Interview Nurse Practitioner & Clerk 4

Perform Random Beeper Study 5

Analyze Data and perform Recommendation 5

Current Situation 5 Alternatives Considered 6 Tasks to Transfer from Nurse Practitioners 6 Limit on Number of Tasks to Transfer to Clerk 7 Workload Distribution between Nurse Practitioners 7 Findings and Conclusions 7

Nurse Practitioner Workload Satisfaction 7

Current Nurse Practitioner and Clerk Workday Tasks 8

Workload Study to Find Proportions 8 NP Percentage of Time Spent on Tasks 8 NP Percentage of Time Spent at Locations 9 95% Confidence Interval for NP 9 NP Data Validation 10 Clerk Percentage of Time Spent on Tasks 10 Clerk Percentage of Time Spent at Locations 11 95% Confidence Interval for Clerk 12 Clerk Data Validation 12

Limit on Number of Tasks to Transfer to Clerk 12

Tasks to Transfer from Nurse Practitioners 13 M.D. Schedule 13 Booking: Admissions on Metaframe 13 Retrieving Outside Films 13

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Scheduling Anesthesia 13

Workload Distribution between Nurse Practitioners 13 Shadowing the Nurse Practitioners 14

Recommendations 14

Tasks to Transfer from Nurse Practitioners 14

Limit on Number of Tasks to Transfer to Clerk 15

Workload Distribution between Nurse Practitioners 15

Expected Outcome and Cost 15

Action Plan 15 Tasks to Transfer from Nurse Practitioners 15

Workload Distribution between Nurse Practitioners 16

Appendix A: Literature Search Titles A-1 Appendix B: Current State Value Stream Map B-1 Appendix C: Workload Survey C-1 Appendix D:

Radiology Associate Tick Sheet D-1

Nurse Practitioner Tick Sheet D-2

Appendix E: Nurse Practitioner Interview Questions E-1

Appendix F: NP and Clerk Validation Pie Charts F-1 List of Figures and Tables Figure 1: Nurse practitioner Pre-procedure VSM 6 Figure 2: Nurse Practitioner Task Distribution (Sample Size?) 8 Figure 3: Nurse practitioner location distribution. 9 Figure 4: Clerk task distribution 10 Figure 5: Clerk location distribution 11 Figure 6: Clerk travel distribution 12 Figure 7: NP workload distribution between inpatient, outpatient and holding 14

Table 1: Tasks to be transferred from the NPs to Supporting Staff 2 Table 2: Survey Results: Nurse Practitioner Workload Satisfaction 7 Table 3: Tasks to transfer from NPs to Supporting Staff 16

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Executive Summary There have been concerns that the nurse practitioners (NP) are overworked in the Interventional Radiology (IR) Department at the University of Michigan Health Services (UMHS). To address the issue, the IR department hired an additional nurse practitioner as well as a radiology associate (or clerk) to handle administrative work thus enabling the nurse practitioners to be more fully dedicated to their main responsibility of patient care. Our team was brought in to complete the project outlined below. This project is based on a key initiative from an IR lean project. The following key issues were identified by the IR lean project team:

• Nurse practitioners are feeling overloaded • Workload of newly hired clerk needs to be analyzed to determine which tasks to transfer

from NP to clerk The goals of our project were to:

• Establish a list of the current nurse practitioner tasks in the IR department • Determine which tasks can be shifted from the NPs • Determine any limits on the number of tasks to be transferred to the clerk • Verify the workload is distributed evenly among nurse practitioners

Maximizing the time the NPs spend on patient care and clinical tasks is a high priority. The objective of this project was to determine what tasks can be transferred to the clerk to improve the utilization of the nurse practitioner. The scope of the project included:

• Workload study of the nurse practitioners and clerk in the IR department • Recommendations for tasks that can be shifted from the NPs • Analysis of NP workload distribution

Since the newly hired nurse practitioner is still being trained, this study focused on the two experienced nurse practitioners in the department. In addition, this project did not include any tasks for which NPs and clerk are not responsible for. Also not included are work studies of nurse practitioners or clerks outside of the Interventional Radiology department. To understand the background of the project, our team first conducted literature searches for workload study methods and methods for reorganizing tasks and duties from staff to support staff such as from a doctor to a nurse. To meet the project objective, our team shadowed and surveyed the two experienced nurse practitioners and the clerk to gain a better understanding of the current state of the department. From our initial observations and previous lean initiative value stream maps (VSM), our team created a NP current state VSM to visualize the NP segment of the entire IR process. Next, our team conducted a workload study on both NPs and the clerk. Data collection occurred over two weeks to measure the proportion of time spent on daily tasks. Finally, both NPs were interviewed to clarify what is involved in a task to identify possible tasks to transfer.

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The results of the surveys given to both NPs confirm the statement that the NPs feel overworked through the day. In addition, they are not satisfied with their current workload and felt the workload is distributed evenly among the NPs. To conduct the workload study, our team used random beepers and tick sheets developed with assistance from the NPs and clerk. The results of our study indicate that the NPs spend the majority of their day on tasks related to assessments – 25%, direct patient care – 19% and communication – 17% (accurate to within ±3% with a 95% C.I.). NPs completed most of their work from their office with the IR Clinic as the second most frequented location. The clerk spends the majority her day on tasks related to scheduling – 20%, administrative tasks – 19% and billing – 19% (accurate to within ±5% with a 95% C.I.). The clerk also spends the majority of time in her office. Interviews of the NPs were conducted to identify possible tasks to transfer and requirements to perform each of the transferable tasks. A list of possible tasks to transfer with suggested transfer dates are listed below in Table 1:

Table 1: Tasks to be transferred from the NPs to Supporting Staff Tasks Transferred to By M.D. Schedule M.D. Administrative Assistant 12/31/2006 Retrieving Outside Films Clerk 12/31/2006 Booking Admissions on Metaframe Clerk 01/31/2007

Scheduling anesthesia is another task that could possibly be transferred to the clerk in the near future. Scheduling anesthesia is a more complex task involving other departments within the hospital. Therefore, this task should not be transferred until the NPs feel the clerk is capable of performing this task and the appropriate training has been completed by the clerk. The three tasks that can be transferred to the clerk account for only 4% of the current nurse practitioner workload. Since the clerk spends more than 29% of her time on low priority tasks, transferring these additional tasks to the clerk will not overload her. In fact, additional responsibilities could be transferred to the clerk at a later time. Distributing the NP workload based on inpatient, outpatient, and holding areas, as currently proposed, may not create an even workload among NPs. From the workload study, holding consisted of about 22%, in-patient consisted of about 17%, and outpatient consisted of around 61% of the workday activities. Instead, because of the staggered start times among NPs, dividing the workload based on time of day that the tasks need to be performed may be a better system. Further study on the workload distribution between NPs should be completed to evaluate other possible alternatives.

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Introduction and Background The Interventional Radiology (IR) department in the University of Michigan Hospital has received complaints that the nurse practitioners (NPs) are feeling overloaded. In response, the department made the decision to hire an additional nurse practitioner to reduce the workload of the two current experienced nurse practitioners. The primary responsibility of the NPs’ is patient care in the pre-procedure segment of the interventional radiology process. NP duties cover everything from interfacing with referring/ordering services, assessing, triaging and prioritizing the patient into the system, problem solving in a variety of situations, discharging the patient and providing routine follow-up care for the chronic population. At present, the nurse practitioners often need to perform tasks that can be done by clerical personnel. Therefore, the department has also hired a radiology associate, or clerk to handle the administrative work for the nurse practitioners, thus enabling the nurse practitioners to be more fully dedicated to patient care. After the new NP has been trained, the IR department plans to implement the following NP schedule and workload distribution proposed by the NPs. The first NP to arrive will work from 7am to 4pm. Her main focus is on outpatients. The second NP’s work hours are currently 9am to 6:30pm, but will soon change to 12pm to 8pm; her focus is on inpatients. The third, new NP will see patients in the radiology Holding/Recovery area; she works from 9am to 5:30pm. The clerk will also be handling administrative work for other staff in the neuro-interventional radiology department in addition to the nurse practitioners in the IR department. Goals and Objective For this project, our team established a list of the current nurse practitioner tasks in the IR department. In addition, the project team determined which duties could be shifted from the NPs, and if there are any limits on the numbers of tasks that can be transferred to the clerk. Finally, the team verified if the workload is distributed evenly among nurse practitioners. The nurse practitioner is a highly trained individual. Therefore, maximizing the time the NPs spend on patient care and clinical tasks is important. The objective of this project was to determine what functions can be transferred from the NPs to the clerk in order to improve the utilization of the nurse practitioner. Key Issues This project was based on a key initiative from a previous IR lean project. Key issues identified by the lean team are the nurse practitioners feel overloaded and the workload of newly hired clerk needs to be analyzed to determine which tasks to transfer from NP to clerk. Project Scope This project focused on the two experienced nurse practitioners in the department since the newly hired nurse practitioner was still being trained. This project included a workload study for both NPs and the clerk, an analysis of tasks performed by the NPs and clerk, and recommendations for tasks that could be shifted to the clerk. Some NP tasks include collecting patient histories, performing physicals on IR patients, as well as obtaining patient consent forms. Any task that the NPs and clerk are not responsible for were not included in this report. For example, NPs do not prepare the surgical room, so this task was not included in our study. Also

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not included were work studies of nurse practitioners or clerks outside of the interventional radiology department. Support Required The support required for our project included our client, the administrative specialist for radiology. She provided a description of the project, project requirements, expectations of the project, and contact information for the NPs and the clerk. In addition, our project coordinator mentored and guided our team to ensure the project was performed professionally and accurately. She provided literature on previous student work study projects and met with us weekly to discuss the progress of the project and review all of the materials prepared. This final report summarizes the approach and methodology taken in the project as well as the current situation, alternatives considered, findings, conclusions, recommendations, and action plan. Approach and Methodology To understand the background of our project, we collected information through literature searches. We also shadowed, surveyed and interviewed both experienced nurse practitioners and the clerk in the IR department, and then performed workload studies using random beepers on the three individuals. With the data that was collected, we analyzed the nurse practitioner workload and developed recommendations. Conduct Literature Search The project team first conducted literature searches for workload study methods and reorganizing tasks and duties from staff to support staff such as from a doctor to a nurse. To begin our search, our project coordinator provided us with information on data collection, as well as reports from previous student projects similar to this project. The student project titles can be found in Appendix A. Shadow, Survey, and Interview Nurse Practitioners and Clerk Next, we collected current state information through shadowing, surveying and interviewing the nurse practitioners and the clerk to gain a better understanding of their daily tasks and procedures associated with their respective positions. First, we shadowed the nurse practitioners and the clerk a total of 24 hours. We did not shadow the third nurse practitioner because as a new hire, she was still shadowing the other nurse practitioners herself. Next, we developed a workload satisfaction survey that was distributed to both nurse practitioners. The survey gauged how the NPs felt about the weight of their workload and the amount of work they thought could be shifted to the clerk. The surveys were distributed and answered on October 4th, 2006. The survey can be found in Appendix B.

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Finally, we created a list of questions for interviewing the nurse practitioners, which helped the project team gain a better understanding of the current processes and requirements for performing certain tasks. Interviews were held during the week of October 9th, 2006. The interview questionnaire can be found in Appendix C. Perform Random Workload Study To determine the amount of time needed to perform each NP/clerk task, we developed two affinity diagrams: one for the nurse practitioners’ tasks and one for the clerk’s tasks. An affinity diagram is a list of information sorted into categories. The affinity diagrams were created using information collected from shadowing, surveying and meetings with the NPs and the clerk. For this project, the list of information or tasks was sorted by clerical or clinical tasks. From the affinity diagram, we created spreadsheets or tick sheets on which the nurse practitioners and the clerk made tick marks to record their current activities at random intervals. The tick sheets can be found in Appendix D. To obtain an accurate representation of workload, the nurse practitioners and the clerk wore random beepers for two weeks. For every beeper alarm, the nurse practitioners and the clerk recorded a tick mark in the category of the task they were currently performing. The beepers were programmed to beep at random intervals of approximately four times per hour. In total, we expected to have 640 data points for the nurse practitioners (480 actual data points) and 320 data points for the clerk (218 actual data points). Finally, we collected the sheets after the two weeks of data collection to record and analyze. Analyze Data and Develop Recommendations Data collected from the workload study was analyzed to determine the proportion of time spent performing various tasks and the 95% confidence interval (C.I.). Based on these proportions, we recommended which tasks should be transferred from the nurse practitioners to the clerk. Our team also verified whether the proposed workload distribution among nurse practitioners is evenly divided using the data obtained from our workload study. Current Situation To more fully understand the daily work activities of the nurse practitioners, our team observed both experienced NPs throughout their workday. From shadowing, interviews, and information from a previous lean project initiative, a current state value stream map (VSM) was created for the nurse practitioners, which can be found in Appendix E. The majority of duties performed by nurse practitioners are considered scheduled pre-procedure tasks. The scheduled pre-procedure task section of the NP current state VSM is shown in Figure 1 on the next page.

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Figure 1: Nurse practitioner Pre-procedure VSM The wavy lines in the diagram are an indication of intermediate tasks that need to be performed by other members of the department before the NPs can complete the tasks listed in the purple boxes. The numerous wavy lines in the map show that the NPs are necessary for many different portions of the entire IR process. It is difficult to create detailed flowcharts specifically for NPs since their duties are fragmented, vary depending on different circumstances, and depend heavily on other members of the department. Alternatives Considered Based on the goals and objectives of the project, the project team decided to consider the following alternatives. Tasks to Transfer from Nurse Practitioners From our initial assessment, our team identified several possible tasks to transfer from the NPs. The tasks came from categories such as Clerical, Administrative and Assessments. The project team further investigated these tasks through interviews with the NPs:

• M.D. Scheduling • Booking Admissions on Metaframe • Retrieving Outside Films • Anesthesia Scheduling • Scheduling Appointments • Faxing Consent Forms to Careweb • Calling/E-mailing for Requests • Procedure Referral & Scheduling

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Limit on Number of Tasks to Transfer to Clerk Because the clerk cannot perform an unlimited number of tasks, the project team decided to analyze the maximum amount of work that could be transferred to the clerk. To do this, the clerk was asked to identify which of her tasks were high priority tasks that must be done as soon as possible and which tasks were low priorities that she performs when she has spare time. Using the workload study data, our team determined the distribution for high and low priority tasks, traveling, and miscellaneous tasks. Workload Distribution between Nurse Practitioners The final portion of our project included determining whether dividing the workload into inpatient, outpatient and holding would distribute the workload evenly among the NPs. Our team decided to gather subjective feedback from our workload satisfaction survey and questioned the nurse practitioners on the distribution of their current workload. For our workload study, tasks were broken up into the location the task was performed to determine the percent of time spent in inpatient, outpatient, and holding areas. However, we did not account for areas such as the NP office where the NPs complete all three types of work. Findings and Conclusions From data analysis, we were able to show that the NPs and clerk spend the majority of their time in their respective offices dedicated to high priority tasks (patient care and clinical tasks for the NPs and clerical and administrative tasks for the clerk). Below is a summary of our key findings and conclusions based on the goals and objectives of our project. Nurse Practitioner Workload Satisfaction From the survey responses of the two nurse practitioners, we found the nurse practitioners agreed or strongly agreed to being overworked. The NPs also felt the workload is evenly distributed among nurse practitioners and disagreed to the statement “You are satisfied with your current workload”. These findings are summarized in Table 2.

Table 2: Survey Results: Nurse Practitioner Workload Satisfaction Average Rating Survey Statements Range

You feel overworked through the day.

Agree/Strongly Agree 3.5

You are satisfied with your current workload. 2 Disagree

The workload is distributed evenly among the NPs.

Agree/Strongly Agree 3.5

Scale: 1-strongly disagree, 2-disagree, 3-agree, 4-strongly agree Sample Size = 2

Data as of October 23, 2006

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In addition, the survey also revealed that the nurse practitioners feel they spend about 1 hour/day on clerical tasks and that when performing clerical tasks, there is always clinical work that needs performed as well. Current Nurse Practitioner and Clerk Workday Tasks Lists of tasks that the nurse practitioners and clerk perform daily are listed in the tick sheets used for the workload study located Appendix D. The nurse practitioners and clerk developed these lists on their own. ‘Other’ was included as a task in the event that a duty not listed on the tick sheet was performed; however, less than 1% of tasks were recorded as ‘Other’ for both the nurse practitioners and clerk. Therefore, the tick sheets consist of a complete list of all tasks performed by both the nurse practitioners and clerk. Workload Study to Find Proportions The NP and clerk analysis was broken up into percentage of time spent on tasks and location. NP Percentage of Time Spent on Tasks. Figure 2 below shows the distribution for the NPs.

Figure 2: Nurse Practitioner Task Distribution (Sample Size=480)

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Figure 2 shows that the nurse practitioners spend the majority of their day on ‘Assessments’, ‘Direct Patient Care’, and ‘Communication’. A sub breakdown for those categories is also included in Figure 2 to show the distribution of the specific tasks included in each category. The ‘Clerical’ and ‘Admin’ categories consume 2% and 3% of the nurse practitioners day respectively, as shown in Figure 2. NP Percentage of Time Spent at Locations. Figure 3 shows the distribution of time the nurse practitioners spend in different locations throughout the hospital.

NP Office44%

IR Clinical20%

Other12%

Holding10%

PACU2%

In Patient6%

Other Clinical6%

CPU0%

Figure 3: Nurse practitioner location distribution (Sample Size = 480)

From Figure 3, the nurse practitioners spend the most time in their offices. However, they also spend a large portion of time in the ‘IR clinic’, ‘Holding’ and ‘Other’ locations. The category ‘Other’ is a significant portion due in large part to breaks and discussion in the hallways. 95% Confidence Interval for NP. Based on the amount of data collected from our NP workload study, we determined that our daily task proportion is accurate to ±3% with a 95% confidence interval (C.I.). The 95% C.I. is calculated using the equation below:

(1)p(1- p)/TES95% C.I. = ±1.96 (1) TES = Total Equivalent Samples p = fraction of category Divilbiss Electronics (1981) Designing a Time Study Using the smallest major category, the calculated confidence interval is ±3%, which means that for all other categories, we can assume that the CI will be within 3%.

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NP Data Validation. To validate the NP workload study, our project team followed the two NPs for six hours each, making tick marks every ten minutes corresponding to the task the NPs were performing. The distribution of the validation data can be found in Appendix F. The three highest categories for the validation data and workload study data are within ± 4% of each other. The ‘Administrative’, ‘Traveling’ and ‘Education’ categories are also within ± 4%. However, the percentages for the ‘Documentation’ and ‘Consent’ categories are not as similar. This variation can be explained by the time of day that the validation data was collected. The NPs spend their mornings obtaining patients consents for procedures later in the day and do not complete documentation for tasks until later in the day. The validation data was collected during the morning and early afternoon, which explains this variation in the ‘Documentation’ and ‘Consent’ categories. Clerk Percentage of Time Spent on Tasks. Figure 4 shows the distribution of the clerk’s categories and tasks from the workload study.

Figure 4: Clerk task distribution (Sample Size = 218)

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From Figure 4 on the previous page, the clerk spends the majority of her day on ‘Scheduling’, ‘Admin’, and ‘Billing’ categories. A sub breakdown of these categories is included to show the specific tasks the clerk works on during this time. One category that seems particularly high is ‘Traveling’. According to the workload study, the clerk spends 16% of her day traveling around the hospital. The ‘Miscellaneous’ category may also seem high at 15%; however, ‘Breaks’, ‘Meetings’ and ‘Other’ tasks are included in this category. Clerk Percentage of Time Spent at Locations. From the clerk’s workload study, we found the majority of day is spent in her office. Figure 5 shows the distribution of time the clerk spends in different locations throughout the hospital. Based on Figures 4 and 5, when the clerk is not in her office, she spends a great deal of time traveling to and from other locations.

Office78%

Other10%

Neuro Office5%

Core4%

NP Office3%

Reading Room0%

Figure 5: Clerk location distribution (Sample Size = 218)

Spending 16% of a day traveling around the hospital is inefficient, so the project team analyzed the clerks traveling patterns to recommend a new office location. Figure 6 on the next page shows the distribution of locations the clerk travels to based on the workload study.

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Core12%

Reading Room

0%

Neuro Office12%

Other15%

NP Office18%

Office43%

Figure 6: Clerk travel distribution (Sample Size = 34)

As expected, the clerk walks back to her office almost half the time. The next two highest locations the clerk travels to are the ‘NP Office’ and ‘Other’ at 18% and 15% respectively. Since traveling to ‘Other’ was mostly traveling to the lunchroom and break areas, little can be done to reduce the required traveling proportion to those locations. However, if the clerk’s office were moved closer to the NPs’ office, the amount of travel time required by the clerk would be reduced. 95% Confidence Interval for Clerk. Based on the amount of data collected from the clerk workload study, our team calculated the task distribution to be accurate to within 5%. The project team used the same formula to calculate the confidence interval for the clerk as was used above to calculate the NP confidence interval. This means that for all categories, we can assume that the CI will be within 5%. Clerk Data Validation. To validate the clerk workload study, the project team followed the clerk for six hours, making tick marks every ten minutes corresponding to the task the clerk was performing. The distribution of the validation data can be found in Appendix F. All of the validation categories, except for ‘Morning Tasks’, are within ± 3% of the workload study. In the validation study, the category ‘Morning Tasks’ is at 13%, whereas the category accounts for only 6% in the workload study. This is to be expected since validation data collection occurred while the clerk received a special request to work on the doctor’s schedules. Limit on Number of Tasks to Transfer to Clerk After the task list was compiled for the clerk, the clerk identified which tasks were not performed for the nurse practitioners. Of the remaining tasks, the clerk identified which tasks were low and high priorities. The high priority tasks that the clerk performs for the nurse practitioners constitute 38% percent of the clerk’s workday. The clerks spends 29% of her time on low priority tasks, 16% traveling, and 17% on miscellaneous. Since the miscellaneous and high priority tasks cannot be eliminated, at most, the clerk could have 45% more work added to her

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day. Therefore, a large portion of the nurse practitioner workload could be transferred to the clerk if needed. Tasks to Transfer from Nurse Practitioners From the interviews with the NPs and the workload study, the project team recommends transferring the three tasks from the nurse practitioners to supporting staff immediately, and one other task that could be transferred in the future. These four tasks are M.D. Scheduling, Booking Admissions on Metaframe, Retrieving Outside Films, and Scheduling Anesthesia. M.D. Schedule. The NPs are currently transferring this task to the physicians’ administrative assistant. At present, the nurse practitioners spend 2.1% of their time working on the M.D. schedule. This percentage is equivalent to about 1 hr/week or 40hrs/year (based on 48 work weeks per year). To transfer this task, approximately 2 hours of training was given by a nurse practitioner, on the M.D. scheduling software. By December 31st, 2006, this task will be completely transferred to the physicians’ administrative assistant. Even though the physician’s administrative assistant will be making the schedule, the NPs will still have to approve and finalize the schedule. Therefore, a portion of the 2.1% of NP time cannot be transferred to the administrative assistant. Booking: Admissions on Metaframe. This task can be transferred to the clerk. At present, the nurse practitioners spend 0.4% of their time working on booking admissions on Metaframe. This percentage is equal to about 0.16hrs/week or 8hrs/year. To transfer this task, a generous estimate of training time was set at four hours, given by a nurse practitioner, on the Metaframe admitting software. In addition, the clerk will need a password to access Metaframe. By January 31st, 2007, this task will be completely transferred to the clerk. Retrieving Outside Films. The NPs’ clerk can already perform this task for the NPs. At present, the nurse practitioners spend 0.4% of their time retrieving outside films. This percentage is equivalent to about 0.16hrs/week or 8hrs/year. To ensure that this task is transferred, the project team will emphasize to the NPs that their clerk can perform this task for them. By December 31st, 2006, this task will be completely transferred to the clerk. Scheduling Anesthesia. In the future, this task could be transferred to the clerk. At present, the nurse practitioners spend 2.9% of their time scheduling anesthesia for patients. This percentage is equal to 1hr/week or 56hrs/year. Although this is a more complicated task, with sufficient training and approval of the NPs, the clerk may be able to schedule anesthesia. The clerk will need a maximum of four hours of training on the anesthesia department’s scheduling software. Additionally, a maximum of two hours of training for comparing anesthesia and radiology schedules to find a time when both departments can perform the procedure. Again, these training times are generous time estimates set by the project team. Workload Distribution between Nurse Practitioners The Interventional Radiology department is planning on distributing the workload between the three nurse practitioners by assigning a NP to inpatient, outpatient and holding tasks. To validate this approach, the nurse practitioners recorded the location they were performing tasks during the workload study. From the location information we were able to estimate the percentage of tasks

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in inpatient, outpatient and holding. Figure 6 shows the percentage of time the nurse practitioners spent on inpatient, outpatient and holding tasks. From Figure 6, the percentage of time spent is uneven between holding, inpatient and outpatient tasks.

In Patient17%

Out Patient61%

Holding22%

Figure 7: NP workload distribution between inpatient, outpatient and holding

(Sample Size = 210)

Shadowing the Nurse Practitioners While shadowing the nurse practitioners, the project team noticed that the NPs perform specific tasks at certain times of the day. For example, consents are performed at the start of the day because the procedure cannot be performed until consent is received. Also, documentation activities are not performed until the end of the day when the NPs have finished working directly with patients. This finding gives support to the concept of distributing the nurse practitioner workload based on time of day. Recommendations Based on these findings and conclusions, the project team has developed the following recommendations. Tasks to Transfer from Nurse Practitioners The project team recommends transferring the following three tasks immediately:

• M.D. Schedule transferred to MD’s administrative assistant • Booking: Admissions on Metaframe transferred to clerk • Retrieving Outside Films transferred to clerk

In addition, we recommend transferring ‘Scheduling Anesthesia’ in the future. ‘Scheduling Anesthesia’ is a more complicated task, and therefore should not be transferred until there is approval from the NPs and the clerk is comfortable with all of her other responsibilities.

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Limit on Number of Tasks to Transfer to Clerk Based on our workload study, only 4% of the nurse practitioner workload will be transferred to the clerk. Since the clerk spends more than 29% of her time on busy work, transferring these tasks to the clerk will not overload her. In fact, additional responsibilities could be transferred to the clerk at a later time. Workload Distribution between Nurse Practitioners The project team recommends that the workload should not be distributed between the nurse practitioners based on inpatient, outpatient, and holding tasks. Instead, a better method would be to divide the workload based on time of day that the tasks need to be done. The staggered start times of the NPs also better suit this method. Other options for dividing the workload include performing the work as it arrives and allowing the nurse practitioners to choose which tasks they would like to be assigned too. Further study on the workload distribution should be completed based on these alternatives. Expected Outcome and Cost Implementing our recommendations will reduce the NP workload by 5.8%, which is equivalent to about 2.3 hours each week or 111 hours a year (based on 48 work weeks/year). While the percentage may be small, this project verifies that the two nurse practitioners have already moved most of clerical or administrative tasks to the clerk. In addition, although 2.3 hours per week is less than the NPs estimate of 5 hours per week (1 hour per day) on clerical tasks, this difference is because several of the clerical tasks cannot be transferred. Cost savings from our recommendation are based on the number of hours transferred or required for training and the pay difference between the nurse practitioner and the clerk. Cost saving are expected to be about $3,030 a year. The cost of implementation is expected to be about $640. This gives us a first year cost savings of $2,400. Action Plan Based on our findings, conclusions, and recommendations, the project team developed the following action plan for implementation. Tasks to Transfer from Nurse Practitioners The dates to transfer the tasks were developed by examining the amount of training required to transfer the task, the difficulty of the overall task, and whether any training had already been started. The clerical tasks should be transferred from the NPs to other hospital staff by these dates:

Table 3: Tasks to transfer from NPs to Supporting Staff Tasks Transferred to By M.D. Schedule M.D. Administrative Assistant 12/31/2006 Retrieving Outside Films Clerk 12/31/2006 Booking Admissions on Metaframe Clerk 01/31/2007 Scheduling Anesthesia Clerk TBD

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Workload Distribution between Nurse Practitioners Before the third, newly hired nurse practitioner begins working independently, the appropriate department staff should meet with the three nurse practitioners to determine whether the workload should be distributed in a different manner such as by time of day. If the nurse practitioners and project staff agree to an alternative workload distribution, a further study should be performed. For example, determine what time of day each task is performed as soon as possible. The best method to accomplish the analysis would be to perform another workload study. For instance, stratify tasks by time of day instead of location.

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A-1

Appendix A Literature Search Titles: Atiset, Ongart; Aziz, Nor A; Hu, Shiyin; Perry, Christopher. Analysis of Nursing Documentation

Process. 4/17/2006. University of Michigan Health System: Program and Operations Analysis.

Designing a Time Study. (1981) Divilbiss Electronics. Johnson, Alexander; Koppinger, Jake; Levy, Natalie; Ollinger, David. Analysis of Afternoon

Shift Staffing Needs in Central Sterile Supply. 4/20/06. University of Michigan Health System: Program and Operations Analysis.

Appendix B Workload Survey Please take a few minutes to fill out this survey; your answers will be kept confidential. Thank you for your participation.

In general, you feel overworked through out the day.

Strongly Disagree Disagree Agree Strongly Agree

Are there times of the day that are more hectic than others? Check all that Apply.

7-10am 10am-1pm 1-4pm 4-7pm None

In general, you are satisfied with your current workload.

Strongly Disagree Disagree Agree Strongly Agree

In general, how much clerical work do you do in a normal day?

None A Little Some A Lot

How many hours would you estimate you spend on clerical work? ____________

When you are doing clerical work, is there clinical work that also needs done?

Never Rarely Sometimes Usually Always

In general, do you finish your work in a normal shift?

Never Rarely Sometimes Usually Always

In general, the workload is distributed evenly among the nurse practitioners.

Strongly Disagree Disagree Agree Strongly Agree

h

Thank you for taking the time to fill out our survey. If you have any additional comments, please share t em on the back of this page. Your input is greatly appreciated.

B-1

B-2

Additional Feedback

Please share any additional comments. ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________

C-1

Appendix C Nurse Practitioner Interview Questions

1. If there was one thing you could change about your job, what would it be? 2. What one thing do you like best about your job? 3. During the beeper study, were there any tasks that you performed that were not on the tick sheet?

These might be tasks that you recorded as “Other.” What is involved in these tasks? 4. You identified several tasks (listed below in the table) as either Administrative or Clerical. I would

like to know a little more about what is involved in each task and what training would be required to transfer the task to a clerk.

Administrative and Clerical Tasks

Tasks What is Involved in the Task?What Training would be

Required to Transfer Task? M.D. and Fellow Schedule

Booking: Admissions on Metaframe

Retrieving Outside Films

Scheduling Appointments

Faxing Consent Form to CareWeb

C-2

5. There are several tasks that you did not identify as Administrative or Clerical (listed below in the table),

but might be possible to have a clerk perform. Again, I would like to know a little more about what is involved in each task and what training would be required to transfer the task.

Other Possible Clerical Tasks

Tasks What is Involved in theTask? What Training would be

Required to Transfer Task? Scheduling Anesthesia for Patients or Urgent Add-Ons

Calling/E-mailing for Requests

Procedure Referrals and Scheduling

Other:

Other:

6. Are there any other tasks that could be transferred to a clerk that I have not mentioned? 7. We would like to know more about which tasks are performed on inpatients, outpatients and in the

holding area. What percentage of time do you spend on each task in the three areas? (Record percentages in table below and on next page)

Nurse Practitioner Beeper Study Tasks In Patient Out Patient Holding

Chemo Order Fill/Fax to Pharmacy Peform H and Ps Explain Procedures to patients Evaluate Patients in holding Patient Follow up after procedure Ordering/Prescribing Medication

Dir

ect P

atie

nt C

are

Order steroids, antibiotics, narcotics

Retrieve patient history on CareWeb Examining CT scans & X rays Approve procedure requests Procedure referrals & scheduling Board Report Meeting Scheduling Patients for anesthesia Urgent add-ons: anesthesia scheduling A

sses

smen

ts

Calling/E-mailing for requests Take care of any board issues Review Schedule Communication Beeper E-mail

Com

mun

icat

ion

Discussion (in person) In Patient H & P form Discharge Summaries Clinic Visits Documentation

Doc

umen

tatio

n

Write Referrals and Laurie Faxes M.D. Schedule Fellow Schedule (IR)

Adm

in

Meetings (Nurse, Faculty, etc.) Teaching (Nurses, Physicians, etc) Radiology Quality Management Mtgs Conferences (Liver, Radiology)

Edu

catio

n

Morbidity and Mortality Statistics Booking: Admissions on Metaframe Retrieving outside films Scheduling Appointments C

leri

cal

Faxing Consent form to Careweb Traveling to Procedure Consents Other M

isc

Breaks

8. How would you classify CPU and PACU in terms of inpatient, outpatient or holding?

C-3

D-1

Appendix D

Start Time: End Time:

Date: Nurse Practitioner Beeper Study:

Data Collection Sheet

Tasks IR

ClinicalOther

Clinical Holding CPUIn

Patient PACU NP

Office OtherChemo Order Fill/Fax to Pharmacy Peform H and Ps Explain Procedures to patients Evaluate Patients in holding Patient Follow up after procedure Ordering/Prescribing Medication

Dir

ect P

atie

nt C

are

Order steroids, antibiotics, narcotics Retrieve patient history on CareWeb Examining CT scans & X rays Approve procedure requests Procedure referrals & scheduling Board Report Meeting Scheduling Patients for anesthesia Urgent add-ons: anesthesia scheduling Calling/E-mailing for requests Take care of any board issues

Ass

essm

ents

Review Schedule

Communication

Beeper

E-mail

Com

mun

icat

ion

Discussion (in person)

In Patient H & P form Discharge Summaries Clinic Visits Documentation

Doc

umen

tatio

n

Write Referrals and Laurie Faxes M.D. Schedule Fellow Schedule (IR)

Adm

in

Meetings (Nurse, Faculty, etc.) Teaching (Nurses, Physicians, etc) Radiology Quality Management Mtgs Conferences (Liver, Radiology)

Edu

catio

n

Morbidity and Mortality Statistics Booking: Admissions on Metaframe Retrieving outside films Scheduling Appointments C

leri

cal

Faxing Consent form to Careweb Traveling to Procedure Consents Other M

isc

Breaks

D-2

Start Time: Date: End Time:

Radiology Associate Beeper Study:Data Collection Sheet

Tasks Your Office NP Office Core

Neuro Office

Reading Room Other

Send films to viewer Compare EWS & groupwise calendar for NP & Doctor Make sure charts and encounter forms are ready Check for add on patients for IR and Neuro. IR M

orni

ng T

asks

Print schedules in the morning and afternoon Request outside film and records

Prep

W

ork

Create patient files for consult Collect Tracking sheet Update additional Procedure or DX codes on encounter forms IDX tracking/complete/accounting/transaction Get encounter form from NPs after dictation is done E-mail reminder to NPs to complete dictations

Bill

ing

Email any billing issues to lead billing clerk Call and confirm consult and exam appointments Schedule consult/follow up on appointments Schedule appointments and EWS Schedule exams needed before consult Follow up on any canceled appointments Call patients at NP request to inform patient about procedures Take phone call messages for NPs

Sche

dulin

g

UFE follow up folder and charts Print brochures Mail letters to clinics and patients Make copies of articles/information when requested by NP Quarterly report for Maria (QAC) Check clinic room and keep stock for brochures Traveling to Meetings Breaks Files

Mis

c.

Other

E-1

Appendix E

F-1

Appendix F

Assessments26%

Communication21%

Direct Patient Care20%

Consents14%

Traveling9%

Documentation1%

Education3%Misc

3%Admin

3%

Figure F-1: Validation for Nurse Practitioner Task Distribution

Scheduling20%

Admin19%

Billing16%

Traveling13%

Misc13%

Morning Tasks13%

Prep Work6%

Figure F-2: Validation for Clerk Task Distribution