Workload management in occupational therapy: the approach taken at University Hospital Nijmegen, St Radboud

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1 Occupational Therapy International, 4(2), , 1997 Whurr Publishers Ltd 151 Workload management in occupational therapy: the approach taken at University Hospital Nijmegen, St Radboud MARIE-ANTOINETTE H. VAN KUYK-MINIS OTR (NL), Occupational Therapy Department, Sint Radboud Ziekenhuis, University of Nijmegen, The Netherlands; Department of Occupational Therapy, Faculty of Rehabilitation Medicine, University of Alberta, Edmonton, Canada. HELEN M. MADILL Professor, Department of Occupational Therapy, Faculty of Rehabilitation Medicine, University of Alberta, Edmonton, Canada. ABSTRACT The board of University Hospital Nijmegen stipulates the roles and responsibilities of allied health professionals. It is expected that members of these disciplines will engage in teaching and applied research that will ultimately develop a solid empirical base for their clinical services. This paper outlines the process and outcome of a study of occupational therapists workload and time management at University Hospital Nijmegen. It describes how members of the Department of Occupational Therapy established their research and teaching priorities, and agreed on a strategy to implement them. Enabling one or two therapists at a time to devote substantial amounts of time to a special task is much more fruitful than trying to split time among many people. A policy and detailed activity plan proved to be a good way of monitoring the output of the department. Key words: restructuring health services, time management, workload measurement, departmental management. INTRODUCTION In 1991, University Hospital Nijmegen, St Radboud, undertook a major reorganisation. With stronger by integration as the theme, the hospital sought to implement a client-centred approach throughout its operations, to increase Address all correspondence to: M.-A.H. van Kuyk-Minis OTR (NL), Sint Radboud Ziekenhuis, University of Nijmegen, Occupational Therapy Department 300, PO Box 9101, 6500 HB, Nijmegen, The Netherlands. Fax. (00) ; M.van=Kuyk-Minis@CZZOPMA.AZN.NL

2 152 van Kuyk-Minis and Madill efficiency, and to reduce costs (Board of University Hospital Nijmegen, 1991). The plan was to implement a system where, for example, divisions might have physicians, nurses, therapists, and laboratory technicians working together as client-centred programme-based teams. The process of reorganisation was accomplished in a series of steps. In 1993, small departments such as occupational therapy, social work, and dietetics were left intact. However, the larger ones nursing, physiotherapy, and all medical departments were dissolved and the personnel reassigned to divisions with clustered programmes or services, ie. similar to a programme management system (Herfst, 1994). The effect on service delivery has been dramatic. Ten separate clinical divisions, two business departments, and five staff departments were created by the reorganisation. Provision of occupational therapy and physiotherapy services to the clinical divisions was determined by a review of past service provision over a number of years. Patients in clinical divisions with the highest use patterns continued to receive services, while those units with lower use had to negotiate and budget for provision of these services. The Allied Health Professions Department (AHPD), which included nursing, paramedical, and psychosocial disciplines, became one of the five staff departments. The AHPD now consists of professionals in several general areas such as teaching, research, quality assurance, and programme management, whose role is to support the work of the allied health professionals independent of their division. PROBLEM The board of University Hospital Nijmegen stipulates the roles and responsibilities of allied health professionals (Herfst, 1994). It is expected that members of these disciplines will engage in teaching and applied research that will ultimately develop a solid empirical base for their clinical services. Research activity is expected to be directly related to the research goals of the medical disciplines and the board decided that the initial focus in occupational therapy and physiotherapy would be the validation of assessment instruments and outcome measures (Board of University Hospital Nijmegen, 1995). In 1996, the AHPD specified that development of sensitive and standardised assessment instruments and outcome measures for disabilities and handicaps and a multidisciplinary approach to diagnostics would be the first priority (Bours, 1996). As part of the hospital s reorganisation, occupational therapy and physiotherapy personnel would be required to spend 5% of their total staff time on research and teaching activities. A physiotherapist with a master s degree was hired by the AHPD to guide research, planning, and development in the two disciplines. These were new responsibilities for the clinical therapists and both disciplines had to begin to develop a research culture. Initially, the Department of Occupational Therapy did not establish any priorities; every new project or research idea was acted on without being

3 Workload management in occupational therapy 153 guided by any strategic plan. It soon became apparent that 5% was not enough time to cover the research and teaching tasks that accumulated. Patient care continued to be the therapists priority and they felt guilty when they worked on a research project if there were patients on waiting lists. Therapists were taking their research work home so they could give patient care precedence while they were in the department. Therefore, a cultural shift was needed within Allied Health so that each activity (research, teaching, and patient care) would be accorded equal value in the eyes of clinicians. Because therapists were having difficulty devoting even 5% of their time to research and teaching, the challenge was to document how much time they currently spent on direct service (patient care), and other aspects of their work such as community services and committee work. The results were then analysed, the necessary changes implemented, and the outcomes evaluated. LITERATURE REVIEW Department documents were reviewed for elements that could serve as the basis for achieving a better balance between responsibilities and, if appropriate, as support for increasing the time devoted to research. The 1994 Annual Report from the Department of Occupational Therapy (Kuyk, 1994) documented an increase in the number of patients served over past years, with no commensurate increase in the number of staff. The department manager (the first author) therefore decided to measure the distribution of tasks across all therapists to obtain an estimate of their workload and time management. Workload measurement is a way of recording the time and/or activities of personnel in the performance of their health-care duties (Cockerill, Scott & Wright, 1994). Time management is the distribution of the available time between the tasks that need to be done and the requirements of the organisation (Ruiter & Bakker, 1990). First, the present time distribution must be systematically determined and, once this has been done, improvements can start to be made. The measurement tool used by most departments at University Hospital captured only the information related to intervention. Time spent completing an orthosis or documenting progress was also recorded as patient care (Hammell & Bjore, 1994). In terms of desirable features of a revised workload system, results of Scott, Cockerill, and Wright s (1993) Canadian survey showed that 87% of occupational therapy managers (n = 89) wanted a system based on diagnostic or case-mix group recording. Client variables (91%), physical and psychosocial aspects of client care (89%), and therapist variables (85%) were also rated as important factors to address when developing new workload systems such as that of the Canadian National Hospital Productivity Improvement Program (NHPIP) (Health and Welfare Canada, 1988). Cockerill, Scott, and Wright (1994) found that workload measurement systems that

4 154 van Kuyk-Minis and Madill record actual time spent have the advantage of being relatively easy to implement, understand, and complete. Like the workload measurement system for occupational therapy, the Dutch hospital workload measurement system also had to be inclusive of non-patient-care activities. For example, therapists had to teach, and carry out research, but these elements were not being currently recorded. Meetings with a panel of experts (Dutch colleagues at other university hospitals) to compare current methods only produced broad general approaches that were unacceptable. Therefore, a workload measurement system was designed that described the therapist variables needed in the present situation. A realistic policy plan and activity plan had to be made. Knowledge, time distribution, the board of University Hospital s expectations, existing policies, and occupational therapy staff s expectations all had to be taken into account. The final plan had to include the time allotted to unrecorded tasks (ie. academic tasks: teaching, research). Using the same workload measurement system to evaluate departmental output before and after any policy changes were implemented would also be essential. This paper outlines both the process and the outcome of a study of occupational therapists workload and time management at University Hospital Nijmegen. It describes how members of the Department of Occupational Therapy established their research priorities, and agreed on a strategy to implement them. METHODOLOGY A pre-test/post-test design was used to determine therapists workloads before and after any policy change. A new workload system was developed to identify previously unrecorded therapy tasks and the workload distribution in relation to therapists hours of employment. Because all but two therapists worked part time, these calculations were particularly important. In the pre-policy assessment, therapists recorded their activities in halfhour blocks using the categories shown in Table 1. The total hours for each week were recorded for the first 13 weeks of A similar process would be implemented for the post-policy assessment 12 months later. RESULTS Pre-policy assessment of workload measurement (1995) The results of workload measurement prior to implementing the policy change are presented in Table 2. Here, the percentages represent the average time spent by occupational therapists for the first quarter January March 1995, before the policy was instituted.

5 Workload management in occupational therapy 155 TABLE 1: Items included in therapist s record sheet Department of Occupational Therapy: Distribution of therapist time in half-hour blocks Name Hours employed Category Examples management and budget control patient care education research teaching quality assurance social services absence miscellaneous job interviews intervention, communication on behalf of patients, reporting congress, symposia research proposals, pilot projects undergraduate OT, PT, medical students management and patient care related, departmental/interdepartmental community services holiday or day off, illness, leave of absence photocopying, department maintenance, planning, and ordering supplies TABLE 2: Time distribution of occupational therapists (n =11, 6.8 FTE) Variable Pre-policy assessment (%) Post-policy assessment (%) patient care miscellaneous management and budget control education 4 6 quality assurance 4 4 teaching 3 3 committee work 3 3 research 2 11 social services 2 1 total However, the percentages alone are somewhat misleading. Patient care and other activities performed by students were not recorded. The head of the department (1 full-time equivalent) contributes only 34% of her time to patient care, while another therapist is not involved in patient care at all. During the pre-policy assessment period, two therapists had external funding for eight hours a week to complete a quality assurance project. A period of time was earmarked to work on this project. Their percentage of time spent on quality assurance (26.8 % and 15.2%) was much higher than that of other therapists devoted to special projects. These factors influence the total output of the department. The pre-policy assessment revealed the positive effect of earmarked time for research and teaching. For example, these two therapists developed a new observational recording system for use with children with writing problems.

6 156 van Kuyk-Minis and Madill Conference presentations were made at the World Federation of Occupational Therapists Congress in London in 1994, at two Dutch occupational therapy conferences in 1996, and at the European Congress of Occupational Therapy in Spain in An article was published in the Dutch Journal of Occupational Therapy (Corstens-Mignot, van Hartingsveldt & Cup, 1996a) and a book on the same topic (Corstens-Mignot, van Hartingsveldt & Cup, 1996b). A course was developed and offered to colleagues in The Netherlands as part of their continuing professional education. An overview of the workload distribution at the pre-policy assessment is shown in Figure Workload of the Department of Therapy percentages patient care miscellaneous management and budget control education quality assurance teaching committee work research social services 1995 pre-policy work tasks 1996 post-policy FIGURE: 1 Overview of pre- and post-policy assessment Policy implementation To set priorities, fortnightly instead of weekly department meetings were held. A department journal was developed to exchange messages, mail, and share department information between meetings. These fortnightly meetings provided a quiet period, every second Thursday morning, from to All staff were present and it was understood throughout the hospital that

7 Workload management in occupational therapy 157 members of the Department of Occupational Therapy could not be disturbed during this time. Initially, the time was used to formulate a policy and activity plan; later it was used to implement the activities. It provided an ideal opportunity to work out details of occupational therapy projects and discuss relevant issues. The team chose to increase research activity while maintaining teaching hours in continuing professional education. It has not been difficult for the therapists to preserve this separate time for these tasks, and we are seeing a change in occupational therapy culture a shift to valuing teaching and research more highly. Two benefits were quickly noticed: higher levels of endorsement for research, and a balanced overall policy in relation to this area. This change of attitude is the underlying benefit of the workload management project. Post-policy assessment of workload measurement (1996) Given that extensive cutbacks to occupational therapy services were expected, the post-policy assessment was completed over a 13-week period (weeks in 1996) while the department still had the same number of therapists and full-time equivalents. This arrangement was not ideal, because the times of year were different and factors, such as the number of public holidays, could influence the outcome. The results showed that, overall, the department s output was very low. Although the time allotted to research increased significantly, the time for patient care decreased dramatically, because of public holidays. Therefore, for calculation purposes, absences owing to illness and holidays have been deleted from both the pre- and post-policy assessments, and the time distribution recalculated as shown in Table 2. An overview of the workload distribution at post-policy assessment is shown in Figure 1. DISCUSSION AND CONCLUSIONS A shift in output was evident in the results of the post-policy workload measurement assessment following the implementation of a research policy and activity plan. The department s overall output in research and publication has increased. A positive effect from this undertaking has been the collaboration and teamwork that have continued since the policy change. What did we learn in the process? 1. Departmental agreement to undertake such a process is essential. 2. The workload measurement methods in place pre-policy assessment were too broad, but, in an effort to correct this, our data collection method seemed too detailed. In trying to determine the output of the department, we found that it is best to limit the number of items therapists must record, eg. illness, public holidays, and vacations all constitute non-working hours.

8 158 van Kuyk-Minis and Madill Administrative tasks, such as management, budget control, and committee work unrelated to interventions (eg. hospital referral procedures or meetings), can also be grouped together. In this way, a general overview can be made, without overloading the therapists in more complex recording of their time than necessary. 3. Measuring time elements in blocks is appropriate as therapists need to complete their forms on a daily basis. 4. The tool must be simple to complete. Each item should be clearly defined to enhance reliability. Therapists are confused when they do not know what to put where, eg. committee work does not give information about the mandate, type, or workload of the committee; therapists become frustrated if they perceive that their efforts are not sufficiently important to record. 5. Decide who will be included in the study and who will not, ie. with or without the head of the department, the therapy assistant/s or student/s. If you include student output, you should also register time used to supervise students. For example, following the data collection it became clear that student supervision by the occupational therapists had been recorded, although the time students spent treating patients had not. This would artificially lower department output and inappropriately imply that student training is too expensive because, in the short term, the hospital has nothing to show for the contribution of its staff. The time used to educate students can be redeemed when they also treat patients. Treatment time contributed by students is likely to have a positive effect on departmental output. 6. Adapting the Canadian Workload Measurement System for use in The Netherlands proved to be effective. 7. Pre post workload measurement assessment should be completed over as short a time as possible, eg. three months. This helps keep therapists motivated to fill out extra forms and is likely to enhance reliability of the measurement, as shown in this study. The department needs to be in a stable situation if you intend to compare pre post measures; however, the time elapsed between pre- and post-testing in this study was too long. The department had already experienced many changes. Unfortunately, the post-policy workload measurement assessment had to be taken at a different time of the year from the pre-policy assessment because of impending budget cuts, and the former was a period with more public holidays which stood to influence overall output dramatically. 8. The whole process of workload measurement is an excellent way to formulate a policy plan. It makes therapists aware of their responsibility to contribute to activities other than patient care and reinforces the value of teaching and research. 9. Although teaching and research were both included in the board s policy statement, the AHPD focus was initially on research. Therefore, research productivity increased and existing teaching commitments were maintained. A separate initiative for teaching may have to be undertaken.

9 Workload management in occupational therapy 159 CONCLUSION Specific tasks, allocated to particular people, over prescribed time periods, resulted in a better academic (teaching/research) output than dividing the same amount of time among all members of staff. When there is a grant for a special project, with deadlines and reporting responsibilities, results are obtained. The process of workload measurement is an excellent way to formulate a policy and activity plan. It increases therapists awareness of their responsibility for activities other than patient care. It contributes to team building within the discipline and enhances interdisciplinary collaboration. In terms of hours spent in patient care, and time devoted to teaching, research, and publication; ongoing monitoring of the department s output is now sufficient to maintain both the desired level and a dynamic environment. The exercise proved to be beneficial on all levels. REFERENCES Board of University Hospital Nijmegen (1991). Stronger by Integration starting points and headlines organization AZN. Internal publication, University Hospital Nijmegen. Board of University Hospital Nijmegen (1995). Strategic policy plan of University Hospital Nijmegen, St Radboud Academic profiling. Internal publication, University Hospital Nijmegen. Bours P (1996). Policy plan of nursing and paramedic disciplines in the Division of Neurological, Psychiatric and Geriatric Specialists. Internal publication, University Hospital Nijmegen. Cockerill R, Scott R, Wright M (1994). Responding to workload measurement needs. Canadian Journal of Occupational Therapy 61: Corstens-Mignot MAAMG, van Hartingsveldt MJ, Cup EHC (1996a). Observatie-instrument schrijven en senso-motorische schrijfvoorwaarden. Nederlands Tijdschrift voor Ergotherapie 24: Corstens-Mignot MAAMG, van Hartingsveldt MJ, Cup EHC (1996b). Observatie-instrument schrijven en senso-motorische schrijfvoorwaarden. Uitgave van de afdeling ergotherapie van het Academisch Ziekenhuis Nijmegen. Hammell KRW, Bjore D (1994). Workload measurement: A tool for accountability. British Journal of Occupational Therapy 57: Health and Welfare Canada (1988). National hospital productivity improvement program: Workload measurement system Occupational Therapy (H30-11/3-3E). Ottawa, ON: Department of National Health Welfare. Herfst D (1994). Stronger by integrated patient care. Policy of the nursing, paramedic, and psycho-social disciplines. Internal publication, University Hospital Nijmegen. Kuyk van MAH (1994). Annual Report, Department of Occupational Therapy. Internal publication, University Hospital Nijmegen. Ruiter D, Bakker CG (1990). Inleiding tot management, pp Amsterdam ND: Samson. Scott E, Cockerill R, Wright M (1993). A survey of workload measurement systems: The occupational therapy manager s perspective. Canadian Journal of Occupational Therapy 60: