How Nurses Spend Their Time: How Nurses Spend Their Time: Effects on Quality & Safety in Effects on Quality & Safety in

HospitalsHospitals

Association for the Advancement ofAssociation for the Advancement ofMedical InstrumentationMedical Instrumentation

June 2, 2008June 2, 2008

Marilyn Chow, RN, DNSc, FAANVice President, National Patient Care Services

Kaiser Permanente

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Big Picture…A View From the Bridge

1. Facility Design and Construction

2. Workforce and Practice Models

3. Patient Safety “Failure to Rescue”

4. Pay for Performance Value-Based Purchasing 27 Never Events

5. Physician Alignment

6. Patient Experience/Competition

7. Operating Margins

8. Vendor code and standardization

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Problem—Nursing Shortage

Increased demand Decreased supply Shortage estimates range from 400,000 to

1 Million RN’s in the United States by 2020 % of RN’s in hospitals has dropped from

65 to 56.2

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Adding to Nursing Supply

Efforts at recruitment have resulted in turning away more than 145,000 qualified applicants last year (NLN 2007)

Shortages in faculty, classrooms, and clinical placements are slowing preparation of new nurses

Inadequate number of nurses prepared to become faculty

Supply cannot keep up with demand

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Retention of Current Workforce

Nurses demand improvements in the hospital work environment Safety Efficient systems Automation Improved communication

Technological products and processes have not incorporated nurses’ viewpoints

Multiple studies nationally and internationally speak to the need to improve the practice environment as a key strategy to retaining nurses and improving patient care outcomes.

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Three Studies Addressing the Work Environment

Technology Drill Downs (TD2)

Time & MotionTransforming

Care at theBedside (TCAB)

Data synthesis across three studies will build evidence-based case for new

technologies to improve med-surg units

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A Catalyst for Change

Without bolder changes in the hospital work environment, the nursing shortage, coupled with the retiring nursing workforce and faculty shortages, will threaten the staffing sustainability of the American hospital as part of the care delivery system within the next 5-10 years.

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Time & Motion Study: How Do Medical-Surgical Nurses Spend Their Time

The purpose of this study is to identify specificenvironmental variables of the acute care nursingworkplace that can be altered to positively impactnursing direct care activity and ultimately, patientsafety. This study is designed to provide detailedinformation about:

The amount of time nurses spend in identified activity categories

Their movement throughout the nursing unit over the course of a typical nursing shift

The physical impact of nursing workload and stress

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Study Partners

Statistics, Data Management and EconomicsStatistics, Data Management and Economics

Track CTrack C

Track A & BTrack A & B

Track DTrack D

Technology OversightTechnology Oversight

Study CoordinationStudy Coordination

Principal InvestigatorsPrincipal Investigators Grant FundingGrant Funding

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Participating Health Systems

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Participating Hospitals

The participating health systems operate a total of 274 hospitals with more than 63,000 beds

The participating hospitals are geographically dispersed across fifteen states

Average length of stay for the study units ranges from 2.62 – 8.67 days, an average of 4.37 days

Unit size ranges from between 11-20 beds to 81-90 beds with a median size of 31-40 beds

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Study Protocols

Protocol A

Baseline for EHR Implementation

Protocol B How Do Nurses

Spend Their Time

Protocol C

Nurse Location & Movement

Protocol D

Nurse Physiologic Response

Data was collected for seven consecutive days, 24 hours a day on the randomly selected medical-surgical units.

!

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Data Collection Overview

Protocol C: Nurses carry

locating RFID tags

Data: Checked for quality and

loaded into Oracle DB

R objects generation

R statistical software

Graphs & reports

Protocol A: Documentation time

Protocol B: Nurse work sampling

Secure data transfer to 24x7 Purdue Server

Wireless Receiver

s

Protocol D:

BodyMedia armband

Data download to laptop

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Participation Results

On average, 76% of all eligible licensed nurses consented to participate during the seven day study period at 36 hospital sites

76%

97%

97% of those who consented completed the study while 3% voluntarily dropped out during the study period

No participants were removed from the study due to non-compliance!

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Track A

Track B

Track C

Track D

385Participants

382Participants

750 Participants

288 Participants

Data Collection Results

763 licensed nurses (RNs, LPNs/LVNs) completed the study

In total, study data has been collected on 2,201 work shifts resulting in 21,882 hours of data

Key Research FindingsKey Research Findings

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Nursing Practice, 77.7%

Waste, 6.6%

Non-Clinical, 12.6%

Unit-Related Functions, 2.8%

How do nurses spend their time?

77.7% of the time devoted to nursing practice

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Where do nurses spend their time? 38.6% of time spent at the nurse station

Patient Room, 30.8%

Nurse Station, 38.6%

Off the Unit, 6.9%

On the Unit, 23.7%

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Three Major Areas Accounted for Most of the Time

1. Documentation (electronic/paper)

2. Medication Administration

3. Care Coordination/communication with the patient care team, physicians and others

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Time With Patients

The amount of time a nurse spends with patients in patient rooms on daytime shifts varies from about 20% (120 minutes out of 10 daytime hours) to 38% (228 minutes out of 10 daytime hours) across the study units. The median is 171 minutes, or 30.8%.

30.8%

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Time on Documentation

The most time consuming nursing practice activity is documentation (includes all documentation categories, chart review, and computer data entry). The amount of time a nurse spends on documentation on daytime shifts varies from about 16% (96 minutes out of 10 daytime hours) to 34% (204 minutes out of 10 daytime hours). The median is 147.5 minutes.

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Time on Medication Administration

A time consuming activity is medication administration: obtaining, preparing, documenting, and giving medication. The amount of nursing practice time spent on medication administration averages 72 minutes, or 17.2%

17%

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Distance Traveled

During daytime shifts, study units averaged distance traveled rates between about 2.4 to 3.4 miles per 10-hours. The median is 3.0 miles.

Individual nurses across all study units traveled from 1 mile to 5 miles per 10-hour daytime period.

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Distance Traveled (continued)

On night shifts, study units averaged distance traveled rates between about 1.3 to 3.3 miles per 10-hours. The median is about 2.2 miles, a reduction of 0.8 miles per 10-hours from day time shifts.

During the day time, while off shift, distance traveled varied from 1.2 miles to 3.5 miles. The median is 2.1 miles, a reduction of 0.9 miles per 10-hours from day time work shifts.

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Other Results

No consistent, statistically significant relationship was found between various unit architecture types and nursing time spent with patients

Distances traveled and time spent on activities varied considerably between shifts. Of interest, variability between individual nurses on the same unit was often greater than the variance across different hospital units.

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7% of a nurse’s time is spent on patient assessment

7% of a nurse’s time is spent on patient assessment

17% of a day shift nurse’s time (median) is

spent on medication administration17% of a day shift nurse’s time (median) is

spent on medication administration

During a typical 10-hour day, a nurse travels 1-5 miles

During a typical 10-hour day, a nurse travels 1-5 miles

35% of a nurse’s time is spent on documentation

35% of a nurse’s time is spent on documentation

Day shift nurses spend about 30.8% of their

time in patient rooms with all of their patients

Day shift nurses spend about 30.8% of their

time in patient rooms with all of their patients

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Technology Drill Down (TD2) Study

Technology Targets Study funded by Robert Wood Johnson Foundation (RWJF)

Aims of the study Create an improved process for

identifying technology solutions to medical/surgical unit workflow inefficiencies.

Capture the attention of and prompt industry to develop technology that improve workflow processes.

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TD2 Process

Two day process of brainstorming and visioning

20 – 30 multidisciplinary representatives

Primary Purpose Map gaps between current workflow & idealized

workflow Identify potential technological applications

that could close the gaps

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Preliminary Findings from TD2 SitesDocumentation

Computerized Order Entry included in electronic record

Touch screen/Voice activated Global Documentation System

Multidisciplinary Real time Universal – physician, hospital, home care

Flash Drive/Smart Card

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Preliminary Findings from TD2 SitesPatient Care

Smart Monitoring Devices – interfaced with EHR

Portable devices to quickly add information and updates to patient charts

ID Bracelet or Tracking Chip System - Use with a handheld scanner. Linked to chart. Interfaces with screen at bedside.

Smart Bed

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Preliminary Findings from TD2 SitesCommunications

Computerized, centralized patient scheduling system for all departments

Wireless voice communication device/Hands free communication device.

RFID for caregivers. Universal Translator/Automatic

language interpretation device.

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Preliminary Findings from TD2 SitesMedications

Robotic delivery Medication Barcode/Chip System

(same system for labs, blood products)

Smart IV/Blood Pump Simplify systems and eliminate

redundancies

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Preliminary Findings from TD2 SitesSupplies & Equipment

RFID tag - item scanned when used Inventory to central computer Include linens, supplies & equipment

Robot to restock and deliver supplies & equipment

Ensure availability at the point of care

What We BelieveWhat We Believe

A Working Proclamation: A Working Proclamation: Recommendation Prototype…Recommendation Prototype…

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Proclamation For Changeo Key study findings presented in January 2007 to more

than 200 health care executives and frontline staffo Leaders developed a set of national recommendations for

the idealized unit design to maximize efficiency and reduce work stress, in order to improve the quality and safety of patient care

o Resulting “Proclamation for Change” presents four principles to guide decisions about hospital design and technology

While they sound simple in theory, implementing While they sound simple in theory, implementing the principles requires that the silos that the principles requires that the silos that

America’s hospital staff operate in – technology, America’s hospital staff operate in – technology, nursing, facilities, etc. – be removed.nursing, facilities, etc. – be removed.

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In order to transform the hospital-patient care environment and improve the delivery of safe, high-quality, patient-centered care, we believe in the need for:

Patient-centered design.Patient-centered design. Hospital and technology design should be organized around patient needs – helping patients and their families feel engaged in the caregiving process rather than removed from it – and be tailored to address unique factors and diverse patient populations.

System-wide, integrated technology.System-wide, integrated technology. Architects and technology vendors should work closely with nurses, physicians and other caregiving departments (i.e., pharmacy, lab, housekeeping, admitting) in all aspects of designing workspace and technologies in order to ensure a system-wide approach to meeting patient needs.

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In order to transform the hospital-patient care environment and improve the delivery of safe, high-quality, patient-centered care, we believe in the need for: Seamless workplace environments.Seamless workplace environments. To consistently

provide the highest quality care to patients, the physical design of medical-surgical units should be completely integrated with caregiver work processes and the technologies they use, so caregivers always have the right medication, materials and information, in the right place, at the right time.

Vendor partnerships.Vendor partnerships. The design and operation of technology devices should be intuitive, error-free, and part of interoperable systems – so that health care providers can access information in hospital or outpatient settings – and not waste time serving as human bridges that link multiple technology devices in different locations.

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We believe…

Our work processes can’t be dictated by technology and space. It must be the other way around.

o Nurses need to be innovators of their own work systems

o Vendors and architects must include us in the co-design of our work systems

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We believe…

Our space and tools must support collaboration (among providers, patients, and family)

o Design environments that allow people to remain connected throughout their work-time and across disciplines

o The renovation and/or new construction design process must include the input of those who will use it

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We believe…

We will only buy technology solutions that work well together (and with us!)

o Technology providers need to align around a common platform for interoperability of different types of equipment

o The user experience must be intuitive, and not require the nurse to be the bridge between different devices and systems

o A nurse is not an interface

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If these principles are followed, then:

Documentation will be a byproduct of care Needed patient supplies and medical equipment will be

available on demand Medication will be administered as part of a seamless

system that provides accurate and timely information about the patient

Communication systems will link healthcare providers as appropriate, fostering efficient, effective communications across and between disciplines

Patients and families will experience nurses and other care providers who spend more time in direct patient care

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How Can You Help Nurses?

Understand the work environment Be alert to how you can simplify the

environment Listen to the concerns of nurses Be astute observers of how nurses interact

with biomedical and clinical IT devices Be translators of technology “gobblygook” Think about how to integrate new clinical

technology seamlessly into the work environment.

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