productivity and workload measurement in ambulatory oncology

Productivity and Workload Measurement in Ambulatory Oncology

Barbara Ruppal M e d v e c

T HERE IS AN increasingly urgent need to determine the levels of staff appropriate for

high-quality ambulatory care. Developing an information system to assess productivity or workload in ambulatory care is complex because of the number of variables that occur in the outpatient setting. These variables include patient volumes, complexity of patient care needs, varied use of ambulatory care space, staff skill levels, and the types of nursing and support staff needed. A universal information system that collects and reports this information about ambulatory care practice is not available. The complexity of these variables within ambulatory care and the lack of a universal information system to gather and report data affect the ability of managers to precisely measure nursing productivity and workload within the ambulatory setting.

The word productive has several meanings: ef- fectiveness, results, abundance, and satisfaction. A basic productivity measurement system includes the time it takes to perform workload activities, the time available to perform the activities and the dif- ference between the two. 2 The dramatic continued shift from inpatient to outpatient care has focused attention on providing the highest quality care using the most efficient and productive means available. Ambulatory care has become highly compet- itive. Reimbursement is more regulated and managed care contracting dominates how payment is determined and where service is delivered. Fo- cusing on understanding and improving ambulatory productivity and workload demonstrates to health care purchasers and consumers of care that their ambulatory setting provides care that is of the highest quality, in the most productive and cost- effective manner. Traditionally, nurse administra-

tors have attempted to quantify productivity through the measurement of nursing workload. This information is then used to determine staffing levels as well as the qualifications of and types of staff needed to support patient care delivery. This information has been used to forecast resource use, to prepare budgets, to project costs, and to identify patient care support needs of new or changing pro- grams.

Through the development of workload analysis, administration can focus on accurate data that al- low clinical and operational improvements. Pro- ductivity data support reorganization by identifying redundant work or steps that can be eliminated. Productivity data facilitates an understanding of which skills best meet the care needs of the patient population. Productivity measurements decrease costs of care and improve quality of care delivered.

Patient classification systems are a type of productivity measurement that have existed for hospi- talized patients. Inpatient nurse managers have long relied on such information to assist in determining nursing workload and staffing assignments. In most cases, applying a traditional patient classification system in ambulatory care has failed because of the inability to reflect the multiple variables that affect ambulatory care. The other primary approach to gathering productivity information is workload analysis. Currently there are limited productivity measurement systems available specific to ambulatory care. This article reviews and defines the types of productivity measurement systems used in ambulatory care nursing. It also reviews the current tools, discusses tool limitations and strengths, and summarizes issues experienced when adapting such tools to individual ambulatory oncology nursing practice settings.

From the Division of Patient Care Services, Flower Hospi- tal, Sylvania, OH.

Barbara Ruppal Medvec, MS, RN, OCN: Assistant Vice President, Oneology and Medical Services.

Address reprint requests to Barbara R. Medvec, MS, RN, OCN, Oncology and Medical Services, Flower Hospital, 5200 Harroun Rd, Sylvania, OH 43560.

Copyright �9 1994 by W.B. Saunders Company 0749-208119411004-000855.0010

WHAT IS PATIENT CLASSIFICATION?

Patient classification instruments have traditionally served as a measurement process to determine inpatient unit staffing requirements. Numerous categorizations for patient care have been proposed including severity of illness, ambulatory visit groups, disease staging, reason/purpose for visit,

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WORKLOAD MEASUREMENT IN AMBULATORY ONCOLOGY

treatment planning, and nursing requirements. Pa- tient classification instruments are tools that pri- marily categorize patients or populations of patients based on their nursing care requirements and then assist in calculating unit staffing requirements.

Common components of a patient classification system include a classification instrument or tool, a method for quantification of nursing hours required per patient, and validity and reliability measurements. 3'4 The two types of patient classification are known as prototype and factor tools. A prototype classification tool compares a patient condition with a category containing a broad description of care requirements. The category description that best identifies the patient's present situation is usually selected. Nursing hours required per patient are then calculated and summed for the entire unit. The factor classification tool uses a scoring system. Each patient care require- ment is associated with a score. Scores are totaled for each patient and their care requirements. The patient is then categorized according to the total numerical value obtained. Nursing hours required per patient are calculated, and all patient totals are summed for the entire unit to determine staff requirements. For each type of classification tool, prototype, or factor, the final category of place- ment determines the total nursing hours required for patient care. The series of calculations to determine the ultimate unit staffing are specific to the methodology identified by the patient classification system developers. A patient classification system to be credible and useful must be both reliable and valid. Reliability concerns the degree of consistency with which the system measures the data intended to be measured. Validity indicates how accurately the data reflect what the system is supposed to measure. 5

WHAT IS WORKLOAD ANALYSIS?

Workload analysis allows us to measure the length of time it takes to complete tasks and how frequently they are performed. The goals of workload analysis are to objectively determine staffing requirements for a set of tasks by evaluating the process in which activities are performed, measuring their frequency of occurrence, and measuring the time required to do the task. From this information, staffing can be determined and work re- distribution can occur.

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Several techniques exist to complete workload analysis. 6 These include interviews with those doing the work, actual documentation of the work process, and timed measurement of the tasks within an activity. Interviews assist in determining the total work to be reviewed, the activities that may be time-consuming and duplicative, and those activities that may be left unaccomplished. Actual work measurements identify all of the tasks to be performed to complete an activity. This information assists in deciding whether work is performed efficiently. Time measurement is accomplished by the actual timing of the entire activity and all of the associated tasks.

Observation of many activities performed by numbers of personnel may be lengthy, time- consuming, and costly. Another technique used in workload analysis is called work sampling. Work sampling is the recording of all activities performed within an area at random times. This is an efficient technique for use with a large number of staff. Work sampling does not eliminate the need to time and measure each individual activity. More recently, random sampling pagers are used to determine when to record the exact activity being completed. Work sampling is best completed over several evaluation periods to ensure that all activities and/or fluctuations in the work are captured.

Workload analysis provides the manager with a complete summary of activities performed, the time required for each activity, and how frequently the activity is performed. Work sampling takes this information further by providing a picture of the percentage of time spent by staff doing each group of activities. This process provides data to improve productivity of all activities and at the same time will identify staff needed for each activity. Once data are available on all activities, staffing requirements are determined.

AMBULATORY PRODUCTIVITY AND WORKLOAD MEASUREMENT

O'Neal first summarized the differences between ambulatory and inpatient care delivery settings. 7 These include patient and provider unique differences such as stage of illness, patient percep- tions of illness, control of therapy or treatment plan, access to care, and the role of the health care providers. Table 1 summarizes all differences between inpatient and ambulatory care delivery set-

290 BARBARA RUPPAL MEDVEC

Table 1. Differences Between Inpatient and Ambulatory Care Settings

Inpatient Outpatient

Patients Stage of illness

Patient's perception of illness Control of therapy Access to care

Health providers Patient observation

Roles Patient volume

Medical records/data Progress notes

Coding system

Patient care delivery systems Longitudinal follow-up

Triage

Patient access to care Appointment system

Noncompliance follow-up

More acute Circumscribed Problem well defined Hospitalization will legitimize illness Passive Once admitted, fewer choices

Intense observation Shorter duration More direct observation

Provider roles more clearly defined More providers for small volume

Progress notes are formalized Daily progress notes

Established coding system

Not necessary because surveillance is with hospitalization

Not necessary

Single entry point Both volume and time of admissions

controlled Not necessary

Chronic/stabilized Ongoing Problem less defined Symptom may be absent or minimal Active Choice to keep or miss appointments,

multiple entry points

Brief observation Intermittent over long time spans Less direct observation, more reliance on

history Less role definition Fewer providers for larger volume

Progress notes variable More said than recorded Progress notes encompass longer time

span Less agreement on what is included on

progress note No universal coding system

No beginning or end point Includes prevention Involves determining acuity as well as

referral to appropriate clinic Multiple points of entry Varies with type of service Hours must meet patient needs System needed to follow up with

noncompliant patients

Reprinted with permission. 7

tings. These differences reflect the barriers and challenges in trying to address productivity measurements that characterize ambulatory care. Many ambulatory workload measurements are recorded retrospectively. They may focus on trending workload over time, provide program planning and evaluation information, validate patient care requirements, or justify resource use. This is very different from our traditional inpatient nursing classification systems, which focus on functional activities of daily living, patient ambulation, nu- trition, bath, skin care, and respiratory assistance.

Ambulatory workload is affected by the demand for care from both general and specialty patients. Variables such as unexpected problems, treatments, nonpatient care activities, and telephone management also determine the workload. Differ- ent levels of staff engage in these activities. Data

from workload analysis and patient classification increase the understanding of the patient care costs and facilitate quality management including facil- ity redesign and space assignments.

Since 1989 the Oncology Nursing Society (ONS) Administration Committee has conducted numerous studies specific to salary, staff, and professional practice patterns. In 1992, the survey specific to ambulatory oncology clinics was reported. This data may assist in the development of unit-specific staffing standards that are consistent with other organizations of like size and geograph- ical location, s Lamkin and Sleven, in 1991 on be- half of the ONS Administration Committee's initial staffing and scheduling report, noted that the ONS does not support the development of national standards using the reported data but offers some additional factors for consideration when deter-


mining staffing levels within an individual unit. 9 These recommendations focus on understanding the unique characteristics of the organization and environment of the individual unit and incorporat- ing national study findings into the decision- making process relative to unit staffing and scheduling systems.

WORKLOAD MEASUREMENT TOOLS IN AMBULATORY CARE

The American Academy of Ambulatory Care Nurses (AAACN) in its "Ambulatory Care Nurs- ing Administration and Practice Standards" defines ambulatory care nursing as nursing care provided in ambulatory settings to patients with institutional episodes of care of less than 24 hours. ~~ AAACN's standard specific to staffing notes that, "professional nursing seeks to maxi- mize the patient's state of health and wellness and is essential to the implementation and supervision of care provided to patients. Nursing care in the ambulatory setting encompasses the provision of direct patient care, health teaching, patient advo- cacy, the supervision and coordination of care given by others, and the coordination of services required for patients outside of the ambulatory care setting".

Initial studies of Verran first defined the role of the ambulatory care nurse. ~ This work provided one of the first valid assessments of ambulatory care nursing responsibilities. Activity in the direct care category included patient counseling, health care maintenance, primary care, patient education, therapeutic care, and normative care. A non- client-centered care or indirect care category was described. Tighe and colleagues 12 as well as Hast- ings and Muir-Nash 13 provided further clarifica- tion of the ambulatory care nursing role in an evaluation study examining agreement by ambulatory nursing staff and managers to a revised Verran taxonomy. Hastings and Muir-Nash 13 address further the issue concerning role overlap and confu- sion between basic and advance practice nurses. This is an additional variable for consideration in developing an ambulatory workload measurement. The delineation of the ambulatory care nursing role has provided a necessary stepping stone for the determination of a nursing patient classification or workload analysis in ambulatory care.

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Patient classification and nursing workload analysis studies have been conducted in ambulatory care. Seaman 14 describes a process and format to identify and quantify patient care activities using workload analysis techniques of actual work measurement and time measurement of activities performed. Each specific staff member listed unit activities and the average time required for completion; the types of patients and the personnel required for care were then studied. A revised staffing plan based on the safest minimum skill level required per patient population and care needs was determined. Limitations of this study are the use of staff members' self-reporting of time and activities that may have decreased the objec- tivity of the data collected. Henninger and Daily describe a self-report study that was completed at a large ambulatory center. 15 The study had a check- list of direct care activities and an additional tally sheet to self-report indirect (non-patient care) activities, ie, lunches, breaks, seeking information. The time identified as spent on procedures was converted into relative value units, and a fixed time for non-patient care or indirect time was added. This study was used to plan for future staffing decisions within the unit.

Further attempts to measure ambulatory oncology workload specific to chemotherapy are reported by Campbell and colleagues ~6 using a cat- egorization for chemotherapy drugs that could be used as a predictor of nursing care time. Nurses were asked to consider the factors of drug preparation time, preadministration time, care during the treatment, postadministration care, and patient teaching when ranking drug administration as compared with a base reference drug administration of 30 mg of intravenous doxorubicin. Three groups of drugs were clustered with distinct nursing time requirements identified. Rank ordering of each of the factors under consideration was achieved. This study identified drug administration as a key variable for ambulatory oncology patient classification instruments. Genovich-Richards and Tracy 17 document a self-report study conducted at a large hospital in six internal medicine clinics. Staff listed their patient care tasks and provided estimates of the time required to perform the tasks. Findings indicate that there were significant time differences in similar tasks completed in different clinics. Average times were determined as a result

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of this work for the common tasks of clinic checkin, checkout, and laboratory drawing. The study is limited by the assessment of only direct patient care activities completed by a licensed practical nurse, an aide, and technical staff. It does not take into account the broad number of activities performed by the professional nurse. In addition, the study did not include the indirect (non-patient care) time and thus did not determine total time of nursing required.

Hoffman and Wakefield discuss an approach for developing an ambulatory classification model using a familiar inpatient classification instrument development methodology. ~s The process identified for instrument development in this article de- serves special consideration because the steps identified are relevant to the development of an ambulatory patient classification instrument. The steps are identifying relevant patient care factors, estimating the time for each activity, and the completion of an observational or work sampling component for review of activities within the work area. This process is a traditional workload analysis that leads to the ability to predict staffing requirements.

In 1986, Verran, published work that used her identified ambulatory nursing taxonomy. The Am- bulatory Care Client Classification Instrument (ACCCI) designed by Verran was studied for construct validity, generalizability, and interrater reliability to measure the nursing care complexity in an ambulatory care setting. The ACCCI measures the complexity or knowledge required to deliver nursing care. Complexity of nursing care required is defined as the degree of regularity, standardiza- tion, predictability, and required knowledge that is involved in delivering a nursing activity. In Ver- ran's ACCCI, the higher the instrument score the greater the degree of nursing care complexity. Study limitations include measurement errors by limited observer agreement on complexity of care ratings partly because of the lack of standardized nursing care. In addition, observers estimated patient requirements versus actual documentation of the care that was received during the visit. The study demonstrated a reliable measure of complexity, beginning construct validity, and limited generalizability across services. High interrater reliability was achieved with training. ~9'2~

Parrinello initially modified a Nursing Patient

BARBARA RUPPAL MEDVEC

Classification Instrument (NPCI) used within the inpatient nursing organization to an ambulatory surgery setting. 2~ Using surgical indicators, nursing care hours were determined for the ambulatory surgical center. Data were collected by staff through self-report means for all hours of the day and all activities both direct and indirect. The study demonstrated that there was closer agreement with the inpatient NPCI versus comparison to medical services or patient diagnosis. The study also demonstrated the ability to adapt an inpatient classification system in an ambulatory surgery center and categorize patients into similar nursing resource requirements. Another research study tested a modified Verran (ACCCI) in four ambulatory care settings. 22 The modified ACCCI, as described, studied the intensity weights per nursing activity needed to meet direct patient care needs and indirect (non-patient care) needs. Patient needs were profiled for each of the four specific clinic settings. Specifically, the indicators of care for ambulatory practice were identified, institutional specific intensity weights were determined for each indicator, and the reliability and validity of the modified ACCCI were established. Inten- sity, for the purposes of this study, was defined as the nursing time required to meet direct and indirect patient care needs. This study also tested a methodology for the ongoing, systematic, and timely evaluation of ambulatory nursing care requirements. Study findings demonstrated a rela- tionship between nursing time required, type of care provider used, and scope of services provided. Four categories of nursing intensity were identified, and times per category were established. Characteristics of patient visits within all categories were differentiated. This suggests the possibility of development of a prototype classification system. Further research is needed to determine the impact of telephone calls on nursing time, the impact of scheduling on nursing workload, and the contribution to care and patient outcomes made by registered nurses conducting patient visits inde- pendent of a physician visit. Miller and Folse used the Verran nursing role taxonomy as a model to plan staffing, z3 Staffing requirements and daily staffing adjustment profiles were determined using average times per direct nursing care activities, self-reporting of unit-based activities, and average census by day of the week.


Specific to oncology nursing, Barhamand reports on an office-based oncology nursing survey completed in 1989. 24 The survey examined the range of tasks involved in office-based oncology nursing as well as identified the expectations and disappointments, and the resulting job satisfaction associated with the role. Office-based outpatient oncology nursing functions were identified and provide another source of comparison when planning workload analysis for ambulatory oncology nurses. The results provide information categorized as nursing related, administrative, clerical related, and ancillary activities.

Mayer describes a workload analysis in a large multispeciality ambulatory health maintenance organization practice. The study uses work sampling as a component of the analysis. 25 The work sampling study evaluates the workload of staff before making new staffing allocations and work redesign. Using an adapted model for ambulatory nursing activities developed by Johnson, 26 ambulatory activities were categorized into direct care, indirect care, unit-related activities, and personal time. These activities are summarized in Table 2. Data collection, using staff observers, occurred ran- domly with all staff at 5-minute "snapshot" inter- vals throughout the work day. Study findings show dramatic differences between types of personnel in time spent on direct care activities. Results have led to further evaluation of indirect care activities and work redesign. A strength of this work is the inclusion of staff and physicians in planning the methodology and reviewing the ultimate results and redesign recommendations.

APPLYING WORKLOAD MEASUREMENTS IN AM B U LATORY CARE

This summary provides an overview to the ap- proaches currently used to address productivity measurement in ambulatory care. Because there is not a single instrument to be applied in every ambulatory care setting, ambulatory nursing managers face the task of adapting the work presented or completing their own development of instruments. The keys to success in beginning this process are three: (1) Carefully compare existing studies with your own organization and consider the needed modifications to fit the instrument to your practice. (2) Completely define the specific process to be

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Table 2. Activities of Ambulatory Nursing Personnel*

Direct care activities Nurse-performed treatments and procedures Transport patient Specimen gathering and testing Obtain history, assess problems, symptoms Physical assessment Measurements Nurse-assisted procedures IVs, medications, fluids, blood products administration Usher patient to room Patient/family education Providing patient/family support Referrals Prepare patient for procedure Postprocedure care Counseling Other

Indirect care activities Medications, IV preparation Communications with others--patient specific Documentation, patient specific Chart preparation Chart checks, computer checks Telephone calls related to patients Make appointments Prepare patient-specific information Prepare specimens Preparation for procedure Computer schedule check

Unit-related activities Clean room Prepare patient education materials Errand off unit or out of clinic Meetings, in-service, unit or clinical reports Check, reorder, restock supplies Communication with others, unit related Unit housekeeping Home visit Respond to emergency Telephone calls for patients not being examined today Clerical Delay at work station

Personal time No observation Personal telephones Meals, breaks, personal time

Abbreviation: IV, intravenous. Reprinted with permission. 2s,2e

undertaken for workload analysis regardless of the intent to modify or create new instruments. Work- load analysis is labor intensive and requires a significant time commitment from implementation through data analysis and report writing. (3) Fi- nally, identify in the early planning stages what your patient classification or workload analysis

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study will or will not do for you. Workload analysis data is subject to many interpretations, but a clear understanding that the tool provides only a general reading of activity within nursing elimi- nates the potential for data to be misused. In general, productivity or workload measurements sug- gest possible problems. Using the workload data and considering other variables such as patient care volume, demand for services, and changing patient care needs, will lead the ambulatory manager to a more complete understanding of variances that exist. This prevents misuse of the data and misinter- pretation of results.

An action plan for tackling ambulatory patient classification or workload analysis includes the following ideas:

1. Know where you stand at present and develop your patient care goals and objectives.

2. Clarify the specific results that are intended to be accomplished.

3. Examine existing methods and tailor the plan to the needs within the organization.

4. Develop support for the plan, including staff participation. Include organizational supports such as management engineering and information systems planning.

5. Pilot the methodology to be used by taking time to educate and communicate staff responsibilities. Redefine work as needed.

6. Provide timely feedback and information al- lowing everyone input and opportunity for improvement planning.

BARBARA RUPPAL MEDVEC

7. Design validity and reliability test measures. 8. Consistently seek out other like institutions

for data comparisons when possible.

CONCLUSION

The future of ambulatory patient classification and workload analysis will depend on the development of an accurate model of data collection, analysis, and reporting. The development of such a valid and reliable tool has been accomplished in other specialty areas such as emergency services and home care. The current knowledge of ambulatory care nursing roles and the delivery of ambulatory services serves as a strong foundation for tool development. Many barriers still exist for instrument development including the ever-changing health care environment, the growing need to pri- oritize patient care, and the intensity of care. The development of a consistent productivity system will make it an easier task to manage resource allocations, determine appropriate staffing, and space allocation. The need to monitor productivity, complete long- and short-range planning, and evaluate trends, costs, and charging, as well as continuous quality improvement will drive the process to achieve highly valid and reliable ambulatory productivity tools in the near future. This demand for accurate instruments will assist nurse managers and administrators to successfully com- pete in the ever-changing environment of ambulatory care.

REFERENCES

1. Webster's Ninth New Collegiate Dictionary. Chicago, IL, G. & C. Merriam Co, 1986

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Staffing and Professional Practice Patterns in Ambulatory On- cology Clinics. Pittsburgh, PA, Oncology Nursing Press, 1992

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21. Parrinello K: Accounting for patient acuity in an ambulatory surgery center. Nuts Econom 5:167-172, 1987

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productivity and workload measurement in ambulatory oncology

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