Clerical Activities Study

April, 1988 Chiistine J. Hanon Project Group: Carolyn M. Chang Evan L. Guttman Management Systems Department University of Michigan Hospitals Clerical Activities Study

April, 1988 Project Group: Christine J. Hanon Carolyn M. Chang Evan L. Guttman Management Systems Department University of Michigan Hospitals Clerical Activities Study

EXECU rrire StJ.1.1ARY.. Page 2 Page 14 CONCLUSIONS AND RECOMMENDATIONS... Page 12 IEStJIi1 S Page 7 APPROACHANDMETIIODOLOGY Page5 INTRODUCTION AND BACKGROUND. Page 4 OUTLINE 1

The rigorous documentation provided by this report serves to provide the 2 Frequency(%) 1 O 20 30 Fixed Inpatient Appointments Process Physicians/TPN Orders C) Order Supplies!Equipment/Serv. UMH CLERICAL ACTIVITIES MODEL (CAM) Figure 1. The CAM categories in terms of frequency of performance. impact of implementing present clerical activities through computer toward the growth for the implementation of computers is forthcoming. systems. The UMH Clerical Activity Model (CAM), Figure 1, is a general Due to the basic desire of improving the hospital system as a whole, a move Therefore, a primary focus in our study is to provide the means to assess the model of the clerical functions in the hospital. CAM ranks the clerk activity specific information provided will also be a needed resource to many other information needed to develop a general model of the clerical units of the University of Michigan Hospitals (UMH). This general model and the larger scale projects of UMFI. EXECUTWE SUMMARY

Records. Therefore, when looking into improving clerical productivity as a whole, more emphasis should be placed upon these three activities. 3 3) differences in the day, evening, and night shifts for each unit. The intention of the development of these models and time studies is to aid members of the Hospital Informations Systems Department in their in the report as a resource about 1) shift differences, 2) unit differences, and computer implementation decisions. More specific information is provided were also studied. These approximate times can be compared to times more efficient the computers could be. percieved after computer implementation, thus determining how much In addition to the CCI, the times required to perform certain clerical tasks Physicians/TPN Orders R Order Supplies/EquipmeritfServ. IMPLEMENTATION MODEL (CCI) UMH CLERICAL COMPUTER Figure 2. The CCI Model feasible categories where computer implementation should be considered. narrows down CAM (the more general model), into the three most important units, the U.M.H. Clerical ComDuter Implementation Model (CCI), Figure 2, However, when focusing on computer implementation within the clerical categories are: Duties, Physician/TPN Orders, and Medical As the chart suggests, the three most frequently performed activity

The Clerical Activities Study was performed to supply the Management 4 obtain as accurate an assessment as possible. The first type of data illustrates the frequency of functions performed by the clerks: this study was done with watches, is a time standard for the duration of clerical functions. three shifts of each of each representative unit were studied in order to the use of random beepers. The second type, calculated with the use of stop The Clerical Activities Study supplies these departments with two types of data, gathered from a representative sample of the inpatient units. All evaluate their levels of productivity. of the full range of responsibilities of the inpatient unit clerks to 2) Patient Unit Support Services Department needs documentation of certain activities. information to determine a focus for computer implementation 1) The Hospital Information Systems Department will use this incliled: Systems Department with detailed documentation on the activities of the clerks on inpatient units as part of several large-scale projects. These ( INTRODUCTION AND BACKGROUND

APPROACH AND METHODOLOGY C 5 performed by each team member on their assigned unit These studies The other type of study conducted was a time study Time studies were on a regular basis shifts. The clerks were responsible for equipping themselves with one of the Each member of the project group was in charge of a specific unit. That team member was responsible for introducing the clerks on that unit to the in a folder in the clerks work place Team members gathered these forms beepers along with any problems that might have arisen during any of the beepers at the beginning of their shift. The data collection forms were kept step-down unit), and 5D, (a general intensive care unit). These units were decided upon by the Patient Support Services Department, who felt these hours a day. studied for three weeks, units 4B and 5D began on March 7, 1988, while 7C began on March 14, 1988, and all were studied continuously, twenty four units were a representative sample of all the inpatient units. Each unit was The units studied were 4B(neurologyf neurosurgery unit), 7C (a cardiology based on information provided the the Patient Unit Support Services data represents the clerks frequency distribution among the many activities performing at the time of the signal on a data collection form. This form, performed (see Appendix C through 0 for all frequency distributions). Each time the beeper sounded, the clerks recorded the activity they were Department, was prepared by the project group. Over a period of time this approximately two times per hour, throughout the clerks shift. were equipped with a beeper that transmitted an auditory signal randomly, methodology using random beepers was decided upon. Clerks on the units allow a large sample to be collected in a relatively short period of time, since particular task during his or her shift. A method was needed that would there was a time constraint on the project team. A work sampling One method was needed to discover how often a clerk performed a Th70,. types of tests were performed to obtain the documentation requested.

systems. This study supplies a documented time standard of clecical C 6 observations and discussing matters of interest with the clerks. These recommendations. observations provided the group with valuable insight needed to make During the time study sessions, the team members were also making implemented. activities, which can be used as a guideline when these systems are to be activities were decided upon by the Patient Support Services Department. consisted of using a stop watch to time specific clerical activities. These and had to do with the future implementation of computerized order entry

Using the data collections forms (see Appendix A), we totalled all the checks made by the clerks for each activity, and calculated the percentage of 7 Figures 3 and 4 show the General and Intensive Care Unit Models. Although the frequencies between units are quite similar, the biggest differences include greater receptionist duties in the ICU and a greater midnight shift. and evening, and much greater processing of medical records during the respectively show the Day, Evening, and Midnight Shift Models. The biggest differences between shifts include greater receptionist duties during the day processing of orders in the General Care Unit. Figures 6, 7, and 8 the Clerical Computer Implementation Model (CCI). These categories are (see Figure 1). From the CAM, we determinçd the three most important clerks activities; this model is called the Clerical Activities Model (CAM) Day, Evening, and Night Shift Models, 2) a combination of all shifts for each We formulated distributions of: 1) each shift for all units, which produced us to form distributions of the frequency of performance for clerical duties. each activity per unit, per shift, and combinations of the two. This enabled unit, which produced the ICU and General Care Unit Models, and 3) made a general model of all shifts and units combined to produce an overall view of feasible categories to consider computer implementation in, thus forming processing orders, medical records, and ordering supplies (see Figure 2). RESULTS

Figure 3. General Care Unit Model. > > Frequency (%) 0 10 20 30 40 I Fixed Order SupplieslEquipmentlServ. Inpatient Appointments Process PhysicianslTPN Orders ICU MODEL Figure 4. Intensive Care Unit Model. Frequency (%) 0 10 20 FIxed MeaL &eak Order SuppliesfEquipmentlServ. Inpatient Appointments Process Physicians/TPN Orders GENERAL CARE UNIT MODEL 8

Referral Ptx,cess C) PhysicianslTPN Orders Frequency(%) 9 0 10 20 30 Fixed Order SupplieslEqUipment SerV. Inpatient Appointments Pracess Physicrans/TPN Orders Figure 7. Midnight Shift Model. Frequency (%) 0 10 20 30 Fixed C) Inpatient Appointments PlDcess PhysicianslIPN Orders Order SupplieslEquipmentlServ. Figure 6. Evening Shift Model. Frequency (%) 0 10 20 30 40 I I Fixed Meatf8reak Order SupplieslEquipment(Serv. Inpatient Appointments Prx>cess Figure 5. Day Shift Model.

Implementation Model). Table 1 shows these approximate times which can records, and ordering supplies (categories from the Clerical Computer C, C. Request Supply: 15 sec. Contact Supplier: 5 sec. - 1 mm. ORDER SUPPLIES. CWSE CHART: 5-45 mm. Return: Stamp Forms: 17 sec. Identify and Collect: BEDSIDE CHART STUFFING: MEDICAL RECORDS. Distribute: 22 sec. Sign Off And Pull: 13 sec. ORDERS: Place in Box: 4 sec. Choose and Complete Form: 35 sec. labs: PROCESS ORDERS. Table 1. Observation times. simultaneously performed. implementation of computers. Table 2 displays activities that were be compared to durations obtained of the same functions after the functions we focused on were processing orders, processing medical performed their jobs in order to determine times for certain functions. The The second part of our study included observing the clerks while they

SIMULTANEOUS ACTIVITIES PERFORMED BY CLERKS / Notify R.N. of Inpatient Appts. Closing Chart I Answering Nurse Requests Pulling Orders / Answering Nurse Requests On Phone / Probing Computer On Phone / Closing Patient Chart On Phone / Pulling Orders Table 2. 11

1) receptionist duties, 2) physicians /TPN orders, and 3) medical orders. units should focus on the most frequencly performed activities which were As was stated in the Executive Summary, overall improvement in clerical 12 more productively. A system that places the patient charts in the computer would greatly reduce the paperwork required, as well as increasing efficiency implemented into a computer system in order enable the clerks to work It is this group s recommendation that the patient charts eventually be activities are actually more significatnt. The activities of processing orders difficulty observed was the clerks management of these patient charts. clerical staff, the project team was able to discover that the most prevalent These charts contain almost every document a patient could possibly need records, the clerks have to spend time locating them. and medical records are centered around the patients charts and require a during his or her stay at the hospital; they can become quite large depending Therefore, in addition to processing orders and dealing with medical supplies/equipment/services make up the CCI model, but the first two Processing physicians /TPN orders and medical records, and ordering great deal of paperwork. By spending time observing and speaking to the doctors and nurses, they are often left accidentally all over the unit. old charts and opening new ones. Because the charts are also used by on the patient s length of stay. The clerks spend a great deal of time closing before the distraction. This, in effect, takes time and makes the clerks less continuously being interrupted by receptionist s duties. Since clerks are who would man the phones and would have face-to-face interactions with staffing change could be allocating receptionist duties to a separate person people. This recommendation is supported by the fact that clerks were Since a great deal of time is dealt with receptionist duties, a possible often being interrupted, they have to remember what they were doing efficient. For newer, i nfamiliar clerks, this would be even more time consuming. CONCLUSIONS AND RECOMMENDATIONS

However, in order to ensure the success of computer implementation, the 13 orders would be processed through the computer This emphasizes the used by doctors and nurses to request appropriate actions. The terminals C long term scope of hospital patient care units, we feel that computerized patient charts would prove to be a great asset It should also be noted that there is a project presently being conducted, growing importance of taking advantage of high technology Thus, in the that the clerks would have access to would be part of this same system. All dealing with the installation of bedside computer terminals which would be effectively analyze the benefits and costs of computer implementation. would be evaluated in later studies that would use this report s information to An increase in the amount of time it takes to perform these activities could be the result, as well as a greater staffing requirement. These are issues that Another point of concern is that the number of activities being performing the reason being that work on a computer demands a great deal of attention. simultaneously will probably decline with further computer implementation, only enable clerks to be more productive with computers, but it would also delicate social issue could be the result. Therefore, providing the necessary after the installation of the iiew diet software packages within the units. information and training for clerks is again recommended; this would not already rather efficient in, has already resulted in some resentment and fear When dealing with a major expansion in computer implementation, a help clerks feel more comfortable with them. Changing the clerks environment, which they are familiar with and their own with their extended knowledge. and hardware. This could also in affect decrease the amount of clerical operators should be well educated in the aspects of basic computer software dependence for technical assistance and computer hardware and software maintenance because they would be better able to trouble shoot problems on the computer terminal). by having all the information conveniently accessible in one compact area (i.e.

,cjajj (ffle/stuff/ PFDCESSN3 - MIDNIGHT/DAY/EVENING SHIFT * TIME: MIDNIGHT/DAY/EVENING SHIFT * TIME: BEEPERSGNAL 1 2 3 4 5 6 7 8 9 1011 12 13 14 15 16 1 2 3 4 5 6 7 8 9 10 1112 1 14 15 16 PFzCEPTXDNT AD+4LSSKN PROCESS 1R4NSFER PRDCESS DcH4F3E PROcESS PROCESSPHYSICL4NS/TPNORDER INPATIENT APPOINTMENTS PRSS thin/pre.-op/assemble/close) OfDER SUPPLIES/EQUIPMENT! S9ES (notinrtiatedbyanordei) OFF UNIT EFANDS MEAL/BREAK FIXED (routine)activities (bed theckjdrug renewal! pager programming) per column. Thank you for your help with this project. * Circle appropriate shift When the beeper signals, please mark the appropriate column of activity. The beeps are random, but they should go off about 16 times per shift, so there will be at least one mark (or more) U U AREA/UNIT: DATE: -.4

: REFERENCE SHEET TO CHECKLIST: Record on MAS ing: Phone/Tube System/Mail Process Referrals Pull Orders Notify Nursing of Orders Phone, PM System/Order Entry, Lab Requests Procedures, Diets, Lab Tests by: Follow Through on Equipment, Supplies, Medications Process Physician/TPN Orders: Notify Appropriate Staff Schedule Follow-up Appointments at UMH Prepare & Complete Discharge Paperwork Obtain Discharge Notice Obtain Discharge Dressings, Medications, etc. Transportation Arrangement : CoNect Patient Charts, Meds, etc. Prepare Necessary Paperwork With Admitting Via PM System Notify Appropriate Staff of Transfer (Housekeeping, Phys., Dietetics) For Inter and Intra Services, Arrange Transfer : Notify Appropriate Staff. Prepare Paperwork Bed Assignment Arranged Greet Patients Provide ID for Bed & Patient Escort Patient to Bed : Distribute Mail/Flowers Locate Necessary PCC Staff Receive/Transmit Messages Procedural Resou roe Answer Phones Page Requested (staff) Face to Face Contact (PatientsNisitors) APPENDIX B. Reference Sheet. 15

Arrange Transportation Notify Nurse of Appts. (APPENDIX B. Reference Sheet. continued) Cl Cl C. Fixed Activities: Nurse Call Pocket Page Programming Beginning of Shift Order Narcotics (M,W,F, am.) Drug Renewals AM Bed Check Pharmacy Satellite Runs : Xeroxing Obtaining Narcotics Clerical Supplies Dietetic Call Backs (Phone/Send Message) Follow Through on Requests from Nursing Call Maintenance Admission Packets Treatment Supplies Patient Articles Check Supplies, Equip., and Order Forms (UARCO) Chart Supplies Order Supplies/Equip/Services: Prepare Pre-op Chart Thin Add New Sheets in Record Audit Medical Record Obtain Old Chart From File Refers & Reports Assemble Chart : Close Discharged Patient s Chart Chart Maintenance Coordinate Xeroxing of Patient Info. Cancel/Reschedulé Appts. Order Prep. Diet, Portable 02 When Applicable Schedule Appts Inpatient Appointments: 16

GENERAL CARE UNIT, DAY SHIFT MODEL APPENDIX C. General Care Unit Models for all shifts. C > 4 0, 20 0 10 20 0 10 30 Fixed 17 MeaVBreak Order Suppfles/EquipmenVSecv. Inpatient Appointments Process PhysiciansfFPN Orders EVENING SHIFT MODEL GENERAL CARE UNIT MODEL, Freiueñcy (%) Fixed MealfBreak Order Supplies!Equipment!Serv. B Inpatient Appointments Process PhysicianslTPN Orders GENERAL CARE UNIT, MIDNIGHT SHIFT MODEL Frequency (%) Fixed MeaVflreak Order Supplies/EquipmentlSecv. Inpatient Appointments Process Physicans/TPN Orders

- 0.34 821 325 30.94 UNIT SD, DAY SHIFT 0 10 20 30 Medical Record Fixed Activities 1 8 Order SupplieslEquipmentfServ. 14.9 1.92 11.54 9.62 1827 = Inpatient Appointments Process 0.48 > PhysicianslTPN Order - -- - 14.42 0, 2.88 24.03 UNIT 50. MIDNIGHT SFT S Frequency(%) Fixed Activities Order SupplieslEquipment(Serv. 0 10 20 30 40 1 I Medical Record 7.81 > 0, Mealf&eak Inpatient Appointments Process 7.03 8.4 1.95 1.76 125 PhysicianslTPN Order 10.35 0.39 12.3 1.95 3.32 - - -- - 32.22 UNIT 50. EVENING SHIFT Frequency (%) I I Order SuppliesFEquipmenttServ. Medical Record Inpatient Appointments Process > Fixed Activities 10.09 5.13 11.71 0.85 2.05 12.65 8.72 0 10 20 30 40 PhysidanslTPN Order 16.07 APPENDIX D. Unit 5D (ICU) Models for all shifts.

Physicians/TPN Orders UNIT4B MODEL 0 10 20 30 I Fixed 19 Order Supplies/Equiprnent/serv > Inpatient Appointments Process C, Physicians,TPN Orders 0, lecepuonist UNIT 7C MODEL Frequency (%) 0 10 20 30 40 Fixed Order SuppliestEquiprnent serv > Inpatient Appontments Process C Physicans/TPN Orders 0, UNIT SD MODEL Frequency (% 0 10 20 Fixed Order SupplieslEquipmentlServ. Inpatient Appointments Process APPENDIX E. Unit Models.

APPENDIX F. Unit 4B Models for all shifts. UNIT4B,DAYSHIFT > PhysicianslTPN Order Inpatient Appointments Process Medical Record Order Supplies/EquipmentlServ. Fixed Activities 122 ni.. JIlL. 10.89 8.71 13.29 4.36 6.54 7.19 5.01 0.87 5.66-3.92 21.35 O 10 20 30 Frequency (%) UNIT 4B, EVENING SHIFT transfer Process Physicians/TPN Order > = Inpatient Appointments Process Medical Record Order SupplieslEquipmentlServ. Fixed Activities 0.96 0.48. 28 1.92 1096 4.33 IflTW 4.81 4.33 -=8.17 8.17 7.69. I 0 10 20 30 Frequency (%) UNIT 48, MIDNIGHT SHIFT C a Admission Transfer Discharge PhysITPN Order Reetra1 Inpatient Appt. Medical Record Order Supp/Equiplserv Oft Unit Errands Fixed Activities 2.91 3.49 J 4.65 6.4-9.3 12.79 M3.95 19.77 26.7 20 0 :20

APPENDIX G. Unit 7C Models for all shifts. UNIT7C, DAY > Physicians/TPN Order Inpatient Appointments Process Medical Record Order SuppliesfEquipmentlServ. Fixed Activities I 4.5 3.6 ms.6 18.47 18.02 0.9 4.05. 24.77 4.5 3.6 6.76 721 I I 0 10 20 30 Frequency (%) UNIT 7C, EVENING SHIFT > Physidans/TPN Order Inpatient Appointments Process Medical Record Order SupplieslEquipmentfServ. Fixed Activities 0 ij 523 3.64 0.91 I16 523 5.91 4.77 8.41 10 12.04 20.68 21.82. - 10 20 30 Frequency (%) UNIT 7C, MIDNIGHT SHIFT Physicians/TPN Order Inpatient Appointments Process Medical Record Order Supplies/Equipment Serv. Fixed Activities ms 18.47 4.5 3.6 19.37 0.9 0.9 27.02 5.41 3.15-7.21 721 21 0 5 10 15 20 25 30

D