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Time Study RN/MD
Standardized Nurse and Hospitalist Time Studies for TCAB!
It all began with “Transforming Care at the Bedside”… Time Study RN was developed in 2002 for a Robert Wood Johnson initiative called “Transforming Care at the Bedside” or TCAB. The initiative was formed because of an observed trend that technology, new unit design, and new Nursing processes were causing the Nurse to spend less time at the bedside. At the same time, LEAN and Six Sigma success stories in manufacturing were catching the attention of healthcare organizations globally. Taking action, RWJ funded a pilot project at 3 hospitals to use emerging LEAN and Six Sigma methods to address the problem of reduced Care Giver time at the bedside.
The 3 pilot hospitals located in Austin TX, Roseville CA, and Pittsburgh PA, each selected a med/surg unit to implement the TCAB methodology.Nurses and staff were designated as TCAB’ers and given the mission to increase Care Giver time at the Bedside through the implementation of change ideas.To measure time at the bedside, the teams turned to Rapid Modeling Corporation to develop a methodology and tool to measure Care Giver time at the bedside and to support the broad range of continuous improvement opportunities in the Nursing environment.
RMC worked with TCAB Nurses to Develop Time Study RN…
Using work activities from a time study research project completed at Clarion health and published by the Institute of Medicine, RMC and the pilot TCAB teams developed the 71 work activities and 7 categories for the TCAB measurement, and RMC developed and integrated the study software and tools that formed the TCAB methodology for measuring time at the bedside.
Ease of use and simplicity were extremely important factors in selecting a data collection methodology. A time study methodology called self sampling was tested and found to be an exceptionally good approach. Self sampling proved to be low impact, non-disruptive, low cost, intensely robust, and sufficiently accurate when enough data points were collected. In addition, we found that when the Nurses entered the data about what they were doing themselves, that the data was significantly more robust when compared to an observers data. Observer data tended to be significantly more generalized, with 3 times higher instances of the “Other” category selected. We also found that Nurses entered the data accurately with no measureable bias or manipulation. We attributed this to the fact that since they were the end users of the data, it was in their own interest to get as accurate of information as possible. Given the continuous nature of the measurement and the observed vitality of self sampling, the TCAB pilot teams determined that self sampling was the only practical alternative.
Time Study RN has evolved over 7 years…
Time Study RN has evolved 5 times since it’s inception with significantly more capabilities. In self sampling, the pilot software randomly alarmed 15 times in 8 hours, and the RN entered their location and work activity. With this information, the software is able to report the percent of time RN’s spend at various locations on the unit, the percent of time RN’s spend in various activities, and the percent of time RN’s spend in the 7 category groups. As more hospitals have joined TCAB and implemented Time Study RN, the tool has been expanded to include a greater variety of locations, work activities, category groups, and capabilities. Working with TCAB teams to improve their metrics has helped us develop more solutions to help TCAB organizations effectively transform themselves.
For example…
1. External Benchmarking with other Hospitals is Critical…
In 2005, several TCAB hospitals expressed an interest to compare their Time Study RN performance with other hospitals using Time Study RN nationally. In 2006, RMC formed and funded the Time Study RN National Benchmarking Database and invited all Time Study RN users to participate. Time Study RN users participate by completing an enrollment form that includes key demographic information about their unit and they send their Time Study RN data to the data processing team, who processes the data into the database. All hospital data is reported anonymously for complete confidentiality among teams and the program is FREE to all participating hospitals. Participation in the database allows each participating hospital to compare performance with the National Benchmarks. In addition, collaboration is encouraged among participating hospitals. A summary report for a participating hospital unit from the National Benchmarking Database is as follows:
Over 350 Hospital Units now Participate in the Time Study RN National Benchmarking Database Project!
With over 50,000 Nurse shifts of data and growing daily, the Time Study RN National Benchmarking Database has captured the interest of researchers around North America. In addition to providing valuable benchmarking and collaboration opportunities for participating hospitals, the database is crucial to understanding the impact of Nursing policy on the Nurses workload and may be an important tool impacting national and state policy on critical issues such as mandatory staffing ratios.
2. Poorly Organized Workspaces push Nurses away from the Bedside...
To address this issue, in RMC Phase IV additional locations were added to the PDA and a new question was added in the following sequence “what location did I come from?”, “what is my current location now?”, and “what activity am I doing?”. This information allows Time Study RN users to estimate the frequency of trips RN’s make between objects and locations and the data can be imported into Layout-iQ where optimal layouts can be generated. Reducing RN travel distance by over 50% can often be achieved by simply re-organizing existing workspace, providing more time for the Nurse to spend at the bedside.
The software can be used to understand the impact of acuity vs. geographic consideration in assigning patients to Nurses. We can use Time Study RN and Layout-iQ together to measure the impact of the patient assignment model on the Nurses workload. Using Time Study RN and Layout-iQ together, TCAB teams are finding the best policies impacting Nurse work assignments that result in optimal patient outcomes and improved Nurse productivity.
3. Inefficient Staffing Models cause poor Performance...
Based on our experience with TCAB units, nothing impacts “time at the bedside” and “Nursing Costs” more than inefficient staffing models and ineffective staffing management systems. There is significant hidden cost in fixed staffing models, because expensive “skilled” resources are made to do tasks (e.g. – ADL’s, family services, patient services, etc.) that could be done by lower cost resources. Not only is cost a factor, but RN satisfaction and performance is impacted because RN’s are forced to perform tasks below their skill level and training.
In our work with TCAB hospitals we found that re-engineering the staffing model requires a complex process using multiple tools. In RMC Phase V, we added an additional question to Time Study RN to measure the percent of time RN’s spend doing work that could be done by other resources. This provides us with an on-going decision support metric as TCAB teams make changes to their Staffing ratios. Because experimenting with the staffing model is not practical at many hospitals, we have developed a simulation model that allows users to experiment with staffing models in the computer simulation. The simulation measures staff effectiveness and performance given known patient and acuity patterns and helps participating teams find the best staffing model for their patient mix and acuity situation.
Once the best staffing model has been determined, we have found that implementing the staffing model without an effective staffing management tool results in less than optimal performance. To solve this problem, RMC has integrated an open shift staff management tool called Shifthound-RMC for all TCAB hospitals participating in RMC’s staffing model improvement project. This tool is free to participating hospitals while they are participating.