University of Michigan Health System. Program and Operations Analysis. CSR Staffing Process. Final Report

University of Michigan Health System Program and Operations Analysis CSR Staffing Process Final Report To: Jean Shlafer, Director, Central Staffing Resources, Admissions Bed Coordination Center Amanda Silva, Central Lean Coach Associate, Quality Improvement, Michigan Quality System Sam Clark, Industrial Engineer Lead, Program & Operations Analysis Mary Duck, Professor, IOE 481 From: IOE 481 Project Team 8, Programs and Operations Analysis Jesse Brauner Paolo DiBenedetto Daniel Weinblatt Date: December 13, 2011 i

Table of Contents Executive Summary... iv Introduction... iv Background... iv Methods... v Findings... v Conclusions... vi Recommendations... vi Final Report... 1 Introduction... 1 Background... 1 Key Issues... 2 Goals and Objectives... 2 Project Scope... 3 Methods... 3 Data Collection... 3 Data Analysis... 4 Findings... 5 Qualitative Findings from Interviews and Observations... 5 Quantitative Findings from Data Sheets... 6 Conclusions... 8 Late Forms and Changes to Forms... 8 Lean Analysis... 8 Insufficient Nurses... 9 Recommendations... 10 Immediate Fixes... 10 Long Term Solution... 10 Further Analysis... 11 Expected Impact... 11 Impact of Immediate Fixes... 11 Impact of Long Term Solution... 11 Appendices... A Appendix A: Sample CSR Request Form... A Appendix B: CSR Management Interview Questions... B Appendix C: Unit Manager Interview Questions... C Appendix D: Charge Nurse Questionnaire... D Appendix E: Sample Data Collection Sheet... E Appendix F: Completed Data Sheets... F ii

List of Figures and Tables Figure i: High Level CSR Process Flow Diagram..iv Table i: Process Times in Minutes... vi Table ii: Wait Times in Minutes...vi Figure 1: High Level CSR Process Flow Diagram..2 Figure 2: CSR Process Flow Chart..4 Figure 3: Form Arrival Time... 6 Table 1: Process Times in Minutes. 7 Table 2: Wait Times in Minutes.. 8 Table 3: Nurses Requested vs. Nurses Available 8 Figure 4: Current State Flow Chart.. 9 Figure 5: Number of Nurses Available Lags Number of Nurses Requested... 9 Figure 6: Future State Flow Chart. 12 iii

Executive Summary Introduction Although over 3,000 nurses work at the University of Michigan Hospital, units frequently need additional nursing support. One of the most important functions of the Central Staffing Resource (CSR) is to deploy RN resources throughout the hospital to meet patient care needs. The Director of the CSR believes the communications and information flow throughout this process is very inefficient, and takes important time away from patient care. Therefore, the CSR director asked a student team to evaluate the CSR nurse request process, in order to identify opportunities to improve the process. This evaluation consisted of observing the CSR request process and interviewing key personnel including the CSR director, CSR manager, Nurse Managers and Charge Nurses. The team collected data during the observations and interviews, and analyzed this data to help develop recommendations. After all data collection was complete, the team developed several short-term recommendations that are immediately implementable to reduce process lead time by eliminating inefficiencies. The team also developed a long-term plan that can significantly improve the overall nurse request process. Background The CSR nurse request process occurs 4 times per day. The charge nurse from each unit fills out a CSR request form and faxes it to the CSR. An administrative assistant (AA) in the CSR enters the charge nurses inputs into a spreadsheet that assesses the current status of all of the units. The House Manager (HM) then decides how to deploy the CSR nurses, and this decision information is relayed to the units. This process includes a long lead time and a significant amount of rework, confusion, and inefficiency within the CSR. A high level process flow diagram can be found in figure i. Figure i: High Level CSR Process Flow Diagram iv

The goal of the project was to examine and evaluate the current process in order to identify inefficiencies and create recommendations to eliminate the problems. Methods The team performed two major types of data collection to evaluate the CSR nurse request process: interviews and observations. Interviews: CSR Director project definition and guidance CSR Manager specific CSR process questions, discuss solution options House Managers group interview with HM s to explain project and ask advice for data collection methods Unit Managers acquire feedback from Unit s perspectives, discuss solution options Charge Nurses gather data regarding process from Unit s perspectives Observations: Observed the nurse request process within the CSR 12 times Collected data by filling out data sheets Informally asked the AA and HW questions regarding their issues and opinions of the process Findings The methods describe above led to both qualitative and quantitative findings for the CSR nurse staffing process. Subjective Findings: CSR Management believes the dynamic nature of the process leads to the confusion and inefficiency within the process CSR office personnel believe the physical layout and hardware within the CSR office can be greatly improved to aid the process flow Unit Managers believe the process should have more automation Charge Nurses believe the CSR form does not relay all relevant information, and that communication with the CSR needs to be standardized Process observations reveal an inefficient and non-standardized process for handling the CSR forms and relaying the information to the units Quantitative Findings: Four late CSR form for every CSR request processes, 2 of which are due to slow faxes Late forms arrived 2 minutes late on average 1.8 changes to request forms per process 0.5 changes to forms per process after HM allocation v

Below are tables representing average process and wait times for the CSR process: Table i: Processing Times in Minutes (8 process observations by team members from Oct 17, 2011-Nov 7, 2011) Average Standard Deviation AA Work Time 2.9 3.3 HM Work Time 7.6 3.9 AA Page Time 12.8 4.7 Total Processing Time 23.3 Table ii: Wait Times in Minutes (8 process observations by team members from Oct 17, 2011-Nov 7, 2011) Average Standard Deviation Fax Travel Time 6.0 3.2 AA Wait Time 16.5 11.9 Paging Wait Time 5.4 4.7 Unit Callback Time 3.3 2.9 Total Waiting Time 31.2 Conclusions Late request forms to the CSR are a minor problem within the process. Units changing their request information is also a minor problem; it has little effect on the overall process time Office layout and hardware improvement can improve office inefficiencies Process details: o 54 minutes total time o 23 minute of actual processing o 8 minutes of value added time Recommendations Immediate Fixes Each computer and phone within the CSR office should be dedicated to a specific cluster. Emails and phone calls from the units should be directed to their specific computer/phone based on the cluster the unit belongs to CSR office should be rearranged so the printer can be reached from the AA s desk Utilize a group paging system to contact the charge nurses as a group Send (automated) reminders via pager to the charge nurses to submit their CSR forms Send the results of the nurse allocation to the units as a page, instead of a page requiring a phone call from the charge nurse. vi

Long Term Solution This process can be greatly improved with the use of an automated CSR request form that utilizes a shared folder within the nurses shared drive (S: drive). The nurse would fill out an equivalent CSR form as an excel spreadsheet, and save it in a specific folder within the shared drive. This information would be automatically extracted to the spreadsheet that the AA and HM currently use to determine the unit status and make allocation decisions. This would greatly streamline the information flow, and reduce much of the inefficiency and confusion that currently exist within the process. vii

Final Report Introduction The University of Michigan Health System employs over 22,000 people who care for nearly 200,000 people per year. Among the caregivers are over 3,000 nurses, the majority of which work for a specific unit within the hospital; however, units frequently need additional nursing support due to multiple causes including fluctuations in patient census and acuity as well as nurse availability. When a hospital unit needs additional nurses, the Central Staffing Resource (CSR) provides backup nurses via a request process that occurs four times per day, once per shift. The Director of the CSR believed the process took important time away from patient care and results in confusion regarding whether the unit would receive sufficient assistance. She felt that the current nurse request and deployment process was very inefficient. Therefore, the Director of the CSR asked a team of Industrial and Operations Engineering (IOE) students to examine the CSR nurse request process to develop recommendations to improve the process by reducing lead time and avoiding confusion. The nurse request process begins when each unit s charge nurse faxes a request form to the CSR office. After the House Manager (HM) decides how to allocate the CSR nurses, the administrative assistant (AA) communicates the results back to the units. The team has determined methods to streamline the CSR request process and improve throughput while reducing lead time. The project goal was to analyze the current process and identify opportunities to improve the process. This final report presents the findings, conclusions, and recommendations of the team in response to the Director s request. Background Units can request nurses from the CSR four times per day. The charge nurse fills out a CSR request form, found in Appendix A, and faxes it to the CSR. An administrative assistant in the CSR enters the charge nurses inputs into a spreadsheet that details the current status of the unit regarding patient census and acuity along with the number and type of nurses. The House Manager then decides how to deploy the CSR nurses appropriately using the information on the spreadsheet, the individual request forms, and other subjective information that the House Manager knows from personal experience. After the House Manager determines the appropriate assignment of CSR nurses, an Administrative Assistant conveys the information back to the unit, primarily via pager. Figure 1 shows a diagram of the process from a high level. 1

Figure 1: High Level CSR Process Flow Diagram Charge nurses would like to know the results of the process immediately after submitting the request forms. If the units will not be receiving a CSR nurse they must make other staffing arrangements. The process s long lead time contributes to inappropriate nurse allocation because sometimes units send nurses home that may actually be needed and other times nurses must work overtime to provide sufficient patient care. Additionally, the dynamic nature of the process, particularly charge nurses making changes to their requests, contributes to the confusion and inefficiency in the process. Key Issues The following key issues drove the need for an investigation and analysis of the CSR process: The long lead time of the CSR process from a charge nurse making a request to the CSR providing a response The confusion and inefficiency of the CSR process including frequent changes to the request forms, resulting in significant rework by the AA and HM and contributing to the extensive lead time Inappropriate nurse allocation leading to unbalanced nurse workloads; for example, at some times nurses may get sent home and have to use vacation hours and at other times nurses may have to work overtime Goals and Objectives The goal of the project was to examine the current CSR process and recommend ways to improve the efficiency of the process by reducing lead time and eliminating errors. To achieve this goal, the team had the following intermediate objectives: Understand the current process by interviewing people relevant to the process. Understand the current process through first-hand observations. Observations consisted of time-studies of the process from the CSR office s perspective. Categorize each step in the process as value-added, incidental work, or waste to determine areas for improvement Develop methods and tools to decrease lead time and reduce rework in the process caused by late forms and changes to forms 2

Project Scope This project included only the CSR staffing process specifically in the Adult Telemetry (ATC) and Adult General Care (AGC) clusters. The process begins when the unit charge nurse expresses its need of nurses via a form. The process ends when CSR communicates the results of the request back to the unit. This process occurs four times a day. Any task not connected to the CSR staffing process for the Adult Telemetry and Adult General Care clusters were not included in this project. Also, the team did not consider changing the assigned hours per patient day (HPPD) for each unit or nurse scheduling matrix. The scope excluded the actual decision making process by the House Manager and focused on the information and communication flow. Methods The following details the data collection methods and data analysis methods. The collection methods include the type of data, quantity of data, and specific methods. The analysis methods include data organization and statistical analyses. Data Collection Interviews and observations provided information to analyze and understand the current process. The team formally interviewed with people involved in the process, and informally interviewed the House Manager and administrative assistant during the observations to enhance understanding of that specific iteration. Interviews The team formally interviewed the following parties involved with the process: CSR Director three interviews, two to firmly define project and one to ensure project was proceeding correctly CSR Manager two interviews, one to further understand the specifics of the CSR process and one to discuss viability of potential solutions House Managers group interview with 12 House Managers to explain project and acquire broad information on the process from CSR perspective Unit Managers five separate Unit Manager interviews to acquire feedback on process from the Units perspectives and to assess viability of potential solutions Charge Nurses fifteen email questionnaires for charge nurses, 6 responses received The interviews clarified the entire process, specifically the human factors. The team assessed the communication flow through the CSR process similarly to a factory manufacturing a product, where the request form is the raw material being processed and the response to the unit is the finished good. However, because of the intangible human aspects to the process the team interviewed the relevant people to understand the personal factors. Appendix B shows the questions used to interview the CSR Director and CSR manager. Appendix C shows the questions used to interview the Unit Managers. Appendix D shows the questionnaire sent to the charge nurses. 3

Observations Separately, each member of the team observed the CSR staffing process from the perspective of the Administrative Assistant and House Manager. The team members observed the communication methods and information flow from the hospital units, through the CSR, until a staffing decision is made and reported back to the units. During the observation, the team member filled out a data sheet that has the length of time for each step of the process and a count of factors that impede the process. A sample data sheet can be found in Appendix E. The team observed the process 12 times and collected 8 data sheets, which can be found in Appendix F. Given the minimal variance found in the results the team determined this was sufficient data. During observations, the team informally interviewed the House Manager who is on duty along with the Administrative Assistant that is working on Adult General Care and Adult Telemetry. The questions varied every time but generally covered reasons the AA and HM made certain decisions along with evaluations of the plausibility of specific solutions. Data Analysis After the data collection phase, the data was analyzed to develop conclusions and recommendations. The primary analysis methods were charting the communication flow and performing statistical analyses to define the current process and understand the impact of potential solutions. Flow Charts The team developed flow charts documenting the current communication flow of the CSR nurse request process. The charts include key statistics such as processing time and waiting time. The flow charts demonstrate bottlenecks and backups in the process, identifying specific problem areas. A flow chart can be found in Figure 2. Figure 2: CSR Process Flow Chart: Total Time = 59.4 minutes 4

Statistical Analyses The team performed statistical analyses to determine the current status of the CSR request process. The team performed basic statistical analysis to evaluate the length and variability of each step in the process. The team also evaluated the frequency of various root causes of delays in the process. Findings The team obtained qualitative information from the interviews as well as from the team s observations. The team acquired objective, quantitative data via the data sheets. Qualitative Findings from Interviews and Observations Completed interviews indicate that personnel associated with the CSR staffing process believe the process is inefficient. Different roles within the process tend to have different opinions about the most significant problem as well as potential solutions. Additionally, the student team developed thoughts about the process during observations. CSR Management Interviews The CSR Director and CSR Manager both believe that the dynamic nature of the process contributes most significantly to the length and confusion of the request process. If the process is nearly completed and a unit has a nurse call out sick, the House Manager must re-evaluate the nurse allocation, delaying the process. CSR Office Personnel Interviews AAs believe that the fax machine causes problems due to both technical errors and human errors like faxing to the wrong number or sending a fax upside-down. AAs also would like larger computer screens so that they would not have to shift between spreadsheets. Finally, AAs feel they frequently receive the CSR request forms late and charge nurses make many changes to the forms. HMs believe that the process could be more automated to save them time. Unit Manager Interviews Four of the five Unit Managers think that the process should have more automation, although the other Unit Manager desires more human interaction within the process. The Unit Managers explained that the information on the CSR form comes from highly variable, handwritten, daily sheets and therefore must always be manually entered. The comment box on the CSR form is used inconsistently; the charge nurses do not follow any standard procedure regarding what type of information they provide. All Unit Managers interviewed find a page an acceptable method of communicating results, although one worried about delays in the paging system. Charge Nurse Questionnaires The charge nurses provided insight to the CSR process from their perspectives. When asked the length of time spent filling out the request sheet, responses varied from 2 to 10 minutes, but the charge nurses agreed that filling out the form takes about 5 minutes total. All 6 charge nurses felt that the form needs to indicate some measurement of patient acuity. 5

Team Observations In addition to information obtained from interviews, team members identified other opportunities to improve the process that cannot be quantified: AAs handle each others CSR request forms and calls, resulting in handoffs AAs must stand up and walk to printer every time a form arrives AAs are not dedicated to only the nurse allocation process; they have other simultaneous duties and tasks. The phone rings often for unrelated reasons. The nurse allocation process is not standardized Some AAs and HMs copy information onto their own personal sheets with which they are more comfortable and familiar AAs page each unit separately, copying and pasting the same message Quantitative Findings from Data Sheets The data from the observations provides quantitative results that describe the current status of the process. These findings include the time for each step in the process and a count of factors that affect the process. Late CSR Forms The team observed the CSR office receive 144 request forms during the course of 8 process observations. Of the 144, 34 forms arrived in the CSR office later than they were due. However, the charge nurses sent 18 of the late forms on time but they arrived late because the fax took time to travel to the CSR office. On an individual process level, which includes 18 total sheets, 14 arrived on time, 2 arrived late but were sent on time, and 2 arrived late and were sent late. Late forms arrived an average of about 2 minutes after they were due. Figure 3 indicates the arrival status of each form observed. Figure 3: Form Arrival Time (144 total forms) 6

Changes to CSR Forms Observations indicated an average of 1.8 total changes to the forms per process. However, only 0.5 changes per shift occurred after the House Manager had allocated the nurses. Process Times The observations provided process times for each step in the process as depicted in the flowchart. The actual portions of the process during which a person was working on the request process to can be broken down in to four main segments: 1. The AA moving the form to the correct folder on the computer, printing the form, and inputting the data on the form to the Excel spreadsheet 2. The HM deciding how to allocate the CSR nurses 3. The AA paging the units informing them that either no nurses are available or they should call to find out the name of the nurse(s) they will be receiving The average process times along with their standard deviations can be seen below: Table 1: Processing Times in Minutes (8 process observations by team members from Oct 17, 2011-Nov 7, 2011) Average Standard Deviation AA Work Time 2.9 3.3 HM Work Time 7.6 3.9 AA Page Time 12.8 4.7 Total Processing Time 23.3 The amount of time the charge nurse takes to fill out the form was not measured by the team but instead estimated by the nurses to be roughly 5 minutes. However, the process usually does not begin until shortly before the forms are due in to the CSR office so that number has not been included in Table 1. The phone call from the charge nurse to the CSR office to obtain the name of the nurse they will be receiving always takes less than 1 minute, and was therefore not included. Wait Times The observations also provided wait times between the processing steps. Waiting generally occurs in the following areas: 1. Waiting for the fax to reach the CSR office 2. Waiting for the HM to begin allocating nurses 3. Waiting to begin paging units 4. Waiting for the units to call the CSR office back 7

The average wait times and their standard deviations can be found below: Table 2: Wait Times in Minutes (8 process observations by team members from Oct 17, 2011-Nov 7, 2011) Average Standard Deviation Fax Travel Time 6.0 3.2 AA Wait Time 16.5 11.9 Paging Wait Time 5.4 4.7 Unit Callback Time 3.3 2.9 Total Waiting Time 31.2 Nurse Availability Although outside the scope of the project, data collected shows a discrepancy between the number of CSR nurses available and the number requested: Table 3: Nurses Requested vs. Nurses Available (8 process observations by team members from Oct 17, 2011-Nov 7, 2011) Adult General Care Adult Telemetry Requested Available Requested Available Average 9.5 4.8 7.3 2.8 Standard Deviation 3.3 1.5 2.1.7 Conclusions The findings from the interviews and observations provide insight to the CSR process including opportunities to improve and areas that require further research and analysis. Late Forms and Changes to Forms The CSR Director and other interviewees felt that a significant inhibitor to the process is units sending their CSR request forms in late or making changes to the forms. However, the findings indicate these problems are fairly minor because forms are late infrequently and generally only a few minutes late. Although about 2 units make changes to their forms every iteration of the process, the majority occur before the HM has made a decision. Late changes create re-work for the AAs, but it does not add to the processing time because the AAs are typically just waiting for the HM when the changes occur. Also, the frequent handoffs of sheets and phone calls add to the confusion of the CSR process. Lean Analysis The team analyzed the process using lean methodologies. The CSR request form is analogous to the raw material and the result (whether a unit will receive a nurse) is analogous to the finished good. Just like in a factory, there is processing time and waiting time that contribute to the total lead time. The only value added step to the process is the House Manager deciding how to allocate the nurses. All other steps are either waste or incidental. Although the process takes 54 minutes on average, only 23 minutes are actual processing time and only 8 minutes are value added. All other steps should be eliminated or minimized. Figure 4 depicts the status of each step in the process as waste, incidental, or value added. 8

Figure 4: Current State Flow Chart (red = waste, yellow = incidental, green = value added) Insufficient Nurses Analysis of the number of nurses requested versus the number of nurses available indicates a shortage of nurses. Fifty percent of requests in AGC are filled and 38% of requests in ATC are filled. If more nurses were available, the House Manager would take less time to make a decision because the decision would not negatively impact as many units. Figure 5 shows the discrepancy between the number of nurses available versus the number of nurses requested. Figure 5: Number of Nurses Available Lags Number of Nurses Requested 9

Additionally, a better rating of patient acuity would ensure that the nurses are allocated properly. The decision currently is based largely on ratio of nurses to patients with no consideration of the condition of the patients. Recommendations The team has developed three types of recommendations: Immediately implementable fixes to make minor improvements Long term solutions that will be more difficult to execute but more effective Areas for further research and analysis Immediate Fixes Several improvements are immediately implementable and can reduce the process lead time and confusion: Dedicate each computer and phone to either AGC and ATC or the other clusters. That way, whenever a unit calls the CSR office the call will go to the correct AA. Also, having dedicated computer inboxes for each cluster will eliminate handoffs between AAs. Rearrange the CSR office so that the printer can be reached from the AAs desks. That would eliminate the AAs constantly standing up and walking over to the printer to retrieve the form printouts. Send reminders to the units to submit their CSR request forms. If the AAs use the group paging system, they could just send one page at a predetermined time reminding the charge nurses to submit the CSR request forms. The reminder page could also probably be automated so the AA would not have to do anything. Utilize the group paging system. All units that requested nurses receive one of two pages, either telling them that no nurses are available or to call the CSR office. If the AA uses the group paging system, only two messages would have to be sent. Send the results of the nurse allocation as a page. Each unit agreed that calling the CSR office to find out which nurses they received is unnecessary. Sending a page with the nurse name would eliminate the waiting time for the unit to call the CSR office. Add some measurement of acuity to the CSR request forms. Long Term Solution Although more complex, long term solutions can significantly improve the nurse request process. The team recommends a system that eliminates the fax machine and simultaneously saves the AAs the time they currently spend inputting the data to the spreadsheet. The team proposes assigning each unit its own spreadsheet into which the charge nurse will type the same information currently found on the CSR nurse request form. The CSR office will have a master file that automatically extracts the information from each unit s file through the shared nursing 10

drive. This live model will also allow charge nurses to make changes to their forms. Immediate solutions above could also be used to further improve the process. Further Analysis The findings demonstrated two specific areas in need of additional analysis, the shortage of CSR nurses and the non-automated nature of the process. As indicated by the shortage of nurses, the number of nurses on each unit as well as the number of CSR nurses should be re-evaluated. Units that constantly need additional CSR nurses probably need more full time nurses. The CSR also may need additional floating nurses. Another potential IOE 481 project would be developing a computer program to automatically allocate the nurses. Because the HMs currently use a combination of objective and subjective information such a program would be complicated; however, simply solving a linear program to minimize the pain factor currently included in the spreadsheet subject to certain constraints would provide a strong basis. Expected Impact Implementing these solutions would both shorten the lead time of the CSR nurse request process and reduce the confusion inherent to the process. Impact of Immediate Fixes The following details the expected impact of the above immediate solutions: Reduce confusion Reduce AA work time Reduce late forms Reduce AA page time Eliminate unit callback time, saving over 3 minutes. Impact of Long Term Solution Implementing the live model would eliminate all steps prior to the HM allocating nurses, saving an average of 34 minutes. It would also reduce confusion because the charge nurses would be inputting their exact requests rather than relying on the AA as an intermediary between the units and the House Manager. Figure 6 depicts the future state of the system if the recommended long term solution is implemented. 11

Figure 6: Future State Flow Chart: Total time = (red = waste, yellow = incidental, green = value added) Implementation of the recommended live model as well as suggested minor fixes will reduce the total time from 59.4 minutes to 25.4 minutes. The only non-value added steps are inputting the information and paging the units with results. Automation of these processes would be next steps in fully optimizing the system. 12

Appendices Appendix A: Sample CSR Request Form A

Appendix B: CSR Management Interview Questions What are your goals for the project? What do you think is the biggest problem? Do you have any ideas for potential fixes? Who are the key people to interview/what are their roles? What is the scope of this project? What units should we study? What is the current process for staffing nurses? Have you had any similar problems before? How were they solved? B

Appendix C: Unit Manager Interview Questions Where do you get the information to fill out the CSR form? Is the data available on a computer (even if you do not use it)? If so, which program? When is the earliest (on average) that you could have the CSR form filled out? When is the latest (on average) that you can afford to know the CSR answer? What are some reasons for filling out the form late? Would you be ok receiving a page with results instead of a call? What works well in the staffing process? What doesn't work well in the staffing process? What would you change? How often do you get a nurse when you request one? If you absolutely need a nurse, how do you get one? Do you use the comment box and what for? What do you do if you do not get your requested nurse? C

Appendix D: Charge Nurse Questionnaire How long, on average, would you say it takes you to fill out and fax the CSR form? Where do you get the information needed to fill out the CSR form? Does the CSR form require all of the information you believe is necessary for CSR to make a staffing decision for your unit? Do you expect to hear a response from CSR all the time (even if you didn't request any nurses)? Is this usually the case? How does the CSR relay the decision regarding nurses to you? When does this usually happen? How often do you have to call CSR to find out about your decision? What would you like to see improved most? (CSR form, overall process, etc.) D

Appendix E: Sample Data Collection Sheet Date: Time: HM: AA: Number Time Time Time Time Time Time Time Number Time Any Nurses Sheet Sheet Sheet Data AA Unit First Changes Change Other Requested Sent Arrived Printed Inputted Paged Called Page To Sheet Call Comments AGC 4A 5A 5B 5C 6A 6B 6C 8A 8B 8C PACU OBS ==================================================================================================================== ATC 4B 4C 7A 7B 7C AMOU CVC 7C AMOU CVC Time HM Starts: Time HM Ends: Time Arrived: # CSR Nurses: HM Time Spent: Total Time: E

Appendix F: Completed Data Sheets 17-Oct HM: Char 4:00 PM AA: Jenn Number Time Time Time Time Time Time Time Number Time Nurses Sheet Sheet Sheet Data AA Unit First Changes Change Requested Sent Arrived Printed Inputted Paged Called Page To Sheet Call AGC 9 4 2 2 2 60 59 0 3 4A 1-29 60 5A 1-17 -11-11 -11 60 1 5B 2-33 54 55 2 5C 1-20 54 55 6A 3-4 2 2 2 54 59 6B 0-36 60 6C 0-20 -13-13 -13 60 8A 0-48 60 8B 0-17 -9-8 -8 60 8C 0-37 60 PACU OBS 1 4 60 ================================================================================================= ATC 7 0 8 8 8 60 59 0 0 4B 1-86 60 4C 2-47 54 57 7A 2-13 -6-6 -6 54 56 7B 1-16 -9-8 -8 54 59 7C 0 0 8 8 8 60 AMOU 0-7 0 0 0 60 CVC 1-33 60 Time HM Starts: 37 HM Time Spent: 14 Time HM Ends: 51 Total Time: 60 Time Arrived: -15 AGC Nurses: 3 AGC Sat. 33% ATC Nurses: 3 ATC Sat. 43% F

18-Oct HM: Orchid 11:00 AM AA: Katie Number Time Time Time Time Time Time Time Number Time Nurses Sheet Sheet Sheet Data AA Unit First Changes Change Requested Sent Arrived Printed Inputted Paged Called Page To Sheet Call AGC 6-4 1 5 6 58 54 0 3 4A 2-115 51 52 5A 1-39 53 5B 1-40 58 5C 1-4 1 5 6 50 54 6A 0-14 -3-2 -2 6B 0-35 6C 0-21 1 8A 1-83 50 51 8B 0-18 8C 0-14 PACU OBS 0-9 -7-7 -7 2 ================================================================================================= ATC 10-39 0 0 0 52 51 0 1 4B 0-48 4C 2-51 52 1 7A 3-40 46 48 7B 3-92 47 51 7C 0-39 AMOU 2-169 48 50 CVC 0-83 Time HM Starts: 34 HM Time Spent: 11 Time HM Ends: 45 Total Time: 58 Time Arrived: -9 AGC Nurses: 4 AGC Sat. 67% ATC Nurses: 2 ATC Sat. 20% G

31-Oct HM: Deanna 4:00 PM AA: Mary Number Time Time Time Time Time Time Time Number Time Nurses Sheet Sheet Sheet Data AA Unit First Changes Change Requested Sent Arrived Printed Inputted Paged Called Page To Sheet Call AGC 7 7 9 10 10 75 73 4 0 4A 3-74 64 64 5A 0-13 -5-5 -3 5B 0 0 2 2 3 1 5C 1 7 7 7 8 65 67 1 6A 1 3 9 10 10 1 6B 0-20 6C 0-44 8A 0-23 8B 1-2 7 7 8 64 73 2 8C 0-35 PACU OBS 1-24 -5 75 ================================================================================================= ATC 7 12 20 20 20 74 69 0 0 4B 2-49 66 69 4C 2-25 73 7A 0-21 73 7B 3-46 67 68 7C 0 12 20 20 20 67 68 AMOU 0-15 -4 74 CVC 0-19 Time HM Starts: 37 HM Time Spent: 11 Time HM Ends: 48 Total Time: 75 Time Arrived: -8 AGC Nurses: 4 AGC Sat. 57% ATC Nurses: 3 ATC Sat. 43% H

31-Oct HM: Deanna 11:00 AM AA: Dawn Number Time Time Time Time Time Time Time Number Time Nurses Sheet Sheet Sheet Data AA Unit First Changes Change Requested Sent Arrived Printed Inputted Paged Called Page To Sheet Call AGC 17-6 1 1 2 56 58 2 1 4A 1-154 5A 2-55 50 51 5B 1-21 5C 4-50 53 55 6A 2-20 6B 0-6 1 1 2-4 6C 4-10 -2-2 0-4 8A 0-11 -6-6 -6 8B 2-51 1-10 8C 0-136 PACU OBS 1-61 56 58 ================================================================================================= ATC 8-2 1 1 2 47 52 1 1 4B 0-2 1 1 2-5 4C 1-35 7A 1-61 7B 3-61 47 52 7C 0-17 -9-9 -8 1-1 AMOU 1-14 -7-6 -6 CVC 2-235 Time HM Starts: 34 HM Time Spent: 7 Time HM Ends: 41 Total Time: 58 Time Arrived: -15 AGC Nurses: 3 AGC Sat. 18% ATC Nurses: 3 ATC Sat. 38% I

31-Oct HM: Deanna 4:00 PM AA: Mary Number Time Time Time Time Time Time Time Number Time Nurses Sheet Sheet Sheet Data AA Unit First Changes Change Requested Sent Arrived Printed Inputted Paged Called Page To Sheet Call AGC 10 7 12 12 13 44 35 2 3 4A 1-131 32 35 5A 0-7 4 4 6 0 5B 0-34 43 5C 3-42 33 34 2 4,14 6A 2-17 -14-11 -9 33 34 1-9 6B 0 7 12 12 13 43 10 6C 0-64 43 8A 0-18 -13-11 -8 8B 3-25 -14-11 -9 43 8C 0-1 4 4 7 PACU OBS 1-29 44 '================================================================================================= ATC 6 2 12 12 12 41 37 1 1 4B 0-7 -4-3 -3 4C 1 2 12 12 12 40 10 7A 0-24 7B 2-46 36 37 7C 0-23 -12-11 -11 41 1 23 AMOU 2-33 36 37 CVC 1-76 40 Time HM Starts: 26 HM Time Spent: 4 Time HM Ends: 30 Total Time: 44 Time Arrived: -16 AGC Nurses: 5 AGC Sat. 50% ATC Nurses: 2 ATC Sat. 33% J

2-Nov HM: Ericka 11:00 AM AA: Katie Number Time Time Time Time Time Time Time Number Time Nurses Sheet Sheet Sheet Data AA Unit First Changes Change Requested Sent Arrived Printed Inputted Paged Called Page To Sheet Call AGC 9 6 6 6 8 43 40 0 0 4A 2-194 35 38 5A 1-211 33 36 5B 1 6 6 6 8 43 5C 2-13 37 38 6A 1-22 36 40 6B 0-15 -5-5 -5 6C 1-2 6 6 7 24 34 8A 1-66 43 8B 0-36 8C 0-60 25 PACU OBS 0-4 -3-3 -1 '================================================================================================= ATC 9-16 -13-13 1 23 25 0 0 4B 0-138 4C 3-33 19 21 7A 0-51 7B 1-19 -13-13 1 22 25 7C 2-78 AMOU 3-16 -13-13 0 23 25 CVC 0-53 Time HM Starts: 11 HM Time Spent: 4 Time HM Ends: 15 Total Time: 43 Time Arrived: -11 AGC Nurses: 6 AGC Sat. 67% ATC Nurses: 4 ATC Sat. 44% K

2-Nov HM: Ericka 4:00 PM AA: Faye Number Time Time Time Time Time Time Time Number Time Nurses Sheet Sheet Sheet Data AA Unit First Changes Change Requested Sent Arrived Printed Inputted Paged Called Page To Sheet Call AGC 9 12 16 16 17 32 45 6 0 4A 0-236 5A 1-34 31 34 5B 2 3 4 4 9 31 37 2 5C 1 4 5 5 10 32 45 3 6A 2-3 -2-2 2 32 34 6B 0-30 -10 6C 0-2 5 5 11 4 8A 0 12 16 16 17 4 8B 3-2 5 5 11 32 35 4 8C 0 3 6 6 11 PACU OBS 0 7 9 9 11 4 '================================================================================================= ATC 8 8 15 16 16 31 42 4 0 4B 0 8 14 16 16 1 4C 3-39 29 38 7A 0-18 -10-10 -10 7B 1-6 3 5 14 31 33 2 7C 2-4 15 15 16 31 42 2 AMOU 2-47 CVC 0-29 5 5 13 2 Time HM Starts: 21 HM Time Spent: 4 Time HM Ends: 25 Total Time: 45 Time Arrived: -11 AGC Nurses: 7 AGC Sat. 78% ATC Nurses: 3 ATC Sat. 38% L

7-Nov HM: Erica 4:00 PM AA: Jenn Number Time Time Time Time Time Time Time Number Time Nurses Sheet Sheet Sheet Data AA Unit First Changes Change Requested Sent Arrived Printed Inputted Paged Called Page To Sheet Call AGC 9 8 11 11 11 57 42 1 0 4A 2-57 -51-13 34 34 5A 3-2 5 6 6 36 42 5B 1-19 -17-13 57 5C 1 0 1 2 2 36 41 6A 0 1 2 4 4 6B 0-23 -17-13 6C 1-46 -38-13 36 40 8A 0-59 -45-12 8B 0-2 8 9 9 8C 1 8 11 11 11 39 10 PACU OBS 0-55 -12 '================================================================================================= ATC 3 19 26 28 13 39 40 4 0 4B 0-6 -3-3 0 1 4C 0-34 -23-16 -14 7A 0-30 -22-16 -14 7B 2-57 -49-14 39 40 2 7C 0-24 -16-11 -11 2 AMOU 1 19 26 28 46 32 35 CVC 0-21 13 13 13 2 Time HM Starts: 19 HM Time Spent: 6 Time HM Ends: 25 Total Time: 57 Time Arrived: -16 AGC Nurses: 6 AGC Sat. 67% ATC Nurses: 2 ATC Sat. 67% M