Bust nurses' time-wasting activities with QI project
Bust nurses' time-wasting activities with QI project
Agency increased staff productivity by 2 visits/day
An Arkansas home care agency director discovered that her field staff's productivity was lower than the staff productivity at other home care agencies in the region.
Nurses and aides at Baptist Home Health Network in Heber Springs, AR, averaged about four to 4.5 visits a day, and then they needed overtime to complete their paperwork, says Wilma Smith, RN, agency director of Baptist Home Health. The small, hospital-based agency is part of a larger health system called Baptist Health, based in Little Rock. Baptist Health has six different home care agencies, as well as hospitals and other provider groups.
Shortly after the agency became a part of Baptist Health in November 1996, Smith started meeting with other home care agency directors and asking them how many visits their staffs were averaging per day. She also talked with other home care agency directors at state home care association meetings. The other agencies reported an average of six to seven visits per day.
When Smith returned to her staff and told them they needed to be making more visits, they complained that they could not possibly do so because of all the time they had to spend on paperwork and other office duties.
So Smith decided to start a quality improvement project to find out exactly how staff were spending their time. "I wanted to look into why they were not making more visits within their paid hours," Smith says.
Smith measured the time her nurses spent with patients and driving between visits, and found that it was similar to other agencies' nursing field times. So that wasn't the problem.
"But when I started to meet with them and asked why their productivity was down, they gave me all these excuses," Smith recalls. The nurses complained that having to make copies and telephone calls wasted too much time.
Survey tracked time spent on nine activitiesSmith took their complaints to the home care agency's central office in Little Rock and met with Carl Woodyear, LCSW, quality assurance and improvement coordinator, with Baptist Home Health/Hospice. She suggested they start a survey to see exactly how long it took staff to complete those day-to-day tasks. The result was a short survey called "The Dragnet Report (Just the Facts, Ma'am)." (See time management survey, p. 76.)
"I wanted to get to the bottom of this and find out if they were just being lazy or if it really was a problem," Smith says.
Smith was a little surprised to find out that the nurses' excuses were not really excuses. Each employee carried around the time survey for 10 days, and tracked each minute spent at one of nine office activities, including: time spent walking to the copy machine; waiting on the copier; walking to the fax machine; waiting on the fax machine; talking with physician offices; waiting on calls from physicians; waiting on laboratory reports; waiting on the telephone: and talking with insurance companies.
The agency employs eight full-time and part-time nurses, two office employees, an RN scheduler, three home care aides, and Smith. Together the employees recorded spending more than 50 hours on these time-consuming chores. The biggest problem was in the category of time spent waiting on the doctor's response. That one alone cost them 40 hours and 20 minutes, the survey showed.
While the nurses probably used much of the waiting time to fill out paperwork and do other office tasks, it still posed a big problem, Woodyear notes.
"They do other things while waiting, but it's still an inefficiency," he adds. "And I think we could try to improve that if we find out more information."
So the agency formed a committee of mostly nurses to look at each time-wasting area and to find improvements.
Here are the five main areas the committee addressed:
· Waiting for physicians.
Within 10 working days, the nurses had spent three hours and 45 minutes calling physicians' offices, plus more than 40 hours waiting for a response.
This category proved to be such a big problem that the agency will pull it apart for a separate quality improvement project. So a new survey is being conducted just to find out exactly how much time is being spent waiting on each individual physician.
The new survey will ask:
- the purpose of the call and to whom;
- how much time is spent calling and talking with the physician;
- how much time is spent waiting for a reply;
- date and time of call.
"We want to see if there is any pattern to the time of day and doctor being called," Woodyear notes.
If the new survey shows that one physician takes too long to return calls, then the agency's managers might be able to meet with that physician to discuss the problem.
If the problem is that nurses have a harder time reaching physicians when they call at certain times of the day, then the agency could ask nurses to call at hours that are better for physicians.
· Making copies.
The nurses were not exaggerating about the time they spent making copies. The 10-day survey showed they spent a total of one hour and eight minutes making copies, plus more than five hours walking to and from the copy machine.
Smith says the small hospital-based agency does not have its own copier, so staff have to walk to a copier in the hospital's front office, which also is used by every other department in the hospital.
"You may stand there for 10 minutes, 20 minutes, waiting for someone to finish up a stack when you have one copy to make," Smith says.
The committee proposed several solutions, including leasing or buying a new copier, and the cost of those possibilities is being researched. Meantime, they have decided to try a more creative solution, Smith says.
First they will try having staff place items they need copied in a basket. Each item will have a sticky note that says how many copies are needed and has the employee's initials, Smith explains.
Then one employee will come in early each day to do all of the copies in the box. "When somebody has something they have to have copied right away, then they can go and get the basket and do all the other copies at the same time," Smith adds.
Another solution, Woodyear says, is to eliminate some of their need to make copies. For example, some of the staff might be making copies of forms that could be printed in advance.
The agency's management office has its own printing shop that could be used to make hundreds of copies of certain forms for less than the individual copies would cost.
"Having them reduce unnecessary copies is another idea," Woodyear says. "Sometimes people are making copies of information for a meeting, but if they would use an overhead projector they wouldn't need to make all those copies."
· Sending/receiving faxes.
This has proved time-consuming because the agency shares a fax machine with the hospital.
"I'm checking to see where they could get a good fax at a good price," Woodyear says.
Then Woodyear will figure out how much it costs each month to continue to have nurses spend so much time walking to the fax machine and waiting on it. For example, if a loaded nursing hour is worth $25, then the more than three hours of wasted time over two weeks will translate into a cost of about $200 a month, he says.
"We could get a fax machine for $150, so our next step is to show how it makes sense economically and maybe we could convince the director to buy one," Woodyear says.
· Placing/receiving phone calls.
"We had an antiquated phone system, and all of our calls had to come through the hospital switchboard," Smith explains.
This meant each employee would have to dial 9 to get an outside line, and sometimes they couldn't get an outside line immediately. Then when physicians returned calls to a nurse, they'd have to call through the hospital switchboard, which would take longer than if they could dial the nurse directly. Then if the nurse happened to be on a telephone when the physician called, then the call would go through the home care receptionist's phone, and she would have to walk a message down to the nurse, Smith explains.
Smith complained about this time-consuming problem for about a year before she received some response from the administration.
The hospital made some changes. First, they put one phone line directly into the home care agency, which has helped somewhat. Then they agreed to buy beepers for the home care nurses at a cost of $40 a month for seven beepers. And finally, they made plans to upgrade the entire phone system, including putting a separate switchboard in the home care area.
· Waiting for laboratory reports.
The agency's nurses had complained that this was one of their worst problems. But when they filled out the survey, it showed that the time spent waiting for laboratory reports was insignificant, and no solution was necessary, Woodyear says.
Smith says the laboratory process was made easier before the survey was conducted.
"The lab changed the process of paperwork we had to fill out to go to the lab, and that was easier," Smith says. "Before, we had to fill out a lab request, copy the doctor's order for the lab, and then we had to go get an admissions sheet from the front office, and now we don't have to do all that."
Now the laboratory has them fill out a report that uses only one side of one page, and nurses may place a patient's name label, generated by the front office, at the top.
Nurses also were required to fax the lab reports to the physician offices, and now the laboratory does that. And finally, the laboratory put in a new chemistry machine that is faster than the old one.
Since the QI project began, staff productivity has risen to five to six visits per day, and they no longer go into overtime, Smith says.
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